Clinical & Biological Factors Affecting The Outcomes Of GTM

Introduction

A normal biological characteristic of human body is its capability to fix hard and delicate tissues. Majority of tissues can fix and repair themselves within biologic restrictions. Though, regeneration is another issue. As in most situations, the tissues are unable to restore themselves to the former state after occurrence of tissue loss. That loss could be a consequence of birth deformity, sickness, injury, malignancy, surgical removal or atrophy. Substitution of missing body component has consistently been a worry to client and physician as well.

The aim of tissue substitution is to reconstruct or rebuild the injured or lost structure. Also, to resemble the initial structure and function as much as possible. Nevertheless, biocompatibility is a must for grafting substance introduced for receiving host at the interfaces of hard and delicate tissues. The tissue of the recipient has the ability to refuse and damage the graft. The goal of the grafting substance and the application protocol must be decided by the doctor. The class of utilized material and the operating method will determine the outcome. Regeneration is categorised into GBR and GTR. Guided regeneration of bone (GBR) points to an edentulous zones. While guided tissue regeneration (GTR) alludes to reconstruction of bone, periodontal membrane and cementum surrounding dentition.

GTR

Guided tissue regeneration. It is defined in periodontal definitions glossary including GBR as interventions try to reconstruct missing and damaged periodontal components via various tissue reactions. GBR conventionally alludes to ridge reinforcement or bone regenerative processes. GTR conventionally alludes to periodontal attachment reconstruction. Barrier approaches are utilized in order to exclude epithelium and gums corium from root or bone surface which is believed to intervene with regenerative process. Materials utilized such as ePTFE, calcium sulfate, collagen, etc. these definitions are part of regeneration concepts, in which recreation or replacement of damaged or lost portion took place. 1

Target

Membrane barrier interventions aim to direct various tissues proliferation while healing following therapy. The defect should be occupied by cells that have the capacity to regenerate bone, cement, and periodontal membranes to promote tissue reconstruction. Progenitor cells exist in PDL, alveolar bone or the two persist around teeth or bony deformity. Physical barriers inserting between gum flap and the deformity prior to relocating and suturing of the flap inhibit gum epithelial and connective structures from approaching the space provided by the barrier. Promoting defect repopulation via regenerative cells as well.

Advantages

• These interventions utilized a barrier that hinder the entry of connective tissue and other structures to the intended area of bone reproduction and avoid any interfering with the regeneration process.
• Extra bone coverage is provided. Working as a repeat surgical flap to give more stability and blood clot protection. Also, avoid ruptures across healing tissue and root surface interface.
• A tent-like zone is provided by membranes for clotting process. Forming a space beneath the surgical flap serves as a growth scaffold. 1
• Several highly significant factors for establishing favourable atmosphere for regeneration including formation and preservation of a blood clot filled area. Avoidance of inflammation as a consequence of bacterial contamination. Segregation of the renewable site from unwanted tissues. Guaranteeing the mechanical strength of repairing wound complex.

Guided Tissue Membranes

In various studies over the years, a large variety of barrier membranes have been utilized. For instance: ePTFE, collagen, polyglactin and polyglycolic acid. Moreover, these can be divided into two main groups: resorbable and non- degradable membranes. In the following table, the pros and cons of barrier membranes are discussed, beside examples of commercial materials used. Since the resorption period vary from membrane to another, the physician has to obey the instructions of the manufacturers.

• Various studies have shown their effectiveness.
• No second surgical intervention is needed.
• No need of removal if exposure happened.
• Reduce morbidity of the patients.
• Enhancement of delicate tissue healing.
• Positive response of tissue to membrane exposure.
• Reasonable cost, as it just required one surgery.
• Unspecific period of barrierof membrane action.
• Challenging and not easy to tack down.
• Somewhat, lower filling of the bone than non-resorbable membranes.
• Tissue inflammations might restrict healing and GBR.
• The technique is sensitive.
• Neomem.
• Bio Gide
• Ossix

Non-resorbable

• Various studies have shown their effectiveness.
• Might have titanium reinforcement.
• Stay integral till removal.
• Effortless attachment to titanium or degradable tacks.
• Higher filling of the bone.
• Necessity of second surgical intervention.
• Rising morbidityNof the patients.
• Should be eliminated when the membrane revealed.
• The technique is sensitive.
• ePTFE membranes.
• Titanium reinforced gore tex.
• Cellulose filters.
• Insignificant tissue reaction.
• Resorbable

The degradation phase of the absorbable membrane begins instantly after inserting it in the surgical site, and the rate of degradation differs from person to person, so there is little control over the duration of membrane application. In 1991, minable stated that absorbable barriers to the biological justification of GTR could retain their in vivo structure for a minimum of four weeks. In addition, tissue reactions which affect healing and regeneration are caused by resorbable barriers due to their biodegradable nature. To mention, they subdivided to natural and synthetic barriers. 5

Non-resorbable

In dental field, the non-resorbable materials were not initially developed for use. However, there are limited studies were used in non-resorbable materials. Cellulose filters and ePTFE were selected as barrier membrane because they permitted fluid and nourishing products to pass via the barrier, but their micro- porosity inhibit cell passage.

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Factors Affecting GTR Outcome

The patient

Patient should have adequate motivation to undergo GTR treatment. Hygienic stage of therapy should be done. This will initially provide evaluation of the willingness and capability of the patient to maintain adequate oral hygiene which is an essential factor. Also, it will overcome gingival inflammation to turn into dense collagen structure which can withstand surgery and avoid post- surgical shrinkage. 2

Morphology of defect

GTR predictability is based on osseus deformities morphology. Bony defects are measured when re-entering and prior to surgery. The relation between newly formed tissue, acquired attachment and defects form is stated. Findings showed that walls of osseus deformity influence the amount of recent tissue formed and gained attachment. The higher the number of defect walls, the more the osseus regeneration predictability. For intar-osseus defects, GTR is impacted by the baseline depth of intra-osseus elements. The width of the deformity. The more the distance, the less the regeneration accomplished. Management of infection, impacts the maturation phase. Also, Protection of reconstructed tissue, inadequate coverage lead to reduction in osseus fill and attachment.

Mobility of Tooth

Splinting of hypermobile tooth is required to hinder the temporal post-surgical hyper movement and discomfort. Avoidance of clot instability risk. Such mobility might affect the barrier and interfere with healing.

Surgical Method

GTR processes are somehow sensitive to technique. Demanding superior skills. And significant experience prior to obtaining predictability. Surgical technique involves managing flaps (Incision. Elevation and positioning of flaps). Deformity debridement. Preparing root surface (scaling and RP. also, chemical preparation). Placing barrier. And suturing of flaps. 2

Infection Avoidance

Avoiding infection following surgery is an essential factor for GTR success. Patient should avoid mechanical cleaning during initial healing period (4-6 weeks). Plaque control measures are accomplished by rinsing or utilizing local antiseptic solution. Applying chlorhexidine 2-3 times a day. Frequent utilize of antibiotics. E.g. tetracycline or its derivatives.

Post-operation care

This is significant for GTR success. Frequent appointments are desirable while membrane is in position. Weekly visits are needed. Gentle removal of any accumulated debris and improving oral hygiene is the primary aim.

According to patient expectation, the procedure should rescue diseased tooth and preserve function and appearance. While to periodontist, therapy should eliminate defect, obtain attachment and osseus filling. The evaluation should be in regards to defect morphology during therapeutic time for retained and missing PDL. And number of osseus walls. 2

To Conclude

GTR has a significant value as a regenerative technique. Especially in intra- osseus, furcation and gum recession defect. In the coming years, GTR could be utilized with biological growth agents to enhance regenerative process. 2

References

1. Journal of dental health oral disorders & therapy. Guided tissue regeneration: a review. [Online]. Available from: https://medcraveonline.com/JDHODT/JDHODT-06-00197.pdf[Accessed 16 December 2020].
2. Bashir Beanish, Ahmed Jawahir, et al. Guided tissue regeneration – Rationale and Factors affecting its outcome. [Online]. Available from: https://www.iosrjournals.org/iosr-jdms/papers/Vol17-issue12/Version-6/H1712064461.pdf [Accessed 16 December 2020].
3. Irinakis Tassos. Rationale for socket preservation after extraction of a single-rooted tooth when planning for future implant placement. [Online]. Available from: https://www.researchgate.net/publication/6612202_Rationale_for_socket_preservation_after_extraction_of_a_single-rooted_tooth_when_planning_for_future_implant_placement[Accessed 16 December 2020].
4. Singh, Awadhesh K. GTR membranes : The barriers for periodontal regeneration. [Online]. Available from: https://www.researchgate.net/publication/306060504_GTR_membranes_The_barriers_for_periodontal_regeneration [Accessed 16 December 2020].