2. Guided tissue regeneration inGuided tissue regeneration in
endodontic surgeryendodontic surgery

3. Regeneration of periodontal defects involves
formation of new cementum, new attached
periodontal fibers and new bone in a region
previously destroyed by periodontal disease.

4. In principle,In principle, four methodsfour methods have been described tohave been described to
increase the rate of bone formation and to augmentincrease the rate of bone formation and to augment
the bone volumethe bone volume: osteoinduction: osteoinduction
by the use of appropriatby the use of appropriatee growth factorsgrowth factors
osteoconductionosteoconduction,,
where a grafting material serves as a scaffoldwhere a grafting material serves as a scaffold
for new bone growthfor new bone growth distraction osteogenesisdistraction osteogenesis ,,
by which a fracture is surgically induced andby which a fracture is surgically induced and
the two fragments are then slowly pulled apartthe two fragments are then slowly pulled apart
and finally,and finally, guided tissue regenerationguided tissue regeneration , which, which
allows spaces maintained by barrier membranes toallows spaces maintained by barrier membranes to
be filled with new bonebe filled with new bone

5. Guided tissue regenerationGuided tissue regeneration
The use of membranes to guide bony tissue
formation by separating the underlying bone
from Nonosseous cells (epithelial cells and
fibroblasts)
and space is preserved between the bone surface
and membrane. Osteoblasts derived from the periosteum
and bone are selectively induced on the osseous
defect area, facilitating new bone formation.

6.  Guided tissue regeneration:
 involves the placement of a barrier membrane to prevent cells other that PDL
cells from migrating first to root surface
 Guided bone regeneration:
 involves the placement of a barrier membrane and a bone graft in the
periodontal defect. Aim is to enhance bone formation

7. While GTR is for the regeneration of periodontal
tissue of
natural teeth GBR is for the regeneration
of supporting bone

8. Historical review of GBRHistorical review of GBR
 Regeneration of alveolar bone beneath
cellulose acetate filler implant
- by Boyne PJ.
1964
 Healing of bone defects by GTR
- by Dahlin C et al.
1988

9. Historical review of GBRHistorical review of GBR
 Bone formation utilizing titanium-reinforced
barrier membrane
- by Jovanovic.
1995
 Augmentation of intramembraneous bone
beyond the skeletal envelope using an
occlusive titanium barrier
- by Lundgren D.
1995

10. Requirement ofRequirement of
GBR barrier membraneGBR barrier membrane
 Biocompatibility & safety
 Cell occlusiveness
 Space-making ability
 Tissue integration
 Clinical manageability & cost effectiveness
- by Teparat T et al.
1998

11. Indication of GBRIndication of GBR
 Extraction site
- Prevention of crestal bone loss
especially when 1 or more wall missing
 Correction of inadequate ridge width or
shape
- Atrophic alveolar bone reconstruction for implant
placement

12. Indication of GBRIndication of GBR
 Dehicence defects
 Apical fenestration
 Residual intraosseous defects
- Fresh or incompletely repaired extraction site

13. Nonresorbable membraneNonresorbable membrane
 Titanium-reinforced expanded
 polytetrafluoroethlene(Gorete)

14. Resorbable membraneResorbable membrane
 Collagen barriers
- Bio-Guide, Bio-Mend, Colla Tape
 Synthetic polymers
- Vicryl Mesh, Resolut, Resolut XT

15. Resorbable membraneResorbable membrane
 Biologically active membrane:
Platelet-rich plasma
 Other barrier materials
- Capset, Lambone

16. Bio-Gide:
Composite Porcine
Collagen Membrane

18. Bio-Oss:XENOGRAFT
Protein extraction of bovine bone to
produce porous bone mineral
hydroxyapatite

19. Decalcified Freeze- Dried Bone (D.F.D.B.)Decalcified Freeze- Dried Bone (D.F.D.B.)
 Variable osteogenic capacity
 Viral particles killed in processing
 Limited success in furcations
 Available in particles and putty

21. BMPBMP
 Highest concentrations
 of BMP gave best clinical
results

27. endodontic-periodontal lesion is a clinical manifestation of the
pathologic inflammatory intercommunication between pulpal
and periodontal tissues via open structures such as apical foramina
lateral, accessory canals, and dentinal tubules
,

28. primary endodontic lesions,
primary endodontic lesions withsecondary periodontic involvement
primary periodontic lesions
primary periodontic lesions with secondary endodontic involvement,
true combined lesions
Simon et al classifiedSimon et al classified
endodontic-periodontal lesions intoendodontic-periodontal lesions into

29. The treatment of endodontic-periodontal combined lesions
requires both endodontic therapy and periodontal regenerative
procedure. The success rate of the endodontic-periodontal
combined lesion without a concomitant regenerative
procedure has been reported to range from 27%–37%
(Hirsch JM1985). This is significantly lower than the
reported success rate of 95% with conventional
nonsurgical root canal therapy (imura 2007)

30. Guided tissue regeneration (GTR) therapy introduced in 1980s
has been widely used to regenerate lost periodontium from
periodontal disease. Both human and animal studies have
demonstrated various degrees of regeneration of bone and
attachment apparatus (Nyman S, Gottlow J, Karring T,
Lindhe J.1982). GTR therapy has also been implemented in
the endodontic surgeries as a concomitant treatment during
the management of the endodontic-periodontal lesions
(Schwartz 2006).

31. A treatment strategy for the application of the regenerativeA treatment strategy for the application of the regenerative
procedures is outlined in Fig. 1 on the basis of theprocedures is outlined in Fig. 1 on the basis of the
26 successful cases reported (Schwartz SA, Koch MA 2006) .26 successful cases reported (Schwartz SA, Koch MA 2006) .
1. Treatment algorithm for periodontic-endodontic combined lesions

32. The presurgical assessment includes establishing and verifying the
nonvital status of the pulp, the extent and severity of the periodontal
destruction,. A localized deep probing depth with minimal tooth
mobility might have a favorable clinical outcome after
the regenerative procedure

33. Cortellini et al (2001) and others (Schulz A, Hilgers RD,
Niedermeier W. 2004) have advocated splinting of the
mobile
tooth before GTR procedure because the baseline
mobility
has been associated with the smaller clinical attachment gain
observed after GTR.

34. The intrasurgical assessment includes:
 morphology of the periodontal defect,
 defect type,
 material of choice to fill the defect and augment healing,
 wound stabilization

35. combination autogenous bone graft and e-PTFE membrane
has been shown to result in the most favorable regenerative
outcome

36.  A 50-year-old healthy,
 nonsmoker female
 Overall periodontal status was stable.
 tooth #3 showed a localized deep probing depth of 9 mm
 and a 5-mm gingival recession on the mesiopalatal aspect of
the tooth with grade II mobility. y.
 It responded to neither the electrical pulp test (EPT) nor the
cold test

37.  no pain on percussion test
 Periapical radiographic views showed a deep vertical bony
defect extending to root apex of tooth #3, in addition to the
periapical radiolucencies to the mesiobuccal root

38. Initial diagnosis was pulp necrosis and asymptomatic apical
periodontitis, and the tooth was thought to have primary endodontic
involvement. However, the pattern of periodontal bone
loss, with a wide base coronally and narrow extent apically,
suggested that there was also primary periodontal
involvement in this case. Therefore, the overall
classification of this case was an
endodontic-periodontal combined lesion.

39. • RCT,SRP during control phase
GTR after 1 month

41. Radiographic evidence of bone fill post surgery is not reliable
because of variation in angulation of X-ray beam and
variations in processing film between preoperative and
postoperative radiographs.