Background/Aim: Guided tissue regeneration is widely used in endodontic surgery. The aim is to aid in the healing process and bone regeneration and provide more successful and predictable outcomes.
Case report: This case report describes the successful treatment of an endodontic-periodontal lesion (with primary endodontic involvement), including root canal retreatment and endodontic surgery with the use of GTR (collagen absorbable membrane-xenogeneic bone graft). CBCT examination was used to aid in diagnosis and in the follow-up examination after two years to provide additional confirmation of the healing process. An extensive literature review was undertaken focusing on clinical studies that assessing the added benefit of GTR in surgical endodontics. The clinical and radiographic examinations showed uneventful healing and the reconstruction of the buccal plate and periapical area. The patient remained asymptomatic throughout the entire two years period after surgical intervention. A literature review concluded that lesion type, lesion size and the selection of the biomaterial are important factors that influence the outcome of GTR in comparison control groups. A favorable outcome was found in cases of large periapical lesions (>10mm), through-through lesions and with the use of an absorbable membrane, with or without a bone graft.
Conclusions: GTR is thought to provide an added benefit in bone regeneration and the healing process in specific cases. The outcomes in the case report are consistent with the conclusions of literature review.
If the inline PDF is not rendering correctly, you can download the PDF file here.
1. Gutmann JL, Harrison JW. Posterior endodontic surgery: anatomical considerations and clinical techniques. Int Endod J, 1985;18:8-34.
2. Tsesis I, Faivishevsky V, Kfir A, Rosen E. Outcome of surgical endodontic treatment performed by a modern technique: a meta-analysis of literature. J Endod, 2009;35:1505–1511.
3. Andreasen JO, Rud J. Modes of healing histologically after endodontic surgery in 70 cases. Int J Oral Surg, 1972;1:148-160.
4. Gurtner GC, Werner S, Barrandon Y, Longaker MT. Wound repair and regeneration. Nature, 2008;453:314-321.
5. Grzesik WJ, Narayanan AS.Cementum and periodontal wound healing and regeneration.Crit Rev Oral Biol Med, 2002;13:474-484.
6. Lin L, Chen MYH, Ricucci D, Rosenberg PA. Guided tissue regeneration in periapical surgery. J Endod, 2010;36:618-625.
7. Krtolica A. Stem cell: balancing aging and cancer. Int J Biochem Cell Biol, 2005;37:935-941.
8. Bansal R, Jain A, Mittal S, Kumar T, Kaur D. Regenerative endodontics: a road less travelled. J Clin Diagn Res, 2014;8:ZE20-24.
9. Nakashima M, Akamine A. The application of tissue engineering to regeneration of pulp and dentin in endodontics. J Endod, 2005;31:711-718.
10. Boccaccini AR, Blaker JJ. Bioactive composite materials for tissue engineering scaffolds. Expert Rev Med Devices, 2005;2:303-317.
11. Ruch JV, Lesot H, Karcher-Djuricic V, Meyer JM, Olive M. Facts and hypotheses concerning the control of odontoblast differentiation. Differentiation, 1982; 21:7-12.
12. Melcher AH. On the repair potential of periodontal tissues. J Periodontol, 1976; 47:256-260.
13. Von Arx T, Cochran DL. Rationale for the application of the GTR principle using a barrier membrane in endodontic surgery: a proposal of classification and literature review. Int J Periodontics Restorative Dent, 2001; 21:127-139.
14. Garrett K, Kerr M, Hartwell G, O’Sullivan S, Mayer P. The effect of a bioresorbable matrix barrier in endodontic surgery on the rate of periapical healing: an in vivo study. J Endod, 2002;28:503-506.
15. Bernabé PF, Gomes-Filho JE, Cintra LT, Moretto MJ, Lodi CS, Nery MJ et al. Histologic evaluation of the use of membrane, bone graft, and MTA in apical surgery. Oral Surg Oral Med Oral Pathol Oral Radiol Endod, 2010;109:309-314.
16. Bergenholtz G, Wikesjö UM, Sorensen RG, Xiropaidis AV, Wozney JM. Observations on healing following endodontic surgery in nonhuman primates (Macacafascicularis): effects of rhBMP-2. Oral Surg Oral Med Oral Pathol Oral Radiol Endod, 2006;101:116-125.
17. Artzi Z, Wasersprung N, Weinreb M, Steigmann M, Prasad HS, Tsesis I. Effect of guided tissue regeneration on newly formed bone and cementum in periapical tissue healing after endodontic surgery: an in vivo study in the cat. J Endod, 2012;38:163-169.
18. Dominiak M, Lysiak-Drwal K, Gedrange T, Zietek M, Gerber H. Efficacy of healing process of bone defects after apicectomy: results after 6 and 12 months. J Physiol Pharmacol, 2009;60:51-55.
19. Vaishnavi C, Mohan B, Narayanan LL. Treatment of endodontically induced periapical lesions using hydroxyapatite, platelet-rich plasma, and a combination of both: An in vivo study. J Conserv Dent, 2011;14:140-146.
20. Taschieri S, Del Fabbro M, Testori T, Saita M, Weinstein R. Efficacy of guided tissue regeneration in the management of through-and-through lesions following surgical endodontics: a preliminary study. Int J Periodontics Restorative Dent, 2008;28:265-271.
21. Pecora G, De Leonardis D, Ibrahim N, Bovi M, Cornelini R. The use of calcium sulphate in the surgical treatment of a ‘through and through’ periradicular lesion. Int Endod J, 2001;34:189-197.
22. Murashima Y, Yoshikawa G, Wadachi R, Sawada N, Suda H. Calcium sulphate as a bone substitute for various osseous defects in conjunction with apicectomy. Int Endod J, 2002;35:768-774.
23. Rankow HJ, Krasner PR. Endodontic applications of guided tissue regeneration in endodontic surgery. J Endod, 1996; 22:34–43.
24. Hirsch JM, Ahlstrom U, Henrikson PA, Heyden G, Peterson LE. Periapical surgery. Int J Oral Surg, 1979;8:173-185.
25. Skoglund A, Persson G. A follow-up study of apicoectomized teeth with total loss of the buccal bone plate. Oral Surg Oral Med Oral Pathol, 1985;59:78-81.
26. Goyal B, Tewari S, Duhan J, Sehgal PK. Comparative evaluation of platelet-rich plasma and guided tissue regeneration membrane in the healing of apicomarginal defects: a clinical study. J Endod, 2011;37:773-780.
27. Marín-Botero ML, Domínguez-Mejía JS, Arismendi-Echavarría JA, Mesa-Jaramillo AL, Flórez-Moreno GA, Tobón-Arroyave SI. Healing response of apicomarginal defects to two guided tissue regeneration techniques in periradicular surgery: a double-blind, randomized-clinical trial. Int Endod J, 2006;39:368-377.
28. Douthitt JC, Gutmann JL, Witherspoon DE. Histologic assessment of healing after the use of a bioresorbable membrane in the management of buccal bone loss concomitant with periradicular surgery. J Endod, 2001;27:404-410.
29. Dietrich T, Zunker P, Dietrich D, Bernimoulin JP. Periapical and periodontal healing after osseous grafting and guided tissue regeneration treatment of apicomarginal defects in periradicular surgery: results after 12 months. Oral Surg Oral Med Oral Pathol Oral Radiol Endod, 2003;95:474-482.
30. Britain SK, Arx T, Schenk RK, Buser D, Nummikoski P, Cochran DL. The use of guided tissue regeneration principles in endodontic surgery for induced chronic periodontic-endodontic lesions: a clinical, radiographic, and histologic evaluation. J Periodontol, 2005;76:450-460.
31. Seidel P, Dingeldein E. Cerabone® – eine Spongiosa-Keramik bovinen Ursprungs. Mater Sci Eng Technol, 2004;35:208-212.
32. Ghanaati S, Barbeck M, Booms P, Lorenz J, Kirkpatrick CJ, Sader RA. Potential lack of “standardized” processing techniques for production of allogeneic and xenogeneic bone blocks for application in humans. Acta Biomater, 2014;10:3557-3562.
33. Schwarz F, Mihatovic I, Ghanaati S, Becker J. Performance and safety of collagenated xenogeneic bone block for lateral alveolar ridge augmentation and staged implant placement. A monocenter, prospective single-arm clinical study. Clin Oral Implants Res, 2017;28:954-960.
34. Murugan R, Panduranga Rao K, Sampath Kumar TS. Heatdeproteinated xenogeneic bone from slaughterhouse waste: Physico-chemical properties. Bull Mater Sci, 2003;26:523-528
35. Tadic D, Epple M. A thorough physicochemical characterisation of 14 calcium phosphate-based bone substitution materials in comparison to natural bone. Biomater, 2004;25:987-994.
36. Brown P, Rau EH, Johnson BK, Bacote AE, Gibbs CJ, Gajdusek DC. New studies on the heat resistance of hamster-adapted scrapie agent: threshold survival after ashing at 600 degrees C suggests an inorganic template of replication. PNAS, 2000;97:3418-3421.
37. Ricucci D, Russo J, Rutberg M, Burleson JA, Spångberg LS. A prospective cohort study of endodontic treatments of 1,369 root canals: results after 5 years. Oral Surg Oral Med Oral Pathol Oral Radiol Endod, 2011;112:825-842.
38. Tsesis I, Rosen E, Tamse A, Taschieri S, Del Fabbro M. Effect of guided tissue regeneration on the outcome of surgical endodontic treatment: a systematic review and meta-analysis. J Endod, 2011;37:1039-1045.
39. Pecora G, Kim S, Celletti R, Davarpanah M. The guided tissue regeneration principle in endodontic surgery: one-year postoperative results of large periapical lesions. Int Endod J, 1995;28:41-46.
40. Taschieri S, Del Fabbro M, Testori T, Weinstein R. Efficacy of xenogeneic bone grafting with guided tissue regeneration in the management of bone defects after surgical endodontics. J Oral Maxillofac Surg, 2007;65:1121-1127.
41. Bashutski JD, Wang HL. Periodontal and endodontic regeneration. J Endod, 2009;35:321-328.
42. Saad AY, Abdellatief EM. Healing assessment of osseous defects of periapical lesions associated with failed endodontically treated teeth with use of freeze-dried bone allograft. Oral Surg Oral Med Oral Pathol, 1991;71:612-617.
43. Apaydin ES, Torabinejad M. The effect of calcium sulfate on hard-tissue healing after periradicular surgery. J Endod, 2004;30:17-20.
44. Pecora G, Andreana S, Margarone JE, Covani U, Sottosanti JS. Bone regeneration with a calcium sulfate barrier. Oral Surg Oral Med Oral Pathol Oral Radiol Endod, 1997;84:424-429.