Guided Tissue Regeneration in relation to Periodontology

Guided Tissue Regeneration in relation to Periodontology

1:Guided Tissue Regeneration in relation to Periodontology[1]

One of the most important roles of any body part is to carry out its functions properly.[2] However, somebody components fail to perform their tasks properly since they have a shortage in either the dimension or volume in terms of tissues or muscles. Therefore, there is a need to trigger the growth of the muscles in a given size or direction to enable the body organs to function as required.[3] One of the areas of the body where muscle regeneration and development are triggered to allow for the organs to carry out their duties properly is the teeth and bones. There is a process carried out targeting those muscles that are close to these organs. The muscles that are close to these organs are blocked and directed to in a specific dimension based on the area that has muscle insufficiency[4].

Image 1

When carrying out guided tissue regeneration, the process does not require the removal of body tissues or bones from any other body part.[5] The level of technology has offered doctors with various options that they use to carry out the process.[6] One of the alternatives that doctors use is the use of membrane barriers and tissues that are stimulated by proteins. In most instances, the muscles are stimulated by a bioactive factor gel, which enables the fabric to grow and improve the dimension or volume of the organ targeted.[7].

Guided Tissue Regeneration (GBR) refers to surgical procedures that are carried out mainly on the dental system. The procedures carried out on the structure related to the surrounding and supporting the teeth use membranes barriers that are used to enable the direct growth of some gingival tissues and bones at the site that are deemed to have insufficient muscles in terms of volume and dimension.[8] The main reason for the given growing aspects of teeth at the bone jaw is meant to allow the teeth to function correctly, be aesthetic, and prosthetic restoration. [9]Being considered the best option in replacing lost tissues, the regeneration of tissues has always been one the leading alternative options in periodontal therapy. [10]The process of periodontitis involves an inflammatory process, which affects bacteria origin that is associated with periodontal tissues. The inflammatory of the bacteria that are related to the source of the muscles in many cases they tend to provoke the muscles supporting the teeth to be destroyed[11]. The result of the process is the lack of weak interaction between the defense mechanism and the oral flora tissue.[12]

Image 2

Teeth are naturally surrounded by some tissues and some gums that are attached to it to make it firm and stable.[13] However, around the gums and jaw that are supporting the gums, some bacteria develop, which later on interfere with the gums. The interference caused by the bacteria leads to the breakdown of the bone supporting the teeth.[14] The analysis of the bone tissues supporting the teeth makes the teeth to experience some difficulties while carrying out its normal functions.[15] Therefore, this is one of the areas where the guided tissue regeneration method is applied to trigger the growth of the bone to the required dimension to make it secure and support the teeth. The growth that is triggered towards the bone helps the bone to attain some strength and support the teeth as required.[16] Apart from offering support, the extension also increases the length of the bone, which is one of the mechanisms needed to provide a large surface area for the attachment of the root bone. [17]The idea of developing new tissues and increasing the surface area does not only support the teeth or offer it a large surface area for the attachment of its roots, but the muscles are also given the teeth the ability to survive for a very long time.[18] The other term that is used to refer to this process is guided tissue regeneration. However, guided tissue regeneration deals with the tissues, while guided bone regeneration deals with issues that are associated with the bone.[19]

1. How guided tissue regeneration works.

Since many of the procedures deal with the body parts, guided tissue regeneration is used for repairing any periodontal defects that are encountered by dental systems.[20] Gums and jawbones are the most vulnerable part, so the body as human beings feed on different types of food, whereby some remains are left within the teeth.[21] Many people in the world do not take good care of their teeth.[22] These are the kind of people who are vulnerable to being attacked by periodontitis. Guided tissue regeneration is associated with periodontitis. Periodontitis is the process by which bacteria that are trapped within the gums cause some of the chronic infections.[23]

The infection, later on, causes the breakdown of the soft and hard tissues that support the teeth and keep them firm towards the jaws.[24] The analysis of the hard and soft tissues is a risky process since it also results in the consequent weakening of the teeth, which return results to poor functioning of teeth.

The weakening of the hard and soft tissues also results in the formation of gaps within the teeth, which in return allows some food particles to be trapped within the gums. [25]To fill these gaps within the teeth and bones, the process requires a specialized procedure that involves the bone grafting. Bone grafting is a process that consists of the introduction of new materials into these defected areas, which in return triggers the development and growth of new content to fill the voids that have already been formed.[26] The process of guided tissue regeneration involves the use of resorbable and, in other cases, non-resorbable materials, which is in the form of membranes. The purpose of the tissues introduced is to prevent the growth of new elements into the area. [27]The prevention of fast-growing tissues into the area gives room for the slower bone growing materials to regenerate and fill the gaps and spaces that were void.[28] Before applying any method that is used to carry out tissue regeneration, various criteria are used to regenerate tissues and bones.[29] The involved stages include;

Image 3

1.   The process of angiogenesis which involves providing enough blood supply as well as carrying out the undifferentiated mesenchyme cell.[30]
2.  Creating the space and maintaining the area to enable the growth of bones to take place with the scope still existing. [31]
3. The wound should be induced such that it will facilitate the formation of blood clots and thus offer room for eventful healing of the injury.[32]
4.  The last stage involves primary closure of the wounded areas form the promotion of smooth and uninterrupted processes of healing.

After these four stages have been carried out, they give room for guided cell regeneration to take place.[33] However, the process of healing around the teeth and gums starts taking place after forty days more so if a tooth has been removed. Healing includes connecting of the tissues after the cloth has been formed (Kao & Fagan, 2020). When convectional bone treatment is carried out, it is responsible for disabling the diseases, but it does not enable the regeneration of the materials to take place.[34] Therefore, I mean that the process can be able to stop the ailment from worsening the condition of the soft and hard tissues. However, the process cannot be able to retrieve back the muscles that were destroyed by the diseases.

However, the process of carrying of guided tissue regeneration is carried out in various procedures. Some of this procedure that is involved includes

2. Application of the guided tissue regeneration

The use of the membrane is one of the standard methods that are used in carrying out this process. The purpose of the barrier membrane is to cover the area of the bone that is under defect. [35]The layer is also capable of creating secluded space, thus barring the connective tissues from growing into the secluded space and thus allowing the required muscles to fill the space. The other benefit of the barrier membrane is that it offers protection to the wounded region, thus preventing it from mechanical injury and any form of contamination that can take place during the healing process. The introduction of the barrier membrane is done through various methods.

Graph 1

Some of the ways that are used to introduce the barrier membrane include [36]

A graph showing the phases that occur during the periodontal wound repair and regeneration.

(Image removed from Humana Press with permission)

• Biocompatibility
• Given the structure where the process is to take place is easy to cut and place the membrane
• The allowance of tissue integration
• Maintaining the space that is created
• Unwanted cell exclusion.

The methods started above are among the many techniques that the regeneration of the guided tissues uses regarding triggering cell growth, which is an idea, based on the dimension of the bones and structure.[37] The generation of the new materials is done by using different bone tissues that are regenerative. The process also looks at properties such as osteoinductive and osteoconductive.[38] After carrying out all the required properties analysis, the materials are then inserted into the bones that are defected where the right membrane is used to cover them as they propagate and integrate to cover the defects.[39] The process of entering the materials into the wounds is done through some given procedure or methods which are advised for under the pathological process.[40] Some of the techniques that are used to carry out the exercise include;

1. Surgery on the gum tissues and bones
2. After healing
3. Separating tissues

• Surgery on the bone and gum tissues

Carrying out surgery on the gum requires being procedural. The opening of the gum is done through a unique technique known as a flap.[41] After the process of flapping has been done, the area that is located below the gum undergoes thorough check-up and cleaning.[42] Cleaning is done to remove all the bacteria and any other infection that is within the wound. The next step is to place a membrane around the area.[43] The layer may be able to be used with or without grafting. However, it depends on the nature of the defect that is being treated.[44]

• After the healing process

After undergoing the process of reconstruction, the defects start the healing process.[45] The healing process is the one that facilitates the regeneration of new tissue. The regenerated tissues develop and grow to fill the defected region.[46] The nature of the membrane used can be dissolved or removed upon the growth of the muscles.

• Separation of tissues

The separation of the muscles, which is necessary for the process of guided tissue regeneration, is carried out after the defected wound has been cleaned, and it’s ready for the introduction of the regenerative materials.[47] After cleaning, the membrane is introduced to the area around the defected area. [48]While carrying out this process of tissue regeneration, one of the most important that should be kept constant is general hygiene.[49] General daily cleanliness will help to avoid any type of infection that might occur in the area of tissue regeneration since periodontal diseases can easily infect the area.[50] As mentioned above, two types of membranes are used as a barrier membrane. The two layers are the resorbable and the non-resorbable membrane, which is used depending on the nature of the defect that is present.[51]

When utilizing guided tissue regeneration, the new tissues that develop are referred to as attachments.[52] The attachment is referred to as connective tissue because it is a tissue that connects the epithelium with the root whose surface has been deprived of the first muscles that were used to exist there. [53]The new fabrics need to adapt to the new environment where it has been introduced to.[54] Thus this is the main reasons to why the properties of the barrier membranes have to be appropriately studied to avoid rejection by the body where they are introduced to.[55] Based on the role played by this kind of tissue regeneration, guided tissues/bone regeneration, there are many areas where this form of treatment is applied.[56] The first application of guided tissue regeneration is the repair bones that are defected, which purposely surround the dental implantations. [57]The problem in this area is caused by the peri-implants of some tissues earlier on in life.[58] Filling of the cavities that are left after the root of a tooth has been removed is another primary purpose of guided tissue regeneration.[59]

Image 3

3. Conclusion

The process of creating bones along implants is another area where this method is applied.[60] The regenerative material is placed into the cavity of the socket of the tooth immediately.[61] The extraction of the tooth is done. Even in the preservation of the devices to be sued for the future, the use of guided tissue regeneration is still required.[62] The cystic cavity is another area where the method is applied.[63] Though the process is beneficial to many periodontal issues, the process also becomes defective in some cases.[64] Many problems come about if defected areas are subjected to certain conditions that are not conducive.[65] One of the challenges that are encountered is when the administration of this procedure becomes unsuccessful. Another severe defect might occur due to the failure of the process of treatment administered.[66] The mistake might be even worse than the early one, and in some instances, it will lead to serious illness. Carrying out guided tissue regeneration also calls for long term maintenance of hygiene and professionalism.[67] Lack of the two virtues can lead to other serious problems.[68] Therefore, it is a requirement to take all the necessary precautions when carrying initiating the process. [69]Guided tissue regeneration can be termed as a useful process only if implemented correctly and under the right conditions.[70]  When guided tissue regeneration has taken place, the healing process of the wound takes different periods due to their healing characteristics and the anatomy that differs from one animal to another. In many cases small animals are used to carry out comparison between small animals and larger animals in a process referred to as preclinical. A table model is usually used for such comparisons.

The table below displays the advantages and disadvantages of the rats defect model

Table 1

The advantages and disadvantages of large animal defects models

They do not regenerate spontaneously

They can be able to make similar lesions as controls in the contralateral defects

Table 2

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67. Fahmy, Rania A., Gehan S. Kotry, and Omneya R. Ramadan. “Periodontal regeneration of dehisence defects using a modified perforated collagen membrane. A comparative experimental study.” Future Dental Journal4, no. 2 (2018): 225-230.
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70. Kao, Richard T., and Mark C. Fagan. “Regeneration of Intrabony Defects Utilizing Stem Cells Allograft.” In Advances in Periodontal Surgery, pp. 101-115. Springer, Cham, 2020.

[1] Majzoub, Jad, Shayan Barootchi, Lorenzo Tavelli, Chin‐Wei Wang, Sunčica Travan, and Hom‐Lay Wang. “Treatment effect of guided tissue regeneration on the horizontal and vertical components of furcation defects: A retrospective study.” Journal of Periodontology (2020

[2] Zhang, Lin, Yunsheng Dong, Na Zhang, Jie Shi, Xiangyun Zhang, Chunxiao Qi, Adam C. Midgley, and Shufang Wang. “Potentials of sandwich-like chitosan/polycaprolactone/gelatin scaffolds for guided tissue regeneration membrane.” Materials Science and Engineering: C (2020): 110618.

[3] Zhang, Hualin, Hairong Ma, Rui Zhang, Kairong Wang, and Jinsong Liu. “Construction and characterization of antibacterial PLGA/wool keratin/ornidazole composite membranes for periodontal guided tissue regeneration.” Journal of Biomaterials Applications (2020): 0885328220901396

[4] Kao, Richard T., and Mark C. Fagan. “Regeneration of Intrabony Defects Utilizing Stem Cells Allograft.” In Advances in Periodontal Surgery, pp. 101-115. Springer, Cham, 2020.

[5] Barbato, Luigi, Filippo Selvaggi, Zamira Kalemaj, Jacopo Buti, Elena Bendinelli, Michele La Marca, and Francesco Cairo. “Clinical efficacy of minimally invasive surgical (MIS) and non-surgical (MINST) treatments of periodontal intra-bony defect. A systematic review and network meta-analysis of RCT’s.” Clinical Oral Investigations (2020): 1-11.

[6] Narvekar, Aniruddh, Kevin Wanxin Luan, and Fatemeh Gholami. “Decision Trees in Periodontal Surgery: Resective Versus Regenerative Periodontal Surgery.” In Advances in Periodontal Surgery, pp. 23-41. Springer, Cham, 2020.

[7] Xu, Chun, Yuxue Cao, Chang Lei, Zhihao Li, Tushar Kumeria, Anand Kumar Meka, Jia Xu et al. “Polymer–Mesoporous Silica Nanoparticle Core–Shell Nanofibers as a Dual-Drug-Delivery System for Guided Tissue Regeneration.” ACS Applied Nano Materials 3, no. 2 (2020): 1457-1467.

[8] Tavelli, Lorenzo, Michael K. McGuire, Giovanni Zucchelli, Giulio Rasperini, Stephen E. Feinberg, Hom‐Lay Wang, and William V. Giannobile. “Extracellular matrix‐based scaffolding technologies for periodontal and peri‐implant soft tissue regeneration.” Journal of periodontology 91, no. 1 (2020): 17-25.

[9] Iranparvar, Aysel, Amin Nozariasbmarz, Sara DeGrave, and Lobat Tayebi. “Tissue Engineering in Periodontal Regeneration.” In Applications of Biomedical Engineering in Dentistry, pp. 301-327. Springer, Cham, 2020.

[10] Needleman, I., H. V. Worthington, E. Giedrys-Leeper, and R. Tucker. “WITHDRAWN: Guided tissue regeneration for periodontal infra-bony defects.” The Cochrane database of systematic reviews 5 (2019): CD001724-CD001724.

[11] Issa, Dalia Rasheed, Khaled A. Abdel‐Ghaffar, Mohamed A. Al‐Shahat, Ahmed Abdel Aziz Hassan, Vincent J. Iacono, and Ahmed Y. Gamal. “Guided tissue regeneration of intrabony defects with perforated barrier membranes, simvastatin, and EDTA root surface modification: A clinical and biochemical study.” Journal of periodontal research (2019).

[12] Fakheran, Omid, Reza Birang, Patrick R. Schmidlin, Sayed Mohammad Razavi, and Parichehr Behfarnia. “Retro MTA and tricalcium phosphate/retro MTA for guided tissue regeneration of periodontal dehiscence defects in a dog model: a pilot study.” Biomaterials Research 23, no. 1 (2019): 1-7.

[13] Geão, Catarina, Ana R. Costa-Pinto, Cassilda Cunha-Reis, Viviana P. Ribeiro, Sílvia Vieira, Joaquim M. Oliveira, Rui L. Reis, and Ana L. Oliveira. “Thermal annealed silk fibroin membranes for periodontal guided tissue regeneration.” Journal of Materials Science: Materials in Medicine 30, no. 2 (2019): 27.

[14] Geão, Catarina, Ana R. Costa-Pinto, Cassilda Cunha-Reis, Viviana P. Ribeiro, Sílvia Vieira, Joaquim M. Oliveira, Rui L. Reis, and Ana L. Oliveira. “Thermal annealed silk fibroin membranes for periodontal guided tissue regeneration.” Journal of Materials Science: Materials in Medicine 30, no. 2 (2019): 27.

[15] Petsos, Hari, Petra Ratka‐Krüger, Erik Neukranz, Peter Raetzke, Peter Eickholz, and Katrin Nickles. “Infrabony defects 20 years after open flap debridement and guided tissue regeneration.” Journal of clinical periodontology 46, no. 5 (2019): 552-563.

[16] Majzoub, Jad, Shayan Barootchi, Lorenzo Tavelli, Chin‐Wei Wang, Hsun‐Liang Chan, and Hom‐Lay Wang. “Guided tissue regeneration combined with bone allograft in infrabony defects: Clinical outcomes and assessment of prognostic factors.” Journal of periodontology (2019).

[17] Artzi, Zvi, Shiran Sudri, Ori Platner, and Avital Kozlovsky. “Regeneration of the periodontal apparatus in aggressive periodontitis patients.” Dentistry journal 7, no. 1 (2019): 29.

[18] Majzoub, Jad, Shayan Barootchi, Lorenzo Tavelli, Chin‐Wei Wang, Sunčica Travan, and Hom‐Lay Wang. “Treatment effect of guided tissue regeneration on the horizontal and vertical components of furcation defects: A retrospective study.” Journal of Periodontology (2020).

[19] Rojas, M. A., L. Marini, A. Pilloni, and P. Sahrmann. “Early wound healing outcomes after regenerative periodontal surgery with enamel matrix derivatives or guided tissue regeneration: a systematic review.” BMC oral health 19, no. 1 (2019): 76.

[20] Andrei, Mihai, Anca Dinischiotu, Andreea Cristiana Didilescu, Daniela Ionita, and Ioana Demetrescu. “Periodontal materials and cell biology for guided tissue and bone regeneration.” Annals of Anatomy-Anatomischer Anzeiger 216 (2018): 164-169.

[21]Sun, Xiaoyu, Chun Xu, Gang Wu, Qingsong Ye, and Changning Wang. “Poly (lactic-co-glycolic acid): Applications and future prospects for periodontal tissue regeneration.” Polymers 9, no. 6 (2017): 189.

[22] Sheikh, Zeeshan, Javairia Qureshi, Abdullah M. Alshahrani, Heba Nassar, Yuichi Ikeda, Michael Glogauer, and Bernhard Ganss. “Collagen based barrier membranes for periodontal guided bone regeneration applications.” Odontology 105, no. 1 (2017): 1-12.

[23] Fahmy, Rania A., Gehan S. Kotry, and Omneya R. Ramadan. “Periodontal regeneration of dehisence defects using a modified perforated collagen membrane. A comparative experimental study.” Future Dental Journal 4, no. 2 (2018): 225-230.

[24] Ravi, Sheethalan, Sankari Malaiappan, Sheeja Varghese, Nadathur D. Jayakumar, and Gopinath Prakasam. “Additive Effect of Plasma Rich in Growth Factors With Guided Tissue Regeneration in Treatment of Intrabony Defects in Patients With Chronic Periodontitis: A Split‐Mouth Randomized Controlled Clinical Trial.” Journal of periodontology 88, no. 9 (2017): 839-845.

[25] Gamal, A. Y., N. N. Al‐Berry, A. A. Hassan, L. A. Rashed, and V. J. Iacono. “In vitro evaluation of the human gingival fibroblast/gingival mesenchymal stem cell dynamics through perforated guided tissue membranes: cell migration, proliferation and membrane stiffness assay.” Journal of periodontal research 52, no. 3 (2017): 628-635.

[26] Kinane, Denis F., Panagiota G. Stathopoulou, and Panos N. Papapanou. “Periodontal diseases.” Nature Reviews Disease Primers 3, no. 1 (2017): 1-14.

[27] Yoshimoto, Itsumi, Jun-Ichi Sasaki, Ririko Tsuboi, Satoshi Yamaguchi, Haruaki Kitagawa, and Satoshi Imazato. “Development of layered PLGA membranes for periodontal tissue regeneration.” Dental Materials 34, no. 3 (2018): 538-550.

[28] Carter, Sarah-Sophia D., Pedro F. Costa, Cedryck Vaquette, Saso Ivanovski, Dietmar W. Hutmacher, and Jos Malda. “Additive biomanufacturing: an advanced approach for periodontal tissue regeneration.” Annals of biomedical engineering 45, no. 1 (2017): 12-22.

[29] Takewaki, M., M. Kajiya, K. Takeda, S. Sasaki, S. Motoike, N. Komatsu, S. Matsuda et al. “MSC/ECM cellular complexes induce periodontal tissue regeneration.” Journal of dental research 96, no. 9 (2017): 984-991.

[30] Sun, Xiaoyu, Chun Xu, Gang Wu, Qingsong Ye, and Changning Wang. “Poly (lactic-co-glycolic acid): Applications and future prospects for periodontal tissue regeneration.” Polymers 9, no. 6 (2017): 189.

[31] Sheikh, Zeeshan, Javairia Qureshi, Abdullah M. Alshahrani, Heba Nassar, Yuichi Ikeda, Michael Glogauer, and Bernhard Ganss. “Collagen based barrier membranes for periodontal guided bone regeneration applications.” Odontology 105, no. 1 (2017): 1-12.

[32] Ravi, Sheethalan, Sankari Malaiappan, Sheeja Varghese, Nadathur D. Jayakumar, and Gopinath Prakasam. “Additive Effect of Plasma Rich in Growth Factors With Guided Tissue Regeneration in Treatment of Intrabony Defects in Patients With Chronic Periodontitis: A Split‐Mouth Randomized Controlled Clinical Trial.” Journal of periodontology 88, no. 9 (2017): 839-845.

[33] Kinane, Denis F., Panagiota G. Stathopoulou, and Panos N. Papapanou. “Periodontal diseases.” Nature Reviews Disease Primers 3, no. 1 (2017): 1-14.

[34] Carter, Sarah-Sophia D., Pedro F. Costa, Cedryck Vaquette, Saso Ivanovski, Dietmar W. Hutmacher, and Jos Malda. “Additive biomanufacturing: an advanced approach for periodontal tissue regeneration.” Annals of biomedical engineering 45, no. 1 (2017): 12-22.

[35] Takewaki, M., M. Kajiya, K. Takeda, S. Sasaki, S. Motoike, N. Komatsu, S. Matsuda et al. “MSC/ECM cellular complexes induce periodontal tissue regeneration.” Journal of dental research 96, no. 9 (2017): 984-991.

[36] Sheikh, Zeeshan, Nader Hamdan, Yuichi Ikeda, Marc Grynpas, Bernhard Ganss, and Michael Glogauer. “Natural graft tissues and synthetic biomaterials for periodontal and alveolar bone reconstructive applications: a review.” Biomaterials research 21, no. 1 (2017): 9.

[37] Mehrotra, Neha, Ajay Reddy Palle, Rajani Kumar Gedela, and Sanjay Vasudevan. “Efficacy of Natural and Allopathic Antimicrobial Agents Incorporated onto Guided Tissue Regeneration Membrane against Periodontal Pathogens: An In vitro Study.” Journal of clinical and diagnostic research: JCDR 11, no. 1 (2017): ZC84.

[38] Cho, Young-Dan, Jung-Eun Lee, Yoonjin Chung, Woo-Cheol Lee, Yang-Jo Seol, Yong-Moo Lee, In-Chul Rhyu, and Young Ku. “Collaborative management of combined periodontal-endodontic lesions with a palatogingival groove: a case series.” Journal of endodontics 43, no. 2 (2017): 332-337.

[39] Andrei, Mihai, Anca Dinischiotu, Andreea Cristiana Didilescu, Daniela Ionita, and Ioana Demetrescu. “Periodontal materials and cell biology for guided tissue and bone regeneration.” Annals of Anatomy-Anatomischer Anzeiger 216 (2018): 164-169.

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[40] Fahmy, Rania A., Gehan S. Kotry, and Omneya R. Ramadan. “Periodontal regeneration of dehisence defects using a modified perforated collagen membrane. A comparative experimental study.” Future Dental Journal 4, no. 2 (2018): 225-230.

[41] Yoshimoto, Itsumi, Jun-Ichi Sasaki, Ririko Tsuboi, Satoshi Yamaguchi, Haruaki Kitagawa, and Satoshi Imazato. “Development of layered PLGA membranes for periodontal tissue regeneration.” Dental Materials 34, no. 3 (2018): 538-550.

[42] Wang, Yunji, Ye Qiu, Jie Li, Chunliang Zhao, and Jinlin Song. “Low-intensity pulsed ultrasound promotes alveolar bone regeneration in a periodontal injury model.” Ultrasonics 90 (2018): 166-172.

[43] Górski, Bartłomiej, Tomasz Kaczyński, Andrzej Miskiewicz, and Renata Górska. “Early postoperative healing following guided tissue regeneration in aggressive periodontitis patients.” Dental and medical problems 55, no. 3 (2018): 289-297.

[44] Satpathy, Anurag, Rinkee Mohanty, and Tapash Ranjan Rautray. “Thin membrane with biomimetic hexagonal patterned surface for guided bone regeneration.” International Journal of Nano and Biomaterials 7, no. 4 (2018): 275-281

[45] Hu, L., Y. Liu, and S. Wang. “Stem cell‐based tooth and periodontal regeneration.” Oral diseases 24, no. 5 (2018): 696-705

[46] Hidalgo Pitaluga, Lucas, Marina Trevelin Souza, Edgar Dutra Zanotto, Martin Eduardo Santocildes Romero, and Paul V. Hatton. “Electrospun F18 Bioactive Glass/PCL—Poly (ε-caprolactone)—Membrane for Guided Tissue Regeneration.” Materials 11, no. 3 (2018): 400.

[47] Maske, B. Shweta, Surekha Rathod, and Ishita Wanikar. “Critical issues in periodontal regeneration.” SRM Journal of Research in Dental Sciences 9, no. 3 (2018): 119.

[48] Elkhatat, Essam I. “Management of Periodontal Infrabony Defects by Guided Tissue Regeneration alone or in Combination with Deproteinized Bovine Bone.” International Journal 6, no. 1 (2018): 12-17.

[49] Ravi, Sheethalan, Sankari Malaiappan, Sheeja Varghese, Nadathur D. Jayakumar, and Gopinath Prakasam. “Additive Effect of Plasma Rich in Growth Factors With Guided Tissue Regeneration in Treatment of Intrabony Defects in Patients With Chronic Periodontitis: A Split‐Mouth Randomized Controlled Clinical Trial.” Journal of periodontology 88, no. 9 (2017): 839-845.

[50] Sheikh, Zeeshan, Nader Hamdan, Yuichi Ikeda, Marc Grynpas, Bernhard Ganss, and Michael Glogauer. “Natural graft tissues and synthetic biomaterials for periodontal and alveolar bone reconstructive applications: a review.” Biomaterials research 21, no. 1 (2017): 9.

[51] Sun, Xiaoyu, Chun Xu, Gang Wu, Qingsong Ye, and Changning Wang. “Poly (lactic-co-glycolic acid): Applications and future prospects for periodontal tissue regeneration.” Polymers 9, no. 6 (2017): 189.

[52] Artzi, Zvi, Shiran Sudri, Ori Platner, and Avital Kozlovsky. “Regeneration of the periodontal apparatus in aggressive periodontitis patients.” Dentistry journal 7, no. 1 (2019): 29.

[53] Takewaki, M., M. Kajiya, K. Takeda, S. Sasaki, S. Motoike, N. Komatsu, S. Matsuda et al. “MSC/ECM cellular complexes induce periodontal tissue regeneration.” Journal of dental research 96, no. 9 (2017): 984-991.

[54] Tavelli, Lorenzo, Michael K. McGuire, Giovanni Zucchelli, Giulio Rasperini, Stephen E. Feinberg, Hom‐Lay Wang, and William V. Giannobile. “Extracellular matrix‐based scaffolding technologies for periodontal and peri‐implant soft tissue regeneration.” Journal of periodontology 91, no. 1 (2020): 17-25.

[55] Fahmy, Rania A., Gehan S. Kotry, and Omneya R. Ramadan. “Periodontal regeneration of dehisence defects using a modified perforated collagen membrane. A comparative experimental study.” Future Dental Journal 4, no. 2 (2018): 225-230

[56] Zhang, Ershuai, Chuanshun Zhu, Jun Yang, Hong Sun, Xiaomin Zhang, Suhua Li, Yonglan Wang, Lu Sun, and Fanglian Yao. “Electrospun PDLLA/PLGA composite membranes for potential application in guided tissue regeneration.” Materials Science and Engineering: C 58 (2016): 278-285

[57] Kaushal, Shalini, Avadhesh Kumar, M. A. Khan, and Nand Lal. “Comparative study of nonabsorbable and absorbable barrier membranes in periodontal osseous defects by guided tissue regeneration.” Journal of oral biology and craniofacial research 6, no. 2 (2016): 111-117

[58] Doğan, Gülnihal Emrem, Hülya Aksoy, Turgut Demir, Esra Laloğlu, Ercan Özyıldırım, Ebru Sağlam, and Fatih Akçay. “Clinical and biochemical comparison of guided tissue regeneration versus guided tissue regeneration plus low-level laser therapy in the treatment of class II furcation defects: A clinical study.” Journal of Cosmetic and Laser Therapy 18, no. 2 (2016): 98-104.

[59] Corbella, Stefano, Silvio Taschieri, Ahmed Elkabbany, Massimo Del Fabbro, and Thomas von Arx. “Guided tissue regeneration using a barrier membrane in endodontic surgery.” (2016): 13-25.

[60] Zhang, Hao, Shiyu Liu, Bin Zhu, Qiu Xu, Yin Ding, and Yan Jin. “Composite cell sheet for periodontal regeneration: crosstalk between different types of MSCs in cell sheet facilitates complex periodontal-like tissue regeneration.” Stem cell research & therapy 7, no. 1 (2016): 168.

[61] Martins, L. M. A., F. L. Valente, E. C. C. Reis, R. V. Sepúlveda, A. P. L. Perdigão, and A. P. B. Borges. “Treatment of periodontal disease with guided tissue regeneration technique using a hydroxyapatite and polycaprolactone membrane.” Arquivo Brasileiro de Medicina Veterinária e Zootecnia 68, no. 6 (2016): 1413-1421.

[62] Rakmanee, Thanasak, Gareth S. Griffiths, Gita Auplish, Ulpee Darbar, Aviva Petrie, Irwin Olsen, and Nikolaos Donos. “Radiographic outcomes following treatment of intrabony defect with guided tissue regeneration in aggressive periodontitis.” Clinical oral investigations 20, no. 6 (2016): 1227-1235.

[63] Rakmanee, Thanasak, Gareth S. Griffiths, Gita Auplish, Ulpee Darbar, Aviva Petrie, Irwin Olsen, and Nikolaos Donos. “Treatment of intrabony defects with guided tissue regeneration in aggressive periodontitis: clinical outcomes at 6 and 12 months.” Clinical oral investigations 20, no. 6 (2016): 1217-1225.

[64] Barreras, Uriel Soto, Fernando Torres Méndez, Rita Elizabeth Martínez Martínez, Carolina Samano Valencia, Panfilo Raymundo Martinez Rodríguez, and Juan Pablo Loyola Rodríguez. “Chitosan nanoparticles enhance the antibacterial activity of chlorhexidine in collagen membranes used for periapical guided tissue regeneration.” Materials Science and Engineering: C 58 (2016): 1182-1187.

[65] Kim, Somin, Yawon Hwang, Muhammad Kashif, Dosun Jeong, and Gonhyung Kim. “Evaluation of bone regeneration on polyhydroxyethyl-polymethyl methacrylate membrane in a rabbit calvarial defect model.” in vivo 30, no. 5 (2016): 587-591

[66] Rakmanee, Thanasak, Gareth S. Griffiths, Gita Auplish, Ulpee Darbar, Aviva Petrie, Irwin Olsen, and Nikolaos Donos. “Radiographic outcomes following treatment of intrabony defect with guided tissue regeneration in aggressive periodontitis.” Clinical oral investigations 20, no. 6 (2016): 1227-1235.

[67] Fahmy, Rania A., Gehan S. Kotry, and Omneya R. Ramadan. “Periodontal regeneration of dehisence defects using a modified perforated collagen membrane. A comparative experimental study.” Future Dental Journal 4, no. 2 (2018): 225-230.

[68] Needleman, I., H. V. Worthington, E. Giedrys-Leeper, and R. Tucker. “WITHDRAWN: Guided tissue regeneration for periodontal infra-bony defects.” The Cochrane database of systematic reviews 5 (2019): CD001724-CD001724

[69] Hu, L., Y. Liu, and S. Wang. “Stem cell‐based tooth and periodontal regeneration.” Oral diseases 24, no. 5 (2018): 696-705.

[70] Kao, Richard T., and Mark C. Fagan. “Regeneration of Intrabony Defects Utilizing Stem Cells Allograft.” In Advances in Periodontal Surgery, pp. 101-115. Springer, Cham, 2020.