Guided Tissue Regeneration in Periapical Surgery

doi:10.1016/j.joen.2009.12.012

Journal of Endodontics

Volume 36, Issue 4, April 2010, Pages 618-625

https://doi.org/10.1016/j.joen.2009.12.012 Get rights and content

Abstract

Tissue regeneration by using membrane barriers and bone grafting materials in periapical surgery is an example of tissue engineering technology. Membrane barriers and/or bone grafts are often used to enhance periapical new bone formation. However, the periapical tissues also consist of the periodontal ligament (PDL) and cementum. For regeneration of the periapical tissues after periapical surgery, one of the important requirements is recruitment and differentiation of progenitor/stem cells into committed pre-osteoblasts, pre-PDL cells, and pre-cementoblasts. Homing of progenitor/stem cells into the wounded periapical tissues is regulated by factors such as stromal cell–derived factor 1, growth factors/cytokines, and by microenvironmental cues such as adhesion molecules and extracellular matrix and associated noncollagenous molecules. Tissue regeneration after injury appears to recapitulate the pathway of normal embryonic tissue development. Multiple tissue regeneration involves a complex interaction between different cells, extracellular matrix, growth/differentiation factors, and microenvironmental cues. Little is known concerning the biologic mechanisms that regulate temporal and spatial relationship between alveolar bone, PDL, and cementum regeneration during periapical wound healing. Simply applying a membrane barrier and/or bone graft during periapical surgery might not result in complete regeneration of the periapical tissues. It has not been clearly demonstrated that these biomaterials are capable of recruiting progenitor/stem cells and inducing these undifferentiated mesenchymal cells to differentiate into PDL cells and cementoblasts after periapical surgery.

Section snippets

Periodontal Tissue Destruction in Periodontal Disease and in Apical Periodontitis

The etiology and pathogenesis of periodontal disease (marginal periodontitis) and apical periodontitis are similar. Both diseases are caused by bacterial biofilm infection and manifest periodontal tissue destruction; gingival tissue, PDL, cementum, and alveolar bone are affected in periodontal disease and the last 3 tissues as well as dentin in apical periodontitis (Fig. 1). Periodontal disease is an open wound, which is constantly challenged by direct oral infection even after therapy. Apical

Biology of Periapical Wound Healing After Periapical Surgery

It is important to understand the natural wound healing potential of periapical lesions after elimination of the etiology, before considering the application of biomaterials such as membrane barriers and/or bone grafts during periapical surgery. As described previously, the wound healing potential of apical periodontitis is different from that of marginal periodontitis after treatment. The principle of periapical wound healing after periapical surgery is similar to that of connective tissue

Membrane Barriers in Periapical Surgery

The application of a membrane barrier in periodontal regenerative therapy is to prevent apical migration of gingival epithelial and connective tissue cells onto the denuded root surface and to facilitate the repopulation of the damaged root surface with PDL progenitor/stem cells to differentiate into PDL cells and cementoblasts 5, 6, 7, 10. Without a membrane barrier, open flap debridement does not prevent apical migration of junctional epithelium along denuded root surfaces (7). Some

Bone Grafts in Periapical Surgery

A systematic review of the literature concerning regeneration of periodontal tissues in periodontal regenerative therapy indicates that combination of barrier membranes and grafting materials might produce histologic evidence of periodontal regeneration, which is predominantly bone repair (74). Bone grafting materials include autografts, allografts, xenografts, and alloplasts. They have been used in periodontal regenerative therapy as space maintainers for selective cell repopulation onto the

Growth/Differentiation Factors in Periapical Surgery

Growth factors/cytokines play a crucial role in tissue wound healing because they regulate immune function and proliferation and differentiation of cells participating in wound healing 27, 93, 94. Growth factors are multifunctional and often have more than 1 target cell 27, 93. Many of the host's natural growth factors have been synthesized in vitro and used alone or incorporated into bone grafts in periapical surgery to enhance new bone formation. In a clinical study, combination of

Factors Influencing Periapical Wound Healing

Numerous factors such as infection, foreign bodies, systemic disease, and an impaired host's immune system can influence wound healing 29, 30. Infection and foreign bodies are the most important factors that can affect periapical wound healing. Implanted biomaterials such as bone grafts, despite being inert and nontoxic, often trigger adverse foreign body reactions such as inflammation, fibrosis, infection, and thrombosis 98, 99. The foreign body reaction composed of activated macrophages and

Conclusion

Except in apicomarginal bony defects caused by combined periodontal-endodontic or endodontic-periodontal lesions 67, 70 or in large periapical lesions communicating with the alveolar crest 68, 69, the use of membrane barriers in periapical surgery has not been shown to have a clear benefit in regenerating periapical tissues. The ability of bone grafts to induce new bone formation has been well-documented 17, 18, 20, 21, 22, 78, 79, 80, 81, 82, 83. However, new PDL and cementum regeneration in

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Comparative histological evaluation of two PRF formulations (PRF High and PRF Medium) on quality of life and healing outcome of apicomarginal defects: A randomized clinical trial
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The objective of this randomized clinical trial was to investigate the effects of two PRF formulations (PRF High and PRF Medium) on quality of life and healing outcome (2D and 3D) of apicomarginal defects.
Patients presenting with endodontic lesions and concomitant periodontal communication were randomly allocated to PRF High and PRF Medium groups. The treatment protocol in each group included a periapical surgical procedure with placement of PRF clot and membrane in the bony defect and on the denuded root surface, respectively. Quality of life was assessed for 1 week after surgery following a modified version of the patient's perception questionnaire. Postoperative pain was assessed using a visual analog scale. Clinical and radiographic evaluations were performed using Rud and Molven 2D criteria and Modified PENN 3D criteria. Buccal bone formation was assessed using sagittal and corresponding axial sections in CBCT. Histological analysis was performed using hematoxylin and eosin (H and E) staining and attaching primary antibodies to tissue sections.
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Review ArticleGuided Tissue Regeneration in Periapical Surgery

Abstract

Section snippets

Periodontal Tissue Destruction in Periodontal Disease and in Apical Periodontitis

Biology of Periapical Wound Healing After Periapical Surgery

Membrane Barriers in Periapical Surgery

Bone Grafts in Periapical Surgery

Growth/Differentiation Factors in Periapical Surgery

Factors Influencing Periapical Wound Healing

Conclusion

J Endod

Oral Surg Oral Med Oral Pathol

J Endod

Oral Surg Oral Med Oral Pathol

Int Dent J

Surg Clin North Am

Lancet

J Endod

Oral Surg Oral Med Oral Pathol Oral Radiol Endod

Exp Haematol

Int Oral Surg

Int J Oral Surg

Int J Biochem Cell Biol

J Endod

J Endod

J Endod

J Am Dent Assoc

J Endod

Oral Surg Oral Med Oral Pathol Oral Radiol Endod

J Oral Maxillofac Surg

J Endod

Br J Oral Maxillofacial Surg

J Thrombosis Haemostasis

J Endod

Oral Surg Oral Med Oral Pathol Oral Radiol Endod

Blood

Semin Immunol

Tissue engineering

Science

Tissue engineering: current challenges and expanding opportunities

Science

On the repair potential of periodontal tissues

J Periodontol

New attachment following surgical treatment of human periodontal disease

J Clin Periodontol

Periodontal regeneration via selective cell repopulation

J Periodontol

New attachment formation by guided tissue regeneration

J Periodontal Res

Bone-grafting materials in implant dentistry

Implant Dent

Tissue engineering: a new paradigm for periodontal regeneration based on molecular and cell biology

Periodontol 2000

A clinical and histological evaluation of autogenous iliac bone grafts in humans

J Periodontol

Histological assessment of autogenous bone graft: a case report and critical evaluation

J Periodontol

Regeneration and repair of periodontal tissue

J Periodont Res

Development of the biological concept of guided tissue regeneration: animal and human studies

Periodontol

Periodontal regeneration: a contemporary evaluation

Periodontol

The efficacy of bone replacement grafts in the treatment of periodontal osseous defects: a systematic review

Ann Periodontol

Guided bone regeneration in the treatment of a large periapical lesion: a case report

Pract Periodontic Aesthe Dent

Efficacy of guided tissue regeneration in the management of through-and through lesions following surgical endodontics: a preliminary study

Int J Periodontics Restorative Dentistry

Guided bone regeneration (GBR) using membrane and calcium sulfate after apicectomy: a comparative histomorphometrical study

Int Endod J

The role of inflammatory mediators in the pathogenesis of periodontal disease

J Periodontol Res

Periapical inflammatory responses and their modulation

Crit Rev Oral Biol Med

Healing of periapical lesion of pulpless teeth after endodontic treatment with controlled asepsis

Endod Dent Traumatol

The molecular and cellular biology of wound repair

Robbin's pathologic basis of disease

Review Article
Guided Tissue Regeneration in Periapical Surgery