"There is no bone around this tooth; it has to be removed." This is a sentence many patients with advanced periodontitis hear in the clinic. And in many cases it is correct. But not always — in selected situations modern periodontology can regenerate lost bone.
What is bone regeneration around a tooth?
In advanced periodontitis the disease destroys the alveolar bone around the tooth root. Bony defects form — "holes" in the bone that weaken the tooth's support. Without treatment the tooth becomes increasingly mobile and is eventually lost.
Bone regeneration (technical terms: GTR — Guided Tissue Regeneration, and GBR — Guided Bone Regeneration) is an attempt to reverse this destruction. The procedure involves placing a bone substitute and a barrier membrane in the bony defect to create conditions for the body's own bone to regrow.
At Modern Dental & Orthodontics we regard bone regeneration as one of the tools in the periodontal arsenal — but a tool that is precisely selected, not applied indiscriminately.
Classification of bony defects — why this determines everything
Periodontal bony defects are classified on the basis of the number of "bony walls" surrounding the defect. The simple rule: the more walls, the better the prognosis for regeneration.
| Defect type | Description | Regeneration prognosis |
|---|---|---|
| 3-wall | Defect surrounded by bone on three sides, like a "pocket" | Very good — bone regeneration often visible |
| 2-wall | Two bony walls, two missing | Good, but requires procedural precision |
| 1-wall | Only one bony wall | Limited — material difficult to maintain |
| Crater-shaped (interdental) | Defect between two teeth without lateral walls | Moderate to good |
| Horizontal, extensive | Defect along the entire ridge | Poor — regeneration usually unsuccessful |
The key message: regeneration works best for narrow, deep, 3-wall defects. For extensive, horizontal defects it is rarely effective, and alternative treatments should be considered.
Materials used in regeneration
In GTR/GBR procedures we use two main categories of materials: bone-filling biomaterials (bone substitutes) and barrier membranes.
Bone substitutes
- Autogenous (the patient's own bone) — the "gold standard" but requires an additional harvest site, increasing invasiveness.
- Allogeneic (from a human tissue bank) — good biological properties, available in various forms.
- Xenogeneic (bovine, porcine) — the most commonly used in periodontology; well studied, predictable.
- Syntetyczne (hydroksyapatyt, β-TCP) – produkowane w laboratorium, bez ryzyka biologicznego.
Barrier membranes
- Resorbable (collagen) — dissolve within 4–6 months, do not require a second procedure for removal. The most commonly chosen.
- Non-resorbable (PTFE) — more durable, offer greater predictability in difficult cases, but require removal after 4–6 months.
The choice of specific materials depends on the defect type, the operator's preference and experience, and the available products. In most cases in our clinic we use a xenogeneic bone substitute (bovine) combined with a resorbable collagen membrane.
What can succeed and what cannot — realistic expectations
Bone regeneration does not mean "the tooth returns to its original state". Even the best GTR/GBR procedures under favourable conditions achieve partial bone reconstruction — typically a gain of 3–5 mm of attachment and partial filling of the bony defect.
| Realistic goals of regeneration: not "a tooth like new" but "a tooth that previously had a hopeless prognosis now has a moderate or good one". For many patients, this means years or decades of additional function. |
In the current European guidelines (Herrera et al. 2022, EFP S3 Stage IV), regeneration is explicitly recommended as "strongly recommended" for deep intrabony defects (≥3 mm residual pocket depth after non-surgical treatment).
Essential conditions for a successful procedure
Bone regeneration in advanced periodontitis does not work on its own. Its success depends on several conditions that the patient and the clinician must fulfil before, during and after the procedure.
- Full control of periodontal disease. Bone cannot be regenerated around a tooth if active inflammation is still present. Treatment always begins with the hygiene phase (scaling, curettage, home hygiene training).
- Very good patient hygiene. This is the most common cause of failure. Regenerated tissue is very sensitive to bacterial plaque. Without excellent daily hygiene the graft becomes infected.
- Cessation of smoking. Smoking dramatically reduces the efficacy of regeneration (many studies show differences of 50% and more between smokers and non-smokers).
- Control of systemic diseases. Diabetes in particular: HbA1c should be well controlled (<7%). In patients with poorly controlled diabetes, regenerative procedures carry a substantially higher risk of failure.
- A maintenance phase lasting many years. After regeneration the patient returns every 3 months — not every 6 months, as for healthy patients. This frequency is essential for maintaining the regenerated tissues.
The alternative: when extraction and an implant are the better option
For a certain group of teeth regeneration is not the best solution. An honest conversation with the patient about the alternative — extraction and an implant — is not defeatism but responsible clinical planning.
Signals that extraction should be seriously considered:
- The tooth has additional problems beyond periodontitis: root fracture, advanced resorption, multiple failed endodontic treatments.
- The bony defect is extensive and predominantly horizontal (not 3-wall).
- The patient is a smoker and does not plan to quit.
- The patient has a history of poor compliance with the maintenance phase (irregular visits, poor hygiene).
- The tooth is very mobile (grade III mobility) — regeneration does not reverse mobility at this stage.
- The cost of the procedure and the uncertain outcome do not justify saving compared with an implant.
At Modern Dental & Orthodontics, before a regenerative procedure we always present the patient with the alternative: the cost, timeline and prognosis of both pathways. The decision is always the patient's.
Timeline and what happens after the procedure
| Stage | Time | What happens |
|---|---|---|
| Preparatory phase | 4–8 weeks | Curettage, control of inflammation, hygiene preparation |
| Regenerative procedure | Day 0 | Surgical flap, defect filling, membrane, sutures |
| Early healing | Week 1–2 | Sutures, gentle hygiene, chlorhexidine |
| Suture removal | Weeks 2–3 | Assessment of early healing |
| Regeneration phase | 3–6 months | The membrane resorbs; bone gradually incorporates the biomaterial |
| First assessment | 6 months | Follow-up X-ray, pocket measurement |
| Long-term stabilisation | 12 months + | Maintenance phase every 3 months |
In the first 2 weeks after the procedure the patient does not brush the surgical area with a standard toothbrush — we use special ultra-soft brushes or chlorhexidine mouthwash only. From week 3, gentle brushing is gradually reintroduced.
The most frequently asked questions from patients
What is the probability of success?
This depends above all on the defect type. In clinical studies, for well-selected cases (3-wall defects, good hygiene, non-smokers), significant bone gain is reported in over 70–80% of cases.
Is the procedure painful?
The procedure is performed under local anaesthesia — the patient feels no pain during it. For 3–5 days afterwards discomfort, swelling and occasionally mild bleeding appear. Standard analgesics (paracetamol, ibuprofen) are usually sufficient.
How much does it cost?
Bone regeneration is one of the more expensive periodontal procedures — mainly because of the cost of the materials (collagen membrane and bone substitute) and the surgical time. The exact cost depends on the number of teeth, the defect size and the materials used.
Read more:
- Periodontist Warsaw — Klinika MDO services
- Closed vs open curettage — a comparison of methods for treating advanced periodontitis
- Surgical crown lengthening — when is it necessary and how is it performed
- Gum recession — why the gum recedes and when surgical treatment is needed
Sources
Source 1
Links
https://pubmed.ncbi.nlm.nih.gov/38182662
https://doi.org/10.1038/s41432-023-00964-7
Pasqualini E, Castro F, Curado D, Martelete A, Heboyan A, Saleh MH, Fernandes JCH, Fernandes GVO. „Minimally invasive periodontal regeneration with the buccal approach: a systematic review and meta-analysis of clinical studies.” Evidence-Based Dentistry. 2024;25(1):54.
Source 2
Links
https://pubmed.ncbi.nlm.nih.gov/38380549
https://doi.org/10.1002/advs.202308848
De Lauretis A, Øvrebø Ø, Romandini M, Lyngstadaas SP, Rossi F, Haugen HJ. „From Basic Science to Clinical Practice: A Review of Current Periodontal/Mucogingival Regenerative Biomaterials.” Advanced Science. 2024;11(17):e2308848.
Source 3
Links
https://pubmed.ncbi.nlm.nih.gov/36598601
https://doi.org/10.1007/s00784-022-04855-6
Ostos-Aguilar BI, Pinheiro Furquim C, Muniz FWMG, Faveri M, Meza-Mauricio J. „Clinical efficacy of hyaluronic acid in the treatment of periodontal intrabony defect: a systematic review and meta-analysis.” Clinical Oral Investigations. 2023;27(5):1923–1935.
Source 4
Links
https://pubmed.ncbi.nlm.nih.gov/32383274
https://doi.org/10.1111/jcpe.13290
Sanz M, Herrera D, Kebschull M, Chapple I, Jepsen S, Berglundh T, Sculean A, Tonetti MS; EFP Workshop Participants and Methodological Consultants. „Treatment of stage I–III periodontitis—The EFP S3 level clinical practice guideline.” Journal of Clinical Periodontology. 2020;47(Suppl 22):4–60.