Periodontal regeneration Periodontal treatment

Step by step

1. Deep cleaning comes first, and surgery treats the pockets that remain.
2. The gum is folded back with a flap that preserves the gum between the teeth.
3. Bacteria and tartar are removed from the root and the bone defect.
4. A membrane, enamel matrix proteins, a bone graft or a combination is placed in the defect.
5. The gum is closed to keep the wound stable while it heals.
6. Maintenance visits follow to protect the result.

What is periodontal regeneration?

Periodontal regeneration is the regrowth of a tooth's full attachment, with new cementum on the root, new ligament fibers and new bone, on a root surface that disease had damaged. Flap surgery alone heals mainly by repair, with a long junctional epithelium sealing the pocket. In research, true regeneration is confirmed on biopsy when new bone, ligament and cementum appear above a notch cut at the base of the defect.

The AAP consensus found that regeneration on previously diseased roots is possible, shown by attachment gain, shallower pockets and bone gain on X-ray. Clinical improvements can be maintained for more than 10 years. Early regenerative treatment of a bone defect offers the greatest chance of success. Can bone loss be reversed? and bone loss around teeth cover the condition itself.

Which bone defects can be regenerated?

The defects that regenerate best are angular bone loss beside a root, called intrabony defects, and Class II furcations of molars.

• Intrabony defects: the European guideline recommends regenerative surgery for residual deep pockets with defects 3 mm or deeper.
• Class II furcations: regeneration is recommended for lower molars and suggested for cheek-side upper molars.
• Class III furcations: evidence is limited to case reports.
• Class I furcations: usually treated predictably without regeneration.

The AAP consensus advises considering regeneration before resective surgery or extraction for a tooth with a Class II furcation. Results depend on the patient and the site: smoking, home care, leftover inflammation, defect depth and angle, the number of remaining bone walls and tooth mobility all affect the outcome. Osseous surgery covers the resective option, and pocket numbers explains the measurements.

How much attachment does regeneration gain?

Regeneration adds about 1.2 to 1.5 mm of attachment gain over flap surgery alone, depending on the method.

Method, compared with flap surgery alone	Added attachment gain
Any regenerative method	1.34 mm
Enamel matrix derivative	1.27 mm
Guided tissue regeneration (membrane)	1.43 mm
Membrane with bone-derived graft	1.5 mm
Guided tissue regeneration, Cochrane review	1.22 mm
Platelet-rich fibrin	1.2 mm
Class II furcations, regeneration	1.3 mm

Long-term trials followed teeth for 3 to 20 years. Tooth loss was 0.4% after regeneration, from sparse evidence. Flap surgery alone had a tooth loss rate of 2.8%. Combination approaches gave shallower pockets and more attachment gain over time. The meta-analysis behind the European guideline names Emdogain or a membrane with a papilla preservation flap as the treatment of choice for deep intrabony defects. PRF and growth factors covers the biologics.

What materials regenerate bone around teeth?

Periodontists use membranes, bone grafts and tissue-stimulating proteins, alone or together, to encourage the body to regrow bone and attachment.

• Guided tissue regeneration: a barrier membrane over the defect, the same principle as guided bone regeneration at implant sites.
• Enamel matrix derivative (Emdogain): proteins that mimic tooth development.
• Bone replacement grafts: donor bone such as DFDBA supports new attachment, and synthetic grafts heal mainly by repair.
• rhPDGF-BB with beta-TCP (GEM 21S): FDA-approved for intrabony and furcation defects.
• Combinations: a graft with a membrane gains more attachment than a graft alone.

The European guideline recommends membranes or enamel matrix derivative, with or without bone-derived grafts. In the AAP workshop review, biologics performed comparably to donor bone grafts and membranes. The guideline advises choosing materials with human biopsy evidence and good clinical trials behind them. Bone graft materials and guided bone regeneration cover the materials.

Does LANAP regenerate bone?

LANAP holds an FDA clearance, granted in 2016, for true regeneration of new cementum, ligament and bone on a previously diseased root when the PerioLase Nd:YAG laser is used under the LANAP protocol. The same clearance covers the laser-assisted new attachment procedure, defined as new attachment of ligament to the root through cementum, without a long junctional epithelium.

The biopsy study filed with the clearance examined teeth 9 months after treatment. True regeneration appeared at 50% of the sites that could be evaluated. The AAP workshop review found histologic evidence of regeneration with laser therapy and limited data on its clinical predictability. Home care matters too: plaque scores below 20% to 25% were linked with better surgical outcomes in the European guideline. LANAP covers the laser protocol, and LANAP candidates covers who qualifies.

Sources

1. American Academy of Periodontology. Surgical procedures: regenerative procedures
2. FDA 510(k) K151763, PerioLase Nd:YAG laser, decided 2016-03-15
3. FDA 510(k) K151763 summary, PerioLase Nd:YAG laser, clinical performance data. 2016
4. Reynolds MA et al. The efficacy of bone replacement grafts in the treatment of periodontal osseous defects: a systematic review. Ann Periodontol 2003
5. Reynolds MA et al. Periodontal regeneration, intrabony defects: a consensus report from the AAP Regeneration Workshop. J Periodontol 2015
6. Kao RT et al. Periodontal regeneration, intrabony defects: a systematic review from the AAP Regeneration Workshop. J Periodontol 2015
7. Reddy MS et al. Periodontal regeneration, furcation defects: a consensus report from the AAP Regeneration Workshop. J Periodontol 2015
8. Sanz M et al. Treatment of stage I-III periodontitis: the EFP S3 level clinical practice guideline. J Clin Periodontol 2020
9. Nibali L et al. Regenerative surgery versus access flap for the treatment of intra-bony periodontal defects: a systematic review and meta-analysis. J Clin Periodontol 2020
10. Needleman IG et al. Guided tissue regeneration for periodontal infra-bony defects. Cochrane Database Syst Rev 2006
11. Castro AB et al. Regenerative potential of leucocyte- and platelet-rich fibrin, part A: intra-bony defects, furcation defects and periodontal plastic surgery. J Clin Periodontol 2017
12. Stavropoulos A et al. Medium- and long-term clinical benefits of periodontal regenerative procedures in intrabony defects: network meta-analysis. J Clin Periodontol 2021
13. Cortellini P, Tonetti MS. Clinical concepts for regenerative therapy in intrabony defects. Periodontol 2000 2015
14. Machtei EE. The effect of membrane exposure on the outcome of regenerative procedures in humans: a meta-analysis. J Periodontol 2001
15. Miron RJ et al. 30 years of enamel matrix derivative: mimicking tooth development as a clinical concept. Periodontol 2000 2025
16. FDA PMA P040013, GEM 21S growth-factor enhanced matrix, approved 2005-11-18
17. Papapanou PN, Wennström JL. The angular bony defect as indicator of further alveolar bone loss. J Clin Periodontol 1991

Reviewed by Steve Schadt, Director of IT and Medical Compliance: 25 years in dentistry, medicine and HIPAA compliance. Updated 2026-10-02. Checked against the sources listed. General information, not medical advice.