125. ORAL SURGERY / PERIODONTICS

# 126 RESTORATIVE / PERIODONTICS                                    

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# 125 ORAL SURGERY / PERIODONTICS

  1. Should the recommendation for third molar removal be made to every patient? Are these teeth more susceptible to periodontal breakdown? What affect does third molar removal have on the periodontium of adjacent teeth?

  1. Osborne WH, Snyder AJ, Tempel TR. Attachment levels and crevicular depths at the distal of mandibular second molars following removal of adjacent third molars. J Periodontol. 53:93-95, 1982.

  2. Kugelberg CF, et al. Periodontal healing two and four years after impacted lower third molar surgery. A comparative retrospective study. Int J Oral Surg 1990; 19: 341-345

  3. Giglio J, Gunsolley J, Laskin D, Short K. Effect of removing impacted third molars on plaque and gingival indices. J Oral Maxillofac Surg 1994; 52: 584-587

  4. Kan KW, Liu JKS, et al. Residual periodontal defects distal to the mandibular second molar 6-36 months after impacted third molar extraction. J Clin Periodontol 29:1004-1011, 2002.

  1. If patients are having maxillofacial surgery, are there any particular concerns with the periodontium about which they should be advised? Do osteotomy cuts damage the periodontium?

  1. Schultes G, Gaggl A, Karcher H. Periodontal disease associated with interdental osteotomies after orthognathic surgery. J Oral Maxillofac Surg 56:414-417,1998.

  2. Foushee D, et al. Effects of mandibular orthognathic treatment on mucogingival tissues. J. Periodontol. 56:727- , 1985.

# 126  Restorative Dentistry / Periodontics

Non-Implant Supported Fixed and Removable Prosthesis

  1. Discuss periodontist/restorative dentist interactions, especially with regard to treatment planning and maintenance. What factors are important to consider for long term success? Does the position, material or span of replaced dentition change any of these factors? What common complications are seen with fixed restorations?

  1. Maynard J., Wilson, R: Physiologic dimensions of the periodontium significant to the restorative dentist. J Periodontol 50:170, 1979

  2. Gracis, S et al: Biological integration of aesthetic restorations: Factors influencing appearance and long –term success. Periodontol 2000 27:29-44, 2001

  3. Kois, J: The restorative-periodontal interface: Biological parameters. Periodontol 2000 11:29-38, 1996

  4. Nyman S, Lindhe J. A longitudinal study of combined periodontal and prosthetic treatment of patients with advanced periodontal disease. J. Periodontol. 50:163-169, 1979.

  5. Goodacre C. et al. Clinical complications in fixed prosthodontics. J Prosthet Dent. 2003 Jul;90(1):31-41

  1. What are some considerations for the margin placement and morphology of dental restorations? How can this affect the periodontium? Can dental treatment of the coronal aspect of a tooth cause changes in the clinical attachment? In the microbial population? How does the periodontal condition of a tooth affect the restorative plan?

  1. Jeffcoat MK, Howell TH : Alveolar bone destruction due to overhanging amalgam in periodontal disease. J. Periodontol. 51:599-602, 1980.

  2. Lang N, Keil R, Anderhalden K : Clinical and microbiological effects of subgingival restorations with overhanging or clinically perfect margins. J. Clin. Periodontol. 10:563-578,1983.

  3. Pack ARC, Croxhead LJ, McDonald BW : The prevalence of overhanging margins in posterior amalgam restorations and periodontal consequences. J. Clin Periodontol.17:145-152, 1990.

  4. Rodriguez-Ferrer HJ, Strahn JD, Newman HN. Effect on gingival health of removing overhanging margins of interproximal subgingival amalgam restorations. J Clin Perio 7:457-462, 1980.

  5. Wang, H et al: The relationship between restoration and furcation involvement on molar teeth. J Periodontol 64:302-305, 1993

  6. Silness J : Periodontal conditions in patients treated with dental bridges. II. The influence of full and partial crowns on plaque accumulation, development of gingivitis and pocket formation. J.Periodontal Res. 5:219-224, 1970.

  7. Valderhaug J et al: Oral hygiene, periodontal conditions and carious lesions in patients treated with dental bridges. J Clin Periodontol. 1993 Aug;20(7):482-9.

  8. Nyman S, Ericsson I : The capacity of reduced periodontal tissues to support fixed bridgework. J. Clin. Periodontol. 9:409-414, 1982.

  9. Lee HE, Wang CH, Chang GL, Chen TY. Stress analysis of four-unit fixed bridges on abutment teeth with reduced periodontal support. J Oral Rehab 1995; 22:705-710. 

  1. Describe the crown lengthening procedure. What anatomic considerations must be taken into account? How constant is the biologic width? Is it the same for all patients? How do we determine whether or not bone or soft tissue needs to be removed? What flap design would be needed for clinical crown lengthening?

  1. Gargiulo A, Wentz F & Orban B: Dimensions and relations of the dentogingival junction in humans. J. Periodontol. 32:261-267, 1961.

  2. Barboza E et al. Supracrestal Gingival Tissue Measurement in Healthy Human Periodontium. Int J Periodontics Restorative Dent 2008,28:55-61.

  3. Perez J et al: Clinical Evaluation of the supraosseous gingivae before and after crown lengthening. J Periodontol 2007:78:1023-1030

  4. Herrero F, Scott J, Maropois P, Yukna R A. Clinical comparison of desired versus actual amount of surgical crown lengthening. J Periodontol 1995:66:568-571.

  5. Bragger, et al: Surgical lengthening of the clinical crown. J Clin Periodontol 19:58-63, 1992

  6. Pontoriero R et al: Surgical crown lengthening: A 12-month clinical wound healing study. J Periodontol 72:841-8, 2001

  7. Deas D., et al: Osseous surgery for crown lengthening: A six month clinical study. J Periodontol, 2004 Sep. 75(9):1288-94

  8. Tarnow DP, Magner AW, Fletcher P. The effect of the distance from the contact point to the crest of the bone on the presence or absence of the interproximal dental papilla. J Periodontol 1992; 12: 995-996

  1. How does esthetic crown lengthening differ from functional crown lengthening? What treatment parameters must be considered prior to surgery? What information about the final restoration is needed to correctly plan? Are there differences if restorations are involved? When is periodontal treatment not enough?

  1. Jorgensen M, Sowzari H: Aesthetic crown lengthening. Periodontol 2000 27:45-58, 2001

  2. Garber, D., Salama M: The aesthetic smile: Diagnosis and treatment. Periodontol 2000 11-28, 1996

  3. Robbins JW: Differential diagnosis and treatment of excess gingival display. Pract Periodont Aesthet Dent. 11(2):265-272, 1999

  4. Wise MD : Stability of gingival crest after surgery and before anterior crown placement. J Prosthet Dent 1985; 53: 20-23

  5. Carnevale G, di Febo G, Fuzzi M. A retrospective analysis of the perio-prosthetic aspect of teeth re-prepared during periodontal surgery. J Clin Perio 17:313-316,1990.

  1. What are the ways in which restorative materials can affect gingival tissue? How would you address changes in oral mucosa that appear soon after a restoration? What if it is a new patient and an older restoration?

  1. Dragoo MR, Williams GB : Periodontal tissue reactions to restorative procedures. Part I. Int. J. Perio. Rest. Dent. 1(1):9-24, 1981.

  2. Dragoo MR, Williams GB : Periodontal tissue reactions to restorative procedures. Part II Int. J. Perio. Rest. Dent. 2(2):35-46, 1982. 

  1. What important considerations must be taken in to account when designing RDPs for patients with periodontally compromised dentition? How does the tissue react on perio healthy patients?

  1. Petridis H, Hempton TJ. Periodontal considerations in removable partial denture treatment: a review of the literature. Int J Prosthodont. 2001 Mar-Apr;14(2):164-72.

  2. Bissada N, et al. Gingival response to various types of removable partial dentures. J Periodontol. 45:651-659, 1974.

  3. Wright PS, Hellyer PH. Gingival recession related to removable partial dentures in older patients. J Prosthet Dent 74:602-607,1995.

  4. Hansen C, Clear K, La Mar S. Removable partial denture design considerations where periodontally compromised teeth exist. Int J Periodont Rest Dent 1997; 17: 89-93.

  1. What kind of splints exist? How does splinting affect the periodontium? What is the relationship between splinting and mobility? When do we offer splinting as part of restorative treatment?

  1. Glickman I, Stein RS, Smulow JB. The effect of increased functional forces upon the periodontium of splinted and non-splinted teeth. J. Periodontol. 32:290 – , 1961.

  2. Kegel W, Selipsky H, Phillips C : The effect of splinting on tooth mobility. I. During initial therapy. J. Clin. Periodontol. 6:45- , 1979.

  3. Serio FG. Clinical rationale for tooth stabilization and splinting. Dent Clin NA 43:1-6,1999.

  1. Are tooth-retained overdentures a valid treatment option? For whom would this be a good option? What complications can be associated with this therapy?

  1. Lauciello, F Ciancio, L: Overdenture therapy: A longitudinal report. Int J Perio Rest Dent. 4:63, 1985

125  ORAL SURGERY / PERIODONTICS

  1. Should the recommendation for third molar removal be made to every patient? Are these teeth more susceptible to periodontal breakdown? What affect does third molar removal have on the periodontium of adjacent teeth?

Osborne 1982                    ARTICLE
Purpose:  To determine whether definitive root planing and curettage would influence the periodontal attachment and crevicular depth on the distal of second molars, following removal of impacted and partially erupted 3rd molars.
Materials and methods:  18 pts (18-25 years old) with similar bilateral impactions classified as either bony or soft tissue impaction or as partially erupted.  PD measured at distobuccal, mid-distal and distolingual of 2nd molars. CAL was measured from cusp tips and marginal ridge to base of pocket.  Also assessed GI and PI.  On left side (test side), the distal root of the 2nd molar was planed and the tissue curetted and sutured after extraction of 3rd molars.  On the right side (control side), neither curettage nor root planing was done following 3d molar extraction.  Measurements, indices, impressions, radiographs and clinical photographs were made pre-op, 3 months and 1 year after 3d molars removal (15/18 returned for 3 month and 1 year follow-up).
Results:  NSSD were seen in PD average (3.8 control vs. 3.4 exp.), attachment level (5.5 control vs. 4.8 exp.), GI or PI.  The results were the same for all the three classes (bony impactions, tissue impactions, and partially erupted) of third molars.
Conclusion: The results of this study support the findings of Ash that root planing of adjacent 2nd molars is of little value in reducing post-op crevice or inducing reattachment.  The best means of preserving periodontal attachment may be the removal of 3rd molars at an early stage of tooth development.

Kugelberg 1990                    ARTICLE                   perio status of second molars
Purpose: To compare the periodontal condition of the adjacent 2nd molar 2 and 4 years after impacted mandibular 3rd molar extraction with special emphasis on age.
Materials and methods:

  1. 51 subjects (23M, 28F, 17-53 years old) selected at random from the retrospective survey.

  2. The patients were examined at 2 and 4 years after impacted mandibular 3rd molar extractions for PI, GI, PD, and radiographic measurements of proximal bone level (BL) and intrabony (IB) defect depth.

  3. The patients were divided into two groups for < 25 years old and > 25 years old.

  4. Only PDs greater than 3mm were recorded. PDs were divided into two groups: 6mm, and 7mm.

  5. The intrabony defects were measured on PA xrays that were taken with and without a perio probe placed in the deepest part of the defect (standarized). The depth of the defect was measured from the CEJ to the bottom of the defect on the PA film (with the probe in place) with a transparent ruler.

Results: 

  1. NSSD in the three clinical variables between 2 and 4 years. 

  2. At 4 years, 25% of  < 25 years old group and 52% of > 25 years old group had PD of 7mm or more on the distal of 2nd molars adjacent to the extraction sites. 

  3. NSSD in height of the alveolar crest on the distal surface was observed between 2 and 4 years for either group. 

  4. SSD between both groups for the alveolar height at both examinations. 

  5. Proximal bone levels showed SS improvement in the younger group.  46% of the young patients showed a decrease in IB defects, and 54% were unchanged. 

  6. None of the younger patients had increased in (IB) defects but 30% increased in IB in the older group (15% decreased).

  7. Intrabony defects 4mm in subjects < 25 yrs were recorded in 17% of the cases 2 years post-op, while present only in 4% of the cases 4 yrs post-op. The older group were 41% after 2 yrs and 44% after 4 yrs.

  8. Mean age for decreased PD was 23.5, unchanged 27.8 and increases in the PD depth the mean was 33 years. 

  9. All deteriorated cases were >26 years and 73% of improved cases were <25 years.

BL: Younger pts have a better resolution of defects after impacted 3rd molar extractions. Periodontal healing after mandibular 3rd molar extractions is a continuing process even after 2 years in young pts. When the need for extraction of the impacted 3rd molar can be foreseen, it may bebeneficial to perform the procedure at a younger age, specifically under 25 years old

Giglio 1994                    NO ARTICLE
P: To investigate the effect of removal of partially erupted mandibular 3rd molars on the plaque & gingival indices of other teeth.
M&M: 60 pts were assigned to 3 groups. Group 1 (Ctrl) had 3rd molars congenitally missing or previously removed, group 2 had asymptomatic, partially erupted 3rd molars, and group 3 was experiencing acute pain associated with a partially erupted 3rd molar. None of the pts were under periodontal maintenance or active perio tx. PII & GI were recorded in all 4 quads before and 6 weeks after surgery. No OHI were given.
R/Disc: Both GI and Pl improved in the symptomatic group while only the Pl improved in the asymptomatic group. Neither of the test groups scored as low as the control group post-op. This could be either due to a possible bias in the ctrl group toward better OH, or to the fact that healing was not yet complete influencing the pts ability to perform proper OH. Data from the 2nd molar adjacent to the sx site was analyzed separately showing that these alone were not responsible for the mean score improvement.
BL: The removal of impacted teeth may provide some benefit in terms of improved gingival health by reducing the plaque index.
Cr: short follow-up period

Kan 2002                   ARTICLE
P: 1) describe the periodontal conditions and other associated features of mandibular 2nd molars after surgical extraction of impacted 3rd molars.
2) identify the characteristics of impaction patterns which were associated with persistent post-extraction periodontal problems of these 2nd molars.
M&M: List of patients that had undergone extraction within a 30-month period was generated from the hospital’s computerized records, in the University of Hong Kong.
Eruption pattern of the 3rd molars and patient data (gender, age, time since extraction, smoking habits and history of scaling since the extraction) were recorded.The pre-extraction panoramic radiograph was studied and the impaction pattern of the 3rd molars and the presence of a crestal radiolucency indicating loss of crestal bone between the mandibular 2nd and 3rd molar were recorded.  Community Periodontal Index (CPI) protocol and the specific clinical condition of the subject mand 2nd molar (PD, Rec, BOP, suppuration on probing (SOP), tooth mobility and furc involvement) were assessed by two calibrated examiners. Plaque control and presence of caries lesion or a restoration at distal surface of the subject tooth were also recorded.
Results: 158 were examined in the study out of the 321 cases sampled initially from the computer list. 39% of patients were men and mean age 27.7 years. 77% had never smoked, 18% were current smokers and 5% former smokers. 67% had history of scaling after extraction, 49% had left 3rd molars extraction and 65% were partially erupted. 76% were classified as mesio-angular impactions and 18% were found to exhibit crestal radiolucency on the pre-extraction radiograph. The % of subjects having a highest CPI score of 2,3 or 4 were 53%, 41% and 6% respectively. Periodontal conditions of Mand 2nd molar 6-36 months following surgical extraction of adjacent impacted 3rd molar (n=156)

Surface

PPD (mean)

Rec (mean)

D

5.4

0.8

96

5

(SOP) Suppuration on probing 

Plaque was detectable on the distal surface of 87% of subject teeth, 1% showed furcation involvement, 3% had Grade I mobility and 1% Grade II. 6% had caries on the distal and 4% restoration.
PD was correlated with plaque detection at the distal of the 2nd molar and presence of crestal radiolucency. No association between PD distal of 2ndmolar and the length of time since surgical extraction of the 3rd molars.
Conclusion: Periodontal breakdown initiated and established on the distal surface of a mandibular second molar in the vicinity of a ‘mesio-angular’ impacted third molar evidenced by pre-extraction crestal radiolucency in association with inadequate plaque control after extraction can predispose to a persistent localized periodontal problem.

  1. If patients are having maxillofacial surgery, are there any particular concerns with the periodontium about which they should be advised? Do osteotomy cuts damage the periodontium?

Schultes 1998                     ARTICLE
Purpose: To evaluate the periodontal situation near interdental osteotomies after orthognathic surgery.
Materials and methods: 
30 patients with Class II malocclusion were studied 4-10 years after orthognathic surgery and orthodontic treatment.
15 anterior maxillary osteotomies, 10 sagittal maxillary splits, 9 Le Fort I osteotomies and 8 anterior mandibular segmental osteotomies were evaluated.
10 patients received ortho before the surgery and 20 patients had orthognathic surgery only.
Panoramic and periapical radiographs were made of the osteotomy region for every patient and the periodontal status was assessed.
A reduction in bone mass of 1/3 of the root length was classified as marginal superficial periodontitis and a further reduction as profound marginal periodontitis.
Post-op tooth loss was confirmed by comparison with pre-op radiographs. Lateral root resorption at the osteotomy sites was recorded.
Results:
51 pathologic periodontal findings in the 74 segmental osteotomy sites.
Periodontal pockets were found in 35 cases and post-op tooth loss in 16 segmental regions.
Average of 1.1 teeth per patient lost because of segmental osteotomies. In addition, 1.2 teeth per segment showed severe damage to the periodontium.
Superficial periodontal lesions were found in 1.7% and deep periodontal lesions in 47.5% of the osteotomy sites. 22% of the osteotomy sites showed a loss of teeth.
Lateral root resorption was present in 15.3% of the osteotomy sites. In the ortho treated patients 7/10 showed apical root resorption of mandibular and maxillary anterior teeth.
BL: A high incidence of dental and periodontal trauma occurs in the region of segmental osteotomies after orthognathic surgery.

Foushee 1985                      ARTICLE
P: To determine if alterations in mucogingival status (recession, width of KG, width of attached gingiva) occur in mandibular anteriors and premolars in patients after chin repositioning (genioplasty)
M+M: 24 patients (12-34 years old, 18 F 6M) evaluated for Orthognathic therapy; orthodontic treatment was performed and then genioplasty with or without mandibular advancement. Pretreatment measurements only on the facial surfaces of mandibular anteriors and premolars: width of KG, PD, recession, and width of attached gingiva. Second evaluation was done between 3 months and 3 years after surgery. 21 patients analyzed statistically looking at centrals, canines, and premolars. 8 patients received maxillary Osteotomies, 6 patients had mandibular advancement, 10 patients had maxillary and mandibular surgeries. 16 / 24 had either mild or moderate gingival inflammation with no PDs > 4 mm preoperative.
R: After Orthognathic treatment: SS decrease in KG for mandibular anteriors (median change = -0.5 mm) but no change for premolars. SS decrease of attached gingival for all teeth after surgery (median change for canines and premolars = – 0.5 mm, median change for incisors= 0). 10 / 24 showed post-treatment recession (4 pts had 0.5mm or less, while 6 pts had 0.5 to 3 mm). 5/6 pts having significant recession post-treatment had mandibular advancement in addition to genioplasty.
BL: The pretreatment width of keratinized and/or attached tissue was not the critical factor in development of recession. Risk of recession increased when genioplasty was combined with mandibular advancement and occur at sites where KG and underlying bone appeared thin.
Cr: All pretreatment measurements were taken by one examiner, and all posttreatment measurements were taken by a different examiner and then they were calibrated and analyzed for agreement.

126  Restorative Dentistry / Periodontics
Non-Implant Supported Fixed and Removable

  1. Discuss periodontist/restorative dentist interactions, especially with regard to treatment planning and maintenance. What factors are important to consider for long term success? Does the position, material or span of replaced dentition change any of these factors? What common complications are seen with fixed restorations?

Maynard 1979                    ARTICLE
D: When treating patients, the objectives of restorative therapy must be clear. The first and most basic objective is preservation of the teeth. The attainment of this objective would be far less complex if it could be considered independent of restoration of function, comfort and esthetics, but such is not the case. The latter objectives usually require sophisticated restorative dentistry and often include restorations with intracrevicular margins. Although it is widely accepted that the best restorative margin is one that is placed coronal to marginal tissue, most restorations have margins in the gingival crevice, and permanent tissue damage is common. In attempting to reach his objective, the restorative dentist must remember the fundamental precept of the health professions, which is: Do no harm. Daily observation of the three physiologic dimensions permits the therapist to restore teeth with minimal injury to the periodontium.

Gracis 2001                    ARTICLE
P: To discuss factors that determines the esthetic and long term success of esthetic restorations.
D:
Anatomical consideration
Biologic Width: Many authors have highlighted the inevitability of penetrating the epithelial attachment during the prosthetic procedures without causing any irreversible damage. Therefore, nowadays, ‘‘true’’ biological width violation means the placement of a restorative margin in the connective tissue attachment.
Papilla: The height of the interproximal papilla depends not only on the bone architecture but also on the relative tooth proximity: the closer the crowns, the more accentuated the papilla because the soft tissues tend to be supported by the proximal contours of the crowns. When preparing a tooth, the tip of the bur should therefore follow the gingival margin or the anatomic
configuration of the cementoenamel junction.
Thin Biotype: More at risk of recession, place margins supragingival.
Root prominences: Must be recognized for presence of fenestrations or dehiscences,
contraindication to placing margins subgingivally.
Supra vs intracrevicular margins
Supragingival, are easier to temporize, take impressions off, allow assessment of the fit of the restoration, allow margin finishing and burnishing, and facilitate plaque removal. Intracrevicular restorations cause more periodontal problems; this might be due to defective margins, inaccurate fit, roughness of the tooth–restoration interface, improper crown contour, violation of the connective tissue attachment, and greater pathogenicity of the subgingival dental plaque.
Factors that may force the clinician to place a restoration margin intracrevicularly:
– Need to improve the resistance and retention form of a short clinical crown
– Presence of caries or restorations extending apical to the gingival margin
– Modification of the emergence profile
– Aesthetics.
Phase one should be done first, Intrasulcular preparations should be performed exclusively in presence of a healthy crevice: only when it is inflammation free is the gingival margin stable and less prone to recession and can be probed and packed more accurately. Therefore, an intracrevicular margin should be placed 0.2 to 0.5 mm apical to the free gingival
margin on the facial side. Interproximally, because the sulcus normally is deeper, the preparation can extend more apically to better support the soft tissues. Some authors suggest placing a retraction cord in the sulcus before finalizing the preparation.
This maneuver has two advantages: it highlights the base of the sulcus and therefore the ultimate limit of the preparation before causing irreversible damage, and it pushes the gingival margin outward and apically to better expose the unprepared tooth structure to be removed.
The sequence of clinical steps consists of:
– Tooth preparation to the gingival margin
– Placement of an extra-thin knitted retraction cord that displaces the gingiva outward and
apically
– Definitive margin preparation to the top of the cord achieving a new, more apical position.
Provisionals
Protect the prepared teeth, to reduce the sensitivity of the vital abutments, and to prevent tooth migration. They are also instrumental in developing the correct aesthetics, phonetics and occlusal scheme before fabrication of the definitive restoration. More importantly, well-contoured and well-fitting provisional restorations allow the periodontal tissues to stay or become healthy.
Special attention should be dedicated to the development of the proper emergence profile of the provisional prosthesis.
Impression technique
The impression technique can have a negative impact on the soft tissues around the abutments, even causing irreversible damage if the technique is not properly carried out. The objective of tissue retraction is to expose all of the prepared tooth structure and, possibly, a portion of the unprepared root beyond the margin by causing a horizontal and vertical displacement of themarginal gingiva. A single-cord technique is the least traumatic option and is normally employed when the sulcus is shallow and the margin is placed only minimally in the crevice. A double-cord technique is used when the sulcus is deeper. Root proximity may create severe problems in obtaining good impressions because there will not be enough space to accommodate the retraction cords and, subsequently, a proper thickness of impression material. The placement of cords in such restricted interproximal spaces
may cause irreversible damage. Possible solutions to this problem are: partial- instead of full-coverage restorations to
1.Avoid preparing and restoring the side of the tooth with the proximity problem
2.More apical placement of the restorative margin if the root trunk tapers apically or an
odontoplasty with a flame-shaped bur to increase the separation
3.Orthodontic movement to separate the teeth
4.Strategic extractions.
Choice of restoration depends on:
1.Tissue type,
2.Tooth vitality
3.Abutment integrity
4.Abutment height
5.Occlusal clearance for proper strength
6.Aesthetic needs of the patient
7.Parafunctional habits

Posts
Fiber posts are more esthetic, however, may flex which has been associated with loss of the cement lute marginal seal and microleakage. Metal posts are rigid but can negatively affect esthetics.

Preparation design
Preparation designs for full-coverage restorations may be classified into four distinct types:
– Feather-edge: Frequently used for gold crowns and porcelain and composite veneers, lack resistance, and can cause over contouring, use should be limited.
– Chamfer: Widely used because of ease of preparation, however, according to some authors, the thin metal collar may distort during the firing of porcelain, thus producing inaccurate margins. The visibility of the metal does not allow these crowns to be used in areas where the aesthetic demands are high
– Shoulder with bevel: It is more conservative than a full shoulder preparation, but the presence of the metal collar necessitates an intracrevicular preparation in aesthetic areas
– Shoulder: The shoulder is probably the most popular design because it is very easily read by the technician, and it allows sufficient bulk for porcelain to produce aesthetically pleasing restorations

Kois 1996                    ARTICLE
Purpose: To examine several biological parameters looking at the restorative-periodontal interface
Discussion: 

  • Bacterial plaque accumulation: Plaque retention depends on surface roughness and the surface energy of the restorative material. The short-term positive gingival response of provisional restorations may not be a good indicator of the long-term gingival health. Mechanical insults such as bands, cord and retraction clamps can disrupt JE and CTA. This might heal with a recession that will self correct in the future. Possibly prescribe CHX for 2-week regimen with OHI if indicated

  • Marginal integrity of restoration: Clinical parameters of what constitutes acceptable margin have never been established. Marginal wear or ill-fitting prosthesis might lead to gingival inflammation but not progression of perio dz. 62% of restorations have an opening of at least 200 μm, bacteria generally range from 1-5 μm. 

  • Coronal contour must mimic natural teeth. It’s unclear what the definition of over- and undercontoured actually is. As contour is increased in 0.5 mm increments to 1.5 mm greater than original tooth dimension, papillary bleeding increases. This can be a problem for both supra- and subgingival margins. Close root proximity increases the importance of interproximal contour. Slight deviations can compromise the gingival tissue. One should be able to pass an explorer through to sulcus. If not, overcontoured. 

  • Alloy sensitivity: Ni containing alloys greatest risk of hypersensitivity. Contact dermatitis is most common mode of adverse reaction.

  • Margin location: Subgingival margins tend to be worse for gingival health. Most critical factor appears to be relationship to supracrestal fiber attachment. If margin placed in biologic width, adverse long term health seen. Need to locate the base of the gingival sulcus; however, in varying degrees of inflammation, probe penetrates differently. The osseous scallop is greatest in the anterior and flattens as move to posterior. If do not follow this scallop, may violate the biologic width in one area and not another on the tooth. If the biologic width is violated, might have recession. This depends on biotype and tissue management. 

BL:The proper margin location of restoration relative to the alveolar bone is one of the critical parameter to ensure long-term gingival health

Nyman 1979                    ARTICLE
Purpose: To present the results of periodontal and prosthetic treatment of patients with advanced breakdown of the periodontal tissues.
Materials and methods: 299 individuals were divided in two groups. Group I:non-bridge treatment group (48 patients). A well-functioning dentition could be established with periodontal treatment only. Group II (251 patients): bridge treatment group. Prosthetic treatment was required subsequent to the treatment of periodontal tissues. Following the active phase of treatment, all patients were placed in a maintenance program which included recalls every 3 to 6 months. Patients of Group I have been followed up for 8 years and those of Group II for 5 to 8 years. Following initial treatment and then once a year, the following parameters were assessed: PI, GI, PD, AL, and marginal alveolar bone height. Also, the frequency of and the reasons for technical failures in the bridgework were assessed. 332 fixed bridges were analyzed.
Results: Final examination (8 year follow-up for Group I and 5 to 8 years for Group II) revealed that both groups maintained low plaque scores and gingival indices. In none of the treatment groups, PDs varied in a significant way during the course of the study. Bone level was maintained unchanged in both groups. The analysis of the 332 bridges regarding frequency and reasons for bridge failures revealed:  1) Loss of retention of retainer crowns from abutment teeth (11 bridges, 3.3%), 2) Fracture of bridge (7 bridges, 2.1%), 3) Fracture of abutment tooth (one tooth in 8 bridges, 2.4%).
Conclusion: Following periodontal treatment, periodontal health can be maintained in patients enrolled in a controlled OH program. Supportive periodontal therapy (SPT) in this study was equally effective for patients with bridge work. Severe reduction of periodontal support around abutments and differences in bridgework design did not influence the periodontal status. However, technical failures occurred in 26 out of 332 bridges. These failures appeared as loss of retention, fracture of bridgework, and fracture of abutments.

Goodacre 2003                    ARTICLE
Purpose: To identify the incidence of complications and the most common complications associated with single crowns, FPDs, all-ceramic crowns, resin-bonded prostheses, and posts and cores.
Materials and methods:
Medline and extensive hand search covered the last 50 years and focused on publications that contained clinical data regarding success, failure, and complications.
Results:
Most common single crown complications

Mean Incidence

Need for endodontic treatment

Porcelain Fracture

Loss of retention

Periodontal Disease

Caries

Most common fixed partial denture complications

Mean Incidence

Caries

18% of abutments / 8% prosthesis

Need for endodontic treatment

11% of abutments / 7% prosthesis

Loss of retention

Esthetics

Periodontal disease

Tooth fracture

Prosthesis Fracture

Porcelain Veneer fracture

Most common all -ceramic crown complications

Mean Incidence

Fracture

Loss of retention

Pulpal health

Caries

Periodontal disease

0.0% No significant changes

Most common resin-bonded prosthesis complications

Mean incidence

Debonding

Tooth discoloration

Caries

Porcelain fracture

Periodontal disease

0.0% No significant changes

Most common post and core complications

Mean incidence

Post loosening

Root fracture

Caries

Periodontal disease

  1. What are some considerations for the margin placement and morphology of dental restorations? How can this affect the periodontium? Can dental treatment of the coronal aspect of a tooth cause changes in the clinical attachment? In the microbial population? How does the periodontal condition of a tooth affect the restorative plan?

Jeffcoat 1980                    ARTICLE                           amalgam overhangs
P: Examine the effects of overhanging amalgams on the alveolar bone height in patients with periodontal disease.
M&M: Examined records of 4600 patients screened for Overhangs. 100 selected with contralateral controls (no overhangs). Overhangs classified as small (occupies< 20% interproximal space), medium (20-50%), large (> 50%). Patients classified as to perio Class I-IV (ADA). Bone loss compared to control measured from CEJ to crest divided by root length using
radiographs.

R:  71% greater bone loss on overhang side vs. control. Small overhangs did not result in SSD vs. control but larger overhangs result in more bone loss. For each periodontal disease type the bone loss around the experimental teeth exceeded the control (5.6% for class I, 6.7% for class II, 12% for class III).
BL: Bone loss from overhanging amalgams is due to plaque retention and inflammation due to impingement of the embrasure space

Lang  1983                    ARTICLE
P: To determine if placement of subgingival restorations with overhanging margins results in change in the subgingival microflora.
M&M: 9 dental students with gingival index scores < 0.1 (pts had SRP and OHI first) requiring 10 gold MOD onlays for caries control. All MOD onlays preps were made with margin 1.0 mm subG;. Each tooth had 2 restorations fabricated: one with clinically perfect margins and one with 1.0 mm proximal overhangs. In a cross-over study, half of the teeth (5) had onlays w/1 mm proximal overhangs for 19-27 weeks that  were then replaced by 5 onlays with perfect margins. Another 5 teeth had onlays with perfect margins placed first (8-24 wks) which were then replaced with the 1 mm overhang MOD onlays (12-27 wks). Patient cleaned normally, except NO IPx cleaning at the site of the onlays. Prior to and every 2-3 weeks after insertion, PI, GI, subG microbiological samples (paper point) and PD to the level of the proximal margin of gold onlay were recorded..
R/D: Without overhangs, no increase in BOP at sites (if overhangs placed first, by the end of 2nd experimental period BOP had resolved). With overhangs, both groups by end of experimental period were at 100% BOP and GI of 2 or 3. For PD, as GI increased, so did the measurement to the FGM. There was no change from margin to base of sulcus (pseudopocketing with inflammation). With overhangs; there no change in the amount of plaque found subG, but rather the subgingival flora began to resemble chronic perio, w/ increased Gram – anaerobic bacteria, black pigmented Bacteroides (1.6%-3.8%) and increased anaerobe facultative ratio. With clinically perfect margins a microflora characteristic of health or initial Gingivitis was observed. Pts individually had different time frames for developing this flora, indicating host resistance/susceptibility.
BL: Placement of restorations with overhanging subgingival margins result in a change of subgingival microflora to one that may be associated with periodontitis, which documents a potential mechanism for iatrogenic initiation of periodontal disease. Host susceptibility plays a role in the time frame of how long it took to shift to a more peridontopathic microflora

Pack 1990                    ARTICLE
P: To determine prevalence of overhanging margins and associated periodontal status in 100 patients with completed treatment by final year dental students.
M&M: 100 subjects. PD, BOP, and clinically detectable margins recorded on all posterior teeth, and BWs were taken. No attempt to determine size of overhangs.
R: 1319 teeth with 2117 restored surfaces were examined.
– Prevalence: 1186 restored surfaces (56%) had overhangs, 62% of all restored interproximal surfaces
– 62% of distal, 60% mesial, 35% buccal, and 40% of lingual restorations had overhanging margins
– 69% of distal, 54% of mesial restorations next to the edentulous space had overhanging margins
– PDs > 3 mm: 64.3% of overhangs, 23.1% for unrestored surfaces, and 49.2% for non- overhanging restorations
– BOP, 32% of pockets adjacent to overhangs bled on probing, 10.5% for un-restored and 21.6% for non-overhangs.
BL: Periodontal disease was more prone in the presence of poor margins. These overhangs significantly affected the periodontal status of the teeth.

Rodriguez-Ferrer 1980                    ARTICLE
Purpose: To resolve the influence of removal of subgingival overhanging margins on the healing of gingival tissues and to determine whether it should be carried out at the beginning or at the end of the initial phase of periodontal treatment.
M&M: 15 pts with early to advanced periodontitis and 52 proximal surfaces that had confirmed overhanging restorations (amalgam) after removal of subgingival calculus were selected. Test group: 26 overhangs were removed at the first visit (no palpable transition between tooth surface and restoration). Control group: 26 contralateral-paired overhangs were left untreated. Every surface was scored for GI, PI, and PD at 0, 4, 8, 12 wks. Pts received OHI and performed Bass technique, flossing, toothpick and a proxy brush.
Results: After initial exam, NSD was observed in any parameters between test and control groups. By 12 weeks there was a SD for all indices except PD comparing test and control. The greatest change in gingival responses was seen in the first four weeks. Many of the restorations became supragingival as the marginal tissues responded to therapy.
BL: Gingival inflammation is a constant finding in areas related to Class II subgingival amalgam restorations with overhanging margins. Gingival inflammation is due to plaque accumulation in relation to overhangs, which impedes OH. Overhangs should be removed as soon as possible during initial phase of periodontal treatment.

Wang 1993                    ARTICLE
P: Cross sectional study The primary aim was to determine the relationship of crowns, proximal restorations and furcation involvement, and Secondarily was to evaluate the influence of the tooth mobility and endo treatment.
M&M: 134 perio maintenance pt (62 M and 72 F) that had restored and non-restored teeth with or w/o furcation involvement on molar teeth. Most of the restoration margins were supragingival and placed about 5 years prior to the study. 1st and 2nd molar were examined for the absence of presence of crown type restorations, restorations involving proximal surface, endo tx, furcation involvement, mobility, AL.
Results: 373 of 771 Molars had furcation involvement and 362 had restorations or crowns. 113 were mobile and 37 had RCT. So, molars with crown or restoration had higher prevalence of furc involvement (P<0.01).
 Loss of attachment associated with restorations was marginal(p=0.051), with more loss shown in the maxilla. The diff in AL b/w restored and non-restored molars occurs mostly in the maxillary arch
BL: pts w/ crowns or interproximal restorations are more likely to have furcation involvement and more CAL loss even undergoing regular maintenance.
-self critique: causality cannot be shown by X-sectional studies

Silness 1970                    ARTICLE
P: To compare the periodontal condition of abutments and contralateral teeth in patients with
full and partial crowns used for retaining dental bridges.
M&M: 261 individuals, 242 abutment teeth were compared with 242 contralateral teeth in the same patients. Patients were divided into groups depending on receiving periodontal treatment and OHI or not, location of crown margins (sub-g and no sub-g) and type of crowns (full or partial). Instructed group (159 individuals): this group had received periodontal treatment, OHI instructions and reinforcement 2-6 years before the examination. Non-instructed group (102 individuals): this group had received no periodontal treatment and no OHI. So 4 groups were formed: 1) GROUP I: non-instructed patients, full crowns with sub-g margins, 2) GROUP II: instructed patients, full crowns with sub-g margins, 3) GROUP III: instructed patients, full crowns with no sub-g margins, 4) GROUP IV: instructed patients, partial crowns with no sub-g margins. GI, PI, PD and margin index (position of margin in relation to crest) were recorded.
R: Abutments with complete crowns with full coverage and sub-g margin showed larger
amount of deposits, more severe gingivitis and increased PD compared to contralateral teeth
whether or not patients were instructed on oral hygiene. In instructed patients, the periodontal
condition of abutments with complete or partial crowns with limited coverage and no sub-g margin did not differ significantly from those of control teeth.
BL: Abutment teeth with crowns with subgingival margins are associated with more severe
gingivitis, deeper PD, and increased accumulation of plaque, compared to the uncrowned
contralateral teeth even in patients who were instructed in oral hygiene methods.

Valderhaug 1993                    ARTICLE
P: The aim of the present study was to assess the level of oral hygiene, periodontal conditions, changes of alveolar bone level and prevalence of caries in a group of patients who had received regular oral prophylaxis following the insertion of fixed partial dentures. Differences of these indices when the crown margins initially were located sub-gingivally, at the gingiva or supragingivally were also recorded.
M&M: 102 patients received a total of 108 cast gold or gold/acrylic bond bridges on 343 abutment teeth. The rest of the teeth on the same jaw that received the restorations served as controls. Clinical and radiographic exams were done at baseline, 5, 10, 15 yrs. PI, GI, PD, were measured. Margins placed >1m below the gingival margins were considered sub-gingival. Bone loss was measured to the nearest 0.5mm. Maintenance was offered every 6 months for the first 10 years. Statistical analysis was done.
R: Data at 5 (88 pts), 10 (71 pts) and 15 years (55 pts) recorded. 16 pts had a new bridge made or extraction of an abutment tooth over time (15.7%). There was NSSD for PI between test and control. Pi increased for 21% to 27% during the 15 year observation period. GI 2 and 3 was more frequent on abutment teeth than control, and more frequent on crowns with sub-gingival margins. A slight increase in PD was observed at 5- years at the teeth with sub-gingival margins. At baseline, 79% of surfaces had PD <2mm, 4% had PD >4mm. At 15 years, 57% of sites were <2 mm, while 3% were >4mm. Buccal surfaces had always shallower PDs than the other 3 surfaces. Sub-gingival crown margins decreased from 64% at baseline to 36% at 15 yrs (more pronounced on buccal). Caries were recorded at 3.3% of the abutment teeth at 5th year, 10% at 10th year, and 12% at 15th year. NSSD in bone loss could be detected between the test and control teeth or between the different crown margins locations.
BL: patients who were seen for regular OH maintained healthy periodontal conditions and relatively low caries. Many subgingival margins were seen at the gingiva or supragingivally after 10 or 15 yr.

Nyman 1982                    ARTICLE
Purpose: To compare the calculated size of the PDL around abutment teeth with the size

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151-152. Furcation Therapy

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Rapid Search Topics:

Discuss the etiology, incidence, and distribution of furcation invasions. Discuss the diagnosis and prognosis of furcation invasions by tooth type and compare to single rooted teeth. What role does root anatomy play in the etiology and management of furcation defects?

  1. Waerhaug J. The furcation problem. Etiology, pathogenesis, diagnosis, therapy, and prognosis. J Clin Periodontol 7:73-95, 1980.

  2. Ross IF, Thompson RH: Furcation involvement in maxillary and mandibular molars. J. Periodontol. 51:450-454, 1980.

  3. Dunlap RM, Gher ME. Root surface measurements of the mandibular first molar. J Periodontol56:234-238, 1985.

  4. Gher MW Jr, Dunlap RW. Linear variation of the root surface area of the maxillary first molar. J Periodontol.1985;56(1):39-43.

  5. Hou G, Tsai CC. Types and dimensions of root trunk correlating with diagnosis of molar furcation involvements. J. Clin. Periodontol. 1997; 24: 129-135

  6. Ward C, Greenwell H, Wittwer JW, Drisko C. Furcation depth and interroot separation dimensions for 5 different tooth types. Int J Perio Rest Dent1999;19:251-257.

  7. PaolantonioM, Placido M, Scarano A, Piatelli A. Molar root furcation: Morphometric and morphologic analysis. Int J Perio Rest Dent 1998;18:489-501.

  8. Ross IF, Evanchik PA: Root fusion in molars: incidence and sex linkage. J Periodontol52:663-667,1981.

  9. Hou G, Tsai C, Huang J. Relationship between molar root fusion and localized periodontitis.J Periodontol 1997; 68: 313-319

  10. Bjorn AL, Hjort P: Bone loss of furcated mandibular molars. A longitudinal study. J. Clin. Periodontol. 9:402-408, 1982.

  11. Tal H: Relationship between the depth of furcal defects and alveolar bone loss. J Periodontol 53: 631-634, 1982.

  12. Mealey BL, Neubauer MF, Butzin CA, Waldrop TC. Use of furcal bone sounding to improve accuracy of furcation diagnosis. J Periodontol1994;65:649-657

  13. Wang HL, Burgett FG, Shyr Y. The relationship between restoration and furcation involvement on molar teeth. J Periodontol 1993;64:302-305.

  14. Joseph I, Varma BR, Mahalinga BK. Clinical significance of furcation anatomy of the maxillary first premolar: a biometric study on extracted teeth. J Periodontol 1996;67: 386-389.

  15. Booker BW 3rd, Loughlin DM. A morphologic study of the mesial root surface of the adolescent maxillary first bicuspid. J Periodontol. 1985 Nov;56(11):666-70.

  16. Howell MM, Cassingham RJ, Yukna RA. Relationship of maxillary molar root angulation and palatal vault height. J Periodontol. 57:25-28, 1986.

  17. Muller H-P, Eger T. Furcation diagnosis. J Clin Periodontol 1999;26:485-498.(Review)

Describe Cervical Enamel Projections (CEPs), their classification and discuss their correlation with furcation involvements.

  1. Masters DH, Hoskins S. Projections of cervical enamel in molar furcations. J Periodontol 35: 49-53, 1964.

  2. Machtei EE, Wasenstein SM, Peretz B, Laufer D. The relationship between cervical enamel projection and class II furcation defects in humans. Quintessence Int. 1997;28:315-320.

  3. Hou G-L, Tsai C-C. Cervical enamel projection and intermediate bifurcational ridge correlated with molar furcation involvements. J Periodontol1997;68:687-693.

FURCATION MANAGEMENT

Discuss debridement, tunneling and root amputations/hemisections for furcation management.

Debridement

  1. Bower RC: Furcation morphology relative to periodontal treatment – furcation entrance architecture. J. Periodontol. 50:23-27, 1979.

  2. Bower RC, Thompson R.: Furcation morphology relative to periodontal treatment – furcation root surface anatomy. J. Periodontol. 50:366-374, 1979.

  3. Otero-Cagide FJ, Long BA. Comparative in vitro effectiveness of closed root debridement with fine instruments on specific areas of mandibular first molar furcations. I. Root trunk and furcation entrance. J Periodontol1997;68:1093-1097.

  4. Otero-Cagide FJ, Long BA. Comparative in vitro effectiveness of closed root debridement with fine instruments on specific areas of mandibular first molar furcations. II. Fucation area. J Periodontol1997;68:1098-1101.

Tunneling

  1. Hellden LB, Elliot A, Steffensen B, et al. The prognosis of tunnel preparations in treatment of Class III furcations, a follow-up study. J. Periodontol. 60:182-187, 1989.

  2. Rudiger SG. Mandibular and maxillary furcation tunnel preparations – literature review and a case report. J Clin Periodontol 2001;28:1-8.

Root Amputation/Hemisection

  1. Carnevale, G., Pontoriero, R., Di Gebo, G: Long-term effects of root respective therapy in furcation – involved molars. A 10-year longitudinal study. J Clin Periodontol 25:209-214, 1998

  2. FugazzottoP., A comparison of the success of root resected molars and molar position implants in function in private practice: Results of up to 15 plus years. J Periodontol 2001 Aug; 72(8):1113-23

  3. Kinsel, R., et al: The treatment dilemma of the furcated molar: Root resection versus single-tooth implant restoration. A Literature review. Int J Oral Maxillofac Impls 13:322-332, 1998.

Review

  1. Cattabriga M, Pedrazzoli V, Wilson, Jr. TG. The conservative approach in the treatment of furcation lesions. Periodontol 2000 2000;22:133-153. (Review)

Is chemical root treatment of benefit in furcation therapy?

  1. Parashis AO, Mitsis FJ. Clinical evaluation of the effect of tetracycline root preparation on guided tissue regeneration in the treatment of Class II furcation defects. J Periodontol 1993; 64:133-136.

How successful are the use of barrier for furcation tx?

Furca Treatment – Barriers – Non-resorbable

  1. PontorieroR, et al. Guided tissue regeneration in degree II furcation -involved mandibular molars. A clinical study. J. Clin. Periodontol15:247-254, 1988.

  2. PontorieroR, Lindhe J. Guided tissue regeneration in the treatment of degree II furcations in maxillary molars. J Clin Periodontol 1995:22:756-763.

  3. Mellonig JT, Seamons BC, Gray JL, Towle HJ. Clinical evaluation of guided tissue regeneration in the treatment of grade II molar furcation invasions.Int J Perio Rest Dent 1994;14:255-271

  4. Pontoriero R, et al. Guided tissue regeneration in the treatment of furcation defects in mandibular molars. A clinical study of degree III involvements.J Clin Perio 16:170-4,1989.

  5. PontorieroR, Lindhe J.Guided tissue regeneration in the treatment of degree III furcation defects in maxillary molars.J Clin Periodontol. 1995 Oct;22(10):810-2.

Furca Treatment – Barriers – Absorbable

  1. Yukna CN, Yukna RA: Multi-center evaluation of absorbable collagen membrane for guided tissue regeneration in human Grade II furcations. J Periodontol1996; 67: 650-657.

  2. Hugoson A, Ravald N, Johard G, Teiwik A, Gottlow J: Treatment of class II furcation involvements in humans with bioresorbable and nonresorbable guided tissue regeneration barriers. A randomized multi-center study. J Periodontol 1995, 66:624-634.

  3. Rosen PS, Marks MH, Bowers GM. Regenerative therapy in the treatment of maxillary molar class II furcations: Case reports. Int J Perio Rest Dent1997;17:517-527.

Discuss the relative long-term effectiveness of various treatment modalities in the management of furcation invasions.

  1. Hamp SE, Nyman S, Lindhe J. Periodontal treatment of multirooted teeth. Results after 5 years. J Clin Periodontol. 1975; 2:126-135

  2. Kalkwarf KL, Kaldahl WB, Patil KD: Evaluation of furcation region response to periodontal therapy. J. Periodontol. 59:794-804, 1988.

  3. Muller H-P, Eger T: Managment of furcation-involved teeth. A retrospective analysis. J Periodontol 1995:22:911-917.

  4. Evans GH, Yukna RA, Gardiner DL, Cambre KM. Frequency of furcation closure with regenerative periodontal therapy. J West Soc Perio (Perio Abstracts) 1996;44:101-109 (Review)

Discuss the etiology, incidence, and distribution of furcation invasions. Discuss the diagnosis and prognosis of furcation invasions by tooth type and compare to single rooted teeth. What role does root anatomy play in the etiology and management of furcation defects?

Waerhaug 1980                     ARTICLE

Purpose: To find out to what extent functional forces and subgingival plaque are involved in the etiology of the furcation involvement, and furthermore, whether or not marginal gingivitis and increased mobility reflect the degree of loss of periodontal attachment.

Materials and methods: 34 max and 12 mand molars with furcation were extracted due to advanced destruction of the periodontal tissues in the furcation area. 20 single roots from molar root resections were also included. All patients had been under periodontal treatment for a few months to several years (sub-g scaling and/or periodontal surgery), and had good OH. Prior to extractions the teeth where evaluated for PI, GI, and mobility. Premature contacts were identified. A landmark was made on the tooth surface at the gingival margin. Following extraction, the teeth were stained and examined under the stereomicroscope. The attachment loss was measured on the different surfaces of the roots with a translucent measuring device with 11 diverging lines.

Results: Gingivitis was found adjacent to 27% of the surfaces, supragingival plaque was present on 26% of them, on 39% of the surfaces there was sub-g, but not supra-g plaque. The average attachment loss was 47.3% on the outer surfaces and 62.8% on those facing the furcation. The average loss of attachment on the outer surfaces was 47.7% in the gingivitis group and 48.2% in the non-gingivitis.

Correlation between downgrowth of sub-g plaque and attachment loss

Distance from the front of the plaque mass (plaque front) to the attachment fibers: average distance 0.8mm on outer surface (0.2-2.4) and average distance 0.91mm on surfaces facing the furcation (0.2-4). 34 teeth exhibited normal mobility and the average loss of attachment was 41% on outer surface and 52% on surface facing furcation. 18 teeth were slightly mobile and average loss of attachment was 47% and 64% respectively. Premature contacts in CO were observed in 26% of teeth and most patients gave a positive answer to the question “has the teeth ever been tender or sore”. BOP and pain on probing were clearly less common in pockets without plaque.

DISC:Conditions below the gingival margin are extremely difficult to predict from clinical examination. Subgingival plaque is common even in the absence of supragingival plaque in patients who have started efficient supra-g plaque control after supra-g plaque has formed. Subgingival plaque may cause an undetectable submarginal gingivitis and lead to attachment loss and furcation involvement. The pathogenesis of attachment loss in furcations is associated with the down growth of subgingival plaque. Supragingival plaque control is ineffective in pockets greater than 3 mm (i.e. supragingival plaque control is effective to 2.5 mm). Surgical elimination of deep pockets is necessary (greater than 3 mm). Mobility and attachment loss do not support the assumption that functional forces are involved in the etiology of furcations. Mobility is the result of attachment loss, not the cause and appears late in the development of furcations.

Conclusion-Until now common solution to furcation problem has been extraction. With the knowledge about its etiology, it should be possible to prevent its development and to some extent treat established cases.

Ross 1980                     ARTICLE                               incidence and distribution of furcation involveme

Purpose: To examine, compare, and evaluate furcation involvement in maxillary and mandibular molars.

Materials and methods:

  • 615 molars of 72 patients (47 F, 25 M, 25-71 yrs old) with generalized chronic periodontitis were examined for age, sex, # of molars present, # of molars with furcation involvement (FI) detected radiographically and clinically, # of molars without FI, # of molars treated surgically.

  • Inclusion criteria:

  • At least one maxillary or mandibular molar with radiographic or clinical evidence of FI

  • The molar w/ FI must be in contact with at least one opposing molar during vertical and horizontal mandibular movements.

  • There must be at least 3 max molars w/ or w/o FI, a minimum of two in one quadrant and one in the contralateral quadrant.

  • At least 3 mandibular molars w/ or w/o FI, a minimum of two in one quadrant and one in the contralateral quadrant.

  • Treatment varied, but in no instance, was osseous surgery performed.

Results:

  • FI is a common occurrence: 90% in the maxillary, 35% in the mandibular.

  • FI 3X more frequently in the max molars.

  • Teeth w/ FI functioned well for a long period of time (5-24 years).

  • FI in max molars is detected more frequently by RAs, while in mandibular molars it is detected more frequently by clinical exam.

Maxillary

Mandibular

FI by radiographic and clinical eval

FI by radiographic eval only

FI by clinical examination only

No FI by radiographic or clinical exam

BL: Furcation involvement is a common occurrence and both radiographs and clinical exams should be performed to detect its presence. Prognosis and treatment should be based upon many factors, not just the presence of furcation. Furcation involvement should not condemn a tooth to an unfavorable prognosis.

Dunlap 1984                     ARTICLE

P:To determine the linear variation of Root Surface Area (RSA) in 1- mm increments from the CEJ to the apex for the mandibular 1stmolars

M&M:20 extracted mandibular 1st molars. Coronal and apical sides of the sections were photographed and the circumference from the root was measured. Teeth with fused root sand obliterated CEJs due to caries or restorations were excluded.

R: The largest RSA and % total RSA values were located 4 to 7 mm apical to CEJ. 48.7% of the RSA was located in the coronal 6mm of total root length root (mean length 14.4mm). Root separation occurred 4 mm apical to CEJ with no teeth having a root trunk longer than 6mm. B and L root concavities were first present 0.7mm and 0.3mm apical to CEJ, respectively. The mean RSA of the mesial root was SSD greater than the distal root and both had greater RSA than the root trunks. Distal roots were always more conical in shape than mesial roots.70% of the teeth had an intermediate bifurcation ridge.

BL:Horizontal attachment loss of 5- 6mm affecting both B and L surfaces of mandibular 1st molars can result in a through and through furcation involvement.

Gher 1984                     ARTICLE                            location of furcation entrances

Purpose:To determine the variation of root surface area in 1mm increments from the CEJ to the apex of max 1st molar. Locations of furcation entrances, root separations and the roof of furcations were also determined.

Materials and methods: 20 maxillary molars were selected, only teeth with fused roots were excluded. After preparation teeth were sectioned in 1-mm increments and root surface area (RSA) for each section was determined.

Results/BL:Mean root length 13.6mm (10.5-16mm) and mean RSA 477mm2.

Maxillary first molar – mean distances of root structures apical to the CEJ

Furcation entrances

Root separations

Furcation root

Mesial 3.6 ± 0.8

Facial 4.2 ± 1.0

Diatal 4.8 ± 0.8

Mesiobuccal 5.0 ± 0.7

Distobuccal 5.5 ± 0.8

4.6 ± 0.6

17/20 teeth had the roots separated with 6mm from the CEJ.

% of RSA increased significantly in the furcation area from 7.53% to 8.8-10.1%.

11/20 teeth demonstrated dome or concavities in the roofs of the furcations and the other 9 teeth a trifurcation ridge.

Hou 1997                     ARTICLE                            furcation anatomy and dimensions

Purpose: To investigate the effect of vertical dimension & types of root trunks on the vertical & horizontal bone losses in molar furcations.

Materials and methods:

  • Extracted teeth: 70 mx 1st molars, 96 mx 2nd molars, 103 mn 1st molars, 97 mn 2nd molars. Measurements of mx molars included vert height of buccal root trunk (BRT), mesial root trunk (MRT), & distal root trunk (DRT). Mn molars –BRT & LRT (lingual). Classified as:

  • Type A –root trunk involving cervical 1/3 or less of root length;

  • Type B-cervical 1/3 to ½;

  • Type C-cervical 2/3 or greater.

Results:

Max 1st molar

Mand 2nd molar

Mand 1st Molar

Max 2nd Molar

Type A

20.85%

83.5%

38.1%

Type B

47.1%

60.8%

15.5%

52.6%

Type C

11.9%

18.4%

BL: Longer root trunks are more common on 2nd molars than 1stmolars

Ward 1999                     ARTICLE

P: To document mean, SD, & range of furcation depth & inter-root separation of 5 multi-rooted tooth types.

M&M: 273 multi-rooted teeth examined:Max 1st & 2ndM,1st PM & Mand 1st & 2nd M. No restorations into the furcation, no fused roots. Furcation measured at level of the furc dome, then 3 & 5 mm apical to it. Inter-root separation measured 3 & 5 mm apical to the dome. Teeth were examined using telescopic lenses with 2.6x magnification.

R:

Furcation Depth (mm)

Mean ± SD

Mean ± SD

Mean ± SD

Max

1stM

2ndM

1stPM

Buccal at dome

7.48± 0.85

6.69 ± 1.02

M-D at dome

6.67 ± 0.52

5.94 ± 0.48

3.54 ± 0.48

Mand

1stM

2ndM

B-L at dome

7.96 ± 0.68

7.46 ± 0.74

Inter-root Separation (mm)

Mean ± SD

Mean ± SD

Mean ± SD

Max

1stM

2ndM

1stPM

B 3 mm apical to dome

2.58 ± 0.61

1.92 ± 0.60

M 3 mm apical to dome

4.17 ± 0.67

3.89 ± 0.86

2.47 ± 0.55

D 3 mm apical to dome

4.48 ± 0.81

4.04 ± 0.79

2.58 ± 0.68

Mand

1stM

2ndM

B 3 mm apical dome

3.15 ± 0.56

2.54 ± 0.59

L 3 mm apical dome

2.95 ± 0.74

2.75 ± 0.60

D: Furc depth ↓ in an apical direction, except for the buccal furcation of max molars, due to flaring of the palatal root. In regenerative healing, this means that as vertical entrance height ↑, the amt of bone ↓. Since root tapers in apical direction, root circumference ↓, decreasing the amt of PDL cells available to re-populate the wound. For max molar buccal furcation, the amt of bone ↑ w/ increasing vertical height, but the amt of PDL cells ↓, due to apical root tapering.

Inter-root separation increased from the dome to 3 then 5 mm except for the lingual of mand 2nd M, due to convergence b/w the mandibular roots in this area (pincher-like curvature)

BL:Height, width & depth of furcation differ for each furcation. As such, optimal conditions for GTR are different for every furcation. Additional research needed to find critical furcation dimensions for GTR.

Paolantonio 1998                      ARTICLE

P:Morphometric and morphologic analysis of maxillary and mandibular first and second molars using three different techniques.

M&M:207 maxillary molars (105 first and 102 second molars) and 207 mandibular molars (110 first and 97 second molars) were measured; root length, radicular trunk length (RTL), mesiodistal(MDD) and buccolingual diameters (BLD) at the CEJ, inter-radicular angle (IRA**) width, and furcal roof area (FRA) were recorded.

Morphologic examination was carried out by stereo microscopy, light microscopy of undecalcified sections, and scanning electron microscopy.

R:Morphometric:

  • IRA width decrease from 1M to 2M in both arches, more pronounced in maxilla.

  • FRA is wider in 1M.

  • 1M longer roots & shorter radicular trunks than 2M.

  • MDD & BLD are greater in 1M.

  • + correlation FRA/IRA for each molar.

  • + correlation BLD/IRA in both max M.

  • inverse correlation IRA/RTL in max 1M.

  • NSS correlations for the other measurement.

Morphologic:

  • Width of furca entrance.

  • Long RT .

  • Concavities internal of roots in mandibular M and M-B root of maxillary M.

  • Furca roof, narrow and irregular shape dimples, holes & crevices.

  • Furca canal orifices coming out into larger depressions.

CL:This study showed the complexity of the furcation area with a large number of anatomic irregularities and plaque-retentive structures that could hamper adequate cleaning during periodontal treatment.
IRA**: this measure was assessed by drawing a line in the center of the cervical third of each root and measure the value of the angle between each pair of lines with a goniometer.

Ross and Evanchik 1981                     ARTICLE                   incidence and distribution ofroot fusion

P:to report the incidence and distribution of root fusion in molars.

M&M:Radiographic examination of 1340 molars from 170 patients. Any molar that had one root or whose roots were fused apical to the usual furcal position was considered a molar with fused roots.

R:Frequency of molar fusion

First molars

Second molars

Third molars

Overall

Maxillary

Mandibular

52.4%

Overall 29% of all molars were fused and 71% non-fused. Fusion occurs bilaterally with equal distribution. Females have more root fusion than males. Root fusion was more common in the maxilla (35%) than the mandible (24%). Furcation can be an important factor in determining the prognosis of a tooth. Usually these roots are shorter (contribute to an unfavorable crow-root ratio) and more likely to become mobile.

BL:29% of all molars had fused roots. Root fusion was more common in the maxilla and more from post to ant (3rd M > 2ndM > 1st M)

Hou 1997                     ARTICLE

P:  To examine the relationship between molar root fusions and localized periodontal disease.

M&M:  143 individuals (1109 molars) aged 23-68 years were examined for molar root fusion at diseased and healthy sites by periapical radiographs and clinical probing.  PD, CAL, GI, and Pl were measured. The molars with root fusions, intact marginal alveolar crest, and CAL ≤ 5mm was considered healthy.

R:  The prevalence of molar root fusions in males was 15.2% vs. 32.2% in females.  Max 2nd molars (51.8%), mand 2nd molars (32.3%), max 1st molars (5.7%), and mand 1st molars (0%).  Prevalence of root fusion in max molars is 28.7% and mand molars is 16.7%.  SSD was observed in GI, CAL, PD and Pl between diseased and healthy sites.  97.5% had bilateral symmetry of fused roots.  A majority of the diseased molars with root fusion exhibited deeper developmental grooves than the healthy molars.

BL: Females tend to have a higher rate of molar root fusion.  Deep developmental grooves and the less resistance to heavy occlusal loads and/or torque forces enhance the possibility of localized periodontitis at molars with root fusion

Bjorn 1982                     ARTICLE

Purpose:To obtain information on the prevalence of interradicular bone destruction in mandibular molars as well as the fate of involved molars in a population not included in any periodontal treatment program.

Materials and methods: 221 staff members of an industrial company in Sweden were utilized. Panoramic radiographs and bite-wings were examined. Furc involvement was diagnosed when there was visible interradicular bone destruction.

No clinical examination was performed. The amount of radiographic bone loss was estimated using a plastic ruler and classified in 5 categories:

  • 0no bone loss

  • 10-25%

  • 225-50%

  • 350-75%

  • 4more than 75%
    The total observation period was 13 years.

Results:The mean number of mand. molars/patient was 3.5 in 1965 and 3.3 13 years later. 15 individuals had lost all the remaining molars. The frequency of molars with interrradicular periodontitis increased from 18% to 32% during the study period.

9.5% of the furcated molars observed at the first examination was lost, 2.5% because of periodontal disease.

2ndand 3rd molars exhibited increased bone loss when compared to the 1st molars. The severity of bone loss increased with age.

Conclusion: Furcation involvement has evidently not played any dominant part in the loss of mandibular molars during this 13-year observation period. This does not imply that furc. involvement may not in the long rung jeopardize the retention of a tooth.

Tal 1982                     ARTICLE

Purpose: To determine whether there is any relationship between the depths of furcal defects and the amount of alveolar bone loss on the buccal and lingual aspects of 1st and 2nd molars in dry mandibles

Materials and methods:

  • 100 dry mandibles of South African tribe members of known sex, tribe and age (20 in each decade, between third and seventh decade; since no dental treatment on these skullsassume no OH education). The depths of furcal defects and the distances between the CEJ and alveolar bone crest were measured on 245 lingual and 235 buccal surfaces of 246 1st and 2nd molars; Class III FI excluded.

Results:

  • High correlation between depth of furcal defects and distance between the CEJ and alveolar crest, w/ higher correlation for first molars than for second molars.

  • For the same degree of vertical bone loss, buccal furcation defects are deeper than the lingual, and buccal furcation defects on 1stMolars are deeper than those on 2nd Molars.

BL: Bone loss is greater on the facial than the lingual and is greater in 1st molars. Also, when 5-6 mm probing depths are present, one should suspect a class III FI. The elimination of furcation disease is essential to the success of periodontal therapy. Detection of furcation involvement is an essential part of any complete oral examination.

Mealey 1994                     ARTICLE

P:To compare vertical and horizontal measurements of furcation invasions taken by probing prior to anesthesia, by bone sounding following anesthesia and by direct assessment after surgery debridement.

M&M:67 patients (42M, 25F), age 30-76 y.o. 276 furcations with vertical & horizontal depth were assessed at 3 separate time points. For the vertical dimension pre-anesthesia, measurements taken with a straight probe from FGM-flute, & then probe advanced until resistance noted. Horizontal dimension was taken with a Nabers probe from FGM-flute and then until resistance felt. After anesthesia, bone sounding performed. Direct measurements were taken during surgery (vertical: straight UNC probe from initial fluting of furcation to bony defect; horizontal: Nabers probe from flute to depth of bony defect into furcation). None of the subjects had 3rdmolars present.

R:Mean vertical (1.8mm) and horizontal (2.16mm) furcation depths prior anesthesia were sig less than surgical measurements (2.79mm & 3.65mm respect). Surgical vertical depth was exactly the same as pre-anesthesia probings in 42% of the furcations, within 1 mm in 72% and within 2 mm in 83%. Surgical horizontal depth was equal to pre anesthesia probing in 47% of furcation, within 1 mm in 68%, and within 2 mm in 77% of cases. Use of post-anesthesia sounding improved agreement in vertical measurements ranging from 59.5% to 93%. Sounding improved the agreement of horizontal measurements from 64%-88%. Vertical sounding provided the greatest improvement in diagnostic accuracy for the facial furcations of mandibular second molars. Horizontal sounding had the greatest beneficial effect for the distal furcation of maxillary second molars. The use of sounding sig improved the accuracy of the measurements, however, there was still a small percentage of horizontal measurements that were significantly underestimated.

BL:Sounding reduced the degree of underestimation in all furcation types.

Wang 1993                    ARTICLE                        the impact of restorative dentistry on furcation involvement

Purpose:To study the impact of crown (CR) or proximal restoration (RE) on furcation involvement (FI) in molar teeth.

Materials and methods: 134 maintenance patients who had molars with and without FI and restorations were selected from University of Michigan patient pool. The majority of the patients had restorations for at least 5 years prior to the study. Clinical evaluation included assessment for CR, RE, endodontic treatment, FI, mobility more than 0.5mm in bucco-lingual direction, AL and PD for six sites/tooth. Data were analyzed and statistical analysis was performed.

Results:

Frequency Table on complete data set (n=771)

Variable

Absence %

Presnece %

Crown placement

Class II restoration

Mobility

Furcation involvement

Endodontic Treatement

  • Molars with CR or RE had a significantly higher presence of FI than molars without restorations.

  • Relationship between restoration status of the molars and mobility was not significant while that of endodontic Tx was significant but with small sample size.

  • More probing AL was measured in molars with RE< FI and mobility than in molars without the occurrences. More AL was found in molars RE and CR especially in the maxilla.

Conclusions:

  • Molars with CR or RE had a higher prevalence of FI and greater AL than non-restored molars.

  • The difference in AL between restored and non-restored molars occurred mostly in the maxillary arch.

  • Mobility was found to be a significant factor for AL but not FI.

Joseph 1996                     ARTICLE

P:to determine the frequency of bifurcation, and to explore the anatomy of max 1st PMs.

M&M:examined 100 extracted max 1st PMs. Teeth w/ caries, restorations, or damage were excluded.

R:

  • Only 37% of the examined teeth had bifurcated roots, the remaining had fused roots 63%.

  • Proximity of the furcation to CEJ- 35% apical third, 38% at the middle third, 27% at the cervical third.

  • The mean furcation width was 0.7 mm, which is less than the blade width of Gracy curette.

  • Concavities were found on the M and D of the root trunk in all 100 teeth examined

  • Furcal concavity was also found in 62% of the teeth with bifurcated roots

Disc:According to Corn et al. (1980), as a rule, the prognosis for maxillary first premolar teeth with osseous defects in the inter-radicular area is poor.

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123-124. Interdisciplinary Problems: PERIODONTICS- ORTHODONTICS- PEDIATRIC DENTISTRY

HOME PERIO TOPICS 

ORTHODONTICS

  1. What effect do malposed teeth have on periodontal health?Can orthodontic therapy improve malposition? What affect does this have on the periodontium? What can patients expect during and after orthodontics?

  1. Ainamo J. Relationship between malalignment of the teeth and periodontal disease. Scand J Dent Res. 80:104-110, 1972.

  2. Chung C-H, et al. Comparison of microbial composition in the subginigval plaque of adult crowded versus non-crowded dental regions. Int J Ortho Orthognath Surg 15:321-330,2000.

  3. Artun J, Osterberg SK, Kokich VG. Long-term effect of thin interdental alveolar bone on periodontal health after orthodontic treatment. J. Periodontol. 57:341-346, 1986

  4. Brown IA. The effect of orthodontic therapy on certain types of periodontal defects. I. Clinical findings. J. Periodontol. 44:742-756, 1973.

  5. Kraal JH, et al. Periodontal conditions in patients after molar uprighting. J Prosthet Dent 43:156 – 1980.

  1. Can patients with periodontitis safely have orthodontics? What tooth movements can be offered for periodontally involved teeth? When can orthodontics be a detriment to periodontal health? How would this change how we treat or manage patients? If flap surgery is indicated, when should open flap debridement be utilized? Grafting? Osseous surgery?

  1. Ong MA, Wang H-L, Smith FN. Interrelationship between periodontics and adult orthodontics. J Clin Perio 25:271-277,1998. (Review)

  2. Ericsson I : The combined effects of plaque and physical stress on periodontal tissues. J. Clin. Periodontol. 13:918 -, 1986. (Review)

  3. Ericsson I, Thilander B, Lindhe J, Okamoto H. The effect of orthodontic tilting movements on the periodontal tissues of infected and non-infected dentitions in dogs. J Clin Perio 4:278 – 1977.

  4. Corrente G et al: Orthodontic Movement into Intrabony Defects in Patients with Advanced Periodontal Disease: A Clincial and Radiological Study. J Periodontol 2003;74:1104-1109

  5. Polson A, et al. Periodontal response after tooth movement into intrabony defects. J. Periodontol. 55:197-202, 1984.

  6. Cardaropoli D: Reconstruction of the maxillary midline papilla following a combined orthodontic-periodontic treatment in adult periodontal patients. J Clin Periodontol 2004; 31:79-84.

  7. Wennstrom J, Stokland B, Nyman S, Thilander B. Periodontal tissue response to orthodontic movement of teeth with infrabony pockets. Amer J Ortho Dento Orthop 1993; 103:313-319.

  8. Araujo M et al: Orthodontic movement in bone defects augmented with Bio-Oss. An experimental study in dogs. J Clin Periodontol 28:73-80,2001

  9. Melsen B, Agerback N, Markenstam G: Intrusion of incisors in adult patients with marginal bone loss. Am J Orthod Dent Orthoped. 96: 232 – 241, 1989.

  1. When should orthodontics be considered as an alternative to periodontal surgery? In which cases is this indicated? What are some considerations for teeth that undergo extrusion? When else might a fiberotomy be considered?

  1. Ingber JS. Forced eruption: Part I. A method of treating isolated one- and two-wall infrabony osseous defects. Rationale and case report. J. Periodontol. 45:199-206, 1974.

  2. Ingber J. Forced eruption. Part II. A method of treating nonrestorable teeth -periodontal and restorative considerations. J. Periodontol 47:203-216, 1976.

  3. Salama H, Salama M. The role of orthodontic extrusive remodeling in the enhancement of soft and hard tissue profiles prior to implant placement: a systematic approach to the management of extraction site defects. Int J Periodontics Restorative Dent. 1993 Aug;13(4):312-33.

  4. Bellamy L et al: using orthodontic intrusion of abraded incisors to facilitate restoration: The technique’s effects on alveolar bone level and root length. J Am Dent Assoc 2008;139;725-733

  5. Carvalho et al: Orthodontic extrusion with or without circumferential fiberotomy and root planing. Int J Periodontics Restorative Dent 2006; 26:87-93

  6. Taner T, Haydar B, Kavuvlu I, Korkmaz A. Short-term effects of fiberotomy on relapse of anterior crowding. Am J Ortho Dentofac Orthop 118:617-623,2000.

  1. How should extractions be managed in conjunction with orthodontic therapy? Are there any long term effects moving teeth into extraction sites? How can this theory of accelerated movement affect ortho therapy?

  1. Reed B, Polson AM, Subtelny JD. Long-term periodontal status of teeth moved into extraction sites. Am J Orthod Dent Orthoped. 88:205-, 1985.

  2. Hasler R, Schmid G, et al. A clinical comparison of the rate of maxillary canine retraction into healed and recent extraction sites – a pilot study. Euro J Orthod 1997;19: 711-719

  3. Liou E, Huang CS. Rapid canine retraction through distraction of the periodontal ligament. Am J Orthod Dentofac Orthop 1998; 114: 372-380.

  4. Ahn HW, Ohe JY, Lee SH, Park YG, Kim SJ. Timing of force application affects the rate of tooth movement into surgical alveolar defects with grafts in beagles. Am J Orthod Dentofacial Orthop. 2014 Apr;145(4):486-95.

  5. Wilcko MT, Wilcko WM, et al. Accelerated osteogenic orthodontics technique: a 1-stage surgically facilitated rapid orthodontic technique with alveolar augmentation. J Oral Maxillofac Surg. 2009 Oct;67(10):2149-59.

  1. What is the significance of keratinized tissue during orthodontic movement? What is the relationship between mucogingival problems and tooth position? What is the relationship between mucogingival problems and tooth movement? Is prophylactic gingival grafting ever indicated?

  1. Coatoam GW, et al. The width of keratinized gingiva during orthodontic treatment. Its significance and impact on periodontal status. J. Periodontol. 52:307-313, 1981.

  2. Edwards JG. The diastema, the frenum, the frenectomy: A clinical study. Amer J Orthod Dent Orthoped. 71: 489-508, 1977.

  3. Pini Prato, et al: Mucogingival interceptive surgery of buccally – erupted premolars in patients scheduled for orthodontic treatment I : A 7-year longitudinal study. J Periodontol 71:172-181, 2000

  4. Pini Prato et al: Mucogingival interceptive surgery of buccally-erupted premolars in patients scheduled for orthodontic treatment II: Surgically treated versus non-surgically treated versus non-surgically treated cases. J Periodontol 71:182-187, 2000

  5. Artun J, et al. Periodontal status of mandibular incisors after pronounced orthodontic advancement during adolescence: A follow-up evaluation. Am J Orth Dent Orthop 119:2-10,2001

  6. Karring T, et al. Bone regeneration in orthodontically produced alveolar bone dehiscences. J. Periodontal Res. 17:309-315, 1982.

  1. What specific challenges are encountered with impacted/unerupted permanent teeth? Are there different approaches based on where and how the tooth is impacted? How should these patients be managed? Are there long term issues with the periodontal health of these teeth?

  1. Kokich V: Surgical and orthodontic management of impacted maxillary canines. Am J Orthod Dentofac Orthoped 2004; 126: 278-283

  2. Artun J, Osterberg SK, Joondeph DR. Long-term periodontal status of labially erupted canines following orthodontic treatment. J Clin Periodontol. 13:856-861, 1986.

  3. Burden D, Mullally B, Robinson S. Palatally ectopic canines: Closed eruption versus open eruption. Am J Ortho Dento Orthop 115:640-644, 1999.

  4. Quiryen M, Op Heij DG, et al. Periodontal health of orthodontically extruded impacted teeth. J Periodontol 71:1708-1714, 2000.

  5. Crescini A et al: Combined Surgical and Orthodontic Approach to Reproduce the Physiologic Eruption Pattern in Impacted Canines: Report of 25 Patients Int J Periodontics Restorative Dent 2007; 27:529-537

  1. How are implants utilized in ortho therapy? Do TADs have the same healing pattern as other titanium based implants?

  1. McGuire M et al: Temporary anchorage devices for tooth movement: A review and case reports. J Periodontol, 2006;Oct:77(10)1613-24

  2. Wiechmann, D et al: Success rate of mini- and micro- implants used for orthodontic anchorage: A prospective clinical study. Clin Oral Impl Res 18, 2007;263-267

  3. Celenza F. Implant interactions with orthodontics. J Evid Based Dent Pract. 2012 Sep;12(3 Suppl):192-201.

Pediatric Dentistry / Periodontics

Discussion Topics

  1. What are some of the anatomical differences in the jaws and periodontium between children and adults? Is the evaluation, etiology, prevalence, and treatment of mucogingival defects different in children as compared to adults?

  1. Maynard GJ, Oschenbein C. Mucogingival problems, prevalence and therapy in children. J. Periodontol. 46:543-552, 1975.

  2. Powell RN, McEniery TM : A longitudinal study of isolated gingival recession in the mandibular central incisor region of children aged 6-8 years. J. Clin. Periodontol. 9:357-364, 1982.

  3. Person M, Linnartsson B : Improvement potential of isolated gingival recession in children. Swed. Dent. J. 10:45-51, 1986.

  4. Bimstein E, Eidelman E : Morphological changes in the attached and keratinized gingiva and gingival sulcus in the mixed dentition period. A 5-year longitudinal study. J. Clin. Periodontol. 15:175, 1988

  5. Andlin-SobockiA, Marcusson A, Persson,M : 3-year observations on gingival recession in mandibular incisors in children. J. Clin. Periodontol. 18:155-159, 1991.

  6. Addy M, Dummer PM, et al.. A study of the association of fraenal attachment, lip coverage, and vestibular depth with plaque and gingivitis. J Periodontol. 1987 Nov;58(11):752-7.

  1. Do periodontal diseases occur at the same rate and with the same frequency in children as in adults? What are some of the periodontal diseases that appear to be specific to children? Are there differences in the composition of microbial plaque in children as compared to adults?

  1. Position Paper. Periodontal diseases of children and adolescents. J Periodontol 67:57-62, 1996.

  2. ClerehughV, Tugnait A. Diagnosis and management of periodontal diseases in children and adolescents. Perio 2000 26:146-168, 2001

  3. Mombelli A, et al. Gingival health and gingivitis development during puberty. A 4 – year longitudinal study. J. Clin. Periodontol. 16:451-456, 1989.

  4. Mombelli A, Rutar A, Lang NP. Correlation of the periodontal status 6 years after puberty with clinical and microbiological conditions during puberty. J Clin Periodontol 22:300-305,1995.

  5. Bimstein E, Ram D, Naor R, Sela MN. The composition of subgingival microflora in two groups of children with and without primary dentition alveolar bone loss. Pediatric Dent 18:42-47, 1996.

  6. Kargul B, Tanboga I, Ergeneli S, Karakoc F, Dagli E. Inhaler medication effects on saliva and plaque pH in asthmatic children. J Clin Pediatric Dent 22:137-140, 1998.

  1. How effective are tooth transplants? What factors govern the success of tooth transplants?

  1. ProyeMP, Polson AM. Repair in different zones of the periodontium after tooth reimplantation. J. Periodontol. 53:379-389, 1982.

  2. Pogrel MA. Evaluation of over 400 autogenous tooth transplants. J. Oral Maxillofac. Surg. 45:205-211, 1987

ORTHODONTICS

What effect do malposed teeth have on periodontal health?Can orthodontic therapy improve malposition? What affect does this have on the periodontium? What can patients expect during and after orthodontics?

Ainamo 1972                           NO ARTICLE             

P:Retrospective study looking at the relationship between malaligned teeth and periodontal disease in different groups of teeth.

M&M:The dentitions of 154 Army recruits (age 19-22) were examined clinically and radiographically. The occurrence and degree of displacement and rotation was recorded in 4,316 teeth. PI, GI, retentive calculus index, and CAL loss were recorded. The teeth were bilaterally pooled and grouped into maxillary and mandibular anterior teeth, premolars and molars.

R: Only 60% of subjects brushed 1 or more times /day, and brushing was limited to anterior teeth and facial surfaces. The maxillary laterals and mandibular second premolars were most commonly malaligned teeth. In the maxillary anterior areas, the mean scores for plaque, gingivitis, dental calculus and loss of attachment increased with increasing severity of malalignment. In mandibular anterior teetha similar association was found between malalignment and extensive plaque formation, gingivitis and loss of attachment but not with calculus accumulation. In the premolar area, the difference was less and it became non-existent in the molar regions.

BL: The incisors and canines showed the most favorable retentive calc index scores, and was the only area that showed a positive correlation between malalignment, gingivitis and CAL loss. The other areas showed no correlation.

Chung 2000                         NO ARTICLE

P: To investigate and compare the presence and proportional distribution of periodontal pathogens in the subgingival plaque of adult crowded versus non-crowded dental regions.

M+M:30 orthodontic patients (19M, 11F; 18-56 years old). Criteria for anterior crowding had to be at least 2mm crowding. Orthodontic records taken: lateral ceph, pano, and FMX; periodontal exam done. PI recorded. Subgingival plaque samples taken from crowded and non-crowded regions (Test and Control of same patient). Supragingival plaque removed with a curette, and subgingival plaque sampled with sterile paper points. 9 bacteria studied: Aggregatibacter actinomycetemcomitans (Aa), P. intermedia, E. Corrodens, C. rectus, Capnocytophaga species. Fusobacterium species, Peptstreptococcus micros. P. Gingivalis and B. forsythus determined using culture and immunoflorescence.

R: Supragingival plaque accummulation in crowded regions was SS greater than non-crowded. Crowded regions contained more species of periodontic pathogens than the samples from non-crowded regions. More spirochetes and motiles were present in the crowded region samples. Fusobacterium species, Capnocytophaga species, C. rectus and P. micros were more common in crowded regions. Amount of crowding was not linearly related to the number of pathogens. Patients with extremely good OH have less pathogens regardless of crowding.

BL:Subgingival plaque of crowded regions provide a more favorable environment for the colonization and growth of the periodontal pathogens.

Artun 1986           (root proximity)             ARTICLE

P: To assess the long-term effect of thin interdental alveolar bone on periodontal health after orthodontic treatment.

M&M: 25 adult patients, ages 28 to 55 years, with at least 16 years after orthodontic treatment were selected for exam based on the following criteria: 1) radiographic evidence with root proximity 2) models showing well-aligned teeth (ej. no open contacts), 3) closed interproximal contacts. Measurements were made on PA radiographs projected on a screen and clinical evaluation of predominantly anterior dentition. The position of the CEJ and the level of the alveolar bone (AB) were determined and the distance between CEJ-AB was measured. Also, the distance between the roots was measured. Root proximity was diagnosed when the roots were closer than 0.8mm.Adjacent or contralateral interproximal areas with more than 1mm between the roots were used as controls. Gingival health, level of attachment and bone in sites of thin interproximal bone were measured and compared with neighbouring control sites having normal bone width.

R:No SSD were observed in hygiene, tissue health or attachment and bone levels between areas with thin interproximal bone and controls with normal interproximal bone. However, when measured radiographically, the distance between CEJ-AB was significantly longer in the root proximity sites. This discrepancy was most likely due to radiographic distortion according to the authors. The study indicates that root proximity between anterior teeth after ortho treatment has no long-term detrimental effect on the periodontium as long as the teeth are well aligned.

D:Too few molar sites were included to draw conclusions for posterior teeth.

BL:In anterior areas, marginal periodontal breakdown is unrelated to the thickness of bone between the roots when the crown of the tooth is in the proper position.

Cr: Pas not standardized

Brown 1973                        ARTICLE

Purpose:To study the effects of a certain type of orthodontic tooth movement (uprighting molars) on existing periodontal osseous defects in humans.

Materials and methods: 5 patients were selected that 1) were Tx planned for extraction of all or many of remaining teeth and mandibular removable prosthesis, 2) advanced periodontal disease with vertical subcrestal osseous lesions and 3) loss of a mandibular posterior tooth, mesial inclination of the distal tooth and osseous defect associated with the mesial surface of that tooth. One patient served as control.

Standardized radiographs were taken at the beginning and the end of the experimental period, after metal endosseous reference points were inserted in order to evaluate the defects. Photographs were taken and casts from alginate impressions were also made. An assessment of the soft tissues was performed (evaluation of marginal gingiva, amount of attached gingiva, recession).

In the experimental group SRP was performed in the beginning of the experiment only and in the control patient it was repeated twice a week.

Orthodontic forces were applied to the test group that resulted in movement of the tooth in more distal and upright position. Following the completion of orthodontic procedures, the experimental teeth were stabilized for a minimum of 3 months to allow the remodeling of the bone. Patients were administered TTC until 14 days before the tooth extraction, which allowed complete clearance of the labeling medium from all tissues except the bone. Teeth in the experimental group were removed in block section and histologic analysis was performed.

Results:Patients had deep defects on the mesial of mandibular 2ndmolars. They exhibited substantial plaque deposition, gingival inflammation and proliferative changes in gingival architecture. Slight improvement was observed after SRP. As the orthodontic treatment progressed, gingival margin was positioned more apically and reduction in plaque retention, inflammation and edema was observed.

In all patients the molars were uprighted within a period of 90-120 days.

The experimental group showed 2.5 mm PD reduction more than the control patient. There was 0.63mm gain in bone height clinically and 1mm radiographically.

The histologic results would be subject of a forthcoming publication.

Conclusion:Orthodontic movement resulted in teeth with favorable axial inclination, significant reduction in the depth of the defects and desirable changes in the gingiva. Lesions would be more amenable to conventional periodontal techniques and complete pocket elimination could be achieved.

Kraal 1980                         ARTICLE

Purpose: To assess periodontal conditions in patients after molar uprighting.

Materials and methods:

  • 22 patients who had molar uprighting an average of 3 1/2 years prior were examined.

  • 15 patients received unilateral uprighting and 7 received bilateral uprighting.

  • Contralateral molars or adjacent molars served as controls.

  • Changes in bone levels, inflammation (gingival index) and probing depths were recorded.

Resutls:

  • Changes in alveolar height mesial to uprighted molars were not different from changes on the mesial of control teeth.

  • Gingival index scores around uprighted molars were not different from controls.

  • Pockets mesial to uprighted molars were shallower than mesial pockets in control (3.3 vs 3.9).

  • Gingival scores were worse around teeth with submarginal restorations regardless whether it was control or test.

BL: Because the periodontium adjacent to molars which were uprighted and retained with fixed partial prostheses was in no worse condition than that around equivalent teeth in a continuous dentition, it is concluded that molar uprighting is a reasonable mode of treatment.

  1. Can patients with periodontitis safely have orthodontics? What tooth movements can be offered for periodontally involved teeth? When can orthodontics be a detriment to periodontal health? How would this change how we treat or manage patients? If flap surgery is indicated, when should open flap debridement be utilized? Grafting? Osseous surgery?

Ong MA 1998                         NO ARTICLE

P: Review article on the interrelationship between periodontics and orthodontics in adults.

D: Ortho can be used to improve the perio condition via 1. Uprighting or repositioning teeth to improve parallelism of abutment teeth 2. Improving future pontic spaces, 3. Correcting cross-bites, 4. Extruding teeth (if fractured)/ Intruding teeth, 5. Correcting crowding of teeth, 6. Achieving adequate embrasure space and proper root position, 7. Repositioning teeth for placement of implants, 8. Restoring lost vertical dimension, 9. Increasing or decreasing overjet/ overbite, 10. Closure of diastemas

  • Ortho forces influence on bone (Reitan 1985, Proffit 1993a): resorption in areas of pressure and new bone formation where there is tension. When pressure is applied to a tooth, there is an initial period of movement for 6-8 days as the PDL is compressed. Compression of the PDL results in blood supply being cut off to an area of the PDL and this produces an avascular cell-free zone by a process termed “hyalinization”. When hyalinization occurs, the tooth stops moving. Light forces will cause only a short delay in txt, whereas heavier forces might cause a longer period of delayed movement. The PDL must be regenerated for movement to occur again. This regeneration cannot occur in areas of inflammation.

  • Lindhe (1989) recommends that in the initial stage of ortho txt in adults, an interrupted force of 20-30 g be used. Later on the force may be increased (up to 30-50 g in tipping and 50-80 g in bodily movements, corresponding to a distance of movement of 0.5-1.0 mm. per month) depending on the degree of marginal bone loss and the amount of remaining alveolar bone. Melsen (1989) published that intrusion can be done in perio healthy patients at a rate of 5-15g/tooth (lower force).

  • Multiple studies show that teeth can be moved into adjacent osseous defects, have extrusion and labial tipping of the anterior teeth without jeopardizing the perio support if there is adequate plaque control.

  • Ericsson has published multiple studies showing that ortho treatment in the presence of perio dz can worsen the perio condition, whereas even in reduced periodontium if the plaque control is adequate, teeth can be moved with no consequence to the perio apparatus.

  • With derotation, circumferential superficial fiberotomies can be done, even multiple times and decrease the possibility of relapse. This procedure should be done very close to the end of ortho txt. Another indication for CSF is forced eruption when the perio apparatus needs to remain at the same apico-coronal dimension as the tooth moves more coronally.

  • Ortho bands on periodontium: short-term: gingivitis and gingival hyperplasia NOT associated w/CALoss in children (Baer & Coccaro 1964, Zachrisson & Zachrisson 1972, Kloehn & Pfeifer 1974, Alexander 1991). There are differing opinions on adults, in that there is no long term effect (Sadowsky & BeGole 1981, Poison & Reed 1984, Poison et al. 1988); some effect – loss of attachment in adolescents (Alstad & Zachrisson 1979); – root resorption in adults (Trossello & Gianelly 1979)

  • Although a higher amt of periopathogenic bacteria can be seen after band placement, neither adults nor adolescents appear to be at a higher risk for developing perio dz.

  • Open and closed SRP and/or gingival augmentation should be performed as appropriate prior to any tooth movement (Glickman 1964, Prichard 1965, Proffit 1993d). Any pocket reduction surgery including osseous should be delayed until the end of txt b/c tooth movement itself might modify the gingival or osseous morphology. (Goldman and Cohen 1968). Close monitoring and shorter SPT intervals might be indicated.

  • Implants and ortho: successful cases have been reported using implants to: retract and realign teeth (Odman et al. 1988, Arbuckle et al. 1991, Block & Hoffman 1995), close edentulous spaces (Shapiro & Kokich 1988, Roberts et al. 1989, Roberts et al. 1994), correct midline and anterior tooth spacing (Odman et al. 1988), reestablish proper A-P and mediolateral positions for malposed molar abutments (Arbuckle et al. 1991, Haanaes et al. 1991), intrude and/ or extrude teeth (Odman et al. 1988, Haanaes et al. 1991, Salama & Salama 1993, Southard et al. 1995), correct a reverse occlusal relationship (Shapiro & Kokich 1988, Van Roekel 1989, Higuchi & Slack 1991), correct an anterior open bite (Roberts et al. 1984), protract a single arch or the entire dentition (Higuchi & Slack 1991) and provide stabilization for teeth with reduced bone support (Odman et al. 1988).

BL:Perio health is essential for any dental treatment. Adult patients must undergo OHI and perio maintenance during active ortho treatment. Close monitoring of adults with reduced perio support is mandatory. Adult orthodontic teeth movement can be performed on both healthy and diseased periodontiom with few detrimental effects (root resorption) if perio inflammation is controlled and meticulous OH maintained throughout active therapy.

Ericsson 1986                        ARTICLE

P: A review to report on studies performed in beagle dogs attempting to evaluate the effect of orthodontic and jiggling-type trauma on the supporting structures of premolars.

D:The reports have unanimously demonstrated that in situations where orthodontic or jiggling forces were inflicted on teeth with a normal periodontium, or on teeth with overt signs of gingivitis, the PDL tissue reacted by transitory signs of inflammation. These phenomena occurred without the concomitant loss of clinical attachment and development of pathologically deepened periodontal pockets. If jiggling trauma was inflicted on teeth with an ongoing plaque-associated destructive periodontitis, the resulting inflammatory reactions caused enhanced loss of attachment and angular bony defects. When orthodontic type of trauma is allowed to act on a single tooth or a group of teeth, separate pressure and tension zones within the PDL will develop and later alveolar bone and root cementum also involved. Orthodontic tilting movement of teeth (ie. Intrusion) in a plaque-infected dentition may shift a supra-gingival located plaque into a sub-gingival position resulting in periodontal tissue breakdown. Forces causes bodily movement will not affect the supra alveolar tissue and not cause AL even with the presence of supraG plaque.

Ericsson 1977                         ARTICLE

P:To study whether it is possible, by orthodontic movement, to shift a supragingival plaque into a subgingival plaque situation and to test the tissue reactions around tilted and intruded plaque-infected teeth.

M&M: 5 beagle dogs had mandibular 3rd PM’s extracted and had defects surgically created on lower 4th PM’s and copper bands placed with plaque accumulation for 21 days. Cotton ligatures were placed for 210 days. The dogs were fed a plaque inducing diet during this period. APF was then performed at day 210 (after perio breakdown had occur), a notch placed at the level of the alveolar bone and OH instructed for 60 days. Ortho appliances producing tipping and intrusion forces were placed. A spring with 40-50 grams of force was installed to tip the lower 4th PM mesial and apical. Plaque was allowed to accumulate on right side (test group), the other side (control group) received OH bid until day 450 when dogs were sacrificed. Standardized radiographs and CAL measurements at days 210 & 450, as well as histometry was performed.

R:Both test and control teeth were tilted and intruded, with NSSD. The size of the CT infiltrate and PDL area was SS greater for the test group. In 4 out of 5 dogs of the test group resulted in the apical shift displacement of CT attachment. Plaque-infected teeth showed subgingival plaque and pocket epithelium, a large supra- & sub-gingival infrabony cell infiltrate, and angular widening of the PDL. Control teeth showed no subgingival plaque and the epithelium had the appearance of a junctional epithelium. Clinical measurement, control group gain attachment and test group loss some attachment (+1.2mm vs. -0.5mm), but histologically in the attachment level no sig difference was found.

BL: Ortho intrusion may shift a supragingival plaque into a subgingival position. This movement in plaque-infected teeth may result in infrabony pocket formation.

Corrente 2003                         ARTICLE

P:To evaluate the effect of a combined approach (periodontal surgery and orthodontic intrusion) in treating adult periodontal patients with infraosseous defects in extruded maxillary central incisors

M&M:10 adult patients with advanced periodontal disease with extruded maxillary central incisor with infrabony defect at its mesial aspect and probing depth (PD) 6 mm were included. Patients were treated by SRP and then orthodontic intrusion. Maintenance therapy was performed every 2 to 3 months until the orthodontic treatment was completed. At baseline, PD and clinical attachment level (CAL) were measured. The vertical distance between the horizontal projection of the bone crest on the root surface (TD) and the most apical point of the bone defect, and the horizontal distance from the bone crest and TD were assessed on standardized radiographs.

R:Mean PD reduction was 4.35 mm, with a residual mean PD of 2.80 mm (Mean initial 7.15 mm). Mean CAL gain was 5.50 mm (Mean initial 8.95 mm, final 3.45 mm). The mean radiological vertical and horizontal bone fills were 1.35 mm (initial 4.3 mm, final 2.95 mm) and 1.40 mm (initial 3.4 mm, final 2 mm) respectively. All differences were of statistical significance (P<0.001).

B/L:The combined orthodontic and periodontic therapy resulted in the realignment of extruded teeth with infrabony defects, obtaining a significant probing depth reduction, clinical attachment gain, and radiological bone fill.

Polson 1984                          ARTICLE

P:To evaluate the effect of tooth movement on the osseous morphology and CTA level of intrabony defects.

M&M:4 rhesus monkeys, all but one incisor in each arch removed and allowed to heal for 6 months. Orthodontic bands were placed on the cuspids (anchoring teeth) and fitted with a rectangular arch wire. The arch wire was connected to the incisor via a bonded bracket. Intrabony pockets (mesial or distal) were created around the incisors by placing elastics around the necks of the teeth. After 5 months of active pocket formation, 7 to 8mm deep pockets could be probed (approximately 50% attachment loss) and radiographs demonstrated the presence of mesial and distal angular defects. The elastics were removed 2 months later, the teeth were root planed to the bottom of the angular defect. OH program (toothbrushing and topical application of 2% CHX 3 times/week) was maintained until the end of the study. 3 weeks after the initiation of OH program, the orthodontic appliance was activated to move the experimental tooth in either a mesial or distal direction into the osseous defect associated with the intrabony lesion. 4 incisors were moved into the defect and the other four incisors with induced intrabony pockets were left as controls (no tooth movement). 3 months after initiation of treatment the teeth had moved 6mm. Retained for 2 months and removed for histology.

R:Controls exhibited angular defect morphology with the epithelial lining extending apical to the level of instrumentation. The end of the epithelium was located 2 to 3 mm apical to crestal bone. Experimental group at pressure side exhibited narrowing of the defect with epithelial lining of the root surface to the apical extent of root instrumentation. The root exhibited some resorption apical to the area of instrumentation. New bone was present adjacent to the PDL space. No new CTA was demonstrated. Tension side: the angular defects were not present and the crest of the bone was apical to the level of root planing. There was no evidence of new CTA to the instrumented portion of the root. New bone and normal PDL were apparent.

CON:Histology is necessary to critically evaluate the remodeling process. Definitive changes in osseous morphology occur without any changes in CTA levels. Ortho may be carried out on compromised teeth without further CAL loss when plaque and inflammation are controlled.

Cardaropoli 2004                        ARTICLE

P:To evaluate the predictability of a combined orthodontic–periodontic treatment in determining

the reconstruction of the interdental papilla between maxillary central incisors.

M+M:28 healthy patients (22F, 6M) with infrabony defect on #8 or #9 w/ PD of at least 6mm; and extrusion of one maxillary central incisor were treated. All defects were treated w/ OFD (no graft or membrane placed)- FTF was reflected extending from the distal of both centrals w/ vertical releasing if needed- intrasulcular incisions only, no attempt for papilla preservation technique. At 7-10 days post-op, ortho movement was begun. Teeth were intruded, realigned, and diastemas closed via contiguous and light forces of 10-15g/tooth. Ortho therapy lasted 6-18 months, w/ a mean time of 11.7 months and pts had maintenance appts every 3-4 months during therapy. PD, CAL, and papilla presence index were assessed at baseline, at end of treatment, and at 1 year.

R:All parameters showed statistical improvement between the initial and final measurements, and showed no changes at follow up time.

The mean residual probing depth was 2.5 with a decrease of 4.3 mm, while the mean CAL gain was 5.93mm. The average distance from bone to contact point was 6.46mm (range 5-9mm).

The initial papilla presence index (used Nordland & Tarnow classification system) mean was 1.57 at baseline and 0.61 at the end of observation.

NSSD in reconstruction of papilla in thin vs thick biotypes.

BL: At the end of orthodontic treatment, a predictable reconstructions of the papilla was reported, both in pts with thin and thick biotypes.

Wennstrom 1993                         ARTICLE

P:To evaluate the effect of orthodontic tooth movement on the level of the connective tissue attachment in sites with infrabony pockets.

M&M:4 beagle dogs had 2nd and 4th premolars extracted. No plaque control measures at any point in the study. Angular bony defects were sx created at the mesial of 3rdpremolars with a notch placed at base of defect on the root. Cotton ligatures were placed for 3 weeks and an additional 2 months of plaque accumulation occurred before ortho movement began. In each dog, one premolar moved through the defect and one moved away from the defect. Maxillary teeth 3rd PM served as controls (no ortho movement). After 5-6 months of ortho movement, teeth were stabilized for 2 months before biopsy, then removal of appliances. Clinical assessment (PPD, CAL and tooth position) with radiographic and histological analysis was done.

R:Plaque accumulation and BOP present in both experimental and control group. Average sagittal movement 5 mm. The stationary control teeth gained some attachment levels at 5 months and had decreased PD, while the experimental teeth experienced some pocket depth increase and a loss of clinical attachment. However, the variance was high for both groups (1-1.5mm standard deviation). Histological evaluations for both groups showed presence of inflammatory cell infiltrate in the CT adjacent to the pocket epithelium extending apical to the crest of the alveolar bone. In the test group, all teeth had the apical level of the JE apical to the notch. This only occurred in 2/8 control teeth (most were at the notch) and the difference was SS.

BL:Orthodontic therapy involving bodily tooth movement with inflamed, infrabony pockets may enhance the rate of loss of the connective tissue attachment. Perio treatment should occur prior to initiating ortho treatment and oral hygiene should be maintained during treatment.

Araujo 2001                        ARTICLE

Purpose:To study if it is possible by orthodontic means to move a tooth in an alveolar ridge augmented with Bio-Oss and the tissue reactions associated with such a movement.

Materials and methods: 5 beagle dogs. After 1st, 2ndand 4th mandibular premolars were extracted in both sides, the interradicular septa of the 4th premolars were resected and the defect of the 4th premolar on the left side was filled with Bio-Oss. Flaps were then adjusted to achieve full coverage on both sides. 3 months later, orthodontic appliances were inserted. The force resulted in tooth displacement of 1mm/month on both test and control sides and treatment continued until the distal root of the 3rd premolar on the sides had been moved into the previous extraction sockets of the 4thpremolar. 2 weeks after the final activation dogs were sacrificed and histologic analysis was performed.

The following regions were identified:

  1. Zone A: bone tissue within the distal portion of the previous 4thpremolar site, 4x6mm

  2. Zone B: distal aspect of the distal root of the 3rdpremolar, pressure side and a 300wide area adjacent to it

  3. Zone C: the mesial aspect of the distal root of the 3rdpremolar, tension side

Results:All sites healed uneventfully. The mean movement of the 3rdpremolars was 3.85±0.57mm in the test group and 3.37±0.45 mm in the control group.

Zone A: In the test side it was comprised of a relatively dense mineralized bone, in continuity with the cortical bone of the alveolar ridge. This tissue contained lamellar bone, Bio-Oss particles and small amounts of immature bone and bone marrow. Some of the particles that were found above the alveolar ridge were encapsulated in connective tissue. In the control side, the marginal region of the extraction sites was occupied by a relatively thin layer of cortical, lamellar bone and cancellous bone apical to it.

Zone B: Same characteristics in both groups (arrested resorption, cellular cementum with fibers on the resorbed root surface, PDL with fibers organized in different directions and osteoclasts on the bony wall facing the PDL). On the test side Bio-Oss particles were found within the PDL, but not in contact with the root surface.

Zone C: Similar features in both groups. Newly formed woven bone and the trabeculae were perpendicular to the long axis of the tooth. Root surface was covered by layers of cellular cementum. No particles of Bio-Oss found.

In Zone A, the alveolar ridge of the test group consisted of 43.5% of mineralized bone, 14.8% Bio-Oss particles and 41% bone marrow. On the control group the ridge included 44.4% mineralized bone and 55.7% bone marrow.

In zone B, Bio-Oss occupied 8.9% of the space. Bone marrow was 23.7% in the test group and 38.8% in the control group.

The width of the PDL ranged between 0.28 – 0.38mm at the tension side (Zone C) in both groups.

Conclusion:Bio-Oss degradation and elimination occurs during orthodontic movement. The detailed mechanism is still not totally understood.

Melsen 1989                         ARTICLE

Purpose: to orthodontically intrude elongated teeth in adult pts with varying degrees of periodontal damage and evaluate the effects of treatment on the periodontal condition.

Materials and methods:

  • 30 adult pts, characterized by marginal bone loss & deep overbites, were treated by intrusion of the upper incisors.

  • Four different appliances for intrusion were placed:

    • a) J hooks & extraoral highpull headgear, b) utility arches, c) intrusion bent into a loop in a 0.17x 0.25inch wire, & d) base arch as described by Burstone.

  • Before treatment all patients received adequate periodontal treatment involving instruction, cleaning, and curettage. 15 pts had a MWF so pockets were <3 mm.

  • The intrusion was evaluated from the displacement of the apex, incision, and the center of resistance of the most prominent or elongated central incisor.

  • Change in the marginal bone level and the amount of root resorption were evaluated on standardized intraoral radiographs. The pockets were assessed by standardized probing and the clinical crown length was measured on study casts.

Results:

  • The results showed that the true intrusion of the center of resistance varied from 0 to 3.5mm and was most pronounced when intrusion was performed with a base arch.

  • The clinical crown length was generally reduced by 0.5 to 1.0 mm.

  • The marginal bone level approached the CEJ in all but six cases.

  • All cases demonstrated root resorption varying from 1 to 3 mm.

  • The total amount of alveolar support, that is the calculated area of the alveolar wall, was unaltered or increased in 19 of the 30 cases.

  • Read More ›

111. Esthetics : Recession

HOME PERIO TOPICS 

 

Etiology and Treatment (Root coverage):

  • FreeGingival Graft

  • Rootcoverage and increasing keratinized tissue

  • CoronallyPositioned Flaps

  • Laterallypositioned Flaps

DiscussionTopics

Whatis(are) the known or suspected cause(s) of recession? Do you considerrecession a pathologic or physiologic process? How do we classifyrecession? Is recession progressive? What is it’s relationshipto the underlying bone?

  1. LoeH, Anerud A, Boysen H. The natural history of periodontal diseasein man: prevalence, severity, and extent of gingival recession. J.Periodontol 63:489-495, 1992

  2. JoshipuraK, Kent R, Depaola P. Gingival recession: Intra-oral distributionand associated factors. JPeriodontol1994;65:864-870

  3. SerinoG, Wennström JL, et al. The prevalence and distribution ofgingival recession in subjects with a high standard of oral hygiene.J Clin Periodontol. 1994 Jan;21(1):57-63.

  4. HujoelPP, Cunha-Cruz J, Selipsky H, Saver BG. Abnormal pocket depth andgingival recession as distinct phenotypes. Periodontol 2000.39:22-9;2005

  5. RajapakseP et al: Does tooth brushing influence the deveopment andprogression of non-inflammatory gingival recession? A systematicreview. J Clin Periodontol 2007; Dec; 34(12)1046-61

  6. KapfererI, BeneschT, GregoricN, UlmC, HienzSA. Lip piercing: prevalence of associated gingival recessionand contributing factors. A cross-sectional study. JPeriodontal Res. 2007 Apr;42(2):177-83.

  7. PiresIL, Cota LO, Oliveira AC, Costa JE, Costa FO. Associationbetween periodontal condition and use of tongue piercing: acase-control study. J Clin Periodontol. 2010 Aug 1;37(8):712-8.Epub 2010 Jun 17.

  8. Endo,Rees, Hallmon, Kono, Kato: Self –inflicted gingival injuriescaused by excessive oral hygiene practices. TexDentJ 2006 Dec;123(12):1098-104

  9. MillerPD. A classification of marginal tissue recession. Int J Perio Restor Dent 5:9- , 1985

  10. LostC. Depth of alveolar bone dehiscences in relation to gingivalrecession. J Clin Periodontol 11:583-589,1984.

  11. Zimmer,Seifi-Shirvandeh: Changes in gingival recession related toorthodontic treatment of traumatic deep bites in adults: J OrafacOrthop; 2007 May; 68(3): 232-44

  12. ClossL et al: Gingival margin alterations and the pre-orthodontictreatment amount of keratinized gingvia: Braz oral Res 2007 Jan –Mar: 21(1)58-63

Whatis the relationship of keratinized tissue and recession? Are patientswho are lacking keratinized tissue more likely to develop recession?Are recessions on teeth with limited KG more likely to progress?

  1. MaynardJG Jr, Wilson RD. Physiologic dimensions of the periodontiumsignificant to the restorative dentist. J Periodontol. 1979Apr;50(4):170-4.

  2. WennströmJ, Lindhe J. Role of attached gingiva for maintenance of periodontalhealth. Healing following excisional and grafting procedures indogs. J Clin Periodontol. 1983 Mar;10(2):206-21.

  3. MiyasatoM, Crigger M, Egelberg J. Gingival condition in areas of minimal andappreciable width of keratinized gingiva. J Clin Periodontol. 1977Aug;4(3):200-9.

Whatis the theory behind a free gingival graft? How does it heal? Inwhich situations is a free gingival graft appropriate? Describe thetechnique you prefer for a Free Gingival Graft. Is there anydifference if attempting to increase keratinized tissue vs coveringrecession? What are the drawbacks or complications of a free gingivalgraft?

  1. SullivanHC et al. Free autogenous gingival grafts. I. Principles ofsuccessful grafting. Periodontics. (1968)

  2. MillerPD: Root coverage using the free soft tissue autograft followingcitric acid application. III. A successful and predictableprocedure in areas of deep-wide recession. Int J Perio Restor Dent. 5(2):15-37, 1985.

  3. MillerPD: Root coverage with the free gingival graft. Factors associatedwith incomplete coverage. J. Periodontol. 58:674-681, 1987.

  4. MatterJ. Creeping attachment of free gingival grafts – A five yearfollow-up study. J. Periodontol. 51:681-685, 1980

  5. Agudio,G Nieri, M, Rotundo R., Cortellini P, Pini Prato G.: Free gingivalgrafts to increase keratinized tissue: A retrospective long-termevaluation (10-25 years) of outcomes. J Periodontol 2008 Apr; 79(4):587 – 94 (ADD Erratum in : J Periodontol 2008 Jul79(7):1312)

  6. FreemanE: Development of the dentogingival junction of the free graft. Ahistologic study. J.Perio Res. 16:140-146, 1981.

  7. PasquinelliK. The histology of new attachment utilizing a thick autogenoussoft tissue graft in an area of deep recession; A case report. IntJ Perio Res Dent 1995; 15: 249-57.

Whatare the differences in recipient site preparation? Is there adifference in making a full thickness or split thickness site? Whatwould you expect to see in the healing?

  1. DordickB, Coslet JG, Seibert JS. Clinical evaluation of free autogenousgengival grafts placed on alveolar bone. Part I. Clinicalpredictability. J Periodontol. 1976 Oct;47(10):559-67.

  2. JamesWC, McFall WT Jr. Placement of free gingival grafts on denudedalveolar bone. Part I: clinical evaluations. J Periodontol. 1978Jun;49(6):283-90.

Whatis a pedicle graft? What are the different ways this can be utilizedto cover recession? How have the classic descriptions been modifiedover time? What is the role of citric acid? How does this type ofprocedure heal? How does this healing compare to the free gingivalgraft? How stable are these grafts?

  1. GrupeH, Warren RF. Repair of gingival defects by a sliding flapoperation. J Periodontol 27:92-95, 1956.

  2. GrupeHE. Modified technique for sliding flap operation. J Periodontol37:491-495, 1966

  3. SmuklerH, Goldman HM : Laterally repositioned “stimulated”osteoperiosteal pedicle grafts in the treatment of denuded roots – apreliminary report. J. Periodontol. 50:379-383, 1979.

  4. RobinsonRE. Utilizing an edentulous area as a donor site in the lateralrepositioned flap. Periodontics 2:79- , 1964.

  5. CaffesseR, et. al. Lateral sliding flaps with and without citric acid. IntJ Perio Restor Dent 7(6):43-57, 1987.

  6. CaffesseRG, Kon S, Castelli WA, Nasjleti CE : Revascularization followingthe lateral sliding flap procedure. J. Periodontol. 55:352-358,1984

  7. CommonJ, McFall WT : The effects of citric acid on attachment oflaterally positioned flaps. J.Periodontol. 54:9-18, 1983.

  8. CohenDW, Ross S : The double papillae repositioned flap in periodontaltherapy. J Periodontol 39:65-70, 1968.

  9. RossS, Crosetti H, Gargiulo A : The double-papillae flap – Analternative. I. Fourteen years in retrospect. Int J Perio RestorDent 6(6):47-59, 1986.

Isthe coronally positioned flap considered a pedicle graft? How usefulis this technique to cover recession? Are there limitations to thistechnique? Histologically, how does this compare with lateral slidingor the double papillae flap? What are some modifications of thistechnique?

  1. BernimoulinJP, Luscher B, Muhlemann HR: Coronally repositioned periodontalflaps. J.Clin. Periodontol. 2:1-13,1975.

  2. AllenEP, Miller PD: Coronal positioning of existing gingiva: short termresults in the treatment of shallow marginal tissue recession. J. Periodontol. 60:316-319, 1989.

  3. HarrisR, Harris A. The coronally positioned pedicle graft with inlaidmargins: A predictable method of obtaining root coverage of shallowdefects. IntJ Perio Rest Dent 1994;14:229-241

  4. BaldiC, Pini-Prato G, et al. Coronally advanced flap procedure for rootcoverage. Is flap thickness a relevant predictor to achieve rootcoverage? A 19-case series. J Periodontol. 1999 Sep;70(9):1077-84.

  5. LucchesiJA, Santos VR, Amaral CM, Peruzzo DC, Duarte PM. Coronallypositioned flap for treatment of restored root surfaces: a 6-monthclinical evaluation. J Periodontol. Apr;78(4):615-23. 2007

  6. GottlowJ, Nyman S, Karring T, Lindhe J: Treatment of localized gingivalrecessions with coronally displaced flaps and citric acid. Anexperimental study in the dog. J. Clin. Periodontol. 13:57-63,1986.

  7. ZucchelliG, Sanctis D. Treatment of multiple recession-type defects inpatients with esthetic demands. J Periodontol 71:1506-1514, 2000.

  8. ZucchelliG, Mele M, et al. Coronally advanced flap with and without verticalreleasing incisions for the treatment of multiple gingivalrecessions: a comparative controlled randomized clinical trial. JPeriodontol. 2009 Jul;80(7):1083-94.

  9. TarnowDP: Semilunar coronally repositioned flap. J. Clin. Periodontol.13:182-185, 1986.

Arethere any techniques to increase keratinized tissue without a pedicleor a free flap? What are the requirements for this?

  1. Carnio J, Camargo P, Passanezi: Increasing the apico-coronal dimension ofattached gingival using the modified apically repositioned flaptechnique: A case series with a 6 month follow-up J Periodontol2007Sep 78(9):1825-30

 

Whatis(are) the known or suspected cause(s) of recession? Do you considerrecession a pathologic or physiologic process? How do we classifyrecession? Is recession progressive? What is it’s relationshipto the underlying bone?
Loe1992        ARTICLE
P:To describe the initiation, pattern of development, and progressionof gingival recession in Norwegian and Sri Lankan population.
M&M:Data presented in this study on recession was obtained throughparallel longitudinal studies of periodontal disease in man conductedin Norway between 1969-1988, and in Sri Lanka between 1970-1990. TheNorwegian group consisted of 565 male high school and non-dental,non-medical university students and junior faculty between 17 and 30+years of age. Norwegian patients reported seeing their dentist on at least an annual basis,owning a toothbrush and brushing their teeth daily. The Sri Lankan group(tea laborers)consisted of 480 male that were healthy but they hadnever received any dental care or any type of instruction on dentalcare. Gingivalrecession was measured on the 4 surfaces of all teeth (except 3rdMolars) from the exposed CEJ.
R:Norwegiangroup: In examsof 20year old subjects, 63% presented recession (between 1-3mm). Itwas confined almost entirely, to the buccal aspects of the maxillaryand mandibular bicuspids and molars. Gingival recession was found inabout 75% of 30year old men, still mainly on the buccal surfaces (13%had rec 1-2mm, 2% had rec 3-7mm). IPx surfaces were still unaffected. In the exams of menbetween 46 and 50 years old, more than 90% had 1 or more sites withgingival recession(26% on buccal surfaces and 4% IPx, 22% of the buccal rec was between1-2mm and 4% between 3-5mm)
SriLankan Group: 29%of men 18 to 19 years old had recession, mainly confined to thebuccal surfaces and did not exceed 4mm. By30 years, 90% had recession on buccal, lingual and IPx surfaces. Byage 40 approximately 100% had recession– 2/3 of which showed recession between 1-2mm and 1/3 between 3-9mm.32% of the lingual surfaces showed recession. At 50 years, recessionoccurred in all teeth types and surfaces with 70% on the buccal, 40%in the IPx, and 50% on the lingual. 50% of the recession measuredbetween 3-9mm.
Forboth groups the distribution of recession was bilaterallysymmetrical.
Conc:
Inboth groups prevalence and severity of gingival recession increasedwith age
Gingivalrecession is something common in both patients with good OH -dentalcare and in patients with poor OH – no dental care.
Severityand extent of gingival recession was higher in tea laborers
Severalfactors determine the initiation and development of recession

Joshipura,1994         ARTICLE

P:To assess the role of poor oral hygiene and forcefultooth-brushing as risk factors for recession.

M+M:298 subjects (42-67 years old) with at least 1 tooth with >1mmrecession examined. Oral hygeine index (debris: 0= no debris;1=debris covering up to a third of the tooth or extrinsic stains;2=debris covering more than a third to less than two-thirds of thetooth surface; 3=debris covering more than two-thirds of the surface;supragingival calculus: 0=no calculus; 1=up to a third of the toothsurface; 2=one third to two-thirds of the tooth surface; 3= more thantwo-thirds of the surface or a continuous band around the tooth), andGI measured . Analyses were performed on buccal surfaces.

R: Analysis of variance on subject means for buccal recession showedboth calculus and presence of buccal root surfaces with abrasion tobe significantly associated with recession after adjusting forage and gender.

59% ofsubjects had buccal abrasion.

Males had morerecession.

Recessionincreased with age.

Premolarshad high amount of recession and abrasion and low levels ofcalculus.

Molarshad high levels of calculus and low levels of abrasion.

BL: OH probably plays an important role on recession in molars (dueto poor OH), and abrasion in PMs (due to forceful brushing).Subjects with poor OH are likely to have more recession due toperiodontal disease; patients who brush with excess vigor haverecession due to trauma; tooth profile can also effect recessionespecially when associated with these two.

Serino 1994            ARTICLE
P: Toevaluate the prevalence and the development/progression of attachmentloss and gingival recession (rec) in a pts with good OH (PI < 30%,BOP < 10%). An additional aim is to study the realationshipbetween ALoss and gingival recession.
M&M:Multi-center study (12 clinics) in Sweden with 225 pts on regulardental care included. Based on age, 4 cohorts were generated: 18-29,30-41, 42-53, 54-65. All subjects had a baseline exam, and thenanother exam at 5 and 12yrs. The exam included PI, GI, PD, PALoss,and rec. FMX was taken at the different exams to determineperiodontal bone support.
R:PALoss (>2mm ALoss on buccal surface) per age group: 18-29 (19%),30-41 (52%), 42-53 (66%), 54-65 (76%).
Rec atbaseline overall was 25%. Over 12 yrs, rec increased in all groupsfrom: 18-29 (7 -> 19%), 30-41 (25 -> 33%), 42-53 (33 ->44%), 54-65 (40 -> 46%). 33% of unaffected sites at baselineshowed rec 12 yrs later, and 87% of sites showing rec at baselinedisplayed an increase in rec from baseline at 12 yrs. Maxillarymolars and PM and mand incisors and PM were the most commonlyaffected at both at baseline and the 12-yr examination. Of the pts<30 yrs of age, 44% displayed rec. Of the pts >41pts of age >90% displayed rec.
Buccalsites with 3mm of ALoss were associated with rec 67% of the time,while 98% of sites with PALoss of 4mm or more had rec. Only 3% ofsites with buccal PALoss of 2mm displayed rec. By including theinterproximal PALoss, interprox bone level, and OH parameters asexplanatory variables, 58% of the variance of the dependentvariable (buccal rec) could be explained.
Only 16% oftth with an intact interproximal periodontium had buccal rec. Tthwith 3mm PALoss and 3mm interprox bone loss had rec 68% of the time.
D: Somebuccal loss of attachment does not necessarily result in recession.Since rec is prevalent in subjects with very good OH and intactinterprox periodontium, it is unlikely that perio dz can account forrec. In fact, rec was uncommon unless the buccal site and had atleast 3mm of ALoss.
BL:Buccal rec was a frequent finding, the proportion of pts with recincreased with age, prevalence and incidence of rec within dentitionshowed different patterns depending on age, sites with rec showedsusceptibility of additional rec, loss of approximal periodontalsupport was associated with rec at the buccal surface.

Hujoel 2005        ARTICLE
Purpose:To distinguish destructive periodontal disease from periodontalatrophy and explore criteria to define when pockets are abnormal.
Discussion:Periodontal atrophy: the gums retain a very healthaspect, are free of pain and inflammation and yet will graduallyrecede. Destructive periodontal disease: presence ofdeepened periodontal pockets and underlying bone loss.
Treatmentand economics:90%of the periodontal procedures would be eliminated if periodontalpocketing disappeared. First, due to the insurance guidelinesrequiring pockets deeper than 4mm. Secondly, because the rationalebehind most (not all) periodontal procedures is the elimination ofdeep pockets. Economic implications of abnormal pocket depth suggestthat its incidence should be tracked as a distinct clinical entity.
Etiology:Osteoporosis, aging , continuous eruption, aggressive oral hygieneprocedures and anatomic periotypes have been suggested as potentialcauses of periodontal atrophy.
Smokingand diabetes are considered the primary driver of destructiveperiodontal disease.
Thebiologic basis for claiming that both phenotypes are the result ofplaque is mostly supported by assumption for the periodontal atrophy,since no such evidence have been presented over the last 30 years.
Theanthropologic and comparative medicine features of destructiveperiodontal disease and periodontal atrophy are different.Studies of 23 different population groups around the world suggestthat age related alveolar bone loss is a normal physiologic process,an observation which is at odds with current thinking that anyattachment loss is pathologic and the result of an inflammatoryprocess caused by plaque.
Authorsbelieve that if pocket-free recession (periodontal atrophy) islabeled a destructive periodontal disease, we will end-up with the“anomalous situation” of being close to 100% ofindividuals with signs of chronic periodontitis.
Isperiodontal atrophy a disease? Attachmentloss is almost universal after the age of 30 and increases with age.Wear-and-tear of aging affects every organ system in the human body.It appears logical that periodontal atrophy is a normal age-relatedprocess.
Abnormalperiodontal pockets: Currently alldefinitions of periodontal diseases are arbitrary, which should because for alarm. Normative values may be superior to arbitraryvalues. These values can be based on parametric or nonparametricpercent of cut-off values.

Diagnosesbased on these values though are irrelevant to underlying factors(diabetes, smoking) and can become disconnected from clinicalrealities (tooth loss, periodontal abscesses, difficulty chewing). Destructive periodontal disease is a complex disease with too muchnatural variability to allow a successful definition based onarbitrary or normative values. The most attractive diagnosis is thetherapeutic diagnosis. A person is screened for the disease only ifthe diagnosis lease to better outcomes. Critical PDs are the exampleof therapeutic reference values in periodontitis, although theshortcoming is that no evidence exists that short term changes inattachment levels relate to clinically relevant outcomes such astooth loss.

Conclusion:Destructive periodontal disease and periodontal atrophy are twophenotypes with distinct clinical features. Different lines ofevidence suggest that the two phenotypes have distinct etiologies,prognosis and are treated differently. The current custom oflabeling both phenotypes as one and the same disease, chronicperiodontitis, merely because they both exhibit attachment loss,needs to be re-evaluated. This will involve evaluating whetherperiodontal atrophy should be labeled as a disease.

Rajapakse2007:         ARTICLE
Purpose: The aim of the systematic review was to search for the bestavailable evidence to evaluate potential role of tooth brushing inthe initiation and progression of non-inflammatory, localizedgingival recession.
Materialsand methods:
Thefocused question of the review was” Do factors associated withtooth brushing predict the development and progression ofnon-inflammatory gingival recession in adults?”
Thesearch covered six electronic database b/w Jan 1996-July 2005. Handsearching included searched of J Perio, J of Clin perio, J of PerioReas.
Results:
29papers were read and 18 texts were eligible for inclusion. One wasRCT (Level I evidence) and 17 were observational/cross-sectionalstudy (Level III evidence).
INRCT, author concluded that the toothbrushes significantly reduce the recession on buccal surface of the tooth over 18 months.
Ofremaining 17 studies, 2 concluded that there is no relationship b/wtooth brushing frequency and recession.
8studies concluded with an association b/w brushing frequency andrecession.
Nostudy concluded the potential risk factor like duration, force,frequency of changing of tooth brushes, and brushing technique or theconfounding factors like age, biotype, crowding, ortho TX wascontrolled.
Noneof the observational studies satisfied all the specified criteria forquality appraisal.
Conclusion:
1.Data supporting the association b/w brushing and recession areinconclusive
2.Tooth brushing factors that have been associated with the developmentand progression of the recession are frequency, technique, force, andhardness of the bristles.
3.The limited evidence of one RCT suggests that the tooth brushingeither powered or manual and with standardized instructions intooth brushing technique may reduce the severity of recession.Importantconclusions to remember

KapfererI  2007            ARTICLE

Purpose:To assess the prevalence and severity of periodontal and dentalcomplications with the contributing factors of gingival recessionassociated with labial piercing.

M&M:A cross sectional study was performed on 100 (14-28yrs) patients withlower-lip studs. The test and control groups were matched accordingto the gender, age and smoking status. Clinical examination includedplaque and bleeding indices, probing depth, recession, clinicalattachment level, width of keratinized gingiva, periodontal biotype,frenula attachment, evaluation of hard tissues, trauma fromocclusion, stud features, radiographs and photographs of the lowerfront teeth.

R: NSSDwas observed in the mean probing depth, plaque control, and bleedingon probing of the test group compared to the controls. No significantcorrelations were observed with the prevalence of buccal recessions athe distribution of periodontal biotype between groups. Amount ofbuccal recession (occluso-apical and mesio-distal) and avg width ofkeratinized gingiva were significantly higher in test group comparedto the controls. Localized periodontitis was recorded in 4% of testsubjects. There were no significant associations between piercingand abnormal tooth wear. Time since piercing and the position of thestud in relation to the cemento–enamel junction weresignificantly associated with the prevalence of buccal recessions.

BL:Labial piercing was found to be significant factor in thedevelopment of the buccal recession in the mandibular anterior teeth.Narrow width of keratinized gingiva is associated with higher amountsof buccal recession.

Pires2010          ARTICLE

P:Cross sectional study to evaluate the periodontal status and riskfactors for gingival recession in individuals with tongue piercings.
M: 60individuals w tongue piercing and 120 w/o were examined from schoolsand universities in Brazil b/t 13 and 28 y/o, entire sampling wastaken from low socioeconomic status. recorded PD, CAL, plaque index,BOP, recession and tooth fracture
R:Thecase group presented with a higher prevalence and severity ofrecession when compared to the control group. The prevalence ofrecession in the anterior lingual mandibular region was associatedwith the use of piercings, male gender and BOP.
Recession inthe lingual of anterior mandible region presence: case: 55% control:10%
case:23% had1-2mm
13% had 3mm
18% had 4mm
control: 10%had 1-2mm
BL: Useof tongue piercings has a strong association with gingival recessionin ant lingual mandibular area.
Side note:prevalence of periodontitis for case: 11.7 and control 4.2
localizedsevere (either man or max: 6.7 and control 1.77
36.7%reported swelling and infection/inflammation
20% reportedfractured teeth

Endo ‘06            NO ARTICLE
Case series:Self inflicted gingival injuries caused by excessive oral hygienepractices
Categorized asNon-plaque induced gingival lesion. Physical injuries are classifiedas: Accidental, Iatrogenic (acute and self-limiting) andSelf-inflicted (SI) (chronic). SI can be deliberate injuries usuallyassociated with emotional disturbances. In kids SI are due damagewith their fingernails and in adults due excessive oral hygienepractice. SI can cause: ulcers, erosions, retractions,hyperkeratosis, CAL and destruction of teeth.

Case I
Female pt,1-month history of pain and bleeding on the buccal gingiva. Marginalgingiva was rolled, horizontal groove in the base of the papilla,linear ulcer #28, white plaque like changes in papilla and marginalgingiva. Brushed teeth 30 min a day due fear to loose more teeth withhard nylon toothbrush (TB), no toothpaste and horizontal motion. Dx:Excessive and improper tooth brushing. Instruction: Use soft TB, 2min, twice a day. Signs disappear within 2 weeks.

Case II
Female pt,3-month history of pain in the gingiva. Horizontal erythematousgroove in the base of the papilla, abrasion, white plaque likechanges in papilla detach with contact. History of 6 Rx fordepression and dry mouth. Brushed teeth 30 min a day/ 3 times becauseshe felt mouth uncomfortable. She used TB and no toothpaste. Dx:Excessive and improper toothbrushing. Instruction: Brush 2 min,twice a day. Use salivary substitute (biotene). Signs disappearwithin 1 week.

Case III
Female pt, 1year hx of painful gingiva in ant mand teeth, loss of tip of papilla.Lesions similar to NUG, lingual ant had lobulated appearance,recession, gingival clefts, white plaque changes, v-shaped gingivalrecessions present. Good medical hx. Pt was concerned withperiodontal disease. Pt used interproximal brush (IB) around 2 hoursa day (she inserted back and forward 100 times in each space b/wteeth, 3 times a day). Dx: Gingival trauma. Instructions: Stop use ofIB, use medium TB twice a day for 2 min. Gingival cleft and whiteplaque lesion disappeared by follow up 1 month later. Lingualgingival enlargements disappeared as well.
Conclusion:
Due fear ofperiodontal disease, these 3 pts practiced excessive tooth brushing.It is important to interview the pts about their oral hygienepractices and ask them to show you. Saliva function as a “blanket”that protects the soft tissue. Pts with xerostomia need to be awareof possibility of tissue damage. Salivary substitute may bebeneficial for them. Abrasion of teeth may be related to toothpaste. No interproximal abrasion in any teeth was noticed on case #3.

Miller,1985            ARTICLE

P: to classify marginal tissue recession.

Disc:

ClassI: Marginal tissuerecession which does not extend to the MGJ. No bone loss ininterdental area & 100% root coverage is expected.
ClassII: Marginal tissuerecession which extends to or beyond the MGJ. No bone loss ininterdental area & 100% root coverage expected.
ClassIII: Marginal tissuerecession which extends to or beyond MGJ. Bone or soft tissue loss ininterdental area is present or there is malpositioning of teeth whichprevents the attempting of 100% root coverage. Partial coverage isexpected.
ClassIV: Marginal tissuerecession to or beyond MGJ. Bone or soft tissue loss in interdentalarea &/or malpositioning of teeth is so severe that root coveragecannot be anticipated.
Rootcoverage is considered to be 100% if the marginal tissue aftercomplete healing is at CEJ & sulcus depth is 2mm or less andthere is no BOP.
Rootcoverage is either primary, which occurs immediately followinggrafting, or secondary, which is known as “creepingattachment.”

Lost,1984            ARTICLE

P:To assess the relationship between bony dehiscence and gingivalrecession.
M&M:Periodontal flap surgery was performed in 50 recession areas, 113affected teeth, in 27 patients (mean age 25.6 years), andpre-operative and intra-operative dehiscence measurements were taken(most apical portionof dehiscence to most apical portion of CEJ).All recessions met thefollowing criteria: located facially, intact interdental papillaeadjacent to area of recession, no interproximal bone loss, absence oftooth mobility, absence of periodontal pockets and no or minimalgingival inflammation.
R:Mean recession and dehiscence depth were 2.67mm and 5.43mmrespectively. The difference between these measurements –2.76mm – consists of 0.82mm sulcus depth, 0.63mm epithelialattachment and 1,22mm connective tissue attachment. Of the 113examined teeth, 16 presented markedly greater distance (4-7.5mm)between the gingival margin and the alveolar bone crest. Acorrelation between dehiscence depth and type of tooth could not befound, but the 1/3 of these 16 teeth presenting 4mm or more betweendehiscence depth and recession were lower canines.
C:In average, a recession depth of 1mm is exceeded by 2.8mm towards theapex of the alveolar bone dehiscence. Almost identical with the valuereported by Gargiulo (2.73mm). Each 1mm increase in recession depthinvolves an average of .98mm in the alveolar bone dehiscence.

Zimmer,2007            ARTICLE

P:To study the effect of orthodontic intrusion on trauma-inducedrecessions
M+M:12 patients (8F, 4M; average age 38 years) with >6 mmoverbite, and recession on at least one incisor caused by directtrauma from contact with opposing dentition. Five had Class 2 Div1and seven had Class 2 Div2. 6 patients had history of periodontaltreatment. All patients received fixed appliances and were treated byintrusion, one patient was taken out of the study due to recurrenceof periodontitis, all were on a 6 week maintenance schedule. 41 teethin total had recession, measured clinical crown lengths intra-orally,on casts and on photographs with an electronic precision slidinggauge. PDs were also measured. Teeth without trauma served ascontrols.
R:Four teeth excluded due to signs of incisal edge abrasion. At the endof treatment the clinical crown measurement of teeth withrecession had SS decreased by an average of -2.05 mm (maxdecrease was –3.2 mm, the min decrease was –0.9 mm; noincreases were observed). The average change in teeth withoutrecession defects was NSS and 0.02 mm (range of -1.2 to +2.4). Nochanges in PDs noted.
BL:Orthodontic treatment is effective in reducing recession caused bytrauma from deep overbite, and in teeth without trauma it can improvegingival marginal contour

Closs 2007             ARTICLE
P:To associate the amount of keratinized gingiva present in adolescentsprior to orthodontic treatment to the development of gingivalrecessions after the end of treatment.
M&M:Retrospective study. The sample consisted of the intra-oralphotographs and orthodontic study models from 209 Caucasian patientswith a mean age of 11.20 +/- 1.83 years on their initial records and14.7 +/- 1.8 years on their final records (28 days or more afterremoval of their appliances). Patients were either Angle Class I orII and were submitted to non-extraction orthodontic treatment. Thespacing or crowding in the lower anterior teeth could not exceed 4mm.Gingival recession was evaluated by visual inspection of the lowerincisors and canines as seen in the initial and final study modelsand intra-oral photographs. The amount of recession was quantifiedusing a digital caliper and the observed post-treatment gingivalmargin alterations were classified as unaltered, coronal migration ofthe gingival margin or apical migration of the gingival margin. Thewidth of the keratinized gingiva was measured from the mucogingivalline to the most apical point of the gingival margin at the center ofthe facial aspect of the teeth on the pre-treatment photographs.
R:The teeth that developed gingival recession and those that did nothave their gingival margin position changed did not differ inrelation to the initial amount of keratinized gingiva (3.00 +/- 0.61and 3.5 +/- 0.86 mm, respectively). Paradoxically, teeth thatpresented a coronal migration of the gingival margin had a smallerinitial amount of keratinized gingiva (2.26 +/- 0.31 mm).
C:The mean amount of initial keratinized gingiva did not predisposelower incisors and canines to gingival recession
CR-Whatmatters more is the direction of the ortho movement: if labially,outside of natural alveolar house, recession will occur.

Whatis the relationship of keratinized tissue and recession? Are patientswho are lacking keratinized tissue more likely to develop recession?Are recessions on teeth with limited KG more likely to progress?

Maynard1979             ARTICLE
Purpose: To present the physiologic dimensions of the periodontium significantto the restorative dentist.
Discussion:Physiologic dimensions have been classified as superficialphysiologic, crevicular physiologic and subcrevicular physiologic.
Intracrevicularmargins are the ones placed into the gingival crevice and aredifferent than subgingival margins that can extent into thejunctional epithelium and connective tissue, which causes gingivitisthat may progress to periodontitis.
Superficialphysiologic dimension extends from MGJ to gingival margin. Ifthere is insufficient attached gingiva restorative procedures mayresult in apical migration of marginal tissue and attachmentapparatus. In these cases preprosthetic surgery should be considered.Adequate band of KG is fundamental to successful restorativedentistry with intracrevicular margins. 2mm of free gingiva and 3mmof attached are required. Thickness of gingiva should also beevaluated. If the probe is visible through the free gingival margin,width should be increased.
When marginaltissue recession is present prior to the restoration twostage approach (increase in KG – root coverage) should beperformed.
Normaldepth of gingival crevice is 0 to 3-4mm. To prepare a toothfor intracrevicular margin a minimum depth of 1.5-2mm should bepresent. If it less than that junctional epithelium will betraumatized during restorative procedures. After periodontal surgeryrestorative procedures should be delayed for at least 6 weeks.Margins of restorations should not be rough and poorly adaptedbecause that will result in mechanical irritation and plaqueretention.
Subcrevicularphysiologic dimensions are on average 0.97mm for JE and1.07mm for connective tissue according to Gargiulo, Wentz and Orban,and violation of these could cause periodontal disease.
Traumafrom occlusion will cause reversible mobility in healthyperiodontium. If inflammation is caused because of the restorations,it will result in more rapid periodontal destruction.
Conclusion:The first and most basic objective of restorative dentistry ispreservation of the teeth. Function, comfort and esthetics are alsoconsidered and margins are intracrevicular although it is widelyaccepted that the best option is supragingival. Daily observation ofthe three physiologic dimensions permits the therapist to restoreteeth with minimal injury to the periodontium.

Wennstrom& Lindhe, 1983            ARTICLE

Purpose:Evaluate the effect of plaque infection on gingiva w or w/o AG andwith different height of the attachment apparatus.
Materialsand methods:
Created4 different dentogingival units in 7 dogs to determine differencesin resistance to inflammation
1. Normal  nonoperated, KG present
2. Normal  excised KG and allowed reformationNarrow KG, no AG, n.height of supp. app.
3. Periodontal breakdown – excised – ungrafted. Narrow KG,no AG, low height of supp. app
4. Periodontal breakdown  grafted. KG present, AG, low height of supp.app
Theyallowed plaque to accumulate for 40 days
Clinicalexam at day 0, day 20 & day 40 (PI, GI, Gingival Exudate, PD, AL,GM, AG)
2dogs randomly chosen for biopsy and sacrifice to perform histologyprior to plaque accumulation.
Results:
Gingivaregenerated postexcision and postgrafting is clinically andhistologically similar to normal gingiva.
Unitw/no AG had FG w/ thinner B-L & keratin layer.
3. After 40d of plaque accumulation, there was NSD btw dentogingivalunits regarding size and apical extension of infiltrated portion ofCT or GCF.
4. FG unit supported by alveolar mucosa is not more susceptible toinflammation than a FG unit supported by a wide zone of AG.
BL: The presence or not and the width of AG has an effect on theclinical evaluation of inflammation of the gingival but no effect ina histologic level. Supports Miyasato; Contradicts Lang & Loe,Bowers.
Cr-is 40 days long enough? This supports the clinical observation ofteeth with little or no AG remaining in a steady state for years.

Miyasoto1977            ARTICLE

P: Toevaluate gingival conditions in areas of minimal and appreciablewidth of KG.
M&M: 250 dental, dental hygiene and dental assisting students and dentalfaculty were screened. 16 subjects were selected, age 19-39. 6 ofthem had one lower PM with a width of KG ≤1mm and a PM with widthof KG ≥ 2mm on the opposite side (contralateral pair). Theremaining pts had width of KG ≤ 1mm on one PM and ≥2mm onanother PM on the same side (unilateral pair). Subjects withhigh frenum attach were excluded. Measured GE, GI, sulcusdepth, PI, AG. The 6 pts with contralateral pairs were used forexperimental gingivitis study- asked to cease OH and were re-examinedat 4,7,11,14,18,21,25 days and measured GE, PI, and GI.
R: Mean widthof KG were 0.7mm and 2.3mm for the study pairs. None of the teethwith minimal KG (≤1mm) had any amount of attached gingiva. 0/16showed presence of plaque on mid buccal surface, 2/16 with min widthof KG showed sigs of GI/color change/swelling. No areas showed BOPin either ≤1mm or ≥2mm KG. NSSD between the groups for GE. For the experimental gingivitis, there was a gradual and similarincrease in plaque and GE for both groups. Not until day 25 didbuccal areas show signs of inflammation, 6/6 areas with KG ≤ 1mmshowed inflammation and 4/6 areas of ≥2mm KG showed inflammation.
C: Gingivawith ≤1mm of KG and ≥2mm of KG only exhibit minute amounts ofgingival exudate, which correlated with lack of clinical signs ofinflammation for both types of marginal gingiva. After the 25 dayexperimental gingivitis, there was only a gradual increase in PI.There was no diff in GE in areas with min or appreciable KG. Thismay indicate that areas of min width of KG are no moreprone to the development of plaque-induced inflammatory changes thanareas of appreciable width of KG.
BL: Overthe 25 day period, there was in increase in plaque and GI andclinical inflammation, with no apparent difference between theareas with minimal or appreciable width of KG.

Whatis the theory behind a free gingival graft? How does it heal? Inwhich situations is a free gingival graft appropriate? Describe thetechnique you prefer for a Free Gingival Graft. Is there anydifference if attempting to increase keratinized tissue vs coveringrecession? What are the drawbacks or complications of a free gingivalgraft?

Sullivan1968          ARTICLE

P:report our observation on free gingival grafting and toattempt to correlate the surgical principles previously developed inplastic surgery to the conditions encountered in periodontal
Recipentsite:
The mostimportant is the capacity of the recipient bed to form capillaryoutgrowths for vascularization of the graft.
Adequatehemostasis. Bleeding site will separate the graft and form ahematoma.

Procedurefor recipient site preparation:
Allow adequatetime for hemostasis – control bleeding.
Epithelium,CT, and muscle fibers are sharply dissected down to the periosteum.
Donor site:
Edentulousridge
Avoid visiblepostextraction scars, decreased vascularity
Attachedgingiva
Limited, notsuitable when inflamed and hyperplastic. Requires reshaping.
Palatal mucosa(most common)
Submucosashould be removed wit ha scalped before grafting, it will act as abarrier both to diffusion and vascularization.
Greaterpalatine foramen/vessels – may limit the surgical site.
Graftstypes: Full thickness and intermediate or thick splitthickness gingival grafts.
Thicker graftwill undergo greater immediate contraction upon detachment from thedonor area (higher elastic fiber in the graft)
Secondarycontraction is caused by cicatrization of the tissue, which unitesthe graft and its base.
A thick grafton a rigid bed offers maximum resistance to cicatrix contraction andthus will undergo little secondary contraction.
Graf survivalis enhanced by decreasing the amount of lamina propria in the graft.Thinner graft can be more easily maintained by diffusion and iseasier to vascularize.
However,thicker graft is indicated in area where greater functional demandsare anticipated (it’s resistance to functional stress)
Procedurefor Donor site preparation:
A tin foil orwax template may be made on the recipient bed.
Atraumaticremoval of donor tissue is the most important aspect.
An accessincision is made at a 45 degree angle adjacent to the outline of thegraft. This assists the surgeon in achieving the desired graftthickness.
The donortissue is placed in the recipient bed as soon as possible to mintrauma and dehydration.
Immobilizationof the graft VERY IMPORTANT)
in arealacking vestibular depth at the recipient site – this conditionmay be corrected by performing a vestibular extension in conjunctionwith preparing the recipient site.
The stepsin immobilization
Suturing:
The graft isstretched to conform to the recipient bed. This tension counteractsprimary contraction and aids in vascularization by reopening thegraft’s collapsed vessels.
Minimal numberof sutures is used (author used 5-0 teflon-coated Dacron suture withan atraumatic needle)
Formation of afibrin clot.
Aftersuturing, Pressure is exerted against the graft for 5 mins todisplace blood under it. Fibrin clot anchors the graft to its bed,allow rapid penetration by capillaries, and act as a matrix throughwhich metabolites and waste products diffuse.
Placement ofthe rubber dam – functions as a sliding film btw the dressingand the graft (reduces the shearing forces that preventvascularization.
Dressing –maintains a positive pressure on the the graft and aids in itsimmobilization.
Stages of agraft “Take”
Plasmiccirculation – diffusion of the graft from its host bed andoccurs most efficiently through the fibrin clot.
Vascularization– capillary proliferation (end of 1st day) ->extended into the graft (2-3rd day) ->circulation (3rdday) -> adequate blood supply (8th day)
Organic union(4-5th day) – a fibrous attachment is complete bythe 10th day.
Post-Opcare
Recipientsite:
The first 6days – the pt is instructed to minimize facial movement.
Do not removethe dressing before the 6th day.
If infectionis present, remove hematoma formation or infection- redress for anadditional 5 days.
Donor site:
Protected by adressing until it has epithelized.
Thinnersplit-thickness grafts heal faster
Full thicknessrequire primary closure or coverage.
Problemsand possible limitation
The capacityof the recipient bed to form capillary outgrowths, hemostasis of therecipient bed, atraumatic handling of tissue, rapid vascularizationof the graft, adequate immobilization during healing, and properpost-op care.

Miller ‘85            ARTICLE

Purpose:To measure the root coverage using a free soft tissue autograftfollowing citric acid (CA) application.
M&M:100 consecutive marginal tissue recession on 49 females and 9 males. Width of the recession was constant (around 3mm), but depth (marginaltissue recession + PD) was very variable 2-14mm. Control group wasdiscontinued after recession and sensitivity were present 10 dayspost op in 3 control pts. Technique: CA solution of pH1 mixedwith anhydrous CA crystals (15 min allowed for dissolution) were usedin combination to make the CA super-saturated. CA on a cotton pelletwas used to “burnished” the root surface. The cotton waschange 2-3times a min, and the area was “burnished “for5min. CA was flushed with abundant water. After CA applicationincisions were made. The horizontal incision in made in theinterdental papilla at the level of CEJ. Vertical incisions made atprox line angles of adjacent teeth. Retracted tissue was completelyexcised. Care was taken to maintain intact periosteum. Graft wasremoved from the donor site using a “dry” foil pattern.Most (but not all) of the submucosa (glandular and adipose tissue) isremoved by sharp dissection. The inner surface of the graft was assmooth as possible. Thus avoiding “dead space”.Resorbable sutures were used on each papilla after positioning thebutt joint of the graft close to the butt joint of the papilla. 2additional interrupted sutures were placed in each corner of thegraft and into the periosteum. Coe-pak and adhesive “dry”foil was placed for 2w. Criteria: 100% root coverage (RC) wasconsidered when gingival margin was at CEJ, PD 2mm and no BOP. RC wasconsidered primary if it was found at 10w post-op or secondary ifobtained after 10w. If RC was not 100% at 10w, a recall visit at 1ywas performed to see if 100% RC could be obtained by a secondary RC.Class I recession were included only when were next to a class II orIII, if had been isolated grafting wouldn’t be needed.
Results:100% RC is attainable only in class I and II. In class I and II 100% RC was obtained in 71 of 79 sites 90%, partial in 4 of 79 (5%) andno RC in 4 of 79 sites (5%). Averaged of overall gain was 3.79mm andof probing attachment gain 4.54mm. Class I recession: 100% RC on all13 sites. Class II: 100% RC on 58 of 66 sites (88%). Only 1 toothneed RCT after therapy (it had 5mm recession, 6mm PD, hx of ortho txand vitality was not performed bf sx.
BL:Complete RC can be successful and predictable using soft tissue graftand the right concentration of citric acid as a one stage procedure.
Ctq:Some sites need a 2nd stage for complete RC. No controlgroups.

Miller1987            ARTICLE

Summary:Complete root coverage has been defined according to the followingcriteria:
A)The soft tissue margin must be at the CEJ. B) There is clinicalattachment to the root. C) Sulcus depth is <2mm D) No BOP. Failing to address certain factors can result in incomplete rootcoverage.
Factorsassociated w/ incomplete coverage:
1.Improper classification of marginal tissue recession. First step inpredicting is classifying recession.
2.Inadequate root planing, not creating anatomy conducive to rootcoverage.
3.Failure to treat the planed roots w/ Citric Acid. Surface changesafter conditioning w/ CA include widening of the dentinal tubules,removal of the smear layer, accelerated healing w/ acceleratedre-attachment, inhibition of epithelial migration, and the formationof a CT attachment. Do this prior to preparing recipient site as CAcauses coagulation of blood.
4.Improper prep of the recipient site. The horizontal incision must bemade at the level of the CEJ. If the incision is made apical to theCEJ, complete root coverage should not be contemplated. Authorrecommends creation of a butt joint margin in the papilla to enhancecirculation to the coronal aspect of the graft. Vertical incisionsshould be made at the line angles of adjacent teeth. Recipient siteshould be prepared a minimum of 3 mm apical to the recession.
5.Inadequate size of the interdental papillae. The broader and thickerthe interdental papilla, the greater the blood supply to the coronalaspect of the graft and the easier the suturing.
6.Improperly prepared donor tissue. The undersurface of the graftshould be flat and smooth w/ the graft having the same type of buttjoint margins as those created in the papilla.
7.Inadequate graft size (too much better than too little) / Inadequategraft thickness (thicker better).
8.Dehydration of the graft. Place graft immediately on a bleedingrecipient bed to minimize dehydration.
9.Inadequate adaptation of graft to root and remaining periosteal bed.Failure to stabilize graft.
10.Excess or prolonged pressure in adaptation of sutured graft.
11.Reduction of inflammation prior to grafting. A bleeding papilla mayenhance circulation to the coronal margin of the graft.
12.Trauma to graft during initial healing. Examples include: loosedressing, excessive edema, or stretching or manipulating the lips,and incising foods that can loosen dressing. Give adequate post opinstructions.
Excessivesmoking. 100% correlation b/w failure to obtain root coverage andheavy smoking (in excess of 10 cigs/day). Heavy smokers shouldrefrain from smoking during the 1st 2 post-op wks.

Matter,1980*         ARTICLE

Background: creeping attachment is apost-op migration of the free gingival margin in a coronal directioncovering partially or totally a previously denuded root.
P: To report creeping attachmentsubsequent to placing a free gingival graft in areas of narrowrecession, over a 5 year follow-up period.
M&M: 10 patients (9 Females, 1Male), age 25-45. Isolated narrow recessions, <3 mm inwidth. After OHI and initial th

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33 GINGIVAL FLAP SURGERY

HOME PERIO TOPICS 

Replaced Flap Technique

  • What are the differences and similarities between the modified Widman, open flap curettage, and replaced flaps? What names, if any, do you associate with these procedures?

  • What were the original objectives of these procedures? Are they achievable? Do they differ from the current objectives?

  1. Ramfjord SP, Nissle RR. The modified Widman flap. J Periodontol 1974; 45;601-607

  2. Ramfjord SP: Present status of the mofified Widman Flap procedure. J Periodontol 48:558-565, 1977

  3. Nabers CL. Repositioning the attached gingival. J Periodontol 1954; 25:38-39

  4. Ammons WF, Smith DH: Flap curettage: Rationale, technique, and expectations. Dent Clin NA 20:215-226, 1976

Flap Design

  1. Kaldahl, W., Kalkwarf, K, Patil, K: A review of longitudinal studies that compared periodontal therapies. J Periodontol 64:243-253, 1993

  2. Johnson RH: Basic flap management. Dent. Clin. North Am. 20:3-21, 1976.

  3. Kon S, Caffesse RG, Castelli WA, Nasjleti CE: Vertical releasing incisions for flap design: Clinical and histological study in monkeys. Int. J. Perio. Restorative Dent. 4(1):49, 1984.

  4. Lynch TJ, et al: A comparison of mandibular lingual surgical flaps with and without a vertical releasing incision. J. Periodontol. 59:12-17, 1988.

Replaced Flap Results

  1. Jenkins MM, Wragg PF, Gilmour WH: Formation of interdental soft tissue defects after surgical treatment of periodontitis. J Periodontol 61:564-570, 1990

  2. Cattermole AE, Wade AB: A comparison of the scalloped and linear incisions as used in the reverse bevel technique. J. Clin. Periodontol. 5:41- , 1978.

  3. Newman PS: The effects of the inverse bevel flap procedures on gingival contour and plaque accumulation. J. Clin. Periodontol. 11:361-366, 1984.

  4. Haffajee AD, et al: Effect of modified Widman flap surgery and systemic tetracycline on the subgingival microbiota of periodontal lesions. J. Periodontol. 15:255 -, 1988.

Replaced Flap Healing

  • Describe the wound healing following each of these procedures.

  1. Listgarten MA: Electron microscopic study of the junction between surgically denuded root surfaces and regenerated periodontal tissues. J. Periodontal Res. 7:68-90, 1972.

  2. Caton J, Nyman S: Histometric evaluation of periodontal surgery. I. The modified Widman flap procedures. J. Clin. Periodontol.7:212-223, 1980.

  3. Proye MP, Polson AM: Effect of root surface alterations on periodontal healing. I. Surgical denudation. J. Clin. Periodontol.9:428-440, 1982.

  4. Caffesse RG, Castelli WA, Nasjleti CE: Vascular response to modified Widman flap surgery in monkeys. J. Periodontol. 52:1-7, 1981.

  5. Steiner SS, Crigger M, Egelberg J: Connective tissue regeneration to periodontally diseased teeth II. Histologic observations of cases following replaced flap surgery. J Perio Res. 16:109-1981.

  6. Svoboda PJ, Reeves CM, Sheridan PJ: Effect of retention of gingival sulcular epithelium on attachment and pocket depth after periodontal surgery. J Periodontol. 55:563-566, 1984.

  7. Bahn L, Broxson A, Yukna RA: Evaluation of the purposeful implantation of epithelium on root surfaces under periodontal flaps. Int. J. Perio. Restor.Dent. 7(2): 69-76, 1987.

  8. Yaffe A, Iztkovich M, et al. Local delivery of an amino bisphosphonate prevents the resorptive phase of alveolar bone following mucoperiosteal flap surgery in rats. J Periodontol68:884-889,1997.

  9. Zitzmann NU, Lindhe J, Berglundh T. Host response to microbial challenge following resective/non-resective periodontal therapy. J Clin Periodontol. Nov;32(11):1175-80. 2005

  10. Zitzmann NU, Berglundh T, Lindhe J. Inflammatory lesions in the gingiva following resective/non-resective periodontal therapy. J Clin Periodontol. Feb;32(2):139-46. 2005

  11. Retzepi M, Tonetti M, Donos N. Comparison of gingival blood flow during healing of simplified papilla preservation and modified Widman flap surgery: a clinical trial using laser Doppler flowmetry. J Clin Periodontol. Oct;34(10):903-11. 2007

  12. Retzepi M, Tonetti M, Donos N. Gingival blood flow changes following periodontal access flap surgery using laserDoppler flowmetry. J Clin Periodontol. May;34(5):437-43. 2007

Fiber Retention

  • Describe the fiber retention procedure. Does it improve clinical results?

  1. Levine HL, Stahl SS: Periodontal flap surgery with gingival fiber retention. J Periodontol 43:91- 98, 1972.

  2. Levine HL, Stahl SS: Repair following flap surgery with retention of gingival fibers. J. Periodontol. 43:99-103, 1972.

  3. Lindskog S, Lengheden A, Blomlof L. Successive removal of periodontal tissues. Marginal healing without plaque control. J Clin Periodontol 1993; 20:14-19.

Replaced Flap Technique

  • What are the differences and similarities between the modified Widman, open flap curettage, and replaced flaps? What names, if any, do you associate with these procedures?

  • What were the original objectives of these procedures? Are they achievable? Do they differ from the current objectives?

Topic:the modified widman flap                               Article

Authors: Ramfjord SP, Nissle RR

Title:The modified Widman flap

Source: J Periodontol 1974; 45;601-607

Type:Dicussion

Rating: Good

Keywords: modified widman flap, incisions

Background:Widman introduced the reverse (internal) bevel scalloping type of gingival incisions in 1916. The term Modified Widman flap was adopted to designate a flap procedure which has been modified by several persons and came to designate an open subgingival curettage for re-attachment and re-adaptation of the pocket walls rather than surgical pocket elimination.

Purpose:To discuss the currently used modifications of the Widman flap and their rationale.

Discussion: Following initial scaling, removal of gross overhangs and OHI at least 3-4 weeks should lapse before the MWF is performed. This will allow for healing and maturation of collagen in the inflamed gingiva and thus facilitate precise flap adaptation and optimal wound contraction towards the tooth surface post-operatively.

  1. The initial incision is directed parallel to the long axis of the tooth.

    • If the buccal pocket is >2mm the incision should be placed at least 0.5-1 mm away from FGM (to remove crevicular epithelium).

    • If shallow PDs are present or in esthetic area, the incision should be intrasulcular or at the free gingival margin.

    • The scalloping effect should be exaggerated on the palatal aspect. Be sure to direct the scalpel slightly palatal to the long axis of the tooth aiming for the alveolar process 1-2mm palatally to the alveolar crest otherwise flap adaptation or flap contour will not be satisfactory.

    • It is important to remove only a minimum amount of interproximal soft tissue to ensure complete coverage. Vertical releasing incisions are usually not required; if necessary, through interdental papilla into AG extending 2-3 mm apical to the initial incision at the end of each flap.

    • Avoid vertical incision in the palate in the second bicuspid, first and second molar areas.

    • Use mucoperiosteal elevators to raise a FTF only for 2-3mm or the minimum needed to reflect the flap enough to gain access to the root surface and alveolar bone with very careful full thickness reflection.

  2. The Second incision is made intrasulcular from the bottom of the crevice to the alveolar crest.

  3. The Thirdand last incision is done with a very sharp Orban interproximal knife to cut loose the collar of gingival tissue that has already been separated. Follow contour of alveolar crest and interproximal septum as much as possible. The loosened collar is removed with curettes.

1

2

3

4

The part of the root surfaces that have been exposed in the periodontal pockets are thoroughly curetted and planned, trying to leave areas previously unexposed with their PDL attachment. Remove soft tissue from the bony surface on intrabony lesions. Avoid prolonged reflection of the flaps and irrigate with saline to avoid drying of the bone. Flaps should be adapted on the bone and meet interproximally. Finger pressure is applied. If adaptation between buccal and palatal flap is incomplete, thin flaps or remove bone from outer aspects of alveolar process to enhance flap adaptation. Suture with interrupted sutures. Do not take deep bites because the interproximal flap margins may fold and prevent primary healing. Periodontal dressing used to hold flaps tightly against the bone. The dressing is removed after one week, teeth are polished an OHI are given.

Advantages:

  • Access for proper instrumentation of the root surfaces and the furcation areas.

  • Intimate post-op adaptation of healthy collagenous tissue to all tooth surfaces.

  • A marginal new epithelial attachment forms which tends to seal off the deeper areas of separation between tooth and surrounding tissues. Thus, the healing CT may adapt closely to tooth surface and re-attachment with new cementum may develop gradually from the apical aspects of the lesion.

  • In the long run, there is less interproximal recession with MWF than surgical pocket elimination, which is esthetically desirable, facilitates OH, results in less sensitivity and caries.

Disadvantages:the flat or concave interproximal architecture immediately following removal of the surgical dressing, especially in areas of interproximal bony craters.

Indications:i) Deep pockets, ii) intrabony pockets, iii) when minimal recession is desired.

Topic: Periodontal flap                                No Article

Authors: Ramfjord SP:

Title:Present status of the mofified Widman Flap procedure.

Source:J Periodontol 48:558-565, 1977

Type:Discussion paper

Rating: Good

Keywords: periodontitis, flap

Discussion:Widman in a modification of his original technique is the first person to describe the reverse bevel incision. The modified Widman flap procedure provides access for proper instrumentation of the root surfaces and immediate closure at the dentogingival junction between the teeth and well fitting flaps. It is important that an Achromycin ointment and a surgical dressing to prevent plaque invasion during the first week of healing and tissue adaptation to the tooth also cover this junction.

  • Rosling, 1976- Based on data from 105 patients studied longitudinally over 7 years. Comparing pocket elimination, curettage and modified widman flap procedure, average pocket reduction for 7- to 12-mm pockets was best following the modified Widman flap surgery.

  • For deep pockets in the mandibular anterior region, the results following subgingival curettage or modified Widman flap surgeries are significantly better with regard to gain of attachment than pocket elimination surgery.

  • The interproximal attachment level is maintained better following the modified Widman flap than following curettage in maxillary molars (4- to 6-mm pockets).

  • Attachment changes are most favorable over 7 years following modified Widman flap surgery, (4- to 6-mm pockets).

Indications for MWF: The greatest advantage of this procedure is in the treatment of (1) deep pockets, (2) intrabony pockets and (3) when minimal gingival recession is desired.

Topic:Attached gingiva and flap repositioning                               No Article

Authors:Nabers CL

Title:Repositioning the attached gingiva.

Source:J Periodontol 1954; 25:38-39

Type:Commentary

Rating:Good

Keywords:attached gingiva, repositioned flap

Purpose:Discussion article on the repositioned flap

Discussion:Repositioning the attached gingiva is indicated when the periodontal pocket extends beyond to mucogingival junction. In these cases, a gingivectomy is not indicated as the incision will be entirely in the mucosa resulting in a gaping wound, delayed healing, pain, and the margin will be covered by a tissue not resistant to the functional requirements of mastication.

Technique:A vertical incision is made mesial to the area of deepest pocket. The flap reflected, the area debrided, inside of the flap cleaned and the gingiva trimmed along the margin leaving 2mm, and the flap was then sutured further apically. This allows for retention of attached gingiva with elimination of the pocket.

Conclusion:Attached gingiva can be repositioned to the alveolar crest in cases where the base of the deep periodontal pocket was located apically to the mucogingival junction.

Topic:Gingival Flaps                               Article

Authors: Ammons WF, Smith DH

Title:Flap curettage: Rationale, technique, and expectations.

Source:Dent Clin NA 20:215-226, 1976

Type:Discussion

Rating: Good

Keywords:curretage

Purpose:To discuss curettage (conventional and open flap) rationale, technique and expectations.

Discussion:Historically a flap approach was used to provide access to underlying structures. Initially (1884) the purpose was to remove the “necrotic or infected” bone and later to visualize and remove calculus and debris from the deep periodontal pockets.

Thefundamental goal of all periodontal therapy is the retention of the natural dentition in a relative state of health, comfort and function for the life of the patient.

Surgical goals are 1) debridement of the pocket and root surfaces, 2) elimination of periodontal pockets, 3) maintenance or establishment of an adequate functional band of attached gingival tissues and 4) production of a contour and form to the periodontium that can be maintained.

Rationale for flap curettage is related to accessibility, debridement, repair and patient comfort. Advantages include access, facilitation of instrumentation, reattachment by regeneration of new tissues, preservation of periodontal support, elimination or reduction of deep pockets, minimization of postsurgical trauma, pain, root sensitivity and promotion of better home care by the patient.

Technique:With a No 15 blade an inverse bevel incision is made following the contour of the necks of the teeth 1mm lateral to apex of the free gingival margin to produce a thinned and scalloped flap. This incision is made to the crest of the marginal alveolar bone, score the periosteum and directed to removal epithelial lining. It should be extended as far as possible in the interdental areas to retain sufficient interdental papillae to ensure tight closure upon re-adaptation of the flaps. A horizontal incision can then be made to thin the papillae or the papillae may be elevated intact.

Flaps can be extended 1-1.5 half tooth mesially and distally for access. Vertical incisions can also be performed.

Since the prime advantage of the flap is access, the flap should be elevated beyond the MGJ. On the palatal side the usual procedure is to exaggerate the scalloping. The tissues that remain attached to the tooth are then removed with an Orban knife and debridement with ultrasonics is performed.

After debridement the flaps should be placed to only cover the buccal and lingual bony margins. This results in stable post-surgical results. Individual or continuous vertical mattress or interrupted sutures are indicated so good adaptation of interproximal tissues is achieved. Dressing can be placed and sutures are removed after 5-7 days. After suturing Pressure is applied for 3 minutes.

Flap curettage can be used in areas where regeneration can be performed or as initial preparation before orthodontic movement.

Subgingival curettage gives more favorable result regarding preservation of attachment level but less favorable pocket reductions comparing to surgical techniques. It is also more difficult to perform in patients with advanced periodontal disease and deep pockets.

Flap Design

Topic: Comparison of therapy                                No Article

Authors: Kaldahl, W., Kalkwarf, K, Patil, K

Title: A review of longitudinal studies that compared periodontal therapies.

Source: J Periodontol 64:243-253, 1993

Type: Clinical

Rating: Good

Keywords: Osseous surgery, MWF, Scaling, root planing, comparison study

Purpose : Literature review of different studies, comparing the effects of two or more periodontal therapies on various clinical parameters.

Materials and methods:

  • Studies that were reviewed included Michigan studies, Swedish studies, Minnesota study, Washington study, Denmark study, Loma Linda study, Arizona study, Nebraska study etc.

Results:

  • Both surgical and non-surgical treatment produced improvement in periodontal health.

  • Surgical treatment lead to more short term PD reduction than non-surgical treatment. In deeper PD sites, the short term results comparing mean attachment change following non-surgical and surgical treatment were mixed.

  • Surgery produced a greater loss of probing attachment in shallow sites, both short and long term.

  • In most studies, no long term differences in mean probing attachment level change were present between surgical and non-surgical studies.

  • NSSD between surgical and non-surgical in gingival inflammatory indices. When the effects of plaque control alone and plaque control with root planing were compared, root planing produced a superior response in the clinical parameters.

BL:SRP w/ plaque control produces better response in clinical parameters than just plaque control. Both surgical and non-surgical treatment produced improvement in periodontal health.

Topic:Gingival Flap Surgery                               Article

Authors:Johnson RH

Title:Basic flap management

Source:Dent. Clin. North Am.  20:3-21, 1976.

Type:Review article

Rating: Good

Keywords: flap reflection, suturing, retromolar pad area, keratinized gingiva

P:Review article on basic flap management.

D:

1. To Split or Not to Split: Author recommends FTF in most situations; in presence of thin bone & dehiscences, a STF may be indicated. It may be considered that by blunt dissection, a FTF retaining the periosteum is like a STF.

2. Don’t throw gingiva away! Retain as much gingiva as possible during flap reflection. Alveolar mucosa is not designed to withstand insults of tooth brushing or eating.

3. Palatal flap: should be scalloped so that margin ends up at crest of bone. 

4. Primary incisions:  extend far enough M or D so proper access to the underlying bone is exposed (at least 1 tooth each side). Not only is it difficult to see what is going on, but healing is delayed because of the trauma inflicted on the flap. Also, this allows the clinician to drape the relaxed flap while apically repositioning.

5. Flap reflection: reflect in a relaxed manner; vertical releasing incisions should only be used when necessary and not over prominence of roots and not on palatal or ling of third molars; author feels extension of sulcular incision (but do not include uninvolved teeth) is better than vertical releasing incisions that can appear to retard healing. Author discusses exposure of tuberosity region and retromolar pad area- incisions should be kept in keratinized mucosa and regions should be opened adequately to expose bony problems distal to the terminal molar. Do not perforate base of flap this will sever blood supply. Preserve KG; thin very wide tissue to approximate flaps.

6. Suturing:Pay attention to suturing to ensure correct placement. Let sutures hang loose on buccal, snug on the palatal. Author recommends using the continuous sling suture described by Dahlberg when FTF. APF the flap when doing pocket reduction surgery. Apply pressure with a gauze for a few minutes to ensure that the flap is resting in the desired position.

Topic:Vertical releasing incisions                               Article

Author:Lynch TK, et al.

Title:A comparison of Mandibular Lingual Surgical Flaps with and without a Vertical Releasing Incision

Source:J. Periodontol. 59:12-17, 1988

Type:Prospective study

Rating: Fair

Keywords:Mandibular lingual flaps; vertical releasing incision; postoperative pain; clinical healing

Purpose: To compare the short-term post-op pain and healing from surgical flaps with mandibular lingual vertical-releasing incisions vs. envelope flaps.

Methods: 12 patients (7M, 5F) were evaluated using a split mouth design: (1) envelope flap and (2) with lingual vertical releasing incisions. The procedures consisted of debridement alone or debridement plus osseous recontouring. All patients were prescribed 6 tables of 300mg acetaminophen and 30mg codeine, and were instructed to only take if they experience pain. Patients were given a Symptom Data Log to complete for the first 14 days post-op: Patients reported daily pain (scale 0-4) and also the number of prescribed tablets taken each day. Photographs were taken at 1 and 2-week post-operative visits, and were used to assess healing.

Results:NSSD was noted between the 2 procedures with respect to healing and pain, however better access was achieved with the releasing incisions.

Discussion: This study supports the use of vertical incisions. Suturing the vertical incision on the mandibular lingual is usually avoided because of the thinness of the tissue. Vertical releasing incisions (VRI) are contraindicated in areas with prominent ledges, concavities and exostoses due to difficulty in tissue management. Guidelines for VRI: Should be done at line angle, extend beyond MGJ, don’t release distal to 2nd molar, and shallow vestibule is not a contraindication.

Topic:flap healing                               Article

Authors: Kon S, Caffesse RG,

Title:Vertical releasing incisions for flap design: clinical and histological study in monkeys.

Source:Int J Periodontics Restorative Dent. 1984;4(1):48-57.

Type:clinical trial

Rating: good

Keywords:vertical incisions, releasing incisions, healing, periodontium,

Purpose: To investigate the clinical and histological healing process of two different vertical releasing incisions in monkeys: one perpendicular and one beveled to the underlying alveolar bone.

Methods:2 Rhesus monkeys received 10 full thickness flaps in molar/premolar areas with 2 vertical releasing incisions at interproximal areas: one perpendicular, the other beveled to the alveolar bone. They extended from the margin straight down apically to the mucogingival line. Incisions were assigned randomly by flipping a coin. The flaps were reflected and the dento-gingival area was curetted. The flaps were replaced and secured by sutures. No sutures were placed at the vertical releasing incisions. Animals were sacrificed at 9, 14, 21 and 28 days after the procedures. Pelican carbon black ink was injected to evaluate revascularization. Cross-sections were obtained, stained, and histological analysis was performed.

Results:Immediately after surgery the full thickness flap was well adapted and the two different vertical releasing incisions showed no clinical difference.

At 9 days post-op, the marginal tissues associated with the perpendicular incision area showed a groove that could not be observed in beveled incision area.

Histologically, 9 days post-op, at perpendicular incision area the smooth keratinized oral epithelium with regular rete pegs is disrupted, irregular and enlarged rete pegs interrupting the normal vascular arrangement of the loop capillaries are noticed. The perpendicular incision showed more inflammation than the beveled one. The soft tissue groove and the microvascular gap are also quite evident at the perpendicular incision site while the beveled incision exhibits only a slight defect.

14 days post-op, at the perpendicular incision area a groove or depression is still evident, the capillary loops at this site are shorter and irregular compared to the beveled incision site.

21 and 28 days post-op a groove is still present at the perpendicular incision, rete pegs more irregular than in beveled incision area. Connective tissue fibers are completely re-organized at the beveled area.

The healing with both of the incisions was always more advanced in the deeper areas, away from the gingival margin.

Conclusion:Healing in the beveled incision was faster owing to a larger soft tissue interface. Soft tissue grooves were more frequently noted in association with perpendicular incisions.

Replaced Flap Results

Topic:soft tissue defects                               Article

Authors: Jenkins MM, Wragg PF, Gilmour WH

Title:Formation of interdental soft tissue defects after surgical treatment of periodontitis

Source:J Periodontol 61:564-570, 1990

Type:clinical study

Rating: Good

Keywords:gingival/anatomy, tissue/anatomy, periodontal disease/diagnosis, interdental clefts, interdental craters, periodontitis/surgery

Purpose:To evaluate interdental soft tissue healing following repositioned (replaced) flap surgical techniques and determine:

  1. How often do interdental soft tissue defects arise and their capacity for repair

  2. If pre-op probing depth, underlying bone defect, or use of periodontal dressing is related to defect development

  3. If soft tissue defects interfere with establishment of periodontal health after surgical treatment

Methods:21 patients (30-57 years old) were selected with remaining deep pockets with BOP after SRP completed. 46 surgical procedures were completed. No osseous recontouring was done, only root planing. Coe-pak was used in every alternate procedure after suturing (silk). Dressing and sutures were removed 1 week post-operatively. Patients were told to brush carefully for the first 2 weeks and CHX was prescribed for 2 months. Maintenance was completed for the duration of the study based on patient needs. Probing depth and BOP were measured pre-operatively, at 1, 3, and 6 months. Bone defects were assed at the time of surgery. At each post-op visit, interdental space was evaluated for the presence of a “crater” (visible depression within the interdental tissue at least 1 mm in depth) or “cleft” (soft tissue interdental defect with no visible concavity but the buccal and lingual interdental tissues could be separated with a probe to a depth of at least 1 mm). Where craters were detected, an impression was taken and poured up in dental stone. Craters were then measured by a reflex microscope. Crater sites were measured in this fashion at 3 and 6 month visits.

Results:At 1 month, 13 clefts and 30 soft tissue craters were noted. There was evidence of some reduction over time of the clefts. Probing depths were reduced at one month at all sites, as well as bleeding regardless of presence of craters or clefts. Generally there was no obvious association between the use of periodontal dressing and the subsequent occurrence of interdental soft tissue defects. 3 craters exceeding 1 mm were noted in 1 patient. At 18 months, 2 craters had entirely disappeared. No BOP was noted and PD were 2mm.

Conclusion: The development of interdental soft tissue defects, both craters and clefts, during the early stages of healing following periodontal surgery does not seem to adversely affect the ultimate establishment of periodontal health.

Topic:Scalloped and linear incisions                               Article

AuthorsCattermole AE, Wade AB

Title:A comparison of the scalloped and linear incisions as used in the reverse bevel technique.

Source: J. Clin. Periodontol. 5:41- , 1978.

Type:Clinical study

Rating: Good

Keywords:scalloped, linear incisions, healing, inflammation

Purpose:To evaluate the use of scalloped and linear incisions in reverse bevel techniques with regard to pocket elimination, rate of healing and gingival contour produced.

Materials and methods:

  • Split mouth design. 20 patients (22-48 years) needing surgery on each side on one or both jaws were included. 40 FTF were performed.

  • Selection criteria:

    • The area involved was from first bicuspid to 2nd molar. Symmetry with regard to PDs on both right and left sides of the arch involved. PD no greater to 6mm. Radiographic evidence of horizontal bone loss. Absence of any systemic disease.

  • Pre-op therapy: scaling, polishing, OHI. Patients should demonstrate high degree of plaque control.

  • Immediately pre-op GCF was collected (filter paper strips), GI, PI, PD, CAL, gingival contour, study models obtained. Measurements for GCF, GI, PI were repeated at 1, 2, 3, 4, and 12 weeks post-op and for PD, CAL at 12 weeks post-op.

  • Using a split mouth technique both posterior segments of an arch were treated at one appointment. On one side of the arch a linear incision was performed on the buccal and lingual aspect and one the other side ascalloped incision. Ιncisions started 1-2mm from the gingival margin. Tissue collar was removed. FTF was reflected, degranulation, sc/rp, osteoplasty performed. Flaps sutured at the bone level. Perio dressing was placed.

Results:

  • Clinical: it was felt that the flap procedure using the lineal incision was completed in a shorter time and with greater ease than the scalloped incision. When the flaps were sutured, the alveolar bone was completely covered with soft tissue when a scalloped incision was used but the interdental bone was left exposed when a linear incision was used. No bone was left exposed mi-buccally or mid-lingually with either procedure. During suturing of the linear flap there was a tendency for the tissues to pull in slightly into the interdental areas. Linear incision healed at a slower rate. At 12 weeks cannot distinguish between 2 procedures.

  • Higher GI was present after the linear incision during the first 2 weeks. The improvement in GI score continued at weeks 3 and 4 and there was no SSD between the two sides. NSSD in gingival fluid flow between the two sides. Pain was even. Clinically, satisfactory results were achieved for both scalloped and linear incisions, as determined by improvement in gingival contour, reduction in PD, slight gain in attachment, lack of gingivitis and low plaque scores.

C: Initially greater inflammation in the linear incision segments than is scalloped. 3 weeks after the operation there was little difference in the degree of healing. Linear incisions were easier to use and the surgery was completed in less time. 

Topic: Periodontal flap                                Article

Authors: Newman PS

Title:The effects of the inverse bevel flap procedures on gingival contour and plaque accumulation.

Source:J. Clin. Periodontol. 11:361-366, 1984

Type:Clinical study

Rating: Good

Keywords: periodontitis, flap

Purpose:To develop a contour index to record changes in gingival contours relative to treatment of periodontal disease that may predispose to plaque accumulation.

Methods:12 pts (4 M, 8 F; mean age=38 years old). The index is scored by examining buccal, lingual and inter-proximal surfaces of the teeth and gingiva. The new contour score: 0= ideal; 4=grossly enlarged like that seen in hereditary gingival fibromatosis. Pre-op recorded perio index, BI, PI at baseline and 90 days. Sites treated with inverse bevel flaps with no osseous recontouring.

R:

  • Mean gingival contour scores increased from 1.45 to 1.65 (SSD).

  • Perio index decreased (SSD).

  • BI decreased (SSD).

  • PI had small increase (NSS).

  • No correlation b/w plaque accumulation and gingival contour.

  • Good gingival contours were not obtained from sx as measured by this index.

BL: Gingival contour was not improved by inverse bevel flap. PD, BI were decreased and PI was only slightly increased because of this. This study questions the importance of a good gingival contour for the maintenance of periodontal health.

Topic:Systemic tetracycline                               Article

Authors:Haffajee AD, Dzink JL, Socransky SS.

Title:Effect of modified Widman flap surgery and systemic tetracycline on the subgingival microbiota of periodontal lesions.

Source:J Clin Periodontol. 1988 Apr; 15(4):255-62.

Type:Clinical study

Rating:Good

Keywords:periodontal lesions, subgingival microbiota, tetracycline, treatment

Purpose:To compare the subgingival microbiota before and after Modified Widman Surgery and systemic tetracycline administration (1g day/21 days) and to compare the microbiota at successfully and unsuccessfully treated sites.

Method:2 subsets of an original 33 pts were examined.

Group 1: 12 patients had microbiota compared at the same 41 sites before and after therapy (6 mo). All sites gained attachment>2mm.

Group 2: 94 post therapy microbiota samples taken from sites exhibiting different responses to therapy and compared with the microbiotas from 100 active sites of all 33 patients. Site breakdown: 24 lost > 2mm attachment, 23 gained > 2mm of attachment, and 47 did not change.

Results:

Group 1: Marked improvement in mean PD and AL was found after therapy. Mean levels of S.Mitis, S. Sanguis and V. parvula increased after therapy, while mean levels of other species including Actinomyces sp, P. gingivalis, P. interm., S. morbillorum, S. uberis, and W. recta decreased.

Group 2: Sites which lost attachment (24 lost > 2mm) had higher levels of Aa, T forsyth. Pg, Pi, P micros, S. intermedius and W.recta, while sites which gained attachment (23 sites gained > 2mm of attachment) had higher levels of Actinomyces sp. Capnocytophaga, C. ochracea, S. mitis, S.sanguis I & II and V. parvula.

None of the suspected periodontal pathogens were eliminated from all sites, though they were reduced in all sites.

Conclusion:The present investigation supports the concept that specific periodontal infections may be better controlled by different therapeutic regimens. In this study MWF with systemic TCN was effective in controlling Aa. Black pigmented bacteriodes may have to be treated by other means.

Replaced Flap Healing

  • Describe the wound healing following each of these procedures.

Topic:Flap Healing                               Article

Authors: Listgarten MA

Title:Electron microscopic study of the junction between surgically denuded root surfaces and regenerated periodontal tissues.

Source:J. Periodontal Res. 7:68-90, 1972.

Type:Clinical

Rating: Good

Keywords:wound healing

Purpose:To study the ultrastructural features of the junction between experimentally exposed root surfaces of monkey teeth and regenerated periodontal tissues at varying interval after surgery.

Materials and methods: 7 monkeys were used. Flaps were elevated on the buccal side of the teeth and 1/3 – 1/2 of the root was exposed using a bur. Root surfaces were ground to expose dentin and smoothed with curettes. Flaps were closed back and one side served as control. Animals were killed at 1, 2, 3, 6, 9, 12 and 18 months. Teeth of the animals that were sacrificed after 9, 12 and 18 months were scaled every 6 months. Histology under electron and light microscope was performed.

Results:The operated segments appeared more inflamed than the controls up to 6 months. Histological evidence of both epithelial and CT reattachment was found at all time intervals.

Regeneration of JE: JE had regenerated over denuded dentin as well as cementum in all time intervals. It included hemidesmosomes along the cell membrane surface facing the tooth and a basement lamina. This attachment apparatus was similar to that connecting the JE with the underlying CT. Superficial alterations were frequently noted in cementum and dentin. In cementum they had the appearance of a granular layer.

Regeneration of cementum: Cementum repair could be noted at all time interval in most of the specimens examined. It was formed over exposed cementum or dentin. Its formation was more advanced at the apical part. The width of the granular layer of cementum did not appear to be to related to the time of healing. The new cementum was often devoid of well-defined fiber bundles, but in specimens obtained at longer intervals root cementum resembled typical cementum with recognizable fiber bundles in its structures.

Artificial splits were found in association with the granular layer that may be associated with the demineralization process.

Conclusion:Morphological alterations on root surface did not interfere with the regeneration of a new JE that was formed over dentin.

Topic: MWF healing                               Article

Authors: Caton, J

Title: Histometric evaluation of periodontal surgery. I. The modified Widman flap procedures.

Source:J. Clin. Periodontol. 7:212-223, 1980.

Type: Clinical

Rating: Good

Keywords: Modified widman flap, connective tissue, bone

Purpose:To determine the effect of the modified Widman flap on the CT attachmen

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