Discussion Topics for Gingival Surgery 1
Describe the gingivectomy technique. What is an unembellished gingivectomy? Does it matter when the scaling is done in terms of healing? If excessive bleeding exists, how is it best controlled?
Goldman,H.M.: Gingivectomy. Oral Surgery, Oral Medicine and Oral Pathology. 4:1136-1157. 1951.
Glickman I: The results obtained with the unembellished gingivectomy technic in a clinical study on humans. J. Periodontol. 27:247-255, 1956.
Ambrose J, Detamore R: Correlation of histologic and clinical findings in periodontal treatment. Effect of scaling on reduction of gingival inflammation prior to surgery. J. Periodontol. 31:238-242, 1960
Ciancio SG, Hazen SP: Local hemostatic agents following gingivectomy. J Periodontol. 38:518-520, 1967.
What are the current indications and contraindications for the gingivectomy? What are some of the specific concerns involved in this procedure in regards to mobility? Esthetics?
Donnenfeld OW, Glickman I: A biometric study of the effects of gingivectomy. J Periodontol. 37:447-452, 1966
Wennstrom J: Regeneration of gingiva following surgical excision. J. Clin. Periodontol. 10:287-297, 1983.
Farnoosh A: Treatment of gingival pigmentation and discoloration for esthetic purposes. Int J Perio Rest Dent. 10: 313-319, 1990
Gillespie BR, Chasens AI, Brownstein CN, Alfano MC: The relationship between mobility of human teeth and their supracrestal fiber support. J. Periodontol. 50:120-124, 1979.
How does gingivectomy compare to flap surgery? What are some of the key differences?
Proestakis, et al.: Gingivectomy versus flap surgery: The effect of the treatment of infrabony defects. A clinical and radiographic study. J Clin Periodontol 19:497-508, 1992
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
How does the gingivectomy heal in humans vs animals? Describe the wound healing sequence for all tissues after gingivectomy.
Afshar-Mohajer K, Stahl SS: The remodeling of human gingival tissues following gingivectomy. J. Periodontol. 48:136-139, 1977.
Stahl SS, et al: Gingival healing. II. Clinical and histologic repair sequences following gingivectomy. J. Periodontol. 39:109-118, 1968.
Engler WO, Ramfjord SP, Hiniker JJ: Healing following simple gingivectomy. A tritiated thymidine radioautographic study. I. Epithelialization. J. Periodontol. 37:298-308, 1966.
Ramfjord SP, Engler WO, Hiniker JJ: A radioautographic study of healing following simple gingivectomy. II. The connective tissue. J. Periodontol. 37:179-189,1966.
Listgarten MA: Ultrastructure of the dento-gingival junction after gingivectomy. J. Periodontal Res. 7:151-160, 1972.
Novaes AB, et al: Visualization of microcirculation of the healing periodontal wound. III. Gingivectomy. J. Periodontol. 40:359-370, 1969.
What problems and special considerations are there when treating the retromolar area? What are some of the flap design options for management of: a) Edentulous b) Tuberosities c) Retromolar areas
What are principal factors in deciding on strategic extractions? Besides periodontal and restorative, are there any other considerations that should be accounted for when deciding on strategic extractions?
Corn H, Marks M: Strategic extractions in periodontal therapy. Dent Clin NA 13:817-843, 1969.
Saadoun AP: Periodontal and restorative considerations in strategic extractions. Compend. Cont.Educ. Dent. 2(1):48, 1981.
Kao RT. Strategic extraction: a paradigm shift that is changing our profession. J Periodontol. Jun;79(6):971-7, 2008
Kim T, Miyamoto T, Nunn ME, Garcia RI, Dietrich T. Root proximity as a risk factor for progression of alveolar bone loss: the Veterans Affairs Dental Longitudinal Study. J Periodontol. Apr;79(4):654-9, 2008
What effect does the retention of hopeless teeth have on adjacent teeth? Is there any difference in the retention of hopeless teeth with or without therapy?
Grassi M, et al: Periodontal conditions of teeth adjacent to extraction sites. J. Clin. Periodontol.14:334, 1987.
DeVore CH, Beck FM, Horton JE: Retained "hopeless" teeth; effects on the proximal periodontium of adjacent teeth. J. Periodontol. 59:647-651, 1988.
Machtei EE, et al: Proximal bone loss adjacent to periodontally "hopeless" teeth with and without extraction. J. Periodontol. 60:512-515, 1989.
Machtei EE, Hirsch I. Retention of hopeless teeth: the effect on the adjacent proximal bone following periodontal surgery. J Periodontol. Dec;78(12):2246-52, 2007
Worthington H, Clarkson J, Davies R: Extraction of teeth over 5 years in regularly attending adults. Comm Dent Oral Epidemiol. 27:187-194, 1999.
Discussion Topics for Gingival Surgery 2: curettage, ENAP, epithelium removal
What is curettage? What is the rationale for this technique? Is this considered a surgical procedure? What are the different ways to accomplish curettage?
Pollack RP: Curettage: A new look at an old technique. Int J Perio Rest Dent 4(5):25-35,1984
Kamansky FW, Tempel TR, Post A.: Gingival tissue responses to rotary curettage. J Prosth Dent. 2:380-383, 1984.
Vierra EM, O'Leary TJ, Kafrawy AH: The effect of sodium hypochlorite and citric acid solutions on healing of periodontal pockets. J. Periodontol. 53:71- , 1982.
How does curettage heal? Where does the tissue originate from? What kind of attachment forms after curettage? Does this have any significance for periodontal stability?
Caton J, Zander HA: The attachment between tooth and gingival tissues after periodic root planing and soft tissue curettage. J. Periodontol. 50:462, 1979.
Braga AM, Squier CA: Ultrastructure of regenerating junctional epithelium in the monkey. J. Periodontol. 51:386, 1980.
Garnick JJ, Singh B, McKinney RV: Maintenance of long junctional epithelium in the rat. J. Dent. Res. 61:681-685, 1982.
Listgarten MA, Rosenbaert S, Lerner S: Progressive replacement of epithelial attachment by a connective tissue junction after experimental periodontal surgery in rats. J. Periodontol. 53:659-670, 1982
Does curettage offer a benefit over scaling and root planing? What is the current thinking about curettage as a treatment option? Is removing the pocket epithelium thought beneficial during surgical procedures?
Ainslie P, Caffesse R: A biometric evaluation of gingival curettage (II). Quintess Int 12:609-614, 1981 OR 5:519, 1981.
Echeverria JJ, Caffesse RG: Effects of gingival curettage when performed 1 month after root instrumentation. A biometric evaluation. J. Clin.Periodontol. 10:277-286, 1983.
American Academy of Periodontology. The American Academy of Periodontology statement regarding gingival curettage. J Periodontol. 73:1229-30, 2002.
Lindhe J, Nyman S: Scaling and granulation tissue removal in periodontal therapy. J. Clin. Periodontol. 12:374-388, 1985.
What is ENAP? What is the difference between ENAP and subgingival curettage?
Yukna RA, Lawrence JJ: Gingival surgery for soft tissue new attachment. Dent Clin NA 24:705, 1980.
Yukna RA: A clinical and histologic study of healing following the Excisional New Attachment Procedure in Rhesus monkeys. J. Periodontol. 47:701-709, 1976.
Yukna RA, Williams JE: Five year evaluation of the excisional new attachment procedure. J. Periodontol. 51:382-385, 1980.
How effective are we at surgically removing the epithelial lining of the periodontal pocket? How does ENAP heal? Does this have any significance for periodontal stability?
Garrett MB, Yukna RA, Cassingham RJ, Zimny ML: Comparison of pocket epithelium removal by sulcular and internally bevelled incisions with and without prescaling. Int J Perio Rest Dent. 6(5): 57-66, 1986
Litch JM, O'Leary TJ, Kafrawy AH: Pocket epithelium removal via crestal and subcrestal scalloped internal bevel incisions. J. Periodontol. 55:142-148, 1984
Magnusson I, Runstad L, Nyman S, Lindhe J: A long junctional epithelium - locus minoris resistentiae in plaque infection? J. Clin. Periodontol. 10:333-340, 1983
Beaumont A, O'Leary T, Kafrawy A: Relative resistance of long junctional epithelial adhesions and connective tissue attachments to plaque-induced inflammation. J. Periodontol. 55:213-223, 1984.
Gräber HG, Conrads G, Wilharm J, Lampert F. Role of interactions between integrins and extracellular matrix components in healthy epithelial tissue and establishment of a long junctional epithelium during periodontal wound healing: a review. J Periodontol. 70:1511-22,1999.
Is the removal of epithelial attachment beneficial during surgical procedures?
What is LANAP? What laser is utilized for this procedure?
Yukna, RA, Carr, RL, Evans GH. Histologic Evaluation of an Nd:YAG Laser-Assisted New Attachment Procedure in Humans. Int J Periodontics Restorative Dent. 2007 (6):577-587
Nevins ML, Camelo M, Schupbach P, Kim SW, Kim DM, Nevins M: Human clinical and histologic evaluation of laser-assisted new attachment procedure. Int J Periodontics Restorative Dent. 2012 Oct;32(5):497-507.
American Academy of Periodontology. The American Academy of Periodontology statement regarding Use of Dental Lasers for Excisional New Attachment Procedure (ENAP). http://www.perio.org 2013
Describe the gingivectomy technique. What is an unembellished gingivectomy? Does it matter when the scaling is done in terms of healing? If excessive bleeding exists, how is it best controlled?
Topic: Gingivectomy procedure Article
Authors: Goldman,H.M
Title: Gingivectomy.
Source: Oral Surgery, Oral Medicine and Oral Pathology. 4:1136-1157. 1951.
Type: Discussion
Rating: Good
Keywords: Gingivectomy, indications, rationale, instrumentation, technique.
Purpose: To give a review on gingivectomy procedure: its indications, rationale, instrumentation, and technique
Gingivectomy: an operative procedure consisting of the removal of the soft tissue side of the periodontal pocket.
Indications:
Shallow gingival pocket composed of dense fibrotic tissue, as opposed to the soft tissue wall being red and edematous which is best treated with curettage.
Long standing fibrotic inflammation and moderately deep pockets with a thin biotype that may lead to perforations w/ curettage are also indicated for gingivectomy.
Presences of interdental craters are also indications for gingivectomy with reduction of the facial and palatal/lingual walls, allowing the base of the crater to now be tip of the IP papilla.
Altered passive eruption where soft tissue covers part of the crown.
Contraindications:
Minimal pocket formation associated with gingival edema
Minimal KG
Patient is medically unfit.
Rationale:
The technique involves excising the tissue to the base of the pocket including the apical portion of the epithelial attachment, leaving a portion of the CT. This allows recontouring to physiologic needs.
If the tissue is resected all the way to bone, festooning is not possible and the resultant form is dependent upon the healing process. So the procedure considers gingival contouring as well as pocket elimination.
Instrumentation:
An angulated blade is critical for this procedure. Without, the long bevel in the intial cut cannot be made especially on palatal and lingual surfaces
Technique:
Thorough scaling of teeth is recommended preoperatively.
Marking of the pockets: Initially, bleeding points should be established. The depth of the pocket should be marked (Crane-Kaplan pocket marker) on the lateral facial and/or lingual surface of the tissue to guide the incision. Author recommends four points on each tooth: F, L, M, D so each papilla will have two.
Primary incision:
In order that the resultant gingiva margin be thin, a knifelike and be in the proper position in regard to the enamel contour of the tooth.
If the tissue type is thin, very little of a bevel is needed since the resultant margin will the thin.
However, should the tissue be thick, then the initial cut must be made as far apically as possible to the bleeding point, angulating the knife so that a long bevel will result.
Using the convex side of the blade and making the bevel as long as possible, the incision is made using the bleeding points as the guide for the depth of the pockets.
The incision should be smooth and terminate at the base of the pocket. When pockets are deep, the incision may begin in the mucosa. preferably it does not, but must end in keratinized tissue. If not, the tissue will curl and become undermined.
Interdental cut: once the buccal initial is made, interdental cuts are made from tooth to tooth. This is done with the tip of the knife so that the excised interproximal tissue will be thoroughly freed upon removal. This cut also allows for a cone sharp interproximal tissue to remain.
Removal of the tissue: the removal of excised tissue must be done carefully so that tears and trauma are avoided.
Electrosurgery can be used as an adjunct to help festoon the tissue and for hemostasis.
Packing: in order to protect the operated area, the surface is covered with periodontal pack. The pack should remain in position from 5-10 days depending on the amount of surgery done and pre-existing condition
Aftercare: Patient is instructed to brush the teeth as much as possible, use salt water irrigation is recommended. Soft toothbrush should be used.
Post-op evaluation: slight irregularities of the contour may exist.
Desensitization of the teeth: Teeth may be sensitive due to root exposure. NaF paste can be used.
Topic: Gingival Surgery Article
Authors: Glickman I
Tittle: The results obtained with the unembellished gingivectomy technic in a clinical study on humans.
Source: J. Periodontol. 27:247-255, 1956.
Type: Clinical study
Rating: Good
Keywords: Disease Activity, periodontitis
Background: An unembellished gingivectomy consists of 2 stages. 1) Resection of diseased pocket wall and 2) the removal of calculus and smoothing the tooth surface. This is performed in 1 operation. It is a technique that does not ordinarily require preliminary or post-gingivectomy procedures or the use of drugs.
Purpose: To present results obtained with the unembellished gingivectomy.
Methods: 252 pts ages (18-63 yr old) with chronic periodontal disease of varied severity were treated by gingivectomy. 200 pts had surgeries broken down into quadrants while 50 pts had a full mouth gingivectomy performed in 1 operation. Procedure included marking the pockets on the facial and inter-proximal with probe, resection of the pocket wall at a level apical to the base of each pocket w/ an incision angled 45 ° to tooth surface, removal of soft granulation tissue, alveolar bone was not filed or trimmed, deposits were removed and roots smoothed. Periodontal pack was used for 1 week.
Results: The unembellished gingivectomy proved to be a predictable and dependable procedure. Its results lasted from 3 months to 7 years. No major post-op complications occurred. No adjunctive procedures (preliminary oral prophylaxis, applications of drugs, or plastic procedures to properly fashion the gingiva) were needed to eradicate periodontal pockets and for the restoration of esthetically and functionally desirable gingival contours.
Topic: Pre-surgical SRP Article
Authors: Ambrose J, Detamore R
Title: Correlation of histologic and clinical findings in periodontal treatment. Effect of scaling on reduction of gingival inflammation prior to surgery.
Source: J. Periodontol. 31:238-242, 1960
Type: Clinical case study
Rating: Fair
Keywords: SRP
Purpose: To determine on a clinical and histological basis the value of pre-surgery S/RP in promoting a favorable operative field and shorter healing time.
Method: 12 Patients needing gingivectomy (GV) had 1 quad pre-S/RP, and other S/RP at the time of surgery. In each quad scaled at time of surgery (surgery), biopsy were taken and repeated 4 weeks post-surgery. Biopsies were taken from the pre-scaled quads before surgery, at GV appointment 3 weeks later, and 4 weeks post-surgery. Photos taken pre-op, and 1, 2 and 4 weeks to record healing.
Results:
Scaled at time of surgery: Pre-surgery biopsy showed minimal to chronic or diffuse inflammation. Post-surgery biopsy showed minimal inflammation with normal healing when minimal inflammation was present initially and minimal healing when chronic/diffuse inflammation was present initially. One pt (w/ poor OH) showed acute inflammation and focal ulceration.
Pre-scaled: Pre-surgery biopsies revealed minimal to chronic/diffuse or acute inflammation. At 3-4 weeks, inflammation was minimal indicating favorable healing response.
Conclusion: The value of pre–surgery scaling is questioned. The only benefit from pre-surgery scaling is that it helps assess the patient’s healing potential and home care abilities.
Topic: Gingivectomy Article
Authors: Ciancio SG, Hazen SP
Title: Local hemostatic agents following gingivectomy
Source: J Periodontol. 38:518-520, 1967.
Type: Clinical
Rating: Good
Keywords: gingivectomy, hemostasis, wound healing
Purpose: To determine the relative efficacy of a number of local anesthetic agents (sterile gauze, 0.9% sterile saline solution, 1/1000 epinephrine solution, 1% tannic acid solution, 1% calcium hydroxide solution) following a gingivectomy procedure.
Method: 8 mongrel dogs (4F/4M) were used in the study. Bleeding time, coagulation time, prothrombin time were assessed in all dogs and the results of all tests were found to lie within the normal ranges. The maxillary and mandibular arches of each animal were divided into 6 equal segments and a different agent was assigned to each segment at random. Each animal was anesthetized, gingivectomy was performed on each segment, after the procedure the segment was aspirated and an agent was applied on sterile gauze and placed over the area of the wound for 2-min period. The agent was then removed and the amount of bleeding was graded: 0-absent, 1-slight, 2-moderate, 3-severe. The grading was performed independently by 2 investigators who did not know which agent had been applied. No grades were recorded when the investigators were not in agreement as to the score. The bleeding was evaluated at 4 intervals as follows: 1) upon removal of the dressing, 2) 5-min post-op, 3) 10-min post-op, 4) after scaling subsequent to the 10-min interval.
Results: Bleeding upon removal of the agent showed that epinephrine, thrombin solution, calcium hydroxide suspension and sterile gauze were the most effective agents. Least effective were tannic acid and saline solution. Bleeding 5 min after application suggest that sterile gauze and epinephrine were the most effective agents, the differences were not significant. At 10-min interval, all agents had relatively the same effectiveness. Following the scaling procedure, the areas where epinephrine and sterile gauze had been applied showed the most hemostasis. The differences were SS.
Conclusion: Sterile gauze and 1/1000 epinephrine were the two agents found to be most effective over all the various observation periods.
What are the current indications and contraindications for the gingivectomy? What are some of the specific concerns involved in this procedure in regards to mobility? Esthetics?
Topic: Gingivectomy technique Article
Title: A biometric study of the effects of gingivectomy
Author: Donnenfeld O., Glickman I
Source: Journal of periodontology, 1966, 37: 447-452
Type: Randomized controlled trial
Rating: Good
Keywords: ginigivectomy, prognosis, bleeding, healing, gingival bleeding.
P: To evaluate the outcome of gingival height after gingivectomy surgery
M+M: 9 patients (25-46 years old), 54 maxillary anterior teeth total, with avg PD= 2.6 mm (range of 1-7 mm). In all pts, the base of periodontal pocket was apical to CEJ. Mean pre-op distance from CEJ to base of sulcus was 1.9 mm (range of 0.4-4 mm) and mean pre-op attached ginigiva was 3.4 mm (range of 1.7-5.4mm). Mucogingival junction marked with tattoo points. Pockets excised by gingivectomy, then SRP completed on roots. CoePak dressign placed for one week. Width of attached gingiva and attachment levels measured at 0, 1, 2, 4, 8, and 12 weeks postoperatively.
R:
Distance from CEJ to the Base of Sulcus during the 12 Week Experimental Period
|
Teeth |
Pre-Op |
Time of Sx |
1 |
2 |
4 |
8 |
12 |
|
|
Mean (9 Pts) |
6 |
1.9 |
2.1 |
1.7 |
1.6 |
2.0 |
2.0 |
2.0 |
Width of the Attached Gingiva During the 12 Week Experimental Period
|
Teeth |
Pre-Op |
Time of Sx |
1 |
2 |
4 |
8 |
12 |
|
|
Mean (9 Pts) |
6 |
3.4 |
3.1 |
3.7 |
3.7 |
3.4 |
3.2 |
3.1 |
There was a tendency for reduction in the attached gingiva of 0.3 mm following gingivectomy surgery which was not statistically significant or clinically noticeable. Comparison with similar measurements following the apically positioned flap indicates less recession following gingivectomy, but apically positioned flap results in significant increase in width of attached gingiva.
BL: Gingivectomy eliminates periodontal pockets without causing significant clinical or statistical changes in the location of the base of the healed gingival sulcus or in the width of the attached gingiva. Slight reduction in the width of the attached gingiva following gingivectomy (0.3mm) is believed to be caused by coronal migration of the mucogingival junction line. These findings are contrary to earlier reports of gingivectomy procedures causing recession. APF might need to be considered if minimal KG present pre-op.
Topic: Gingival Surgery Article
Title: Regeneration of gingiva following surgical excision
Author: Wennstrom
Source: J. Clin. Periodontol. 10:287-297, 1983.
Type: Clinical Study
Rating: Good
Keywords: Attached gingiva; gingival recession; keratinized gingival; periodontal surgery
KG: FGM+AG
B: Per Nabers, 1954 gingivectomy is contraindicated in sites where pockets extends to or beyond MGJ. If gingivectomy is performed, entire zone of KG and AG is removed and healing will result in non keratinized loosely attached soft tissue margin.
P: To analyze in humans whether a zone of KG and AG will regenerate following surgical removal of the entire zones of the existing gingiva & to determine changes in the position of the soft tissue margin (FGM).
M&M: 6 pts, 40-55 yrs, after initial therapy, looked at bilateral mandibular canine-premolar area with PD >5 mm and BOP with narrow zone of gingiva on the buccal. Baseline measurements: PD, CAL, width of KG & AG and FGM, PI, and GI (used acrylic stents). External bevel gingivectomy (14 sites) done on one side of the mouth and "Flap Excision" (14 sites: full thickness, removal of all gingiva, coronal advancement of mucosa to cover denuded bone) on the other side. 1, 3, 6, 9 mo post-op they recorded their measurements.
R: Gingivectomy – at 1mo, 100% pts had KG (mean width 1.65mm); AG was re-established in 83% with mean of 0.6mm; at 9 mos, KG width increased (to mean of 2.05mm) & AG was 0.85 mm (remained absent in 2/12 pts)
Flap excision – at 1mo, 64% pts had KG (mean 0.58mm); no AG was seen at first 3 mos post-op; at 9 mos, KG was regenerated in 100% (mean 1.45 mm); AG was present in only 29% cases (0.17mm).
Both groups: recession (apical displacement of FGM) for both groups at 3 months was 0.9 mm and did not change during remainder of study. CALoss was ~0.4mm & occurred by 1 month post op. No further loss. Both groups had decreased amount of KG following surgery.
D: KG consistently regenerates; if granulation tissue is derived from remaining or adjacent gingival CT or from PDL, the surface epithelium becomes keratinized. Author also implied that one of the reason being incomplete removal of gingival CT during gingivectomy caused higher frequency of KG. Therefore, thin bone (which is more likely to resorb after a flap procedure,) harbors more PDL surface to form a wider band of KG (normally seen around canine and 1st premolars) than thick bone (molars). Zone of KG greater in gingivectomy vs flap excision. Amount of rec was not influenced by presence/absence of AG nor width of KG.
BL: Even if KG is surgically removed around teeth, it is capable of reforming. However, a zone of AG formed less frequently.
Topic: gingival pigmentation treatment Article
Authors: Farnoosh A
Title: Treatment of gingival pigmentation and discoloration for esthetic purposes
Source: Int J Perio Rest Dent. 10: 313-319, 1990
Type: review
Rating: good
Keywords: gingival pigmentation, de-epithelialization,
Purpose: To describe a periodontal surgical procedure of de-epithelialization to eliminate dark pigmentation or gingival discoloration.
Methods: Superficial layer of epithelium of pigmented areas is removed with high-speed hand piece & diamond bur (diameter: 2- 2.5 mm) with copious water lavage (small burs create pits). Feather-light brushing strokes, without holding the bur in one place. All the remnants of pigmented areas should be completely removed to prevent relapse. Surgical dressing or stent may be used.
Results: Author describes the results of 20 treated cases followed for 20 months. Slight re-pigmentation occurred in 2 patients (both heavy smokers)- possible correlation with heavy smoking.
Conclusion: Re-pigmentation is a “spontaneous” activity. If re-pigmentation occurs, de-epithelialization can be done repeatedly without causing any permanent damage.
Topic: Tooth Mobility Article
Author: Gillespie BR, Chasens AI, et al.
Title: The Relationship Between the Mobility of Human Teeth and Their Supracrestal Fiber Support
Source: J. Periodontol. 50:120-124, 1979.
Type: Clinical trial
Rating: Good
Keywords: Tooth mobility, supracrestal fibers
Purpose: To investigate the possible relationship between labiolingual movement of human premolar teeth to their supracrestal fiber support.
Methods: 35 patients (16m, 19f) requiring periodontal surgery in a maxillary or mandibular premolar area. 20 teeth with minimal bone loss (0-2.7mm), 20 teeth with moderate bone loss (3.2-4.7mm), and 20 teeth with severe bone loss (>5.2mm) were included in this study.
Patient criteria included posterior support, no hormonal changes, and no metabolic diseases among others. Initial tooth mobility was recorded using the O’Leary method. Next, a Bard-Parker 12B blade was used to incise the supracrestal fibers and mobility was recorded again.
Results: The Minimal Group showed no significant difference on the 2 readings. In the Moderate Group the results were significant at the 5% level. In the Severe Group the results were significant at the 1% level
Conclusions: The supracrestal fibers do not contribute significantly to the support of a normal premolar tooth. As a human premolar tooth develops moderate to severe loss of osseous support, the relative contribution of the supracrestal fibers to the support of the tooth increases significantly.
How does gingivectomy compare to flap surgery? What are some of the key differences?
Topic: Soft tissue surgery Article
Authors: Proestakis G, et al.
Title: Gingivectomy versus flap surgery: the effect of the treatment infrabony defects
Source: J Clin Periodontol 19:497-508, 1992
Type: Clinical study
Rating: Good
Keywords: Periodontal healing, infrabony defects, surgical treatment, clinical measurements, subtraction radiography
Purpose: To compare clinically and radiographically the results of gingivectomy (GV) and modified Widman flap (MWF) surgery in the treatment of infrabony defects.
Methods: 14 patients participated in the study. OHI and scaling was completed by a hygienist 2 months before surgery. 68 teeth with PD of ≥ 5 mm were selected for surgical treatment. A split mouth design was applied (GV- 32 teeth, MWF- 36 teeth). A clinical examination was completed at baseline and post-surgery at 3 months and 6 months. Clinical exam included gingival conditions (GI), probing pocket depth (PPD), probing attachment level (PAL), bleeding on probing (BOP), and oral hygiene status (plaque index, PI). Acrylic stents were used to ensure accuracy of PAL and radiographs. Radiographs were classified into 3 categories- gain, continued loss, or unchanged. Teeth were cleaned every 3-4 weeks after the first month but no subgingival scaling was performed.
Results: A statistically significant improvement was noted in oral hygiene status, gingival index, BOP, PPD (1.5 mm reduction), and PAL after both surgeries at 3 and 6 months post-op, however no differences in improvement was noted in the GV vs MWF sites. Increased recession was noted in the GV group (1.92 mm vs. 1.57 mm) but was not significant. Variation was seen in the bone tissue changes, with 1 subject accounting for 25% of the defect sites showing gain of bone and 4 of the 14 subjects accounting for 50% of sites with gain of bone. No statistically significant association could be shown between bone and PAL changes.
Conclusion: Pockets associated with infrabony defects can be successfully treated by both GV and MWF. Bone gain can occur but not in a predictable manner.
Topic: Resective vs Non-resective periodontal therapy No Article
Authors: Zitzmann NU, Berglundh T, Lindhe J.
Title: Inflammatory lesions in the gingiva following resective/non-resective periodontal therapy Source: J Clin Periodontol. Feb;32(2):139-46, 2005
Type: Clinical study
Rating: Good
Keywords: gingiva, respective, non-resective, periodontal therapy.
Purpose: To describe histological features of clinically healthy gingiva in subjects with advanced chronic periodontitis after that were treated with either resective (internal bevel gingivectomy (GV)) or non-resective therapy (open flap debridement (OFD))
Materials and Methods:
15 patients with mean age 56 years having advanced chronic periodontitis.
Prior to study, detailed OH, extraction of hopeless teeth, restoration w/FPD or RPD.
After 8 weeks plaque control then baseline exam (Day 0) w/PI, Modified GI*, PD, CAL & rec.
Split mouth design: 2 quads (1 maxilla and 1 mandible) the pockets were scheduled to be eliminated by GV while in the contralateral quadrants OFD was used.
Baseline Biopsy taken: non-molar interproximal, BOP +, w/PD >5 mm.
Following Surgery therapy, patients recalled every 2-3 weeks for cleaning. 6 months post surgery, re-eval. Soft tissue biopsies from GV & OFD sites.
Tissue stained w/markers for T & B cells, T-helper, cytotoxic, T-cells, PMNs & leukocyte adhesion molecules: inter-cellular (ICAM), endothelial (ELAM), vascular (VCAM), & mucosal vascular adhesion protein (MAd-CAM-1)
Results:
Clinical results 6 months post surgery: gingiva clinically healthy with both therapies.
GV: reduced PD from mean 6.9 to 1.9mm, increase in recession 3.7mm
OFD: reduced PD from mean 6.6 to 2.9mm, increase in recession 2.5mm.
Histology findings:
Baseline: in all sections an ulvcerated pocket epithelium was present and the connective tissue was dominated by a large inflammatory cell infiltrate. The size of the inflammatory infiltrate was similar in sites assigned to GV and OFD. B cells predominate (2:1 over T cells), PMNs present in both epithelium and in CT.
After 6 months:
GV: 60% sites had inflammatory lesion in marginal portion of gingival CT (40% had scattered inflammatory cells) with a more equal proportion of B and T cells.
OFD: 87% sites had a larger sized inflammatory infiltrate than GV (average size of residual lesion in OFD sig larger than GV).
Density of B cells was almost 2x as large in OFD than GV, as well as larger PMN infiltrate in OFD.
D: Resective surgical therapy (GV) reduces PD at site with initially deep pockets better than non-resective approach (OFD). B cells are the most predominate in advanced periodontitis lesions at baseline. Sx therapy decreased the inflammatory cell infiltrate & the percentage of B cells from baseline. MAdCAM-1 was present in both infiltrated & non-infiltrated CT in majority of gingival tissue samples. As it is important for the binding of lymphoid cells, it is possibly important in recruitment of leukocytes into periodontal lesions.
BL: Surgical therapy of advanced periodontitis lesions vastly decreases the inflammatory infiltrate when comparing it to non-surgical therapy; however inflammatory cells are still found in perio pockets even after surgical reduction. OFD appears to have a larger inflammatory infiltrate post Sx when compared to GV.
How does the gingivectomy heal in humans vs animals? Describe the wound healing sequence for all tissues after gingivectomy.
Topic: Gingival Surgery Article
Authors: Afshar-Mohajer K, Stahl SS
Tittle: Site-specific attachement level change detected by physical probing in untreated chronic adult periodontitis: Review of studies 1982-1997.
Source: J Periodontol. 48:136-139, 1977.
Type: Clinical study
Rating: Good
Keywords: Gingival surgery, flap, healing
Purpose: To describe the position of the new forming gingival margin by clinically monitoring its formation, utilizing reproducible clinical measurements and photographs for documentation.
M&M: 30 facial gingivectomy were performed in 21 pts. Pre-Surgical treatment included OHI, Occlusal Adjustment and root planing. Surgical procedures consisted of standard GV excision to the base of the clinical pocket. A splint was used to record measurements at initial examination, immediately before Sx, immediately after Sx, and at 4, 8, and 12 wks post-Sx. Clinical photographs were also taken.
Results:
|
Baseline |
4 wks |
8 wks |
12 wks |
|
|
PD |
2.8 mm |
0.6 mm |
0.8 mm |
0.74 mm |
|
Position of GM |
0 mm immed a/f Sx |
1.1 mm |
1.2 mm |
1.2 mm |
BL: Healing after GV leads to the formation of a new sulcus. After GV in humans, the marginal gingiva remodels and grows coronally from the initial incision line (supports creeping attachment), and is relatively stable by 8 weeks.
Topic: Gingival healing Article
Authors: Stahl SS, Witkin GJ, Cantor M, Brown R
Title: Gingival healing. II. Clinical and histologic repair sequences following gingivectomy.
Source: J. Periodontol. 39:109-118, 1968
Type: Multi-center clinical study
Rating: Fair
Keywords: gingivectomy, healing
Purpose: To evaluate gingival healing following gingivectomy.
Method: 128 adult patients with periodontitis; 218 supra-bony pockets 3-8 mm (scaling in all pockets & curettage in half of sites at least 1 week pre-op) had buccal and lingual gingivectomy; post-op biopsies taken at 1 day, 1, 2, 3, 4 weeks for histologic evaluation.
Results: No significant correlation between healing response & age, sex, or socioeconomic level of patients, location and depth of pocket, between curetted/non-curetted sites. Surface epithelialization of the gingivectomy wound appeared complete in 61% of specimens 7 days after gingivectomy & in all patients at the 14 day post-op. Young connective tissue & vascularity in wound margin increases with time & had not returned to pre-op level at 28 days after gingivectomy. Inflammation increased with time. Collagen fibers increased at 7 days & remained the same throughout experiment; some showed decreased keratinization post-op. Active CT repair still present at 28d; surface epithelialization complete at 14 days. Gradual increase in inflammation at the newly formed gingival margin with time.
Conclusion: Active CT repair still present at 28 days; surface epithelialization complete at 14 days. Gradual increase in inflammation at the newly formed gingival margin with time. Neither age, sex, depth of pocket, location of pocket, nor curettage had any effect on the gingival healing sequence.
Topic: Gingivectomy Article
Authors: Engler WO, Ramfjord SP
Title: Healing following simple gingivectomy. A tritiated thymidine radioautographic study. I. Epithelialization
Source: J. Periodontol. 37:298-308, 1966.
Type: Clinical
Rating: Good
Keywords: gingivectomy
Purpose: To examine the healing flowing simple gingivectomy through a combination of histologic and radioautographic techniques. Administration of tritiated thymidine to experimental animals provides a radioautographic method for demonstration of cellular synthesis of DNA in preparation for mitosis.
Method: 3 healthy male adult Rhesus monkeys were included. The animals had varying amounts of supra-g and sub-g calculus, moderately severe marginal gingivitis and PDs 2-4mm. All teeth were scaled 2 weeks prior to the experimental procedures. Simple gingivectomies were performed at 35,21,14,9,7,5,3 days and at 49, 37,25,13,9,5, and 2 hours prior to sacrifice of the animals. The marginal gingivae were excised to the bottom of the epithelial attachment as located by periodontal probe, with a regular beveled incision. Following gingivectomy, the teeth were rescaled for removal of residual calculus and the exposed root surfaces were planed with curettes. No surgical dressing was used. Control areas were left untreated in all 3 monkeys. 1hour prior to sacrifice each animal was injected intravenously with tritiated thymidine. Histologic analysis was performed.
Results: Control sites: Normal keratinized gingival epithelium, and a thin well adapted epithelial attachment at or slightly apical to the CEJ. Lymphocytes and plasma cells were present adjacent to the sulcular epithelium.
Experimental sites: Following gingivectomy:
2hrs: Incision surface was free of debris and was covered by a thin fibrinoid exudate in which PMNs were incorporated. An acute inflammatory reaction (dilated vessels, leukocytes) had already been established in the connective tissue of the wound margin. The connective tissue beneath the incision, for a depth of approximately 0.2mm exhibited disrupted collagen bundles and new fibrocytes.
5hrs: A well- defined clot apparently had sealed the incision. The acute inflammatory reaction had progressed and many PMNs were present in the connective tissue underlying the incision. The basal layer of the epithelium at the wound margin was normal in appearance.
9hrs: A band of basophilic cells, 5-6 cells in thickness, was present in the basal portion of the epithelium at the wound margin.
13hrs: migration was definitely established, basophilic cells extended from spinous and basal cell layers of the epithelium beneath the clot, on the top of the underlying normal connective tissue.
25hrs: The cells of the epithelium at the wound margin exhibited layering and staining typical of stratified squamous epithelium. Migration of basal and deeper spinous layers had advanced approximately 0.4mm across the wound. The connective tissue was heavily infiltrated with PMNs. Synthesis of DNA in the epithelium at the wound was greatly increased 24hrs following gingivectomy.
36hrs: A substantial decrease was noticed in the synthesis of DNA by epithelial cells of the wound margin.
5-7days: An upgrowth of the connective tissue of the wound occurred, creating a sulcus along the surface of the root. The epithelium migrated apically as a thin layer between the tooth surfaces and the connective tissue to reform a gingival sulcus.
Keratinization was definitely established on the surface of the newly formed marginal gingiva by the 14th day. Radioactivity indices declined at the wound margin at 7, 9 and 14 days post-op, indicating that the demand for cells for regeneration from the original wound margin was ended. 21 days post-op the outer surface of the marginal gingiva was normal in appearance. The surface of the gingival sulcus was not completely epithelialized in many sections. By 35 days, the epithelium of the sulcus was well organized as a thin layer closely adapted to the tooth surface. Plasma cells and lymphocytes were present in the connective tissue adjacent to the gingival sulcus.
Conclusion: The epithelium migrated and regenerated from the wound margin to the tooth, a distance of approximately 3mm at 5-6 days at a rate of approximately 0.5mm/day. An up-growth of the connective tissue of the wound then occurred, creating a sulcus along the tooth surface which subsequently became epithelialized and established a new epithelial attachment. By 35 days, the marginal gingiva was completely regenerated and indistinguishable from that of the control sections.
Topic: Gingivectomy technique Article
Title: A radioautographic study of healing following simple gingivectomy. II. The connective tissue.
Author: Engler WO, Ramfjord SO et al
Source: J. Periodontol. 37:179-189,1966
Type: Case study
Rating: Good
Keywords: ginigivectomy, prognosis, bleeding, healing, gingival bleeding.
P: Concerned with gingival connective tissue healing and regeneration following simple gingivectomy
M+M: 3 adult male rhesus monkeys underwent gingivectomies involving posterior teeth 7, 5, 3, 2 days and 37, 25, 13, 9, 5, and 2 hrs prior to sacrifice. Approximately 3mm wide ginigivectomy wound created buccally and lingually at each test tooth with interproxal papilla removed. Alveolar crest not exposed and no postop dressing used. Radioautographs and histologic study were performed.
R: Connective tissue healing starts 0.3mm to 0.5 mm under the "poly-band" (band of PMN cells) protective surface. The connective tissue proliferation is initiated 1 to 2 days after surgery and reaches a peak 3 to 4 days after surgery. Most of the regeneration of the free gingiva takes place from 3-9 days after surgery and initially consists of vascular granulation tissue.
Functional arrangement and collagenous maturation of the gingival connective tissue require 3 to 5 weeks.
A physiologic gingival crevice, with a sealing normal epithelial attachment is dependent on a firm gingival tone which requires 3 to 5 weeks to establish following gingivectomy.
BL: Takes 21 to 35 days for complete healing of a gingivectomy wound and restoration of functional gingival health.
Topic: Gingival Surgery Article
Title: Ultrastructure of the dento-gingival junction after gingivectomy
Author: Listgarten
Source: J. Periodontal Res. 7:151-160, 1972.
Type: Animal Experiment
Rating: Good
Keywords: Regeneration, dento-epithelium junction, gingivectomy
P: To investigate early stages in the regeneration of the dento-epithelial junction (DEJ) following gingivectomies in monkeys
M&M: 2 cynomolgus monkeys had GV's around the lateral incisors, allowed to heal until extractions and biopsies. At 12 days, & 3, 4, & 7 wks: 1 max/1 mand tooth were extracted with surrounding tissues & studied under EM.
R: As early as 12 days, JE was completely re-established b/w regenerated CT and tooth surface. A thin layer of afibrillar cementum (approx. 1micrometer thick) was frequently observed b/w epithelium & enamel (when JE was on enamel). New epithelium became closely adapted to irregularities in tooth surface. Hemidesmosomes were present even in the most apically located epithelial processes. No differences in later specimens. Hemidesmosomes appear to form prior to the basement lamina. Epithelium has the ability to attach to a wide variety of surfaces via hemidesmosomes & basement lamina.
BL: EM studies of the DEJ after GV shows that the epithelium is attached to enamel & cementum in 12 days or less, first w/ hemidesmosomes, then w/ a basement lamina.
Topic: healing of gingiva Article
Authors: Novaes A, Kon S,
Title: Visualization of microcirculation of the healing periodontal wound. III. Gingivectomy.
Source: J. Periodontol. 40:359-370, 1969. doi:10.1902
Type: clinical
Rating: good
Keywords: gingivectomy, vascularization, periodontium, healing,
Purpose: The purpose of this study was to observe the wound healing process and the behavior of the blood vessels after gingivectomy.
Methods: 8 mongrel dogs were included. Gingivectomy was performed on labial side of lower incisors. Sulci with average depth of 2.5mm, initial incision was beveled and surface was contoured to achieve physiologic contour. No dressing used. Penicillin IM for first 2 days was administered. Dogs were fed soft diet for 3 weeks, normal diet for the remainder. Intra-arterial injections with carbon black suspension preformed before sacrifice at 2,4,6,7,12,16,23,31,38,55 and 85 days. Block sections taken and histologic analysis performed.
Results & Conclusion:
ZERO HOUR: A thick blood clot covered the wound, which resembled the excised tissue
Perfused material flowed from the vessels and remained between the blood clot and the connective tissue
2-4 DAYS: thick clot was covering the entire wound. Vasodilation and an increase in vascularization noted by the carbon black leaking from vessels. Suggesting either damaged vessels were not repaired or an increase in their permeability.
7 DAYS: complete epithelium over the wound
Sulcular parallel lines disappeared after surgery but were apparent at 7 d post-op. Carbon black injection confirmed that lines were sulcular parallel capillaries.
16 DAYS: epithelium showed rete pegs and keratinized surface, normal appearance of vessels are observed.
23 DAYS: gingiva was entirely healed, along with squamous stratified keratinized epithelium and rete pegs
Vital perfusion techniques demonstrated to be of significant value in studying the vascularization during the healing process of wounds.
A new cuticle, histologically similar to the secondary cuticle (of odontogenic origin) is observed bordering the enamel space after a new sulcular well and epithelial attachment are formed during the healing process.
What problems and special considerations are there when treating the retromolar area? What are some of the flap design options for management of: a) Edentulous b) Tuberosities c) Retromolar areas
Topic: Distal Wedge Article
Author: Robinson E
Title: The Distal Wedge Operation
Source: Periodontics 4:256-264, 1966
Type: Discussion Article
Rating: Good
Keywords: distal wedge, periodontal pocket, pocket reduction
Background/Purpose: A pocket on the distal of a mandibular or maxillary second or third molar may be exaggerated in depth because of the anatomy of the area. In the past, a gingivectomy has been the treatment of choice; however, failure resulted in many instances, especially when a bone deformity was present. The Distal wedge attempts to eliminate the pocket, utilize mature gingival tissue and create precise wound closure.
Discussion:
Objectives of the distal wedge procedure
To obtain access to the bone
To preserve and utilize attached gingival tissue
To eliminate the pocket by wound closure
To decrease the healing period
To minimize periodontal pocket recurrence.
Indications
To manage any periodontal pockets on a terminal tooth which does not require access to bone, but does require precise closure with mature surface gingiva
Management of any proximal periodontal pocket which requires elimination through establishing access to bone for a number of procedures
Contraindication
When the ascending ramus and external oblique ridge on the mandible limits the distal space
When a pocket is present on the maxilla, which has either a limited distal space, or a flap palate, which would result in deformity upon repair.
Distal wedge incision designs
|
1. Triangular Incision |
|
|
2. Square Incision |
|
|
3. Linear Incision |
|
Topic: Soft tissue procedures Article
Authors: Pollack RP
Title: Modified distal wedge procedure
Source: J. Periodontol. 51:513-515, 1980
Type: Report
Rating: Good
Keywords: distal wedge, soft tissue
Purpose: To describe a procedure designed to obtain primary intention healing of soft tissue in the furcation regions of the distal or mesial aspects of molars adjacent to edentulous areas.
Methods: 1) Internal beveled incision made, passes nearly parallel to the long axis of the tooth, creating partial thickness, periosteal retention buccal flap and thinned palatal flap.
2) An “imaginary” interdental papilla is outlined in the distobuccal and distopalatal aspect with distal releasing incisions.
3) Soft tissue underlying the reflected papilla is then removed.
4) Thorough cleaning of the interproximal and distal area.
5) Osseous recontouring if needed.
6) Suturing starts from the papilla created in the distal aspect, then the interdental areas.
7) Periodontal dressing placed.
-Mandibular distal wedge is handled similarly. If there is little keratinized tissue, technique may be varied (“Z” plasty design)
Conclusion: Advantages of procedure: 1) Access to the osseous architecture, 2) Provides a parabolic and thin soft tissue form, 3) Facilitates flap design in the distal wedge region, 4) Provides a means of primary soft tissue closure and permits coverage of furcation (less bone resorption, discomfort and more predictable healing). Limitations include areas where non-keratinized tissue exists and the proximity of the ascending ramus or internal oblique ridge.
What are principal factors in deciding on strategic extractions? Besides periodontal and restorative, are there any other considerations that should be accounted for when deciding on strategic extractions?
Topic: Strategic extractions No Article
Authors: Corn H, Marks M
Title: Strategic extractions in periodontal therapy
Source: Dent Clin NA 13:817-843, 1969.
Type: Clinical study
Rating: Good
Keywords: gingiva, respective, non-resective, periodontal therapy.
P: Discussion article presenting the periodontal aspects of strategic extractions and their indications.
Discussion: The importance of sacrificing certain teeth or individual roots of multi-rooted teeth must be considered in order to enhance prognosis of the periodontium: Precise documentation & diagnosis tools (radiographs, casts, pulp testing) are necessary before deciding on a strategic extraction.
A thorough periodontal examination should include the chief complain, comprehensive medical and dental history, clinical measurements (PD, MOB), occlusal analysis.
Suggested Tx sequence:
Initial prep (emergency relief of pain, extractions of hopeless teeth, OHI, SRP, occlusal adjustment, orthodontics, splinting)
Re-evaluation
Pocket elimination
Final occlusal adjustment, then restorative
Supportive periodontal maintenance
Report to restorative dentist
Indications for strategic extractions
Mixed dentition. Impacted permanent mandibular central incisor, must extract the retained deciduous incisor. The space must be maintained with the hope that the permanent tooth will erupt. if the permanent tooth does not erupt within 6 months to 1 year then surgical exposure. Make sure all deciduous tooth roots have been removed. Retained deciduous root may result in periodontal disease. If the deciduous root is in close proximity with the permanent tooth, pocket formation and osseous defects may occur more rapidly.
Extract hopeless teeth in order to preserve crestal bone on adjacent teeth.
Mand 3rd molar extraction facilitates uprighting of 2nd molar that is mesially tilted due to loss of the 1st mandibular molar.
Over-erupted mand 3rd molar should not always be extracted because the alveolar bony plate has grown coronally and extraction of the teeth results in infrabony defect distal to 2nd molar.
Crowded mand anterior teeth. Extract the incisor with moderate bone loss so that when the adjacent teeth is moved to its place there will be enough bony support.
Teeth with one wall bony defects have poor response with grafting and should be extracted.
Topic: Extractions Article
Authors: Saadoun AP Dent. 2(1):48, 1981.
Tittle: Periodontal and restorative considerations in strategic extractions.
Source: Compend. Cont.Educ.
Type: Review
Rating: Good
Keywords: Strategic extractions
Purpose: A review article to discuss the periodontal & restorative considerations in strategic extractions
Discussion: Before determining which teeth are to be extracted, precise documentation & varied diagnostic methods must be utilized. The decision to extract or save a tooth must rest on valid diagnostic criteria. Thorough medical & periodontal examination is also needed. The sequence of treatment and the design of the exact treatment plan will depend on many considerations: Periodontal considerations (amount of bone loss, tooth morphology, furcation problems, root proximity), Restorative (# & location of remaining teeth, occlusal factors, esthetics). Tooth mobility & indications for extraction of 3rd molars are also discussed. The objective of periodontal treatment is the long-range survival of the dentition. A tooth seriously affected may respond completely and function in the dentition. Attempting to save hopeless teeth that cause constant irritation may compromise the result.
BL: It is far easier to extract a tooth than to decide whether it should or could be retained.
Topic: Strategic extraction No Article
Authors: Kao RT
Title: Strategic extraction: a paradigm shift that is changing our profession.
Source: J Periodontol. June;79(6):971-7, 2008
Type: Commentary
Rating: Fair
Keywords: Dental implants; prognosis; treatment
Purpose: To discuss strategic extraction
Method: n/a
Results:
Definition: Original description - removal of a tooth or root to create a more hygienic environment
Objective: to enhance the status and prognosis of an adjacent tooth or the overall prosthetic prognosis
Consideration:
Periodontal: problem with accuracy of prognosis (Hirschfeld and Wasserman, McGuire and Nunn). BOP is a poor predictor of periodontal disease progression. Furcations can be one of the main reasons for tooth loss. Mobility is controversial as a risk factor for tooth loss. Patient compliance can further complicate an assessment of periodontal prognosis as well as systemic factors (smoking, diabetes, and immunosuppression). Strategic extraction should be made when a potential implant site is in danger because of continual bone loss and it should be based on to what extent we can still predictably offer the patient the implant option.
Endodontic: High success rate in conventional. Lower in preoperative periapical lesions, retreatment, root perforation, and poor obturation. There are limitations to the comparison of endodontically treated teeth survival vs implant survival.
Prosthetic: Effectiveness of FPD 85% survival at 10 years, decrease after 15 years. Complications of FPDs are costly financially and often require additional procedures that increase the chances of failure.
Implant: Functional success > 90% 8-15 years. Principle challenges in implant dentistry are to regenerate adequate bone volume and clinical esthetics.
Conclusion: No clear algorithm for decision making for strategic extraction. Earlier strategic extraction to preserve the bone volume necessary for implant placement should be considered. It is important to take into account the patient’s age, personal preferences, and finances. Due to the acceptance of dental implants, the emergence of biologic modifiers, and growing reliance on evidence-based dentistry, our profession needs to changes its view of prognosis and its clinical implications for treatment.
Topic: Root Proximity No Article
Authors: Kim T, Miyamoto T, Nunn ME, Garcia RI, Dietrich T
Title: Root proximity as a risk factor for progression of alveolar bone loss: the Veterans Affairs Dental Longitudinal Study
Source: J Periodontol. Apr;79(4):654-9, 2008
Type: Longitudinal Study
Rating: Good
Keywords: root proximity, Alveolar bone loss, periodontal disease, periodontitis, risk factor
Purpose: To evaluate the association between interradicular distance (IRD) and local progression of alveolar bone loss (ABL) in longitudinal cohort study.
Method: The study sample was selected from the Veterans Affairs (VA) Dental longitudinal study (DLS), a longitudinal cohort study of 1.231 men enrolled in 1968, with comprehensive medical and dental examinations and with interviews to assess behavioral factors performed every 3 years. Dental examinations included periodontal examination and periapical radiographs. The study was limited to mandibular incisors. Inclusion criteria: 1) >10 years of follow up for IPx space, 2) presence of IPx contact without overlap of crowns, 3) teeth without previous restorations, 4) teeth with fully intact clinical crowns and roots completely visible and measurable. In total, 1069 IPx spaces in 473 subjects met all of the inclusion criteria. All radiographic assessments and measurements were performed by one investigator. IRD was measured at the level of CEJ from digitized radiographs. Alveolar bone level was measured from the CEJ to the alveolar crest at the mesial and distal aspects of the roots defining the IPx space. ABL was expressed as millimeters per 10 years. Men were classified as never-smokers, former smokers or current smokers of cigarettes. At each follow-up, plaque and calculus were assessed. Site-specific multivariate regression models were fit to evaluate the association between IRD and ABL rate, adjusting for age and smoking.
Results: There were 473 subjects, 28-71 years at baseline, with ≥10 years of follow-up data available for analysis. The mean follow-up time was 23 years. IRD varied from 0.3 to 2.4mm (mean 1±0.3mm). There was an inverse association between IRD and rate of ABL. Compared to sites with IRDs≥0.8mm, sites with IRDs <0.6mm were 28% more likely to lose ≥0.5mm of bone during 10 years and 56% more likely to lose ≥1mm of bone during 10 years. On average sites with IRD<0.6mm had 0.22mm more bone loss during 10 years compared to sites with IRD>0.8mm. Adjustment for age, smoking, plaque and calculus did not weaken the association between IRD and rate of bone loss.
Conclusion: There was a dose-dependent non-linear, inverse association between IRD and ABL. IRDs <0.8mm were associated with a moderately increased risk for loss of alveolar bone.
What effect does the retention of hopeless teeth have on adjacent teeth? Is there any difference in the retention of hopeless teeth with or without therapy?
Topic: Extraction site healing No Article
Title: Periodontal conditions of teeth adjacent to extraction sites
Source: J. Clin. Periodontol.14:334, 1987.
Author: Grassi et al
Type: Case study
Rating: Good
Keywords: periodontal pocket, extraction, extraction socket, extraction healing.
P: To evaluate the effect of tooth extractions on the periodontal condition of adjacent teeth.
M+M: 40 patients requiring one tooth extraction (fully erupted + normally occluding) and having the same number of teeth in the contralateral jaw. Teeth extracted: 15 3rd molars, 16 2nd+1st molars, 10 incisor or canines. Group 1: PD=1-3 mm; Group 2: PD=4-9 mm. Baseline data (PI, GI, PD, PAL) of teeth adjacent to ones being extracted were taken. Alveolar bone height determined radiographically in relation to CEJ adjacent to extraction sites; contralateral side used as control. SRP at test sites only prior to extraction, all sites re-evaluated at 2-4 months for short term, 6-9 months for long term following extractions. No attempt was made to alter OH habits of pts.
R: Teeth adjacent to extraction sites had a decrease in PD by 0.5 - 1.5 mm; PD decrease more pronounced in Group 1 than in Group 2; extraction did not alter radiographic bone level; neither PI nor GI showed improvements during the 9 month period.
BL: Extractions can have a beneficial effect on the periodontal conditions of the adjacent teeth in certain clinical presentations. Author states that the decision to extract should be made on an individual basis and in conjunction with an overall comprehensive treatment plan.
CR: SRP was performed only on the test group not the control. There may be an issue claiming reduced PD could be attributed to SRP and not extraction site healing.
Topic: Gingival Surgery Article
Title: Retained "hopeless" teeth; effects on the proximal periodontium of adjacent teeth
Author: DeVore et al
Source: J. Periodontol. 59:647-651, 1988
Type: Clinical Study
Rating: Fair
Keywords: hopeless teeth, maintenance therapy, osseous recontouring, osseous respective surgery
P: To assess the status of the periodontium of adjacent teeth proximal to hopeless teeth.
M&M: 17 patients (9m, 8f) mean age 55.8+1.4 years. Tx: surgical therapy (osseous recontouring/ resection) in all except for two cases. 65% of them received maintenance therapy (3 months) and the remaining 35% received maintenance less than or equal to once a year.
To be characterized as hopeless, teeth required to possess at least 2 criteria proposed by Becker et al: Loss of over 75% of supporting bone, PD>8mm, class III furcation, class III mobility, poor root/crown ratios, root proximity with horizontal bone loss, history of repeated Perio abscess formation. 17 teeth mesially adjacent to the hopeless teeth were evaluated. PD, radiographic bone level (R-BL) & Width of PDL space (W-PL) measured for both adjacent and non-adjacent interproximal surfaces. Post-treatment evaluation: 3.41+1.46 years later. 59% of hopeless teeth were multi-rooted.
R: At both pre- & post-treatment, no SSD for any of the variables for the adjacent & non-adjacent interproximal surfaces. SS reduction in mean PD for adjacent interproximal surfaces with treatment.
BL: Teeth diagnosed as hopeless may have no effect on the normal periodontium of adjacent teeth. (when hopeless teeth are treated surgically)
Cr: Authors use and describe a complicated technique to compare pre- & post-treatment radiographs. The therapeutic approach was not the same for all patients, but maybe this is an advantage for this study. However long term results would be more appropriate in order to draw any conclusions regarding our decision on these teeth. The author’s did not state proximity of the hopeless teeth to adjacent teeth (vertical defect on hopeless tooth vs horizontal defect on adjacent and hopeless tooth)
Topic: retention of hopeless teeth No Article
Authors: Machtei EE, Zubrey Y,
Title: Proximal bone loss adjacent to periodontally "hopeless" teeth with and without extraction.
Source: J Periodontol. 1989 Sep;60(9):512-5. DOI: 10.1902/jop.1989.60.9.512
Type: retrospective study
Rating: good
Keywords: hopeless teeth, periodontal health, proximal bone loss,
Purpose: To evaluate proximal bone loss adjacent to periodontally “hopeless” teeth with and without extraction.
Methods: 145 teeth from 129 pts were included in this retrospective study. Teeth were classified as “hopeless” when, the they had >50% bone-loss or class III furcation involvement. These teeth were separated into two groups;
(A) 82 hopeless teeth (71patients) retained through experimental period
(B) 63 hopeless teeth (58 patients) were extracted.
These patients had no systemic conditions or perio treatment during the study. They had follow-up x-rays at a minimal of 2yrs and an average of 4yrs. The alveolar bone changes as % of anatomic root (apex-CEJ) were analyzing using Scheir ruler.
Results:
Alv bone loss of hopeless teeth= 3.42%
Alv bone loss adj. to retained teeth= 3.12%
Alv bone loss adj. to retained multi-rooted hopeless teeth= 3.86%
Alv bone loss adj. to extracted hopeless teeth= 0.23%
Conclusion: in absence of perio treatment, the retention of hopeless teeth has a destructive effect on the periodontium of adjacent teeth; 3.12% vs. 0.23% (>10x the bone-loss). Number of roots of hopeless teeth is of secondary importance when comparing the effect of their extraction or retention on the proximal periodontium of the adjacent teeth.
Topic: Tooth Prognosis No Article
Author: Machtei E, Hirsch I
Title: Retention of Hopeless Teeth: The Effect of the Adjacent Proximal Bone Following Periodontal Surgery
Source: J Periodontol. Dec;78(12):2246-52, 2007
Type: Retrospective Study
Rating: Good
Keywords: Bone loss; periodontitis; retention; surgery
Purpose: to compare the long-term effect of extracting or maintaining hopeless teeth on the alveolar bone height of the adjacent teeth.
Methods: Retrospective study looking at the X-rays of patients who were treated between 1990-2003. Inclusion criteria included: at least 1 hopeless tooth (>70% bone loss) and its proximal neighbor, a follow up x-ray (24 months), non-smokers, and no systemic disease. 110 teeth in 93 patients were included in this study. These participants were divided into 2 groups:
1) Retained (57 hopeless teeth in 50 patients)
2) Extracted (53 hopeless teeth in 43 patients)
Radiographs were digitalized and measurements were taken. The measurements assessed included: 1) Root Length (CEJ to apex)
2) Bone height (Apex to alveolar crest)
3) Radiographic Bone Distance (RBD)=difference between above measurements
Bone loss was assessed as the difference between RBD preoperatively and postoperatively. Subjects were followed for 2-13 years. Changes in RBD between the 2 groups were compared.
Results:
For the retained hopeless teeth, there was a mean bone gain of 0.82mm from the baseline the final exam. The postoperative % of RBD of the retained hopeless teeth showed SS improvement from the baseline (57.46%to final exam (52.32 Teeth adjacent to the hopeless teeth had a slight bone gain post operatively which was greater in the extracted group. It is SS only for the distal neighboring teeth (1.50% versus 11.36% respectively)
Discussion:
Previous studies reported that the retention of hopeless teeth had a negative effect on their proximal neighbors; however, in those studies no initial periodontal therapy was completed. The present study showed that periodontal surgery inhibited further bone loss and resulted in slight radiographic bone gain for the hopeless teeth. The present study showed that the retention of hopeless teeth did not exert any detrimental effect on the adjacent proximal teeth. However, teeth adjacent to hopeless teeth that were extracted had slightly greater radiographic bone gain for the distal neighbor of the hopeless tooth. Prospective longitudinal studies involving larger sample sizes and combining radiological and clinical parameters are necessary to substantiate this present study.
Conclusion: Long term preservation of hopeless teeth following periodontal surgery is an attainable goal with no detrimental effect on the neighboring teeth, but further studies are needed.
Topic: Tooth loss Article
Authors: Worthington H, Clarkson J, Davies R
Title: Extraction of teeth over 5 years in regularly attending adults
Source: Comm Dent Oral Epidemiol. 27:187-194, 1999
Type: Prospective study
Rating: Fair
Keywords: adults, epidemiology, incidence, prediction, tooth loss
Purpose: To describe the incidence of tooth loss in a group of regularly attending adults and to asses factors that are predictive for tooth loss within this group.
Method: 24 dentists recruited 4211 of their patients, all over age 24, denate, and considered to be regular attenders (2x’s in last 2 years). Number/location of fillings, crowns, sites with recession, arrested caries and presence of partial/bridges was recorded at baseline. Patients were asked to return once a year, and all treatments were recorded. A postal questionnaire was also sent out in the first year and asked questions pertaining to predicted need for treatment, dental behavior, attitude towards dentures, past dental attendance, diet, smoking and alcohol consumption. Participants were also grouped into social classes based on occupation (professional occupations, intermediate occupations, skilled occupations (manual and non-manual), partly skilled occupations and non-skilled occupations).
Results: 2293 (54%) of the initially seen subjects attended every year over the 5 years and 2799 (69%) were seen within 3 months either side of the fifth annual examination. The latter group was included in this study. Most participants (2329, 83%) did not have extractions in the 5 years, however 470 (17%) participants had a total of 717 teeth extracted. Age was a significant factor in extraction patients, with over 20% of these patients being over 45 years old. Most teeth (79%) were extracted for reasons other than caries, and posterior teeth were more commonly extracted for caries (25% compared to 13% anterior). Patients with fewer teeth, fewer sound teeth, and fewer filled teeth present more likely to have an extraction. Patients with more fillings in posterior teeth were more likely to have extractions than people with fillings in anterior teeth. Patients who had sensitive teeth, a sweet tooth, lived alone, or smoked were more likely to have an extraction. Predictive factors varied based on clinical model used to evaluate data.
Conclusion: The final clinical model contained 3 significant predictors for tooth extraction: number of teeth, crowns, and sites of recession. The final model had a sensitivity of 0.57 and a specificity of 0.72. Although these models are probably not suitable for prediction purposes, they are useful for identifying factors that are strongly related to future tooth loss.
a. Curettage / ENAP
b. Epithelium removal
Discussion Topics
What is curettage? What is the rationale for this technique? Is this considered a surgical procedure? What are the different ways to accomplish curettage?
Authors: Pollack RP
Title: Curettage: A new look at an old technique.
Source: Int J Perio Rest Dent 4(5):25-35,1984
Type: Discussion
Rating: Good
Keywords: Curettage, gingiva, pocket elimination, tissue shrinkage, reduce inflammation.
Purpose: To review closed crevicular curettage as an integral part of initial preparation.
Gingival curettage: the removal of soft tissue comprising the pocket wall by scraping with periodontal instruments.
Aims were: (1) to obtain soft tissue shrinkage; (2) to evaluate healing response; (3) to reduce inflammation.
The technique is outlined including 6 visits for moderate-advanced periodontitis:
4 visits (at 2 week interval) with hygienist for OHI & S/RP “by layers (layer is that amount of calculus or root deposit that can be removed by a hygienist in a single visit), not by quads” (at 2-week intervals).
Then, 3-4 weeks later, 1 for each side of the mouth for curettage by the periodontist.
A healing period of 3-4 weeks is allowed prior to re-evaluation.
4 case reports described in detail.
Uses: when esthetics prohibits flap surgery; as part of initial preparation to obtain shrinkage; when medical problems limit definitive surgery, or emotional patient who can’t undergo surgery.
Advantages: no suturing or periodontal dressing is needed.
Results: At least 2-3mm of soft tissue shrinkage predictably obtained in case reports over time.
BL: Advocates this procedure for early to advanced stages of disease. Re-evaluation will determine if
surgical therapy is required.
Topic: Gingival tissues Article
Authors: Kamansky FW, Tempel TR, Post A.:
Tittle: Gingival tissue responses to rotary curettage.
Source: J Prosth Dent. 2:380-383, 1984.
Type: Clinical Study
Rating: Good
Keywords: Rotary curettage
Purpose: To compare human gingival tissue response to rotary curettage with chemically treated cord lateral tissue displacement.
Methods: 10 Male patients scheduled to have anterior bridges. 1 abutment prepared with rotary curettage (this technique uses a specially designed rotatory diamond instruments to remove a portion of the inner epithelial lining of the sulcus during placement of the finish line on tooth preparations), the other w/retraction cord (soaked in hemodent). All pts exhibited no signs of inflammation prior to procedure. Reference notches placed on abutments and measurements taken prior to procedure, then 14 and 19 d post-op.
Results: Curettage showed significantly less facial gingival crest height changes than with the retraction cord (a change of 0.15mm to 0.29mm). Curettage showed a greater increase in sulcus depth (0.15mm to 0.035mm). Palatal tissues showed NSD between the 2 methods (Curettage had slight increase in depth of lingual gingival sulcus, while cord had a decrease.)
Conclusion: Curettage compared favorably to retraction cord in amount of gingival crest recession. Curettage caused a disruption of apical sulcus & epithelial attachment w/an apical repositioning of the tissues after repair and stabilization. Changes in gingival crest and lingual sulcus were not found on the palatal tissue w/either method.
Cr: no mention of thickness of biotype
Topic: Chemical curettage Article
Authors: Vierra EM, O'Leary TJ, Kafrawy AH
Title: The effect of sodium hypochlorite and citric acid solutions on healing of periodontal pockets
Source: J. Periodontol. 53:71- , 1982.
Type: Animal study
Rating: Fair
Keywords: chemical curettage, long junctional epithelium
Purpose: To determine the benefit of using NaOCl-citric acid therapy in conjunction with root instrumentation.
Method: 4 beagle dogs with clinically healthy gingiva. 2 amalgam dots were placed on facial of all teeth for probe orientation. PD and FGM to most apical amalgam dot were recorded for test & control teeth. Mesial and distal subgingival grooves were prepared to enhance ligature retention. Silk ligatures were placed around all teeth. OH was stopped and dogs were fed a soft diet for 40 days. All test teeth then received SRP and sodium hypochlorite (NaOCl) of pH 14 and citric acid (CA) 5% was applied and left for 60 sec. Areas were irrigated and soft tissue curettage was performed. Control teeth received SRP and soft tissue curettage. 1 dog was sacrificed in 5 hours and the rest in 7,14, & 28 days after performing OH 2x/day and feeding them a hard diet. A fluorescent dye was injected prior to sacrifice, and block sections were examined under light microscope.
Results:
Clinical: Mild to moderate inflammation was seen at 40 days of ligature placement and increased PD; After treatment, PD returned to pre-treatment levels except dog #1(sacrificed @ 5 hrs).
Radiographic: All had bone loss at 40d.
Histologic: Test & control specimens of all time periods showed essentially similar findings at each evaluation period. The 5 hour specimen showed increased inflammation with osteoclastic activity and no evidence of LJE. At 28 days, test group showed slight increase in osteoblastic activity. Cementogenesis was similar in both groups.
Conclusion: NSD between chemical and mechanical curettage. Long junctional epithelium was seen more often in the mechanically treated areas. Citric acid did not damage the tissues. Healing was similar in both groups chemical curettage did not result in improved healing.
How does curettage heal? Where does the tissue originate from? What kind of attachment forms after curettage? Does this have any significance for periodontal stability?
Topic: Gingival Curretage Article
Authors: Caton J, Zander HA
Title: The attachment between tooth and gingival tissues after periodic root planing and soft tissue curettage
Source: . J. Periodontol. 50:462, 1979
Type: Clinical
Rating: Good
Keywords: scaling and root planing, gingival curettage, new attachment
Purpose: To determine the nature of the attachment between the tooth and gingival tissues following periodic root planing and soft tissue curettage.
Method: 2 adult Rhesus monkeys were used. 22 contralateral pairs of periodontal pockets were produced with orthodontic elastics around maxillary and mandibular central incisors, 1st molars, maxillary 1st bicuspids, and mandibular 2nd bicuspids. Orthodontic elastics remained in place 60 to 180 days to produce sufficient loss of connective tissue attachment and bone.3 months after elastic removal, all teeth with induced periodontal defects had SRP and plaque control regime was initiated (toothbrushing, flossing, and topical application of 2% CHX 3x week. At the time of scaling, the pockets on one side of the jaws received root planing and tissue curettage, and this instrumentation was repeated 3,6, and 9 months after initial root planing and curettage. Animals were sacrificed 3 months after last root planing and curettage. Histological analysis was performed. Measurements taken were: CEJ to apical end of JE (CEJ-JE), distance between crest of marginal gingiva and apical end of JE (MAR-JE), distance between coronal and apical ends of JE (JE).
Results: LJE was observed in both experimental and control sides. Cementoid was present on the root surface apical to the JE in 5/22 experimental pockets (23%). None was found on the control sides. “Windows” of CT in JE occurred in 8/22 experimental pockets (36%), and were not seen in the controls. CT was adjacent to the root surface in the area of these windows. There was no difference in CT attachment level (CEJ-JE) between control and experimental pockets, indicating that no CT attachment had occurred.
Conclusion: Periodic root planing and soft tissue curettage combined with plaque control 3x/week resulted in the formation of a LJE with no CT attachment. At the time of obtaining the experimental specimens, 3 months had elapsed since last instrumentation. If the windows of CT that occurred on curettage side are maintained, they may allow for new CTA. Further research is needed.
Topic: Gingival healing Article
Title: Ultrastructure of regenerating junctional epithelium in the monkey
Author: Braga AM, Squier CA
Source: J. Periodontol. 51:386, 1980.
Type: Randomized controlled trial
Rating: Good
Keywords: healing, junctional epithelium
P: To study reformation of epithelial attachment after partial and complete removal of junctional epithelium.
M+M: 3 adult monkeys. Mechanical prophy and OH as to reduce oral/gingival inflammation. At the end of 8 wk period established GI=0 and PI <1. An external bevel incision used on buccal aspect of maxillary 2nd PM, 1st and 2nd molars to remove all sulcular epithelium and partial junctional epithelium. Internal bevel incision was used to completely remove both in the mandibular teeth on same side. Biopsies were taken at 5, 10, 15, and 20 days post-op and of 2 untreated teeth for control. All prepped for exam with light microscopy and electron microscope.
R: A new JE developed from adjacent gingival oral epithelium regardless of whether or not JE was remaining. In group with external bevel, the residual JE persisted as small cell rests close to the CEJ and did not participate in regeneration of attachment. Epithelialization of gingival tissue occurred in 5 days in external bevel group and 10 days in internal bevel group. Both appeared similar to control at 20 days. Difference in rate of epithelialization was attributed to greater amount of coagulum and cell debris remaining after internal bevel, retarding epithelial migration and reattachment.
BL: Existing junctional epithelium does not participate in regeneration of junctional epithelium after excision. Increased coagulum and cell debris associated with an internal bevel incision hinder epithelial migration. By 20 days both techniques resembled the controls.
CR: Small sample size (3) and lack of variation in location of teeth.
Topic: Gingival Surgery Article
Title: Maintenance of long junctional epithelium in the rat
Author: Garnick et al
Source: J. Dent. Res. 61:681-685, 1982.
Type: Animal Experiment
Rating: Good
Keywords: Long junctional epithelium, epithelial cuff, mitotic activity, sub epithelial inflammation
P: To evaluate persistence of surgically induced LJE in rats at 3 and 6 months post-op and to compare the mitotic activity in the LJE at the same intervals.
M&M: 16 rats divided equally into 2 groups, first grp sacrificed in 3 months, second grp at 6 months, 4 ctrl. Connective tissue attachment incised in sulcus on mesial surface of mandibular left 1st M. The rats were had a stainless steel ligament placed around the cervical aspect of their teeth in combination with a high protein-powdered diet (as mentioned in other studies) to create a LJE. Irritant for 2 months and then removed. Put back on hard-pelleted diet. Allowed to heal for 3 months or 6 months and sacrificed.
R: Apical end of LJE appears to be a stable tissue, which will maintain itself over an extended period of time. Coronal end of LJE may become detached, resulting in increased pocket depth. The mitotic index was not related to the cell density (NSSD between groups). NSSD between groups with respect to the length of the LJE, extent of subepithelial inflammation, or in the length of the epithelial cuffs (increased in both groups).
BL: Epithelial cuff increased in length with time (1 month), that it is a self-renewing tissue, and that the LJE may reduce in length with time due to sulcus deepening which was not related to subgingival epithelial inflammation. Mitotic activity at the apical end of JE was found similar to the oral epi of facial gingiva, hence JE is stable and does not extend coronally with time.
Topic: healing after curettage Article
Authors: Listgarten MA, Rosenbaert S,
Title: Progressive replacement of epithelial attachment by a connective tissue junction after experimental periodontal surgery in rats.
Source: J Periodontol. 1982 Nov;53(11):659-70. DOI: 10.1902/jop.1982.53.11.659
Type: clinical
Rating: good
Keywords: curettage, healing, periodontal surgery,
Purpose: To assess if connective tissue attachment can replace the long junctional epithelium formed during the early stages of periodontal wound healing.
Methods: 56, 4-month-old Sprague-Dawley rats received a surgical injury on the left maxillary 1st molar. Right side served as unoperated control. The injury consisted of the excision of a thin wedge of gingival tissue from the mesial surface of the first molar from the gingival margin to the alveolar crest and root planing was performed. Animals were sacrificed at 10 days, 3 & 6 weeks, 3, 6, & 12 months.
Results:
After root planning and removal of cementum, a long JE is formed by 3rd week post-surgery
Early stages of the regeneration of the epithelium indicate that epithelium is derived from gingival epithelium from the wound edge, which connects to the tooth near the apical border of the root planed defect (layer of epithelium separates the CT from the inflammatory infiltrate)
After making contact with tooth, epithelium migrates coronally and a long JE is established, while inflammatory infiltrate is eliminated.
Progressive recession on the control side was noted
JE reestablished on experimental side, with gradual coronal extension, over a period of about 6 months.
The sulcus depth gradually decreased in the experimental and increased in the controls.
In the experimental group, the length of the JE increased initially and then decreased as the CT increased from the apical region, displacing the JE coronally.
Conclusion: This study provides the first published evidence that the long JE which forms after instrumentation of the root surface can be replaced by connective tissue from the apical region over a period of time.
Does curettage offer a benefit over scaling and root planing? What is the current thinking about curettage as a treatment option? Is removing the pocket epithelium thought beneficial during surgical procedures?
Topic: Gingival Curettage Article
Author: Ainslie P.
Title: A Biometric Evaluation of Gingival Curettage (II)
Source: Quintess Int 12:609-614, 1981
Type: Clinical Trial Discussion
Rating: Good
Keywords: Gingival curettage; pocket depth; level of attachment; inflammation
Purpose: Discussion of an article form a previous study evaluating the changes that occur in pocket depth, level of attachment and gingival inflammation with SRP+gingival curettage vs SRP alone
Methods: 15 subjects with a split mouth design. 408 teeth were treated; 206 SRP and 202 SRP+ curettage
Discussion:
Pocket Depth
-Either with SRP or SRP + curettage, a decrease in pocket depth occurred.
-The greatest pocket reduction was interproximally for both treatment modalities
Level of attachment
-Gain of clinical attachment after 5 weeks was observed with both treatments
-Increased level of attachment ranging from 1.2 to 3.8 mm was found after treatment with either procedure
-SRP alone had a tendency for greater gain in AL but it was not significant.
Inflammation
-The study supports that a reduction in inflammation occurs after SRP
-Elimination of local factors, such as plaque and calculus, along with daily OH most likely result in the reduction in gingival inflammation.
Conclusion:
-Transient increases in PD and decreases level of attachment occur immediately after scaling root planning and gingival curettage.
-SRP decreased PD, Increased level of attachment and reduced gingival inflammation five weeks after treatment
-SRP + Gingival curettage decreased PD, increased level of attachment and reduced gingival inflammation 5 weeks after treatment.
-No Statistical difference in decrease PD, increase level of attachment or decrease gingival inflammation with either SRP or SRP+ gingival curettage
-SRP alone had a tendency for greater gain in AL.
Topic: Curettage Article
Authors: Echeverria JJ, Caffesse RG
Title: Effects of gingival curettage when performed 1 month after root instrumentation. A biometric evaluation
Source: J. Clin.Periodontol. 10:277-286, 1983
Type: Clinical study
Rating: Good
Keywords: curettage, clinical measurements, root instrumentation
Purpose: To biometrically evaluate changes in location of the free gingival margin, probing depth and level of clinical attachment as well as variations in gingival inflammation when gingival curettage was performed 4 weeks after scaling and root planning (SRP) in patients with shallow, suprabony pockets.
Method: 15 patients (age 25-38, 375 teeth total) with mild periodontitis, probing depths less than 5mm, at least 24 teeth, no subgingival crown margins, no fixed prosthesis, no removable or orthodontic appliances were selected. Gingival index (GI), probing depth (PD), and distance from free gingival margin (FGM) to cementoenamel junction (CEJ) were measured at 4 points per tooth at baseline, 4 weeks and 9 weeks (5 weeks after curettage).
Results: At baseline, no difference existed between the two treatment groups. GI: 4 and 9 weeks after SRP, GI decreased significantly with no significant differences noted between treatment groups. FGM location: A significantly different change in initial location of FGM was observed in both treatment groups at 4 weeks (recession), with no significant difference noted between treatment groups. PD: Immediately after SRP, a significant increase in PD was noted in both treatment groups. After 4 weeks, PD decreased significantly in both groups. At 9 weeks, both procedures led to a significant decrease in PD but no differences were noted between groups. CAL: At 4 and 9 weeks, the CAL was improved and similar between both treatment groups.
Conclusion: No significant differences were found between the 2 groups regarding GI, FGM location, PD, and CAL. Significant improvement in the periodontal condition of patients was noted regardless of treatment used. Results of this study suggest that SRP alone is responsible for these results. Gingival curettage does not predictably improve the health of periodontal tissues and is not necessary in the routine treatment of shallow, suprabony pockets.
Topic: AAP statement regarding gingival curettage No Article
Authors: American Academy of Periodontology
Title: The American Academy of Periodontology statement regarding gingival curettage
Source: J Periodontol. 73:1229-30, 2002.
Type: Statement
Rating: Good
Keywords: Gingival curettage
AAP Statemnt Paper 2002
Gingival curettage is a surgical procedure designed to remove the soft tissue lining of the periodontal pocket with a curette, leaving only a gingival connective tissue lining. The original idea was to promote new CT attachment by removal of pocket lining and JE.
The results obtained are most often LJE, which is the same result from SRP. Short and long-term clinical trials have confirmed that gingival curettage provides no additional benefit when compared to SRP alone in terms of PD reduction, attachment gain or inflammatory reduction.
Since there is no evidence that gingival curettage has any therapeutic benefit in the treatment of chronic periodontitis, the AAP has removed it from its guidelines for periodontal therapy.
Topic: Periodontal therapy Article
Authors: Lindhe J, Nyman S
Tittle: Scaling and granulation tissue removal in periodontal therapy.
Source: J. Clin. Periodontol. 12:374-388, 1985.
Type: Clinical study
Rating: Good
Keywords: Therapy, periodontitis
Purpose: To study whether subgingival scaling is equally effective as “access” flaps in reducing gingivitis and probing depths (PD), and to assess whether granulation tissue removal is a determining factor for proper healing in the Tx of periodontitis.
Methods: 15 patients (60 quads) with advanced periodontitis (at least 4 sites per jaw quadrant with probing depth of > 6 mm). Baseline exam to evaluate PI, GI, BOP, PD, CAL. In each quadrant 3 sites of different PD were selected for analysis of subgingival microbiota. Randomly 4 quads in each pt were treated by: 1) MWF 2) MKF (Modified Kirkland Flap: Sulcular incisions without VRI’s, no attempt to remove granulation tissue from the flap, nor the pocket epithelium and reposition of the flap) 3) SRP. In all, 20 quads were treated with each of the 3 procedures. SPT q 2 wks for 3 mos then q 3 mos /year. Exam at 6, 12 months.
Results:
-Except for PD>6mm, subgingival SRP was equally effective as access flap procedures in reducing gingivitis and PD.
-5% of PD >6 mm in subgingival SRP quads remained with BOP after12 months vs 1% in the surgery groups.
-Such sites harbored >20% spirochetes and motile rods.
-Granulation tissue removal in flap surgery is not a critical measure for establishment of proper healing in periodontal tissues.
-Shallow pockets lost attachment especially with surgery. These results are valid only for tooth surface devoid of furca involvement.
BL: With good OH and SPT, subgingival SRP and access flaps are equally effective in reducing gingivitis and PD in PD< 6mm with no furca involvement.
What is ENAP? What is the difference between ENAP and subgingival curettage?
Topic: Soft tissue new attachment Article
Authors: Yukna RA, Lawrence JJ
Title: Gingival surgery for soft tissue new attachment.
Source: Dent Clin NA 24:705, 1980
Type: Review
Rating: Good
Keywords: new attachment, curettage, ENAP, MWF
Purpose: Review of new attachment procedures (Curettage, excisional new attachment procedure (ENAP), mod. ENAP, modified Widman flap (MWF), and flap curettage).
Subgingival curettage: For shallow edematous pockets where shrinkage is the main goal. New attachment can possibly be achieved. Should not be used on firm, fibrous pockets, because shrinkage may not be realized. Disadvantages: A blind procedure during which residual plaque and calculus may be left behind. If done properly takes just as long as surgery. Can’t predictably remove pocket epithelium, interproximal granulation tissue and epithelial attachment. Trauma can occur if operator is inexperienced.
ENAP: This is subgingival CU performed with a scalpel. Incision from FGM to base of pocket, pocket content removal, root planning & primary closure with sutures if needed. Advantages: clean excision of the pocket lining, epithelial attachment, & granulomatous tissue. Access to root surface and more predictable new attachment. Minimal recession post-op. Disadvantages are similar to curettage.
Modified ENAP: Initial incision is from FGM to bone rather than the base of the pocket. All of the pocket + CT coronal to crest are removed. Advantages: greater access and the potential of utilizing the healing capabilities of the PDL. Disadvantages: the removal of CT fibers with potential for attachment loss.
MWF: Continuation of ModENAP with incision in sulcus, horizontal incision to remove supracrestal gingival tissues, & exposure of 1-2mm of bone. For treatment of PD >5mm. Advantages FTF, better access in infrabony defects. Disadvantages: Technique sensitive.
Flap Curettage: Same as MWF except flap is reflected past the MGJ for treatment of deeper pockets & infrabony defects. Flaps are apically positioned. Advantages: regenerative potential in infrabony defects, eliminates B or L pockets by placement of tissue at alveolar crest. Disadvantages: lack of attachment gain potential on B or L surfaces and possible recession or compromised esthetics.
Conclusion: Most of these procedures heal with LJE with occasional CT adhesion. New attachment is rare. Patient comfort may be decreased, root sensitivity and root caries increased, and esthetics can be compromised as the procedures become more extensive.
Topic: ENAP Article
Authors: Yukna RA
Title: A clinical and histologic study of healing following the Excisional New Attachment Procedure in Rhesus monkeys
Source: J. Periodontol. 47:701-709, 1976
Type: Clinical
Rating: Good
Keywords: ENAP
Purpose: To study the healing sequence clinically and histologically after Excisional New Attachment Procedure (ENAP) in monkeys.
Method: The incisors of 5 male Rhesus monkeys were used in the study. Small amalgam restorations with central depressions and vertical grooves on midfacial and midlingual surfaces were placed to standardize measurements. Suprabony periodontal pockets were induced with the used of elastic bands. At the time of final band removal oral hygiene procedures were initiated. Periodontal conditions throughout the study were assessed by means of the Navy Periodontal Disease Index (NPDI). At the time of the surgery two teeth were selected for treatment and the rest of teeth of the segment served as controls. ENAP was performed, immediate post-surgical measurements were made and no periodontal dressing was used. OH procedures were continued and animals were placed on soft diet. Photographic records and clinical measurements were made at monthly intervals and/or at the time of sacrifice. No PDs measurements were made until 90 days post-op. Monkeys were sacrificed at 0, 30, 90 and 180 days and histologic analysis was performed.
Results: The average time to achieve at last 4mm of PD was 4 months.
Untreated control pockets showed a tendency to deepen with time and for continuing loss of attachment.
0 days: epithelial lining of the pocket was completely eliminated by the incision. Fibrin clot would be seen occasionally between the CT surface and the root.
30, 90 and 180 days post-op: All section demonstrated long, thin JE. The JE was thin with no rete ridges and minimal inflammatory infiltrate. The re-formed lamina demonstrated abundant CT. Occasionally areas of apparent new CT attachment were seen apical to the JE. Rarely areas of root resorption were seen.
Control areas: Control pockets at all time frames demonstrated uniform histologic appearances with thick pocket epithelium, ulcerated with rete ridges and moderate to severe inflammatory infiltration.
Conclusion: The consistent finding of a long, thin epithelial attachment and a minimal amount of CT attachment does not fulfill the histologic criteria for new attachment.
Topic: ENAP long term study Article
Title: Five-year evaluation of the excisional new attachment procedure.
Author: Yukna RA, Williams JE:
Source: J. Periodontol. 51:382-385, 1980
Type: Randomized controlled trial
Rating: Good
Keywords: healing, junctional epithelium, excision new attachment procedure
P: 5 year post-op evaluation of the ENAP.
M+M: ENAP procedure is done by a scalloped internally-beveled, partial thickness incision from the free gingival margin to the point where the base of the pocket meets the tooth surface. The excised tissue removed and the root surfaces SRP. Gingival tissue repositioned as closely as possible to pre-sx position, maintaining contact with the root and secured with sutures. ENAP patients were recalled every 4 months for 5 yrs. Height of free gingival margin, PD, and KG were recorded, 56 sites eval’d.
R: There was an overall continuous increase in mean sulcus depth (0.6mm), an overall decrease in mean recession (0.3mm) and an overall decrease in the mean amount of previously gained new attachment (0.4mm) between 3year and 5 year re-eval. Only isolated sites were the same as or worse than pre-tx levels. An overall mean net gain CAL of 1.5 mm was found at 5 years post-op, and mean probing depths approached 3.0 mm at 5 yrs. Both of these 5 year findings were SSD improvements over preop measurements.
BL: 5 year evaluation of ENAP has shown statistical and potentially clinically significant improvements over pre-op measurements (mean of 1.5mm of attachment at 5 years post-op).
How effective are we at surgically removing the epithelial lining of the periodontal pocket? How does ENAP heal? Does this have any significance for periodontal stability?
Topic: Gingival Surgery Article
Title: Comparison of pocket epithelium removal by sulcular and internally bevelled incisions with and without prescaling
Author: Garrett et al
Source: Int J Perio Rest Dent. 6(5): 57-66, 1986
Type: Human Experiment
Rating: Good
Keywords: pocket epithelium, sulcular incision, internal bevel incision, long junctional epithelium
P: To determine effectiveness of pocket epithelium removal with sulcular and internally beveled incisions. In addition, to determine if a single session of S/RP 4-6 weeks prior to incision would affect the ability to completely remove pocket epithelium.
M&M: 7 (6F, 1M) pts provided 36 tissue specimens from max. incisors with PD 3-6 mm. They were divided into four groups as follows:
Gp Ia - internally beveled incision + scaling 6 weeks prior to sx (and supra-g prophylaxis every 2 weeks until biopsy)
Gp Ib - sulcular incision + scaling 6 weeks prior to sx (and supra-g prophylaxis every 2 weeks until biopsy)
Gp IIa - internally beveled incision, no scaling
Gp IIb - sulcular incision, no scaling
Specimens were viewed by LM and SEM.
R: In no instance was all of the epithelium removed. 16/18 specimens from internally beveled incisions had > 50% but < 100% pocket epi removal. Only 3/18 sulcular incision specimens showed the same efficiency. Difference was SS. Pre-surgical SRP did not affect the amount or frequency of pocket epi removal with either type of incision. In four specimens epi was present due to exposure of oral epithelial rete pegs.
BL: Epi was not completely removed with either internal bevel or intrasulcular incisions. Prescaling has no effect on the amount of epi removed.
D: Since tissues had inflammation at the time of sample collection, residual plaque and calculus may have accounted for hyperplasia of pocket epithelium and elongation of oral rete ridges. Also while removing thin gingival tissue, chances are that oral rete ridges of the epithelium are exposed and along with residual epithelium could contribute to formation of LJE. This will then reduce the opportunity of forming new CTA.
Cr: residual pocket or oral epithelial islands could therefore reduce the opportunity to achieve new CTA to previously exposed root surface (needs more research at this point in time)
Topic: pocket removal Article
Authors: Litch JM, O'Leary TJ,
Title: Pocket epithelium removal via crestal and subcrestal scalloped internal bevel incisions.
Source: J. Periodontol. 55:142-148, 1984 DOI: 10.1902/jop.1984.55.3.142
Type: clinical
Rating: good
Keywords: pocket epithelium removal, scalloped internal bevel,
Purpose: To determine whether either crestal or sub-crestal incisions result in complete removal of sulcular epithelium during full thickness flap procedures.
Methods: 52 patients needing extraction of periodontally involved teeth volunteered to have biopsies taken at same time as ext. Test incisions were an inverse bevel, either crestal (initial incision at crest of gingival margin close to the neck of the tooth & directed toward crest of the bone) or sub-crestal (1-2 mm away from gingival margin & angled just apical to alveolar crest). Sulcular incisions, which severed the epithelial attachment, served as control. Teeth included were BOP +, PD of 4mm or more on at least 3 sites/tooth. In total, 56 samples (14 F, 14 L, 14 Palatal, & 14 Papillary) were taken, with 20 control sites biopsied.
Results: Total of 1167 control and experimental sections were examined for presence & extent of residual epithelium. Residual pocket epithelium was found in 90% of control group. Crestal incisions: residual pocket epithelium present in 83% of sites (F, L, and P). Sub-crestal incisions: residual pocket epithelium only remained in 33% of the sites (F, L, and P). Residual pocket epithelium in papillary area: present in 100% of crestal incisions & 80% of sub-crestal.
Conclusion: Pocket epithelium is not consistently removed with either crestal or sub-crestal beveled incisions. The papillary area is persistently resistant to removal of epithelium; possibly because epithelial rete ridges between adjacent M & D tooth surfaces are too close together and could only be removed by complete papilla removal.
If flap is thinned too much to remove all pocket epithelium, chances of necrosis & bone exposure increase greatly. Removal of pocket epithelium to allow new CT attachment is not indicated, especially since other research shows new JE originates from adjacent oral epithelium.
Topic: Long Junctional Epithelium Article
Author: Magnusson I, Runstad L, Nyman S, Lindhe J
Title: A long junctional epithelium- A locus minoris resistentiae in plaque infection?
Source: J. Clin. Periodontol. 10:333-340, 1983
Type: Animal Study
Rating: Good
Keywords: Dental plaque; gingivitis; junctional epithelium; periodontal disease
Purpose: to examine whether a gingival unit with a long junctional epithelium provides a less efficient seal against plaque infection than a unit with a junctional epithelium of normal length.
Methods: In 4 adult monkeys, over a period of 3-4 moths, periodontal tissue breakdown was produced around 8 teeth with ligatures. One month after removal of ligatures, the teeth with induced periodontitis were subjected to periodontal surgery (no osseous surgery was completed). Healing after these interventions resulted in long junctional epithelium. After surgery and suture removal, plaque control was instituted for 4 months. During the next 6 months, all oral hygiene was abandoned and plaque was allowed to accumulate on test teeth and controls. In each animal, half of the control and experimental sites had cotton fibers to enhance plaque formation and the other half did not. Animals were sacrificed 6 months after the start of the plaque accumulation period and a histological exam was performed.
Results: Histologic evaluation revealed that all teeth with plaque accumulation showed a formation of inflammatory cell infiltrate within the CT adjacent to the epithelium. This zone was similar in both groups; however, since the epithelium of the experimental group was longer, the infiltrated CT covered only about 60% of the JE while control regions had 90% coverage. The original length of JE is unrelated to the size of the developing inflammatory cell infiltrate.
Discussion: These findings failed to support the hypothesis by Barrington (1981), that a long junctional epithelium may be a disadvantage in that the area may be prone to new pocket formation and reinstitution of disease.
Topic: Inflammation Article
Authors: Beaumont A, O'Leary T, Kafrawy A
Title: Relative resistance of long junctional epithelial adhesions and connective tissue attachments to plaque-induced inflammation
Source: J. Periodontol. 55:213-223, 1984
Type:
Rating: Good
Keywords: inflammation, long junctional epithelium, connective tissue, plaque
Purpose: To compare the resistance of the long junctional epithelial adhesion and the naturally occurring dentogingival junction to artificially induced periodontal disease in beagle dogs.
Method: 6 male beagle dogs were assigned to control (Group 2) and experimental (group 1) groups. Initial phase: GI was recorded over each root. A horizontal reference groove was placed on the buccal crown surface of each tooth and used to measure to the FGM as well as the depth of the sulcus. Silk sutures were used for 6 weeks to induce periodontal disease in the experimental group, while control animals were scaled and polished. Surgical phase: Full thickness flaps were done on experimental group animals and granulation tissue was removed with curettes. After SRP, reference grooves were placed in the root surface at the level of the alveolar bone. Both control and experimental groups then received identical plaque control maintenance for a 53 day healing period, leading to long junctional epithelial adhesions in the experimental group. Combined disease phase: Control (Group 2) and experimental (Group 1) groups were treated similarly in this phase. Ligatures were positioned subgingivally. Disease induction periods represented were days 17, 20, 11, 14, 4 and 7. Animals were then sacrificed, and block sections were obtained of relevant teeth and supporting structures. Status of the connective tissue, crevicular epithelium, root surface, periodontal ligament space, cementum layer and junctional epithelium was studied on the buccal side of both groups. Connective tissue was divided vertically into three zones and inflammation was evaluated with a 10-point system data. Bone activity was recorded, as well as changes in attachment in Group 1 (cementogenesis if present, root resorption).
Results: GI score kept increasing till day 11 and remained stable at that level over the 20 day experimental period. Mean probing depths where consistently less in the Group 1 animals except for the 14-day evaluation period, when they were equal. Recession and attachment varied within small limits over the 20-day period. Histologic findings showed group 1 animals had a higher Tagge inflammatory score from day 11 on. Long junctional epithelial attachment was seen more often in the earlier Group 1 time periods. Ulcerated sulcular epithelium was seen frequently in the earlier time periods of Group 2 animals. Connective tissue, cementogenesis in the notch area and root resorption were more common in Group 1. Group 1 showed more osteoblastic and less osteoclastic activity.
Conclusion: Findings in this study suggest that long junctional epithelium that develops after surgical treatment may not be less resistant to plaque and its associated toxins compared to true connective tissue.
Topic: Integrins and extracellular matrix components No Article
Authors: Gräber HG, Conrads G, Wilharm J, Lampert F
Title: Role of interactions between integrins and extracellular matrix components in healthy epithelial tissue and establishment of a long junctional epithelium during periodontal wound healing
Source: J Periodontol. 70:1511-22,1999.
Type: Review
Rating: Good
Keywords: integrins, extracellular matrix, epithelial tissue, long junctional epithelium, periodontal wound, healing.
P: A review of Integrin effect on ECM in establishment of LJE during healing.
Integrins are part of the cellular adhesion molecule (CAM) family which are expressed by different cell types (epithelial cells, fibroblasts, lymphocytes, endothelial cells, leukocytes and platelets) and function as cell surface receptors for different molecules in the ECM.
Each integrin is a heterodimer consisting of α-subunit and β-subunit.
Epithelial cells can synthetize a total of 8 integrin subunits, the combination of which results in the 5 inegrins (α2β1, α3β1, α5β1, α6β1, αVβ5).
Only proteins and glycoproteins of the ECM are known to be ligands of the epithelial integrins.
Of the epithelial integrin, α3β1 is the receptor capable of binding on multiple ligands , specially Type I and Type V collagen, laminin, fibronectin, epiligrin/Kalinin, and entactin/nidogen.
Integrin α5β1 is the receptor exclusively for fibronectin and thus is of particular significance in the migration involved in wound healing.
In health, they are found in the basal epithelium and at a specific polarization- allowing for adhesion of basal cells to the basal lamina, as well as the basement membrane to the CT.
As differentiation increases in upper cell layers, integrin expression is decreased. Integrins also play a significant role in cell-cell adhesion of basal cells.
Cell-cell adhesion is taken over by other CAMs (eg Cadherins) and increasing number of desmososmes.
Integrins can bind either with each other or another unknown, bridge forming ligand.
Two types of proliferating cells are found in the epithelium: Stem cells (high proliferative capacity) and transit amplifying cells (low capacity and these enter into terminal differentiation w/I 1-5 divisions).
Stem cells express integrins intensely and exhibit rapid ECM adhesion- especially to Type IV collagen and fibronectin. There seems to be a relationship in integrin density/ability to adhere to ECM and proliferation rate and capacity.
Apoptosis is regulated by a cells adhesion to the ECM. This adhesion suppresses IL-1B converting enzyme, a crucial enzyme for apoptosis. Once this adherence is broke, the enzyme is upregulated and cell death is initiated. Antibodies that target the integrins specific to ECM adherence have been show to initiate this process.
Wound Healing: Damage to the epithelium causes the basal cells to change phenotype, entering into a horizontal migratory activity ( as opposed to vertical under normal circumstances).
The adhesion of migrating basal cells to the wound matrix is mediated by integrins.
In Cavani, Juhasz and Larjawa studies, wounds were created in human palatal mucosa into CT and tissue samples were taken at different intervals.
Integrin expression changes were seen w/I 1-2 days.
Filpodic extensions into the wound matrix from the basal cells were high in density in integrins. This upregulation continued up to 14 days after re-epithelialization.
EGF (Epithelial Growth Factor) and TGF-α have been show to upregulate integrin expression
C: Integrins play a central role in re-epithelialization of wounds by their interaction between ECM and epithelium. Integrins mediated interaction plays an important role in the regulating the proliferation, migration and differentiation of the epithelial cells.
Is the removal of epithelial attachment beneficial during surgical procedures?
Topic: Periodontal treatment Article
Authors: Smith B, et al
Tittle: Mucoperiosteal flaps with and without removal of the pocket epithelium.
Source: J. Periodontol. 58:78, 1987.
Type: Review
Rating: Good
Keywords: treatment, periodontitis
P: A comprehensive review of the pros and cons of remaining pocket epithelium with regard to achieving re-attachment.
Discussion: Is it necessary to remove pocket epithelium to achieve reattachment: Majority of the anecdotal and scientific evidence points toward the importance of removing pocket epithelium to achieve re-attachment. (Ramfjord, 1951; Ingle, 1952; Morris, 1949; Carranza, 1957).
Carranza, 1957: Observed that if the epithelial lining remained in the pocket; 1) No reattachment of connective tissue was possible 2) due to its state of ulceration and degeneration, no reattachment was possible; and 3) if some islands of pocket epithelium remained, they could proliferate, causing recurrence of the pocket.
However, few studies have shown reattachment even when the pocket epithelium was not removed. Studies contradict each other on whether the pocket epithelium can be completely removed.
Methods and effectiveness in removal of the pocket epithelium:
Curettes and knives; chemical agents such as sodium sulphid, phenol camphor; antiformin; ultrasonic and abrasive stones.
Results of surgery vs non- surgery approaches in the treatment of periodontitis: similar. Flap operations, such as open curettage & MWF, aim at reattachment or readaptation. Healing is mediated by means of long junctional epithelium. In most cases connective tissue attachment is minimal. Periodontal repair mediated by LJE does not represent an area of less resistance to bacterial insult.
Topic: Removal of pocket epithelium Article
Authors: Smith B, Echeverria M
Title: The removal of pocket epithelium: A review.
Source: J West Soc Periodontol. 32:45-59, 1984.
Type: Review
Rating: Good
Keywords:
Purpose: A comprehensive review of the pros and cons of remaining pocket epithelium with regard to achieving re-attachment.
Review: reattachment, new attachment
Is it necessary to remove pocket epithelium to achieve reattachment: Majority of the anecdotal and scientific evidence points toward the importance of removing pocket epithelium to achieve re-attachment. (Ramfjord 1951; Ingle 1952; Morris 1949; Carranza 1957).
Carranza, 1957: Observed that if the epithelial lining remained in the pocket; 1) No reattachment of connective tissue was possible 2) due to its state of ulceration and degeneration, no reattachment was possible; and 3) if some islands of pocket epithelium remained, they could proliferate, causing recurrence of the pocket.
However, few studies have shown reattachment even when the pocket epithelium was not removed. Studies contradict each other on whether the pocket epithelium can be completely removed.
Methods and effectiveness in removal of the pocket epithelium:
Curettes and knives; chemical agents; ultrasonic and abrasive stones.
Results of surgery vs non- surgery approaches in the treatment of periodontitis: similar. Flap operations, such as open curettage & MWF, aim at reattachment or readaptation. Healing is mediated by means of long junctional epithelium. In most cases connective tissue attachment is minimal. Periodontal repair mediated by LJE does not represent an area of less resistance to bacterial insult.
Histological results after performing flap surgery aimed at reattachment: Junctional epithelium vs true CT attachment LJE is observed against cementum rather than true CT attachment. Some studies suggest that over time this may be replaced by a CT junction. Barrier function of LJE against plaque infection is not inferior to that provided by a dentogingival epithelium of normal length.
Conclusion: In order to obtain re-attachment it is necessary to remove the pocket epithelium, though some studies have shown re-attachment or readaptation in spite of the presence of the pocket epithelium. There are several methods to remove pocket epithelium and studies comparing instrumentation (hand vs ultrasonic) are contradictory. Surgical vs non-surgical yield similar results. Healing occurs in a long junctional epithelium, though some studies have shown CT attachment in rats. LJE does not represent an area of less resistance to bacterial disease.
What is LANAP? What laser is utilized for this procedure?
Topic: LANAP No Article
Authors: Yukna, RA, Carr, RL, Evans GH
Title: Histologic Evaluation of an Nd:YAG Laser-Assisted New Attachment Procedure in Humans
Source: Int J Periodontics Restorative Dent. 2007 (6):577-587
Type: Clinical
Rating: Good
Keywords: LANAP, laser, regeneration
Purpose: To report histologic wound healing following use of Laser Assisted New Attachment Procedure (LANAP) for periodontal pockets.
Method: Six patients (26-54 years, 3M/3F) provided two single-rooted teeth each. Six pairs of single-rooted teeth with moderate to severe periodontitis that were treatment planned by the restorative dentists for extractions were selected. Pre-operatively, the subjects received occlusal adjustment, splinting, SRP was performed on other teeth on same segment, supra-g prophylaxis was provided for the rest of the mouth. Documentation consisted of photographs, radiographs with stent, GI, PI, MOB, CEJ-gingival margin, CEJ-base of the pocket, CEJ-apical extent of calculus, CEJ-mucogingival junction, BOP. A notch was placed at apical extent of calculus. One of each pair of teeth randomly received: Nd:YAG laser (3 W, 150-us pulse duration, and 20 Hz) to remove the pocket epithelium, relax the gingival collar and expose more of the contaminated root surface, SRP coronal to the notch, laser again (4W, 635-us pulse duration, and 20 Hz) to help achieve a solid fibrin clot and for a pocket seal. Control: teeth received SRP only. All teeth received a triple antibiotic ointment, and a light-cured dressing, NSAID, Doxycycline 100 mg for 10 days, and 0.12 CHX mouthrinse. After 3 months, experimental teeth were removed for histologic analysis.
Results: LANAP treated teeth exhibited greater mean PD reduction and greater CAL gain than the control teeth. GI, PI, BOP were improved on all test and control teeth. All six LANAP-treated specimens showed new cementum and new CT attachment in and occasionally coronal to the notch. In two specimens, the notch was within the infrabony pocket (subcrestal) and the new cementum and new CT attachment were adjacent to new aveolar bone, technically showing periodontal regeneration. 5/6 control teeth had a LJE, with no evidence of new attachment or regeneration. 1/6 control specimen did show a small amount (0.1mm) of new CEM and CT attachment. No evidence of any adverse histologic changes to root surface or pulp of any teeth.
|
Procedure |
PD Reduction |
Attachment gain |
Recession |
|
LANAP |
4.7 mm |
4.2 mm |
0.2 mm |
|
Control |
3.7 mm |
2.4 mm |
0.8 mm |
Conclusion: Consistently positive histologic responses in periodontal pockets in humans treated with the LANAP. CEM-mediated new attachment and occasionally apparent periodontal regeneration was noticed.
Topic: LANAP No Article
Title: Human clinical and histologic evaluation of laser-assisted new attachment procedure
Author: Nevins ML, Camelo M,
Source: Int J Periodontics Restorative Dent. 2012 Oct;32(5):497-507.
Type: Histological study
Rating: Good
Keywords: LANAP, Healing, Histology
P: To histologically evaluate the healing response to minimally invasive laser-assisted new attachment procedure (LANAP).
M&M: 12 advanced periodontal defects in 8 subjects were included. Inclusion criteria: 1 tooth requiring extraction with a PD 7mm and tx suggestion of a 4mm or deeper intrabony defect. Smokers and those with a history of active SRP tx or perio sx in the past 12 months were excluded. Full arch LANAP was provided in a single visit with Nd:YAG laser (Millenium). A notch was placed at the estimated extent of calculus (the authors performed a flapless notch validation study with histo and found that there was calculus present a mean of 2.2 +/- 1.3mm apical to their notches). First, the laser was used to removed the disease pocket epithelium. Next, teeth were aggressively root planed with piezo ultrasonic instrumentation (4 to 5 tips were used on each root surface with repetitive cleaning until the roots were smooth and there was no calculus detected). After the US cleaning, either a Piezo tip insert or a periodontal knife no. 11, blunt dissection of any remaining fibers into the PDL space. This was for stimulation vascular access to the periodontal wound and also giving more visual access now that the tissues were relaxed from the first pass with the laser. Lastly, another pass was performed with the laser (to stimulate the blood clot). Occlusal adjustment with selective grinding and extra- or intra-coronal splinting of the teeth was provided immediately POT and as needed at follow-up visits to eliminate mobility. Pts were put on CHX rinse for 4 weeks, prescribed amoxicillin 500mg TID/7 days and ibuprofen 600mg every 6 hours prn. Pts were seen for follow-up care and OHI at 7, 14, 28, 42, and 56 days. Prophylaxis was provided and OH reviewed at 2.5, 4, 5.5, 7, and 8.5 months. Rx were updated at 5.5 and 9 months. At 9 months, bloc biopsy of study teeth was done and histology performed.
R: Some pts experienced increased dentinal sensitivity during the first 4 weeks POT, which decreased to normal limits. There were no signs of root damage from the laser therapy clinically or histologically. After 9 months, the test teeth had a mean CALgain of 3.8mm +/- 2.8mm and PD reduction of 5.4mm +/- 2.64. 10 teeth had histology performed. 5 teeth healed with regeneration (new cementum, PDL, bone). With respect to the other 5 teeth, one tooth had a new attachment apparatus with new cementum and inserting collagen fibers, and 4 teeth healed via LJE.
BL: LANAP appears to be a safe procedure that may result in periodontal regeneration (5/10 teeth).
Cr: The apical notch was not placed in the manner required by the definition of perio regeneration. In their notch study, they found that they were 2.2mm away from the apical extent of calculus. Occlusal adjustment, splinting, and antibiotics could influence the outcome. Only half the teeth had possible regeneration (notch not accurately placed). No control group.
Topic: AAP statement regarding ENAP No Article
Authors: American Academy of Periodontology
Title: The American Academy of Periodontology statement regarding Use of Dental Lasers for Excisional New Attachment Procedure (ENAP)
Source:
Type: Statement
Rating: Good
Keywords: Dental Laser
The American Academy of Periodontology statement regarding Use of Dental Lasers for Excisional New Attachment Procedure (ENAP)
The ENAP was first described in 1976 as "a definitive subgingival curettage performed with a knife." Like subgingival curettage, the ENAP results in "a long, thin epithelial attachment and a minimal amount of connective tissue attachment." The only published human clinical study comparing gingival curettage to the ENAP found no significant differences in probing depth reduction or gains in attachment.
It should be noted that the preponderance of evidence indicates that curettage fails to achieve any clinical result that cannot be accomplished by routine scaling and root planing. The Academy is not aware of any published data that indicates that the ENAP laser procedure is any more effective for these purposes than traditional scaling and planing.
To date, there are only four published human studies involving a total of 57 patients that have evaluated the effects of subgingival laser application. All four papers report reductions in putative periodontal pathogenic microbes following laser treatment. Two of the papers also reported laser induced root damage. The remaining two papers did not evaluate treated teeth for root damage. Elimination of pocket epithelium by gingival curettage, ENAP or other internal bevel incision designs appears not only nearly impossible but unnecessary for long-term therapeutic goals. In addition, there are no published data that demonstrate that either curettage or ENAP are effective in periodontal regeneration.
To the contrary, there is peer reviewed evidence, both in vivo and in vitro, that use of lasers for ENAP procedures and/or gingival curettage may place patients at risk for damage to root surfaces and subjacent alveolar bone that, in turn, could render these tissues incompatible to normal cell attachment and healing.
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