Osseous autografts. III. Comparison of osseous coagulum-bone blend implants with open curetage

Treatment of juvenile periodontitis patients by control of infection and inflammation. Four case reports

Four patients, ages 14-17, who demonstrated characteristics of juvenile periodontitis, underwent antibiotic and surgical therapy to control microbial etiologic factors. No occlusal equilibration or bone grafting techniques were employed. Subsequent to treatment, all four patients demonstrated decreased pocket depths and mobility on teeth associated with vertical osseous defects. Osseous repair was evident on postoperative radiographs. Reentry procedures, on one patient, confirmed that osseous repair had occurred in 2- to 3-wall, 3-wall, hemi-circumferential and furcal defects. If infection and inflammation are controlled, it appears that the potential for osseous repair in juvenile periodontitis patients is greater than has been thought.

Periodontal repair after surgical debridement with and without cartilage allografts

The effect of a cartilage allograft on healing in intrabony defects treated by open flap curettage was investigated at 130 surgical sites in 4 patients. Thinned mucoperiosteal flaps were elevated and the intrabony defects were debrided. A stent with stainless steel pins was used to measure defect depth at fixed locations adjacent to the root surfaces. The bony defects treated ranged from 0-9 mm with a mean intraosseous depth of 2.4 mm. 62 sites received cartilage implants and 68 sites were treated by surgical debridement only. The flaps were readapted and sutured to the level of the alveolar crest. After 16 weeks the defects were remeasured. Both treatment methods resulted in a mean apical shift of -0.09 mm of the base of the defects that were less than 3 mm and a mean coronal shift of 0.9 mm in defects that were greater than 3.5 mm in depth. The repair in deeper lesions increased with the number of intrabony walls. Mean pocket depth at flap curettage sites was reduced from 5.4-3.3 mm (P less than 0.01) at 16 weeks. At sites receiving the cartilage, the mean pocket depth decreased from 5.6-3.6 mm (P less than 0.01). Pocket reduction resulted from a combination of surgical recession and a mean gain of 1 mm in clinical attachment (P less than 0.05 for flap curettage sites only). The cartilage implants provided no statistically significant advantage in either bony or soft tissue repair over flap debridement alone. Although bony repair is influenced by depth and configuration of the intrabony defects, significant gains in attachment and reductions in pocket depth may occur independently of changes at the base of the intrabony defects.

Alloplastic implants of tricalcium phosphate ceramic in human periodontal osseous defects

Initial pilot studies using tricalcium phosphate ceramic placed into human periodontal osseous defects demonstrated osseous repair. Therefore, further evaluation of this material was undertaken on 17 carefully selected patients with 1-wall, 2-wall, crestal and furcation defects using standardized preoperative and postoperative radiographs, clinical measurements and clinical photographs. Inverse bevel, full-thickness flaps were raised, the areas debrided, root surfaces planed with ultrasonic and hand instrumentation, osseous penetrations made with curet point and the flaps sutured after the defects were filled. Eighteen-month reentry surgical procedures were performed on 10 of the 17 patients, with a resultant average of 2.8 mm of new bone. Controls were not used in this study since a protocol describing a sham procedure with other than 3-wall osseous defects was not acceptable in 1973 to the Clinical Human Use Committee. Although the tricalcium phosphate ceramic material was not found to be totally predictable in this study, it may nevertheless become a useful graft material because of its potential for osseous repair in combination with its availability, host acceptability, ease of manipulation and storage advantages.

A six-month clinical evaluation of decalcified freeze-dried bone allografts in periodontal osseous defects

The osteogenic potential of decalcified freeze-dried bone allografts in the treatment of human periodontal osseous defects was evaluated over a 6 month period. Cortical bone, obtained under sterile conditions from a human donor within 24 hours after death, was decalcified, freeze-dried and ground to a particle size of 250 to 500 microns. Twenty-seven osseous defects with one-, two- and wide three-wall morphology were treated. Clinical measurements were made with a stent and a calibrated periodontal probe before surgery, at the time of surgery, and at re-entry. The combined mean osseous regeneration for all defects was 2.4 mm. This represented a 65% mean bone-fill of the original defect. The findings demonstrate that decalcified freeze-dried bone allograft has potential as an osseous grafting material in periodontal therapy.

Periodontal healing following open debridement flap procedures. II. Histologic observations

Four tooth-containing blocks were obtained from patients being treated for infraosseous lesions of significant depth as part of their periodontal therapy. Treatment consisted of open flap debridement and professional cleansing at least every 4 weeks. Teeth in block were removed for histologic study 4 to 6 months after surgery. Histologic evaluation of the repair process showed pocket closure by epithelial and connective tissue adhesions in the form of an elongated junction epithelium, beneath which parallel-oriented fibers adhered to the root for a limited distance. Apical to this adhesion, functionally inserted fibers were present. Since no cementogenesis was seen at these latter areas, it must be assumed that the inserted fibers were present before the surgery and were not significantly affected by the procedure. No significant evidence of crestal osteogenesis was noted. However, comparison of the clinical osseous profile recorded at the time of surgical debridement with the flat crest seen in two of our cases histologically, suggests that significant crestal resorption had taken place postsurgically in some of these lesions.

Healing after treatment of periodontal intraosseous defects. II. Effect of citric acid conditioning of the root surface

Citric acid conditioning of the root surface as a supplement to replaced flap surgery of intraosseous periodontal defects was evaluated. Thirteen patients and a total of 45 proximal defects with residual probing pocket depth greater than or equal to 6 mm after initial preparation were used. The effect of treatment was studied in matched subsamples of the total material including one acid-treated and one nonacid-treated defect from each subject. The results demonstrated that an average gain of probing attachment level amounting to 2.l0 mm was obtained following acid treatment as compared to 1.1-1.2 mm for the nonacid-treated controls. Corresponding figures for gain or probing bone level were 1.2-1.3 mm for acid treatment and 0.8-0.9 mm for controls. The clinical significance of these findings was discussed.

Evaluation of durapatite ceramic as an alloplastic implant in periodontal osseous defects. I. Initial six-month results

Eight patients received a new polycrystalline ceramic form of pure hydroxylapatite (Durapatite) as a bone implant material in various types of infrabony defects following internally beveled full thickness flaps, root planing, and defect debridement. All osseous margins and defects were measured from the CEJ using a standardized periodontal probe. Similarly debrided defects that were not implanted served as controls. Defect selection as either experimental or control site was based on either split-mouth or alternating defects design. Periodontal dressing and systemic tetracycline were used for 10 days. Results for documentation and plaque control were at 10, 20, and 30 days, and 3 and 6 months. Measurements relating to defect changes were made at the 6-months surgical re-entry. For evaluation purposes original defect depths were divided into three groups. In Group I (less than 3 mm) defect fill was 1.2 mm (60%) for the implanted defects and 0.6 mm (40.5%) for the control sites (significantly different at P less than 0.05). In Group II (3--6 mm) defect fill of 1.7 mm (48.5%) for implanted sites was significantly better than the 0.1 mm (11.1%) for the control sites. In the deepest group (Group III greater than or equal to 6 mm) Durapatite placement yielded 2.6 mm (39.9%) of defect fill while debridement alone resulted in 1.3 mm (14.8%) of fill. Hard tissue changes demonstrated a substantial advantage for use of Durapatite over controls, while soft tissue changes were similar for both. The clinical impression at re-entry and the numerical data indicate that pure hydroxylapatite ceramic has a definite potential as an alloplastic implant in the treatment of periodontal osseous defects.

Tomography of the alveolar process

This radiologic study using hemisected dog jaws was undertaken to determine whether or not tomographic techniques would be superior to standard dental x-ray techniques in detecting prepared periodontal defects within the cancellous bone of dog jaws. Specifically, it was done to determine whether or not tomography might be a reliable method of checking for bone fill in periodontal bone-grafting therapy. As an additional measure, a radiographic study, using a hemisected dog mandible and standard dental x-ray techniques, was undertaken to determine whether lesion size or cortical plate involvement was the determining factor in radiographic visibility. When tomographic techniques were used 55% of thirty-one prepared defects were visible, while standard dental x-ray techniques detected 29% of the same defects radiographically. The differences in detection rate were not statistically significant when analyzed by chi square. Although tomography resulted in radiographic visibility of a greater number of prepared defects, it is not reliable enough to replace re-entry procedures for documentation of bone fill in clinical studies of periodontal bone-grafting procedures. In the additional study it was determined that cortical plate involvement was the determining factor in radiographic visibility of bony defects.

Lyophilized bone allografts in periodontal intraosseous defects

Nine patients with 10 pairs of intraosseous periodontal defects were treated. Most of the patients had identical bilateral lesions (referred to as "mirror-image" defects). In each pair, one of the defects was randomly selected and treated as a flap and currettage control whereas the other defect was grafted with freeze-dried cortical powdered allografts of bone. Evaluation was based on radiographs, photographs, and measurements taken during both the initial surgery and at reentry approximately 1 year after transplantation. Control procedures (flap and curettage) demonstrated the same amount of osseous regeneration as that seen with the graft procedure. The amount of osseous regeneration demonstrated with the grafting procedures agreed with previously published studies. Evaluation revealed that (1) an autologous control such as incorporated in the "mirrow-image" design of this study is probably the most valid experimental model available for evaluating the clinical effectiveness of any human periodontal grafting procedures; (2) the effectiveness of freeze-dried cortical powdered bone allografts in human periodontal osseous defects is questionable and needs additional study; and (3) nongrafting procedures may be more effective in generating new attachments or reattachments in human periodontal osseous defects than previously believed.

Measurement of the millimeter markings of periodontal probes

All periodontal probes used by five periodontists were collected and their millimeter markings were measured for accuracy. It was found that most probes were not precise, especially those manufactured by Hu-Friedy more than 3 years ago. However, new probes manufactured by Hu-Friedy were shown to be more accurate. It is recommended ttht dentists use periodontal probes with accurate and consistent markings.

Present status of osseous grafting procedures

Osseous grafting techniques represent one mode of therapy to manage combination pocket-osseous defects. They have their greatest applicability in the intrabony defect although encouraging results have been noted in furcation and suprabony sites. Like all treatment modalities, their usage is dictated by the therapeutic objectives for specific problems and whether their respective advantages and limitations outweigh other management techniques. They are neither a panacea nor an unproven experimental venture. When properly employed, they are a valuable component of currently accepted therapy. When compared with other treatment approaches, the following relative advantages and limitations have been noted with osseous grafts: Advantages 1. Reconstruct lost periodontium. 2. Idealistic therapeutic objective. 3. Reversal of disease process. 4. Increase tooth support. 5. Enhance esthetics. 6. Improve function. Limitations 1. Additional treatment time. 2. Autograft disadvantages. 3. Availability of graft material. 4. Additional postoperative care. 5. Unique postoperative problems. 6. Variations in repair. 7. Longer post-treatment evaluation interval. 8. Predictability. 9. Greater expense. 10. Multistep therapy common. 11. Vulnerability to recurrence.

Human clinical and histologic repair responses following the use of citric acid in periodontal therapy

Seven blocks containing one tooth each were obtained from two patients undergoing treatment for periodontitis. Sixteen weeks prior to block removal, these sites were treated by periodontal flap surgery. In six teeth a citric acid solution (pH = 1) was applied for 2 minutes to the planed root surfaces. The seventh tooth received identical periodontal therapy except that saline was applied to the planed root for 2 minutes. At the end of the experimental period, the blocks were removed and prepared for histologic study. In five out of six citric acid treated specimens, no evidence was observed suggesting that citric acid applications either initiated or accelerated cementogenesis or functional connective tissue attachment at root surfaces previously exposed to periodontal pockets. In one specimen, repair cementum was seen crestally to the alveolar margin. This cementum was deposited on the surface of acellular cementum. Unfortunately, however, the specimen does not allow us to date the deposition of the repair cementum. It thus remains questionable whether this cemental deposition is indeed a repair response to the specific treatment performed.