PERIODONTAL LITERATURE REVIEW

PERIODONTAL LITERATURE REVIEW

Session No. 8

Osseous Surgery: Anatomy; Wound Healing

Dr. Palcanis and Dr. Green

1.Lackler K, et al.Development of an invitro wound healing model for periodontal cells. J Perio 2000;71:226-237.

2.Bower RCFurcation morphology relative to periodontal treatment. Furcation root surface anatomy. J Perio 1979B;50:366-374.

3.Clarke M, et al.Anatomical consideration in periodontal surgery. J Perio 1971;42:610-625.

4.Easley JRMethods of determining alveolar osseous form. J Perio 1967;38:112-118.

5.Gher ME, Vernino ARRoot morphology - clinical significance in pathogenesis and treatment of periodontal disease. JADA 1980.

6.Hiatt WH, et al.Repair following mucoperiosteal flap surgery with full gingival retention. J Perio 1972;39:11-16.

7.Karring T, et al.Potentials for root resorption during periodontal wound healing. J Clin Perio 1984;11:41-52.

8.Moghaddas H, et al.Alveolar bone remodeling following osseous surgery. J Perio 1980;51:376-381.

9.Nyman S, et al.Periodontal surgery in plaque infected dentitions. J Clin Perio 1977;4:240-249.

10.Pfeifer JSThe growth of gingival tissue over denuded bone. J Perio 1963;34:10-16.

11.Pfeifer JSThe reaction of alveolar bone to flap procedures in man. Periodontics 3:135, 1965.

12.Polson AM, Caton JFactors influencing periodontal repair and regeneration. J Perio 1982;53:617-625.

13.Wilderman MNExposure of bone in periodontal surgery. Dent Clinics N Am 1964;8:23-36.

14.Wilderman MN, et al.Histogenesis of repair following osseous surgery. J Perio 1970;41:551-565.

PERIODONTAL LITERATURE REVIEW

Session No. 9Apically Positioned Flaps and Osseous Resective Surgery

& Post-Op Management

Dr. Reddy and Dr. Parker

1.Friedman NPeriodontal osseous surgery: Osteoplasty and osteoectomy. J Periodontol 1955;26:257-269.

2.Siebert JTreatment of infrabony lesions by surgical resection procedures. In: Stahl SS, ed. Periodontal Surgery: Biologic Basis and Technique. Springfield, IL; Charles C. Thomas; 1976;339-357.

3.Ochsenbein C, Bohannan HThe palatal approach to osseous surgery. I. Rationale. J Periodontol 1963;34:60-68.

4.Ochsenbein C, Bohannan HThe palatal approach to osseous surgery. II. Clinical application. J Periodontol 1964;35:54-68.

5.Tibbetts L, Ochsenbein C,Rationale for the lingual approach to mandibular osseous

Loughlin D.surgery. Dent Clinics N Am 1976;20:61-78.

6.Selipsky HOsseous surgery how much need we compromise? Dent Clinic N Am 1976;20:79-106.

7.Barrington EAn overview of periodontal surgical procedures. J Periodontol 1981;52:518-528.

8.Ochsenbein CCombined approach to the management of intrabony defects. Int J Perio & Rest Dent 15(4):328-343, 1995 Aug.

9.Zamet JSA comparative clinical study of three periodontal surgical techniques. J Clin Perio 2(2):87-97, 1975 Apr.

10.Curtis JW Jr, McLain JB,The incidence and severity of complications and pain following

Hutchinson RAperiodontal surgery. J Perio 56(10):597-601, 1985 Oct.

11.Vogel RI, Desjardins PJ,Comparison of presurgical and immediate postsurgical ibuprofen

Major KVon postoperative periodontal pain. J Perio 63(11):914-918, 1992 Nov.

12Linden ET, Abrams H,A comparison of postoperative pain experience following

Matheny J, Kaplan AL,periodontal surgery using two local anesthetic agents. J Perio

Kopczyk RA, Jasper SJ Jr57(10):637-642, 1986 Oct.

13.Vaughan ME, Garnick JJThe effect of a 0.125% chlorhexidine rinse on inflammation after periodontal surgery. J Perio 60(12):704-708, 1989 Dec.

14.Ruben MP, Kon S, Complications of the healing process after periodontal surgery.

Goldman HM, Alpha K,J Perio 43(6):339-346, 1972 Jun.

Bloom AA

15.Pack PD, Haber JThe incidence of clinical infection after periodontal surgery. A retrospective study. J Perio 54(7):441-443, 1983 Jul.

16.Baumhammers AControl of excessive bleeding following periodontal surgery. General Dentistry 31(5):384-385, 1983 Sep-Oct.

SUPPLEMENTAL

SESSION 9

APICALLY POSITIONED FLAPS AND OSSEOUS RESECTIVE SURGERY AND POST-OP MANAGEMENT

1.Ochsenbein CA primer for osseous surgery. Int J Periodontics Restorative Dent 1986;6(1):9-47.

2.Ochsenbein C, et al.In our opinion. When and to what extent do you remove or recontour bone in periodontal therapy? J Perio 43(3):184-188, 1972 Mar.

3.Olsen C, Ammons W,A longitudinal study comparing apically repositioned flaps, with

van Belle Gand without osseous surgery. Int J Perio & Rest Dent 1985;5(4):11-33.

PERIODONTAL LITERATURE REVIEW

Session No. 10Furcation Management/Root Resection

Dr. Wang and Dr. Vassilopoulos

1.Kalkway KL, Reinhardt RAThe furcation problem. Current controversies and future directions. (Review 75 refs.) Dental Clinics of North American 32(2):243-266;1988 Apr.

2.Muller H P, Eger TFurcation diagnosis. J Clin Perio 26:485-498; 1999.

3.Hempton TA review of root resective therapy as a treatment option for maxillary molars. (Review 30 refs.) JADA 128(4):449-455;1997 Apr.

4.Haskell EVital Root Resection OSOMOP 27:266-274;1969.

5.Benoliel RPalatal root hemisections and subsequent tooth restoration: a simple procedure? (Rev 15 refs.) British Dent J 178(10):375-378;1995 May 20.

6.Newell DHThe role of the prosthodontist in restoring root-resected molars: a study of 70 molar root resections. J Pros Dent 65(1):7-15;1991 Jan.

7.Langer B, et al.An evaluation of root resections. A 10 year study. J Perio 52:719-722;1981.

8.Buhler HEvaluation of root-resected teeth. Results after 10 years. J Perio 59(12):805-810;1988 Dec.

9.Carnevale G, Pontoriero R,Long-term effects of root-resective therapy in furcation-

Di Febo Ginvolved molars. A 10 year longitudinal study. J Clin Perio 25:209-214; 1998.

10.Hellden L BThe prognosis of tunnel preparations in treatment of Class III furcation: a follow-up study. J Perio 60(4):182-187;1989 Apr.

12.Little LA, Beck FMLack of furcation bone loss following tunneling procedure. J Clin Perio 22(8):637-641;1995 Aug.

13.Masters DH, Hoskins SWProjection of cervical enamel into molar furcations. J Perio 39:49-53;1964.

14.De Leonardis D, et al.Clinical evaluation of the treatment of class II furcation involvements with bioabsorbable barriers alone or associated with demineralized freeze-dried bone allografts. J Perio 70:8-12; 1999.

15.Gutmann JLPrevalence, location and potency of accessory canals in the furcation region of permanent molars. J Perio 49(1):21-26;1978 Jan.

SUPPLEMENTAL

SESSION NO. 10FURCATION MANAGEMENT/ROOT RESECTION

1.Green ENHemisection and root amputation. (Rev 51 refs.) J Amer Dent Assoc 112(4):511-518;1986 Apr.

2. Saadoun AP Management of furcation involvement. (Rev 158 refs.) J West Soc Perio-Perio Abstracts 33(3):91-125;1985.

PERIODONTAL LITERATURE REVIEW

Session No. 11

Mucogingival - Frenectomy, Vestibuloplasty -

Dr. Palcanis and Dr. Barnes

1.Ariavdo A & Tyrrell HRepositioning and increasing the zone of attached gingiva. J Perio 28:106-110, 1957.

2. Nabors JMFree gingival grafts. Periodontics 4:243-245, 1966.

3.Sullivan and AtkinsFree autogenous gingival grafts. I. Principles of successful grafting. Periodontics 6:121, 1968.

4.Lang NP and Loe HThe relationship between the width of keratinized gingiva and gingival health. J Perio 43:623, 1972.

5.Karring T, et al.The origin of granulation tissue and its impact on postoperative results of mucogingival surgery. J Perio 46:577-585, 1975.

6.Matte JCreeping attachment of free gingival grafts - a five year follow-up study. J Perio 681-685, Dec. 1980.

7.Kennedy JE, et alA longitudinal evaluation of varying widths of attached gingiva. J Clin Perio 12:667, 1985.

8.Wenstrom JLLack of association between width of attached gingiva and development of gingival recessions five year study. J Clin Perio 14: 181, 1987.

9.Addy M, et al.A study of the association of fraenal attachment, lip coverage, and vestibular depth with plaque and gingivitis. J Perio 58(11):792-757, 1987 Nov.

10.Miller PD JrRegenerative and reconstructive periodontal plastic surgery. Dent Clin North Am 32(2):287-306, 1988 Apr.

11.Nabuto T, et al.Microvascularization of the free gingival autograft. J Perio 59(10):639-646, Oct. 1988.

12.Wennstrom JL, Zucchelli GIncreased gingival dimensions. A significant factor for successful outcome of root coverage procedures? J Clin Perio 23:770-777; 1996.

13.Paolantonio , et al.Subpedicle connective tissue graft versus free gingival graft in the coverage of exposed root surfaces. J Clin Perio 24:51-56; 1997.

14.Giovanpaolo PP, et al.Mucogingival interceptive surgery of buccally-erupted premolars in patients scheduled for orthodontic treatment I. A 7 year longitudinal study. J Perio 2000; 71:172-181;

PERIODONTAL LITERATURE REVIEW

Session No. 12Root Coverage - Pedicles, C T Grafts

Dr. Wang and Dr. Bowie

1.Hall WalterThe current status of mucogingival problems and their therapy. J Perio 569-575;1981 Sept.

2.Grupe H & Warren RRepair of gingival defects by a sliding flap operation. J Perio 27:92-95;1956.

3.Bernimoulin JP, et al.Coronally repositioned periodontal flap. Clinical evaluation after one year. J Clin Perio 2:1-13;1975.

4.Caffesse R, et al.Treatment of localized gingival recessions. Part II. Coronally repositioned flap with a free gingival graft. J Perio 49:357-361;1978.

5.Baldi C, et alCoronally advanced flap procedure for root coverage. Is flap thickness a relevant predictor to achieve root coverage? A 19-case series. J Perio Vol 70:9:1077-1084; 1999 Sept.

6.Cohen D & Ross SThe double papillae repositioned flap in periodontal therapy. J Perio 39:65-70;1968.

7.Tarnow DPSemilunar coronally repositioned flap. J Clin Perio 13:182-185;1986.

8.Langer B & Langer LSubepithelial connective tissue graft technique for root coverage. J Perio 56(12):715-720;1985.

9.Nelson SThe subpedicle connective tissue graft. A bilaminar reconstructive procedure for the coverage of denuded root surfaces. J Perio 58(2):95-102;1987.

10.Harris RThe connective tissue and partial thickness double pedicle graft: a predictable method of obtaining root coverage. J Perio 63:477-486;1992.

11.Harris RA comparative study of root coverage obtained with guided tissue regeneration utilizing a bioabsorbable membrane versus the connective tissue with partial-thickness double pedicle graft. J Perio 68:779-790; 1997.

12.Paolantonio M, et al.Subpedicle connective tissue graft versus free gingival graft in the coverage of exposed root surfaces. J Clin Perio 24:51-56;1997.

13.Silverstein LH, et al.An acellular dermal matrix allograft substitute for palatal donor tissue. PGD Vol 3:4:14-21.

14.Wei PC, et al.Acellular dermal matrix allografts to achieve increased attached gingiva. Part I. A clinical study. J Perio 71:1297-1305; 2000.

15.Tatakis DN & Trombelli LGingival recession treatment: guided tissue regeneration with bioabsorbable membrane versus connective tissue graft. J Perio 71:299-307; 2000.

Periodontal Literature Review

Session No. 13

Cosmetic Periodontal Surgery; Crown Lengthening; Gummy Smile; Ridge Augmentation; Onlay Grafts; Ovate Pontics; Papilla Restoration

Dr. Weatherford and Dr. Gonzalez

1.Seibert J & Lindhe JEsthetics in periodontal therapy. Textbook of Clinical Periodontology. 3rd ed; chap 21:647-681.

2.Townsend CLResective surgery: An esthetic application. Quintessence International. 8(24):535-542; 1993.

3.Allen EPUse of mucogingival surgical procedures to enhance esthetics. Dent Clinics of No Amer. 32:307-330; 1988.

4.Miller PD Jr & Allen EPThe development of periodontal plastic surgery. Perio 2000 Vol 11:7-17; 1996.

5.Garber DA & Salama MAThe aesthetic smile: diagnosis and treatment. Perio 2000 Vol 11:18-28, 1996.

6.Cranham JThe functional esthetic interface. Compendium Vol 20(6):585-595, 1999 June.

7.Jacques LB, et al.Tissue sculpturing: An alternative method for improving esthetics of anterior fixed prosthodontics. J Pros Dent Vol 81(5):630-633; 1999 May.

8.Levine R & McGuire MThe diagnosis and treatment of the gummy smile. Compendium. Vol 18(8):757-819; 1997 August.

9.Allen EPSurgical crown lengthening for function and esthetics. Dental Clinics of N Amer. 37(2):163-179;1993 April.

10.Becker W, et al.Crown lengthening: The periodontal-restorative connection. Compendium Vol 19(3):239-254;1998 March.

11.Rosenberg ES, et al.Crown lengthening revisited. Compendium Vol 20(6):527-540; 1999 June.

12.Abrams H, et al.Incidence of anterior ridge deformities in partially edentulous patients. J Pros Dent Vol 57(1):191-194; 1987 Feb.

13.Seibert JS & Salama HAlveolar ridge preservation and reconstruction. Perio 2000 Vol 11:69-84; 1996

14.Han TJ & Takei HHProgress in gingival papilla reconstruction. Perio 2000 Vol 11:65-68; 1996.

15.Azzi R, et al.Surgical reconstruction of the interdental papilla. Int J Perio & Restor Dent Vol 18(5):467-473; 1998.

16.Blatz MK, et al.Reconstruction of the lost interproximal papilla presentation of surgical and nonsurgical approaches. Int J Perio & Restor Dent Vol 19(4):395-406; 1999.

17.Dylina TJContour determination for ovate pontics. J Pros Dent Vol 82(2):136-142; 1999.

SUPPLEMENTAL

1.Johnson CK & Leary JMPontic design and localized ridge augmentation in fixed partial denture design. Dent Clin of N Amer. 36:591-605; 1992.

2.Page L & Halpern BGRestorative dentistry - interactions with periodontics. Dent Clin of N Amer. 37:457-463; 1993.

3.Becker CM & Kaldahl WBCurrent theories of crown contour, margin placement and pontic design. J Pros Dent. 45:268-277; 1981.

4.Carnevale G, et al.A retrospective analysis of perio prosthetic aspect of teeth re prepared during surgery. J Clin Perio. 313-316; 1990.

5.Ingler JS, Rose LF &The biologic width - a concept in periodontics and

Caslef JGrestorative dentistry. Alpha Omegan. 70:62-65; 1977.

6.Bragger U, Lauchenaur D &Surgery lengthening of the clinical crown. J Clin Perio.

Lang NP18:58-63; 1992.

7.Cohen DW & Ross SEDouble papilla repositioned flap in periodontics. J Perio. 39:65-70; 1968.

8.Allen EP, et al.Improved technique for localized ridge augmentation. J Perio. 56:195-199; 1985.

9.Palomo F & Kopczyk RRationale and methods for crown lengthening. JADA. 96:257-260; 1978.

10.Abrams LAugmentation of the deformed residual edentulous ridge for fixed prosthesis. Compendium for Cont Educ. 1(3):206-214; 1980; May/June.

11.Tabita PVSurgical correction of alveolar ridge form to enhance esthetics of fixed partial dentures. J Prosth Dent. 46:284-289; 1981.

12.Goodacre CJGingival esthetics. J Prosth Dent. 64:1-2; 1990.

13.Kaldahl W, et al.Achieving an esthetic appearance with a fixed prosthesis by submucosal grafts. JADA. 104:449-453; 1982.

14. Langer BThe subepithelial connective tissue graft. J Prosthetic Dent. 44:363-367; 1980.

15.Abbott D & Harrington WManagement of the isolated deformed dentino alveolar complex by subepithelial graft and resin-bonded fixed partial denture. JADA. 113:65-67; 1986.

16.Seibert JRidge augmentation to enhance esthetics in fixed prosthetic treatment. Compendium. 12: 548-562; 1992.

17.Seibert JReconstruction of deformed, partially edentulous ridges, using full thickness onlay grafts. Part I. Technique and Wound Healing. Compendium. 4:437-453; 1983.

18.Seibert JReconstruction of deformed, partially edentulous ridges, using full thickness onlay grafts. Part II. Prosthetic/Periodontal Inter-relationships. Compendium. 4:549-564; 1983.

19.Takei HMaxillary anterior esthetics. (Preservation of the interdental papilla). Dental Clinic of N Amer. 33:263-273; 1982.

Periodontal Literature Review

Session #14

Bone Grafting Materials/Techinques I

Alloplast; Perioglass; Zenograft; Bovine bone; Ceramic HA

Dr. Reddy and Dr. Nielsen

1.Fetner AE, Hartigan MS &Periodontal repair using PerioGlass in non-human

Low SBprimates: clinical and histologic observations. Compend Contin Educ Dent. 15(7):932-939; 1994.

2.Frame JWHydroxyapatite as a biomaterial for alveolar ridge augmentation. Int J Oral Maxillofac Surg. 16:642-655; 1987.

3.Hislop WS, Finlay PM &A preliminary study into the uses of an organic bone in

Moos KForal and maxillofacial surgery. Br J Oral Maxillofac Surg. 31:149-153; 1993.

4.Meffert RM, Thomas JR &Hydroxyapatite as an alloplastic graft in the treatment

Hamilton KM, et al.of human periodontal osseous defects. J Perio. 56(2):63-73; 1985.

5.Pinholt EM, Bang G &Alveolar ridge augmentation in rats by BIO-OSS. Scan J

Haanaes HRDent Res. 9:154-161; 1991.

6.

Second-hand bones? (editorial) Lancet. 340:1443; 1992.

7.Anson DCalcium sulfate: a 4 year observation of its use as a resorbable barrier in guided tissue regeneration of periodontal defects. Compend Contin Educ Dent. 17(9):895-899; l996, Sept.

8.Stahl SS, Froum SJ &Human clinical and histologic responses to the placement

Tarnow Dof HTR polymer particles in 11 intrabony lesions. J Perio. 61:269-274; 1990.

9.White E & Shors ECBiomaterial aspects of Interpore-200 porous hydroxyapatite. Dent Clin North Am. 30(1):49-67; 1986.

10.Yukna RAClinical evaluation of coralline calcium carbonate as a bone replacement graft material in human periodontal osseous defects. J Perio. 65:177-185; 1994.

11.Yukna RA

Clinical evaluation of HTR polymer bone replacement grafts in human mandibular class II molar furcations. J Perio. (4):342-349; 1994.

Periodontal Literature Review

Session #15

Bone Grafting Materials/Techniques II

Alloplast; Perioglass; Zenograft; Bovine bone; Ceramic HA

Dr. Reddy and Dr. Yoda

1.Meffert RM, et al.Hydroxyapatite as an alloplastic graft in the treatment of human periodontal osseous defects. J Perio. 56(2):63-73; 1985.

2.Yukna RA, et al.5-year evaluation of durapatite ceramic alloplastic implants in periodontal osseous defects. J Perio. 60:544-551; 1989.

3.Stahl SS, et al.Human clinical and histologic responses to the placement of HTR polymer particles in 11 intrabony lesions. J Perio. 61:269-274; 1990.

4.Nery EB, et al.Tissue response to biphasic calcium phosphate ceramic with different ratios of HA/TCP in periodontal osseous defects. J Perio. 63:729-735; 1992. 5.Yukna RAClinical evaluation of coralline calcium carbonate as a bone replacement graft material in human periodontal osseous defects. J Perio. 65:177-185; 1994.

6.Hall EE, et al.Comparison of bioactive glass to demineralized freeze-dried bone allograft in the treatment of intrabony defects around implants in the canine mandible. J Perio. 70:526-535; 1999.

7.Karatzas S, et al.Histologic observations of periodontal wound healing after treatment with perioglas in nonhuman primates. Int J Perio Rest Dent. 19:489-499; 1999.

8.Richardson CR, et al.Clinical evaluation of bio-oss(: a bovine-derived xenograft for the treatment of periodontal osseous defects in humans. J Clin Perio. 26:421-428; 1999.

9.Persson GR, et al.A retrospective radiographic outcome assessment study of intro-bony defects treated by osseous surgery or by bone graft procedures. J Clin Perio. 27:104-108; 2000.

10.Simonpietri-C JJ, et al.Guided tissue regeneration associated with bovine-derived anorganic bone in mandibular class II furcation defects. 6-month results at re-entry. J Perio. 71:904-911; 2000.

11.Yukna RAMulti-center clinical comparison of combination anorganic bovine-derived hydroxyapatite matrix (ABM)/cell binding peptide (P-15) and ABM in human periodontal osseous defects. 6-month results.

J Perio. 71:1671-1679; 2000.

Periodontal Literature Review

Session #16

Guided Tissue Regeneration: Materials and Techniques

Dr. Geurs and Dr. Parker

1.Becker W & Becker BETreatment of mandibular 3-wall intrabony defects by flap debridement and expanded polytetrafluoroethylene barrier membranes. Long-term evaluation of 32 treated patients. J Perio. 64:1138-1144; 1993, Nov.

2.Newman, MGThe role of infection and anti-infection treatment in regenerative therapy. J Perio. 64:1166-1170; 1993, Nov.

3.Hugoson A, Ravald N,Treatment of class II furcation involvements in humans

Fornell J, Johard G,with bioresorbable and nonresorbable guided tissue

Teiwik A & Gottlow Jregeneration barriers A randomized multi-center study. J Perio. 66:624-634; 1995, July.

4.Gottlow J, Nyman S &Maintenance of new attachment gained through guided

Karring Ttissue regeneration. J Clin Perio. 19:315-317; 1992.

5.Brgger U, Hmmerle CHF, Remodeling of periodontal tissues adjacent to sites

Mombelli A, Brgin W &treated according to the principles of guided tissue

Lang NPregeneration (GTR). J Clin Perio. 19:615-624; 1992.

6.Chaves ES, Geurs NC,Clinical and radiographic digital imaging evaluation

Reddy MS & Jeffcoat MKof a bioresorbable membrane in the treatment of

periodontal bone defects. Int J Perio Rest Dent. 16:443-453; 1996.

7.Becker W, Becker BE,A prospective multi-center study evaluating periodontal

Mellonig J, Caffesse RG,regeneration for class II furcation invasions and

Warrer K, Caton JG &intrabony defects after treatment with a bioabsorbable

Reid Triciabarrier membrane: 1-year results. J Perio. 67:641-649; 1996, July.

8.Yukna CN & Yukna RAMulti-center evaluation of bioabsorbable collagen membrane for guided tissue regeneration in human class II furcations. J Perio. 67:650-657; 1996.

9.Zarkesh N, Nowzari H,Tetracycline-coated polytetrafluoroethylene barrier

Morrison JL & Slots Jmembranes in the treatment of intraosseous periodontal lesions. J Perio. 70:1008-1016; 1999.

10.Zybutz MD, Laurell L, Treatment of intrabony defects with resorbable

Rapoport DA & Persson GRmaterials, non-resorbable materials and flap debridement. J Clin Perio. 27:169-178: 2000.

11.Machtei EEThe effect of membrane exposure on the outcome of regenerative procedures in humans: a meta-analysis. J Perio 72:512-516; 2001.

Periodontal Literature Review

Session #17

Regeneration Principles

Dr. Geurs and Dr. Green

1.Melcher AHOn the repair potential of periodontal tissues. J Perio. 47(5):256-260; 1976.

2.Karring T, et al.Healing following implantation of periodontitis affected roots into bone tissue. J Clin Perio 7:96-105; 1980.

3.Caton J, Nyman S &Histometric evaluation of periodontal surgery II.

Zander HConnective tissue attachment levels after four regenerative procedures. J Clin Perio. 7:224-231; 1980.

4.Nyman S, Gottlow J,The regenerative potential of the periodontal ligament.

Karring T & Lindhe JAn experimental study in the monkey. J Clin Perio. 9(3):257-265; 1982.

5.Nyman S, Gottlow J,New attachment formation by guided tissue regeneration.

Lindhe J, Karring T &J Perio Research. 22(3):252-254; 1987.

Wennstrom J

6.Aukhil I & Iglhaut JPeriodontal ligament cell kinetics following experimental regenerative procedures. J Clin Perio. 15:374-382; 1988.

7.Aukhil IBiology of tooth-cell adhesion. Dental Clinic of N Am. Vol 35(3):459-467; 1991, July.

8.Minabe MA critical review of the biologic rationale for guided tissue regeneration. J Perio. 62:171-179; 1991.

Periodontal Literature Review

Session #18

Root Conditioning, Growth Factors

Dr. Palcanis and Dr. Duong

1.Garrett J, Crigger M &Effects of citric acid on diseased root surfaces. J Perio

Egelberg JRes. 3:155-163; 1978.

2.Albair WB, Cobbs CM &Connective tissue attachment to periodontally diseased

Killoy WJroots after citric acid demineralization. J Perio. 53(8):515-526; August 1982.

3.Moore JA, Ashley FP &The effect on healing of the application of citric acid

Waterman CAduring replaced flap surgery. J Clin Perio. 14:130-135; 1987.

4.Terranova VP, Franzetti LCA biochemical approach to periodontal regeneration:

& Hic S, et al.tetracycline treatment of dentin promotes fibroblast adhesion and growth. J Perio Res. 21:330-337; 1986.

5.Claffey N, Bogle G, et al.Topical application of tetracycline in regenerative periodontal surgery in beagles. Acta Odont Scand. 45:141-146; 1987.

6.Bouchard P, Nilves R &Clinical evaluation of tetracycline HCI conditioning in

Etienne Dthe treatment of gingival recessions. A comparative study. J Perio 68:262-269; March 1997.

7.Caffessee RG, Smith BA,Cell proliferation after flap surgery, root conditioning

Nasjleti DE & Lopatin DEand fibronectin application. J Perio 58:661-666; 1987.

8.Heijl L, Heden G,Enamel matrix derivative (EMDOGAIN() in the treatment

Svardstrom G, Ostgren Aof intrabony periodontal defects. J Clin Perio 24:705-714; Sept. 1997.

9.Lynch SE, Williams RC &A combination of platelet-derived and insulin-like

Polson AM, et al.growth factors enhances periodontal regeneration. J Clin Perio 16:545-548; 1989.

10.Howell TH, Fiorellini JP,A phase I/II clinical trial to evaluate a combination of

et al.recombinant human platelet-derived growth factor-BB and recombinant human insulin-like growth factor-I in patients with periodontal disease. J Perio 68:1186-1193; 1997.

11.Kinoshita A, Oda S,Periodontal regeneration by application of recombinant

Takahashi K, et al.human bone morphogenetic protein-2 to horizontal circumferential defects created by experimental periodontitis in beagle dogs. J Perio 68:103-109; 1997.

12.Froum SJ, et al.A comparative study utilizing open flap debridement with and without enamel matrix derivative in the treatment of periodontal intrabony defects: a 12 month re-entry study. J Perio 72:25-34; 2001.

13.Soory M & Virdi HImplications of minocycline platelet derived growth factor, and transforming growth factor-beta on inflammatory repair potential of the periodontium. J Perio 70(10):1136-1143; 1999.

14.Baker PJ, Rotch HA,An in vitro screening model to evaluate root conditioning

Trombelli L, Wikesjo UMprotocols for periodontal regenerative procedures. J Perio July;71(7):1139-1143; 2000.

Periodontal Literature Review

Session #19

Implant Surgery Principles I

History And Biomaterials

Dr. Wang and Dr. Vassilopoulos

1.Friberg BSterile operating conditions for the placement of intraoral implants. J Oral & Max Surg. 54(11):1334-1336; 1996, Nov.

2.Adell R, Lekholm U,A 15 year study of osseointegrated implants in the

Rockler B, Branemark PItreatment of the edentulous jaw. Int J of Oral Surg. 10(6):387-416; 1981, Dec.

3.Eriksson RA, Albrektsson TThe effect of heat on bone regeneration: an experimental study in the rabbit using the bone growth chamber. J Oral & Max Surg. 42(11):705-711; 1984, Nov.

4.Ten Cate ARBiological determinants in implant design. Int Dent J. 39(2):108-112; 1989, June.

5.Albrektsson T,Osseointegrated titanium implants. Requirements

Branemark PI, Hansson HA, &for ensuring a long-lasting, direct bone-to implant

Lindstrom Janchorage in man. Acta Ortho Scan. 52(2):155-170; 1981.

6.Puleo DA, Nanci AUnderstanding and controlling the bone-implant interface. Biomaterials. 20(23-24):2311-2321; 1999, Dec.

7.Cochran DLA comparison of endosseous dental implant surfaces. J Perio. 70(12):1523-1539; 1999 Dec.

8.Buchs AU, Hahn J, Interim clinical study report: a threaded,

Vassos DMhydroxylapatite-coated implant five-year post-restoration safety and efficacy. J of Oral Implantology. 21(4):266-274; 1995.

9.Jones JD, Lupori J, Van Sickels JE,A 5-year comparison of hydroxyapatite-coated

Gardner Wtitanium plasma-sprayed and titanium plasma-sprayed cylinder dental implants. Oral Surg, Oral Med, Oral Path, Oral Rad & Endo. 87(6):649-652;1999, June.

Periodontal Literature Review

Session #20

Implant Surgery Planning

Techniques - Immediate

Delayed, Grafts, Single Stage

ITI Grafting

Extraction replacing with Implants

Dr. Geurs and Dr. Barnes

1.Hmmerle & LangTissue integration of oral implants. Proceedings of the lst European Workshop on Periodontology. pg 297-316; 1993.

2.Jeffcoat, MKDentomaxillofacial radiology. Vol 21:203-207; 1992, Nov.

3.Truhlar RS, et al.Distribution of bone quality in patients receiving endosseous dental implants. J Oral & Maxillofac Surg. 55(12 Suppl 5):38-45; 1997, Dec.

4.Scharf DR & Tarnow DPThe effect of crestal versus mucobuccal incisions on the success rate of implant osseointegration. Int J Oral Maxillofac Impl. 8:187-190; 1993.

5.Barzilay I, et al.Immediate implantation of pure titanium implants into extraction sockets of mucosa fascicularis. Part II: Histologic Observations.

6.Tarnow DP, et al.Immediate loading of threaded implants at stage 1 surgery in edentulous arches: ten consecutive case reports with 1 to 5 year data. Int J Oral Maxillofac Impl. 12:319-324; 1997.

7.Becker W, et al.The use of e-PTFE barrier membranes for bone promotion around titanium implants placed into extraction sockets: a prospective multicenter study. Int J Oral Maxillofac Impl. 9:31-40; 1994.

8.Schwartz-Arad D &Placement of implants into fresh extraction sites: 4 to 7

Chaushu Gyears retrospective evaluation of 95 immediate implants. J Perio. 68:1110-1116; 1997.

9.Rosenquist B, Grenthe BImmediate placement of implants into extraction sockets: implant survival. Int J Oral Max Imp. 11:205-209; 1996.

10.Becker BE, Becker W,A prospective clinical trial of endosseous screw-shaped

Ricci A & Geurs NCimplants placed at the time of tooth extraction without augmentation. J Perio. 69:920-926; 1998.

Periodontal Literature Review

Session #21

Guided Bone Regeneration

Dr. Reddy and Dr. Gonzalez-Toledo

1.Buser D, et al.Localized ridge augmentation using guided bone regeneration. I. Surgical procedure in the maxilla. Int J Perio and Rest Dent. Vol 13(1):29-45; 1993.

2.Buser D, et al.Localized ridge augmentation using guided bone regeneration. II. Surgical procedures in the mandible. Int J Perio and Rest Dent. Vol 15(1):11-29; 1995.

3.Tinti C, et al.Vertical ridge augmentation: surgical protocol and retrospective evaluation of 48 consecutively inserted implants. Int J Perio Rest Dent. 18:435-443; 1998.

4.Tinti C, et al.Vertical ridge augmentation: what is the limit? Int J Perio and Rest Dent. Vol 16(3):221-229; 1996.

5.Fugazzotto PAReport of 302 consecutive ridge augmentation procedures: technical considerations and clinical results. Int J Oral Maxillo Imp. 13:358-368; 1998.

6.Barboza EPClinical and histologic evaluation of the demineralized freeze-dried bone membrane used for ridge augmentation. Int J Perio Rest Dent. 19:601-607; 1999.

7.Brugnami F, et al.GBR in human extraction sockets and ridge defects prior to implant placement: clinical results and histologic evidence of osteoblastic and osteoclastic activities in DFDBA. Int J Perio Rest Dent. 19:259-267; 1999.

8.Cordioli G, et al.Postloading behavior of regenerated tissues in GBR-treated implant sites. Int J Perio Rest Dent. 19:45-55; 1999.

9.Corrente G, et al.Long-term evaluation of osseointegrated implants in regenerated and nonregenerated bone. Int J Perio Rest Dent. 20:391-397; 2000.

10.Kohal RJ, et al.The effects of guided bone regeneration and grafting on implants plaed into immediate extraction sockets. An experimental study in dogs. J Perio. 69:927-937; 1998.

11.Doblin JM, et al.A histologic evaluation of localized ridge augmentation utilizing DFDBA in combination with e-PTFE membranes and stainless steel bone pins in humans. Int J Perio Rest Dent. 16:121-129; 1996.

12.Zeiter DJ, et al.The use of a bone block graft from the chin for alveolar ridge augmentation. Int J Perio Rest Dent. 20:619-627; 2000.

13.McGinnis M, et al.Comparison of resorbable and nonresorbable guided bone regeneration materials: a preliminary study. Int J Oral Maxillo Imp. 13:30-35; 1998.

14.Nowzari, Hessam, et al.The dynamics of microbial colonization of barrier membranes for guided tissue regeneration. J Perio. Vol 67(7):694-702; 1996.

Periodontal Literature Review

Session #22

Posterior implant management

Sinus lifts; complications

What dont we know

Long term results

Predictability

Dr. Geurs and Dr. Nielsen

1.Tatum HMaxillary and sinus implant reconstruction. Dental Clinics of No America. 1986;30:207-229.

2.Boyne PJ, James RAGrafting of the maxillary sinus floor with autogenous marrow and bone. J Oral Surg. 38:613-616; 1980.

3.Hrzeler MB, Kirsch A,Reconstruction of the severely resorbed maxilla with

Ackerman K-L,dental implants in the augmented maxillary sinus: A 5-

Quinones CRyear clinical investigation. Int J Oral and Maxillo Imp. 1996;11:466-475.

4.Wallace SS, Froum SJ,Histologic evaluation of a sinus elevation procedure: a

Tarnow DPclinical report. Int J Perio Res Dent. 16:46-51; 1996.

5.Lazzara RJThe sinus elevation procedure in endosseous implant therapy. Current Opinion in Periodontology. 1996;3:178-183.

6.Timmenga NM, et al.Maxillary sinus function after sinus lifts for the insertion of dental implants. J Oral and Maxillo Surg. 1997;55:936-939.

7.Wheeler SL, Holmes RE,Six-year clinical and histological study of sinus-lift

Calhoun CJgrafts. Int J Oral and Maxillo Imp. 1996;11:26-34.

8.Hrzeler MB, et al.Maxillary sinus augmentation using different grafting materials and dental implants in monkey. Part I. Clin Oral Imp Res. 1997;8:476-486.

9.Hrzeler MB, et al.Maxillary sinus augmentation using different grafting materials and dental implants in monkey. Part II. Clin Oral Imp Res. 1997;8:401-411.

10.Froum SJ, et al.Sinus floor elevation using anorganic bovine bone matrix (OsteoGraft/N) with and without autogenous bone: a clinical, histologic, radiographic, and histomorphometric analysis part 2 of an ongoing prospective study. Int J Perio & Rest Dent. 18:528-543; 1998.

11.Dario LJ, English R JrAchieving implant reconstruction through bilateral mandibular nerve repositioning. J American Dental Assoc. 1994 Mar.;125(3):305-309.

12.Tong DC, et al.A review of survival rates for implants placed in grafted maxillary sinuses using meta-analysis. Int J Oral & Maxillo Imp. 13:175-182; 1998.

Periodontal Literature Review

Session 23

Implant Maintenance

Failing and Ailing

Microbiology

Diagnosis inf vs overload of implant

Prognosis

Dr. Wang and Dr. Yoda

1.Fox SC, Moriarty JD, et al.The effects of scaling a titanium implant surface with metal and plastic instruments: An in vitro study. J Perio. 1990;61:485-490.

2.Grondahl K, et al.The predictive value of radiographic diagnosis of implant instability. Int J Oral Maxillo Imp. 1997;12;59-64.

3.Lee KH, et al.Pre- and post-implantation microbiota of the tongue, teeth, and newly-placed implants. J Clin Perio. 1999;26:822-832.

4.Lekholm V, Ericsson IThe condition of the soft tissues at tooth and fixture

Adell R, Slots Jabutments supporting fixed bridges. A microbiological and histological study. J Clin Perio. 1986;13:558-562.

3.Smith DE, Zarb GACriteria for success of osseointegrated endosseous implants. J Prosth Dent. 1989;62:567-572.

4.Salcetti JM, et al.The clinical, microbial, and host response characteristics of the failing implant. Int J Oral & Maxillo Implants. 1997, Jan.-Feb.;12(1):32-42.

5.Kalykakis G, et al.Clinical and microbiological status of osseointegrated implants. J Perio. 1994, Aug.;65(8):766-770.

6.Drake DR, et al.Primary bacterial colonization of implant surfaces. Int J Oral Maxillo Imp. 1999;14:226-232.

7.Hutton J, et al.Factors related to success and failure rates at 3-year follow-up in a multicenter study of overdentures supported by Branemark Implants. Int J Oral Maxillo Imp. 1995;10:33-42.

8.Lee KH, et al.Microbiota of successful osseointegrated dental implants. J Perio. 1999;70:131-138.

9.Salcetti JM, et al.The clinical, microbial, and host response characteristics of the failing implant. Int J Oral Maxillo Imp. 1997;12:32-42.

10.El Askary AS, et al.Why do implants fail? Part I. Implant Dent. 1999;8:173-185.

11.El Askary AS, et al.Why do implants fail? Part II. Implant Dent. 1999;8:265-277.

12.Esposito M, et al.Differential diagnosis and treatment strategies for biologic complications and failing oral implants: a review of the literature.

13.Mellonig JT & Nevins MGuided bone regeneration of bone defects associated with implants: an evidence-based outcome assessment. Int J Perio Rest Dent. 1995;15:169-185.

14.Yukna RA, et al.Optimizing clinical success with implants: maintenance and care. Compend Cont Educ Dent. No. 15:5554-5561.

Schluger, S. Osseous resection: a basic principle in periodontal surgery. Oral Surg, 2:316, 1949

This article was written in order to describe a new procedure designed to overcome some of the problems presented by the gingivectomy technique.

When gingivectomies are performed, unsupported soft tissue is removed, but no attention is paid to the bony outline of the pockets. As a consequence, it is common to observe soft tissue growth creating some area areas of depth after these operations specially in interdental areas. According to the author, it is due to the irregular bony resorption caused by periodontal disease; soft tissue does not have the ability to follow these irregularities.

When the angle formed by the bone line between teeth and the soft tissue pocket outline exceeds 30, in general, we can expect increased depth after gingivectomy. A gradual rise and fall in the bony architecture with the greatest curvature of the arch being the deepest point of the pocket should be promoted by bony recontouring. The best way to perform the procedure is to perform a gingivectomy first and then reflect a flap for access. This way the exposed bone will be covered at the end.

Indications: (a) localized narrow and deep bone loss on the buccal and lingual surfaces; (b) mesial aspect of tilted second molars where the lowest first molar has been lost and replaced; (c) isolated areas of deep interproximal pocket on a single tooth when the adjoining teeth have normal bone support; (d) some deep lingual and buccal pockets where there is ledging of the bone and a thinning of the bone margin is indicated; (e) interdental craters.

Technique: flap should be designed to cover the remaining bone. Bone resection should be done with burs, bone files, and bone gouges and chisels. The interseptal bone should be removed first and then the buccal and lingual bone. A lingual approach can be used in a great number of cases leaving the buccal bone intact. Surgical dressing and penicillin should be used.

An important consideration before performing osseous recontouring is to avoid furcation exposure or removal of a lot of supporting bone from areas adjacent to the defect, when recurrent deep areas or even tooth extraction may be more appropriate.

Back: Osseous Surgery ArticlesMenu: Literature Review TopicsHome: PIC HomepageFriedman, N. Periodontal osseous surgery: osteoplasty and ostectomy. J Periodontol, 26:257, 1955

As described by Schluger, the gingival soft tissues do not have the ability to follow the bony resorption pattern observed in periodontal disease. Pocket elimination is the goal of periodontal treatment. It can be achieved by subgingival curettage, reattachment, gingivectomy, and osseous resection. Pockets should be carefully clinical and radiographically examined to determine the morphology of the defect and the technique for elimination chosen.

Osteoplasty: bone removal to get physiologic contour of the bone itself and gingiva overlying it. The bone removal is not part of the attachment apparatus.

Ostectomy: the bone removed to get phydiologic contour is part of the attachment apparatus of one or more teeth. The amount of bone to be removed is an important criterion for its use.

Osteoplasty indications:

1. Deep interproximal pockets on posterior teeth involving the buccal interdental bone: the cone-shaped interdental bone should be reinstituted by means of grooving.

2. Pockets on the buccal, lingual, and palatal surfaces where resorption of bone results in thick ledges.

3. Tilted lower second molar adjacent to non-replaced extracted first molar.

Ostectomy indications:

1. Interproximal craters in bone: shallow and wide craters are not favorable for reattachment while deep and narrow are. When ostectomy is the procedure of choice one of the spines is removed and the bone is ramped to the other side.

2. Extremely deep interproximal pockets where the neighbor areas are intact or minimally affected.

3. Shallow infrabony defects (interproximal), and where reattachment has failed.

Methods:

1. Modified flap: a gingivectomy is performed first and flap is elevated later and bone gouges, chisels, files and burs are used to reshape the bone.

2. Full flap: used when the operator did not decide between reattachment procedure or resective procedure. A full flap is indicated when a visualization of the field is desired before therapy.

3. Use of diamond stones without a flap.

Postoperative care:

Infection is rare; saliva is an important defense. Antibiotics can be used if healing is poor.

Back: Osseous Surgery ArticlesMenu: Literature Review TopicsHome: PIC HomepageGoldman, HM, Cohen, DW The infrabony pocket. Classification and treatment. J Periodontol, 29:272, 1958

The morphology of the intraosseous defect is important for the decision about its regeneration or eradication. The classification is therefore based on the number of osseous walls surrounding the defect.

1. Four osseous walls: (a) buccal, lingual, mesial, and distal walls

2. Three osseous walls: (a) proximal, buccal, and lingual walls; (b) buccal, mesial, and distal walls; (c) lingual mesial and distal walls

3. Two osseous walls: (a) buccal and lingual (crater walls); (b) buccal and proximal walls; (c) lingual and proximal walls

4. One osseous wall: (a) proximal wall; (b) buccal wall; (c) lingual wall

5. Combination: (a) 3+2 walls; (b) 3+2+1 wall; (c) 3+1 wall; (d) 2+1 wall

The recording of the size and general topography of the defect by clinical and radiographical means is very important.

Etiology: Calculus and food impaction are the primary etiology. Tooth anatomy as well as tooth position are important. Occlusal traumatic lesion, although not an attachment loss factor per se, may work as a secondary factor. Infrabony defects are also commonly observed in cases of periodontosis.

Therapy: elimination of signs and symptoms. Tooth anatomy conductive to food impaction, uneven marginal ridges, tilting of teeth and occlusal trauma should be corrected before surgery is performed. Splinting of mobile teeth is often necessary.

Selection of therapeutic procedure: The objective of the treatment is pocket elimination. Two basic ways are described: (a) curettage of the part of the defect below the bone crest to enhance formation of new cementum, bone and PDL; (b) osseous resection to level of the base of the defect. The higher the number of osseous walls present the better is the chance of having success with curettage.

Treatment of 3-wall osseous defects: curettage-gingivectomy procedure for new attachment. A gingivectomy is performed and the contents of the pockets are removed. Roots should be carefully debrided.

Treatment of the infrabony defect with one or two osseous walls by ostectomy-osteoplasty: contraindications to this procedure may be weakening of support of an adjacent tooth or creation of gingival form not conductive to self-cleansing or areas difficult to be cleaned. When the pocket is shallow and not much support is lost, the procedure is indicated. In this modality of treatment, a flap is raised and bone is trimmed. A gingivectomy can be performed before the flap is raised. To treat the interdental creater, it is often advisable to remove the buccal wall (as opposed to what we do today) for oral hygiene access. (This article is prior to #5 Oschenbein- palatal approach).

Back: Osseous Surgery ArticlesMenu: Literature Review TopicsHome: PIC HomepagePrichard, J. F. The etiology, diagnosis, and treatment of the infrabony defect. J Periodontol, 38:455, 1967

Interalveolar bone defects: intrabony defects, hemisepta, or craters.

Crater: the lingual and buccal walls are left by the mesial and distal are gone.

Hemisepta: the mesial or the distal wall of the interdental bone is present (marginal bone is intact).

Intrabony defect: the mesial or the distal wall plus the buccal and the lingual walls are present. The tooth wall forms the fourth wall.

Marginal bone defects: when the bone is thick, the defect can occur between the bone and the tooth. If not, it causes inconsistencies on the bony contour. These defects are often associated with interalveolar bony defects.

It is important to give defects their proper names in order to have a better scientific communication.

Pathogenesis: the form of the dental arches and the vascular pathways determine the topography of osseous defects. Craters and intrabony defects are present where arch is wide; marginal defects are present where bone is thin.

Inflammation follows the blood vessels into the bone marrow causing bone destruction.

Trauma from occlusion is one of the factors that can direct the destruction of interalveolar bone to one side, but it is not an essential factor. If the marginal bone is thick, a circumferential defect may take place. Thin marginal bone is resorbed totally when inflammation occurs; in thick marginal bone the destruction takes place between the tooth and the cortical plate.

Diagnosis: the exact topography of osseous defects can be done only during surgery, although an idea of the defect can be taken from X-rays.

Therapy: the objective is the formation of a new attachment apparatus. Usually an intern beveled incision is used. The defect should be curetted out and ostectomy may have to be performed in case of a hemisepted defect. Root planing should not be very aggressive because cementum forms more easily on old cementum than dentin. Occlusal adjustment and splinting may be necessary. Endodontic therapy may be necessary because the pulp may become infected through lateral canals. Foil and dressing are placed over the area and antibiotics are prescribed.

Back: Osseous Surgery ArticlesMenu: Literature Review TopicsHome: PIC HomepageOchsenbein, C. and Bohannan, H. M. The palatal approach to osseous surgery. I. Rationale. J Periodontol, 34:60, 1963

The purpose of this article was to discuss reverse gingival architecture on the buccal aspect of maxillary molar teeth and to introduce the palatal approach as a possible solution to this problem.

Normally, the interproximal bone is at a more coronal level than that on the buccal and lingual surfaces. The common interdental bone loss causes the reverse of this situation. As well, when osseous surgery is not performed according to its principles, reverse architecture can also be created. The presence of gingival architecture after osseous surgery results in recurrence of pocket depth.

Problems from the buccal:

Up to that date, the buccal approach was being used because of accessibility.

1) One of the serious problem with this approach is the increased risk of opening the buccal furcation in order to attain positive architecture.

2) Reversed architecture on the upper molar area is the development of a prominent, bulbous interradicular papilla.

3) The buccal bone on maxillary molars is very thin usually, with absence of cancellous bone. Fenestrations and dehiscences are not rare on this areas because of tooth rotation. Therefore, once bone is exposed, its resorption on buccal area is greater than in interproximal bone where cancellous bone is present. It will induce an accentuation of the interradicular papilla and assure an abnormal physiologic contour.

4) After surgery, as time goes, the gingival margin on the buccal side tends to become rolled and thick. The same fact does not take place on the palatal side.

5) If the buccal wall of the crater is removed, root proximity problems can be created between roots of two teeth.

Buccal wall reduction can, therefore, be performed to a certain extent, especially in medium and deep crater, but most of the reduction should be done from the palatal side. The bone on the palate is thicker and presents cancellous bone, which has good potential for osseous deposition after surgery as well as less bone resorption.

Visibility from the palatal is enough to perform this reduction.

The same rules do not apply for mandibular molars because of different anatomy.

Back: Osseous Surgery ArticlesMenu: Literature Review TopicsHome: PIC HomepageOchsenbein, C and Bohannan, HM. The palatal approach to osseous surgery. II. Clinical application. J Periodontol, 34:54,1964.

The palatal approach does not completely substitute buccal osseous reduction. If the clinician has the choice, the palatal approach is more convenient.

The type of the interproximal crater present and the anatomical relationship of the point of bifurcation of the buccal roots of the maxillary molars with the position of the marginal bone will determine the amount of buccal bone that can be safely removed in conjunction with the palatal approach.

Crater classification

(a) class I: 2-3 mm deep with thick buccal and lingual walls; (b) class II: 4-5 mm deep with thinner walls; (c) class III: 6-7 mm deep with a sharp drop of the crater wall from the margin to a broad, flat base; (d) class IV: variable depths with extremely thin buccal and lingual walls sometimes with the base being wider than the orifice. Maxillary first molars have a more coronal buccal furcation and thicker bone covering the buccal surface than the 2nd molar.

Crater therapy:

(a) class I: can be treated by the buccal approach because it is not likely that the buccal furcation will be open. But it should still be treated by removal of the palatal wall and just by that a physiologic contour established, because the slope degree is gradual.

(b) class II: should be treated by the palatal approach because the buccal approach would end up in opening of the buccal furcation. But the palatal bone removal alone will not be sufficient and some bone have to be reduced from the buccal aspect 2-3 mm, creating a favorable slope in the interdental area. It is important to emphasize that the buccal wall should not be eliminated at the beginning. Marginal and interdental bone should be removed gradually and simultaneously.

(c) class III: the palatal approach should also be used for the same reasons in class II. In these cases the clinician has to compromise often times and accept reversed architecture and post surgical depth. Buccal bone should be eliminated similarly to class II. Palatal osseous removal can be carried out as far as the limits of acceptable architecture.

(d) class IV: because the walls are too thin, it is very easy to remove more bone than necessary. The simple exposure of thin bone may end up in resorption; flap should always close these area. The palatal approach should also be the one of choice.

Particular cases:

(a) buccal bone loss involving buccal furca associated with craters: theses case require osteoplasty and ostectomy on the buccal side, but the gross interdental aberrations should be treated from the palatal side.

(b) very coronal buccal furcations: no bone removal on the buccal is possible.

(c) posterior bite collapse may cause root proximity problems in conjunction with buccal furcation problems and no bone can be removed from the buccal aspect.

(d) sometimes tooth extraction is indicated to avoid extensive bone removal in neighbor areas

Back: Osseous Surgery ArticlesMenu: Literature Review TopicsHome: PIC HomepageTibbetts, LS, Ochsenbein, C, and Loughlin, DM. The rationale for the lingual approach to mandibular osseous surgery. Dent Clin North Am, 20:61, 1976.

This paper discusses the anatomical patterns of the mandible and alveolar bone as well as tooth inclinations, suggests how periodontitis and the elimination of its effects relate to its basic formation, and introduces the rationale for the lingual approach to mandibular osseous surgery as a further refinement in achieving and maintaining pocket elimination in the mandibular posterior segments.

Size and anatomical thickness, as well as depressions and prominences are presence and vary to a great extent from mandible to mandible.

Anatomical considerations:

(a) external surface of the mandible: external oblique ridge - if it is heavy and the buccal vestibule shallow, osseous recontouring is limited. A depression called retromolar area is located between the internal lateral border of the retromolar triangle and the external oblique ridge.

(b) internal surface of the mandible: the mylohyoid ridge can be blunt and slightly elevated to marked elevated and spiked and therefore create different degrees of thickening of the mandible in the molar/second bicuspid region. Bone prominences or exostoses are found in different locations of the mandible.

Axial root inclinations:

Distal inclination of the root apex increases from canine back. The root apices of canine and first bicuspid are inclined lingually, while the posterior teeth are inclined buccally.

The buccal bony plate is higher than the lingual plate.

Normal relationship of alveolar bone to gingiva: the normal alveolar bone parallels the CEJ. Alveolar crest is convex in the bicuspid area and flat in the molar area.

Locations and types of bony defects: the most common lesion is the interdental crater, followed by thickened alveolar margin and bone loss. Lower molars and premolars are the teeth most affected by osseous defects in the mouth.

Reverse architecture is a common finding in the mandible after interproximal craters are eliminated and can be easily eliminated without furcation compromise if ostectomy is performed.

Rationale for the management of mandibular defects:

Due to the lingual inclination of mandibular molars ( 20) the base of the crater in that area is located lingually. One common mistake is to ignore this situation and over treat the buccal and under treat the lingual (fig. 8). It should be remembered that bone should be conserved in the buccal because it is supporting bone. The lingual approach therefore removes the lingual wall of the crater and corrects bone thickness on the buccal by osteoplasty that should go apical to the mylohyoid ridge; buccal bone should be preserved. The fact that the buccal furca is situated further coronal than the lingual one is another reason to do osseous from the lingual.

Back: Osseous Surgery ArticlesMenu: Literature Review TopicsHome: PIC HomepagePennel, BM, King, KO, Wilderman, MN., and Barron, JM Repair of the alveolar process following osseous surgery. J Periodontol, 38:426, 1967.

Aims:

This article studied the alterations to the crestal portion of the vestibular alveolar process following flap operation and osseous surgery.

Materials and Methods:

34 teeth from 20 patients participated in the study. A mucogingival flap was elevated and the alveolar process classified as thin, medium, or thick. Notches were placed at the gingival margin, 5 mm apical to the bone margin, and vertical and cross notches made in bone as indicated in fig. 1. Osseous reduction was done with rotatory instruments or bone chisels. 1 mm of bone was reduced. A standardized photograph was taken after osseous surgery was done. After periods ranging from 14 to 545 days, a flap was again elevated and another picture was taken.

Results:

The average reduction in bone was 0.54 mm. following flap retraction and osseous surgery. 47% of the teeth showed no loss and 82% of the teeth showed less than 1 mm. loss.

Back: Osseous Surgery ArticlesMenu: Literature Review TopicsHome: PIC HomepageDonnenfeld, WO, Hoag, PM, and Weissman, DP. A clinical study on the effects of osteoplasty. J Periodontol, 41:131, 1970.

Aims

This study was done in order to investigate the effects of contouring the alveolar bone profile in the absence of intraosseous defects with respect to pocket elimination, location of the epithelial attachment and alveolar bone height.

Materials and Methods

4 patients were selected for a split-mouth design study. One side received a full thickness flap surgery where the granulation tissue was removed and the roots planed. The experimental side received the same procedure but osteoplasty was performed. No attempt was made to treat intraosseous defects. All areas were reflapped 6 months later.

Measurements taken included location of the epithelial attachment and height of the interradicular bone as well as pocket depth.

Results

Three out of the four patients received reentry surgeries. Pocket elimination was similar for both groups.

The epithelial attachment was located 0.6 mm apical for the control and 1 mm apical for the experimental group.

There was a loss of interproximal bone height for both procedures: 0.4 mm (E) X 0.6 mm (C).

Radicular bone (straight buccal and lingual) was of 0.8 mm for control and 1.0 mm for the experimental group.

The results were not statistically significant when comparing control and experimental sites. Other changes that were not measured occurred in the area and could be observed by photographs. Remodeling toward ideal architecture occurred on both control and experimental sites.

Back: Osseous Surgery ArticlesMenu: Literature Review TopicsHome: PIC HomepageMoghaddas H and Stahl S. Alveolar bone remodeling following osseous surgery. A clinical study. J Periodontol, 51:376, 1980.

Aims

This study was done in order to monitor human osseous remodeling following periodontal surgery including osseous recontouring.

Materials and Methods

26 sites in 17 patients presenting pockets ranging from 4 to 7 mm received an apically positioned flap including osteoplasty and ostectomy. A stent was used for the clinical measurements during surgery. The measurement taken was the distance between the base of the stent to the crest of the alveolar bone at the mesio-facial, mid-facial, and distofacial site. This measurement was taken before and after bone recontouring and after 3 and 6 months.

Results

Results showed that the amount of bone resected for both groups was similar. There was an interradicular bone reduction of 0.38 mm at 3 mo. and 0.23 mm at 6 mo. At the radicular site, the loss was 0.84 mm at 3 mo. and 0.55 mm at 6 mo. In the furcation site the loss was 0.79 mm at 3 mo. and 0.88 mm at 6 mo. All these differences were significant as compared to measurements taken right after bone recontouring.

The bone was recontoured in favor of scalloping and grooved areas presented buttressing bone formation.

Back: Osseous Surgery ArticlesMenu: Literature Review TopicsHome: PIC HomepageMatherson, D. An evaluation of healing following periodontal osseous surgery in monkeys. Int J Perio Rest Dent, 5:8, 1988.

Aims

This work was conducted in order to determine the maintenance of surgically produced osseous contour in monkeys and the influence of the resultant bony profile on overlying soft tissue morphology. Two questions were asked: (1) will postoperative resorption lead to a permanent and significant reduction in bone height, or will there be coronal regeneration in the healing process, and (2) will the surgically produced osseous contour be maintained?

Materials and Methods

3 monkeys were used in the study. Each quadrant on each animal received a flap curettage, interdental osteoplasty, osseous resection, and one quadrant was left unoperated. Animals received oral hygiene twice a week for the time of the experiment. One animal was killed 1 week following surgery, 1 at 4 months and 1 at 6 months. Macroscopic evaluation was done by means of a three-dimensional Plexiglas reconstruction and a wax model reconstruction. Measurements were taken as shown on page. 14. Microscopic evaluation of the specimens was also performed.

Results

1. Radicular areas:

postoperative position of the crest is dependent on the amount of supporting bone between cortical plate and alveolar bone. The greatest amount of crest regeneration and reattachment occurred in all palatal areas and in the maxillary premolar vestibular region.

the surgically produced osseous morphology has been maintained in every radicular area regardless of the position of the alveolar crest.

although the bone does appear thinner, elevation and replacement of full thickness flaps does not appear to significantly alter the 6-month postoperative level of the alveolar crest.

similar amounts of soft tissue exhibited morphologic differences and overly resected and control radicular areas, indicating a relationship between radicular bone contour and soft tissue architecture.

2. Interdental areas:

surgically produced osseous morphology is maintained in interdental areas. Osseous resection in conjunction with recontouring procedures appears to be more effective in maintaining surgical contour than is interdental plasty alone.

interdental osteoplasty does not alter the morphology of the col.

following osseous resection, the interdental soft tissue reflect the underlying osseous contour when sufficient interproximal space exists between the contact area and the level of the alveolar process.

Back: Osseous Surgery ArticlesMenu: Literature Review TopicsHome: PIC HomepageSmith OH Ammons WF and Van Belle G. A longitudinal study of the periodontal status comparing osseous recontouring with flap curettage. I. Result after 6 months. J Periodontol, 51:367, 1980.

Aims

The purpose of this study was to evaluate the short-term clinical differences in periodontal status of patients treated with osseous recontouring and flap curettage in humans.

Materials and Methods

12 patients having bilateral periodontal destruction participated in the study. One side received open flap curettage and the other side received osseous recontouring. Tooth mobility, supragingival plaque, gingival inflammation, pocket depth, attachment levels, and level of the supporting marginal bone were measured 1 week before surgery, and 3, 6, 12, 18, and 24 weeks after surgery.

Results

1. There were no significant differences in tooth mobility between the two treatment modalities

2. plaque scores were equally reduced for both treatments

3. gingival inflammation was equally reduced by both treatments

4. the increase of attached gingiva was equal for both procedures

5. pocket reduction was maintained over the 6 mo. period with osseous surgery; with the flap curettage however, the initial decrease in pocket depth was not maintained and pockets tended to recur

6. open curettage did not induce bone regeneration

7. osseous recontouring did not lead to irreversible tooth mobility

8. osseous recontouring ended up in a net loss of attachment; flap curettage in a gain

9. both procedures improved periodontal health

Back: Osseous Surgery ArticlesMenu: Literature Review TopicsHome: PIC HomepageKnowles JW et al. Results of periodontal treatment related to pocket depth and attachment level. Eight years. J Periodontol, 50:225, 1979.

Aims

The purpose of this article is to evaluate the long-term effects of different modalities of periodontal treatment in pockets of different depths and different levels of attachment loss.

43 patients with 1038 teeth were followed for years. Patients had half of their mouth assigned to one of the three treatments: (a) subgingival curettage, (b) Modified Widman flap, and (c) pocket elimination surgery. Patients had recall visits every 3 months. Results were evaluated for pocket depths up to 3 mm (class I), 4-6 mm (class II), and 7-12 mm (class III).

Results

Results showed that pockets were initially deeper interproximally. Treatment was equally effective for pockets of the same depth range in different parts of the mouth. Pockets deeper than 4 mm stayed reduced for the 8 year period and ranged 3-4 mm. Attachment is initially gained in pockets deeper than 5 mm and lost in pockets of 1-3 mm. Pockets of 7-12 mm had their depth significantly decreased over eight years; 4-6 mm pockets had also a significant reduction in depth; no differences were observed for pockets of 1-3 mm. Pocket elimination produce a greater loss of attachment. All methods presented loss of attachment during the 8-year period. All the methods promoted sustained decrease in pocket depth of 4-6 mm, although the curettage group experienced less pocket reduction. The gained attachment was significant for curettage and modified Widman over 8 years and pocket elimination over 4 years. Pockets of 7-12 were significantly less reduced after curettage and sustained for all methods. Greatest attachment gain was obtained by Mod. Widman and the gain was sustained over 8 years for all methods, except curettage over 7 years.

Back: Osseous Surgery ArticlesMenu: Literature Review TopicsHome: PIC HomepageOlsen CT Ammons, WF and Van Belle G. A longitudinal study comparing apically positioned flaps with and without osseous surgery. Int J Perio Rest Dent, 4:11, 1985.

Aims

This study was done in order to evaluate the differences between flap curettage with and without osseous surgery after 5 years.

Materials and Methods

12 patients having bilateral similar periodontal destruction participated in the study. Split mouth design was employed. Half of the mouth received apically positioned flap with osseous recontouring and half apically positioned flaps alone. Patients were placed in a 6 month recall basis for 2 years and in a 3 month recall basis afterwards.

Results

Plaque and gingival inflammation were reduced at the first 6 months and came back to presurgical levels at 6 mo. for both groups. The width of attached keratinized gingiva is essentially the same for both procedures, although the width of keratinized gingiva seems to be slightly greater for the non-osseous group (osseous group had scalloped). The level of the gingival margin was more apical for the osseous group.

Interproximal pocket depth was significantly higher for the non-osseous group at five years; buccal and lingual pocket depth was the same. Pocket depth tends to rebound to baseline values for the non-osseous group but the reduction seems to be sustained in the osseous group.

If only 4 or more mm pockets are analyzed, bleeding points were noted 2.3 times more frequently for the non-osseous group.

Pockets of 1-3 mm: were 1-3 mm post-surgically

Pockets of 4 mm: 85% were 1-3 mm for osseous and 65% were for non-osseous

Pockets of 5 mm: 85% were 2-3 mm for osseous and 47% for non-osseous

Pockets of 6-8 mm: 5% went back to preop values for osseous and 30% for non-osseous. Osseous reduced 6-8 mm to 2-4 mm 95% of time was opposed to 70% non-osseous

No differences were found between osseous and non-osseous in regard to length of attachment during the 5 years.

Bone margin was located more apically in the osseous group.

Areas with loss of attachment of more than 4 mm: the margin of gingiva is more apical for the osseous surgery group but level of attachment is not. The pocket depths are even greater than the preop values for flap curettage.

Conclusions

Osseous surgery is more effective than flap curettage in reducing 4-8 mm pockets.

Back: Osseous Surgery ArticlesMenu: Literature Review TopicsHome: PIC HomepageBarrington EP O'Bannon, JY Ochsenbein C and Stallard RE. In our opinion: to what extent do you remove or recontour bone in periodontal therapy. J Periodontol, 43:184, 1972.

Barrington: Prior to surgery, patients should be performing good oral hygiene and must have received and responded well to phase I. Full thickness flaps should be used because of minimized trauma to the tissues and because the flap will be fully vascularized for covering the area. Radiographs and probing will tell us about the morphology of the defect. Not only vertical bone but also horizontal bone loss require surgery, because it also induce reverse architecture. Ledging is another indication for osseous surgery. Intraoral grafts can be used in combo with osseous surgery in 3-wall defects, the latter being performed to create a better defect shape or to avoid a reentry. The goal of osseous surgery is to reestablish the bony physiologic contour. Very advanced bone loss is not an indication for osseous resection because all alveolar bone existent should be preserved. Ledges and bulges should be thinned and discrepancies between alveolar margin of two teeth corrected. Interproximal bone should be grooved because bulky ones work as food traps. Exostoses are reduced if they are part of the periodontal problem. Bone should cover the bone although sometimes apical reposition of the flap should be done to increase attached gingiva.

O'Bannon: Most of the osseous problems are not amenable to grafting and cannot be solved by subgingival curettage. They are corrected by osteoplasty or ostectomy. Oral hygiene and scaling and root planing are performed before the surgery. Depth can be accepted in areas the patient is able to remove plaque. Bone should be reshaped with the idea of enhancing oral hygiene. Principles of positive architecture include ostectomy on the palatal and buccal sides and on the line angles. Sometimes a split flap can preserve bone on the buccal side and osteoplasty can be done in some areas through the periosteum. Contouring following root amputations should be done visualizing what is desired after healing. Oral hygiene seems to be the key for long term success. -Point: sometimes we tend not to pay attention to oral hygiene very much because we are anxious to do surgery, which is a mistake. Patients unable to control plaque should not be candidates for surgery. Ochsenbein: heavy maxillary osseous plates, mandibular tori, and interdental creaters should be eliminated by osseous surgery. Osseous correction of craters is often necessary even to eliminate residual defects after grafting. Removal of widow-peaks are important after ramping the crater. The removal of marginal bone to get scalloped architecture should be based on the existing architecture; it is wrong to standardized scalloping for all patients because some tend to have a flatter contour. The opposite is also wrong; a flatter recontouring in a patient with scalloped contour will induce pocket recurrence. Osseous surgery should be done with minimal detailing in order to eliminate pocket.

Stallard: The periodontal ligament is vital for the maintenance of the alveolar bone; if it disappears by means of periodontal disease or extraction the alveolar bone also disappears (why don't we see this with ankylosed teeth then?!). Thick bone and ledges should be removed because they interfere with harmonious gingival contours and are not providing any support for the teeth. Osseous surgery should be limited to non-supportive bone areas.

Back: Osseous Surgery ArticlesMenu: Literature Review TopicsHome: PIC HomepageSelipsky H. Osseous surgery. How much need we compromise? Dent Clin North Am, 20:79, 1976.

The most difficult cases to treat are the moderate to advanced ones. The common question in these case is how much bone can be removed. Very little bone support is sacrificed if a rational choice of patients for osseous correction is made and the need for permanent splinting can be predicted before osseous surgery is performed.

Ostectomy actually removes little attachment. Loss of interdental bone is often negligible, except for some hemisepted defects. Ostectomy on buccal and lingual surfaces usually do not exceed 1-2 mm. Buccal and lingual areas are usually smaller and give less support to the teeth than the interproximal, situation that also makes ostectomy to get positive architecture less bad. Sometimes the visual effect of osseous surgery scares the clinician, but the actual amount of supporting bone removed is minimal.

The last part of crater are often left untreated and its total treatment would implicate in minimal ostectomy; this cases will also have a compromised result. In cases where extraction decision is not sure, the bone should be recontoured as if it was going to be retained and in many times, even if defect elimination is not possible an area of easier access was created for maintenance. Sequence for osseous reduction:

Vertical grooving between teeth and roots should be done first. Buccal and lingual thinning of the bone should be performed between the grooves. Craters should then be removed and ostectomy to achieve positive architecture performed.

We should be concerned about the amount of supporting bone left, it should be enough to avoid secondary occlusal trauma and tooth mobility.

Presence of plaque, inflammation and occlusal prematurities are more important than osseous surgery when well indicated in terms of tooth mobility. Mobility is something that tends to decrease once a healthy environment is established, although it is increased for up to a few months after surgery. The need for splints is basically based on patient's comfort, replacing of missing teeth, retention of teeth after orthodontic movement, prevention of extreme mobility related to severe parafunctional habits. There is no evidence that temporary splinting may help in decreasing tooth mobility and it has not been shown that looser teeth have worse prognosis than tighter teeth. The clinician should be concerned about increased mobility rather than mobility at a point in time.

The best therapy is the minimal therapy that will adequately preserve the oral structures in health, in function acceptable to the individual's patient biology, and in comfort and form acceptable to the patient.

Back: Osseous Surgery ArticlesMenu: Literature Review TopicsHome: PIC HomepageOchsenbein C. Current status of osseous surgery. J Periodontol, 48:577, 1977.

This paper discusses the status of osseous surgery in periodontics in 1977.

Rationale

Gingival form is independent of bone architecture. If their contour is different, it will be reflected in pocket depth. Bone is not a scaffold for gingiva to rest upon.

Indications

Osteoplasty: heavy bony ledges and tori on buccal and palatal of maxillary teeth; thick bone on the lingual of lower mandibular molars, lower tori interfering associated with pocketing, thick bone on buccal of lower molars, specially the second. Early furcation invasions.

Ostectomy: management of the shallow creater, that is accomplished by removal of either the buccal or the palatal wall. The degree of sloping is important because it will determine the amount of ostectomy on the palate.

Contra-indications

Three-walled intraosseous defect that can be treated successfully by the denudation technique. Bony defects situated on the terminal buccal aspect of mandibular molars and associated with the external oblique ridge. Moderate to deep circumferential defects are better treated by grafting techniques. Advanced periodontal lesions or isolated deep craters that should be treated by grafts, root amps, extractions, or simple curettage. Wide-orifice three wall defects should be treated by grafting. Osseous surgery should be done meticulously in order to achieve pocket elimination.

Bone remodeling: thin bone does a certain amount of reshaping and rounding. However, cases such as shallow craters do not resolve alone. It seems that when cancellous bone is present, the bone is not able to reshape by itself.

Although the simple exposure of some bony areas may be risky and detrimental it may be necessary and beneficial in other areas. (Widow's peaks)

Shallow crater: its buccal and lingual walls are not thin; they are thick and have slopes toward the bottom of the crater. If the clinician thinks that the wall of the crater are at right angle with the tooth and its manipulation is casual, there will be little effect on pocket depth. Bone conservation: conservation of supporting bone should be a major concern in osseous surgery. This and some other anatomic considerations were the reasons to develop the palatal approach and the lingual approach.

"Osseous surgery is a very useful procedure in the practice of periodontics but should be performed properly and applied where it is indicated."

Back: Osseous Surgery ArticlesMenu: Literature Review TopicsHome: PIC HomepageFlores-de-Jacoby L and Fesseler A. The efficacy of osseous surgery. In: Efficacy of treatment procedures in periodontics. Shanley, DB (ed.), Chicago, Il. Quintessence, 1980.

Osseous surgery: Surgical procedure performed on bone with the purpose of reshaping or restoring it.

Osseous resection: correcting osseous defects produced by periodontal disease or anatomic architectural abnormalities or a combination of both.

Osteoplasty: reshaping of bone without removal of alveolar bone.

Ostectomy: same thing but involves the removal of alveolar bone.

Healthy peridontium: gingiva follows the bone; when there are bone deformities the gingiva does not follow and plaque accumulates and pockets reoccur. Osteoplasty and ostectomy are employed to eliminate these defects (horizontal and vertical bone loss).

Full thickness flaps are used for osseous surgery. The basic technique for flap management is then described. Osteoplasty is recommended for buccal, lingual, and interproximal correction of thick bone ledges seen in horizontal bone loss as well as other osseous deformities. Ostectomy should be used for correction of bony deformities affecting the alveolar supporting bone, specially reverse architecture.

Biological basis of osseous surgery: new cementum formation after surgery is found at 1 month. Only 3/4 of the surgically exposed root will be covered by cementum. The epithelial attachment after surgery forms between 3 weeks to 2 months. Connective tissue proliferation in the area of the periodontal ligament reaches its peak at 2-3 days after surgery. New bone formation occurs 4 weeks to 4 months after surgery. There is difference between pocket reduction with different methods using osseous surgery or not.

Indications for osteoplasty: thick marginal ledges, exostoses, tori.

Indications for ostectomy: interproximal craters, inconsistent margins, hemisepta, furcation involvement, combinations of deformities, combinations of deformities and anatomical aberrations Contra-indications for osseous surgery: three walled intrabony defect, bony effects situated on the buccal aspect of the terminal mandibular molars and associated with external oblique ridge, moderate to deep circumferential defects, advanced periodontal lesions or isolated deep creaters, wide orifice three wall bony defects and other severe deformities.

In any periodontal treatment, the most important phase is the maintenance visits and good oral hygiene.

Back: Osseous Surgery ArticlesMenu: Literature Review TopicsHome: PIC HomepageHall, W., The current status of mucogingival problems and their therapy. J. Perio. 62:669, 1981

Attached gingival is defined as that gingiva that extending from the free margin of the gingiva to the mucogingival junction minus the pocket or sulcus depth measured with a thin probe in the absence of inflammation.

At the present, no specific number of millimeters of attached gingiva has been determined to be adequate.

Long term studies indicate that attached gingiva can be created or increased on a predictable basis employing grafting procedures. Coverage of roots exposed by recession through grafting or grafting plus coronal repositioning appears to be predictable. Root deminerialization may prove to be useful when combined with root coverage procedures.

Placing gingival grafts on bone is a predictably successful procedures but appears to provide no advantage over grafting to a periosteal bed and is more likely to increase the incidence of delayed healing or necrosis of the graft.

Increasing the band of attached gingiva by orthodontic means has not been demonstrated. As the legal doctrine of informed consent spreads, the need to fully discuss the pros and cons of grafting to prevent or correct recession relating to inadequate attached gingiva has become increasingly obvious.

Back: Soft Tissue ArticlesMenu: Literature Review TopicsHome: PIC HomepageLang, N., Loe, H. The relationship between the width of keratinized gingiva and Oral health. J. Perio. 43:623, 1972

The purpose of the present study was to examine the width of the facial and lingual keratinized gingiva and to determine how much keratinized gingiva is adequate for the maintenance of gingival health.

32 dental students, 19-29 yo w/ no pathologic pockets performed supervised OH. for 6 weeks. The gingiva from of all the B and L surfaces was assessed using the GI and PlI system. The width of attached gingiva was determined by subtracting the crevicular depth from the width of keratinized gingiva. Gingival exudate was measured on all B and L surfaces which had 2 mm or less of keratinized gingiva. The amt. of gingiva exudate from 118 tooth surfaces randomly selected from a total of 371 which had 2.5 to 3.0 mm gingiva was measured. Only plaque free surfaces were scored.

PlI - 0.22, GI - 0.09

Crevicular depth averaged 1.0 mm range 0.5-1.5 mm

The width of B and L attached gingiva tooth area to tooth area was similar to other studies.

Although teeth were free of clinically plaque, areas with less than 2 mm of keratinized gingiva persisted w/ inflammation (gingival exudate)

The region which consistently showed narrowest width of keratinized gingiva were the lingual surface of the lowers anteriors and the B of the lower canine and 1st premolars.

Conclusion

Less gingiva is needed to maintain health than generally believed . In areas of less than 2 mm keratinized gingiva inflammation persisted in spite of effective OH. It is suggested that 2 mm of keratinized gingiva is adequate to maintain gingiva health.

Criticism: assume no MGP noted, did they just subtract the average.

Back: Soft Tissue ArticlesMenu: Literature Review TopicsHome: PIC HomepageNabers, J., Free gingival graft. Periodontics. 4:243, 1966

Problem with mucogingival areas of the mandibular incisors. minimal, thin or no attached gingival.

Where a vestibular fornix problem exists, an incision into the fornix to deepen it is indicated

Incision should leave in place the periosteum with a marginal amount of connective tissue.

The gingival tissue to be grafted is excised and the sulcular epithelium is removed leaving the lamina propria of the connective tissue of this donor tissue exposed.

The tissue is custom shaped to fit

The tissue is sutured in place to the periosteum with the CT of the donor in contact with the underlying CT of the recipient area. Foil is placed to cover the donor site, then rubber dam material then the dressing.

The fundamental importance to this entire procedure is the maintenance of the nutritional needs of the donor tissue by re-establishment of satisfactory blood circulation

Back: Soft Tissue ArticlesMenu: Literature Review Sullivan, H., Atkins, J., Free autogenous gingival grafts. I. Principles of successful grafting. Periodontics. 6:5, 1968

The object is to attempt to correlate the surgical principles previously developed in plastic surgery to periodontics

Recipient Site - The most important principle in recipient site selection is the capacity of the recipient bed to form capillaries outgrowths for vascularization of the graft. Adequate hemostasis of the recipient bed is another essential principle for successful grafting

Recipient Site Preparation - the recipient site's epithelium, connective tissue, and muscle fibers are sharply dissected down to the periosteum. This forms a rigid base, for immobilization

Donor Site - Basically: edentulous ridge tissue, attached gingiva, palatal mucosa. avoid post-extraction sites, inflamed or hyperplastic tissue. Palatal most common- anterior palate is rich in fat, posterior palate contains the greater palatine foramen. Grafts classified into full-thickness and split-thickness, split-thickness is further subdivided into thin, intermediate or thick. With immediate detachment of donor there is shrinkage this is primary contraction. Secondary contraction occurs with healing . Less primary contraction with thick donor. Thinner graft can easily be maintained by diffusion and is easier o vascularize.

Donor site preparation - an access incision is made allowing the surgeon to observe the thickness of the graft to be removed.

Immobilization - vestibular extension if needed. steps- suturing, formation of the fibrin clot, placement of the rubber dam and dressing, 5-0 atraumatic needle, pressure 5 minutes

Stages of a graft Take - plasmic circulation, vascularization, and organic union, plasmatic circulation occurs most efficient throughout the fibrin clot.

Back: Soft Tissue ArticlesMenu: Literature Review TopicsSullivan, H., Atkins, J., Free autogenous gingival grafts. III. Utilization of grafts in the treatment of gingival recession. Periodontics. 6:152, 1968

The purpose of this paper is to report some basic concepts developed in plastic surgery for grafting over avascular areas and to derive from these a technique for the treatment of gingival recession.

Phenomenon of Bridging - in cases requiring coverage of exposed roots, a small part of the recipient bed will be the avascular root surface. To prevent necrosis over this avascular area, the graft must receive circulation from the adjacent vascular portions of the bed. This result in graft survival over the avascular area is known as the phenomenon of bridging.

Classification of Gingival Recession - it can be classified according to depth and width into four general morphologic categories 1) deep wide recession, 2) shallow wide recession, 3) deep narrow recession, 4) shallow narrow recession. The most difficult to treat is the deep wide recession. There is two and three point collateral circulation , 3 point will maintain approximately 1-2 mm of new keratinized tissue over the apical portion of the deep wide recession.

For the deep narrow recession extending into the alveolar mucosa, theoretically two-point collateral circulation should bridge the narrow avascular area. The shallow narrow recession is usually maintained by conservative therapy.

Surgical Technique - Modification techniques- 1) surgical correction of existing soft tissue deformities by gingivoplasty-gingivectomy. Osteoplasty through incisions may be used to correct any minimal osseous defect. 2) the beds apical margin should be placed several millimeters apical to the apex of the recession. 3) the avascular root should be curetted as the final step.

Donor Site - Bridging often requires a large amount of tissue, usually from the palate. T