The Vector Method · taining silicon carbide (SiC) (Vector Fluid abrasive) is used. The average grain size of the extremely hard, block-shaped cutting SiC particles is approx-imately

Clinical application and scientific principles

PeriodontitisTherapy and prophylaxis

PeriimplantitisTherapy and prophylaxis

Dental hygiene

Microinvasivecavity preparation

The Vector Method

Published by: Dürr Dental

Clinical application and scientific principles

PeriodontitisTherapy and prophylaxis

PeriimplantitisTherapy and prophylaxis

Dental hygiene

Microinvasivecavity preparation

Published by: Dürr Dental

The Vector Method

The Vector Method:A translation of the clinical application and scientific principles

Published by:Dürr Dental GmbH & Co. KGHöpfigheimer Strasse 1774321 Bietigheim-BissingenGermany

Autor:Private Institute for minimal invasive dentistry GmbH, Tübingen, GermanyPriv.-Dozent Dr. Rainer Hahn

© 2000, Dürr Dental GmbH & Co. KG

All rights reserved, in particular rights of reproduction and distribution and translation. No part of thistext may be reproduced in any form (by photocopy, microfilm or another process) without the writtenpermission of the publisher, nor may it be processed, reproduced or distributed using electronic systems.

Protected trade names (trademarks) are not specified. It should not be assumed from the lack of such ref-erence that names mentioned are unprotected trade names.

Important note

Dentistry as a science is subject to constant change.The results of research, observations from practiceand clinical experience extend our knowledge;technical developments add to the number ofoptions available to us in the diagnostics andtherapy of disease.

In so far as a compendium such as this recom-mends methods of treatment, applications, instru-ments, drugs, doses, etc., the reader may rely onthe fact that the author and publisher have madeevery effort to ensure that this information corre-sponds to the latest scientific knowledge at thedate of publication.

Nevertheless, all users are asked to make theirown decisions as regards therapy, on their own responsibility, taking account of all the requisite information, for instance, specialist publications or the information leaflets whichaccompany the various products, or medical contraindications, etc.

Attention is drawn to strict observance of theinformation laid down in the Medical Productsand Drugs Laws. Users must be guided by theregulations issued by the national Authorities relevant in their particular case.

Foreword

Index

Contents

1 The Vector Method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6General application information

2 Periodontal aspects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

2.1 Pathogenesis of periodontitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

2.2 Periodontitis and systemic diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

2.3 Differential diagnostics of marginal periodontitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

2.4 Early onset and rapidly progressing periodontal diseases . . . . . . . . . . . . . . . . . . . . . . . . . . 11

2.5 Periodontal diagnostics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

2.6 Cause-orientated minimally invasive periodontal therapy withparticular focus on the Vector Method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

2.7 Treatment of early onset and rapidly progressing periodontal disease . . . . . . . . . . . . . . . . . 22

2.8 Contraindications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

2.9 Supportive periodontal therapy(Maintenance therapy) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

2.10 Case studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

3 Aspects of periimplant mucositis and periimplantitis . . . . . . . . . . . . . . . . . . . . . . 38

4 Aspects of dental hygiene . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

4.1 Removal of coarse supragingival calculus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

4.2 Removal of supragingival plaque and discolorations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

5 Aspects of microinvasive preparation of non-metal restorationsand hard dental surfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

6 Literature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

The Vector Method

1 The Vector MethodGeneral application information

The characteristic feature of the Vector system is aring-shaped oscillating resonance body driven byan ultrasonic motor in a dental handpiece. Thecyclical deformation of this ring arranged in thehead of the handpiece induces a secondary verticaloscillation movement. An instrument attached at90° offset to the handpiece longitudinal axis istherefore moved up and down linearly, passivelydriven by the ring.

Uncontrolled tumbling movements and mechanicalvibrations from standard sonic and ultrasonicinstruments and their self-oscillation characterizedby oscillation loops and nodes as well as theresulting development of heat are therefore elimi-nated. High volumes of cooling water are notneeded and the water supplied is not sprayed asan aerosol. The design of the Vector instruments isnot subject to the usual restrictions (form anddimension, limited length or risk of breakage) andis exclusively oriented to the established clinical needs.

The strict linear movement of most of the instru-ments results in high tactile sensitivity for the oper-ator. Together with the shape of the instruments,designed according to the criteria of minimal invasiveness, a high level of patient acceptance is achieved. Mechanical damage to the tooth and root surfaces or to sensitive restoration materials or implants are reliably avoided. With curved instruments too, such as, for example,the curved periodontal probe with a slightly superimposed up and down movement of theinstrument tip, disconnection of the instrument fromthe actual ultrasonic motor and the associated dras-tic reduction of the active oscillating mass result ina high error tolerance. In the event of forced handling or excessive contact pressure the highfrequency digitally controlled oscillation driveswitches off spontaneously for the duration of thisincorrect application.

Fig. 1 - 1 Vector system for initial periodontal treatment in situ. Adetermining factor in its functioning is the coating of fluid or suspen-sion adhering around the instrument. Excess fluid may therefore notbe removed directly from the site of treatment.

Fig. 1 - 2 The deflection of the oscillation in the ring-shaped reso-nance body is typical of the Vector. If the ring is compressed in thehorizontal by the ultrasonic motor, a downward movement in the ver-tical is enforced. The following horizontal expansion induces a vertical upwards movement.

6

General application information

The fluid supplied to the Vector instruments servesfor indirect transmission of the dynamic ultra-sonic energy to the surfaces being treated. Thefunctional principle is therefore similar to ultrason-ic cleaning baths or lithotripter systems (e.g., forbreaking up kidney stones). In medical ultrasonicdiagnostics, too, the energy is applied via awatery gel.

Due to the longitudinal oscillations of the Vectorinstrument the wetting behaviour of the instrumentsurface for applied fluid is greatly improved. Anadhering water droplet becomes a film of watersurrounding the instrument, regardless of its positionon the instrument. Through the high accelerationof the instruments driven linearly in the ultrasonicrange, the water coating is bound firmly to thesurface of the instrument. This means that even insmall gingival pockets, narrow cavities or in deep

root canal areas – regardless of gravitation (instrument position in the upper jaw) – an adequate film of liquid is always available.Circular impulses, which lead to a dispersion ofvery fine water drops forming an aerosol, areeliminated.

The whole instrument is subject to practically thesame movement pattern on all surface sections.There are no nodal surfaces without a movementor zones of maximum acceleration (oscillationloops). This results in marked fluid (rinsing)dynamics around the whole instrument, which, in combination with the excess fluid applied bypulsation, ensures a high degree of cleaning effi-ciency. The additional option of adding dissolvedactive ingredients to the open fluid system extendsthe degree of therapeutic freedom.

Fig. 1 - 3 Due to the linear movement of the instrument, the wetting behaviour of an active Vector instrument for supplied fluid is improved. An active Vector instrument is surrounded by a firmlyadhering coating of fluid.

Fig. 1 - 4 Hydrodynamic flow: staggered still video images of aVector probe in a model periodontal pocket (left boundary surface: sim-ulated soft tissue of the pocket; right boundary surface: simulated rootsurface, biofilm simulated by metal sputter layer). The loosened metalparticles are seen on the image as light reflective points.

7

The Vector Method

Fig. 1 - 5 Energy contact during the Vector treatment is achieved indirectly via a water film adhering to the instrument. The dosing of energy is determined by varying the contact conditions (instruments material and use of particle suspensions).

8

General application information

For traditional sonic and ultrasonic instruments,which mainly act on a mechanical operating prin-ciple, the dosing is achieved by presetting thevibration amplitude. This regulating variable is ofsecondary importance with the Vector system.Most applications are carried out at constantamplitude of about 30 µm (all green LEDs lightup). The maximum amplitude of approximately 35 µm (kick-down function) is intended for theremoval of solid hard calculus, for recontouringapplications or during microinvasive preparations.Control of energy transmission is carriedout by influencing the contact conditions. Thesecan be effectively varied by the preselection ofinstrument materials and by the use of differentsuspensions. A high application of energy isachieved by using metal instruments with lowattenuation characteristics and high abrasion resistance. Metal instruments are therefore suitablefor the removal of hard calculus and for recontouring,finishing or microinvasive preparation of hardtooth tissue or non-metallic dental restorations.

Alternative instruments which are available madeof flexible fibre composite materials, work in theVector system with reduced energy application. Partof the instrument’s energy is subject to attenuationeffects on the flexible instrument surface. On theother hand the abrasion resistance of the instru-ments made out of a fibre reinforced composite isdecreased in comparison to the Vector metalinstruments. These instruments are particularly beneficial for gentle removal of subgingivalbiofilms and supragingival plaque or discolorations,with maximum protection for sensitive structures,such as root cementum, exposed dentine surfaces,initial caries, sensitive tooth, dental restoration orimplant surfaces. The resultant high error tolerancesimplifies the use of these instruments even fortrained dental assistants. Hard calculus deposits orrestoration overhangs can therefore only beremoved with these instruments to a limited extent.The flexibility and design in accordance with mini-mally invasive criteria facilitate access and han-dling even in anatomically difficult areas. The useof fibre composite instruments is therefore especial-ly recommended during supportive periodontaltherapy for removing of staining as well as for thetherapy and prophylaxis of periimplant mucositisor periimplantitis.

A straight probe made of an unfilled, highly flexi-ble plastic is available for almost exclusive use ofthe fluid dynamic effects with insignificant energycontact to the surfaces being treated. It is mainlyintended to be used as a rinsing instrument forexample during the treatment of endodontic-peri-odontal lesion.

A further influence on the application of energycan be achieved by particle additives in the contact fluid. The medium is more or less abrasive,depending on its hardness or the shape and thesize of the particles suspended in the fluid. Byusing the Vector Fluid Polish suspension with ultra-fine hydroxyapatite (HA) particles added (averagegrain size approximately 10 µm), thoroughremoval of subgingival adhesive biofilms is achieved.The fine grains and the low surface hardness ofthe HA particles, whilst having a gentle polishingeffect, prevent damage to or removal of the surfaceof the hard tooth tissue, implant or dental restora-tion. The natural root structures, which are impor-tant for periodontal regeneration, are therefore notendangered.

For abrasive indications, such as for cavity prepa-ration according to minimally invasive criteria, thefinishing of cavity margins or the recontouring orfinishing of dental restorations, a suspension con-taining silicon carbide (SiC) (Vector Fluid abrasive)is used. The average grain size of the extremelyhard, block-shaped cutting SiC particles is approx-imately 40 - 50 µm. In this case, too, there is anindirect application of energy, as is familiar in sim-ilar form from lapping or polishing methods. Thisresults in a very gentle, almost non-thermal pro-cessing of hard tooth tissues and non-metallicrestoration materials, with maximum care of thetissue and pulp and without marginal fractures.Metal alloys (with the exception of slight contouroverhangs, e.g. of amalgam fillings) or soft dentine caries, on the other hand, can be pre-pared only to a very limited extent.

9

The Vector Method

2 Periodontal aspects of the Vector system

2.1 Pathogenesis of periodontitis

Gingivitis and periodontitis are caused and sus-tained by the products of mixed bacterial flora(Kahnberg et al. 1976). Some substances in thesubgingival, microbial biofilm, such as virulentenzymes or lipopolysaccharides (LPS) of gram-negative bacteria, may cause direct harm to hostcells and tissue. However, the periodontal tissuecan be attacked in particular by inflammatorymechanisms and by cellular and humoralimmunoprocedures activated by the microorgan-isms in the sulcus and biofilm or their products.This inflammatory response in the affected peri-odontium is mostly clinically visible (reddening,swelling, bleeding on probing, suppuration, etc.).

The patient suffering from periodontitis does notgenerally show homogeneous findings. The sever-ity of the periodontitis varies between individualsand in the same individual from tooth to tooth,and not unusually, from tooth surface to tooth surface. Each site is to be regarded as an individual, specific niche.

At some sites the inflammatory lesion may berestricted for a long time to the gingiva and isreversible. At other sites the inflammation maypenetrate the deeper layers of tissue, causing irreversible damage to the surrounding host cells,connective tissue structures and alveolar bone.Cells of the gingiva and the sulcular epitheliummay come into contact with metabolites, enzymesand surface substances (LPS) of bacteria due tomicrobial plaque accumulation. The irritation ofthe host cells increases as the mass of vital bacte-ria grows. Bacterial substances cause the epithe-lial cells continually to produce an increasingnumber of chemical mediators (e.g. cytokines). In an attempt to maintain epithelial integrity, thesemediators force an inflammatory reaction with allthe classic symptoms. Cascade-like reactions ofthe immunodefence system result in the formationof proteinases which lead to the destruction ofgingival and periodontal connective tissue structures. Induced prostaglandins are significantmediators for the destruction of periodontal bone.

Fig. 2 - 1 Microbially induced inflammation and immune reactionscharacterize gingivitis and periodontitis; they cause invasion andspread of microorganisms into the deeper tissues.

Fig. 2 - 2Problems of causally orientated periodontal therapy.

10

Supragingivalcalculus

Tissue trauma

Bleeding

Immune reaction

Bacterial infection

Subgingivalcalculus

Subgingivalbiofilm

Accessibility to difficult areas, e.g., base of pocket or

interradicular

Opendentine canal

The Vector Method

Supragingivalcalculus

Tissue trauma

Bleeding

Immune reaction

Bacterial infection

Subgingivalcalculus

Subgingivalbiofilm

Accessibility to difficult areas, e.g., base of pocket or

interradicular

Opendentine canal

Pathogenesis of periodontitis

Whilst gingival inflammation is very probablycaused by the quantity of plaque, and in manycases by hormonal processes (Löe et al., 1965),current literature dealing with the pathogenesis ofperiodontitis still leaves many questions open. It ispossible that an hereditary immunodeficiency dueto defective inflammatory, immunological orregenerative reactions is also involved.Susceptibility to periodontitis possibly relates tothe ability or inability to build sufficient effectiveantibodies against the specific causative bacteria.Occlusal trauma is not sufficient to destroy theperiodontal tissue. However, if teeth with plaque-associated periodontitis are affected by centricprematurity or functional overload, these may becofactors in accelerating the progression of thedisease.

2.2 Periodontitis and systemic diseases

Recent scientific evidence has increasingly indicatedthat periodontal disease may increase the risk ofsystemic diseases, such as coronary heart disease,heart attacks, strokes, arteriosclerosis, but also therisk of premature births (Page, 1998). The extensiveinflammatory lesions of generalized marginal periodontitis (analogous to the size of a hand sur-face), the large, constantly renewing reservoirs ofbacteria and the high stability of the biofilms aremajor causes for the systemic effects of periodontaldisease. Lipopolysaccharides, vital gram-negativebacteria or inflammatory cytokines can continuallypenetrate the blood circulation from the inflamedperiodontal tissues in pathobiologically significantvolumes, and may mediate the effect of diseasein other areas of the body. On the other hand,the same risk factors contribute to periodontitisand to various systemic diseases, in particularsmoking, stress and increasing age.

2.3 Differential diagnosis of marginal periodontitis

In many cases it is difficult to differentiate betweenan endodontic lesion, which often concerns theapical periodontium and is caused and sustainedby an infection inside the root canal system, anda marginal lesion caused by plaque accumulationon the outer surface of the tooth and root. Undercertain clinical conditions, it is possible that thedisease of one tissue compartment causes the disease of another. A correct diagnosis can alsobe made more difficult due to the simultaneouspresence of periodontal disease as well asendodontic disease on a tooth (endodontic –periodontal lesion).

Furthermore, advanced periodontal lesions can,more rarely, be caused by fracture or iatrogenicperforation of the root. Knowing the pathogenesisof these syndromes and making correct diagnosesare decisive in effective therapy and in prevent-ing iatrogenic periodontal lesions resulting fromincorrect treatment on the marginal periodontium.

2.4 Early onset and rapidly progressing periodontal diseases

A small group of rare, often severe and rapidlyadvancing forms of periodontitis is subsumedunder the designation ”early onset periodontitis”.These forms of periodontitis are frequently characterized by early clinical occurrence and afamily history of the disease (Page et al. 1983).In most cases early infections with highlyvirulent bacteria and individual suscepti-bility to periodontal diseases are in evidence. At all events, the presence of systemic diseaseswhich significantly weaken the immune systemare to be excluded by means of differential diag-nosis. Depending on the age at which the onsetoccurs and the manifestations of the disease, it ispossible to distinguish between prepubertal periodontitis, localized juvenile periodontitis, generalized juvenile periodontitis and rapidly progressing periodontitis, which can affect boththe deciduous teeth as well as the permanentteeth.

11

The Vector Method

2.5 Periodontal diagnostics

Periodontitis is characterized clinically by inflam-mation of the affected gingiva (in particular reddening and swelling), and by an increasedtendency to bleed on probing (BOP). The periodontal tissue often shows reduced resistanceto probing, gingival pockets and gingival reces-sion. Typical in the advanced stages are toothmobility or loosening of the dental arch, toothdrifting or elongated teeth. Negative papillaealso frequently occur.

Fig. 2 - 4 Clinical periodontal charting on the above patient with documented sulcus probing depth and gingival recession, attachment level drawn in (red line), proven furca invasion and loosening of teeth, as well as indexed positive bleeding on probing (BOP) and pus drainage on probing (suppuration).

Fig. 2 - 3 Clinical findings on a 41-year old patient with advanced periodontitis.

Pocket depths (mm), furca invasion (I - III)


Gingival retraction (mm)


BOP (red), suppuration (green), degree of loosening (I - III)


12

Periodontal diagnostics

On the X-ray periodontitis is shown by moderateor severe periodontal bone loss (horizontal or vertical bone loss). The X-ray image also suppliesvaluable information for excluding lesions ofendodontic origin. Histologically, periodontitis ischaracterized by an inflammatory infiltration.

Successful treatment demands correct diagnosisand a differential diagnostic evaluation, in particular in relation to endodontic factors or general medical conditions and reproducible documentation of findings.

Fig. 2 - 5 Circular probing with pressure-calibrated periodontalprobe at a standardized contact pressure of 0.2 N (e.g. probe no. DB765R Aesculap, Tuttlingen, Germany).

Fig. 2 - 6 Oral X--ray film status created using the paralleling technique with orthoradial ray path, using intraoral film mount holders and leadscreens for delimiting the ray field equivalent to the film size (e.g. RWT window X-ray film mount holder, Kentzler & Kaschener Dental,Ellwangen, Germany).

13

The Vector Method

A standardized, periodontal diagnostic procedureand comparable documentation are importantprerequisites for the reproduction of findings andfor recording changes in findings following thera-peutic measures. Frequently it is only possible torecord the dynamics of the progress of thedisease by continuous monitoring of the patient inorder to determine recall intervals for supportiveperiodontitis therapy (maintenance therapy) whichare to the requirements of each individual patient.The basis of all dental diagnostics is a detailedgeneral medical and specific anamnesis.Important indicators for the general health are not infrequently derived in this way, e.g., systemicdiseases to be clarified by interdisciplinary meansby a specialist in internal medicine, for example.Dental findings should note the condition of theintraoral and extraoral mucosa, the hard sub-stances of the teeth and dental restorations.Particular attention should be paid to the record-ing of diseases of the mouth and mucous mem-branes, lesions of the hard substance of the teeth(erosion and caries) and defective restorations(poor marginal obturation, excessive contour, sub-gingival extension, blocked interproximal areas,missing approximal contacts, etc.). A sensitivitytest (e.g., with dry ice) documents the sensitivityof the teeth and, together with the intraoral X-rayfilm status (Fig. 2 - 6), provides important informa-tion on the assumed vitality of the teeth or indica-tions of endodontic lesions. In general it may beassumed that vital teeth do not produce sufficientirritation to produce a pathological process in the periodontium (Langeland et al., 1974).

Specific periodontal charting (Fig. 2 - 4) isbased on a circular probing of the periodontium

of all the teeth using a recommended contactpressure of approximately 0.2 N. The use of apressure calibrated probe (Fig. 2 - 5) facilitatesreproduction of the measured values. This mea-surement should be taken on all the surface of allthe teeth, documenting the deepest value for alltooth surfaces (at least six measuring points pertooth). The pocket depth (PD) is the distancebetween the gingival margin to the base of the gingival pocket. ”Pocket measurement”alone, however, does not provide information asregards actual loss of attachment, due to the fre-quent presence of inflammatory gingival oedemaor gingival recession. Attachment loss shouldtherefore be measured by also examining andrecording gingival recession at the same measur-ing points (or gingival hyperplasia as an indica-tion of pseudo pockets). Gingival recession or hyperplasia is recorded by measuring the dis-tance between the present or reconstructed (e.g.,from the neighbouring tooth level) cemento-enamel-junction and the gingival margin. The total of thePD and gingival recession gives the attachmentlevel (Fig. 2 - 4). Assessment of the furca invasioncan be undertaken using a curved periodontalprobe (e.g., the Nabers probe). Three levels ofseverity can be distinguished according to theloss of horizontal support:Grade I: Horizontal loss of support < 1 / 3Grade II: Horizontal loss of support > 1 / 3Grade III: The furcation can be explored

completely.

Tooth mobility is also recorded and document-ed according to levels of severity (grades I - III). Ifocclusal trauma is suspected, a clinical func-tional analysis is recommended.

Fig. 2 - 7 - 1 Hygiene index (HI) according to coloration using plaque revealing solution (in this example 59 % of the surfaces evaluated are affected by plaque)

78HI 6 5 4 3 2 1 1 2 3 4 5 6 7 8 59 %

14

Periodontal diagnostics

In each case, the presence of inflammation is alsodocumented on all sites by recording pocketswhich start to bleed during the examination witha probe (bleeding on probing: BOP) (Fig. 2 - 4).Delayed slight bleeding of gingival origin is gen-erally not documented. The most serious symptomof advanced acute destruction of periodontal tis-sue is the discharge of pus from a pocket (sup-puration), which often can be detected onlyunder relatively dry conditions (Kaldahl et al.,1990). This, too, if present, must be specificallyrecorded in the periodontal charting (Fig. 2 - 4).

Before periodontal therapy a complete oral X-rayfilm status is required (individual intraoral X-rays,not a panoramic), from which the position of thealveolar bone and the course of the buccal andlingual bone ridge can be seen (Fig. 2 - 6).Furthermore, the X-ray supplies important informa-tion for excluding lesions of endodontic origin orendodontic involvement. During recall more orless regular X-ray checks are required. The neces-sary comparison of X-rays taken at different timescalls for a standardized X-ray technique, prefer-ably the paralleling technique with orthoradialray path. Intraoral film holders with lead screensare recommended, in order to restrict the ray fieldto the size of the film, which in critical patientscan be customized with thermoplastic material,for example, and can be repositioned in futurewith reproducible occlusal bite locations. Notleast, it is necessary to establish the patient’soral hygiene status (Fig. 2 - 7 - 1), for whichit is recommended that the presence or absenceof plaque be documented by coloration of theplaque using plaque revealing solution. The statusof oral hygiene is an important finding for opti-mizing the patient’s oral hygiene and for motivat-ing the patient to maintain it. It can also provide information for setting recall intervals during thesupportive periodontal therapy.

Recently a group of high risk patients has beenidentified by a simple test on specific interleukin 1 genotypes. In these patients the production ofthe body’s own inflammatory mediators may beincreased, which can accelerate periodontaldestruction.

In patients with critical findings or with what areassumed to be rapidly progressing types of thedisease, which are generally revealed only afterthe conclusion of the initial treatment during thefirst reevaluation of the findings (preferably 4 - 6weeks after the initial treatment), a microbialanalysis of samples taken from the gingivalpockets is recommended. These are taken understandard conditions by means of a sterile papertip, and the genetic make-up is duplicated (i.e.using the PCR method) with subsequent geneticidentification of critical species of bacteria, suchas Aa, Pg, Pi, Bf or Td (Fig. 2 - 7 - 2).

Fig. 2 - 7 - 2 Example of a PCR gene probe test for identifying critical subgingival bacteria in quantitative relationship to the totalbacterial load.Aa = Actinobacillus actinomycetemcomitansPg = Porphyromonas gingivalisPi = Prevotella intermediaBf = Bacterioides forsythusTd = Treptomena denticola

(e.g., microDent Test, Advanced Diagnostic Systems ADS, Nehren,Germany)

Tooth: 36, Site: d.b., Pocket depth: 12 mm

15

The Vector Method

2.6 Cause-orientated, minimally invasiveperiodontal therapy with particularfocus on the Vector Method

Numerous animal studies and clinical longitudinalstudies have shown that eliminating or controlling the subgingival biofilm andthe supragingival plaque can create a healthyenvironment for both the teeth and periodontium in most, if not all cases (Ramfjord et al. 1968,Axelsson & Lindhe 1978, 1981, Lindhe & Nyman1975, 1984). Even in the case of early onset periodontitis with rapid progression of the disease,where it is not possible to create healthy condi-tions in every case, the mechanical removal of thebiofilm is an important condition for arresting theprogress of the disease, along with additionaltherapy, such as antibiotics. Successful periodontaltherapy is divided into several stages, which buildon one another in a consistent way.

In the pretreatment hygienic conditions arecreated and areas encouraging plaque accumula-tion are eliminated. In particular, this involvesopening up blocked approximal spaces, correctinginadequate approximal contacts, eliminating medium-sized and large carious defects andrecontouring overhanging restorations. If this cannotbe achieved satisfactorily by subtractive or simpleadditive measures, individual restorations affectedshould be removed, defects temporarily preparedand an adequate long-term restoration should becarried out. Non-viable teeth are removed at thisstage in the therapy. If there are endodontic causesfor marginal lesions, or if these causes play a part,cause-orientated endodontic treatment of these teethis carried out, in most cases without endosurgicalmeasures. Parallel to this, the patient is instructedindividually in relation to adequate oral hygienetechniques and the use of oral hygiene aids appro-priate to his situation. Supragingival calculus andcalculus located at the entrance to the pockets is notremoved during an initial treatment, if the maintain-ing of hygienic conditions is not affected.Temporary healing and firming of the marginalgingiva, restricting therapeutic access for the actu-al therapy of deeper periodontal tissue areas istherefore avoided. By dispensing with such initial,but incomplete treatment of the diseased periodon-tal tissue, the danger of periodontal abscesses following incomplete treatment is also minimized.

Cause-orientated therapy is aimed at effectiveremoval of the biofilm associated withthe subgingival root surfaces and thesupragingival deposits (principle of a full mouthdesinfection). If the deposits have mineralized inthe form of calculus, the removal of these depositsis an important prerequisite to achieve effectiveremoval of overlaid, settled or adjacent biofilms orplaque deposits. Special care must be applied toprotect tissue structures which are important forregeneration or for supporting regeneration, espe-cially the root cementum and the soft tissue in thepockets. Nyman et al. have proved that when theroot is intensively smoothed with removal of theroot cementum, no additional healing effect canbe achieved as compared with the careful use ofthe instruments, leaving the cementum intact(Nyman et al., 1986, 1988).

It is likely, however, that especially in the case ofvital teeth, posttherapeutic hypersensitivity can beminimized by leaving of the root cementum or thedentine intact. Additional flap surgery or soft tis-sue curettage going beyond the mechanicalremoval of the biofilm would not be able toremove problem bacteria such as Actinobacillusactinomycetemcomitans (Aa) successfully even inearly onset periodontal diseases (Christersson etal., 1985).

Local antibiotic applications or systemic antibioticadministration are not necessary in most cases –with the exception of early onset, rapidly progress-ing types of the disease.

Cause-orientated periodontal treatment follows areevaluation of the findings, from which fur-ther periodontal, endodontic, functional or restora-tive treatment measures are derived. Subsequentsupportive periodontal therapy should counter re-infection at recall intervals which are orientated tothe requirements of each individual patient.

16

Periodontal therapy

Fig. 2 - 8 Vector curette. The approximal tooth and root surfaces are treated with the Vector curette by using an access via buccal (labial) andlingual or palatinal. The slender shape and the minimal thickness of the curette allow easy handling even in narrow approximal spaces. In thecase of deep intrabony pockets the end of the instrument is introduced more or less vertically into the pocket.

Fig. 2 - 9 Straight Vector probe. The buccal (labial) and lingual (palatinal) tooth and root surfaces are treated with the Vector lancet (sites withpocket depths up to 5 mm) or the straight Vector probe (sites with pocket depths deeper than 5 mm). The instrument is handled in a similar wayto a periodontal diagnostics probe, using the same contact pressure and with tactile feedback against the base of the pocket and against thetooth surface. The instrument is guided circularly and in tangential linear fashion around the surface sections undergoing treatment.

Fig. 2 - 10 Curved Vector probe. Mesial, distal, lingual or buccal furcations as well as the concave surfaces around the enamel-cementumjunction are treated with the curved Vector probe. It has been proven that the furcation areas are best preprobed initially with an inactive instrument, allowing the instrument to turn inward following its curve. After safe localization of the furcation surfaces are requiring treatment theinstrument is activated and the surfaces are treated with the instrument.

17

The Vector Method

Through its indirect application of energy via thefluid film surrounding the instrument (warning:do not evacuate excessive liquid directlyat the sites being treated), and the support ofhydroxyapatite particles, which act smiliar to adentifrice, the Vector system allows for the veryeffective removal of the biofilm and plaque, sub-and supragingivally. The typical pulse transferenables for removal of calculus, without damag-ing the “soft” cementum and dentine surface orthe soft tissue of the pockets. A biological accept-able surface is achieved in a reliable matter dur-ing the repolishing of the root surfaces with thehydroxyapatite slurry. The characteristic of thesystem is that it avoids extensive mechanical pro-cessing, thus also allowing gentle treatment ofsensitive tooth restoration surfaces, especially inmarginal areas. The main reason for this high effi-ciency is the design of the instruments, which isbased on minimally invasive criteria, allowing tac-tile, sensitive instrumentation with maximum tissue protection even in poorly accessible areas, suchas furcations. The straight and curved probes arefurnished with the same measuring scales (3 mm –3 mm – 2 mm – 3 mm) as conventional periodon-tal diagnostic probes, and allow better orientationduring subgingival probing deep in the pocket.

Since the Vector Method is easily accepted bypatients, in many cases it is possible to treat all ofthe subgingival and supragingival surfaces (oftenwithout using anaesthesia) in one session, whichhas a favourable effect on slowing the rate ofreinfection.

Additional, manual smoothing of the surfacesusing hand instruments, such as curettes, as recommended for many traditional sonic or ultra-sonic instruments (Björn & Lindhe, 1962), is notnecessary for root surfaces treated with the Vectorinstrument, and should be avoided in order toprevent damage to the hard tooth tissue (Fig. 2 -11). Any blackish discolorations which may occuron ceramic restoration surfaces are due to microscopic abrasion from the metal instrumentsand can be selectively removed by subsequentuse of non-metal probes or by means of traditionalpolishing pastes.

The high tactile sensitivity, achieved by theelimination of vibration in the instrument, allowsfor both exploration and therapeutic use of thetool on the treated surfaces. The instruments areguided horizontally and/or vertically along miner-alized deposits (calculus) until they are removedby touch-sensitive feedback. In cases of doubt, thepocket sections concerned can be expanded usingcompressed air and checked visually. For siteswith extensive calculus deposits or overhangingrestorations, these can be removed using the sameinstrument in combination with an abrasive siliconcarbide suspension (Vector Fluid abrasive). If necessary, traditional polishing pastes and rotatingbrushes, etc. can also be used for removal of massive supragingival staining. The treatment canbe concluded beneficially by professional fluoride application to all the tooth surfaces, e.g.,with highly concentrated fluoride gels.

The following treatment system guaranteesthe most effective and efficient Vector therapy: initially, all approximal surfaces are treated withthe Vector curette (shown in blue on Fig. 2 - 12).This is best done by starting at the palatinal (lin-gual) side of the first quadrant and continuingwith the instrument held in the same way (theinstrument at a 90-degree angle to the right, view-ing in the handpiece direction) cleaning the buc-cal (labial) surfaces in the second quadrant. The

Fig. 2 - 11 Scanning electron microscope image of a tooth androot surface treated with the Vector curette (on the left of the picture)using a ultrafine hydroxyapatite slurry. The natural surface topography and the hard tissue are largely preserved apart fromslight polishing effects, and adsorbed deposits, mineralized deposits and biofilms are effectively removed.

18

Periodontal therapy

instrument is then turned by 180 degrees (instru-ment adjusted at a 90-degree angle to the left,viewing in the handpiece direction). Then followstreatment of the other contralateral surfaces whichare accessible in the second quadrant on thepalatinal (lingual) side and in the first quadranton the buccal (labial) side.

Next is the treatment of the furcations with thecurved Vector probe (shown in green in fig. 2 -12), adjusting the probe to a 90-degree angle tothe left. In this way the buccal furca openings ofthe right molars and, in the lower jaw, also thelingual furca openings of the left molars can bereached. The contralateral furcations are probedwith the instrument adjusted 90 degrees to theright. To reach the mesial furca openings, the curvedprobe is inserted at an angle of approximately20 degrees to the handpiece longitudinal axis(either to the right or to the left depending on thetreatment of the patients right or left half of thejaws), and slanting forward. The distal furca

openings are reached by using the probe adjust-ed at an angle of 20 degrees to the handpiece,to the right or left. Lastly, the buccal and lingualsurface of the teeth and roots are treated usingthe Vector lancet (sites with pocket depths up to 5mm) or the straight Vector probe (shown in red inFig. 2 - 12; for sites with pocket depths deeperthan 6 mm). The tool must be guided along thetooth surface in a tangential, linear way. To treatthe maxilla, a right-handed user should sit in aposition between 12 - 2 o’clock to the patient,who is lying down. An ambidextrous practitionercan treat the buccal tooth surfaces of the firstquadrant and the lingual tooth surfaces of the second quadrant with his left hand, whilst seatedin the usual position (between 9 and 12 o’clock).To treat the mandible, it is recommended that thepatient is sitting in an inclined position and thatthe practitioner works from a position between 9and 12 o’clock.

Fig. 2 - 12 Treatment concept on the maxilla using the Vector Method.

19

The Vector Method

Four to six weeks after the initial periodontal treat-ment, a reevaluation of the main findings isnecessary. The sulcus probing depths, gingivalrecession, furca invasion, mobility of the teeth,bleeding on probing, suppuration and plaqueaccumulation are again documented. This newlyobtained data is indispensable as a reference forthe frequency of recalls for supportive periodontaltherapy. The clinical signs of inflammation shouldhave largely disappeared, and the sulcus probingdepth should be reduced in most areas (Kaldahlet al., 1988). Some teeth will present less mobilityand there should be diminished gingival recession,mainly because of the subsiding of swelling of the

marginal gingiva. In most cases, the attachmentlevel may not have changed significantly in soshort a time.

Individual pockets that are still bleeding on probingat this stage should again be evaluated by diag-nosis and differential diagnosis, and should beexamined for residual subgingival calculus,plaque retention sites, insufficient approximal con-tacts, missed residues of luting cements, signifi-cant plaque accumulations or root configurationswhich are particularly difficult to access, all mayhave been left from the initial therapy.

Fig. 2 - 13 Clinical periodontal charting on the patient from Fig. 2 - 4 six weeks after initial Vector therapy. A few sites, which are withoutexception associated with inadequate restorations, show persistent inflammatory signs (positive BOP). The restorations were recontoured and fin-ished and these sites were selectively retreated with the metallic Vector instruments.







20

Periodontal therapy

Careful retreatment with the same instruments usedin the initial treatment and a subsequent manualcheck are carried out. In cases of doubt, a sharpcurette can be used as a diagnostic instrumentwithout applying much contact pressure, to checkthat all hard deposits have been completelyremoved. At this stage it will be necessary toevaluate the maintainability of the teeth, and theneed for hemisections or root amputations, aswell as the removal of plaque retention sites byrestorative measures. Gingival pockets which donot show bleeding on probing are not treatedduring this check. Supportive periodontal therapywill follow directly; a three-month interval is re-commended as a first recall (Axelsson et al.,1991). At least once a year, dental findings, sensitivity, gingivitis, pathologically deepenedpockets, furcations, tooth mobility and changes inbone level should be diagnostically reevaluated.Whilst in many cases, this reevaluation of find-ings and supportive periodontal therapy will suffice once a year, some patients may requirechecks and prophylaxis therapy more often; asmall number of patients even once a month.

21

The Vector Method

2.7 Treatment of early onset and rapidly progressing periodontal disease

Successful treatment of early onset periodontitis ismainly dependent on early diagnosis, causally ori-entated therapy directed against the bacteria con-cerned and consistent supportive periodontal thera-py (maintenance therapy) at recall intervals basedon requirements. As well as removing the biofilmand the objective of reducing the quantity of subgin-gival bacteria, specific elimination and suppressing the growth of highly virulentanaerobic bacteria, such as Actinobacillus actinomycetemcomitans (Aa), Porphyromonas gingi-valis (Pg) or Bacteriodes forsythus (Bf), are central tothe therapy.

Mechanical removal of the biofilm alone is frequent-ly not enough to eliminate these highly virulent bac-teria to a sufficient degree in patients with earlyonset periodontitis and rapidly progressing forms ofthe disease (Kornman & Robertson, 1985). Additionalflap surgery or soft tissue curettage are also subjectto these limitations (Christersson et al., 1985).

In these cases, therefore, the systemic administrationof antibiotics is recommended as an additionalmeasure to the mechanical removal of the biofilm.The effect of antibiosis is determined to a greatextent on the quality of the removal of the subgingi-val biofilm, as if this is intact, it protects the targetbacteria from the antibiotics (van Winkelhoff et al.,1996). The choice of antibiotic depends, in the indi-vidual case, on the composition of the pathogenicsubgingival bacterial flora. Combinations of metro-nidazole (e.g., Clont, Bayer, Leverkusen, Germany)plus amoxicillin (e.g., Amoxicillin, Ratiopharm, Ulm,Germany) have proved particularly effective incases of infection with Aa and Pg, and significantlyor entirely eliminate Aa and other pathogenic, sub-gingival microorganisms from periodontal lesionsand also from other oral sites subject to colonization (e.g., the back of the tongue or the tonsil recesses),generally after application of 8 to 10 days(Kornman et al., 1989, van Winkelhoff et al.,1989, 1992).

In most cases a gradual approach is recommended.Firstly, traditional initial periodontal therapy, which,after creating hygienic conditions, and instructing

the patient in oral hygiene, serves for carefulremoval of the subgingival biofilm and dentalhygiene. 4 to 6 weeks later the main findings arereevaluated in the normal way. In the case of gener-alized, persistent periodontal lesions, a microbialanalysis is recommended (Fig. 2 - 7 - 2). In anotherphase of therapy the removal of the subgingivalbiofilm is repeated with equal care, and antibioticswhich are as far as possible targeted towards thepathogen spectrum, or, in many instances, combinations of antibiotics, are used parallel withand immediately after the mechanical cleaning. It is recommended that the microbiological test isrepeated after 4 to 12 weeks, to check the elimina-tion or suppression of the virulent bacteria whichare causing the problem. Subsequent supportiveperiodontal therapy should prevent a recurrence orreduce further progression of the disease if recallintervals are adjusted to requirements and consis-tently observed.

22

Contraindications

2.8 Contraindications

As a general rule, instruments and devices drivenby ultrasonic motors should not be used on patientswith cardiac pacemakers or with sensitive, e.g.,implanted drug dosing systems or pumps.

Patients who suffer from a blood disease should betreated only after consultation with the internist inattendance.

Within 6 months after a heart attack, a patientshould not undergo surgical or invasive treatment.These patients are often taking anticoagulants,which increase the risk of excessive bleeding. Atall events, either the internist or cardiologist concerned must be contacted before treatment.

The bacteremia occurring during periodontal treat-ment or even during dental hygiene may endangerpatients suffering from rheumatic endocarditis, congenital heart defects and those patients withcardiac or vessel implants. Before periodontalexamination, but at all events before periodontaltherapy or extensive dental hygiene, these patientsshould rinse the mouth twice with a 0.2 % chlor-hexidine-digluconate solution for 20 seconds eachtime, in order to reduce the intraoral bacterialflora. An antibiotic should be given an hour beforeperiodontal therapy or dental hygiene. For adults,the American Heart Association (1997) recom-mends 3 g of amoxicillin 1 hour before the inter-vention. For those allergic to penicillin, clindamycinmay be administered.

After organ transplants, most patients take drugs to prevent organ rejection. Many of these drugscause gingival hyperplasias. Rinsing the mouthwith antiseptic solutions and antibiotic therapy arerecommended before periodontal therapy andextensive dental hygiene measures.

Patients who suffer from diabetes mellitus are moreprone to infections and often experience problemswith the healing of wounds. Furthermore, there is a risk of arteriosclerosis. Only stabilized patientsshould be treated, and it is vital that the attendinginternist is consulted.

Wound healing is also negatively affected by nico-tine addiction. This does not necessarily mean thatsmokers cannot undergo periodontal therapy.However, the success of periodontal treatment isusually limited in the case of heavy smokers (Ah et al., 1994).

23

The Vector Method

2.9 Supportive periodontal therapy

As a supplement to the initial periodontal diagnosis,which records the results of the progress of thedisease to date (inflammation, pocket formation,attachment loss, tooth mobility), diagnostics during the supportive periodontal therapy (mainte-nance therapy) documents the change in therepaired or regenerated condition of the perio-dontium achieved by the initial treatment and bythe recall treatments to date. The reference pointhere is the periodontal charting documented 4 to6 weeks after the initial therapy and the last documented recall condition (Claffey, 1991).

Under optimal conditions, the regular infectioncontrol forming part of supportive periodontaltherapy is aimed at long term maintenance of theperiodontal conditions and attachment levelachieved after the initial treatment. A balance issought between subgingival bacterial infectionand the immune reaction. The initial setting ofrecall intervals will be made taking into accountthe risk factors. Taking the general findings andthe compliance of a patient suffering from perio-dontitis into consideration, the major risk factorsare nicotine abuse, significant attachment loss inrelation to the age of the patient, a persistent tendency to bleeding or poor oral hygiene. Riskfactors relating to the teeth or the teeth surfacesinclude abnormal positions of the teeth, in particulardysgnath teeth, furca invasions or iatrogenicplaque retention sites, which are often associatedwith extended subgingival tooth restorations (Lang et al., 1983).

For a long-term success of all the periodontal treat-ments it is crucial to reevaluate the pockets andinflammatory site activity continuously during therecall as well as to reinstrument sites before up-coming recurrent inflammation. Only by accuratemonitoring of the pockets and regular profession-al dental hygiene in combination with the regulardestruction of the subgingival biofilm reinfectioncan be prevented or delayed (Axelsson et al.,1991; Isidor & Karring, 1986; Kahldahl et al.,1988).

Reinfections at the beginning of the supportiveperiodontal therapy are frequently the result ofpartially inadequate initial therapy. Generally

such sites can be detected by positive bleedingon probing. These sites are to be retreated withparticular care, in order to remove any missedresidues of biofilm or calculus (warning: atraumat-ic process with maximum care taken in respect ofthe hard dental tissue and the soft tissues of thepockets). If it is suspected that subgingival calcu-lus have been missed during the initial treatment,the Vector Method recommends the use of metalinstruments. Otherwise instruments made of fibrecomposite materials are available for supportiveperiodontal therapy, as these are specially adapt-ed to the requirements of supported periodontaltherapy. These ”recall” instruments areshaped in analagous to the metal instrumentsused for the initial treatment and flexible for easieradaptation to the complex root surface topography.Recurrent biofilm can be effectively removed alsoin combination with ultrafine hydroxyapatite slurry(Vector Fluid polish). Due to the filigree instrumentsmade of a soft fibre-reinforced composite and theuse of the fine-grained hydroxyapatite slurry witha surface hardness of the particles adjusted to thewear sensitive dentine tooth substrates and softtissues are reliably protected. The formation of tulip-shaped teeth, which is well known as a frequent consequence of regular periodontalmaintenance therapy with excessive wear on thehard substances of the teeth, is therefore reliablyprevented.

Although not all sites with persistent inflammatorysigns (positive BOP) indicate imminent loss ofperiodontal supportive tissue. However, the pres-ence of numerous pockets which bleed on prob-ing are considered as an indication that recallintervals should be shortened and that more inten-sive prophylactic measures should be taken. Forpatients whose situation has been stabilized, butwho nevertheless show individual sites whichprove resistant to therapy, additional applicationof local medication carriers, such as tetracycline-containing periodontal threads (e.g., Actisite,Wybert, Lörrach, Germany) or antimicrobial gelscontaining metronidazole (e.g., Elyzol-Dentalgel,Dumex, Bad Vilbel, Germany) or chlorhexidinslow releasing chips (Perio-chip, Atid Pharma,Alzenau, Germany) could be considered in individual cases.

24

Supportive periodontal therapy

Fig. 2 - 14 Vector recall probe. Thanks to this instrument’s flexibility and filigree design, according to minimally invasive criteria, in manycases all the surfaces of the teeth and the periodontal sites can be treated during the supportive periodontal therapy. The instrument is used simi-larly to the metallic Vector probe. Using the habitual probing pressure against the base of the pockets and the tooth surfaces the instrument isguided in tangentially around the teeth. The tactile feedback of the active instrument infrequently allows differentiation of an intact epithelialattachment. Such sites are treated very cautiously or they are only partially treated with the instrument if there are no signs of inflammation.Discolorations from abraded material are also prevented on sensitive ceramic tooth restorations. The instrument is suitable for subgingival andsupragingival use.

Fig. 2 - 15 The Vector recall curette is used for supportive periodontal therapy on approximal tooth and root surfaces which cannot bereached with the straight recall probe. The instrument is used in the same way as the metal Vector curette. The slender shape and the minimalthickness of the instrument tip, and, in particular, the flexible working end and the partly flexible shaft allow safe, touch-sensitive handling even in narrow approximal spaces. In the case of deep intrabony pockets the end of the instrument is introduced more or less vertically into the pocket

25

The Vector Method

If the patient is remotivated or reinstructed in oralhygiene, it is beneficial in many cases to checkthe hygiene status again a few weeks later.Usually during supportive periodontal therapy isalso supragingival staining is removed. It is re-commended that all teeth treated are dried as faras possible and fluoridated, preferably usinghighly concentrated adhesive gels (e.g., Duraphat,Colgate, Hamburg, Germany). In this way sur-face-associated deposits and accumulations of flu-oride ions are reconstructed. In order to preventroot caries, in particular in older patients withgeneralized gingival recession and/or a reducedflow of saliva, highly concentrated chlorhexidinevarnishes (e.g., EC 40, Explore, Nijmegen, NL)are suitable, which are applied on the exposedsurfaces after drying.

When non-inflammatory conditions and stabiliza-tion have been achieved over several recall inter-vals, regenerative periodontal measures may beconsidered in the individual case independentlyof periodontal therapy. In choosing the variousmaterials and techniques it is important to note,however, that hitherto many of these options, forreasons of methodology, are obliged to use initiallysurgery techniques and generally involve consid-erable posttreatment supportive care.

Fig. 2 - 16 The curved Vector periodontal probe (metal) can also be used for supportive periodontal therapy in the furcation area if these surfaces are out of reach of the straight recall probe or the recall curette.

26

27

ded crown margins to a paragingival or supra-gingival level using rotating diamond burs andfiles (Fig. 2-20).Particular care was required for the restoration ofa proximal accessability with a thin interdentalbrush. Finally, the Vector method was used for thecareful subgingival and supragingival cleaning ofdeposits, biofilm, calculus and plaque from allteeth using metallic instruments and aqueoushydroxyapatite slurry (Vector fluid polish andwater). Anesthesia was unnecessary up to theanterior part of the maxilla. Medicinal treatmentwas not administered.

Six weeks after the initial treatment, the findingswere re-evaluated using a pressure-calibratedprobe (Fig. 2-21). The periodontal inflammationwas healed apart from several individual locati-ons with positive bleeding on probing (Fig. 2-22).These were re-instrumented selectively with theVector system during the evaluation of findings.No further treatment was given. The next re-eva-luation of findings was scheduled for threemonths later.

Criteria for successful treatment:

– Elimination of suppuration (pus exudation fromthe pocket)

– Considerable reduction in the number of blee-ding pockets with standardized probing (e.g.pressure-calibrated probe)

– Significant reduction in pocket depth– Securing of loose teeth– Attachment gain– Reduction of the typical inflammatory

fetor ex ore

Case studies

2.10 Case studies

Case 1:”Criteria for successful treatment”

The example below of a 54 year old male patientwith advanced marginal adult periodontitis illu-strates the criteria used to assess a successful treatment.

The patient’s anamnesis was unremarkable. Withthe exception of the information that both parentshad already lost their teeth at an early stage,there was no indication of risk factors such as, forexample, serious general diseases or nicotineabuse. The clinical examination revealed an insuf-ficiently cared for set of teeth from conservativeand prosthetic aspects (Fig. 2-17). Apart from theroot canal treated tooth 16, all teeth reacted sen-sitively to dry ice with tooth 26 revealing a delay-ed reaction. The analysis of oral hygiene revea-led adequate proximal contacts and a massivecoating of plaque, particularly proximal and cer-vical. A large amount of restoration work indica-ted overcontoured subgingival margins. The clini-cal function diagnosis produced evidence of acompensated functional disturbance. The clinicaland radiological periodontal findings revealedpartially deep bony defects with massive perio-dontal inflammation (multiple bleeding on pro-bing) with partially acute episodes (countlesspockets with suppuration) (Fig. 2-18, 2-19). Agenetic susceptibility test for periodontis was madeto determine an increased periodontogenetic risk(Paro Gen Test, (IAI Institute, Zuchwil, Switzerland).The result (IL-1A [-889] mutated heterozygot; IL-1B[+3953] mutated heterozygot) indicated the pro-bable presence of a genotype risk. The subgingi-val probes obtained with sterile paper tips attooth positions 26 mesio-buccal (Probing depth:13 mm), 16 disto-buccal (Probing depth: 12 mm),37 mesio-buccal (Probing depth: 8 mm) and 46mesio-buccal (Probing depth: 6 mm) revealed noindication of an infection with Actinobacillusactinomycetemcomitans or with Porphyromonasgingivalis (see Section 2.5).

After a thorough examination, an initial periodon-tal treatment was carried out in one session (fullmouth desinfection principle). This consisted ofrecontouring all overcontoured restorations plusconsiderable shortening of the subgingival exten-

28

The Vector Method

Fig. 2-17 Initial clinical findings with massive gingival and periodontal inflammation

Fig. 2-18 Clinical periodontal finding prior to treatment: massive periodontal inflammation with pronounced pocket formation and multiplepus exudation on probing.

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29

Case studies

Fig. 2-19 Radiological status: condition before treatment.

Fig. 2-20 Buccal views after remodelling of the existing tooth restoration before starting Vector therapy.

30

The Vector Method

Fig. 2-21 Clinical condition 6 weeks after initial Vector therapy: labial and buccal views.

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31

Case studies

Case 2:”Therapy concept”

The Vector therapy concept together with longterm care of a patient with previous marginalperiodontitis is illustrated by the example of a 57year old man at the start of treatment. In summer1997, the patient presented at our surgery withsuspicion of refractory periodontitis a few daysbefore an extraction appointment to removevarious teeth in the front of the mandible andmolar maxillary regions (Fig. 2-23). He requestedan independent consultation concerning the treat-ment concept devised by his family dental surge-on. His anamnesis and family anamnesis revealedno indications of general diseases or specific riskfactors. At this point in time, his teeth were inade-quately cared for both from a conservative and aprosthetic aspect. Apart from the root canal trea-ted teeth 24 and 25 with radiological suspicionof endodontic lesions and the non-sensitive situ-ation relating to tooth 16, all teeth reacted sensiti-vely to dry ice. The periodontal finding revealedcountless deep pockets with pocket depths downto 14 mm along with a massive periodontalinflammation (locations with positive bleeding onprobing) with acute lesions (locations with sponta-neous pus exudation or pus exudation on pro-bing) (Fig. 2-24). Particularly noticeable was afistula regio 32, which using gutta percha pins inradiological diagnosis indicated a probable cor-relation with a periodontal origin (Fig. 2-25). Theoral hygiene analysis revealed some completelyblocked proximal spaces, multiple subgingivalextended restoration margins with some consider-able overcontouring and massive plaque depo-sits, particularly lingual and proximal.

After detailed instruction of the patient concerningthe etiology of the disease, initial cause-based treat-ment and necessary supportive periodontal therapy, preliminary treatment was carried out inseveral sessions to achieve conditions favorablefor hygiene and to eliminate endodontic lesions.In addition to the removal of restorations to teeth24 and 25 with subsequent revision of the rootcanal fillings and long-term provisional care, sub-gingival crown margins were considerably short-ened, contour overhangs remodelled by grindingand closed proximal spaces opened with dia-mond files. A conscious decision was taken not tocarry out coarse depuration in the sense of a

preliminary removal of subgingival calculus ineasily accessible areas (see Section 2.6). Thepatient was carefully instructed in appropriateoral hygiene techniques.

A few days after the initial treatment, a closedinitial periodontal treatment was carried out withthe Vector method using metallic instruments andaqueous hydroxyapatite slurry (Vector fluid polish)(see Section 2.6). Disinfection additives were notused. Neither additional chemical or medicinaltherapy nor the use of regeneration-supportingmeasures were used.

A re-evaluation of the periodontal findings wascarried out six weeks after the initial treatment(Fig. 2-26). The signs of periodontal inflammationhad completely disappeared apart from a fewlocations (Fig. 2-27). The fistula regio 32 hadhealed and teeth 31 and 32 appear considerablyfirmer. Differential diagnosis was now able toexclude critical and progressive forms of perio-dontitis with a high degree of probability. Theunderlying adult periodontitis reacted very well tothe treatment without the necessity for performinga subgingival bacterial analysis or for more radi-cal surgical treatment. The few bleeding pocketsfrom standardized probing were checked for anyremaining residual calculus or incompletely recon-toured restorations and reinstrumented usinginstruments made of fiber composite materialsduring a first recall. The recall intervals were initially set at three months. The supportive perio-dontal treatment given during these recall sessionscovered re-evaluation of the signs of periodontalinflammation (at least circular probing of all perio-dontia with standardized pressure against thepocket fundus and indexing of the bleeding onprobing and where necessary of suppuration).Individual bleeding pockets on probing were selectively reinstrumented using the Vector method.

32

The Vector Method

Fig. 2-23 Initial clinical finding: massive gingival and periodon-tal inflammation with fistula regio 32.

Fig. 2-24 Clinical periodontal finding before Vector therapy: massive periodontal inflammation with pronounced pocket formation and par-tial pus exudation on probing.

Fig. 2-25 Radiological status: condition before Vector therapy. Reg-io 31, 32: gutta percha tips in situ to determine the origin of the fistel.

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33

Case studies

Fig. 2-26 Condition 6 weeks after Vector therapy: drastic reduc-tion in the signs of clinical inflammation. Healing of the periodontalfistula regio 32 with local residual inflammation.

Fig. 2-27 Clinical periodontal finding: condition 6 weeks after Vector therapy.

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The Vector Method

Fig. 2-29 Clinical periodontal finding: condition 1 year after single Vector therapy and supportive Vector periodontal therapy at 3 monthlyrecall intervals.

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Fig. 2-28 Condition 1 year after Vector therapy: freedom frominflammation but gingival retraction (photo before recall treatment).

35

Case studies

Fig. 2-30 Condition 2 years after initial Vector therapy and after removal of the old restorations, core build-ups and preparations immedi-ately before prosthetic rehabilitation: maxillary occlusal view (left), anterior view (middle), mandibular occlusal view (right).

occurred in the area of the deep intrabony pocketregio 32, 33, which was able to be confirmed bya follow-up radiograph in the sense of a bonyapposition of several millimeters (Figs. 2-31, 2-32, 2-33). Apparently, nature alone was in aposition to perform partial regeneration. As aresult of the persisting inflammation-free situation,the recall interval was further extended to 9months. The periodontal condition has further sta-bilized also after this extension of the recall inter-val apart from a local inflammation at 31 (Figs.2-34, 2-35). After local treatment of this inflam-mation (Vector fiber composite instruments andVector fluid polish) and after consultation with thepatient, the intervals have been provisionally setat 6 months.

This was followed by professional teeth cleaningand fluoride treatment of all teeth. A stable, perio-dontal inflammation-free condition (Fig. 2-29) wasable to be recorded one year after the initial tre-atment (Fig. 2-28). The attachment losses regio32, 33 were hardly changed compared with theinitial findings despite a considerable reduction inthe correlating pocket depths and final fixing ofthe teeth. The patient’s oral hygiene was rated asgood, with small exceptions in the area of thefront of the mandible. The recall intervals werethereupon extended to 6 months.

The healthy periodontal situation was also stabletwo years after initial treatment and with supportiveperiodontal therapy at six monthly intervals. Anew prosthetic provision was decided and perfor-med (Fig. 2-30). Surprisingly two years after theinitial treatment, a considerable attachment gain

36

The Vector Method

Fig. 2-31 Condition 2 years after Vector therapy and prostheticrehabilitation

Fig. 2-32 Clinical periodontal finding 2 years after initial Vector therapy and supportive Vector therapy at 6 monthly recall intervals

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Fig. 2-33 Radiological status two years after initial Vector therapyimmediately after prosthetic rehabilitation (arrow: partial bony tissueregeneration).

37

Case studies

Fig. 2-34 Condition 2 years and 9 months after initial treatment.The final supporting periodontal therapy carried out was 9 monthspreviously (Photo before recall).

Fig. 2-35 Clinical periodontal finding 9 months after prosthetic rehabilitation and last Vector supportive periodontal therapy (2 years and 9months after initial Vector therapy).

The Vector Method

3 Aspects of periimplant mucositis and periimplantitis

The supraalveolar tissues surrounding the teeth(gingiva) and the periimplant mucosa differ in thecomposition of the connective tissue, the arrange-ment of collagen fibres, the missing cementum aswell as the vessel structures in the marginal epithe-lium (Berglundh et al., 1991). Plaque, however,collecting on the tooth or implant surfaces (e.g.,on titanium) over equivalent time intervals differsneither in mass or structure (Leonhardt et al.,1992). As with the subgingival biofilm on thetooth surfaces, the biofilm of subgingival implantsurfaces is also dominated by gram-negativebacteria, where the microbial flora consists of upto 25 % of Porphyromonas gingivalis andPreventolla intermedia.

Persistent plaque accumulation can have the sameeffect on the periimplant mucosa as the gingiva,with an inflammatory infiltrate developing.According to Leonhardt et al. (1992), within thefirst three weeks no differences could be deter-mined. Later, too, the extent of gingival destructionis similar. However, whilst the lesion around thenatural tooth is restricted to the gingiva for alengthy period and in most cases an intact barrierof connective tissue exists to the alveolar bone, theperiimplant bone is affected by the inflammationearly. The periimplant tissue seems to be lessresistant against plaque-induced, inflammatorylesions than the periodontal tissue of the naturaltooth. For this reason, great emphasis should beplaced at an early stage on the removal of surface-adsorbed biofilms on implant surfaces andon continuous infection management. Ongoingmonitoring of the periimplant mucosa and comple-mentary measures for infection control, professionaldental hygiene and instructions to the patient onoral hygiene are indispensable in the majority ofcases. Patients who are suffering from periodontaldisease, or have suffered from it in the past, andhave had implant restorations, are particularly sus-ceptible to periimplant mucositis or periimplantitis.In these patients the time intervals between recallsare not infrequently determined by the inflammatoryrelapses in the area of the periimplant mucosa.

Fig. 3 - 1 Flexible Vector recall probe made out of a soft fibrecomposite material on a textured implant surface in situ (schematicrepresentation).

38

Periimplant mucositis and periimplantitis

Infection management on implant surfacesis frequently made more difficult by their retentiveshape (e.g., screw threads) and/or by rough sur-face textures. The minimally invasive design andflexibility of the Vector fibre-reinforced compositeinstruments recommended for treating the implantsurfaces make access to the base of the pocket easi-er even in cases of non-linear bone loss with cavitylike undercuts or intrabony pockets. The low surfacehardness of the instruments and the ultrafine hydroxyapatite slurry (Vector Fluid polish) which canbe used as required, guarantee reliable removal ofthe biofilm without damaging the surface.Furthermore, there is scarcely any mechanical trau-ma to the periimplant mucosa.

A major reason for the high cleaning efficiency isthat the fibre composite tool partially adapts to thetreated surface by selective wear during its use (Fig. 3 - 3).

The instrument’s surface is thus able to come intoclose contact with the structured or textured surfaces,which results in more efficient energy contact throughthe film of liquid surrounding the tool. Handling ofthe instrument, the prohibition on evacuating thecontact fluid at the treatment site and the pressurerequired are exactly the same as for treating toothand root surfaces.

In most cases the use of fibre-reinforced compositeprobes on implants is sufficient both for the initialtreatments and also for maintenance therapy. Thesequence of treatment and the criteria for riskassessment and implementation of a consistentmaintenance therapy programme correspond tosupportive periodontal therapy, generally with short-er intervals of recall.

Fig. 3 - 3 Representative scanning electron microscope image of a thread structured, textured aluminum-oxide coated titanium implantafter treatment with the Vector fibre-reinforced composite probe. The implant is almost completely free of deposits and there is no evidence of surface damage. The composite probe shows thedesired wear traces in the sense of a negative image of the treatedsurface, which increases the efficiency of cleaning.

Fig. 3 - 2 Maintenance therapy on an implant with the straightVector recall probe after prior removal of the suprastructure.

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The Vector Method

Fig. 3 - 4 Maintenance therapy on an implant with the straight flexible Vector fibre-reinforced composite probe, without removing the all-ceramic suprastructure, in order to minimize the danger of fracturing. (top illustration: buccal view; bottom illustration: lingual view)

40

Dental hygiene

4 Aspects of dental hygiene

4.1 Removal of supragingival calculus

Conventional ultrasonic instruments removesupragingival calculus deposits by blasting them offwith three-dimensional vibrations of the instrumenttip. The desired efficiency of the instrument is set by selecting the amplitude, which determines thedegree of the mechanical micro-blasting effect.Cooling of the instrument requires large amounts ofliquid, regulated according to the chosen amplitude.The resulting aerosol causes a significant risk ofinfection to the entire dental team. To avoid damageto the tooth surface, the vibrating instrument tip hasto be guided along parallel to the tooth surface in awiping movement. Manual rework with scalers,curettes and the use of polishing paste and rotatingbrushes is recommended (Björn & Lindhe, 1962).

With the Vector system, vibrating instruments,mechanical blasting and heat effects, high volumesof cooling water, severe sensitivity reactions of thepatients or aerosol formation etc. are eliminated.The system works according to the principle of indi-rect energy contact via a film of liquid adhering tothe instrument’s surface. Working in a similar man-ner to a lithotripter, calculus is pulverized andremoved due to the differing elastic moduli betweentooth substrate and deposit. Therefore the mass ofcalculus is correlated to the time needed for theinstrument to remove it. In severe cases of tough cal-culus formation, it may be desirable, for reasons oftime, to loosen the coarse mass of deposits by usingadditional targeted mechanical means. The Vectormethod uses its own instrument for this special indi-cation (the Vector Supra Scaler). Only this instru-ment has a minimal vibration characteristic in addi-tion to the usual effects of the Vector method. Theseparation of the instrument from the direct ultrason-ic drive, attaching it to the resonance ring typical ofthe Vector system, results in a considerably lowerimpulse transfer to the treated surfaces due to theassociated significant reduction in the total vibratorymass. The risk of surface damage and the quantityof aerosol spray are considerably reduced in spiteof the highly efficient cleaning effect. Using a particlesuspension, for instance Vector Fluid polish or incases with extensive calculus formation Vector fluid

abrasive, increases the working efficiency of theinstrument and achieves an additional polishingeffect.

4.2 Removal of supragingival plaque and discolorations

In addition to the metal tools used for periodontaltreatment, further dental hygiene tools made ofmetal are also available for the removal partly calci-fied plaque deposits. Soft overlaying deposits canbe removed with fibre composite tools in combina-tion with hydroxyapatite particle suspension (VectorFluid polish). There are also various speciallyshaped tools available for this task. Unlike air abra-sion units, all tooth surfaces can be treated with norisk of harm to soft tissues, irreversible injury to ini-tial caries lesions or to the sensitive margins of fillings and without forced erosion of exposed dentine (Galloway & Pashley, 1987). The achieve-ment of adequate surface smoothing and the complete removal of any stainings, in particular frommicrotextures, which are often seen after the appli-cation of air abrasion methods, correlates directlywith the treatment time needed for this, however. By

Fig. 4 - 1 A special instrument with defined vibratory characteristics(the Vector Supra Scaler) is available for removal of solid supra-gingival calculus deposits (schematic representation).

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The Vector Method

using plastic instruments containing no reinforcingfibres (the flexible Supra Probe), energy input canbe minimized and the fluid dynamic effects of thesystem can be used selectively (for example, theflexible probe can be used as an effective irrigationaid or for the extensive polishing of tooth surfaces).

Fig. 4 - 2 Condition after the removal of solid calculus deposits with the Vector Supra Scaler, using Vector Fluid polish. Efficient, time-savingremoval of large quantities of supragingival calculus can be achieved using the minimally vibrating special instrument. The instrument is generallyheld at a 90-degree angle to the longitudinal ring axis. Under optimal working conditions the instrument tip, about 2 mm long and adverselycurved, penetrates the sulcus opening, all the contour of the tool adapting to the shape of the tooth. When moved horizontally following the garland-shaped course of the gingiva, the instrument removes solid calculus deposits. For interdental cleaning the instrument canbe physically rotated into the interdental spaces with the tip in front. Residual deposits are removed during dental hygiene with the other Vectorinstruments.

Fig. 4 - 3 As well as periodontal treatment and recall instruments, which are also used in preference for supragingival dental hygiene, bud-shaped instruments (see illustration on the left) made of metal or fibre composite materials are available for concave surfaces (e.g., the lingualsurfaces of the front teeth and the transitions in the area of the cementoenamel junction). A thin, flexible metal plate (see illustration on the right)facilitates cleaning of the interdental spaces, including the contact area and the transitions to the buccal and lingual surfaces.

42

Microinvasive preparation

5 Aspects of microinvasive preparationof teeth or non-metal restorations

The Vector system offers specially shaped metaltools for use with an abrasive slurry of silicon carbide (Vector Fluid Abrasive) for micro-invasive preparation, contouring and finishing of tooth substance and non-metalrestorations. In contrast to rotating tools, the Vectorinstruments are inserted longitudinally in a parallelmanner, which allows maximum material removal.Cutting performance is reduced by horizontalpreparation movements. Hollow instruments pro-vide exact positioning and the best degree ofmaterial removal. These instruments are availablein different cylindrical and oval shapes for a pre-cise preparation. The contours of the cavity arepreferably prepared with the appropriate shapinginstrument, the geometry of which comprehendsas large a section as possible of the cavity to becreated. Under some circumstances the same ordifferent instruments can be inserted several timesin an alongside parallel way. The resultant edgeson the connection points of these cavities canfinally be contoured using lateral movements ofthe tool. For approximal cavity segments, toolsthat are flat on one side (e.g., hemispheres, semi-ellipses, half-flames, etc.) are available, to removeprojections in the cavity edge area and to minimizethe risk of damaging adjacent teeth or restorations.

The indirect energy connection via a film of liquidsurrounding the instrument and the addition of aparticle suspension, typical of the Vector system,are also features which characterize cavity prepa-ration. Removal of material is effected throughaccelerated silicon carbide particles between thetool and the surface being prepared. These particlesoffer a high surface hardness and a block-shapedcutting grain geometry. The average grain size isapproximately 40 - 50 µm, and is therefore analo-gous to fine finishing diamonds. The materialremoval process using loose grains is similar to alapping process, which explains the accurate,athermal and extremely gentle nature of theprocess. Since heat induction has been virtuallyeliminated, only a small amount of liquid is need-ed, even for extensive preparations.

The contact pressure applied with activated instru-ments is the same as that used in the periodontal

application. In combination with highly efficientremoval a typical erosive preparation sound iscreated, which will soon become familiar to the user.

In order to achieve optimal cutting performanceand results, the preparation instruments should beheld in place continuously and moved as the cut-ting progresses. The high contact pressures andcontinuous wiping movements used with rotatingdiamond instruments prevent optimal energy con-tact. Evacuation of the fluid surrounding the instru-ment at the preparation site will hinder a sufficientenergy contact. For this reason the amounts ofexcess fluid, which are in any case low, should

Fig. 5 - 1 Microinvasive cavity preparation with Vector instru-ments, using an abrasive slurry (Vector Fluid abrasive). For theapproximal opening, the application of a matrix band and/or separation of the approximal space is recommended for temporaryprotection of the adjacent teeth, even if flat instruments are used(schematic representation).

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The Vector Method

be evacuated only at intervals, preferably in thearea of the dorsal oral cavity on the contralateralside. As well as the very gentle effect on theenamel, dentine and non-metallic restorationmaterials in finishing mode, the reliable protectionof the soft tissue close to the cavity, the avoidanceof heat stress and damage to the pulp andoptions for the use of different shaped tools, theVector system offers highly sensitive tactile han-dling for the practitioner. The high level of patientacceptance is particularly important for applica-tions in paediatric dentistry.

Fig. 5 - 3 Illustration on the left: condition immediately before completion of the cavities formed according to adhesive criteria, using variousshaped Vector instruments. Separate finishing of the cavities is not required.Illustration on the right: condition after adhesive restoration (traditional enamel and dentine etching with 37 % orthophosphoric acid, applica-tion of an enamel and dentine adhesive, matrix technique and layered application of flowable and high-filled composite using soft start poly-merization). The whitish opaque coloration of the composite filling material is deliberately chosen due to the desired long-term monitoring of themarginal obturation of the fillings and for easy differentiation from intact hard substrate.

Fig. 5 - 2 Initial caries lesions on 26 d and 27 m requiringrestoration, and composite filling needing replacement on 26 o.

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Microinvasive preparation

as to refine their final shape. No marginal flake-offs occur and no enamel prisms are dispersed(Fig. 5 - 4, 5 - 5). The same advantages applywhen processing sensitive restoration margins (for example, of composite restorations or adhesivebonded ceramic reconstructions), which are espe-cially prone to fracture immediately after poly-merization of the composite due to high volume-inherent residual tension in combination with theuse of rotating diamond instruments.

The Vector system is not suitable for the removalof soft dentine caries or to prepare metal dentalrestorations, except for recontouring smalloverhangs of amalgam fillings, for example. Thepreparation of extensive cavities or dies for pros-thetic rehabilitation is not recommended either,since the Vector tools will take much longer toaccomplish this than conventional high-speed diamond burs. However, the Vector system maybe used to advantage to finish the margins ofconventionally prepared cavities and dies, as well

Fig. 5 - 4 Representative scanning electron microscope image of anocclusal cavity prepared with the Vector system.

Fig. 5 - 5 Representative scanning electron microscope image ofan approximal cavity prepared according to minimally invasive criteria using Vector instruments and Vector Fluid abrasive.

Fig. 5 - 6 Finishing of sensitive restoration margins with metal Vector instruments in combination with abrasive or polishing particle suspensions (schematic representation).

45

6 Literature

Ah, M.K.B., Johnson, G.K., Kaldahl, W.B., Patil,K.D., Kalkwarf, K.L.: The effect of smoking on theresponse of periodontal therapy. J ClinPeriodontol 21, 91-97 (1994).

Axelsson, P., Lindhe, J.: Effect of controlled oralhygiene procedures on caries and periodontaldiseases in adults. J Clin Periodontol 5, 133-151(1978).

Axelsson, P., Lindhe, J.: The significance of main-tenance care in the treatment of periodontal dis-eases. J Clin Periodontol 8, 281-295 (1981).

Axelsson P., Lindhe, J., Nyström, B.: On the prevention of caries and peridontal disease.Results of a 15-year longitudinal study in adults. J Clin Periodontol 18, 182-189 (1991).

Berglundh, T., Lindhe, J., Ericsson, I., Marinello,C.P., Lijenberg, B., Thomsen, P.: The soft tissuebarrier at implants and teeth. Clin Oral Impl Res 2, 81-90 (1991).

Björn, A-L., Lindhe, J.: The influence of periodontalinstruments on the tooth surface. A methodologicalstudy. Odontologisk Revy 13, 355-369 (1962).

Christersson, L.A., Slots, J., Rosling, B.G. et al.:Microbiological and clinical effects of surgical treatment of localized juvenile periodontitis. J ClinPeriodontol 12, 465-476 (1990).

Claffey, N.: Decision making in periodontal therapy.The reevaluation. J Clin Periodontol 18, 384-389(1991).

Galloway, S.E., Pashley, D.H.: Rate of removal ofroot structure by the use of the Prophy-Jet device.J Periodontol 58, 464-469 (1987).

Isidor, F., Karring, T.: Long-term effect of surgicaland non-surgical periodontal treatment. A 5-yearclinical study. J Periodont Res 21, 462-472(1986).

Kahnberg, K.-E., Lindhe, J., Hellden, L.: Initial gingivitis induced by topical application of plaqueextracts. A histometric study in dogs with normalgingivae. J Periodont Res 11, 218-225 (1976).

Kahldahl, W.B., Kalkwarf, K.L., Patil, K.D., Dyer,J.K., Bates, R.E.: Evaluation of four modalities ofperiodontal therapy. Mean probing depth, probingattachment level and recession changes. J Periodontol 59, 783-793 (1988).

Kahldahl, W., Kalkwarf, K., Patil, K.D., Molvar,M.: Evaluation of gingival suppuration andsupragingival plaque following 4 modalities ofperidontal therapy. J Clin Peridontol 17, 642-649(1990).

Kornman, K.S., Robertson, P.B.: Clinical andmicrobiological evaluation of therapy for juvenile periodontitis. J Periodontol 56, 443-446(1985).

Kornman, K.S., Newman, M.G., Flemmig, T.,Alvarado, R., Nachnani,S.: Treatment of refractoryperiodontitis with metronidazole plus amoxicillinor Augmentin. J Dent Res 68, 917 (1989).

Lang, N.P., Kiel, R., Anderhalden, K.: Clinicaland microbiological effects of subgingival restora-tions with overhanging or clinically perfect margins.J Clin Periodontol 10, 563-578 (1983).

Langeland, K., Rodrigues, H., Dowden, W.:Periodontal disease, bacteria and pulpal histo-pathology. Oral Surg 37, 257-270 (1974).

Leonhardt, A. Berglundh, T., Ericsson, I., Dahlén,G.: Putative periodontal pathogens on titaniumimplants and teeth in experimental gingivitis andperiodontitis in beagle dogs. Clin Oral Impl Res 3, 112-119 (1992).

46

Lindhe, J., Nyman, S.: The effect of plaque controland surgical pocket elimination on the establish-ment and maintenance of periodontal health. Alongitudinal study of periodontal therapy in casesof advanced disease. J Clin Periodontol 2, 67-79(1975).

Lindhe, J., Nyman, S.: Long-term maintenance ofpatients treated for advanced periodontal diseases.J Clin Periodontol 11, 504-514 (1984).

Löe, H., Theilade, E., Jensen, S.B.: Experimentalgingivitis in man. J Peridontol 36, 177-187(1965).

Nyman, S., Sarhed, G., Ericsson, I., Gottlow, J., Karring, T.: The role of diseased root cementumfor healing following treatment of periodontal dis-ease. J Clin Periodontol 13, 496-503 (1986).

Nyman, S., Westfellt, E., Sarhed, G., Karring, T.: Role of diseased root cementum in healing following treatment of periodontal disease. A clinical study. J Clin Periodontol 15, 464-468(1988).

Page, R.C., Altman, L.C., Ebersole, J.L.,Vandesteen, G.E., Dahlberg, W.H., Williams,B.L., Osterberg, S.K.: Rapidly progressive periodontitis. A distinct clinical condition. J Periodontol 54, 197-209 (1983).

Page, R.: The pathobiology of periodontal diseasesmay affect systemic diseases: Inversion of a para-digm. Annals of Periodontol 3, 108-120 (1998).

Ramfjord, S.P., Nissle, R.R., Shick, R.A., CooperJr., H.: Subgingival curettage versus surgical elimination of periodontal pockets. J Periodontol39, 167-175 (1968).

van Winkelhoff, A.J., Rodenburg, J.P., Goene,R.J., Abbas, F., Winkel, E.G., de Graaff, J.: Metronidazole plus amoxicillin in the treatmentof Actinobacillus actinomycetemcomitans associ-ated periodontitis. J Clin Periodontol 16, 128-131 (1989).

van Winkelhoff, A.J., Tijhof, C.J., de Graaff, J.: Microbiological and clinical results of metron-idazole plus amoxicillin therapy in Actinobacillusactinomycetemcomitans – associated periodonti-tis. J Periodontol 63, 52-57 (1992).

van Winkelhoff, A.J., Rams, T.E., Slots, J.: Systemic antibiotic therapy in periodontics.Periodontology 2000, 10, 45-78 (1996).

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Dürr Dental GmbH & Co. KG Höpfigheimer Strasse 17 D-74321 Bietigheim-Bissingen

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Dürr Dental GmbH & Co. KG Höpfigheimer Straße 17 D-74321 Bietigheim-Bissingen

Dürr Dental Online:http://www.duerr.deeMail: [email protected]. Rainer Hahnhttp://www.zahnerhaltung.com

Documents

The Vector Method · taining silicon carbide (SiC) (Vector Fluid abrasive) is used. The average grain size of the extremely hard, block-shaped cutting SiC particles is approx-imately