Root coverage and papilla reconstruction using autogenous osseous and connective tissue grafts.

Previous studies have reported that the distance from the interdental crest of bone to the apical portion of the contact of the two approximating teeth must be 5 mm or less to support a stable interdental papilla. The reconstruction of a stable, long-term papilla for esthetic purposes must therefore consider interdental bone reconstruction. Autogenous osseous graft material was harvested from the tuberosity and augmented with a subperiosteal connective tissue graft for papilla reconstruction between the maxillary central incisors. Flap design, osseous graft fixation with a screw, connective tissue placement, wound closure, and suturing techniques are presented. To enhance the final result, porcelain veneers were bonded to the approximating central incisors. This case report demonstrates a surgical procedure that has not been reported to date for papilla reconstruction to enhance periodontal esthetics.

Surgical treatment of cyclosporine A- and nifedipine-induced gingival enlargement: gingivectomy versus periodontal flap.

The purpose of this study was to compare probing depth resolution achieved by gingivectomy and periodontal flap techniques in the treatment of cyclosporine A- and nifedipine-induced gingival enlargement. Ten kidney transplant patients who were receiving cyclosporine A and nifedipine for at least 6 months participated in the study. Five patients were randomly assigned to the gingivectomy group and 5 patients to the periodontal flap group. Only anterior segments of the oral cavity (canine to canine) were surgically treated. Clinical measurements, including probing depths, plaque index, and gingival sulcus index, were taken at baseline, 6 weeks, 6 months, and 1 year. Results showed that probing depths, while similar for both groups in the first 6 weeks of the study, were significantly shallower for the periodontal flap group when compared to the gingivectomy group at 6 months (2.48 +/- 0.34 mm versus 4.87 +/- 0.79 mm, respectively) and 1 year (322 +/- 0.65 mm versus 6.40 +/- 1.02 mm, respectively). Within its limitations, this study suggests that the pocket reduction achieved by the periodontal flap may be sustained for longer periods of time than by the gingivectomy technique in the treatment of cyclosporine A- and nifedipine-induced gingival enlargement.

Clinical success in regeneration: report of a case.

Occasionally in clinical periodontics we are confronted with exceptional examples of the potential for healing. This is the report of one such instance in a young patient with a history of juvenile periodontitis and significant localized bone loss. Following relatively simple treatment, marked bone fill of a periodontal defect was observed over the course of 1 year. The factors which contributed to the remarkable healing response are considered, and the techniques used during therapy are presented.

In vitro comparison of aged and young osteogenic and hemopoietic bone marrow stem cells and their derivative colonies.

The purpose of this in vitro study was to determine whether there were differences in the number and size of osteogenic and hemopoietic colonies derived from bone marrow stem cells of aged and young adult male Sprague-Dawley rats. Using a Ficoll-Paque gradient, stem cells were harvested from aged male rats 18 to 22 months old and young adult males 55 days of age. Single cell suspensions from the red marrow of the long bones were cultured 14 days in vitro and subsequent colonies were assessed by light microscopy for number and size. A computerized histomorphometric linear measuring system was utilized to assess colony area in square millimeters. The results clearly show that young animals have a statistically significant increased cellular potential for osteogenic and hemopoietic colony formation. Cultures from aged animals showed an average formation of 0.45 +/- 0.6863 osteogenic colonies while those from younger animals had an average of 3.6 +/- 2.3523 osteogenic colonies per 3 million cells plated. Hemopoietic colonies from aged animal cell cultures numbered 5.25 +/- 2.2449 while those from the young animals averaged 8.23 +/- 3.3601 per 3 million cells plated. The difference in size of the osteogenic and hemopoietic colonies between age groups was not statistically significant. The area of osteogenic colonies derived from aged animals measured 0.1244 +/- 0.0891 mm2, while those derived from the young animals averaged 0.1276 +/- 0.0518 mm2. Hemopoietic colonies from the aged cells measured 0.0759 +/- 0.0514 mm2, while hemopoietic colonies from the young animal cells measured 0.06010 +/- 0.0180 mm2. The results of this study may have implications for consideration in the cellular healing aspects of aged versus young individuals.

The regenerative potential of plaque-induced peri-implant bone defects treated by a submerged membrane technique: an experimental study.

The aim of the present study was to experimentally induce peri-implant bone defects around three different types of implants by plaque accumulation and to determine whether new bone formation can occur on previously contaminated dental implants. Dental implants were placed into the mandibles of beagle dogs. Gross plaque accumulation around the implants was undisturbed for 3 months, which resulted in circumferential peri-implant bone defects. Bony defects surrounding the hydroxyapatite implants were significantly greater than those around the titanium implants. Surgical treatment consisted of granulation tissue removal, preparation of the implant surface, and the placement of an e-PTFE membrane over each test implant. Before the flap was closed to cover the implants, perforations were made into the cancellous bone. Each control implant received identical treatment, but without placement of a membrane. Surgical exposure after an uneventful submerged healing period showed evidence of closure of the peri-implant bone defects. Corresponding histologic examination of 2-month sections demonstrated large amounts of rapidly formed lamellar bone beneath the membrane. Some areas of the previously contaminated implant surface showed evidence of "re-osseointegration." These preliminary results support the hypothesis that plaque-induced peri-implant bone defects can be successfully treated by a submerged membrane technique in the dog model.

The strip gingival autograft technique.

In keeping with the concept of rapid epithelialization of close wound edges, the strip technique was developed to maximize the area of gingival grafting with less trauma to the donor site or the recipient site. An incision is made and a partial-thickness flap is reflected so that stable periosteum is left. The apical mucosal border of the recipient site is sutured to the periosteum. Donor tissues are obtained in 2-mm-wide strips, transferred to the recipient site, and sutured. Dry foil and surgical packing are used to stabilize and protect the site during healing. The donor site is rapidly epithelialized (within 10 days) and produces minimal patient discomfort.

The use of autogenous periosteal grafts as barriers for the treatment of Class II furcation involvements in lower molars.

This study clinically analyzed the efficacy of a connective tissue graft including the periosteum used as a barrier to enhance new attachment and osseous regeneration. Fifteen patients, with no systemic diseases, and adult periodontitis including 2 Class II furcation involvements in lower molars comprised the study group. After completion of the initial phase of therapy, all patients were treated with full-thickness periodontal flaps, using sulcular incisions, and thorough scaling and root planing. One furca, selected at random, had a connective tissue graft, obtained from the palate and including the periosteum, placed over the furca with the flap sutured over the top of this graft. Control furcas received no graft and the flap was sutured in its original position. Both molars were treated in the same session. The following presurgical measurements were made: probing pocket depth, attachment level, gingival recession, sulcular bleeding index, and plaque index. The horizontal and vertical dimensions of the osseous defects were recorded after flap elevation and debridement. Six months later all clinical parameters were again measured and reentry flaps were performed to measure the bony defects. No statistically significant differences were found preoperatively between control and experimental molars with respect to soft tissue and osseous measurements. Six months after surgery, the experimental molars showed, in comparison to the controls, significant reduction in pocket depth and gain in attachment level as well as in vertical and horizontal measurements of the inter-radicular osseous defect.

Current status of periodontal therapy for furcation involvements.

The treatment of furcation involvements is difficult because of the anatomic problems that interfere with the clinician's accessibility in treating the area and the patient's ability in maintaining adequate plaque control afterwards. The goal of traditional methods of treatment is to arrest the progression of bone loss; the rate of success with these methods has been poor, except for Grade I involvements. Advances in the last decade have resulted in the development of treatment techniques that attempt to reconstruct the lost periodontal structures. These techniques have greatly improved the prognosis of Grade II furcation involvement. The recommended technique combines the principles of guided tissue regeneration using polytetrafluoroethylene membranes with grafting with porous hydroxyapatite. The use of decalcified freeze-dried bone instead of hydroxyapatite also may be a successful method. Grade III and IV furcation involvements still have a poor long-term prognosis because predictable reconstructive techniques for their treatment have not been demonstrated. When possible, a root resection approach may be advisable.

Treatment of class II furcation defects using porous hydroxylapatite in conjunction with a polytetrafluoroethylene membrane.

The purpose of the present study was to determine whether the use of a porous hydroxylapatite in conjunction with guided tissue regeneration technique influenced the clinical results in the treatment of Class II furcation defects in humans. Fifteen subjects with a mean age of 39.4 +/- 9.3 years were used in this study. All subjects had Class II furcation defects on the buccal surfaces of 2 lower molars. In each subject one furcation defect was filled with granular porous hydroxylapatite and then a barrier of polytetrafluoroethylene periodontal material was positioned over the furcation. The other furca was treated in the same manner except that no hydroxylapatite was used. The flaps were placed coronally to their presurgical level. Before the surgery and 6 months postsurgery all areas were clinically evaluated using the same clinical parameters. Reentry procedures were used to repeat measurements of the osseous defects made during the initial surgery. At 6 months both surgical procedures resulted in statistically significant reduction in pocket depth and gain in probing attachment level with no significant difference between the two surgical procedures. When porous hydroxylapatite was used in conjunction with a polytetrafluoroethylene membrane, however, less gingival recession and more defect fill were obtained. This study suggests that there is a difference in healing of molar furcations when porous hydroxylapatite is used in conjunction with a barrier membrane. The lesions treated with porous hydroxylapatite gain in clinical attachment and horizontal and vertical bone fill, while the lesions treated with membrane only gain probing attachment with less bony fill.

Comparative clinical study of porous hydroxyapatite and decalcified freeze-dried bone in human periodontal defects.

Interproximal bony defects were treated with either porous hydroxyapatite (PHA) or decalcified freeze-dried bone allograft (DFDB) implants at two different clinical centers. Twelve paired defects in 12 patients were treated at each center. Six months post-surgically the defects were measured to assess changes from the presurgical status. No statistically significant differences were found between the groups in changes in gingival fluid, bleeding index, plaque index, or tooth mobility. The porous hydroxyapatite implant produced greater reduction in pocket depth (P = 0.03) and more gain in clinical attachment level (P = 0.001) and defect fill (P = 0.001) when compared with DFDB grafted sites. This study indicates that more clinical resolution of interproximal periodontal defects in humans can be obtained with the use of PHA than with the use of DFDB.

Evaluation of guided tissue regeneration in Class II furcation defects. A clinical re-entry study.

Twelve patients with two comparable furcation Class II lesions in lower molars were included in this study. After adequate presurgical preparation and pertinent clinical measurements, the areas were treated with full thickness flaps and thorough debridement and scaling and planing of the root surfaces. One of the defects was randomly selected to be covered with Gore-Tex periodontal material, held in place by sling sutures of expanded polytetrafluoroethylene. On both sites the flaps were positioned slightly coronal to their original level and sutured. After 6 months both sites were re-entered surgically and remeasured. The test sites showed a statistically significant reduction in pocket depth and gain in attachment levels while the controls had not changed from preoperative levels. No changes in bone levels were detected in test or control sites. However, because of the large variability in the measurements, and the short period of observation, there may be differences in bony changes between the two therapies. Studies with larger groups, more accurate methods, and longer time intervals are needed to better evaluate the effects of barrier membranes in periodontal healing.

[Implantation of collagen coated hydroxyapatite particles. A clinical-histological study in humans]. / Implantación de partículas de hidroxiapatita-colágeno. Estudio clínico-histológico en humanos.

In this study, histologic behaviour of collagen coated hydroxylapatite particles implanted in human periodontal osseous defects has been analyzed. This material was surgically implanted in four patients, and reentry and block biopsies were carried out 4 and 6 months later. The histologic results demonstrate that this material is well tolerated by surrounding tissues, not eliciting an inflammatory reaction. At four months, the hydroxylapatite particles appear encapsulated by a very cellular connective tissue and at 6 months are found in direct contact with osteoid and mature bone. This material acts as a filler material, being fully biocompatible and stimulating an osseoconductive reaction of the adjacent alveolar bone.

A comparative clinical study of solid and granular porous hydroxylapatite implants in human periodontal osseous defects.

Solid and granular porous hydroxylapatite implants were compared in the surgical treatment of angular interproximal periodontal defects in 10 subjects. After completion of initial therapy, presurgical measurements of pocket depth, attachment level, gingival recession, gingival fluid and tooth mobility were recorded. Six months after the surgery the measurements were repeated. The use of both forms of porous hydroxylapatite resulted in reduction in pocket depth, and probeable attachment level gains as well as gingival recession and reduction of gingival fluid and tooth mobility. These changes were similar for both granular and solid forms of porous hydroxylapatite.

The use of a porous hydroxylapatite implant in periodontal defects. II. Treatment of Class II furcation lesions in lower molars.

Twenty-three human subjects with two Class II furcation involvements in lower molars were treated with initial therapy following which presurgical measurements of pocket depth, gingival recession and attachment level were made. Periodontal flaps were used to expose the furcation defects, and one defect was implanted with porous hydroxylapatite while the other served as an unimplanted control. At the time of surgery, bone defects were measured obliquely and horizontally using a specially designed device to ensure reproducible probe angulation. Six months later the presurgical measurements were repeated, and reentry surgical procedures were carried out to measure the changes in the bone defects. Areas implanted with porous hydroxylapatite showed a statistically significant reduction in pocket depth and a statistically significant improvement in attachment level and fill of bone defects when compared with control defects. There was statistically less gingival recession in the implanted areas compared with the control sites. Control sites at six months showed no significant change in pocket depth, an increased loss of attachment and worsening of the bone defects.

Bacterial invasion in experimental gingivitis in man.

Gingival biopsies of the mesial papilla area of the first molar were obtained from each patient at 0-, 14- and 21-day intervals during plaque formation. The biopsies were fixed, serially sectioned, and Gram-stained. The incidence and distribution of the bacteria-like structures were studied by microscopy. In all the specimens the bacterial nature of Gram-stained material was substantiated. In the epithelium the highest number of bacteria was found at the outer layer of marginal oral epithelium, sulcular epithelium and apical oral epithelium along with a decreasing pattern of penetration progressing deeper into the layers of tissue. For junctional epithelium the situation was just the opposite. Each subject had significantly higher counts at Day 21 than at Day 14 for both epithelium and connective tissue. Also significantly higher counts were found in connective tissue compared with epithelium. The higher bacterial density of intragingival bacteria was associated with the higher gingival and plaque indices. This study suggests that early stages of gingival inflammation may be mediated by invasion of bacteria.

Histologic study of healing of human periodontal defects after placement of porous hydroxylapatite implants.

Two intrabony pockets on teeth that were to be extracted for prosthetic reasons, in two patients, were treated by means of papilla preservation flaps and implantation with porous hydroxylapatite. The teeth, with a portion of their periodontium, were extracted 5 and 6 months after treatment and processed histologically. Both cases showed the implants invaded by connective tissue, which was actively forming bone. There was no inflammatory reaction triggered by the implant material, although there was some recurrence of inflammation in the vicinity of the pocket wall. The junctional epithelium in both cases extended slightly beyond the coronal level of the implant. One of the cases had an abundant new cementum formation with fibrous tissue next to the implant, that appeared to be a rebuilt attachment of collagen fibers. Although some multinucleated giant cells were found in the pores and next to the newly formed bone, the implanted material did not appear to be resorbed in the period of time studied.

The presence of bacteria in the oral epithelium in periodontal disease. III. Correlation with Langerhans cells.

Langerhans cells (LC) are cell types found in the skin and gingiva. LC have immunological functions as phagocytic cells and as antigen-presenting cells for T and B lymphocytes. Sections from biopsies of the gingiva in cases of periodontal disease were found to have increased numbers of LC. These biopsies also contained intragingival bacteria. Serial sections of frozen specimens of human gingiva were prepared for staining. Hematoxylin and eosin were used for tissue survey, the Gram stain for assessment of bacterial invasion, anti-Leu-6 monoclonal antibody associated with peroxidase technique (PAP) to identify LC, antibacterial sera to Bacteroides gingivalis and Actinobacillus actinomycetemcomitans associated with peroxidase to specifically identify these two common periodontopathogenic bacteria. Additional positive identification of bacteria was performed by preparing the same histological section containing gram-stained particles for scanning electron microscope and transmission electron microscope LC confirmation. The results suggest that the increased number of LC seen in diseased sites of oral epithelium containing intragingival microorganisms may be one of the host immune mechanisms to penetration by bacteria.

A comparison of oral and intravenous diazepam sedation for periodontal surgery.

Intravenous and oral diazepam were evaluated as to their effectiveness in conscious sedation during two similar surgical episodes. Ten patients, six females and four males, from 30 to 60 years of age were included in the study. Patients received either 10 mg oral diazepam and saline intravenous injection or oral placebo and 10 mg intravenous (IV) diazepam at each trial. Half the patients received the oral diazepam first and the other half received the IV diazepam first. Patients were not informed as to the route of administration during each trial. Physiologic stress was measured by monitoring blood pressure, heart rate, skin temperature, galvanic skin response, and plasma catecholamine levels. Patients evaluated their comfort and nervousness levels on a questionnaire. Anterograde amnesia was tested by patient's ability to recall objects shown them during the procedure. As evidenced by the physiologic and biochemical parameters, intravenous diazepam was more effective in reducing anxiety and stress as compared with an equivalent oral dose. Patients' subjective ratings were consistent with these findings. Intravenous diazepam was effective in producing anterograde amnesia in the majority of patients, whereas no amnesic effect was noted with oral diazepam. Correlation statistics demonstrated a relative independence of the parameters measured in the present study indicating that all parameters must be considered in overall patient evaluation. Reduction of anxiety during the first surgery resulted in less anxiety on the subsequent visit.

The presence of bacteria in the oral epithelium in periodontal disease. II. Immunohistochemical identification of bacteria.

Serial histological sections of gingiva obtained from each of six advanced adult periodontitis, two localized juvenile periodontitis and two periodontally healthy patients were used for specific identification of bacteria within the oral epithelium and adjacent connective tissue. Healthy gingival biopsies served as controls. Sections from patients and control biopsies were Gram-stained and also screened with antibacterial sera associated with the peroxidase immunocytochemical technique for specific bacterial identification. The "Pop-off" electron microscopic technique was also used to further demonstrate the bacterial nature of peroxidase-stained material. In addition, the possible correlation between bacteria and areas of possible reduced keratinization was investigated. The results showed that sections of orthokeratinized healthy gingiva did not contain bacteria. Gram-stained sections from diseased sites contained large numbers of bacteria in the oral epithelium and adjacent connective tissue. Bacteroides gingivalis and to a lesser extent Capnocytophaga gingivalis were found in periodontitis, and Actinobacillus actinomycetemcomitans was found in juvenile periodontitis when the immunoperoxidase technique was used. The bacterial nature of peroxidase-stained material was confirmed by the "pop-off" technique. In the disease biopsies, bacterial presence was correlated with areas of reduced amounts of keratin suggesting that the oral epithelium may be a portal of entry for bacteria into gingival tissues.