Osseous resective surgery.

Osseous resective surgery necessitates following certain guidelines for proper recontouring of the alveolar bone and proper management and positioning of the gingival tissues. The results from osseous resective surgery are technique sensitive. It has limited use in treating cases with very deep intrabony or hemiseptal defects, which should be treated with a different surgical approach. If osseous resective surgery is used in advanced lesions, a compromise in the amount of probing depth reduction should be expected. Yet, osseous resective surgery provides the surest method of reducing pockets with an intrabony or hemiseptal osseous component of 3 mm or less, albeit at the expense of some attachment in the neighboring less involved sites. Osseous resective surgery has been and remains one of the principal periodontal treatment modalities because of its proven success (Fig. 17).

The evolution of temporary fixed splints--the A-splint.

This article presents a review of the evaluation of the temporary splint leading up to the present-day acid-etched composite, wire-reinforced, internal splint called the "A-splint." Nine general uses for the A-splint in the modern dental practice and some common problems are presented.

Levels of cigarette consumption and response to periodontal therapy.

Seventy-four patients with moderate to advanced periodontitis were classified by cigarette consumption at the initial exam: heavy smokers (HS) > or = 20 cigarettes/day (n = 31); light smokers (LS) < or = 19 cigarettes/day (n = 15); past smokers (PS) had a history of smoking but had quit by the initial exam (n = 10); and non-smokers (NS) had never smoked (n = 18). All patients were treated with four modalities of periodontal therapy followed by supportive periodontal treatment (SPT) for a period of up to 7 years. Clinical parameters including probing depth (PD), clinical attachment level (CAL), recession (REC), presence of bleeding on probing (BOP), and supragingival plaque (PL) were assessed at six sites around each tooth. Horizontal probing attachment level (HAL) was obtained at molar furcation sites. Data were collected initially, 4 weeks after non-surgical therapy, 10 weeks after surgical therapy, and yearly during SPT. HS and LS demonstrated less PD reduction and less CAL gain than PS and NS following active treatment and throughout SPT. Following active treatment, HAL changes were similar for all groups, but during 7 years of SPT, HS and LS experienced greater loss of HAL. There were no differences in BOP among the four groups. HS demonstrated a higher percentage of PL positive sites compared to the other groups. In summary, HS and LS responded less favorably to therapy than PS and NS. A past history of smoking was not deleterious to the response to therapy.

Long-term evaluation of periodontal therapy: II. Incidence of sites breaking down.

Eighty-two patients were treated in a split mouth design with coronal scaling (CS), root planing (RP), modified Widman surgery (MW), and flap with osseous surgery (FO) which were randomly assigned to the various quadrants in the dentition. Following phase I and phase II therapy, the patients received supportive periodontal treatment (SPT) at 3-month intervals for up to 7 years. Clinical attachment level (CAL) was determined initially, post-phase I, post-phase II and prior to each SPT appointment. If a site lost > or = 3 mm of CAL from its baseline, it was classified as a breakdown site. Baselines were the initial exam for sites treated by CS and 10 weeks post-phase II for sites treated by RP, MW, and FO. Data were grouped by probing depth (PD) severity at the initial exam and at post-phase II. The breakdown for CS sites was assessed separately from RP, MW, and FO sites because of different baselines and retreatment protocols. Sites treated by CS had a higher incidence of breakdown than the other therapies through year 1 of SPT. The breakdown incidences/year for RP and MW sites were similar and greater than for FO sites in 1 to 4 mm and 5 to 6 mm PD categories. Breakdown incidence of RP sites was greater than MW sites which was greater than FO sites initially > or = 7 mm. Differences in incidence of breakdown between therapies after recategorizing data by post-phase II PD were the same as above, except no difference was present between RP and MW sites > or = 7 mm. Breakdown incidences were greater in increasing PD severities regardless of when they were categorized. There was no further loss of CAL one year after retreatment in 88% of sites. Patients with higher breakdown incidences tended to be smokers at the initial exam.

Long-term evaluation of periodontal therapy: I. Response to 4 therapeutic modalities.

Eighty-two periodontal patients were treated in a split mouth design with coronal scaling (CS), root planing (RP), modified Widman surgery (MW), and flap with osseous resection surgery (FO) which were randomly assigned to various quadrants in the dentition. Therapy was performed in 3 phases: non-surgical, surgical, and supportive periodontal treatment (SPT) < or = 7 years. Clinical data consisted of probing depth (PD), clinical attachment level (CAL), gingival recession (REC), bleeding on probing (BOP), suppuration (SUP), and supragingival plaque (PL). Because of the necessity to exit many CS treated sites due to breakdown, data for CS were reported only up to 2 years. All therapies produced mean PD reduction with FO > MW > RP > CS following the surgical phase for all probing depth severities. By the end of year 2 there were no differences between the therapies in the 1 to 4 mm sites. There were no differences in PD reduction between MW and RP treated sites by the end of year 3 in the 5 to 6 mm sites and by the end of year 5 in the > or = 7 mm sites. FO produced greater PD reduction in > or = 5 mm sites through year 7 of SPT. Following the surgical phase, FO produced a mean CAL loss and CS and RP produced a slight gain in 1-4 mm sites. RP and MW produced a greater gain of CAL than CS and FO following the surgical phase in 5 to 6 mm sites, but the magnitude of difference decreased during SPT. Similar CAL gains were produced by RP, MW, and FO in sites > or = 7 mm. These gains were greater than that produced by CS and were sustained during SPT. Recession was produced with FO > MW > RP > CS. This relationship was maintained throughout SPT. The prevalences of BOP, SUP, and PL were greatly reduced throughout the study and were comparable between sites treated by RP, MW, and FO while the CS sites had more BOP and SUP.

Postsurgical timing of restorative therapy: a review.

Knowledge of wound healing is necessary for the clinician when determining the time of prosthodontic treatment after periodontal surgery. Wound healing and longitudinal clinical studies indicate that the clinician should wait approximately 8 weeks before proceeding with the final restoration. Restorative procedures could be considered as early as 6 weeks if (1) the patient shows good systemic health; (2) injury is not inflicted on the gingiva by the restorative technique; (3) restorative margins are supragingival; and (4) esthetics are not critical. With a thick periodontium, more common in posterior areas, the gingiva often will move coronally as the tissue matures. Thin periodontal tissues may recede postsurgically, and in areas of esthetic concern, postponement of final restoration for up to 5 to 6 months may be desirable to assure gingival margin stability. Modifiers that may affect time and quality of healing, such as the patient's smoking frequency and age, should be considered when scheduling restorative treatment after periodontal surgery.

The effect of smoking on the response to periodontal therapy.

This study evaluated the effect of smoking on the clinical response to non-surgical and surgical periodontal therapy. 74 adult subjects with moderate to advanced periodontitis were treated according to a split-mouth design involving the following treatment modalities: coronal scaling, root planing, modified Widman surgery, and flap with osseous resectional surgery. Clinical parameters assessed included probing depth, probing attachment level, horizontal attachment level in furcation sites, recession, presence of supragingival plaque and bleeding on probing. Data were collected: initially, 4 weeks following phase-I therapy, 10 weeks following phase-II therapy and on a yearly basis during 6 years of maintenance care. Data analysis demonstrated that smokers exhibited significantly less reduction of probing depth and less gain of probing attachment level when compared to non-smokers immediately following active therapy and during each of the 6 years of maintenance (p < 0.05). A greater loss of horizontal attachment level was evident in smokers at each yearly exam during maintenance therapy (p < 0.05). There were no differences between groups in recession changes. In general, these findings were true for the outcomes following all 4 modalities of therapy and were most pronounced in the deepest probing depth category (> or = 7 mm). Statistical analysis showed a tendency for smokers to have slightly more supragingival plaque and bleeding on probing. In summary, smokers responded less favorably than non-smokers to periodontal therapy which included 3-month maintenance follow-up.

A review of longitudinal studies that compared periodontal therapies.

There have been numerous longitudinal periodontal studies that have compared the effects of two or more therapies on various clinical parameters. These studies are reviewed and their results are compiled. Both surgical and non-surgical therapy produced improvement in periodontal health. Surgical therapy tended to create greater short-term probing depth reduction than non-surgical therapy; however, the advantage was lost in some studies over time. In shallow probing depths, surgery produced a greater loss of probing attachment than non-surgical therapy. In deeper probing sites, the short-term results comparing mean probing attachment change following non-surgical and surgical therapy were mixed. In most studies, no long-term differences in mean probing attachment level change were present between non-surgical and surgical therapy. There were no differences between surgical and non-surgical therapy in any of the gingival inflammatory indices.

Gingival fluid IL-1 and IL-6 levels in refractory periodontitis.

Selected gingival bacteria and cytokine profiles associated with patients who did not respond to conventional periodontal therapy (refractory) were evaluated. 10 subjects with a high incidence of post-active treatment clinical attachment loss (> 2% sites/year lost > or = 3 mm) were compared to 10 age-, race-, and supragingival plaque-matched patients with low post-treatment clinical attachment loss (< 0.5% sites/year) relative to the following parameters at 2 sites/patient with the deepest probing depths: (1) presence of 3 selected periodontal pathogens (Actinobacillus actinomycetemcomitans, Porphyromonas gingivalis, Eikenella corrodens) in subgingival plaque as determined by selective culturing, and (2) gingival crevicular fluid (GCF) levels of 3 cytokines associated with bone resorption (IL-1 alpha, IL-1 beta, IL-6) as determined by two-site ELISA. Results indicated no significant differences in any clinical measurement (except incidence of clinical attachment loss), in the presence of any bacterial pathogen, or in GCF cytokine levels between refractory subject sites versus stable subject sites. However, when sites producing the greatest total GCF cytokine/patient were compared, sites from refractory patient produced significantly more IL-6 (30.1 +/- 4.0 versus 15.4 +/- 2.8 nM, p < 0.01). The subgingival presence of each of the 3 bacterial pathogens was associated with elevated GCF IL-1 concentrations. These data suggest that gingival IL-1 and IL-6 production is different in response to local and systemic factors associated with periodontitis, and that IL-6 may play a role in the identification and mechanisms of refractory periodontitis.

Patient preference regarding 4 types of periodontal therapy following 3 years of maintenance follow-up.

It has been shown that certain types of periodontal therapy result in greater post-therapy gingival recession. It has been suggested that this recession may lead to maintenance complications for patients. This study evaluated patient perceptions 3 years following the completion of 4 types of periodontal therapy (coronal scaling (CS), root planing (RP), modified Widman surgery (MW), and flap with osseous resectional surgery (FO)). 75 individuals completed split-mouth therapy and 3 years of maintenance follow-up. An interview survey of all patients categorized their perception for each treatment of their mouth concerning difficulty in cleaning, sensitivity to temperature, general "feeling" of the region, prevalence of localized symptoms, food retention, comfort of oral examination, and attitude toward repeating therapy. Responses to questions showed no statistically significant differences between treatment regions. Patterns demonstrated that FO-treated regions were perceived to have less food retention, but were more difficult to clean. It was generally found that at the end of 3 years of maintenance, patients felt their mouths were "normal", they experienced few localized symptoms, and were very willing to repeat any of the treatment regimens if necessary.

Evaluation of gingival suppuration and supragingival plaque following 4 modalities of periodontal therapy.

This study evaluated the effect of coronal scaling (CS), root planing (RP), modified Widman surgery (MW) and flap with osseous resectional surgery (FO) upon the presence of gingival suppuration and supragingival plaque. 75 patients completed split-mouth therapy and 2 years of maintenance care. Data were collected prior to the initiation of therapy, following initial therapy, following surgical therapy and yearly during 2 years of maintenance care. All 4 types of therapy reduced the prevalence of suppuration with RP, MW and FO producing a greater reduction than CS in sites greater than or equal to 5 mm. Sites were grouped according to presence of suppuration at 2 consecutive examinations. The mean changes in probing depth and probing attachment level for each time period were compared. Sites that began to suppurate between 2 exams or were suppurating at both exams had a less favorable response in mean probing depth reduction and mean probing attachment gain when compared to sites that stopped suppurating between exams or did not suppurate at either exam. The prevalence of supragingival plaque decreased during active therapy and 2 years of maintenance. There was no difference in the prevalence between the therapy groups except for FO-treated sites showing more plaque accumulation after surgical therapy. The presence or absence of supragingival plaque at specific sites was dynamic, frequently converting to a new status between 2 examinations.

Relationship of gingival bleeding, gingival suppuration, and supragingival plaque to attachment loss.

This study evaluated the relationship between the presence of gingival bleeding, gingival suppuration, and supragingival plaque at 3 month appointments to the incidence of probing attachment loss during a 2-year period of maintenance therapy. The data included in this report were taken during the second and third year of maintenance from 75 periodontal patients who had previously received active therapy in an ongoing longitudinal study. The diagnostic sensitivity, specificity, and positive and negative predictive values were calculated for different frequencies of positive responses for each clinical parameter in relation to sites demonstrating greater than or equal to 2 mm probing attachment loss. Gingival bleeding and plaque were not prognosticators and gingival suppuration was a weak prognosticator of attachment loss during a 2 year maintenance period.

Responses of four tooth and site groupings to periodontal therapy.

The responses of four tooth/site groupings to periodontal therapy were evaluated. Eighty-two patients with periodontitis were treated in a split mouth design with coronal scaling, root planing, modified Widman surgery, and flap with osseous resectional surgery. Patients were evaluated prior to therapy, 4 weeks post-Phase I therapy, 10 weeks post-Phase II therapy, and at yearly intervals during 2 years of maintenance therapy. The tooth/site groupings evaluated were: 1) interproximal sites of single rooted teeth (T1), 2) facial and lingual sites of single rooted teeth (T2), 3) nonfurcation sites of molar teeth (T3), and 4) furcation sites of molar teeth (T4). Following 2 years of maintenance, no clinically significant differences in probing depth reduction or probing attachment loss were present between the four tooth/site groupings in 1 mm to 4 mm sites. T2 had the greatest decrease of probing depth in 5 mm to 6 mm sites followed by T1, T3 and T4. T1 and T2 showed a greater gain of probing attachment followed by T3 and T4. T1 and T2 had the greatest decrease of probing followed by T3 which was greater than T4 in greater than or equal to 7 mm sites. T4 had significantly less probing attachment gain than the other groups. There was a trend for T1 and T2 to have less gingival bleeding post-therapy and for T2 to have less plaque accumulation than the other groups at both pre- and post-therapy examinations.

Evaluation of gingival bleeding following 4 types of periodontal therapy.

This study evaluated the effects of 4 types of periodontal therapy (coronal scaling (CS), root planning (RP), modified Widman surgery (MW), and flap with osseous resectional surgery (FO] and subsequent maintenance care upon bleeding on probing (BOP). 75 individuals completed split mouth therapy and 2 years of maintenance followup. Data were obtained by 1 calibrated examiner prior to the initiation of therapy, following the hygienic phase and surgical phase of active therapy and yearly during maintenance care. All types of therapy reduced the prevalence of BOP. At the end of 2 years of maintenance therapy, regions greater than 5 mm treated by CS demonstrated a significantly (p less than 0.05) greater prevalence of BOP sites than regions treated by the other modalities. Generally, sites associated with deeper probing depths exhibited a greater tendency to bleed and sites with associated plaque accumulation bled more frequently. RP resulted in a significantly (p less than 0.05) higher % of bleeding sites that stopped following active therapy than did CS. Throughout the study, BOP was extremely dynamic, with 15-88% of sites converting to a new status between any 2 examination periods. This dynamic nature may explain the inability of previous investigations to establish BOP as a reliable predictor of periodontal breakdown.

IgG subclasses in gingival crevicular fluid from active versus stable periodontal sites.

Since IgG subclasses are common immunoglobulins associated with the periodontium and have different biological characteristics, these subclasses were measured in gingival crevicular fluid (GCF) from periodontally active (greater than or equal to 2 mm clinical attachment loss within three months of sample) versus clinically similar but stable or healthy sites. A sandwich enzyme-linked immunosorbent assay (ELISA) using monoclonal antibodies was performed to quantitate IgG subclass and albumin concentrations in serum and interproximal GCF samples from at least one each of the three disease categories from each of 20 periodontal maintenance patients. Although much variability existed among sites, mean IgG1 (p less than 0.05) and IgG4 (p less than 0.01) concentrations were higher in GCF from active periodontitis areas than stable sites, even though both had similar clinical characteristics. When IgG subclass concentrations were adjusted per mg albumin, both IgG1 and IgG4 levels in GCF from active sites were still significantly elevated over stable areas (p less than 0.05). Mean adjusted concentrations in GCF were generally greater than in serum, especially for IgG4 (active site GCF:serum = 24.2:1). GCF IgG4 concentrations may be useful as an indicator of the immunopathological changes which occur in active periodontitis.

Evaluation of four modalities of periodontal therapy. Mean probing depth, probing attachment level and recession changes.

Eighty-two periodontally involved patients were treated in a split mouth design such that one quadrant received coronal scaling (CS), root planing (RP), modified Widman surgery (MW), and flap with osseous resection surgery (FO). The therapy was performed in three phases: Phase I: the teeth previously designated to receive RP, MW, and FO were thoroughly root planed and the teeth designated to receive CS were scaled with no subgingival instrumentation, plaque control was initiated and reinforced for the entire mouth; Phase II: the designated teeth received MW or FO surgery; and Phase III: maintenance therapy every three months. The CS teeth received coronal scaling and polishing during maintenance appointments, while RP, MW, and FO teeth received supragingival instrumentation, subgingival instrumentation and polishing. Clinical measurements were taken initially, four weeks post-Phase I, 10 weeks post-Phase II, and after each of two years of maintenance care. All therapy modalities resulted in a decrease of mean probing depth with the FO producing the greatest decrease followed by MW, RP, and CS. The deeper the initial probing depth, the greater was the mean reduction of probing depth. FO created a loss of mean probing attachment in the 1 to 4 mm category. RP and MW produced the greatest gain of mean probing attachment in the 5 to 6 mm category. RP, MW, and FO produced similar gains in the greater than or equal to 7 mm category. FO created the most gingival recession followed by MW, RP, and CS.

Evaluation of furcation region response to periodontal therapy.

Five hundred fifty-eight molars were treated with one of four types of periodontal therapy: coronal scaling (CS); root planing (RP); modified Widman surgery (MW); or flap with osseous resectional surgery (FO). This report presents the probing depth and probing attachment changes in the furcation region following therapy and two years of maintenance follow-up. All types of therapy were effective in reducing probing depths. FO was the most effective in reducing probing depth followed by MW, RP, and CS. Reduction in probing depth was primarily due to gingival recession. FO resulted in a loss of probing attachment in both a vertical and horizontal direction following therapy. Following two years of maintenance care, sites treated with FO continued to exhibit a mean net loss of vertical probing attachment. A mean net loss of horizontal probing attachment was present after two years of maintenance care, regardless of the treatment modality employed. Many more sites were initially removed during osseous resectional surgery to achieve treatment criteria than were initially removed from the other groups. FO treated teeth demonstrated a lesser percentage of furcation sites demonstrating clinically significant breakdown during the two years of maintenance care.

In situ lymphocyte subpopulations from active versus stable periodontal sites.

The purpose of this study was to evaluate lymphocyte subset densities and distributions within gingival biopsies from active sites (greater than or equal to 2 mm clinical attachment loss within three months of biopsy) versus clinically similar but stable or healthy sites. Small interproximal gingival biopsies representing at least one of each of the above categories were obtained from each of 20 periodontal maintenance patients. Serial cryostat sections displaying a cross section of the gingiva were labeled with monoclonal antibodies for (1) pan T cells, (2) T cytotoxic/suppressor cells, (3) T helper/inducer cells and (4) pan B cells and were developed using an avidin-biotin-peroxidase system. Lymphocyte populations were enumerated in repeatable fields from the sulcular, middle and oral one-third of each section. Relative proportions of the same lymphocyte subsets were analyzed in peripheral blood samples from the same patients using direct immunofluorescence. Pan B cells were significantly more prevalent in infiltrates from active sites than in stable (P less than 0.05) or healthy (P less than 0.01) sites. The T/B cell ratio was also significantly lower in active than stable biopsies (P less than 0.05), and in active biopsies versus blood (P less than 0.05). The T helper/T suppressor cell ratio did not vary significantly between blood and any gingival tissue disease group or location, but a trend toward lower relative numbers of T helper cells in the sulcular infiltrates of active sites was noted. These results support the premise that active periodontal sites display elevated B cell populations and abnormal immune regulation possibly involving the T helper cell subset.

Drug-induced gingival hyperplasia: phenytoin, cyclosporine, and nifedipine.

This article has summarized observations and results of controlled laboratory and clinical studies of drug-induced gingival hyperplasia associated with phenytoin, cyclosporine, and nifedipine use. Furthermore, information regarding the pharmacologic aspects of these medications is presented. More information is needed for a greater understanding of drug-induced gingival hyperplasia. It appears that the primary preventive measure is to maintain a high standard of oral hygiene and the elimination of gingival irritation. As stated by Tyldesley and Rotter, because the structures of the three drugs are different, the gingival changes may result from a metabolic by-product rather than the drugs themselves. Similarly acting metabolites of all the drugs may be involved. Further laboratory investigations and controlled clinical trials are needed for more understanding of this phenomenon.