Clinical and radiographic findings following application of enamel matrix derivative in the treatment of intrabony defects. A series of case reports.

AIM: The purpose of this case report study was to evaluate the clinical and radiographic findings following application of enamel matrix derivative (EMD) in the treatment of 2- or 3-wall intrabony defects in a private periodontal practice one year after surgery. METHOD: 15 consecutive patients (age range 38 67 years, 9 females, 6 males, 3 smokers) with 25 intrabony defects were included in the study. The decision to use reconstructive surgery was taken at least 3 months after termination of the presurgical treatment phase. Inclusion criteria were: presence of an interproximal area with residual probing depth (PD) > or =6 mm, probing attachment level (PAL) > or =6 mm and an associated intrabony defect > or =4 mm deep and > or =2 mm wide as measured during surgery (defects were not associated with adjacent furcation lesions). Open-flap surgery was performed to expose the defects and the EMD gel was applied after proper debridement. The patients were instructed to rinse 2x daily for 6 weeks with a 0.12% solution of chlorhexidine. RESULTS: At 12 months, mean PD decreased from 8.4 mm to 4.0 mm and PAL from 10.2 mm to 6.6 mm, while recession increased from 1.8 mm to 2.6 mm. Residual PD greater than 4 mm was observed only in 7 sites. 14 sites demonstrated a PAL gain of 2-3 mm, 9 sites a gain of 4-5 mm and 2 sites a gain of 6 mm. Radiographic assessment indicated a mean crestal bone resorption of 20.7% and a mean improvement in the distance between the CEJ and the base of the defect of 22.9%. The combination of defect fill from the bottom of the defect and crestal resorption resulted in a mean defect resolution of 61%. CONCLUSION: Within the limits of this study, the application of EMD gel in 2- or 3-wall intrabony defects resulted in clinically significant gain of PAL and radiographic bone. Further controlled clinical studies are required to confirm the effectiveness of the EMD gel in the treatment of various osseous defects.

Prevalence and distribution of bone defects in moderate and advanced adult periodontitis.

The purpose of the present investigation was to evaluate the prevalence and distribution of different forms of bone defects using direct observation during periodontal surgery. 286 patients with moderate or advanced adult periodontitis diagnosed during clinical and radiographic examination provided a sample of 5476 teeth. After full thickness mucoperiosteal flaps were raised, osseous defects were explored and classified according to their morphology as interdental craters, hemisepta and infrabony defects with 1, 2, 3 or 4 osseous walls. 981 defects were detected; 533 were in the maxilla and 448 in the mandible (15.4% and 22.4%, respectively, of the teeth examined). The posterior mandibular segment had the highest % of teeth with defects (33.8%) followed by the posterior maxillary segment (19.9%). The proportions of teeth with defects in the anterior segments of both arches were similar. The comparison between maxilla and mandible showed a highly significant difference for the posterior segments (p= 0.00001) but no difference for the anterior segments (p=0.88). The distribution of defects differed between the maxilla and the mandible, both for the posterior and anterior segments. Craters accounted for almost half the defects, being more prevalent in posterior segments, while hemisepta formed the lowest proportion. Anatomical variations in shape and the original morphology of the alveolar bone between the maxilla and the mandible and the anterior and posterior regions might have been the reason for the differences observed.

Comparison of 2 regenerative procedures--guided tissue regeneration and demineralized freeze-dried bone allograft--in the treatment of intrabony defects: a clinical and radiographic study.

The purpose of this study was to compare clinically and radiographically the effectiveness of guided tissue regeneration (GTR), using a bioabsorbable polylactic acid softened with citric acid ester barrier and commercially available demineralized freeze-dried bone allograft (DFDBA) in the treatment of 2- and 3-wall intrabony defects. Twelve patients each with one treated defect comprised each group. Conservative treatment was completed 2 to 4 months prior to surgery. Clinical measurements, plaque index, gingival index, probing depths (PD), clinical attachment levels (CAL) and recession (REC), were comparable in both groups at baseline. They were repeated at 12 months. Surgical measurements were also comparable at baseline in both groups. In the GTR group, at baseline the mean distance between the cemento-enamel junction (CEJ) and base of the defect was 12.3 +/- 2.9 mm and in the DFDBA group 11.3 +/- 1.8 mm. The defect depth was 6.3 +/- 2.0 mm and 5.4 +/- 1.3 mm, respectively. Radiographs were taken at baseline and 12 months later and compared using non-standardized digital subtraction radiography. In the GTR group, mean PD decreased from 7.9 +/- 2.5 mm to 3.5 +/- 1.4 mm and mean CAL from 10.8 +/- 2.8 mm to 7.0 +/- 1.6 mm, the differences being statistically significant (P = 0.002), while REC increased from 2.9 +/- 1.2 mm to 3.5 +/- 1.1 mm. In the DFDBA group, mean PD decreased from 7.1 +/- 1.1 mm to 3.5 +/- 1.1 mm and mean CAL from 9.8 +/- 1.5 mm to 6.6 +/- 1.7 mm (P = 0.002), while REC increased from 2.8 +/- 1.0 mm to 3.1 +/- 1.2 mm. No significant differences were found when the clinical results of the 2 groups were compared. Radiographic differences between the baseline and reconstructed images 12 months later were observed in both groups. Mean crestal bone resorption was 15.3 +/- 22.5% in the GTR group and 10.4 +/- 31.8% in the DFDBA group, and mean improvement in the distance between the CEJ and the base of the defect was 22.8 +/- 18.1% in the GTR group and 15.3 +/- 13.6% in the DFDBA group. However, the mean improvement in the intrabony depth was larger in the GTR group (71.9 +/- 29.1%) than in the DFDBA group (35.4 +/- 21.6%) (P = 0.007). In conclusion, within the limits of this study, both regenerative procedures were beneficial in treating intrabony defects. No statistical significant differences were observed between the 2 groups, with the exception of radiographic defect resolution which was significantly greater in the GTR group.

Clinical application of a new bioresorbable guided tissue regeneration device: case reports.

Bioresorbable barriers have been recently introduced in clinical practice for guided tissue regeneration therapy. One of these is the Guidor matrix barrier which is made of amorphous polylactic acid softened with a citric acid ester to increase malleability and facilitate clinical handling. The advantages of the bioresorbable barrier include: the elimination of second surgery; better handling and adaptation around the tooth and over the bone; and integration of the connective tissue of the flap with the barrier preventing epithelial migration, gingival recession, and pocket formation. In the case of matrix exposure the material disappears within 6 to 8 weeks. The purpose of this report is to present the clinical application of the Guidor matrix barrier in the treatment of two- or three-wall intrabony defects that were followed up for more than 1 year. The evaluation included soft tissue changes using clinical parameters and hard tissue changes using nonstandardized digital subtraction radiography. In the authors' opinion, the incorporation of a bioresorbable barrier in guided tissue regeneration therapy represents a significant improvement in the treatment of intrabony defects.

Compliance with supportive periodontal treatment in private periodontal practice. A 14-year retrospective study.

The purpose of this study was to determine the degree of compliance with supportive periodontal treatment (SPT) recommended in private periodontal practice and to determine if any significant differences existed in the characteristics of compliant, non-compliant, and erratically compliant patients. The study covered a period of 14 years (1977 to 1991) and included 521 patients who were classified by sex, age, socioeconomic class, disease severity, treatment rendered, and the year maintenance began. Compliance was categorized into four groups: complete compliance, erratic compliance, patients who discontinued SPT, and patients who never presented for SPT. Females began SPT more often than males (P = 0.054). Only 27.4% of the patients were in complete compliance at the end of the study. A significantly greater percentage of females (P = 0.032) and patients who had been treated by only scaling and root planing (P = 0.014) were in complete compliance. Drop-out rates from SPT tended to decrease during the first 6 years from 13.9% in the first 2 years to 9% in the sixth year. Thereafter, the percentage of patients presenting for SPT stabilized at 48.4% after 6 and 43.2% after 11 years. Younger patients (P = 0.04), those who had received only scaling and root planing (P = 0.008), and individuals in socioeconomic class I (P = 0.017) had a significantly lower tendency to drop out. The results confirm that compliance to SPT in private periodontal practice is far from ideal. Suggestions for improving compliance are discussed.

Crown lengthening and restorative treatment in mutilated molars.

Crown lengthening has been advocated as a treatment modality to restore teeth with a clinical crown reduced subsequent to different kinds of trauma. Multirooted teeth, however, present certain anatomic features, such as the furcation area and corresponding interradicular bone, the retromolar area, and the external oblique ridge, that may limit the possibility for soft tissue and bone reduction and minimize the effectiveness of crown-lengthening procedures. This article describes surgical modifications to overcome the anatomic difficulties that multirooted teeth present when crown lengthening is required. Furthermore, root resection is discussed as an alternative to conventional surgery when the latter is not possible.

Calculus removal from multirooted teeth with and without surgical access. II. Comparison between external and furcation surfaces and effect of furcation entrance width.

The purpose of this study was to evaluate the effect of furcation entrance width on the efficacy of calculus removal from furcation areas as well as to compare this efficacy between external and furcation surfaces after closed root planing, open root planing and use of a rotary diamond for the furcation area. 30 first and second lower molars scheduled for extraction with a calculus index > or = 2 and a degree II or III furcation involvement were divided into 3 groups: 10 molars were scaled and root planed using a closed approach: 10 molars were scaled and root planed using an open approach; 10 molars were scaled and root planed with an open approach and rotary diamond was used for removal of deposits in the furcation area. After extraction, the width of the furcation entrance was measured buccally and lingually 2 mm apical from the bifurcation and furcations were categorized as wide (width > 2.4 mm) or narrow (width < 2.4 mm). The teeth were assessed in a stereomicroscope and the % of residual calculus on external and furcation surfaces was calculated. The width of the furcation entrance influenced the efficacy in root planning in the open group (p = 0.0015). The use of rotary diamond was the most effective method for removing calculus both for narrow and wide furcations. The effectiveness of open root planning in the mesial root was related to the width of the furcation entrance where the % of residual calculus was significantly higher for narrow furcations (p = 0.008).(ABSTRACT TRUNCATED AT 250 WORDS)

Clinical evaluation of the effect of tetracycline root preparation on guided tissue regeneration in the treatment of Class II furcation defects.

The purpose of this clinical trial was to evaluate the effect of tetracycline root preparation on guided tissue regeneration in the treatment of Class II furcation defects. Nine pairs of defects with horizontal clinical attachment level value > or = 5 mm comprised the study group. Measurements were made to determine presence of plaque, gingival condition, probing depth, and vertical and horizontal clinical attachment level. Defects from each pair were randomly assigned for treatment with an expanded polytetrafluoroethylene membrane (e-PTFE) and tetracycline root conditioning (100 mg/ml) or the membrane alone. The membranes were removed 4 to 6 weeks postsurgery. Patients were then seen monthly for the duration of the study. Six months postsurgery, all clinical measurements were repeated. Following either treatment, improvement was observed in all clinical parameters, particularly in horizontal clinical attachment level. However, there was not a statistically significant difference in the improvement observed between sites treated with guided tissue regeneration in conjunction with tetracycline as compared to membrane placement alone. Further studies are needed to fully evaluate tetracycline root preparation in conjunction with regenerative therapy.

Calculus removal from multirooted teeth with and without surgical access. (I). Efficacy on external and furcation surfaces in relation to probing depth.

The purpose of this study was to evaluate the efficacy of the calculus removal from multirooted teeth after closed root planing, open root planing and use of a rotary diamond for the furcation area. The effect of pocket depth on the effectiveness of calculus removal was also examined. 30 first and second lower molars scheduled for extraction, with a calculus index > or = 2 and a degree II or III furcation involvement, were divided into 3 groups: 10 molars were scaled and root planed using a closed approach; 10 molars were scaled and root planed using an open approach; 10 molars were scaled and root planed with an open approach and rotary diamond was used for removal of deposits in the furcation area. After extraction, the teeth were assessed in a stereomicroscope and the % of residual calculus was calculated on external and furcation surfaces. The % of residual calculus on the external surfaces was significantly higher after closed than open root planing (p = 0.002). Pocket depth affected the effectiveness of scaling and root planing, with more residual calculus observed for depths > or = 7 mm for both groups. Differences between the 3 groups in the % of residual calculus on furcation surfaces were statistically significant (p < 0.0001 and p < 0.0005). The most effective method was the combination of open root planing and rotary diamond. More calculus was observed in all groups for pocket depths > or = 7 mm but the difference was significant only in the closed group (p = 0.006).(ABSTRACT TRUNCATED AT 250 WORDS)

[Is it possible for periodontal patients to recognize periodontal disease]. / Mporoun kai se ti bathmo na anagnorisoun ten parousia tes periodontikes nosou oi astheneis sto stoma tous.

The purpose of this study was the evaluation of clinical symptoms of periodontal disease in a sample of adult periodontal patients, that were presented for periodontal treatment in the private clinics of the authors during a period of ten years. A questionnaire was designed for this reason which included questions related to gingival bleeding, gingival enlargement, tooth migration and tooth mobility. 330 questionnaires were evaluated from a total of 1175 consisting a representative sample. The results have showed that the clinical symptoms that directed patients to look for periodontal treatment were (a) gingival bleeding when brushing or spontaneously (74.78%), (b) tooth mobility (65.65%), (c) presence of gingival enlargement (60%) and (d) tooth migration (36.96%). Comparison between positive answers, in all questions in relation with the presence of the clinical symptoms of periodontal disease showed significant differences between men and women. Furthermore, women were presented for appropriate periodontal treatment with the presence of two symptoms while men with the presence of three. In conclusion gingival bleeding when brushing or spontaneously is a symptom that is easily evaluated by the patient--as the results of this study indicated--provided he knows its significance. Therefore, emphasis must be given in informing the patients regarding its significance.

Perio-prosthetic management in restoring teeth with reduced clinical crown in children.

The purpose of this article is to underline the importance and to discuss the indications and techniques of crown lengthening procedures prior to prosthetic treatment of mutilated or undererupted permanent teeth of children. The aim of surgical crown lengthening is the exposure of at least 3 to 4 mm of healthy tooth structure coronally to the alveolar crest, length that will allow the formation of the new epithelial attachment and the existence of 1 to 2mm of tooth structure for the construction of a biologically acceptable crown margin. If the margin of the defect is inadequate distance from the alveolar crest the surgical procedure involves reduction of the attachment complex and is limited to the soft tissues only (a gingivectomy, apically repositioned full thickness flap, distal wedge). When the margin of the defect is close to the alveolar crest, less than 3 mm, the surgery involves also modification of the hard tissues of the periodontium (apically repositioned full thickness flap with ostectomy-osteoplasty). Although cases of children generally call for a conservative approach, the necessity for harmony between restorative procedures and materials with the supporting structures make surgical intervention inevitable.

[Oral hygiene habits of periodontal patients in relation to age]. / Poies einai oi synetheies tes stomatikes hygieines ton periodontikon asthenon se schese me ten elikia.

The relationship between age and oral hygiene habits as it was defined by the answers in a special questionnaire was studied and evaluated in a group of adult periodontal patients. The answers of 185 patients were evaluated from a total of 987 questionnaires from patients presented for periodontal treatment in the private offices of the authors during the last ten years, consisting a representative sample. The questions related to the personal habits of the patient in relation with the frequency of brushing, the method of brushing, the hardness of the toothbrush, the possibility "of brushing their gums" and the possibility of using additional mechanical aids of oral hygiene. The results showed that the frequency of the everyday brushing is decreasing steadily and progressively from the younger to the older patients. The method of brushing as well as the choice regarding the hardness of the toothbrush that the periodontal patients are using is not influenced by age. However the knowledge of patients regarding brushing the use of additional mechanical aids of oral hygiene except the toothbrush and the value of the toothpaste are statistically significant influenced by the age of the patients. The results of this study confirm that the younger age groups of periodontal patients are more informed about oral hygiene. The greater awareness which is higher in younger patients is possible explanation for these results.

[Relationship between age and clinical symptoms of periodontal disease]. / Schese elikias kai klinikon symptomaton tes periodontikes nosou.

The purpose of this study was to evaluate the relationship between age and clinical symptoms of periodontal disease as they were evaluated by themselves when they were presented for periodontal treatment in the private clinics of the authors during a period of ten years. A questionnaire was designed for this reason which included questions related to gingival bleeding, gingival enlargement, tooth migration and tooth mobility. 230 questionnaires were evaluated from a total of 1175 consisting a representative sample. The answers were evaluated in relation to the age of the patient. The results showed that a positive and significant relationship exists between the age and gingival bleeding, gingival enlargement, tooth migration and tooth mobility. The patients are becoming aware of two, three or four symptoms of periodontal disease during the fifth decade of life (40-49 years old). The symptoms that are mainly appearing in the groups of patients below forty are the gingival bleeding and the gingival enlargement. After the age of forty the main symptoms are tooth mobility and tooth migration. In conclusion, the results of this study indicate: a) that age could be a parameter that can influence the symptoms of periodontal disease, and b) that the bigest percentage of patients are becoming aware of the presence of symptoms of periodontal disease in a later age and when the disease has progress remarkably.

[Surgical crown lengthening procedures. Preparatory step for fixed prosthesis]. / Cheirourgike auxese tes klinikes myles: proparaskenastiko stadio gia ton akinete prosthetike apokatastase.

Necessary restorative requirements for full coverage are adequate axial wall height of the preparation for retention as well as sufficient vertical width of sound tooth structure cervically for the crown margins. In cases where adequate healthy tooth structure does not exist coronally to the epithelial attachment due to various crown damages, the margins of the crown might traumatize the periodontal attachment and the periodontium will be jeopardized iatrogenically. Teeth with inadequate axial Reight of the clinical crown, subgingival caries, vertical or horizontal fractures will require surgical crown lengthening procedures before prosthetic treatment is performed. These procedures may either involve only the soft tissues or bone remodeling as well. Irrespective of the procedure, crown lengthening must be performed with the objective of at least 3 mm. of healthy tooth structure coronally to the bone. This width will permit the formation of a new dentinogingival junction and the existence of 1-2 m.m. of sound tooth structure coronally to the new attachment line for the construction of a biologically acceptable crown margin. The purpose of this article is to discuss the clinical problem and underline the importance of crown lengthening procedures as a preparatory step for prosthetic treatment in fixed partial dentures.