A clinical study of healing in humans following the excisional new attachment procedure

Biophotonics in Dentistry

The aim of this review paper is to concentrate on the use and application of photonics in dentistry. More than one hundred review and research articles were comprehensively analysed in terms of applications of photonics in dentistry, including surgical applications, as well as dental biomaterials, diagnosis and treatments. In biomedical engineering, various fields, such as biology, chemistry, material and physics, come together in to tackle a disease/disorder either as a diagnostic tool or an option for treatment. Engineers believe that biophotonics is the application of photonics in medicine, whereas photonics is simply a technology for creating and connecting packets of light energy, known as photons. This review paper provides a comprehensive discussion of its main elements, such as photoelasticity, interferometry techniques, optical coherence tomography, different types of lasers, carbon nanotubes, graphene and quantum dots.

Current Concepts in the Management of Periodontitis

Periodontitis is a common disorder affecting >40% of adults in the United States. Globally, the severe form of the disease has a prevalence of 11%. In advanced cases, periodontitis leads to tooth loss and reduced quality of life. The aetiology of periodontitis is multifactorial. Subgingival dental biofilm elicits a host inflammatory and immune response, ultimately leading to irreversible destruction of the periodontium (i.e. alveolar bone and periodontal ligament) in a susceptible host. In order to successfully manage periodontitis, dental professionals must understand the pathogenesis, primary aetiology, risk factors, contributing factors and treatment protocols. Careful diagnosis, elimination of the causes and reduction of modifiable risk factors are paramount for successful prevention and treatment of periodontitis. Initial non-surgical periodontal therapy primarily consists of home care review and scaling and root planing. For residual sites with active periodontitis at periodontal re-evaluation, a contemporary regenerative or traditional resective surgical therapy can be utilised. Thereafter, periodontal maintenance therapy at a regular interval and long-term follow-ups are also crucial to the success of the treatment and long-term retention of teeth. The aim of this review is to provide current concepts of diagnosis, prevention and treatment of periodontitis. Both clinical and biological rationales will be discussed.

Scaling and root planing vs. conservative surgery in the treatment of chronic periodontitis

A renewed interest in conservative surgical techniques has been fueled by new technology, changes in referral patterns to periodontists and a desire to achieve periodontal health in the least invasive, most cost-efficient manner possible. Trends suggest that an increasing amount of periodontal care is being provided in the offices of general dentists. If true, it is likely that patients receiving care in these offices will be offered simpler surgical treatment modalities that do not require an extensive armamentarium. The purpose of this article was to review the effectiveness of six relatively simple surgical techniques - gingivectomy, flap debridement, modified Widman flap, excisional new attachment procedure, modified excisional new attachment procedure and laser-assisted new attachment procedure - and to compare the results obtained using these procedures with the well-known clinical benefits of scaling and root planing. The intent was to determine whether the benefits of surgical procedures in the hands of most general dentists extend beyond those of conventional nonsurgical therapy.

Bioactive glass granules for regeneration of human periodontal defects

PURPOSE

A comparative study which evaluated the effectiveness of bioactive glass granules of uniform size (300-335 microns) for the regenerative treatment of interproximal intrabony periodontal defects was conducted.

MATERIALS AND METHODS

Twelve pairs of advanced periodontal lesions in 12 patients (6 males and 6 females) were treated in a split-mouth design with open flap débridement in the control sites and open flap débridement with bioactive glass particles placed in the test sites.

RESULTS

At 6 months post-treatment, both treatment modalities demonstrated a gain in clinical attachment level (CAL), with the test sites having a significantly (p < .01) greater gain in CAL than the control sites. Reentry procedures were performed to assess the amount of hard tissue fill. The test sites demonstrated significantly (p < .001) more gain in hard tissue fill than the controls.

Pulsed laser beam effects on gingiva

The effects of CO2 lasers on human gingiva have been evaluated. Pulsed Nd:YAG lasers have only been available for clinical use in dentistry since 1990. This study evaluated the efficacy of a low-power pulsed laser in removing pocket lining epithelium in humans with moderate periodontitis. 24 specimens of gingival tissue, from 6 patients, were studied microscopically following the application of a pulsed Nd:YAG laser (1064 nm) contact probe with a spotsize of 320 mu. Power settings of 1.25 and 1.75 Watts and a frequency of 20 Hz were used. Treatment time varied from 2 to 3 min. The specimens were fixed and processed in the usual manner. Four representative sections for each tooth were examined with the light microscope at 25 and 100 x magnification. Most sections (83%) exhibited complete removal of epithelium except for traces of viable basal cell remnants at the coronal sulcular margin (17%). The underlying connective tissue demonstrated no evidence of necrosis or carbonization. Morphologic features showed minimal change other than removal of pocket lining epithelium, compared to control sites. The pulsed Nd-YAG laser can remove pocket lining epithelium in moderately deep pockets at 1.25-1.75 W of power.

Sounding depth measurements: a method for evaluating various surgical techniques

Fourteen patients undergoing periodontal treatment for moderate to severe adult-type periodontitis were included in the study. Seven patients (a total of 210 sites) were treated with modified Widman flap surgery while the other 7 patients (the same number of sites) were treated with apically-positioned flap surgery. The 2 modalities were compared using sounding depth measurements before and immediately after surgery. The mean sounding depth decreased from 4.89 mm to 3.42 mm in the modified Widman flap group, compared to a drop from 4.77 mm to 2.46 mm in the apically-positioned flap group. Neither of these procedures resulted in the total eradication of all periodontal pockets. The final outcome of modified Widman flap surgery may, at times, result in zero sounding depth (placement of the flap at the crest of the bone); on the other hand, very often the flap was placed far supra-crestally in an intended apically-positioned flap procedure. This lack of consistency between intended and actual flap placement would suggest that studies which try to compare different treatment modalities using a flap approach should include sounding depth measurements immediately post-surgery. This is needed to assure that the intended procedure has actually been carried out.

Clinical effects of closed root planing compared to papilla reflection and fiber optic augmentation

Mini-surgical approaches in 4 to 7 mm probing depths have been shown to facilitate improved deposit removal as compared to closed instrumentation. At the same time this treatment is less traumatic than more extensive flap reflection for root planing. The purpose of this study was to compare the clinical effects of closed root planing (C/SCRP) to those of root planing augmented by papilla reflection and fiber optic illumination (PR/SCRP) over a 6-month period. Fourteen patients with moderate/advanced adult periodontitis received each therapy in 2 experimental periodontitis sites (PS = greater than or equal to 5 mm probing depth and greater than 5 mm attachment loss) and one non-periodontitis site (NPS = less than or equal to 3 mm probing depth and no recession). Presence of supragingival plaque, bleeding on probing, probing depths, and clinical attachment levels were measured before treatment and 6, 12, and 24 weeks posttreatment. Mean supragingival plaque levels were high and did not vary significantly over the course of the study, but bleeding on probing was significantly reduced in PS following both C/SCRP and PR/SCRP (P less than or equal to 0.0001). Mean probing depths were significantly reduced after 6 months (P less than or equal to 0.01) in NPS-PR/SCRP from 2.8 +/- 0.1 to 2.0 +/- 0.2 mm, in PS-C/SCRP from 5.5 +/- 0.2 to 4.5 +/- 0.4 mm, and in PS-PR/SCRP from 5.8 +/- 0.2 to 3.2 +/- 0.1 mm. In periodontitis sites, PR/SCRP demonstrated greater probing depth reductions than C/SCRP at all time periods (P less than or equal to 0.004). PS attachment levels also improved following C/SCRP and PR/SCRP at all postoperative times (P less than or equal to 0.01). PR/SCRP appears to provide better short-term mean probing depth reduction (2.6 mm) than C/SCRP (1.0 mm), presumably due to apical positioning of the papillae and periodontal repair following improved access for root planing.

The effect of supracrestal tricalcium phosphate ceramic-microfibrillar collagen grafting on postsurgical soft tissue levels

In this clinical study, a combined tricalcium phosphate ceramic (TCP) microfibrillar collagen supracrestal graft was used in conjunction with pocket elimination surgery as a soft tissue space filler to maintain marginal and interproximal tissue heights. Fifteen volunteer adult patients (8 male, 7 female) aged 37 to 48 years were selected. Standardized clinical probing measurements were used to evaluate soft tissue recession, clinical attachment, and probing pocket depths. Intraoral photographs and radiographs supplemented documentation. Twenty-five paired test and control sites were evaluated. Following flap surgery and minor osteoplasty, test defects received supracrestal grafts of TCP microfibrillar collagen prior to flap closure. Intrabony defects were excluded. Treatment modalities were compared by analyzing changes in clinical probing measurements over four months using the students t test for paired samples at the 0.01 level of significance. Supracrestal grafting resulted in 16.74% less soft tissue recession than the control sites. In addition, there was a significant gain in clinical attachment levels compared with the controls. All implanted sites demonstrated an advantage in the use of supracrestal TCP-collagen grafts compared with the controls. This treatment modality may have value in reducing esthetic deformities, food impaction areas, and root exposure that often occur following periodontal surgery.

A modification of the "curtain technique" incorporating an internal mattress suture

An internal mattress suture is described for suturing labial papillae to palatal flaps when using the "curtain technique." The suture is simple to perform and does not violate the intact labial sulci. It gives stability to both the labial papillae and palatal flap while maintaining maximum esthetic results.

The long-term effectiveness of periodontal therapy in a clinical practice

A retrospective study was conducted of 620 patients in a periodontal practice over the years 1960 to 1982. Various periodontal therapies were assessed by using careful office protocols, meticulous record-keeping and well-defined outcome criteria. Four treatment outcome categories were used: two representing satisfactory outcomes (referred to as "STABLE"), and two unsatisfactory outcomes ("UNSTABLE"). The percentages of patients in the STABLE categories following different therapies were: (1) nonsurgical treatment, 63.6%; (2) closed curettage, 73.1%; (3) open curettage, 95.0%; (4) modified Widman flap, 91.6%; (5) full flap and osseous surgery, 71.1%. The major conclusions were that the modified Widman flap and open curettage were more effective than flap and osseous surgery, and much more effective than closed curettage when it was employed as an alternative treatment (54.8% STABLE) to the osseous surgery (71.1% STABLE). Thus, moderate surgical therapies appear to be at least as effective as ostectomy procedures in the treatment of periodontal disease, while nonsurgical and closed curettage therapies appear to be less effective.

Effect of retention of gingival sulcular epithelium on attachment and pocket depth after periodontal surgery

Both the modified Widman flap and the intrasulcular incision technique produced significant and similar reductions in pocket depth and increases in attachment. Loss of attachment occurred where the initial pocket depth was less than 3 mm. Both techniques resulted in significant and similar increases in gingival recession. Neither technique affected tooth mobility or plaque scores to a clinically important degree. Historically, the necessity for removal of the sulcular epithelium in the course of periodontal therapy is a widely accepted tenet. This study fails to clinically validate this concept.

Connective tissue attachment to periodontally diseased roots after citric acid demineralization

PREVIOUS INVESTIGATIONS have demonstrated that application of citric acid to a root surface results in exposure of dentin and/or cementum matrix collagen fibrils. Several studies have suggested a rapid and consistent connective tissue reattachment to citric acid treated roots. This study was initiated to determine if such an attachment was obtainable on human periodontally diseased teeth, in vivo, and could be confirmed through observations using the scanning electron and light microscopes. Full thickness flaps were raised on 18 single rooted teeth with moderate to advanced periodontitis. Citric acid (pH = 1.0) was applied to nine teeth with contralateral teeth serving as controls. Six to fifteen weeks later, the teeth with attached periodontal tissue were removed. Sagittal sections were obtained, with one-half of the root being processed for light microscopy and the remaining half studied by scanning electron microscopy. Six of nine citric acid treated roots provided evidence of fibrous attachment. Connective tissue was apposed directly to old or newly formed cementum, but never directly to dentin. Fibrous attachment was usually functionally oriented, i.e., perpendicular to the root surface. No evidence of fibrous attachment was found among the control specimens.

Healing after treatment of periodontal intraosseous defects. I. Comparative study of clinical methods

Four clinical methods to evaluate healing after reconstructive therapy of intraosseous periodontal defects were compared: 1. probing attachment level, 2. probing bone level, 3. entry/re-entry bone height measurements, 4. radiographic bone height determinations. Thirteen patients with a total of 33 defects volunteered for the study. It was found that the depth of the lesions recorded by the various methods showed differences which seem to relate to the varying nature of the methods. On the average, the periodontal probe penetrated 0.8 mm deeper during probing for bone level than during probing for attachment level and another 0.3 mm deeper after denudation of the lesions during entry/re-entry. The average gain of periodontal support following treatment was approximately 1.4 mm as recorded by probing attachment level, probing bone level and entry/re-entry bone height determinations, respectively. A high degree of correlation was found between all three probing methods when the changes following therapy for the individual sites were compared (r = 0.85, 0.75 and 0.81, respectively). Radiographic bone height showed lower degrees of correlation with all three probing parameters (r = 0.45, 0.46 and 0.47, respectively).

An overview of periodontal surgical procedures

It is obvious from the foregoing that there are many technical approaches to periodontal surgery. The mere presence of a periodontal pocket of a cerain depth as the major indicator for surgery is not as steadfast as once believed. Other criteria such as hemorrhage and exudate must also be used in evaluating the need for surgery. The decision on which approach to use remains with the therapist and the individual situation which he/she is faced. However, in the past decade it has become increasingly clear that the need for so-called more advanced surgical procedures is not as important to the control of periodontal diseases as was once thought. Regardless, it is also clear that some form of surgical intervention, as defined by this paper, is still necessary to interrupt the sequence of events that make up the pathogenesis of periodontal disease that leads to eventual tooth loss. This paper has reviewed and evaluated some of the current procedures available to the therapist in the surgical approach to therapy.

Use of the fiber retention procedure in treating the maxillary anterior region

THE MAXILLARY anterior region presents a difficult and unique therapeutic challenge to both the periodontist and restorative dentist. Although access for surgical and prosthetic procedures is certainly easiest in this part of the mouth, the problem of esthetics, in terms of increased tooth length and loss of interdental papillae, creates an environment in which the clinician's therapeutic choices may either be severely limited or the result compromised. The two cases presented show how this area can be successfully treated using fiber retention procedures to eliminate pathologic periodontal pockets effectively while minimizing root exposure, loss of interdental papillae and root sensitivity. This type of procedure enables the clinician to provide the patient with an acceptable biologic, functional and esthetic result.

Five year evaluation of the excisional new attachment procedure

Patients treated with the Excisional New Attachment Procedure were evaluated 5 years or more following the procedure. They had received maintenance therapy about four times a year. Clinical measurements of free gingival margin height, pocket depth, and width of keratinized gingiva were made from the cemento-enamel junction in 56 surgical sites and compared to the same parameters recorded presurgically and at 1 and 3 years postsurgically. Probeable depths increased slightly and the amount of previously gained new attachment decreased slightly at each postoperative evaluation period. Only isolated sites were the same as or worse than pretreatment levels. An overall mean net gain in clinical attachment of 1.5 mm was found at 5 years after treatment, and probeable depths approached 3.0 mm at this time. Both of these 5 year findings were statistically and clinically significant improvements over preoperative measurements.

Histometric evaluation of periodontal surgery. I. The modified Widman flap procedure

The present investigation was performed in the Rhesus monkey to determine the effect of the modified Widman flap procedure on the level of the connective tissue attachment and supporting alveolar bone. Two adult male Rhesus monkeys were used. Eighteen contralateral pairs of periodontal pockets were produced in a standardized manner. Surgical treatment of the pockets was performed around experimental teeth and the contralateral teeth were used as the unoperated controls. Twelve months following treatment the animals were sacrificed and histological sections obtained. Using the cemento-enamel junction (CEJ) as a fixed reference point, linear measurements along the root surface were made to the most apical cells of the junctional epithelium (JE), to the crest of the interproximal alveolar bone (CR), and to the apical extent of angular bony defects (AAD). These measurements from operated and unoperated pockets were then compared. The data revealed that treatment of periodontal pockets using the modified Widman flap procedure produced no gain in connective tissue attachment and no increase in crestal bone height. In angular bony defects a certain degree "bone fill" was noted. This bone repair was never accompanied by new connective tissue attachment.

Histometric evaluation of periodontal surgery. II. Connective tissue attachment levels after four regenerative procedures

The present study was undertaken to determine the effect of four periodontal regenerative procedures on the connective tissue attachment level. The procedures tested were: 1) the modified Widman flap procedure, 2) the modified Widman flap procedure combined with transplantation of previously frozen autogenous red marrow and cancellous bone, 3) the modified Widman flap procedure in combination with implantation of beta tricalcium phosphate, and 4) periodic root planing and soft tissue curettage. Eight adult Rhesus monkeys, divided into four equal groups, were used. Periodontal pockets were produced around contralateral teeth in a standardized manner. In each group of animals, the pockets on one side of the jaws were subjected to one of the above-mentioned surgical treatments, while the contralateral pockets remained as unoperated controls. Three weeks before surgery, a carefully designed plaque control program was instituted and continued until the animals were sacrificed 12 months after surgery. In histologic sections, linear measurements along the root surfaces were made from the cemento-enamel junction (CEJ) to the most apical cells of the junctional epithelium (JE). These measurements from operated and unoperated sites were then compared. The data revealed that healing following the four different regenerative procedures resulted in the reformation of an epithelial lining (long junctional epithelium) along the treated root surfaces, with no new connective tissue attachment.

Vital root retention in humans: a final report

A research protocal for submucosal vital root retention in humans has been developed based on laboratory animal studies. Procedures, patient management, and statistical results have been reported in a series of three articles. Changes in techniques have also been reported, along with explanation of a flowchart for tooth root retention and alveolar ridge preservation. Some ideas for future investigations are presented. Vital root retention in humans appears to be a valid means of retaining residual bony ridge tissues to a greater degree than when patients are rendered totally edentulous.

Longitudinal evaluation of the excisional new attachment procedure in humans

Evaluation of the Excisional New Attachment Procedure (ENAP) was extended to 3 years postoperatively. Generally, there was an overall mean increase in sulcus depth of 0.5 mm; an overall mean increase in recession of 0.1 mm; and an overall mean decrease in the amount of previously gained new attachment of 0.6 mm between 1 year and 3 years after surgery. These values reflected a statistically significant, but clinically insignificant, difference in mean sulcus depth and mean attachment level between the two evaluation periods. Only one tooth site demonstrated clinical findings worse than those determined preoperatively. These results are similar to those of other longitudinal studies.

A clinical and histologic study of healing following the excisional new attachment procedure in rhesus monkeys

Experimental suprabony periodontal pockets were established around the incisors of Rhesus monkeys and subsequently were treated by the Excisional New Attachment Procedure. Healing was evaluated clinically and histologically for up to 6 months. Clinical examinations demonstrated an overall mean pocket depth reduction from 5.02 mm to 2.82 mm, of which 0.57 mm was recession and 1.59 mm (73.6%) was clinical new attachment. Histologic evaluation of experimental sites consistently revealed a long, thin junctional epithelium with a minimal amount of inflammatory infiltrate in the subjacent, densely fibered, lamina propria. Control areas demonstrated the classic histologic picture of periodontal disease and tended to be progressive in nature clinically.