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This case report uses a resin-ionomer restoration as a barrier in the treatment of a Class III furcation defect. There was a reduction in tooth mobility and plaque count, no bleeding on probing, and a decrease in probing depth with the use of the resin ionomer. The study offers another treatment option in the treatment of a seemingly hopeless maxillary molar.
Predictable and complete regeneration of lost periodontium remains an elusive goal, despite advances in surgical procedures and materials. Nevertheless, studies clearly demonstrate the potential for significant clinical improvements after regenerative therapy. Collectively, studies support the use of bone grafts and guided tissue regeneration (GTR) for the correction of intrabony and furcation defects. Results of several studies suggest the possibility of enhanced periodontal regeneration and enhanced stability following the use of combination techniques, such as GTR procedures with osseous grafts. Demineralized freeze-dried bone allograft (DFDBA) remains the most widely used allogeneic graft material in periodontics. Recent evidence suggests that substantial variations exist in the osteoinductive potentials of available DFDBA material. The predictability and extent of periodontal regeneration are associated with defect morphology, compliance, plaque control, inflammation, bacterial colonization, and smoking. Long-term (3- to 5-year) studies suggest that improvements following periodontal regeneration remain stable provided that patients comply with oral hygiene regimens and regular supportive periodontal treatment.
The successful use and placement of subgingival resin-ionomer restorations in both anterior root and molar furcation defects are demonstrated in this article. Sustained tissue health and minimal probing depths at the surgical site demonstrate clinical success. These case reports illustrate the continued success of alternative treatment procedures for restoring subgingival mechanical root or periodontal lesions.
Advanced furcation invasion has long been a treatment dilemma for the clinician. The present two case reports used a glass ionomer restorative material as a barrier in the treatment of maxillary Class III furcation defects. One year follow-up results showed a reduction in tooth mobility and probing depths and no bleeding on probing with the use of the glass ionomer. These case reports offer another option in the treatment of a seemingly hopeless periodontally involved maxillary molar.
This paper evaluates the use of guided tissue regeneration for treating 19 pairs of molar grade II furcation defects. Presurgical measurements were taken for the determination of aveolar crestal resorption, vertical open probing attachment, and horizontal open probing attachment. The surgical procedure consisted of sulcular incision, full-thickness facial and lingual flaps, soft tissue debridement, and root planing. One defect from each pair of furcas was treated with an expanded polytetrafluoroethylene membrane, which was left in place for 4 to 6 weeks. Postsurgery soft tissue measurements showed a reduction in probing depth and a gain in vertical and horizontal open probing attachment.
Enamel matrix derivative (EMD) has recently been introduced as a new modality in regenerative periodontal therapy. This case report demonstrates a combined approach in topical application of EMD gel (Emdogain) and autogenous bone grafts for treatment of intrabony defects and furcation involvement defects in a patient with chronic periodontitis. The seven-month post-surgery clinical and radiographic results were presented. The combined application of EMD gel with autogenous bone grafts in intrabony osseous defects resulted in clinically significant gain of attachment on diseased root surfaces and bone fill on radiographs. Further controlled clinical studies are required to confirm the long-term effectiveness of the combination of EMD gel and autogenous bone grafts in treatment of various osseous defects in subjects with chronic periodontitis.
This article describes two common varieties of osseous lesions within the furcation--hemifurcal and crescent-intrafurcal defects--and their appropriate management. Although hemifurcal lesions are difficult to assess both radiographically and clinically, once they are diagnosed, they can be readily resolvable using a self-regeneration procedure or an osseous graft. Crescent-intrafurcal defects are more common than hemifurcal lesions and can be discerned more easily on radiographs than clinically. The treatment of a crescent-intrafurcal defect focuses on minimizing the vertical component. Self-regeneration or osseous grafting is considered an appropriate treatment course.
The aim of the present trial was to study if carefully practiced supragingival plaque control influenced the subgingival microbiota at periodontal sites with suprabony, infrabony, or furcation pockets. 12 subjects, 5 males and 7 females aged 44 to 69 years (mean age 55 years) participated in the study. None of the participants had during the last 12 months received periodontal therapy, and none of the subjects had used antibiotics during a 3-month period preceding the study. Following a screening examination, 6 to 8 sites per subject were selected which had a probing depth of > or = 5 mm. Among these sites, 1-3 sites had a suprabony location, 1-3 sites had an infrabony location, and 1-3 sites were associated with a furcation defect. The selected sites were exposed to a baseline examination at which the following parameters were recorded: plaque, gingivitis, probing pocket depth and probing attachment level. A bacterial sample was obtained from each of the selected sites: 2 sterile paper points were inserted into the pocket and kept in place for 30 seconds. The paper point samples were removed, placed in a vial containing an anaerobically prepared transport medium, and processed using routine procedures. Following the baseline examination, each subject was given a case presentation, received thorough supragingival scaling and was instructed to practice proper plaque control with the use of toothbrush and dentifrice. During the subsequent 30 weeks they were recalled 2-3xper week for professional tooth cleaning. Each session was handled by a dental hygienist and required about 15 min. Re-examinations were performed after 30 weeks. The findings indicated that professionally delivered and frequently repeated supragingival tooth cleaning, combined with careful self-performed plaque control had a marked effect on the subgingival microbiota of moderate to deep periodontal pockets. Thus, at sites with suprabony and infrabony pockets, as well as at furcation sites, the meticulous and prolonged supragingival plaque removal reduced the total number of microorganisms that could be harvested, as well as the % of sites with P. gingivalis.
OBJECTIVE: Report of clinical and microbiological periodontal findings before and 6 months after treatment of two siblings with Papillon-Lefèvre syndrome (PLS) and tinea capitis. METHODS: Two brothers, RG 3 years and NG 5 years of age, were referred for treatment due to premature mobility of their deciduous teeth. Probing depths (PPD), attachment levels (PAL-V), and furcation involvements were examined clinically. Panoramic radiographs were taken. Subgingival plaque samples within the deepest pocket of each tooth were taken and analysed by real-time polymerase chain reaction (PCR) for Actinobacillus actinomycetemcomitans (AA), Porphyromonas gingivalis, Tannerella forsythensis, Treponema denticola, Fusobacterium nucleatum, and Prevotella intermedia. One-stage full-mouth scaling and extraction of hopeless teeth were performed under general anaesthesia, followed by systemic amoxicillin and metronidazole for 7 days. Clinical and microbiological analyses were performed 6 months after treatment. RESULTS: Before treatment, both siblings had exhibited PPD of up to 13 mm, Class III furcation defects at four teeth, and marginal suppuration. AA was detected in both patients and at all teeth at levels ranging from 3.0 x 10(2) to 5.1 x 10(6). Both patients exhibited palmar and plantar hyperkeratosis. Seven teeth were extracted from RG, and nine from NG. Six months after treatment, PPD had been reduced to <or=5 mm. AA was not detected in any of the remaining teeth. CONCLUSION: Even periodontally affected deciduous teeth of PLS patients can be treated successfully. Suppression of AA to below detection level seems to be of high significance.
30 periodontally compromised adult subjects with mandibular buccal class II furcation defects were recruited for this study. All selected defects were treated according to the biological principles of guided tissue regeneration. The subjects were randomly assigned to 2 parallel groups. The test group (n=15) received a bioabsorbable polyglycolic-polylactic membrane (PGA/PLA group); the control group (n=15) received a non-resorbable expanded polytetrafluoroethylene membrane (ePTFE group). After initial therapy, baseline measurements were recorded including plaque index, gingival index, vertical and horizontal probing depths, clinical attachment level and depth of the recession. Recall visits were made at 1, 2, 4, 6, 8, 12, and 24 weeks. At 12 months, all baseline clinical parameters were again measured. The data analysis did not demonstrate a significant difference between the 2 groups. The vertical probing depth and attachment level changes were statistically significant in each group. The postoperative recession was 0.6 mm in the ePTFE group (p<0.05) and 0.8 mm (p<0.05) in the PGA/PLA group. Compared to the initial measurements, the mean changes in horizontal probing depth were 2.7 mm and 2.5 mm (p<0.001), corresponding to mean reductions of 41.5% and 40.9% for the ePTFE and the PGA/PLA groups respectively. The results of this study suggest that 12 months after initial surgery, similar clinical improvements can be obtained in GTR therapy of buccal class II furcation lesions, regardless of whether bioabsorbable PGA/PLA membranes or non-resorbable ePTFE membranes are used.
This study evaluated and compared four different barrier membrane materials used to treat class II mandibular premolar and molar furcations in seven dogs with naturally occurring periodontitis. Five class II furcation defects in each animal were randomly assigned to one of four experimental groups or to a control group. Each defect was treated by surgical debridement, root planing, and barrier membrane coverage with one of the four test materials or no barrier membrane (control). Thus, each animal served as its own control. Following 6 months of healing, block sections were used to histologically measure the amount of regenerated tissue and stereometrically enumerate the inflammatory cell infiltration observed with each of the treatment modalities. The four barrier membrane materials (polycarbonate filter, silicone rubber, expanded polytetrafluoroethylene, and polycaprolactone) all provided a wound healing environment that promoted new cementum formation, with mean values ranging from 1.96 +/- 0.031 mm to 2.18 +/- 0.015 mm, and facilitated alveolar bone regeneration, with mean values ranging from 1.18 +/- 0.019 mm to 1.44 +/- 0.014 mm. Control-treated sites showed mean values of only 0.24 +/- 0.007 mm new cementum formation and 0.32 +/- 0.017 mm bone fill. Polycarbonate filter and polycaprolactone membrane barriers elicited a significantly greater chronic inflammatory cell response of lymphocyte and plasma cell infiltrates as compared to expanded polytetrafluoroethylene and silicone rubber, which were comparable to control-treated sites.
Revascularization of the periodontal tissues was studied following guided tissue regeneration (GTR) procedures using both nonresorbable and bioabsorbable membranes. The procedures were performed in 8 female beagle dogs, 4 to 6 years old. Second, third, and fourth mandibular premolars were involved; experimental periods covered from 3 days to 49 days. After elevation of soft tissue flaps, Class II furcation defects were prepared by removing buccal alveolar bone from the teeth and exposed root surfaces were planed in order to remove root cementum. The quadrant was then flushed with sterile saline. Randomly selected, in one quadrant, the second and fourth premolars received nonresorbable expanded polytetrafluoroethylene (ePTFE) membranes. The other quadrant, second and fourth premolars, received the bioabsorbable membranes, made of glycolide and lactide polymers. After the membranes were in place, they were sutured. The third premolars of both quadrants served as negative controls. The animals were sacrificed by exsanguination under general anesthesia and then perfused through the carotid arteries with a combined solution of equal parts of India ink and 10% buffered formalin. Following fixation and demineralization, part of the blocks were processed to obtain cleared specimens following the method of Spalteholtz. The remaining blocks were processed for routine histologic examination. The findings, mainly from the cleared specimens, showed that at the early phase of healing, ePTFE membranes interfered with the revascularization while they were in place. Contrary to this, bioabsorbable membranes allowed earlier anastomosis of the vasculature of the flap and regenerated tissues. However, the long-term vascular response was similar for both membranes.
Periodontal regeneration requires formation of periodontal tissues lost due to periodontal disease. To better understand the formation of new periodontal tissues during periodontal repair and regeneration, immunohistochemical expression of extracellular matrix components of normal as well as healing periodontal tissues was evaluated and compared using the avidin-biotin complex immunohistochemical technique. For this purpose, horizontal furcation defects were created around mandibular P2 and P4 of 6 dogs after extraction of P1 and P3. The root surfaces were conditioned with citric acid and expanded polytetrafluoroethylene (ePTFE) membranes were placed and retained 0.5 mm above the cemento-enamel junction. The mucoperiosteal flaps were sutured in a coronal position. Two animals were sacrificed at 2, 4, and 8 weeks, and mesio-distal tissue slices containing normal or healing periodontal tissues were demineralized, dehydrated, and embedded in paraffin. Immunohistochemical localization of type I collagen (CI), fibronectin (FN), secreted protein, acidic and rich in cysteine (SPARC), vitronectin (VN), and bone sialoprotein (BSP) was performed on 6 microns thick sections. Morphological results demonstrated that at 2 weeks after defect creation, lesions were filled primarily with granulation tissue which was gradually replaced by newly-formed fibrous connective tissue, periodontal ligament (PDL), cementum, and bone between 4 and 8 weeks. The results of immunohistochemical study revealed that at 2 weeks the granulation tissue, especially in the intercellular spaces of inflammatory cells, was intensively stained for FN and VN. At 4 and 8 weeks, staining for CI, FN, and VN was found in fibrous connective tissue, the newly-formed PDL, cementum, and osteoid. Further the attachment zone of the PDL collagen fibers to cementum showed intense staining for FN. Immunostaining for SPARC was positive in the new PDL, cementum, and bone, while staining for BSP was restricted to the new cementum and bone. Interestingly, the PDL, especially in areas adjacent to active bone formation, demonstrated intense staining for BSP. However, fibrous connective tissue and PDL proper were unstained for BSP. These results indicate that FN and VN are involved in the early stages of periodontal repair, and periodontal regeneration is achieved through formation of periodontal tissues that are composed of different matrix components specific to different types of periodontal tissues.
The purpose of this study was to determine the effect of use of an absorbable collagen membrane in guided tissue regeneration (GTR) therapy upon the subgingival microflora. The study group consisted of 12 systemically healthy patients with bilateral mandibular furcation defects with attachment loss > or = 6 mm; one site was randomly assigned for GTR treatment while the contralateral site received surgical flap debridement only. Subgingival plaque samples were collected by paper point on the day of surgery and at 2, 4 and 6 months post-surgery. Three sites were sampled in each patient: a collagen membrane site, a control surgical site, and an unoperated control site. Plaque samples were transported in a non-phosphated buffer solution and examined by phase-contrast microscopy. Cocci, rods, spirochetes, fusiforms, curved rods, and total bacteria were recorded per 10 high-power fields. Following statistical analysis utilizing the Bonferroni (Dunn) t test, no differences in total bacterial counts were found among the sites at any of the time intervals examined. Total bacterial counts were found lower at both the collagen membrane and control surgical sites post-surgery as compared to unoperated control sites, but these differences were not statistically significant (P > .05). In addition, no significant differences were detected in bacterial profiles between sites or individual time points. Results from this 6-month limited clinical trial suggest that the placement of an absorbable collagen membrane as part of a standard surgical regimen for GTR therapy does not alter the local microflora.
OBJECTIVE: To evaluate the effectiveness of guided tissue regeneration (GTR) on class II furcation involvement with absorbable atelocollagen membranes made in China. METHODS: GTR was performed on 26 sites with class II furcation defect in 17 patients. Clinical measurements and digital subtraction radiography were used to evaluate the effect. RESULTS: Clinical measurements showed significant attachment gain, significant decrease of probing depth (PD) and horizontal probing depth (HPD) at 3, 6, and 12 month after surgery. The mean reduction of HPD were 1.8 mm, 2.2 mm, 2.5 mm at 3 month (23 sites), 6 month (12 sites), and 12 month (6 sites) after surgery respectively. PD decreased by 1.22 mm, 1.56 mm and 1.75 mm. Attachment gained by 1.17 mm, 2.11 mm and 1.75 mm. Three sites showed complete defect fill during 3 to 12 months after surgery. Only 1 mm or less could be probed horizontally in another 4 furcation lesions during 3 to 12 months post-operation. The HPD of pre-operation in these 7 cases were 2.0 mm to 4.0 mm, and the bone defects observed during surgery were smaller in these cases than in other cases. The other 19 furcation involvement improved significantly. The result of digital subtraction radiography showed that increase of bone density was found at 2 months after surgery. The amount of bone gain increased with time. The areas of increased bone density were 0.3-25.7 mm2 in 13 teeth. CONCLUSION: The class II furcation involvement can be treated by GTR with absorbable atelocollagen membranes with good results.
BACKGROUND: Class II furcations present difficult treatment problems. Several treatment approaches to obtain furcation fill have been used with varying success. METHODS: The response of mandibular Class II furcations to treatment with either a microporous biocompatible composite of PMMA (poly-methyl-methacrylate), PHEMA (poly-hydroxyl-ethyl methacrylate) and calcium hydroxide graft synthetic bone (HTR) replacement graft material; ePTFE barrier membrane; or a combination of the two was evaluated in trios of mandibular molars with Class II furcations in 8 patients with moderate to advanced periodontitis. Following initial preparation, full-thickness flaps were raised in the areas being treated, the bone and furcation defects debrided of granulomatous tissue, and the involved root surfaces mechanically prepared and chemically conditioned. By random allocation, HTR, ePTFE, or a combination of both was placed into and/or fitted over the furcations, packed and/or secured in place, and the host flap replaced or coronally positioned with sutures. Postsurgical deplaquing was performed every 10 days leading up to ePTFE removal at approximately 6 weeks. Continuing periodontal maintenance therapy was provided until surgical reentry at 6 months for documentation and any further necessary treatment. RESULTS: Direct clinical measurements demonstrated essentially similar clinical results with all 3 treatments for bone and soft tissue changes. There were no statistically or clinically significant differences except for better horizontal amount and percent defect fill with HTR alone. Four of 8 furcations became Class I clinically with HTR alone, 5 of 8 became Class I with ePTFE alone, and 5 of 8 with combination treatment. The only complete furcation closure occurred with HTR. CONCLUSION: The findings of this study suggest essentially equal clinical results with HTR bone replacement graft material alone, ePTFE barrier alone, and a combination of the two in mandibular molar Class II furcations. However, a real difference may not have been detected based on the small number of subjects in the study.
Freeze-dried cortical bone allografts of a fine particle size were implanted into wide three-wall, two-wall, one-wall, combination, and furcation defects. Of the 97 defects treated, 23 manifested complete bone regeneration; 39 showed greater than 50%; and 24, less than 50% osseous repair. Twelve defects failed to demonstrate any bony regeneration, of which nine were furcation involvements. From the preliminary data available, there is strong evidence which indicates that freeze-dried bone allografts have definite potential as grafting material in certain periodontal osseous defects. However, final determination must await the outcome of a larger number of cases and also histologic evidence.
UNLABELLED: The therapy of deep infrabony defects in periodontal diseases has been a great problem for decades both for dentists and their patients, as well. After application of classic therapy in patients with serious stages of periodontal diseases (subgingival curettage, Modified Widmann flap surgery with and without implantation of implants) a significant strengthening of teeth in alveolus was observed, as well as alleviation of patient's discomfort, and decrease of the depth of periodontal pockets, bleeding, inflammation, etc. However, in spite of the application of this therapy a postoperative defect was sometimes filled with different low tissues of periodontium, in other words periodont reparation took place. For this reason, recidives could happen, as well as gingival recession, inflammation, root resorption. At the beginning of the nineties a new principal was introduced in the therapy of periodontal diseases: Guided Tissue Regeneration. This principal includes a controlled action between four different species of periodontal tissue: gingival epithelium, gingival connective tissue, alveolar bone, and periodontal ligament. This is achieved by surgical placement of non resorbale or bioresorbable periodontal membranes, which are placed during flap surgery above the previously treated infrabony defect. With membranes placed in that way the periodontal defect is for some time phisically separated from epithelium and gingival connective tissue and in that way alveolar bone is regenerated, as well as periodontal ligament in other words restitutio ad integram takes place. Nowadays, two concepts of guided tissue regeneration can be considered: a concept of isolation and a concept of integration. The first concept includes application of non resorbable, most frequently synthetic, membranes (so-called E-PTFE polyterafluorethylene) which replace the mucoperiosteal flap into its original position. After six weeks a patient is subjected to one more surgical intervention when flap is raised again and the non resorbable membrane is removed. The second operation diminishes the value and partially discredits the application of non resorbable membranes. For this reason, the concept of integration is today more frequently applied, that is to say the application of bioresorbable membranes is nowadays very frequent. They are by their chemical composition poly D,L lactides and they provide membranes with ideal resorption properties. Of great importance is their property to stay unchanged for six weeks, and then to be resorbed by geometrical progression. As the membrane is resorbed, it is not necessary to remove it, so there is no need for another surgery, and that enables the process of healing to proceed undisturbedly. For this reason, the concept of integration is also called a Single Step Method. CONCLUSION: On the basis of papers of the leading scientists from the field of guided tissue regeneration it can be concluded that by application of Single Step Method or in other words by application of bioresorbable membranes a tremendous progress was made in the therapy of infrabony periodontal defects. The application of these membranes is especially indicated in treating degree II furcation defects, then infrabony defects particularly with 2 and 3 walls and good results were also achieved in the therapy of a big problem in esthetic periodontology--gingival recession. A relatively low price, as well as simple application, biological compatibility and undisturbed process of healing of the wound are great advantages of the application of bioresorbable membranes, so in the near future their application on a large scale can be expected in the therapy of periodontal diseases, as well as further research work on their development, especially on their impregnation by growth factors, antibiotics, etc.