11 clinical assessment of soft tissue and osseous repair

7/27/2019 11 Clinical Assessment of Soft Tissue and Osseous Repair

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1 Periodontal Healing Following Open Debridement FlapProcedures

I. Clinical Assessment of Soft Tissue and Osseous RepairS. J. Froum, M. Coran, B. Thaller, L. Kushner, I. W. Scopp, andS. S. Stahl*

Accepted lo r publication 18 April 1 981

T H E H E A L I N G R E S P O N S E of the periodonlium was evaluated after periodo nial flap and deb ride-ment pro cedures in patients with different levels of postsurgical pla que contro l. T hirty -on esites in 19 patients were included. Me asur em enls were performed from a fixed reference p ointpresurgically and before reentry surgery . A ll reentries were performed 24 to 28 weeks aftersurgery. Surgery consisted of elevating an inverse bevel mucoperiosteal flap, debriding rootaccretions and osseous defects, penetrating into the marrow, and suturing with interruptedsutures at or near the presurg ical level. A ll patients were recalled at least once every 4 weeksafter surgery for professional m aintenanc e. T he nu mber of postsurgical m aintenance visitsand plaque scores (N P I) before reentry were recorded for each surgical site. A verage pocketdepth at the 31 sites was 7.4 mm initially an d 4.1 mm at the time of reentry . T his reduc tion inpocket depth consisted of gingival recession, which averaged 2.0 mm, and a gain in attachmentlevel, which a veraged 1.4 mm . A t no site was there a loss in attachm ent level. A verage osseousdepth of the 31 defects was 3.7 mm presurgically and 1.7 mm at reentry. In addition, there wasan averag e crestal resorption of 0.8 mm and a n averag e osseous fill of 1.2 mm . A significantpositive correlation (/* < 0.001) was found between gain in attac hm ent, osseous fill andnum ber of postsurgical main tenan ce visits. A significant negative correlation was foundbetween the amo unt of plaqu e (N P I) at the study site and both gain in soft tissue attachm entand osseous fill. Multiple measurements at various points within several osseous defectsrevealed that osseous remodeling and fill varied significantly at different locations within thesame defect

R estoration of diseased human p eriodontal sup portingstructures takes place with or without the use ofgrafts.1"10 A lthough only limited hum an histological dataare available, a somewhat more favorable healing poten-tial has been demonstrated when grafts have been used.' 'H owever, recent clinical reports have indicated that un-der conditions of optimum plaque control maintained by"professional tooth cleaning." predictable levels of os-seous as well as soft tissue repair are attained followingperiodontal flap and open debridement procedures.1"1 I nfact, clinical studies suggest that the level of plaquecontrol may be the most significant factor affecting levelsof repair.'1-7"10T he present study was undertaken to monitor levels ofsoft tissue and osseous repair with different levels of

* From lhe Dental Service. Veterans Administration Medical Cen-ter, N ew York, NY and the Department of Periodontics. N ew YorkUniversity College of Dentistry, N ew York, N Y.

plaque control after periodontal flap and open debride-ment procedures.

MATERIALS AND METHODST hirty -one sites in 19 patients, (18 males and 1 female)20 to 62 years of age (average 48.5 years) were included

in our study. T he 19 patients were those remaining froma patient pool selected on a first-come basis from thosebeing seen for routine periodontal therapy at the DentalService. Veterans A dministration Medical Cen ter. N ewYork, N .Y. T he only criterion for initial inclusion in thestudy was that the patient be medically cleared andwilling to participate. E ach patient was given a com pleteexplanation of the study before signing a consent form.Initial therapy for the patient pool consisted of oralhygiene instruction, scaling and root planing and occlu-sal adjustm ent for gross interferences. A fter initial ther-apy, a N avy P laque Index was recorded. O nly when theindex approached 0 were patients identified for subse-


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Volume 5?N um be r Iquent surgical the rap y." T he index was reduced to sur-gically acceptable levels by frequent (in some cases threeor four limes a week) prophylaxes by a hygienist withoral hygiene reinforcement at every session.Sites for the study were chosen at random from allsites requiring periodo ntal surgery. O nly osseous defectsat least 2 mm deep were included.Measurements

Measurements were made with a stem, boley gauge,endodontic silver point, and locking pliers. Using thebase of the stent as a fixed point of reference, measure-ments were recorded before surgery from: a) the stent tothe gingival margin; b) the stent to the deepest part ofthe pocket: and c) the stent to the cementoenamel junc-tion.Pocket depths (the distance from the gingival marginto the base of the pocket) were calculated as (b-a) andwere obtained to the nearest 0.1 mm . A t the time ofsurgical exposure of the osseous defect, the stent wasregrooved and measurements were made from stent toosseous crest and stent to the deepest part of the osseousdefect. T he measurem ent from the stem to the cemen-toenamel junction was repeated at each site to test for

Periodontal Hea ling: C linical Assessment 9seating of the stent. T he same investigato r performed allmeasurements to eliminate interexaminer discrepancies.Six to seven months after initial surgery, all sites werereentered. A t the time of reentry, each measurem ent w asrepeated. Measurements were made to the osseous crestat the same point as in the original defect and to thedeepest part of the residual osseous defect (where oneexisted). In most cases, the latter point was not identicalwith the original deepest point of the defect. A t all time*.however, the deepest point of the defect was used for themeasurement recorded.

A lso , in four lesions of three patients, multiple mea-surements were made at several sites within the originaldefect. A t the time of reentry, these measure men ts wererepeated at the identical sites to record osseous remod-eling at various points within the sam e defect. T hesevalues were recorded sep arately (T able VI) but averagedwhen calculating "initial osseous depth" and "osseousfill" (T able I I) .Surgical Techniques

Surgery consisted of an inverse bevel flap procedure,retaining as much of the marginal gingiva as possible:debridement of root accretions and osseous defect: mul-Table ISoft Tissue Response to Open D ebridemem Flap Procedures With 24-28 Week Reentries

Maintenance Postsurgicalvisits pocket dep thN u m b erof sites

Presurgicalpocket depth R eentry M'l x IN

G ing iva lrecessionChange in at-

tachment

II mm7.41.93

weeks24.8

1.4211.2

3.44mm4.11.67 0.60.26

mm2.0

1.24mm+ 1.4

0.98

1C i d

Figure la. Radmgraphic appearance of the osseous defect on the mesial of the miindihular left 2nd molar immediately before surgery, b. Clinicalappearance ollowing debridemem of the wide i-wall infraosseous defect, which measured 5. mm al its deepest point tmirror photograph), c. R adiographkappearance of ihe surgical site, 24 weeks postsurgicatiy, just before reentry, d. C linical appearance of the surgical site, a: the 24-week reentry, with aresidual defect which measured I. 7 mm in depth and a fill which measured 3.3 mm.


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10 Frown, Coran, Thaller, Ku.shner, Scopp, Stahltiple intramarrow penetration s of the defect wall with anexplorer or curetie; and suturing of the flap with inter-rupted sutures at or close to presurgical levels. A ll pa-tients were placed on antibiotic coverage (penicillin orerythromy cin, I gm day) for I week and a dressing wasapplied. Penicillin or erythromycin was chosen to stand-ardize the antibiotic therapy being used, since these werethe drugs of choice for several patients requiring prophy -lactic antibiotic coverage for preexisting medical condi-tions.Postsurgical Treatment

O ne week after surgery, sutures and dressings wereremoved. At this appointment and at intervals of nomore than 4 weeks, the periodontist performing theinitial surgery debrided the site. E ach debr idem ent visitconsisted of an oral hygiene review and scaling andflossing of the surgical sites. E ach pa tient was m aintainedin this manner until the reentry appointment.T he four surgical sites with multiple m easure men trecordings within the osseous defect were also profes-sionally cleaned al least once every 4 weeks between thetime of initial surgery and reentry.For all sites, reentries were performed 24 to 48 weeksafter initial surgery (average reentry time 24.8 weeks).Before reentry, a modified N avy P laque I ndex of thetooth at the surgical site was recorded and all measure-ments were repeated. R adiogra phs (with probes inserted)

J Pe r iodomol .January. 1982and photographs were taken before, during, and afterthe initial and reentry procedures.

OBSERVATIONSTissue Response of 31 Sites Treated With OpenDebridement Flap Procedures

T he pert inent pocket measurement data are presentedin T able I. T here w as no loss of attachmen t at any siteevaluated.A s stated previously, a modified N avy P laque Indexwas recorded for each surgical site at the time of reentry.Most patients were unable to maintain optimum levelsof plaque control even when professionally maintainedwith "cleanings" at least once every 4 weeks postsurgi-cally. T he average N P I at reentry was 0.6 (SD 0.26)and ranged from 2/18 to 18/18 (Fig. I).T able II records the osseous response of the 31 studysites as measured during the initial surgical procedureand at reentry. Clinical responses are demonstrated in

Figure 1.Tab l e III classifies the soft tissue response of the sitesaccording to the type of osseous defect present at thetime of initial surgery. Since most infrabony lesions werecombination type defects, classifications were made ac-cording to predominant morphology.T able IV classifies the osseous response of the 31 sitesaccording to the type of osseous defect present at thetime of initial surgery.Table IIOsseous Response In Open Dehridemenl flap Procedures With 24-2HWeek Reentries

N uniher Initial O sseous _ Maintena nce O sseous depthR eentry . . rof sues depth * visits al reentr y

mm3.7

1.56

NP I x/18 Osseous fill

) lweeks24.8

1.42 11.23.44mm1.71.57

0.60.26mm

1.21.04T a b l e I I ISoft Tissue Response to Open Debridement According in Type of Defect

Typeofdefec.

Crestal re-sorption

mm0.80.63

N ff. gpocket dept h visits

P ostsurgical G ingivai Chang e in at-N r l x /1 o , , .pocket depth recession tachmen t

Combined I and I- 142 wall

2 W a l l 10C o m b i n e d 2 - 3 a n d 73 wall

mm8.0 l. %7.6 I 556.1 1.98

12.1 3.359.7 2.67

11.9 3.98

0.6 0.2S0.7 0.220.5 0.34

mm3.7 2.085.0 0.893.5 1.39

mm2.5+ 1.291.7 1.041.2 0.99

mm+1.7 0.88+ 1.2 0 .85+ 1.5 1.27

["Me IVOsseous Tissue Response to Open Debridement According to Type of Defect

T ype of delect

Combined 1 and 12 wall

2 WallCombined 2 3 and1 wall

N

1-107

Initial os-seous depth

njtti4.2 1.903.2 0.723.4 1.29

Postoperativevisits

12.1 3.39.7 2.711.9 4.0

N P I x / lK

0.6 0.30.7 0.20.4 0.3

R esidual os-seous depth

mm2.0 2.101.6 1.051.3 0.93

O s s e o u s fillmm

1.3 1.210.8 0.751.5 1.01

Cresial resorp-tionmm

1.0 0.600.8 0.790.7 0.58


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Volume S3Number I Periodontal Healing: Clinical Assessment 11In summary, our measurements indicate that flapdebridement procedures in our patient pool universallyled to gingival recession (average 2.0 mm) and limitedpocket closure (average 1.4 mm ). L oss of attachm ent wasnot observed at any treated site during our observationperiod. T he infraosseous portion of the lesions mirroredthe soft tissue (supracrestal) responses to debridement.

We recorded crestal resorption (average 0.8 mm) coupledwith apical fill (average 1.2 mm).When the gain in soft tissue attachment was comparedto the number of postsurgical maintenance visits, a sta-Table VCorrelation of iiain in Attachment Level, Crestal Resorption, Osseousfill, ami \umber of Postsurgical I'isits and \P l

G ain in attachmentO sseous fillCrestal resorptionN umber of postsurgical vis-

it s

P ostsurgical visits0 .89 '0.59*

- 0 . 0 4 t

NP I at reentry- 0 . 7 0 *-0 . 60*-0 . 00**- 0 . 8 4 *

A ll values significant P< 0.001.t N ot significant.

tistically significant correlation was found (/ = 0.89. P< 0.001). Comparing the gain in attachment with theam ount of plaque at the surgical site (N P I) resulted in anegative correlation (r = 0.70. P < 0.001). A similarnegative correlation was found when the amount ofosseous Fill was compa red w ith the N P I {r = -0 . 6 0 , P< 0.001). N o significant corr elation could be establishe dbetween the amount of crestal resorption and the numberof postoperat ive visits or N P I . When the number ofpostoperative visits were compa red to the N P I, a statis-tically significant negative correlation was found r =-0 . 8 4 , P< 0.001 (T able V).Multiple measurements of sites within the osseousdefect of three patients (T able VI) indicated varyinglevels of remodeling within each defect. In our samples.the deepest part of the defect was different at reentryfrom wh at it was at the time of initial surgery. T hisdiscrepancy in osseous fill can be seen with patient N o.1 (Fig. 2) where the osseous fill at two points within thesame defect measured 3.3 mm and 0.4. mm . A t thedeepest part, this defect measured 3.8 mm at the time ofinitial surgery (Fig. 2c). A t reentry a 3.3 mm "osseous

f A

2e

Figure 2a. Clinical appearance of the surgical site /mesial of the maxillary left canine/ before periudontal surgery, b. Clinical appearance of theinlraosseous lesion immediately after debridement. c. Osseous defect with probe inserted measured i.7 mm in depth, d. Clinical appearance, at 24-weekreentry surgery, of the residual osseous defect measuring 1.1 mm. Fill and remodeling are evident, e. Surgical site, at time of reentry, wilh a fill whichvaried rom 0.4 to 3.3 mm at two separate points of measurement.


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12 Frown, Coran, Thaller. Kushner, Scopp, Siahl J. Penoduntol.January, 1982

3g1 3a. ( linical appearance of the surgical ale, mesial of the maxillary left canine, before periodontal surgery, h. Clinical appearance of the site

probed with an X.4 mm soft tissue pocket depth.c. Appearance of the osseous defect immediately following debridement. The defect measured 4.1 mm indepth, d. ( linical appearance oj the surgical site, 24 weeks postsurgicalfy, just before reentry, e. Soft tissue probing before reentry, reveals a residual softtissue pocket depth of 4.5 mm, with 2.7 mm gingival marginal recession and 1.2 mm of "new attachment." f. Osseous site at time of reentry. Crestalresorplion measured 0. ? mm . white the residual osseous defect varied from 0.4 mm to 3.6 mm ui Iw o different Kludy points, j>. Probing the residual osseousdefect at time of reentry reveals tin osseous fill of 0.6 mm At ike 2nd study point, 1 mm mesial to the deepest point, the osseous fill measured 2.2 mm.fill" was measured (Fig. 2d). H owever, at a second sitewithin the same defect which measured 3.7 mm in depthat initial surgery, "osseous fill" measured 0.4 mm atreentry (Fig. 2e). A lthough an average fill for the entiredefect was calculated to lie 1.9 mm, the greatest filloccurred at the deepest part of the defect and along theosseous walls. A similar type of remodeling took placeon tooth N o. 11 on patient N o. 2 (Fig. 3). Comparingthe initial osseous defect with the defect at reentrv

showed considerable rem odeling. T he deepest part of thedefect at initial surgery w as 4.1 mm (Fig . 3c). A t reen trythe osseous fill was 0.6 mm. H owev er, at a point jus t 1mm mesial to this point osseous fill measured 2.2 mm(Figs. 3f. 3g). A gain in soft tissue attachm ent occurredat all four sites in all three p atien ts, rang ing from 1.2mm to 2.7 mm (Table VI).T a b l e VII depicts tooth mobility patterns at the 31surgically treated sites. T hese values were observed using


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Volume S3N u m b er LTable VIOsseous Response at Multiple Points in tour SitesPatient

N o.

1

2

3

A ge

54

JN

53

Site

M i l

M i lM22

M 3l

R eentryweeks

24

2424

28

Initial osseousdepthmm

3.7J.73.63.8

3.7

4 14,13.03.05.05.0

Treated With OpenMainte-nancevisits

16

1312

17

NP1 x /18

6

6

6

2

Periodontal Healing: Clinical AssessnDebridement Flap

R esidual os-seous depth

mm0.02.22.10.10.43.6

l. l

2.0a-3.02.0 2.5

ProceduresO sseous fill

mm3.30.4' 1 4JJ

19

2 ' 2 } l 40.61- 4l I A.. ,' 1-42.4J" I 2 ' 0

Crestal re-sorption

mm0.7

(1 7

0.8

0.5

Change inattach-mentmm+2.2

+ 1.2+ 1.3

+2.7

T ab le VI IMobility Patterns for Various Types of Defects

T ype of Defect \ A verage initialmobilityA verage 24-48week postsurgi-

cal mobilityCom bined I and 1-2 wall 142 wal l 10Combined 2-3 and 3 wall

1.1 0.4 61.3 0.590.9 0.690.6 0 .511.1 0.570.6 0.69

the Miller Index,'' which has been reported to be highlysubjective.13 Within these limits, our findings showed nosignificant effect of flap debridement on mobility pat-terns.COMMENT

R espons es of diseased periodo ntal tissues to debride-ment long have been described as ranging from limitedhealing, caused by a reduction in inflammation, to theformation of new coronal at tachm ent. u In early reports,debridement of infrabony lesions caused fill in many ofthe treated cases.'"' lh With increasing experience, variousmodalities for treating the infrabony lesion have beenevaluated over time. T he data at hand show that m anylesions exhibit repair regardless of treatment modalityused.1' H owev er, levels of repair seem to be related to:(a) depth of lesion, (b) configuration of lesion, (c) plaquecontrol at surgical site, and (d) modality of treatment.R esults of the current investigation show a signif-icantly high correlation between gain in attachmentlevel-osseous fill and level of plaque control at the sur-gical sites. A similar correlation exists between frequencyof postsurgical maintenance visits and reduction ofplaque index at the surgical site. Th ese findings und er-score the importance of plaque control following peri-odontal surgery.1"'1 T hus variations in clinical responseswhen similar surgical techniques are used may relate tovarying levels of plaque control achieved during thehealing phase of the studies.O ur results com pare favorably with those of publishedstudies showing a reduction in pocket depth after de-

bridement and careful oral hygiene measures. For ex-ample, new coronal soft tissue adhesion to previouslyexposed root surfaces has been reported to be 1.5 mmfor a 5-year evalu ation perio d.'" O ur net gain in softtissue attachment averaged 1.4 mm.

T he respons e of fill after use of the procedu res o utlinedshowed crestal resorption of 0.8 mm (SD 0.63), whichis similar to that described by Moghaddas and Stahl, 1Husing identical measurement techn iques. Th is resorptiontook place regardless of the level of plaque control at thesurgical sites. A mea n osseous fill of 1.2 mm (SD 1.04)in the present study compares favorably with our previ-ously reported responses of 0.66 mm fill following de-bridement, but is less than the 2.98 mm fill we reportedwith the use of bone blend grafts.' Since the presentnumber of sites was limited, the topography of defectsvariable, and the conditions responsible for these lesionsnot clearly understood, comparison of healing responsesmust be evaluated with caution. In the current study,such caution is underscored by the demonstration thatfill may vary considerably within each defect. T husextreme accuracy in finding the same spot along the fill,both pre- and postoperatively, becomes a necessity foraccurate comparisons. H owever, such a degree of preci-sion is not av ailable in clinical practice. N or can we besure of the prognostic implications of such pinpointresponse within the total repair of an infrabony defect.Clinically, then, we must recognize the limited repairpotential of infrabony lesions and further evaluate therole of the various etiologic and therapeutic factors whichinfluence the repair potential. H owever, the present data ,albeit limited, demonstrate the ability of periodontaltissue to repair and even regenerate, a concept questionedby a previous generation of periodontists.20

REFERENCES1. N yma n, S.. Rosling, B., and L indhe. J.: Effect of professional

tooth cleaning on healing after periodontal surgery. J Clin Periodomol2: 80, 1975.

2, R osling, B., N yma n. S., and L indhe. J.: T he effect of systematicplaque conlrol on bone regeneration in infrabony pockets. J ClinPeriodonwi 3: 38, 1976.


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14 Froum. Coran. Thaller. Kushner, Scopp, Siahl J. PeriodontoLJanuary. IVN2.1 Kosling, B., N yman, S.. l.indhe. J.. and Jern. B.: T he healing

potential of the periodontal tissues following different techniques ofpenodonlal surgery in plaque-free dentitions J < lin Periodontol 3: 233,1976.

4 P oison, A . M.. and H eijl. L. C : O sseous repair in infrabonyperiodonml defects. J Clin Periodontol 5: 13. 1978.

5. hllegaard, B., and L oe. H .: N ew atiachnient of periodontaltissues after treatment of infrabony lesions. J Periodontol 42: MS, 1971.

f. Hiatt, W. [1. , Schatlhorn. R. G . . and A aronian. A. J ,: T heinduction of new bone anil cementum formation. IV Microscopicexamination of the periodonlium following human hone and marrowallogral'l. aulografl. and non-grafi peno dom al regenerative procedu res.J Periodoruot 49 : 495. 1978.

7. Froum, S. J., O rtiz, M., Witkin. R . T .. Thale r, R ., Scopp, I . W..and Stah l. S S.: O sseous auto^rafts. I I I . Comparison of osseouscoagulum hone blend implants with open curettage. J Periodontol 47 :287. 1976.

8. Carraro. J. J., S/.najder. N .. and A Jonso. (. A .: Intraoral e an-cellous hone auiografts in the ireaiment infrabony pockets, J ClinPeriodontol 3: KM, 1976,

9. R amljord, S.. Knowles. J. W.. Nissle. R. R.. Shick. R. A ., andBurgell, F. G .: Lo ngitudinal study .if periodom al therapy. J Periadoniol44: 67. 1973.

10. Knowles. J. W., Burgett, F. G-, N issle, R R ., Shick. R A .Morrison. E . C , and R amljord. S . P . : R esults of periodontal ireaimenirelated to pocket depth and attachm ent level. Hight years. J PeriodonuA50 : IIS, I W .

11. G rossm an. R . D., and Kedi, P . F.: N avy periodontal screeningexamination. J Am Soc Prev Dem 3: 41. !974.

12. Miller. S. C : Oral Diagnosis and Treatment, ed 3. p 9. NewYork. T he Blakision Division McGraw-Hill Book Company. Inc..1957.

13. Pam eijer , C. H. , and Slallard, R . E. : A method for quantita tivemeasurenieiH s ol .oath mobility. J I'enodontol 44: 3.19. 197.1.

14. Stahl. S. S,: Repair or regeneration. J Clin Periodomol 6: 389.1979

15. G redm an. H . B.: A rationale for the treatment of the infrabonypocket. J Periodontol 20: 83. 1949.

16. P riehard. J.: T he infrabony techniq ue a.s a predictable proce-dure ./ Periodontol 28 : 202, 1957.

17. Smith, F . H . , A mmons, W. F, , and Van Belle . G . ; L ongitudinalstudy of periodontal status comparing osseous recontounng with flapcurettage- J Periodomol 51 : 367. 1980.

18 Yuk na, R . A ., and Williams. J. E.: Five year evaluation of* theexcisional new attachment procedure, J Periodontol SI: 382. 1980.

19 Mog haddas, H ., and Siahl, S. S.: Alveolar bone re modelingfollowing osseous surgery. J Periodontol 51 : 376, 1980.

20, O rban, B. : Pocket e limination or reatlachment? NY State DemJ 14: 227. 1948.

Send reprint requests to: Dr. S.S Stahl, Depa rtmen t of P eriodontics.N ew York University College of Dentistry. 421 First Ave. New York.N Y l(K)10.

11 clinical assessment of soft tissue and osseous repair

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