Osseous Autografts
I. Clinical Responses to Bone Blend or Hip Marrow Grafts
by S. J. FROUM, R. THALER, I. W. SCOPP, S. S. STAHL
A PRIMARY GOAL of penodontal therapy is the restoration of lost periodontium destroyed by periodontal disease. Various graft materials1"1' have been used in the treatment of infrabony deformities. Currently, two such graft materials, autogenous iliac marrow-cancellous bone19'22 and osseous coagulum-bone blend,23"25 have been reported to give highly favorable results. Histological evidence in animal and human studies,26"29 using autogenous iliac marrow and cancellous bone suggested possible poteniiation of regeneration and reattachment with the use of these materials. Animal30 32 and human studies 25- 33- 3* using autogenous intraoral graft material have supported clinical reports of regeneration of the periodontium.
The purpose of the present investigation was to clinically evaluate and compare regeneration following implantation of either osseous coagulum-bone blend obtained from intraoral sources or autogenous marrowcancellous bone obtained from the posterior iliac crest.
MATERIALS AND METHODS
A total of 32 transplants were performed in 15 males, 23 to 64 years of age, each of whom consented to take part in this study. Twenty-five sites were treated with osseous coagulum-bone blend from intraoral sources. while seven sites were treated with frozen marrow-cancellous bone from the posterior iliac crest. Four patients received both marrow and bone blend implants in different sites.
All patients selected for this study were being treated for periodontitis at the New York Veterans Administration Hospital. These patients also suffered from a variety of other diseases (Chart I). Each patient had a complete medical work-up and where necessary, medical clearance was obtained. Pre-operative treatment, in all cases, consisted of oral hygiene instruction, adjustment for occlusal interferences, root planing, and curettage. Temporary splinting was employed where toolh mobility exceeded class II (Miller classification).35
Periodontic Section, Denial Service, New York Veterans Administration Hospital and the Department of Periodontics, College of Dentistry at the Brookdale Denial Center of New York, University, New York, New York.
After initial therapy, clinical and radiographic evaluations were used to determine whether surgery was necessary to eliminate the defect. An oral hygiene index (OHI-S)36 was utilized during initial treatment. Onh when the index approached zero was surgery considered. Prior to surgery, periodontal conditions at the surgical site and other pertinent presurgical information were recorded on a specially prepared data sheet (Chart 11).
Surgical Procedures
In all cases, an inverse bevel lull thickness, mucoperiosteal flap was reliected. An effort was made to retain the marginal gingiva to ensure maximum soft tissue coverage of the graft material. Site preparation consisted of removal of chronically infiammed tissue from the osseous defects and root planing to remove root accretions. Following debridement, the donor material was prepared for insertion.
Intraoral donor sites used were tuberosities, edentulous ridges, and extraction sites. Graft material was removed with a rongeur. The spicules of cancellous and cortical bone, with a few drops of blood, were then placed in a sterile capsule, and triturated to obtain a bone blend as described originally by Diem et al.37
Autogenous marrow and cancellous bone was obtained by a punch biopsy from the posterior iliac crest by the Chief of Hematology at the New York Veterans Administration Hospital. The material was stored in Eagle's minimal essential medium in a nitrogen freezer at -79°C for two weeks, then cut into small pieces, and inserted into the delect.
Regardless of the graft material used, all defects were overfilled. Following the graft placement, all patients were put on antibiotic coverage for one week beginning with the day of surgery.
Reentries were performed seven to ten weeks after the initial surgery in 23 out of 25 cases of bone blend implantation. The two remaining cases were reentered at 16 and 22 weeks. Reentries were performed four to seven months after initial surgery in all seven cases of iliac crest implants.
Documentation of Responses
During initial therapy two sets of study models were constructed. An Omnivac stenl was then fabricated from 0.10 mm thickness surgical tray material to serve as a fixed reference point.
At the site of the defect, the stents were grooved in an occlusal-apical direction with a no. 556 fissure bur. All measurements were recorded using a no. 50 endodontic silver point inserted into the notch and held by locking pliers with the beaks parallel to the occlusal surface (Fig. 1). A Boley gauge was used to measure the distance to the nearest O.I mm. All measurements were performed by the same operator to eliminate interexaminer discrepancies. This technique of measurement using fixed distances was tested previously for variance of measurements over a period of time and no statistically significant differences were noted.
Froum, Thaler, Scopp,Stahl
At the time of surgical exposure, another notch was cut into ihe stenl which enabled the silver point lo be positioned at the deepest point in the defect. The following measurements were recorded:
1. Base of stenl to crest of the most coronal wall of defect (Fig. 2).
2. Base of slent lo the deepest part of the defect (Fig. 3).
3. Base of stem to cemenloename! junction to cheek for sealing of the stent. In addition, roentgenograms and clinical photographs were taken of the surgical site immediately prior to and during periodontal surgery. Similar measurements, photographs, and roenlgenograms were obtained at the time of reentry. At this time the tissues had to appear clinically healed as demonstrated by reduction in { I } pocket depth and (2) clinically evident inflammation.
CHART I. Patient Data .I. Periodonlol. Stplember, IW Patienl No. I : i 4 5 6 7 8 9 10 I : : 13 14 15 Age(yr) 54 26 47 52 62 56 23 64 49 52 50 54 37 44 39 Medical diagnosis Cirrhosis of liver, TB None llv pertensiofi Neuropsychiatric Rheumatoid arthritis, psoriasis Femoral bypass None Hypertension, cirrhosis of liver Neuropsychiatric Colitis Menicre's ..vndrome Nerv ous disorder Apptrndicil is Folie acid deficiency, nervous disorder Duodenal ulcer
RESULTS
Response to Osseous Coagulum-Boiie Blend
Osseous coagulum-bone blend was the implant material in 25 infrabony lesions in 14 patients. Among the 25 infrabony lesions were nine one-wall, six two-wall, eight three-wall wide (including one combination two. threewall defect) and two furcation defects (Chart III). Fill in the one-wall lesions ranged from a loss of 0.8 mm lo a gain of 5.3 mm with an average fill of 2.53 mm. Fill in the two-wall lesions ranged from 1.2 to 4.0 mm with an average fill of 3.0 mm. Fill in the three-wall wide lesions ranged from 2 lo 6.4 mm with an average fill of 3.64 mm. Fill in ihe two furcation defects averaged 1.25 mm. Therefore, the total average increase in bone height with the osseous coagulum-bone blend graft material was 2.93 mm while the initial intraosseous depth averaged 4.0 mm. This represents a 73*8 fill of all defects (Figs. 4 and 5).
Response lo Hip Marrow
Iliac marrow and cancellous bone was utilized as a graft material in seven treatment sites in five patients. Among the seven infrabony lesions were five one-wall, one two-wall and one combination one, two-wall defect. Fill in the one-wall lesions ranged from 1.2 to 9.2 mm with an average fill of 4.3 mm. The fills in the combination one, two-wall defect and the two-wall defect were 5.6 and 3.4 mm. respectively. Therefore, the total average increase in bone height with the hip marrow graft material was 4.36 mm while the intraosseous depth averaged 7. IS mm. This represents a 60.!'-'< average fill of all defects (Fig. 6). A comparison of the above reported repair trends demonstrated that the difference in percentage of fill obtained with the various bone graft materials used was
CHART II. Operative Dam Chart 1. Name 2. Tooth No. 3. Previous R.C.T. 4. Mobility 5. Opposing Tooth f>. Splinled 7. Date Marrow Taken 8. Storage Method 9. Date Marrow Implanted Bunc Blend 10. Class ol' Lesion 11. Type of Incision 12. T> pe of Closure 13. Dale ol Re-entry ]4_ Antibiotic A. Soft Tissue Lesion 1. Guard to ging margin 2. Guard to pocket depth B Osseous Lesion 1. Guard toossom.s crest 2. Guard to depth ot lesion 3 FillOUE C. Oral Hygiene Index D. Histology Prior to Implantation MBD ML!) Prior lo Re-Enlrv MBD MLD Volume 4fi Number 9 Osseous Autogrqfts 517
FIGURE I. For standardization of measurements, a no. 50 endodontic silver point is inserted into a groove on the Qmnivac \tent at the site of the delect. The beaks of the locking pliers unplaced parallel lo the apical border of the stem.
FIGI KI 2. Silver point measuring the distance between the base of the stem mid the most coronal wall of the delect.
not statistically significant (I = 1.62. P < 0.05). However, our results suggest that average fill with marrow grafts was less than that obtained with osseous coagulum- bone blend. Furthermore, it is also obvious thai marrow grafts were used in deeper defects. Because of these trends we subjected our results to lurlher statistical analysis.
Comparison of Repair Responses in Intraosseous Defects Less or More Than 4 mm in Depth
Table I summarizes the repair trends considering average intraosseous fill in relation to the preoperative osseous depth.
In 15 cases using bone blend (defects less than 4.0 mm) we had an average fill of 2.3 mm, while average fill using marrow (defects less than 4.0 mm) was an identical 2.3 mm. In defects greater than 4.0 mm, the average fill using bone blend was 3.8 mm; using marrow it was 5.9 mm. The difference in osseous fill between marrow and bone blend was not statistically significant at the 0.05 level of confidence.
Table 2 lists the intraosseous depth remaining at the time of reentry. In cases where marrow was used the residual osseous depth ranged from 0 to 3.9 mm. In cases where bone blend was used, residual osseous depth ranged from 0 to 6.6 mm.
Table 3 summarizes the average reentry intraosseous depth in relation lo the preoperative osseous depth.
In cases where the initial intraosseous defect was less than 4.0 mm, the average residual osseous defect was 0.6 mm using marrow, compared to 0.3 mm using bone blend.
The average residual defect where the initial intraosseous depth exceeded 4.0 mm was 1.7 using marrow compared to 1.4 mm using bone blend.
Based on these trends, it appears that similar levels of osseous regeneration apparently took place regardless of graft material used. FlCt RI 3. The silver point is placed into the regrooved stem to measure the distance between the base of the stem and the deepest part of the defect. CHART 111. topography o) Deject and Qrati Material Used Type of defect Onc-uull Two-wall Combination Three-wull Furcation Grail Bone blend 9 6 0 : 25 material used Marrow 5 1 1 0 0 7 518 Froum, Thaler, Scopp,Stahl .I. Periodontol, September. 1975 }i(ii KI 4 A. Preoperative appearance <>/ the osseous defect showing horizontal bone loss, prior lo placement of a bone blend graft. B. Appearance oj the detect shown in A at reentry, nine weeks alter initial surgery. Sate osseous crestal apposition of lesion. DISCUSSION Several comments should be made on ihe significance of our findings. Case report evidence has been used in reporting our results. Recognizing thai different human periodontal defects are seldom identical, we wish to stress thai our results represent trends rather than possible universal repair results. However, ihe results of the present study generally agree with the previous literature20-25 which demonstrates comparable results using either intraoral cancellous bone and marrow or iliac marrow and cancellous bone as an implant material. Theories attempting to explain the role of autogenous implants in regeneration of periodontal osseous defects suggest three possibilities: I. Both inlraoral and iliac autografts have inductive capabilities which induce osseous regeneration.30- 3'2 2. Neither material has "inductive" abilities. 3. The degree of induction may vary with the site and the graft material used. Although many investigators lend to support the third of the above possibilities.39 our clinical data suggest no significant difference in repair responses. Of further interest is pocket topography in our cases. We classified our defects as one-, two-, three-wall wide defects and a combination of these, following ihe classic terminology of describing osseous defects.39 Seldom, however, did we find a defect which was purely a "one" or "two" wall delect from its base to the most coronal aspect of the remaining osseous wall. Most delects presented as a "confluence" of bony architecture. Other researchers have mentioned this phenomenon.2' For example, a one-wall defect usually had three walls at its r I K.I Ki 5 \ Preoperative appearance nf the combination one. two-wall inlraosseous delect prior to placement <>! a bone blend graft, B. Appearance of the one. two-null inlraosseous defect shown in A at reentry, eight weeks after initial surgery. Sole the apparent lilt and remodeling .>! the lesion. \ nluMIL- Ah Number .> IK,i KI d A. Preoperative appearance oj the two-wall irttraosseous defect prior to placement of an iliac marrow and cancellous bone implant B. Appearance of two-wall imraosseous defect shown in A at reentry. Id weeks after initial surgery. Again now the apparent till and remodel/tit? of the lesion. TABI t I. Average Fill tit Relation to Preoperative Osseous Depth in Two Procedures Graft material used Iniii.il iniruosseous depth (mm) No. of oust?. Average Till (mm) Bone blend Less ih^n -4-.lt Greater than 4.0 Iliac marrou Less than 4.0 Greater than 4.0 15 in 3 4 2.3 3.8 2.3 5.9 most apical part, two walls in the middle, and one wall at its most coronal portion. The implication of such classification in clinical research becomes apparent upon analysis of biomeiric data in studies dealing with osseous Fill. If we take one of our cases, for example, we see how a reported complete fill could be deceiving. In this case (an Osseous Auiografis 519 osseous coagulum-bone blend graft) no residual defect apparently remained upon reentry. However, of the original 8.5 mm osseous defect. 4.9 mm filled with new hone while 3.6 mm were eliminated b\ resorption of the walls of the defect. Thus, in evaluating a successful ""fill." one must separate ihe extent of the actual osseous fill from the remodeling with and/or without resorption of the original crestal architecture. We observed that the amount of new bone (fill) ma) depend on available osseous surfaces rather than number of osseous walls. In fact, as noted in our results, the difference in fill using osseous coagulum-bone blend in defects greater than 4.0 mm and defects less than 4.0 mm showed a statistically significant difference (f = 2.42, P < 0.05). Thus, the deeper the defect, the greater the fill. In this manner, one, two, or three walls may be considered as a clinical expression of variations in available osseous surfaces. Therefore, a 10 mm defect of one- or two-wall configuration may give significant responses because it may present greater surface area than a wide, shallow three-wall defect. The possibility that treatment of any single surface 2. Reentry tntraosseous Depth lluicmumm Bone blend Lessthun4mm Greater than 4 Less than 4 mm Greater than 4 preopcr,iii\c mm preoperalive preoperalile mm preoperative depth depth depth depth no Oil I * 0.0 0.8 2.0 3.9 66.0'-;' 0.0 o.o o.o 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 ' I I u I I - 3.0 86.79 0.0 0.0 0.0 0 4 0.5 0.6 1 5 2.1 : ' 6.6 60.0'T . P e r c e n t a g e of c a s e s with < I m m defect remaining. T\BI1 3. Average Reentry Imraosseous Depth in Relation to Preoperative Osseous Depth in THO Procedures Graft material UNL'd Bone blend 1 liac marrow Initial intraosseous depth (mm) Less than 4.0 Greater than 4.0 Less than 4.0 Greater than 4.0 No. of cases I- 10 3 4 Average intraosseous reentry depth (mm) 0.3 4 0.6 1.7 520 Froum, Thaler, Scopp, Stahl J. Periodonlol. September. 1975 may lead lo considerable osseous remodeling also exists, Certainly our data show remodeling of the crest including resorplion as a common phenomenon in the repair of infrabony lesions occurring within the first lew weeks alter surgery. It may, however, continue for many months29' 3a or years after surgery as part of the functional demands placed on the periodontium during the lifetime of the tooth. Finally a comment should he made concerning the timing of reentry procedures which in all but two cases of osseous coagulum-bone blend grafts, were performed seven to ten weeks postoperativety. Experimental histologic data in monkeys have demonstrated that hone responses following the use of osseous coagulum implants were completed by 90 days after graft surgery.32 Another study dealing with grafts of cancellous bone obtained from intraoral sources implanted into bifurcation defects showed evidence of new^ bone "connecting adjacent graft particles" as early as three weeks postoperatively.30 Using rabbits, Urist10 created defects in the rami of mandibles and filled these with deminerati/ ed bone. These grafts were "resorbed and refilled partially with new bone within four weeks."40 Other studies dealing with graft resorplion, demonstrated a mean resorptive time of six weeks when autogenous cancellous bone was implanted intramuscularly in dogs.41 Since our study was aimed essentially at comparisons of repair potential rather then complete remodeling, and furthermore since human studies indicated that remodeling may not be complete until about five years after graft placement,34 we felt that the seven- to ten-week time interval chosen would give us adequate documentation for an analysis of repair potential following the use of different graft modalities. SUMMARY A clinical evaluation was undertaken to compare regeneration of osseous defects following implantation of either osseous coagulum-bone blend from intraoral sources or autogenous iliac marrow-caneellous bone. Thirty-two transplants were performed in 15 male patients. The intraosseous delects in which marrow was placed (initial average depth --.. 7.18 mm) filled 60.7% (average fill 4.36 mm). Defects in which osseous coagulum-bone blend was placed (initial average depth 4.0 mm) filled 73% (average fill 2.93 mm). The difference in results between the two materials was not statistically significant. Therefore, similar levels of osseous regeneration apparently took place regardless of graft material used. ACKNOWLEDGMENTS The authors wish to express their appreciation to Mr. T. Willers, Mr. R. Vollmer, and Mrs. C. Yarlett of the Medical Illustration Service of the Northpor: Veterans Administration Hospital for their assistance with the photography. REFERENCES I. Haegedus, Z.: The rebuilding of alveolar processes by bone transplantation. Dem Cosmos 65: 736, 1923. 2. Beube. F. F_, and Silvers, H. I'.: Influence of devitalized hclcrogenous bone powder on regeneration of alveolar and maxillar) bone of dogs. J Dent Res 14: 15, 1934. 3. Beube, F. E., and Silvers. H. F.: Further studies on bone regeneration with the use of boiled heterogenous bone, / Periodontol 7: 17. 1936. 4. Cross, W.: Bone grafts in periodonUil disease: A preliminary report. Dent. Pract. 6: 98, 1955. 5. Cross. W.: Bone implants in periodontul disease: A further study. J Periodontol 28: 184, 1957. 6. Cross. W.: The use of bone implants in the treatment of periodontal pockets. Dent Clin IV Am 107, March, I960. 7. Forsberg, H.: Transplantation of os puruni and bone chips in the surgical treatment of periodontal disease. Ada Odoniol Scand 13: 235, 1956. 8. Kromer, H.: Bone homografts. Odoni Tdskrft 68: 9, 1960. 9. Schaffer, E. M.: Cartilage transplants into the periodontium of rhesus monkeys. Oral Surg 9: 1233, 1956. 10. Schaffer, E. M.: Cemenlum ;md denim impUinls in a dog and a rhesus monkey. J Periodontol 28: 125, 1957. 11. Ramjford, S. P.: Experimental periodontal reattaehment in rhesus monkeys./ Periodoniot 22: 67. 1951. 12. Scopp, I. W., Morgan. H., Dooner, J. J., Fredrics, H. J., and Hey man, R.: Bovine bone (Boplant) implants for infrabony lesions. Periodontics4: 169, 1966. 13. Scopp. I. W.. Kassouny. I). Y., and Morgan, F. H.: Bovine co9ne (boplant). J Periodontol 37: 400, 1966. !4. Hurl. W. C: Freeze dried bone homogralls in periodontal lesions in dogs. J Periodoniol 38: 89, 1968. 15. Radent/. W. H.. and Collings, C. K.: The implantation of plaster of paris in the alveolar process of the dog. /. Periodoniol 36: 357, 1965. 16. Patterson, R. L.. Collings, C. K., and Zimmerman. E. R,: Autogenous implants in the alveolar process of the dog with induced periodontitis. Periodontics 5: 19. 1967. 17. Schaffer, C. D.. and App, G. R.: The use of plaster of paris in treating infrabony periodontal delects in humans. / Periodontol 42: 685, 1971. IN. Schallhorn, R. G.: Eradication of bifurcation defects ulili/iiig fro/en autogenous hip marrow implants. Periodont Abstr 15: 101, 1967. 19. Schallhorn, R. G.: The use of autogenous hip marrow biopsy implants for bone crater defects. J Periodoniol 39: 145. 1968." 20. Schallhorn. R G., Hiatl, W 11., and Boyee, W.: Iliac transplants in periodonlal therapy./ Periodoniol41: 566. 1970. 21. Haggerty. P. C, and Maeda, I.: Autogenous bone grafts: A revolution in the treatment of vertical bone defects. / Periodoniol 42: 626, 1971. 22. Seibert. J. S.: Reconstructive periodonlal surgery: Case report. J Periodoniol 41: 113. 1970. 23. Robinson, E. R.: Osseous coagulum for bone induction. J Periodontol 40: 503. 1969. 24. Rosenberg, M. M.: Free osseous tissue autografts as a predictable procedure./ Periodoniol 42: 195. 1971. 25. Hiatt, W. H.. and Sehallhorn. R. G.: Intraoral transplants of cancellous bone and marrow in periodonlal lesions, / Periodoniol 44: 194, 1973. 26. Stovall. J., and Saxe, S. R.: Autogenous bone marrow implantation in periodontitis afflicted beagle dogs. 1ADR Abslr no. 546, 1972. 27. Sullivan. H.. Vito. A., and Melcher. A.: A histological evaluation of the use of hemopoietic marrow in intrabony periodontal defects. 1ADR Abstr no. 474, 1971. 28. Dragoo, M. R., and Sullivan, N. C: Histological evaluation of autogenous iliac bone grafts in humans. 1ADR Abstr no. 547, 1972. 29. Dragoo, M. R., and Sullivan, H. C: A clinical and histological evaluation of autogenous iliac bone grafts in Volume 46 Number 9 Osseous A utografts 521 humans: Part !. Wound healing 2 to 8 months. J Periodontol 44: 599. 1973. 30. hlletufurd, B., karnn;;, T., Listgarten, ML, and I iio, H.: New attachment alter treatment of interradicular lesions. J Periodontol 44: 209, 1973. 31. Yukutnanduna. I.: Bone grafts in the treatment of infrabonj periodonlal pockets in dogs. J Periodontol 36: 17 26. 1959. 32. Rivault, A. I-., Tolo. P. I)., Levy, S., and Garguilo, A. W.: Autogenous hone grafts Osseous coagulum and osseous retrograde procedures in primates. J. Periodoniot 42:7K"\ 1971. 33. Ross, S. ti., and Cohen. D. W.: The late of a free osseous tissue autograft: A clinical and histologic case report, Periodontics 6: 145. I96K. 34. Nabers, C. Reed. O. M., and Haniner, J. b.: Gross and histologic evaluation of an autogenous bone grail 57 months postoperatively. J Periodontol 43: 702. 1972. 35. Miller. S. C : Oral Diagnosis and Treatment, ed 3, p 9. New York, The Blakiston Division. McGraw-Hill Book Company, Inc.. 1957. 36. Greene, J. C . and Vermillion. J. R.: The simplified oral hygiene index. JADA 68: 7. 1964, 37. Diem, C. R., Bowers. G. M.. and Moffitt, W. C: Bone blending: A technique for osseous implants. J Periodontol 43: 295. 1972. 38. Burwell. G. R.: Studies in the transplantation of bone. J Bone Joint Surg. 46B: 110. 1964. 39. Goldman, H. M., and Cohen. D. W.: The infraborn pocket: Classification and treatment. J Periodontol 29: 272. 1958. 40. Unst, M. R.: Bone histogenesis and morphogensis in implants of deminerali/ed enamel and dentin. J Oral Surg 29: 88, 1971. 41. Bell, \Y. H.: Resorption characteristics ol bone and bone substitutes. Oral Surg 17: 650. 1964.
Abstracts
fin Roi> oi- ANTIBIOTICS IN mi MANAGEMENI OI OPEN FRACII K I S Patzakis, M. J., Harvey, I P., and Mer. I). J Bone Joint Surg 56-A: 5 3 : . April. ll>74. Four culture specimens were obtained from Ihe open Fractures of 310 patients divided into groups receiving penicillin and streptomycin, cepthalolfain, or no antibiotics and studied fur infection. An infection w;is considered to have occurred when clinical signs and symptoms oF infection such as fever, erythema, tenderness, ;md wound drainage were present along with a positive pram stain or ;i positive culture. The relationship of retrieval of bacteria after injury and incidence of infection was then correlated The incidence of infection was 13.991 in the control group .ind 9.7''J in the penicillin und streptomycin group. This difference was mil statistical!) significant. In the group receiving cephulolhm there was a significant!) lower infection rate of 2.3%. The resulis suggested that eephalothin is an effective antibiotic for proph>- lactic therapv of open fracture due to direct iruurnu. Department of Surgery-Orthopedics and the Department of Microbiology, University oj Southern California, School o/ Dental Medicine, Los Angeles, California tin i< i oi ANTI-THYMOCVTI ON CHRONIC GINGIVAI INFLAMMATION IN DoliS Nobreus. N.. Allsirom, R . imd Egelberg, J. J Periodont Ret 9: 236. No. 4. 1974. To determine the rule of cellular immunity in chronic gingivitis, six experimental and lour control beagle dogs with well-established chronic g i n g i v i t i s were used I h e e x p e r i m e n t a l g r o u p was i n j e c t e d with anti-thymocyte serum (ATS) to suppress cellular immunity and the control group was injected with rabbil lg(i The immunosuppressivc effect of ATS was measured using l-diniuo-2.4-chlorohenzene (DNCB). ,i chemical which will initiate a delayed tnperscnsuiviu reaction. The level of gingivai inflammation w;is determined before and after administration of ATS h\ measurements ol crevicular leukocytes, gingiwil liuid. and acid phosphalase aclivil) in crevicular samples. 1 he results showed the ATS mhihned skin reactions of DNC'B. The gingsval parameters were onl> slighlh reduced in both experimental and control groups. The role of cellular imniunn> in chronic gingivitis appeared to be a minor one. Other inflammatory mechanisms ma\ he active in the maintenance of this condition. School of Dentistry, Carl Oustavs v'dg 34. S-:i4 21 Malmu, Sweden Tfif PLAQUE-REMOVINC A B I I N I oh SOMH COMMON [NTERDENTAI AIDS AN IKTRA-INDIVIDUAL STUD\ Bergenholt/, A.. Bjorne, A., and Vskslrom. B. J din Periodont 1: 160. No. 3. 1974. Interdental aids including a soft toothbrush, waxed dental tape, and rectangular, round, and triangular toothpicks were tested for plaque removal on f>3 teeth which were in contact with neighboring teeth and with open interdental spaces Each of the 2~5 subjects was required to use each of the aids with the toothbrush for different randomized periods of two weeks and in one session, the brush wus used alone as a control. Plaque accumulation was measured b\ a modified Plaque lnde\ (Silness and Loe) at the beginning and end of each period and a gingivai index (LiJe and .Silness) of inflammation at the start and completion of the ten weeks. No significant differences were found in the plaque-removing ability of the different aids on an\ surfaces exctpi that all interdental aids were more effective in cleaning buccul interdental!) than toolhbrushing alone. The triangular toothpick was significantly more effective than the rectangular one. Lingualh localized interdental areas were best cleansed by the triangular toothpick and dental tape while on Imguoaxial surfaces the triangular toothpick was the only one more effective than toofhbrushing alone. There was no significant difference in gingivai inflammation between the si.iri and completion of the study. Department of Periodontoiogy, University ot Umea. S-901 H7 lined. Sweden BOM INDUCTION BY ALLOCENOUS RAI DtNTiNt IMPLANTED Suactn >LNCOI SI I De Grool. K Arch Oral Biot 19: 477. June, 1974. Upper and lower incisors of Sprague-Dawlev strain adult rats were demincrali/cd. mechanically scraped free of pulp tissues, hophihzed and incubated at various temperatures, limes, and pH levels. Quantitative evaluation, 2& days tullowmg implantation, was deu-rnnned b\ the calcium content in implants and by histometric calculations of calcium concentration due to new bone formation and remineralization of nld dentine matrix. Bone morphogenelie properties of dentine were found to be labile when incubated at neutral pH, higher temperature, and longer time, although mineralization properties of bone and dentine matrix were different. Deportment of Material Science, School of Dentistry and Medicine. Free University, Amsterdam, de Boeleiaan. 15. Setherfonds
Results Following Three Modalities of Periodontal Therapy*
by
SIGURD P. RAMNORD, L.D.S., PH.D.
jAMIiS W. KNOWLES, D.D.S., M.S.
ROBERT R. NISSLE, D.D.S., M.s.
FREDERICK G. BURGETT, D.D.S., M.s.
RICHARD A. SHICK, D.D.S., M.s.
CONVINCING EVIDENCE of new connective tissue1 and epithelial attachment^ following periodontal therapy has revived the interest in therapeutic methods aimed at reattachment. Although new attachment has been reported following several modalities of treatment,3"5 there is a remarkable lack of data from controlled clinical trials to indicate the short and long term potential for gain or loss of periodonlal attachment following treatment. Some treatment methods such as subgingival curettage and Widman flap surgery* are more specifically aimed at reattachment than pocket elimination surgery which basically is aimed at stopping the progress of destructive periodonlal disease through surgical elimination of periodontal tissues corona I ly to the most apical extent of the pockets, and to restore surgically a "physiologic" gingival contour at that level. In selection of periodontal therapy the main concern is to maintain as much attachment for the teeth as possible for the lifetime of the individual. Whether this goal can be served best by therapy aimed primarily at reattachment or by surgical pocket elimination still is a highly controversial issue. The purpose of the present study was to compare over a period of five years results following two methods aimed at combined reatlachment and surgical pocket reduction (i.e. subgingival curettage and modified Widman Hap surgery) with results following attempted complete surgical pocket elimination and restoration of gingival contour. METHOD The criteria for acceptance of patients and lor scorings were the same as published in our previous studies.7 8 Calibration tests before and during the study indicated * This research was supported in purl by U.S. Public Health Service (irant DE 01430. tTht University of Michigan School of Dentistry, Department of Periodontics, Ann Arbor, Mich. 4X104. that the scoring errors would have an insignificant effect on the total results reported in this paper. After examination and scoring, all patients had initial treatment consisting of scaling, initial root planing, instruction in oral hygiene, and occlusal adjustment. They also received emergency dental care and recommendations to have denial restorations placed in carious lesions. As in our previous studies,3 the teeth in one half of the mouth (divided in the midsagittal plane between the central incisors) constituted the experimental unit. The means from measurements and scores for individual teeth within this unit were used for clinical evaluation and for statistical analysis of results. Using the analysis of variance to test for significant differences between the three modalities of treatment does not maximize the power of the analysis since the advantage of the paired treatment design was not fully utili/.ed. This resulted in conservative significance levels for the analysis of variance which were considered to be appropriate considering the small clinical magnitudes of the differences. With three treatment modalities for either the left or the right side of the mouth there were six possible combinations for each patient. One of these six combinations was assigned to each patient using a table of random numbers as he entered the study. The subgingival curettage and the surgical pocket elimination were performed as described in previous reports.7- 9 The Widman flap surgery was modified as described recently.9 All patients were recalled for prophylaxis by a dental hygienist every three months, and rescored every year following the initial treatment by the investigator who did the original scoring. All patients admitted to ihe study after July I, 1966 were included in this routine. Results from patients treated prior to that time were not in any way included in the present report since it is essential for fair comparison of the results that each method of treatment had equal chance to be compared with the other methods of treatment in the same patients, performed at the same time, and by the same therapists. Unfortunately it is, for practical reasons, impossible to start all patients at the same time, and they cannot be completed at the same time. Thus we had to organize our data on the basis of time intervals of years following the initial treatment. Most of the patients included in this report had their initial treatment in 1967 to 1969, but a few have been admitted later. The cut off date for the data included in this report was December 31, 1973. SAMPLE A total of 82 patients had their periodontal treatment completed in the study. The present report is based on followup results in 79 patients. L-ighteen patients have been lost, and at the time when ihe present data was compiled (December 31, 1973) there were 64 patients |
