JOHN PRICHARD, D.D.S., FORT WORTH,
INGHORNE and O’Connell1 demonstrated regeneration of previously lost periodontium histologically in experimentally produced epithelized pockets in dogs. Regeneration following rational periodontal therapy for specific resorptive lesions (namely, the infrabony pocket and the acute periodontal abscess) has been shown by clinical case reports.2-4 An infrabony pocket differs from a gingival pocket only in that there is bone in its lateral wall, that is, the alveolar crest is coronal to the base of the pocket. Pocket elimination therapy also differs in that the pocket cannot be eliminated by reduction of edema. or by removal of the soft tissue wall through gingivectomy, as the bony scaffold supports the gingiva coronal to the base of the pocket. Infrabony pockets can occur on any tooth surface where the bone is thick enough to have supporting bone between the alveolar bone proper and the cortical plate. The infrabony pocket is frequently associated with the periodontal traumatic lesion. Goldman5 offers the following explanation for this occurrence: “If inflammation destroys the gingival fibers, and a pocket develops in an area where periodontal traumatism has destroyed the periodontal membrane in the crestal region, the epithelial attachment can migrate apically beyond the alveoWhether the periodontal membrane is lar crest since there are no barriers.” destroyed by necrosis due to pressure or weakened by tension has not been established beyond controversy. The acute periodontal abscess is an area of high metabolic activity, and treatment following resolution of acute inflammation has the advantages of the presence of repair elements in the tissues not present in the chronic lesion. In disease generally, the more acute the inflammatory reaction, the more dramatic the response to rational therapy. This is true of periodontal pathology as well.
Case Reports Case L-A 45-year-old housewife w:as examined on May 13, 1954. plaint was discomfort in the left mandibular molar region and a popping Presented at the Rome Smith Memorial
Her chief eomin her right ear
Seminar on Bone, December, 1955. 247
on the distal
of the left
m olar :
secpocket marker showing pocket depth of 12 mm. ; c’, right mandibular B. with Hirschfleld in the bifurcation and distally between the molars. The t bifur“II, f molar with bone absorption cat :ion could not br rntrre~l with a probe from either the bucral or the lingual surfaces.
BONE during mastication. The joint symptoms more severe.
REGENERATION She could “feel were of about
[her] jaw slip out of place when she opened wide.” four years’ duration anal had become progressively
Previous periodontal treatment consisted of subgingival curettage in home care of her mouth. This was completed about two years prior date.
and instruction to examination
Oral examination showed evidence of good oral hygiene. Moderate amounts of subgingival deposits were present; the attached gingivae were stippled and pink, except. in the molar regions where some hyperemia was noted marginally; and the papilla between the left mandibular molars was cyanotic and edematous. The mandibular papillae generally showed some blunting and slight enlargement anll the sulcus depth averaged 4 mm. in the anterior and premolar regions. There was a 12 mm. pocket on the distal side of the left mandibular first molar and a 6 mm. pocket on the distal side of the right mandibular second molar. In t,he maxilla the anterior gingiva approachetl the ideal or normal texture and contour. Posteriorly, the tissue was enlarged with pocket tlepth of 4 to 6 mm. in the molar regions. The consistency was firm, but, gentle probing caused hemorrhage. The right maxillary lirst molar had been lost about fifteen years earlier due to caries. It was not replaced. The second and third molars had tilted forward into the edentulous space and the mandibular first molar hat1 erupted above the occlusal plane, The resulting uneven marginal ridges and plunger causing premature occlusal contact. cusps caused foot1 impaction with caries, gingival inflammation, and pocket formation. There was also a plunger cusp on the maxillary le”ft first molar with food impaction between the opposing first and second mandibular molars. The roentgenographic examination (Fig. 1, A and 13) showed an infrabony deformity extending to the apical third of the distal root of the left mandibular first molar with lateral A witlenetl periodontal membrane space suggested extension kmecally into the bifurcation. periodontal traumatism. The right mandibular second molar showed bone absorption in the bifurcation and distally there was bone loss between the molars (Fig. 1, C). It is significant that the bifurcation could not be probed from either the buccal or the lingual sides. The patient was in fair health; she had sufferetl a Ijack sprain flve years before and had The tcmporomandibular joint symptoms developed sho\vn some anxiety since the accident. during t,his time. Marginal periotlontitis tlue to local environmental factors traumatism from subconscious occlusal hyperactivity triggered with temporomantlibular joint symptoms resulting.
described above. hp occlusal pre-
Therapy consisted of subgingival scaling, occlusal adjustment, and gingivoplasty for the manrlibular gingivae and the maxillary molar gingivae with subgingival curettageinfrabonp pocket therapy for the left mantlibular first molar.6 When explored under anesthesia: the interproximal area between the right mandibular second and third molars provetl to have a
folThe te~nporomantlib~~lar joint J-mpt ems were relieved, but recurre~l ternporaril~ lowing amalgam restorations of carious areas on the right side in November, 1954. Food escape grooves and marginal ridges were established in the restorations which were devoid of occlusal anatom . There haa been no Pnrther cliscornfort.
H. Pig. 2.--A, lione tegenttration in the infrabony defect fourteen months after therapy: h’, bone regeneration has fllled in the infrabony defect between the right second and third molars and the bifurcation of the second molar, Case 2.--A 30-year-oltl male aircraft worker W Y W emamine~l on July 6, 1954. He had an acute periotlontal alwess irrvolvinr the left maxillary central incisor with drainage of purulent exudate on both the lingual an11 labial surfares (Fig. 3, A and IS). The incisor could be ch~vatcll :III~ ~leprrsswl in its swket.
periodontal and B, Acute dr, ainage of a purulent
abscess between the nlaxillary exudate on the palatal and labial
in<3isa central surface :s.
0. s..0. M..6 (1J’.
This area was reshapctl 1,~ gingi\-oplasty with a suture betw-een the central incisors. during periodontal treatment which was done at a later tlat.e (Fig. 4). The roentgenograms in Fig. 5, .4 and I< show hone absorption before treatment; Fig. 5, C: shows the estcnt of Ijonc regeneration fifteen months after therapy. B.
c. P’ig. 5.---A, Roentgenosranr shmving bone absorption involved in acute periodontal abscess; R, with Hirschfleltl tion fifteen months after therapy.
around left maxillary pocket
References 1. Linghorne, \V. .I., anti O’Connell, T). C.: Studies in the Reattachment and Regeneration of the Supporting Structures of the Teeth, .J. 11. Res. 34: 164-177, 1955. 2. Goldman, H. hf.: Subgingival Curettage, a Rationale, .J. Periodont. 19: 54-63, 1948. 3. Goldman, H. M.: A Rationale for the Treatment of the Tnfrabony Pocket, .J. Periotlont. 20: X3-92, 1949. 4. Prichartl, .John: Management of the Periollontal Abscess, OKAT, SIXI:., OK.U. MED., ANI) OKAI, PATH. 6: 474-482,. 1053. 5. Goldman, H. M.: Periodontra, ed. 3, St. Louis, 1953, The C. V. Mo~by Company, p. 161. 6. Goldman, H. M., Schluger, Saul, and Fox, l,ewis: Periodontal Therapy, St. Louis, 1956, The C. V. Mosby Cornpan>-. 4121 CAMP UOWIE Bnvn.