A Clinical Study on the Gingival Regeneration with Reference to the Curative Process. Masao K US UNOKI * and Noriko F UJISAKI *

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1 A Clinical Study on the Gingival Regeneration with Reference to the Curative Process by Masao K US UNOKI * and Noriko F UJISAKI * In 1962 the authors published their study as " 303 Clinical Cases of the Gingival Regeneration in Periodontal Diseases " (The Journal of Nihon University School of Dentistry, Vol.5, No.2). The feature of our technic described in that study is to excise in a fairly wide area the region periodontally afflicted and expose an alveolar bone about 3-4 mm by removing the alveolar mucosa and apply a surgical pack directly on the exposed alveolar bone after having cleaned the deposit and imperfect gingiva and, if necessary, osteoplasty is administered. In that study, we stated to the effect that the advantage of this technic consists in the reduction of operational time since it does not require suturing as in the case of flap operation and the good postoperational growth of interdental papilla. As distinct from any previous gingival restoration or curettage technic, a cure under this technic can be effected by means of entirely new gingiva, not from the old native gingiva. A brief summary of the technic together with illustrations appeared in the Dental Abstracts, American Dental Association (Vol. 9, No. 2, pp , 1962). Since this study was published, we have further applied the same technic to more patients amounting to over 1000 at the time of writing. Based on these numerous clinical cases, we here report on their curative process by means of roentgenographical findings and magnified photographs to illustrate the manner of curative process in the light of histology. Roentgenographic Findings Of over 1000 patients, 2 have been selected which best serve the purpose. The case (I A) was a woman of 21-year-old and the chief diagnosis was a bone atrophy extending all over the jaws with all the teeth being in the state of highly loose movement. A few dentists whom she had consulted recommended the complete extraction and a subsequent installation of a complete denture. The overall gingiva revealed no pathologic change worthy of note but there were spots which discharged a certain quantity of pus under digital pressure. The oral cleaning was fairly good and no dental calculus was noted. Some of the teeth were so loose as to extend the blind pocket by as much as 5 mm. As revealed by a roentgenogram (I A) above, an irregular disappearance of bones in the vertical manner is noted and in particular, pathologic changes are observed in the periodonteum around the apexes of Taken after a full year of our operation, I B clearly indicates the rebirth of alveolar tip and an evident state of Dept. of Periodontology, Nihon Univ. School of Dentistry (Director Prof. Masao Kusunoki).

2 periodontal white line. Particularly, in 5 4 the periodontal line at the apex and root portion assumed a white color. At this stage the loose movement of teeth had completely stopped and the gingiva appeared to be normal under both the visual and palpative inspections. The second case (II A), which was a woman of 53 years of age, had only the anterior teeth left on her lower jaw. 1 2 were abnormally arranged, 2 suffered from a severe caries and were loose more than half the normal state, the blind pocket being about 4 mm with the gingiva somewhat swollen and hard to the touch. 73 II A which is a roentgenogram of the preoperative state is contrasted with II B which was taken one year and three months after an operation. In the preoperative state, we notice that the alveolar region had been resorbed and the bone beam was destroyed, resorbed and rendered quite coarse. A pathogenic focus was noted with 2. After one year and three months (II B), during which time the patient underwent our operation, was given a resin previsional retainer, an extraction of 2, a pulpectomy, cavity filling and an inlay of 1. As can be seen from a photograph here, we confirm the consistency of bone and that the white line has become quite distinct. The loose movement of teeth nearly stopped, gingiva became firm and solid with the normal color restored. However, as this case had, originally lost more than 1/2 of the alveolar bone

3 74 through resorption, even with the gingival regeneration technic about 1/3 remains still exposed. As attested to by these findings, the majority of gingival regeneration operations have resulted in restoring the residual alveolar bone to become solid in texture and in arresting the loose movement of teeth. We have encountered no case as yet which has turned for the worse because of the fact that a patient underwent this operation. Stereoscopic Microscope Findings of the Curative Process In order that the curative process after our gingival regeneration operation might be treated photographically, we have used the camera in conjunction with a surgical stereoscopic microscope. At 24 hours following an operation, film-like tissues of yellowish tinge were observed to grow from between the rim of alveolar bone and teeth, the direction of growth being in the crown region. On the following day, the tissues already began to cover the exposed alveolar bone and, on the other hand, the border between the rim of alveolar bone and teeth started to assume a scarlet color. In this manner, yellowish tissues were gradually replaced by scarlet tissues in the passage of time. As has been described by the aid of photographs, one learns that after our gingival regeneration operation new gingiva will gradually cover the dental root surface and alveolar bone in proportion to the passage of time. The curative process may be sum- III A. Preoperative view of 5. III B. Exposed alveolar bone during operation. III C. One-week-view after operation (alveolar bone is covered with pale yellow covering and scarlet tissues). III D. 2 weeks after operation. Note that the new tissues of scarlet color are completely connected with native gingiva.

4 marily stated. When a surgical pack is removed after one week of an operation, the wound still looks raw and appears as if to bleed easily to the touch but the patient does not complain of pain under the palpation. New pack is dressed and when it is removed in the second week, pinkish color is distributed all over the wound with sporadic scattering of scarlet spots here and there. The gingival surface is firm and solid, and its contact with the dental root is quite close. At this stage, connection between the removed native gingiva and new tissues is completed and the exposed alveolar bone is consequently covered. From two weeks onward, there is not indicated need of a surgical pack but

5 the patient is instructed not to brush his teeth for yet a week or so longer. Thus, in proportion to the length of time, tonus of the gingival surface increases and in the fourth week distinction can be hardly made between the native and new gingiva, having f ully regained the state of normal health. But when the resorption of alveolar bone exceeds more than 2/3 of the root, a certain degree of exposure even after the complete cure cannot be avoided. For this

6 reason, it may be necessary to obtain understanding of a patient if this type of advanced resorption has taken place in him. Need of the patient understanding is particularly indicated when an operation is effected on the anterior teeth. Even with this limitation, our technic enables the gingiva of interdental papillae to attain better growth than in other technics. Histological Findings As it was fairly difficult to obtain adequate specimens for histological investigations, we had to be contented with what we could obtain. The photograph (VII A) is a microscopic view of teeth, new gingiva and alveolar bone after one week of operation. Supporting tissues of root membrane raised themselves along the root surface (left side) and they went downward after going over the rim of alveolar bone (center). At this stage, no growth of epithelial tissues is as yet noted. Photograph (VII B) was taken of another patient after 120 days of operation. As the right side of J 3 4 was yet to be treated, inflammational symptoms were apparent. On the left side of the picture, however, the growth of normal gingiva is distinctly noted, which was new gingiva that had been regenerated as a result of our operation. Penetrated epithelial rope seems to have derived from what was pussed in at the time of operation and thus remained as a kind of border. 77 This kind of histological image was also observed in common with few other specimens. In one specimen the growth of epithelial cells in a very thin layer was detected after two weeks postoperatively. However, we failed to determine the source of origin. Conclusions On the basis of more than 1000 patients on whom our gingival regeneration technic has been tried, we can confidently attest to the advantage of our method over others.

7 Advantage of our technic consists in the ease of operation, no restriction on the operative area, reduction in operative time, better possibility of papillar gingiva growth and better prognosis. Success of this technic can be attributed to the complete and thorough removal of not only diseased gingiva but also of gingiva of pathogenic possibility surrounding teeth. The authors are interested in an application of this technic by other practitioners and welcome their comment. References [1] GOLDMAN, SCHLUGER, Fox and COHN : Periodontal Therapy, [2] OCHSENBEIN, C.: Osseous Reaction in Periodontal Surgery, J. Periodont., 28, 15 (January), (1958). [3] OCHSENBEIN, C. : Newer Concepts Mucogingival Surgery, J. Periodont., 31, 175 (July), (1960). [4] FRIEDMAN, N. : Periodontal Osseous Surgery, J. Periodont., 26 : 276 (Oct.), (1961). [5] PRICHARD, J. F. : Gingivoplasty, Gingivectomy and Osseous Surgery, J. Periodont., 32 : 275 (Oct.), (1961). [6] SEIBERT, J. S. : Technique for the Stabilization of Tissue Flap employing Chrome-cobalt Alloy Tissue Tacks, J. Periodont., 32 : 283 (Oct.), (1961). [7] KUSUNOKI, M. : 303 Clinical Cases of the Gingival Regeneration in Periodontal Diseases, J. Nihon Univ. Sch. Dent., 5, (1962). [8] STAFFILENO, H. : Histologic Study of Healing of Split Thickness Flap Surgery in Dogs, J. Periodont., 33 : 1 (Jan.), (1962). [9] CLARK, G. W. : Mucogingival Surgical Techniques : An Appraisal, J. Periodont.,34 : 2 (March), (1963). [10] BOHANNAN, H. M. : Studies in the Alteration of Vestibular Depth, J. Periodont., 34 : 3 (May), (1963).

Surgical Therapy. Tuesday, April 2, 13. Alessan"o Geminiani, DDS, MS

Surgical Therapy. Tuesday, April 2, 13. Alessano Geminiani, DDS, MS Surgical Therapy Alessan"o Geminiani, DDS, MS Periodontal Flap: a surgical procedure in which incisions are made in the gingiva or mucosa to allow for separation of the epithelium and connective tissues