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Occlusal and

Prosthetic Therapy
Tooth-Supported Fixed Partial
Dentures


Rhea A. Ong, DMD
Clinical Periodontology and Implant Dentistry, 5
th
Edition
Jan Lindhe, Niklaus P. Lang, Thorkild Karring
Chapter 51, p1125-1137, 2008
OUTLINE

Clinical symptoms of trauma from occlusion
Angular bony defects
Increased tooth mobility
Progressive (increasing) tooth mobility
Tooth mobility crown excursion/root displacement
Initial and secondary tooth mobility
Clinical assessment of tooth mobility (physiologic and pathologic
tooth mobility)
Treatment of increased tooth mobility
Situation I
Situation II
Situation III
Situation IV
Situation V
Terminology
Trauma from occlusion is a term used to describe pathologic
alterations or adaptive changes which develop in the periodontium
as a result of undue force produced by the masticatory muscles.

Trauma from occlusion was defined by Stillman (1917) as a
condition where injury results to the supporting structures of the
teeth by the act of bringing the jaws into a closed position.

The World Health Organization (WHO) in 1978 defined trauma from
occlusion as damage in the periodontium caused by stress on the
teeth produced directly or indirectly by teeth of the opposing jaw.

In Glossary of Periodontic Terms (American Academy of
Periodontology 1986), occlusal trauma was defined as an injury to
the attachment apparatus as a result of excessive occlusal force.
Clinical symptoms of trauma
from occlusion
Angular bony defects
-It has been claimed that angular bony defects and increased
tooth mobility are important symptoms of trauma from
occlusion (Glickman 1965, 1967).

-angular bony defects have been found at teeth affected by
trauma from occlusion as well as at teeth with normal occlusal
function (Waerhaug 1979)


This means that the presence of angular bony defects
cannot per se be regarded as anexclusive symptom of
trauma from occlusion.
Increased tooth mobility
Increased tooth mobility, determined clinically, is
expressed in terms of amplitude of displacement of
the crown of the tooth.
Increased tooth mobility can, indeed, be observed in
conjunction with trauma from occlusion. It may,
however, also be the result of a reduction of the
height of the alveolar bone with or without an
accompanying angular bony defect caused by plaque-
associated periodontal disease. Increased tooth
mobility resulting from occlusal interferences may
further indicate that the periodontal structures have
become adapted to an altered functional demand
Progressive (increasing) tooth mobility
Progressive tooth mobility can be identified only
through a series of repeated tooth mobility
measurements carried out over a period of several
days or weeks.
Tooth mobility crown
excursion/root displacement


The resistance of the tooth-supporting structures
against displacement of the root is low in the initial
phase of force application and the crown is moved only
5/10010/100 mm.
This movement of the tooth was called initial tooth
mobility (ITM) by Mhlemann (1954) and is the result
of an intra-alveolar displacement of the root

- there are good reasons to assume that the initial
displacement of the root (ITM) corresponds to a
reorientation of the periodontal membrane fibers into a
position of functional readiness towards tensile strength
When a larger force (225 kg (500 pounds)) is
applied to the crown, the fiber bundles on the
tension side cannot offer sufficient resistance to
further root displacement. The additional
displacement of the crown that is observed in
secondary tooth mobility
Periotest
A new method for determining tooth mobility was
presented by Schulte and co-workers
Periotest device measures the reaction of the
periodontium to a defined percussion force which
is applied to the tooth and delivered by a tapping
instrument.
Clinical assessment of tooth mobility
(physiologic and pathologic tooth
mobility)
it is not the length of the excursive movement of
the crown that is important from a biologic point
of view, but the displacement of the root with in
its remaining periodontal ligament.

In plaque-associated periodontal disease, bone
loss is a prominent feature, regarded as
physiologic; the movement of the root within the
space of its remaining normal periodontal
ligament is normal.
Only progressively increasing tooth mobility,
which may occur in conjunction with trauma
from occlusion, is characterized by active bone
resorption and which indicates the presence
of inflammatory alterations within the
Periodontal ligament tissue, may be
considered pathologic.
Treatment of increased
tooth mobility
Situation I
Increased mobility of a tooth with increased
width of the periodontal ligament but normal
height of the alveolar bone
If a tooth (for instance a maxillary premolar) is fitted with an improper filling or crown restoration,
occlusal interferences develop and the surrounding periodontal tissues become the seat of
inflammatory reactions, i.e. trauma from occlusion (Fig. 51-5).












Since such traumatizing forces in teeth with normal periodontium or overt gingivitis cannot result
in pocket formation or loss of connective tissue attachment, the resulting increased mobility of the
tooth should be regarded as a physiologic adaptation of the periodontal tissues to the altered
functional demands.
A proper correction of the anatomy of the occlusal surface of such a tooth, i.e. occlusal
adjustment, will normalize the relationship between the antagonizing teeth in occlusion, thereby
eliminating the excessive forces. As a result, apposition of bone will occur in the zones previously
exposed to resorption, the width of the periodontal ligament will become normalized and the
tooth stabilized, it reassumes its normal mobility (Fig. 51-5).
In other words, resorption of alveolar bone which is caused by trauma from occlusion is a
reversible process which can be treated by the elimination of occlusal interferences. The
capacity for bone regeneration after resorption following trauma from occlusion has been
documented in a number of animal experiments (Waerhaug & Randers-Hansen 1966; Polson
et al. 1976a; Karring et al. 1982; Nyman et al. 1982).









In the presence of an untreated, plaque-associated lesion in the soft
tissue, however, substantial bone regrowth did not always occur (Fig. 51-7)
(Polson et al. 1976b).

Situation II
Increased mobility of a tooth with increased
width of the periodontal ligament and
reduced height of the alveolar bone
When a dentition has been properly treated for moderate to advanced periodontal
disease, gingival health is established in areas of the dentition where teeth are
surrounded by periodontal structures of reduced height.







If a tooth with a reduced periodontal tissue
support is exposed to excessive horizontal
forces (trauma from occlusion),
inflammatory reactions develop in the
pressure zones of the periodontal ligament
with accompanying bone resorption. These
alterations are similar to those which occur
around a tooth with supporting structures
of a normal height; the alveolar bone is
resorbed, the width of the periodontal
ligament is increased in the
pressure/tension zones and the tooth
becomes hypermobile (Fig. 51- 8a).
If the excessive forces are reduced or
eliminated by occlusal adjustment, bone
apposition to the pretrauma level will
occur, the periodontal ligament will regain
its normal width and the tooth will become
stabilized (Fig. 51-8b).
Conclusion: situations I and II
Occlusal adjustment is an effective therapy
against increased tooth mobility when such
mobility is caused by an increased width of
the periodontal ligament.
Situation III
Increased mobility of a tooth with reduced
height of the alveolar bone and normal width
of the periodontal ligament
The periodontal condition of this patient is
illustrated by the probing depth, furcation
involvement and tooth mobility data as well as the
radiographs from the initial examination in Fig. 51-
9 a.

Periodontal disease has progressed to a level
where, around the maxillary teeth, only the apical
third or less of the roots is invested in supporting
alveolar bone.

The most likely definitive treatment should
include:
periodontal and adjunctive therapy in the
following parts of the dentition: 15 and 25,
and 13, 12, 11, 21, 22, 23.
For functional and esthetic reasons, 14 and 24
obviously had to be replaced. The question
now arose as to whether these two premolars
should be replaced by two separate unilateral
bridges, using 13, 15 and 23, 25 as abutment
teeth, or if the increased mobility of these
teeth and also of the anterior teeth (12, 11,
21, 22) (Fig. 51-9) called for a bridge of cross-
arch design, with the extension 1525, to
obtain a splinting effect.


Example: Case A, 64-year-old male
From the radiographs it can be seen that the increased mobility observed in the maxillary teeth of
this patient is associated mainly with reduced height of the alveolar bone and not with increased
width of the periodontal ligaments. This means that the mobility of the individual teeth should be
regarded as normal or physiologic for teeth with such a reduced height of the supporting tissues.
This in turn implies that the increased tooth mobility in the present case does not call for
treatment unless it interferes with the chewing comfort or jeopardizes the position of the front
teeth. This particular patient had not recognized any functional problems related to the increased
mobility of his maxillary teeth. Consequently, there was no reason to install a cross-arch bridge in
order to splint the teeth, i.e. to reduce tooth mobility.

Following proper treatment of the plaque associated periodontal lesions, two separate
provisional bridges of unilateral design were produced (15, 14, 13; 23, 24, 25, 26 palatal
root). The provisional acrylic bridges were used for 6 months during which the occlusion, the
mobility of the two bridges and the position of the front teeth were all carefully monitored.
When, after 6 months, no change of position of the lateral and central incisors had occurred
and no increase of the mobility of the two provisional bridges had been noted, the definitive
restorative therapy was performed.

Figure 51-10 presents radiographs obtained 10 years after initial therapy. The position of the
front teeth and the mobility of the incisors and the two bridges have not changed during the
course of the maintenance period. There has been no further loss of periodontal tissue
support during the 10 years of observation, no further spread of the front teeth and no
widening of the periodontal ligaments around the individual teeth, including the abutment
teeth for the bridgework.
Conclusion: situation III
Increased tooth mobility (or bridge mobility)
as a result of reduced height of the alveolar
bone can be accepted and splinting avoided,
provided the occlusion is stable (no further
migration or further increasing mobility of
individual teeth), and provided the degree of
existing mobility does not disturb the patients
chewing ability or comfort.
Situation IV
Progressive (increasing) mobility of a tooth
(teeth) as a result of gradually increasing
width of the reduced periodontal ligament
Example: Case B, 26-year-old male
Figure 51-11 presents radiographs taken prior to therapy and Fig. 51-12 those obtained after
periodontal treatment and preparation of the remaining teeth as abutments for two fi xed
splints. All teeth except 13, 12, and 33 have lost around 75% or more of the alveolar bone
and widened periodontal ligaments are a frequent fi nding. The four distal abutments for the
two splints are root-separated molars, the maintained roots being the following: the palatal
root of 17, the mesio-buccal root of 26, and the mesial roots of 36 and 47. It should be
observed that tooth 24 is root-separated and the palatal root maintained with only minute
amounts of periodontium left. Immediately prior to insertion of the two splints, all teeth
except 13, 12, and 33 displayed a mobility varying between degrees 1 and 3.
From the radiographs in Fig. 51-12 it can be noted that there is an obvious risk of extraction of a
number of teeth such as 24, 26, 47, 45, 44, 43, and 36 if the patient is allowed to bite with a
normal chewing force without the splints in position. Despite the high degree of mobility of the
individual teeth, the splints were entirely stable after insertion, and have maintained their
stability during a maintenance period of more than 12 years.
Figure 51-13 describes the clinical status and Fig. 51-14 presents the radiographs obtained
10 years after therapy. From these radiographs it can be observed (compare with Fig. 51-
12) that during the maintenance period there has been no further loss of alveolar bone or
widening of the various periodontal ligament spaces.

Conclusion: situation IV
Splinting is indicated when the periodontal
support is so reduced that the mobility of the
teeth is progressively increasing, i.e. when a
tooth or a group of teeth ar
Situation V
Increased bridge mobility despite splinting

Example: Case C, 52-year-old female
Figure 51-15 shows radiographs obtained at the initial examination. A 12-unit maxillary
bridge was installed 1015 years prior to the present examination using 18, 15, 14, 13, 12,
11, 21, 22, 23, and 24 as abutments.

Radiographs obtained 5 years after therapy are shown in Fig. 51-16. The bridge/splint had a mobility of degree
1 immediately after its insertion and this mobility was unchanged 5 years later. The radiographs demonstrate
that no further widening of the periodontal ligament occurred around the individual teeth during the
maintenance period. When a cross-arch bridge/splint exhibits increased mobility, the center (fulcrum) of the
movement must be identified. In order to prevent further increase in the mobility and/or to prevent
displacement of the bridge, it is essential to design the occlusion in such a way that when the bridge/splint is in
contact with the teeth of the opposing jaw, it is subjected to a balanced load, i.e. equal force on each side of
the fulcrum. If this can be achieved, the force to which the bridge is exposed in occlusion can be used to retain
the fixed prosthesis in proper balance (a further increase of mobility being thereby prevented).
The maxillary splint in the patient described in Figs. 51-15 and 51-16 exhibited increased
mobility in a frontal direction. Considering the small amount of periodontal support left
around the anterior teeth, it is obvious that there would have been a risk of frontal
displacement of the total bridge had the bridge terminated at the last abutment tooth (23)
on the left side of the jaw. The installation of cantilever units in the 24 and 25 region
prevented such a displacement of the bridge/splint by the introduction of a force
counteracting frontally directed forces during protrusive movements of the mandible (Fig.
51-17). In addition, the cantilever units provide bilateral contact relationship towards the
mandibular teeth in the intercuspal position, i.e. bilateral stability of the bridge.
In cases similar to the one described above, cantilever units can thus be
used to prevent increasing mobility or displacement of a bridge/splint. It
should, however, be pointed out that the insertion of cantilever units
increases the risk of failures of a technical and biophysical character
(fracture of the metal frame, fracture of abutment teeth, loss of retention,
etc.).
Conclusion: situation V
An increased mobility of a cross-arch
bridge/splint can be accepted provided the
mobility does not disturb chewing ability or
comfort and the mobility of the splint is not
progressively increasing.
Long-term clinical outcomes of
abutments treated with guided tissue
regeneration
Pierpaolo Cortellini, MD, DMD,a Gabrielle Stalpers
DMD,b Giovanpaolo Pini Prato, MD, DMD,c
and Maurizio S. Tonetti, DMD, PhD, MMScd
University of Bern, Bern, Switzerland, and University of
Florence, Florence, Italy
THE JOURNAL OF PROSTHETIC DENTISTRY,
Vol. 81 Num. 3, p305-311, 1999-March
Terminology
Abutment
1: that part of a structure that directly receives thrust or pressure; an
anchorage
2: a tooth, a portion of a tooth, or that portion of a dental implant that serves
to support and/or retain a prosthesis (Glossary of Prosthodontic Terms of the
Academy of Prosthodontics, 2005)

Guided Tissue Regeneration
any procedure that attempts to regenerate lost periodontal structures or
alveolar process through differential tissue responses. Barrier techniques,
using synthetic materials that may or may not resorb, to exclude epithelial
ingrowth (periodontal regeneration) or connective tissue ingrowth (alveolar
process regeneration) that is believed to interfere with regeneration (Glossary
of Prosthodontic Terms of the Academy of Prosthodontics, 2005)

INTRABONY DEFECT
Is define as a periodontal defect within the bone surrounded by one, two or
three bony walls or a combination thereof (Glossary of Periodontal terms of
the American Academy of Periodontology, 2001)
INTRODUCTION
Periodontal infections frequently result in a pattern of
breakdown characterized by the presence of intrabony lesions. Angular
bony defects have been treated with a variety of different surgical
approaches, including resective and regenerative procedures. Among
the others, guided tissue regeneration (GTR) is generally considered an
efficacious and predictable approach for the treatment of deep
intrabony defects around natural teeth. This defects are frequently
located at strategically important abutments whose prognosis is key to
the performance of the prosthodontic treatment plan.

A recent short-term study demonstrated that GTR can be
successfully applied to treat intrabody defects around prosthetic
abutments and a series of independent clinical trials have
demonstrated that clinical attachment levels gained with GTR can be
maintained over long periods around teeth that are nonabutments. A
key issue, however, is the long-term stability of the clinical outcomes
obtained with the treatment approach around prosthetic abutments.



The aim of this prospective study was to investigate the
long-term stability of the clinical outcomes obtained with GTR in
a cohort of patients presenting with strategically important
abutments whose prognosis was compromised by deep
intrabony defects.

Material and Methods
Subjects:
Sixteen patients (5 men and 11 women)
36 to 60 years of age (49.6 7.7 years)
Patients with compromised abutments, selected after
completion of initial therapy

Inclusion Criteria for Patients:
(1) absence of systemic disease
(2) no use of systemic medications
(3) no known allergies
(4) good oral hygiene (full mouth plaque score of 20% or lower)
(5) absence of cigarette smoking
(6) presence of advanced periodontal disease previously treated
with scaling and root planing, and oral hygiene instructions
* Each patient had at least 1 deep intrabony defect at an abutment of strategic
importance for prosthetic rehabilitation. - Sixteen defects (1 defect per patient)
Inclusion Criteria for Defects:
(1) probing attachment loss equal to or greater than 6 mm
(2) clinical and radiographic evidence of the presence of an
intrabony defect at least 4 mm deep;
(3) loss of 50% or more of the radiographic bone support at the
defect site and
(4) no furcation involvement

Clinical patient characterization:

Clinical measurements and standard periapical parallel technique
radiographs were taken
immediately before surgery,
1 year after the surgical procedure, and
at the long-term follow-up visit, performed at least 4 years
after GTR surgery
Oral hygiene was measured with the full mouth plaque score
(FMPS), recorded as the percentage of total surfaces (4 aspects per
tooth)
Bleeding on probing was assessed dichotomously at a force of 0.3
N. with a manual pressure sensitive probe (Brodontic probe equipped with a PCP-UNC 15
tip, Hu-Friedy)
Full mouth bleeding scores (FMBS) were calculated.
Probing pocket depths (PPD) taken and
Clinical attachment levels (CAL) taken


*Both PPD and CAL were recorded to the nearest millimeter with a manual
pressure sensitive probe (Brodontic probe equipped with a PCP-UNC 15 tip, Hu-Friedy)
by a single investigator at the deepest interproximal point of the
selected tooth.
During the surgical procedure, the following defect morphologic
parameters were evaluated after debridement of the area essentially
as previously described:
(1) distance from the cementoenamel junction (CEJ) to the bottom
of the defect (CEJ-BD);
(2) Distance from the CEJ to the most coronal extension of the
interproximal bone crest (CEJ-BC).



These measurements were performed at the deepest interproximal
point of the defect.


The intrabony components of the defects (INFRA) were calculated
as:
INFRA = (CEJ-BD) (CEJ-BC)
Surgical procedures and infection control:
The treatment consisted of the placement of expanded-
polytetrafluoroethylene (e-PTFE) barrier membranes (Gore-Tex Periodontal Material,
Gore & Associates, Flagstaff, Ariz.) according to the principles of GTR.

After local anesthesia, the long-term provisional FPD was removed.
Defect access was achieved through the elevation of full thickness
buccal and lingual flaps.
Intrasulcular incisions were performed at the defect site and
extended buccally and lingually to the adjacent teeth.
Crestal incisions were traced when edentulous ridges were
adjacent to the defects. Particular attention was paid to fully
preserve the soft tissues, especially at the defect sites.
Vertical releasing incisions were performed when needed to
improve access to the defects.
Defects were fully debrided to expose the residual bony walls and
roots were carefully planed with a combination of hand and
mechanical instrumentation (Soniflex, Kavo, Dental GmBh, Biberach/Riss, Germany).
Conditioning of the root surface was not performed.

Surgical procedures and infection control:

The optimal configuration of e-PTFE membranes was then selected
according to defect morphologic parameters.
Barriers were shaped, adapted, and positioned just coronal to
the interproximal bone crest to cover the defects completely
and to overlap 2 to 3 mm of the adjacent residual bone. Barrier
membranes were firmly secured to the adjacent teeth with
Teflon sutures (Gore-Tex Associates).
Complete coverage of the membranes and primary closure of the
flaps in the absence of tension was obtained with mattress sutures.
Provisional FPDs were temporarily cemented, taking care that no
cement extended subgingivally.
No periodontal dressing was applied.



Surgical procedures and infection control:

Tetracycline HCl 1 g/day were prescribed for the first postoperative
week.
Patients were instructed to avoid brushing and interdental cleaning of
the treated site, and to refrain from chewing on the treated area
while the membranes were in place.
During this period, control of plaque accumulation was
performed with 0.2% chlorhexidine mouthrinses 3 times daily,
and with weekly recall visits for control and professional
prophylaxis that consisted of accurate supragingival
cleaning of the treated sites with hand instruments and a
low-speed rubber cup with chlorhexidine gel.

Sutures were removed after 1 week.
Surgical procedures and infection control:

6 weeks after placement, membraines were removed through
elevating partial thickness buccal and lingual flaps.
After membrane removal, the newly formed tissue was carefully
protected with the gingival flaps.
When dehiscence of the flaps did not allow proper protection of
the regenerated tissue, free gingival grafts were positioned.
The provisional FPD was immediately reinserted, and the periodontal
dressing was positioned so as not to compress the experimental
areas.

Sutures and dressing were removed after 1 week.



Surgical procedures and infection control:

Patients were reinstructed:
to rinse 3 times daily with 0.2% chlorhexidine,
to avoid brushing and interdental cleaning, and
to refrain from chewing on the experimental sites for a period of
6 weeks.

During this period, patients were recalled weekly for control
visits and prophylaxis, as previously described. After this period,
chlorhexidine was discontinued and full oral hygiene was
resumed.


Surgical procedures and infection control:

Patients were then maintained by monthly professional cleaning up to
the 1 year reevaluation.

Provisional FPDs were removed every 3 to 4 months to control and
clean the abutments and then immediately reinserted.
Periodontal and/or prosthetic procedures involving the crevice
of the treated abutments were avoided until the 1 year follow-
up appointment, when the final FPDs were delivered.

After the 1 year reevaluation, all patients were included in a
supportive periodontal care program with recall visits every 3 months.
Radiographic evaluation of bone loss
Loss of radiographic bone was evaluated:
at baseline,
at the 1 year follow-up, and
at reevaluation visits, 4 to 8 years afterward, with a modified version
of a previously described method.

Linear measurements of bone loss, as described by Albandar et al, were
taken on the radiographic images (original magnification 10).
The position of the CEJ, as described by Schei et al, was identified.
Whenever an interproximal restoration was present, its most apical
extension was used instead of the CEJ. The most coronal region
where the periodontal ligament maintained an even width was
identified on the image in accordance with the criteria established
by Bjrn et al.

Linear distances between:
(1)the CEJ and the root apex (root length), and
(2)the CEJ and the most apical extension of the intrabony defect
(CEJ-BD), were recorded.
The linear percentage of residual bone support (residual bone) was
calculated as:
1 (CEJ-BD/root length)

Radiographic evaluation of bone loss


Measurements were recorded by 2 investigators, who were blinded
with respect to clinical measurements. The investigators had to reach
agreement in terms of location of both anatomic and bone loss landmarks.
Statistical analysis

Data were expressed as means standard deviations of 16 defects in
16 patients.


Significance of differences was tested by statistical application
software (SAS Institute version 6.09, Cary, N.C.) at an a error level of
.05.


Significant differences between:
baseline and 1 year
between 1 year and long-term follow-up visit
were evaluated with the Wilcoxon ranked sum test.
RESULTS
Baseline patient and defect characteristics

Baseline FMPS and FMBS were 12.7% 2.9% and 10.7% 3.5%,
respectively (Table I)









The experimental tooth population consisted of 3 incisors, 5 canines,
5 premolars, and 3 molars.
Twelve teeth were located in the maxillae and 4 were located in the
mandible.
Selected abutments exhibited deep periodontal lesions with a mean CAL
loss of 10.8 2.2 mm, a PPD of 8.8 2.1 mm, and a radiographic residual
bone support of 32% 17%. The average intrabony component depth was
6.9 1.5 mm (Table II).







Changes in oral hygiene parameters and patient compliance

At 1 year, FMPS decreased from 12.7% 2.9% to 8.6% 2.4. Similarly,
FMBS decreased from 10.7% 3.5% to 7.1% 2.9%.
At long-term follow-up visits performed 4 to 8 years after surgery, oral
hygiene parameters were not significantly different from those detected at
1 year.








All patients regularly participated in the supportive periodontal care
program.
None of the patients reported smoking cigarettes during the
investigation period.
Treatment effect at 1 year

The healing period progressed uneventfully, and no side effects or patient
complaints were registered. Data presented in Table II show significant
improvements after GTR therapy in all the treated sites in terms of CAL gains,
PPD reduction, and gains in residual bone support at 1 year.
Treatment effect at 1 year

A 6.1 3 mm decrease in PPD was observed along with a CAL gain of 5.3 1.7
mm and an increase in the percentage of radiographic bone support of 31%
18% (Table III).







All differences between baseline and 1-year measurements were clinically
and statistically highly significant. Only 12.5% of the cases resulted in CAL
gains of 3 mm, 50% gained 4 to 5 mm, whereas 37.5% of the cases displayed
CAL gains of 6 mm or more.
Long-term measurements

Long-term follow-up appointments were conducted after a period ranging
from 4 to 8 years after GTR surgery (mean 5.6 1.6 years).

Long-term measurements

The comparison between the CAL measured at 1 year and at the long-term
follow-up appointments did not reveal any clinically and statistically
significant differences (0.1 0.6 mm, P=.4, NS) (Table III).



Long-term measurements

The percentages of radiographic residual bone measured at the long-term
follow-up visits increased slightly compared with the percentages measured
at 1 year (Table II), and the difference was statistically significant (P=.04)
(Tables II and III).



Long-term measurements

A slight increase of 1 to 2 mm in PPDs was observed in some patients (Table
II). The average difference between 1-year and long-term PPDs was
statistically significant (0.8 0.8 mm, P=.004) (Table III).

DISCUSSION
This investigation indicated that consistent clinical improvements can
be obtained with GTR treatment of deep intrabony defects that affect
prosthetic abutments. These improvements can be maintained over periods
extending up to 8 years.

Thus, this study allows one to extend to abutments the conclusions
of a series of independent clinical trials that demonstrated stability of the
clinical outcomes obtained with GTR in nonabutments.

Substantial and highly predictable gains of tooth support in terms of
CAL and bone were observed in our study at 1 year. CAL gains were 5.3 1.7
mm, on average, and 87.5% of cases gained 4 mm or more of CAL. These
results are consistent with previous results obtained by the same group of
clinicians. A similar pattern was observed in terms of bone changes, where
average bone gain was 31% 18%. At baseline, radiographic bone loss
extended to more than half of the root length in 87% of the cases, whereas
this percentage decreased to only 37% 1 year after GTR. This observation is
consistent with the previously reported association between CAL gains and
bone gains after GTR in intrabony defects.
Another relevant clinical result of the study was the significant
decrease in PPD observed at 1 year. Residual PPD were 2.5 0.9 mm on
average. Only 2 sites displayed pockets of 4 mm. The observed improvements
in PPD probably played a role in facilitating the supportive periodontal care
procedures of the involved abutments. PPD at the experimental sites
increased slightly over time. At the long-term follow-up visit, the average PPD
was 0.8 0.8 mm deeper than at 1 year. However, in most of the patients (7
sites), the changes in PPD were of 1 mm. Only in 4 cases they measured 2
mm.

After the 1-year follow-up visit, clinical outcomes were maintained
over a period ranging 4 to 8 years in prosthetic abutments in patients who
complied with a 3-month supportive periodontal care program, were not
smokers, and maintained a high standard of oral hygiene.

CONCLUSIONS
The results of this study indicated that guided tissue regeneration
(GTR) treatment with nonresorbable barrier membranes can predictably
increase the periodontal support around abutments presenting with deep
intrabony defects. The clinical outcomes obtained can be maintained over
time in a nonsmoking population that complies with oral hygiene instructions
and participates in a supervised supportive care program. Thus Guided tissue
regeneration therapy can be one of the options discussed at the time of
treatment plan for patients with complex perioprosthetic problems where
strategic abutments are compromised by deep intrabony defects.