Jan Lindhe. Clinical Periodontology
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ORTHODONTICS AND PERIODONTICS •
775
Fig. 31-27. Clinical illustration of Edwards' frenotomy procedure. The surgery includes a V-incision (b), removal of
the frenum tip (c), some vertical and horizontal cuts into periosteum (d), and, optionally, one or two sutures (e).
One month later (f), some slight scarring may be observed below the relocated frenum attachment (arrow), but
there is predictably no loss of the interdental gingival papilla.
may result in infolding or invagination of the gingiva (
Fig. 31-28). The clinical appearance of such invagina-
tions may range from a minor one-surface crease to
deep clefts that extend across the interdental papilla
from the buccal to the lingual gingivae. Although
gingival invaginations are quite common, the precise
cause of the infolding as teeth are moved through an
extraction area remains unclear. Since approximated
teeth appear to displace the gingival tissue more than
move through it, a "piling-up" of gingival tissue is
conceivable. There is some resolution of these defects
with time, but many invaginations persist for 5 years
or more after completion of orthodontic therapy.
Several authors have suggested that compression
of transseptal fibers and alterations of gingival tissue
will contribute to extraction-space reopening, but no
correlation was found between space reopening and
presence and severity of invaginations by Rivera Cir-
cuns and Tulloch (1983). They still felt the damage to
the gingiva was severe enough to warrant the surgical
removal of these defects in selected patients (Fig. 31-
28). Edwards (1971) suggested that simple removal of
only the excess gingiva in the buccal and lingual area
of approximated teeth would be sufficient to alleviate
the tendency for the teeth to separate after orthodontic
movement. The removal of the gingival papillae in
closure sites may enhance the restitution of a more
normal connective tissue, although the epithelial hy-
776 • CHAPTER
31
Fig. 31-28. Surgical removal of gingival invagination after first premolar extraction and orthodontic space closure
in adult female patient (a,b). A mesiodistally narrow but deep excision of tissue (c) was made to avoid loss of the in
-
terdental papilla. (d) shows condition 2 years later.
perplasia, invaginations, and loss of collagen in the
underlying gingiva are surprisingly long-standing.
Gingivectomy
The relationship of the gingival margins of the six
maxillary anterior teeth plays an important role in the
esthetic appearance of the crowns (Kokich 1996a,b). In
some instances, it may be necessary to increase clinical
crown length of one or several teeth during or after
orthodontic treatment. If a gingival margin discrep-
ancy is present, but the patient's lip does not move
upward to expose the discrepancy upon smiling, it
does not require correction. If the gingival discrepancy
is apparent, however, one of four different techniques
may be used:
1.
gingivectomy
2.
intrusion + incisal restoration or porcelain
laminate
veneer (Fig. 31-17)
3.
extrusion + fiberotomy + porcelain crown (Fig. 31-
16)
4.
surgical crown lengthening, by flap procedure and
ostectomy/ ostoplasty of bone (Bragger et al. 1992).
Each of these techniques has its specific indications,
and whenever gingival margin discrepancies are pre-
sent, the clinician must determine the proper solution
(see also Chapter 27). For example, gingivectomy is
not indicated when there is a risk for root exposure,
such as when one single incisor has supra-erupted
(
Fig. 31-17).
The gingivectomy technique has proven to be use-
ful in improving orthodontic results, particularly in
difficult cases with missing maxillary central or lateral
incisors (Fig. 31-29); after premolar autotransplanta-
tion to the anterior region; and in some "gummy"
smiles (Fig. 31-30). Clinical and histologic examina-
tion demonstrated that it was possible to permanently
increase clinical crown length after orthodontic treat-
ment by making a labial gingivectomy to the bottom
of the clinical pocket. The healing and regeneration of
the gingiva was uneventful, provided excellent oral
hygiene was maintained in the wound area for 2
months. The result may be explained by one or more
of three factors: (1) the effect of the gingivectomy itself,
(
2) elimination of accumulated hyperplastic gingiva
often seen associated with fixed appliance therapy
(
Fig. 31-29), and (3) elimination of a normally occur-
ring deep pocket. Whatever the reason, the net gain in
crown length was close to half the probing depth in all
instances (Monefeldt & Zachrisson 1977). The increase
in crown length of 1-2 mm may be important to im-
prove the clinical outcome, as shown in Figs. 31-29 and
31-30. Similar long-term results on the position of the
marginal soft tissue following periodontal surgery
have been reported by others (Lindhe & Nyman 1980).
ORTHODONTICS AND PERIODONTICS • 777
Fig. 31-29. Orthodontic space closure substitution after accidental loss of maxillary right central incisor in young fe
-
male patient (a). The marginal gingival level on the "new
"
central incisor was corrected by selective intrusion
bends in the archwire (b-d) and local gingivectomy and frenotomy (c-d). Local gingivectomies were also performed
on the right first premolar in the canine position, and on the left lateral incisor (e). Enamel-bonded ultrathin porce
lain veneer on lateral incisor, and vital bleaching of right canine courtesy of Dr S. Toreskog. By these means, it
was
possible to obtain an optimally esthetic result (e,f).
Interestingly, Wennstrom (1983) demonstrated that
even if the gingivectomy is extended into the alveolar
mucosa, the regenerated tissue will still be normal
gingiva with keratinized epithelium. Thus the human
periodontal membrane tissue has the capacity to form
a granulation tissue which will prevent the alveolar
mucosa from becoming the border-tissue against the
tooth. When local labial gingivectomies are made in
adults, the cut is reduced mesiodistally in order to
eliminate the risk for developing interdental recession.
Then the incision should not follow the gingival
contour all the way, but should be limited by two small
vertical cuts towards the interdental papillae (Fig. 31-
26, 31-30).
778 • CHAPTER 31
Fig. 31-30. Young female with long face and pronounced
"
gummy" smile remaining after active maxillary incisor
intrusion (a,b). Labial gingivectomies over six anterior teeth, using
"
adul
t
"
excisions, with frenum relocated and su
-
tured (c). Healing of gingiva after one week (d) and four months (e) resulted in acceptable tooth display and smile (
f). Further improvement can be expected with normal aging.
ORTHODONTICS AND PERIODONTICS • 779
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CHAPTER
32
Supportive Periodontal
Therapy (SPT)
NIKLAUS
P.
LANG, URS BRAGGER, GIOVANNI SALVI AND MAURIZIO
S.
TONETTI
Definitions
Basic paradigms for the prevention of
periodontal disease
Patients at risk for periodontitis without
SPT
SPT
for patients with gingivitis
SPT
for patients
with periodontitis
Continuous multilevel risk assessment
Subject risk assessment
Tooth risk assessment
Site risk assessment
Radiographic evaluation of periodontal disease
progression
Clinical implementation
Objectives for
SPT SPT
in daily practice
Clinical trials on the long-term effects of treatment of
periodontitis have clearly demonstrated that post-
therapeutic professional maintenance care is an inte-
gral part of the treatment. This also constitutes the
only means of assuring the maintenance of long-term
beneficial therapeutic effects. Mainly through the
rigid surveillance of patients involving professional
visits at regular intervals could reinfection be pre-
vented or kept to a minimal incidence in most patients.
However, the maintenance systems presented in vari-
ous studies do not allow the presentation of a clear
concept with general validity for the frequency of
professional maintenance visits and the mode of
maintenance therapy. A danger for supervised neglect
of reinfection and recurrent disease in some patients
coexists with a tendency for overtreatment in others.
Objective criteria for assessing the patient's indi-
vidual risk for recurrent disease have been the focus
of attention of recent years. However, the evaluation
of the patient's individual risk still has to be based on
a
probability estimation based on the analysis of pa-
tient, tooth or tooth site risk assessments.
The purpose of this chapter is to discuss the basics
of continuous patient monitoring following active
periodontal therapy in order to prevent reinfection
and the continued progression of periodontal disease
following therapy. Also, the mode and extent of inter-
ceptive therapeutic measures needed to achieve this
goal will be evaluated.
DEFINITIONS
Periodontal treatment includes:
1.
systemic evaluation of the patient's health
2.
a cause-related therapeutic phase with, in some
cases,
3.
a corrective phase involving periodontal surgical
procedures
4.
maintenance phase
The 3rd World Workshop of the American Academy
of Periodontology (1989) has renamed this treatment
phase "supportive periodontal therapy" (SPT). This
term expresses the essential need for therapeutic
measures to support the patient's own efforts to con-
trol the periodontal infections and to avoid reinfec-
tion. Regular visits to the therapist should serve as a
positive feedback mechanism between the patient and
the therapist with the purpose of ensuring that the
patients have the opportunity to maintain their denti
-
tions in a healthy status for the longest possible time.
An integral part of SPT is the continuous diagnostic
monitoring of the patient in order to intercept with
adequate therapy and to optimize the therapeutic in-
terventions tailored to the patient's needs.
782 •
CHAPTER
32
BASIC PARADIGMS FOR THE
PREVENTION OF PERIODONTAL
DISEASE
Periodontal maintenance care, or SPT, follows the
paradigms of the etiology and pathogenesis of peri-
odontal disease and — at the present time — must
consider the fact that these diseases are coping with
the result of the host defense on an opportunistic
infection.
Almost 40 years ago, a cause-effect relationship
between the accumulation of bacterial plaque on teeth
and the development of gingivitis was proven (Loe et
al. 1965). This relationship was also documented by
the restoration of gingival health following plaque
removal. Ten years later, a corresponding relationship
between plaque accumulation and the development
of periodontal disease, characterized by loss of con-
nective tissue attachment and resorption of alveolar
bone, was shown in laboratory animals (Lindhe et al.
1975). Since some of these animals did not develop
periodontal disease despite a persistent plaque accu-
mulation for 48 months, it must be considered that the
composition of the microbiota or the host's defense
mechanisms or susceptibility for disease may vary
from individual to individual. Nevertheless, in the
study mentioned, the initiation of periodontal disease
was always preceded by obvious signs of gingivitis.
Hence, it seems reasonable to predict that the elimina
-
tion of gingival inflammation and the maintenance of
healthy gingival tissues will result in the prevention
of
both the initiation and the recurrence of periodontal
disease. In fact, already in 1746, Fauchard stated that
"little or no care as to the cleaning of teeth is ordinarily
the cause of all diseases that destroy them" (Fauchard
1746).
From the clinical point of view, the above-men-
tioned results must be translated into the necessity for
proper and regular personal plaque elimination, at
least in patients treated for or susceptible to periodon
-
tal disease. This simple principle may be difficult to
implement in all patients; however, interceptive pro-
fessional supportive therapy at regular intervals may,
to a certain extent, compensate for the lack of personal
compliance with regard to oral hygiene standards.
These aspects have been imitated in a beagle dog
model with naturally occurring periodontal disease
(
Morrison et al. 1979). Two groups of animals were
used. The test group was subjected to initial scaling
and root planing and, subsequently, plaque was elimi
-
nated by daily toothbrushing and biweekly polishing
with rubber cups for a period of 3 years. In the control
group, no initial scaling and no oral hygiene practices
were performed during the same period of time. Every
6 months, however, the teeth in two diagonally op-
posed jaw quadrants in both test and control animals
were scaled and root planed. The results showed that
the reduction of probing depth and the gain of probing
attachment, obtained after the initial scaling and root
planing in the test animals, were maintained through
-
out the entire course of the study irrespective of
whether or not repeated scaling and root planing had
been performed. The control animals, on the other
hand, continued to show increasing probing depths
and loss of attachment in all quadrants irrespective of
whether or not repeated scaling and root planing had
been performed. However, in the jaw quadrants
where the teeth were repeatedly instrumented every
6
months, the progression of periodontal destruction
was significantly less pronounced (Fig. 32-la,b). These
results indicate that professional supportive therapy,
performed at regular intervals, may, at least to a cer-
tain extent, compensate for a "suboptimal" personal
oral hygiene standard. In this respect, it has been
demonstrated that following root instrumentation,
the
subgingival microbiota is significantly altered in
quantity and quality (Listgarten et al. 1978), and that
the re-establishment of a disease-associated, subgingi
-
val microbiota may require several months (Listgarten
et al. 1978, Slots et al. 1979, Mousques et al. 1980, Caton
et al. 1982, Magnusson et al. 1984.)
In a number of longitudinal, clinical studies on the
outcome of periodontal therapy, the crucial role of SPT
in maintaining successful results has been docu-
mented (Ramfjord et al. 1968, 1975, Lindhe & Nyman
1975, 1984, Rosling et al. 1976, Nyman et al. 1977,
Knowles et al. 1979, 1980, Badersten et al. 1981, 1987,
Hill et al. 1981, Lindhe et al. 1982a,b, Pihlstrom et al.
1983, Westfelt et al. 1983, 1985, Isidor & Karring 1986,
Kaldahl et al. 1988). In all these studies, probing
depths and clinical attachment levels were main-
tained as a result of a well-organized professional
maintenance care program (recall intervals varying
between 3 and 6 months) irrespective of the initial
treatment modality performed. In one of the studies (
Nyman et al. 1977) an alarming result was that pa-
tients treated for advanced periodontal disease in-
volving surgical techniques, but not incorporated in a
supervised maintenance care program, exhibited re-
current periodontitis including loss of attachment at a
rate three to five times higher than documented for
natural progression of periodontal disease in popula-
tion groups with high disease susceptibility (Loe et al.
1978, 1986). Within this area, the effect of negligence
in providing adequate supportive maintenance care
following periodontal treatment has been studied
over
a 6-year period by Axelsson & Lindhe (1981a).
Following presurgical root instrumentation and in-
struction in oral hygiene practices, all study patients
were subjected to modified Widman flap procedures.
During a 2-month healing period, professional tooth-
cleaning was performed every 2 weeks. Following this
time period, baseline clinical data were obtained and
one out of every third patient was dismissed from the
clinic, while the two others were incorporated in a
professionally conducted maintenance program with
a recall once every 3 months. These patients main-
tained excellent oral hygiene and consequently
yielded a very low frequency of bleeding sites. In
addition, probing depths and probing attachment lev
-
els were maintained unchanged over the 6-year pe-
riod.
h1
contrast, the non-recalled patients demon-
strated obvious signs of recurrent periodontitis at the
3-year and 6-year re-examinations. Further evidence
for the likelihood of recurrent disease in patients not
subjected to professional maintenance care was pre-
sented by Kerr (1981). Five years after successful treat
-
ment, 45% of the patients presented with periodontal
conditions similar to their status before treatment.
Supportive therapy had only been provided at inter-
vals varying between 9 and 18 months.
Similar results have been described for private
practice patients who decided not to participate in an
organized maintenance care program following active
periodontal therapy (Becker et al. 1984). Subsequent
examinations revealed clear signs of recurrent peri-
odontal disease including increased probing depths
and involvements of furcations of multirooted teeth
concomitant with tooth loss. Also, loss of alveolar
bone observed in radiographs and tooth loss have
been reported for a group of patients in whom post-
therapeutic supportive maintenance care was pro-
vided less frequently than once every 12 months (De
Vore et al. 1986). From all these studies it is evident
that periodontal treatment is ineffective in maintain-
Fig. 32-lb. Mean gain (+) or loss
(-) of probing attachment with or
without repeated scaling and root
planing in experimental (oral hy-
giene) and control (no oral hy-
giene) animals relative to baseline
means. (Data from Morrison et al.
1979).
Fig. 32-la. Mean probing depth re-
duction (+) or increase in probing
depth (-) in millimeters with or
without repeated scaling and root
planing in experimental (oral hy-
giene) and control (no oral hy-
giene) animals relative to baseline
means.
SUPPORTIVE PERIODONTAL THERAPY (SPT) • 7
8
3
Reduction (+) or Increase (-) in Pocket Depth
784 • CHAPTER 32
ing periodontal health if supportive maintenance care
is neglected, denied or omitted.
Even though the number of well-controlled longi-
tudinal clinical trials is rather limited for patients who,
in addition to periodontal treatment, have undergone
extensive reconstructive therapy, it should be realized
that the concept of professional maintenance care has
unrestricted validity. In a longitudinal study of com-
bined periodontal and prosthetic treatment of patients
with advanced periodontal disease, periodontal
health could be maintained over a study period of 5-8
years with regular recall appointments scheduled
every 3-6 months (Nyman & Lindhe 1979). Similar
results have been presented by Valderhaug &
Birkeland (1976) and by Valderhaug (1980) for periods
of up to 15 years. Another study of 36 patients who
received extensive poly-unit cantilevered bridgework
following periodontal therapy, confirmed the mainte-
nance of periodontal health over 5-12 years (Laurell et
al. 1991). More recent studies on the long-term main
-
tenance over 10 and 11 years of periodontal patients
who, following successful treatment of chronic perio-
dontitis, were reconstructed with extensive fixed re-
constructions revealed that regularly performed SPT
resulted in periodontal stability. Only 1.3% (Ham-
merle et al. 2000) and 2.0% (Moser et al. 2002) of the
abutments showed some minor attachment loss dur
-
ing these long periods of observation. In contrast, a
report of insurance cases who were not regularly
maintained by SPT yielded a recurrence rate for peri-
odontitis of almost 10% after an observation of 6.5
years (Randow et al. 1986).
Summary
The etiology of gingivitis and periodontitis is fairly
well understood. However, the causative factors, i.e.
the microbial challenge which induces and maintains
the inflammatory response, may not be completely
eliminated from the dento-gingival environment for
any length of time. This requires the professional re-
moval of all microbial deposits in the supragingival
and subgingival areas at regular intervals, since
recolonization will occur following the debridement
procedures, leading to a reinfection of the ecologic
niche and hence, giving rise to further progression of
the disease process. Numerous well-controlled clini-
cal trials, however, have documented that such a de-
velopment can be prevented over very long periods of
time only by the regular interference with the sub-
gingival environment which aims at the removal of
the subgingival bacteria.
PATIENTS AT RISK FOR
PERIODONTITIS WITHOUT SPT
The effect of an omission of SPT in patients with
periodontitis may best be studied either in untreated
populations or patient groups with poor compliance.
One of the few studies documenting untreated pe-
riodontitis-susceptible patients reported on the con-
tinuous loss of periodontal attachment as well as teeth
in Sri Lankan tea plantation workers receiving no
dental therapy (Loe et al. 1986). In such a — for the
western world — rather unique model situation an
average loss of 0.3 mm per tooth surface and year was
encountered. Also, the laborers lost between 0.1 and
0.3 teeth per year as a result of periodontitis. In another
untreated group in the United States, 0.61 teeth had
been lost per year during an observation period of 4
years (Becker et al. 1979). This is in dramatic contrast
to reports on tooth loss in well-maintained patients
treated for periodontitis (e.g. Hirschfeld & Wasserman
1978, McFall 1982, Becker et al. 1984, Wilson et al.
1987). Such patients were either completely stable and
lost no teeth during maintenance periods ranging up
to 22 years or lost only very little periodontal attach-
ment and only 0.03 teeth (Hirschfeld & Wasserman
1978) or 0.06 teeth (Wilson et al. 1987), respectively.
Non-complying, but periodontitis-susceptible pa-
tients receiving no SPT following periodontal surgical
interventions continued to lose periodontal attach-
ment at a rate of approximately 1 mm per year regard
-
less of the type of surgery chosen (Nyman et al. 1977).
This is almost three times more than would have to be
expected as a result of the "natural" course of peri-
odontal disease progression (Loe et al. 1978, 1986).
In a British study of a private practice situation
(
Kerr 1981) where the patients were referred back to
the general dentist after periodontal therapy, 45% of
the patients showed a complete reinfection after 5
years.
Probably the most impressive documentation of the
lack of SPT in disease-susceptible individuals arises
from a clinical trial in which one third of the patients
had been sent back to the referring general practitio-
ner for maintenance, while two thirds of the patients
received SPT in a well-organized maintenance system
(Axelsson & Lindhe 1981a). The 77 patients were ex-
amined before treatment, 2 months after the last sur
-
gical procedure and 3 and 6 years later. The 52 patients
on the carefully designed SPT system visited the pro-
gram every 2 months for the first 2 years and every 3
months for the remaining 4 years of the observation
period. The results obtained from the second exami-
nation (2 months after the last surgery) showed that
the effect of the initial treatment was good in both
groups. Subsequently, the recall patients were able to
maintain proper oral hygiene and unaltered attach-
ment levels. In the non-recall group, plaque scores
increased markedly from the baseline values, as did
the number of inflamed gingival units (Fig. 32-2a).
Concomitantly, there were obvious signs of recurrent
periodontitis. The mean values for pocket depth and
attachment levels at the 3-year and 6-year examina-
tions were higher than at baseline (Fig. 32-2h). In the
recall group, approximately 99% of the tooth surfaces
showed either improvement, no change or less than 1
mm loss of attachment, compared to 45% in the non-