Healing After Periodontal Therapy

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The bask healing processes are the same following all forms of periodontal therapy. They consist of the removal of degenerated tissue debris and the replacement of tissues destroyed by disease. Regeneration, repair, and new attachment are aspects of periodontal healing that have a special bearing on the results obtainable by treatment.


Regeneration is the growth and differentiation of new cells and intercellular substances to form new tissues or parts. Regeneration takes place by growth from the same type of tissue that has been destroyed or from its precursor. In the periodontium, gingi val epithelium is replaced by epithelium, and the underlying connective tissue and periodontal ligament are derived from connective tissue. Bone and cementum are not replaced by existing bone or cementum but by connective tissue, which is the precursor of both. Undifferentiated connective tissue cells develop into osteoblasts and cementoblasts. which form bone and cementum.

Regeneration of the periodontium is a con tin iioiis physiologic process, tinder normal conditions new cells and tissues .ire constantly being formed to replace those that mature and die. I bis is termed weai ami War repair.1* It is manifested by mitotic activity in the epithelium of the gingiva and the connective tissue of the periodontal ligament, by the formation of new bone, and by the continuous deposition of cementum.

510 PARI 5 ■ Treatment of Periotlontal Disease

Gingiva Treatment
Fig. 36-4 Sources of regenerating cells in the healing stages of a periodontal pocket. Left, Intrabony pocket Right, After therapy, the clot formed is invaded by cells from A, the marginal epithelium; B, the gingival connective tissue; C, the bone marrow; and D, the periodontal ligament.

Fig. 36-3 Two possible outcomes of pocket elimination A, Periodontal pocket belore treatment. B, Normal sulcus reestablished at the level of the base of the pocket. C, Periodontium restored on the root surface previously denuded by disease. The latter is called new attachment. Shaded areas show denudation caused by periodontal disease.

Regeneration is also going on during destructive periodontal disease. Most gingival and periodontal diseases are chronic inflammatory processes and, as such, are healing lesions. Regeneration is part of the healing. However, bacteria and bacterial products that perpetuate the disease process and the inflammatory exudate they elicit are injurious to the regenerating (.t ils and tissues and prevent the healing from proceeding to completion.

By removing bacterial plaque and creating the conditions to prevent its new formation, periodontal treatment removes the obstacles to regeneration and enables the patient to benefit from the inherent regenerative capacity of the tissues. There is a brief spurt in regenerative activity immediately following periodontal treatment, but there are no local treatment procedures that promote or accelerate regeneration.


Repair simply restores the continuity of the diseased marginal gingiva and reestablishes a normal gingival sulcus at the same level on the root as the base ot the preex-istcnt periodontal pocket (Pig. 36-3). 11 iis process, called healing by scar,2* arrests bone destruction without necessarily Increasing bone height. Restoration of the destroyed periodontium involves mobilization of epithelial and connective tissue cells into the damaged area and increased local mitotic divisions to provide sufficient number of cells (Fig. 36-4).

New Attachment

New attachment is the embedding of new periodontal ligament fibers into new cementum and the attachment of the gingival epithelium to a tooth surface previously denuded by disease (see Tig. 36-3). I he critical phrase in this definition is "tooth surface previously denuded by disease" d ig. 36-5). Attachment of the gingiva or the periodontal ligament to areas ot the tooth from which they may be removed in the course of treatment or during the preparation of teeth tor restorations represents simplt healing or reattachment of the periodontium, not new attachment.n The term reattachment has been used in the past to refer to the restoration of the marginal periodontium, but because it is not the existing fibers that reattach but new fibers that are formed and attach to new cementum, the term has been replaced by the term new attachment. Reattachment is currently used only to refer to repair in areas ot the root not previously exposed to the pocket, such as after surgical detachment of the tissues or following traumatic tears in the cementum, tooth fractures, or the treatment of periapical lesions.

Epithelial adaptation differs from new attachment in that it is the close apposition of the gingival epithelium to the tooth surface without complete obliteration ot the pocket. The pocket space does not permit passage of a probe (Tig. 36-6). Studies have shown that these deep sulci lined by long, thin epithelium maybe as resistant to disease as true connective tissue attachments. " The absence of bleeding or secretion on probing, the absence of clinically visible inflammation, and

Periodontitis Junctional Epithelium

Fig. 36-5 A, Enamel surface. B, Area of cemenlum denuded by pocket formation C, Area of cementum covered by junctional epithelium. D, Area of cementum apical to the junctional epithelium. The term new attachment refers to a new junctional epithelium and attached connective tissue fibers formed on zone B.

Fig. 36-5 A, Enamel surface. B, Area of cemenlum denuded by pocket formation C, Area of cementum covered by junctional epithelium. D, Area of cementum apical to the junctional epithelium. The term new attachment refers to a new junctional epithelium and attached connective tissue fibers formed on zone B.

Rationale [or Periodontal heatment • (HAI'llR to SI I

Cancer Disease Images

Fig. 46-6 Epithelial adaptation following periodontal treatment. A, Periodontal pocket B, Alter treatment The pocket epithelium is closely adapted to, but not attached to, the root the absence of stainable plaque on the root surface when the pocket wall is deflected from the tooth may indicate that the "deep sulcus" persists in an inac tive state, causing no further loss of attachments '' A post-therapy depth of 4 or even 5 mm may therefore be acceptable in these cases.

New attachment and osseous regeneration have been a constant but elusive goal ol periodontal therapy since beginning of this century. Since the ll>7()s, renewed laboratory and clinic,d research efforts have resulted in new-concepts and techniques that have moved us much closer to attaining this ideal result ol therapy. < haptcr 6 * presents the recommended methods of treatment and their indications and accomplishments.

Melcher pointed out that the regeneration of the periodontal ligament is the key to new attachment because it "provides continuity between the alveolar bone and the cementum and also because il contains cells that can synthesize and remodel the three connective tissues ol the alveolar part of the periodontium." '1

During the healing stages of a periodontal pocket, Ihe area is invaded by cells from four different sources (see Fig. 36-4): oral epithelium, gingival connective tissue, bone, and periodontal ligament.

The final outcome of periodontal pocket healing depends on the sequence ol events during the healing stages 1 If the epithelium proliferates along the tooth surface before the other tissues reach the area, the result will be a long junctional epithelium. II the cells from the gingival connective tissue are the lirst to populate the-

area, the result will be fibers parallel to the tooth surface and remodeling of the alveolar bone with no attachment to the cementum. II bone cells arrive first, root resorption and ankylosis may occur. Finally, only when cells from the periodontal ligament proliferate coronally is there new formation of cementum and periodontal ligament.'1 Several methods have been recommended to improve the likelihood of attaining new attachment. Ihey arc-presented in ( haptcr 63.

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  • mebrat
    What is the treatment procedure for periodontal intrabony pocket formation?
    8 years ago
  • mckenzie fleming
    How long after deep cleaning is periodontium ligament reattachment?
    4 years ago
  • leonie
    How long does it take for long junctional epithelium to get reattached after perio?
    3 years ago
  • Ella
    Why you need cementum for gingival tissue healing?
    16 days ago

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