a ‘An In Vivo Study of Teeth Reprepared During Periodon- tal Surgery is Giankonco Comevote MD, DMD, MS-D* ‘Geantanco bi Feb, 418, BOS" [aonelo Becoro, ODS" Sank Fron Soncrna, 40, ODS! ‘Messina Fuss 11D, DDS, 1D" The present aricle is the last in o series" dealing with the technique of tooth preparation during periodontal surgery, both from a clinical and & histologicel point of view. In paric- ular, this crticle onalyzes the precision ‘and biological compatiiliy of pros- thetic margins alter tooth prepora- tion, In those cases in which the abul- ment has been intraoperatively re- prepared, the final preparation may very according to clinical needs? If there is an adequate amount of tooth * Department of Periodontology "Deparment of Prosthodontics Bologna Univesty Den'al School, Via San Vile, $9, Bologna, hay. * Via Di Vila Reo, 26, Rome, aly: Conespondence address: Or G. Came: vale, Poza di Porte Mascaro, 7, 40126 Bolegna, lay sivctue left, the decision con be made to poriorm a chamfer or © shoulder preparation; if he thickness of the hard fssue isnot sulicient, os is more frequently the cose, tooth preparation will be limited 10 minor conection of the parallelism or to slight ocelusel finishing touches, maintaining a feather-edge prepo- ration as the defintve one. Because inkaoperctive prepara~ ‘ion eliminates ol the undercuts of the ‘obuiment up to the connective tissue ‘ttachment or to the bone level, 6 diferent relotonshia from the one biained with on abuiment not ce- Prepored intraoperatively is created between the prosthesis and the root suface (Fig 1). This article ottempis to verfy such © uation and to onalyze the per edontal conditions of inraoperatively treated teeth by comparing them to teeth prepared with « shaulder-bevel preparation offer surgical reciment Votime 19, Number 1, 1990,2 Materiols and methods Five patients with advanced per odontis, three males and two fe moles, portcipoted in this study. Ten teeth sloted for extraction were se- lected, two in each patient: one tooth wos reprepored intaoperatvely with 6 feather-edge morgin (experimental group) ond one tooth was repre pared 3 months ofter surgery wih o shoulderbevel preparation (contol group} [Fig 2} ‘Alter undergoing © complete ex cominaten, each potent began inal therapy, which included motivation, coral hygiene instructions, scaling, root planing, and provisionalization After 60 days, the patients under: went periodontal surgery, which con: sisted of opically positioned flops ‘and, where required, bone recon- touring. At this ime the five teeth of the expermentol group were repre pared up to the connective tissue at tachment or fo the bony crest (Figs 30 ond 36). During the ensuing 3 months, the patients underwent monthly recall vist. ‘After 150 days, final prosthetic preparation was corried out; this con- sisted of refining the parallelism of the experimental abuiment preparations ‘ond repreporing the control abut ments with © shoulder-bevel margin. Finol impressions were made using reversible hydrocolloids. In the ex perimental group no retraction cords were used; in the control group re- traction cords (Gingibroid, Van Dental Products Inc) were used, in order to visualize @ small section of unprepared root surface to be able to reproduce its profile in the final crown (Fig 4) The nemesona Jounal of Poodones & Reeerave Desshy Fig 1 let) The eloson that is obtained ‘aly eto toulerbavel pepeoton benvaen the crown margin ond fre prepared 190! Wih the inooperaioy preparation {gh on angles formed) Betrean the ciown margn ond te pe pared root aufoee A new metolacryic prosthesis was then fabricoted without ditching the dies of the control teeth but with ditching the dies of the test teeth [Figs 5a and 5b} High titer gold alloy (OP Due Frac: cori St] was used for the castings, The margins of the cowns were equivalent in cccwracy and precision to those of © definitive prosthesis [Figs 60 and 6b) After 180 doys, finel cementation wih zinc phosphate cement (55. White Co} wos corried out. After | sdditional month (day 210), the po: fienls ceosed interproximal oral hy: giene measures in the interestedConte) gun. 0 anol orion of urprepared 00! Fig 5b Experimental group: the fish ine of the model is Figs 62 and &6 Adaptation of the crown to the madel before (lef! and aftr (ight) refining ond polishing the margins.Experimental ‘group Days 0 Temporization No oral hygiene PD Pr a Control ‘group PO PD AL AL PL Pl Gi a Plaque sample Plaque sample biopsy Temporizaton fio? Fig 30 Doy 60. The mexillay second ‘molar wes not prepared during periaden- {ol surgery and was used os @ conro! tooth No oral hygiene roleca! ofthe experiment. PD ~ Probing depth; P! = plaque index: Gi = gingival index: AL ~ attachment level, Fig 4 Doy 150. The distal 00! of the molar was reprepared wh a shoulder Dovel preparation, whereas the mesio! Fig 3% The mesial mot of the second ne [ewpermenta! group) wos only re molar ves intoopersively prepared and fined. A reaction cord can be seen 10 thos Used ar one of he experimental femose the frshing ine and port of on weer, prepared roo! of the contol tooth 10, Nuno 199045 Alter 4 weeks without brushing {day 240}, the experimental and con- trol teeth were extracted with @ small section of adjacent soft tissue, The following indices wore recorded ot six sites (mesiobuccal, mesiolingual, midbuccal, midlingual, cistobuccal, ‘and distclinguel) around each tooth: 1 2, Plaque index according to Silness ‘and Loet Gingivol index according to Loe ‘and Siiness? Probing depth, measured by po- stoning a Willams probe parallel to the tooth’s long oxis Measurements were token: At the moment of inital exomi- nation [day 0} Belore periodontal surgery (doy 60) Belore cementation (dey 180} Belore oral hygiene interuption (doy 210) Before extraction (day 240) ‘The attachment level (distance be- tween the coronal portion of the gold collar of the crown and the fip on the probe} was recorded only on days 180, 210, ond 240. Microbiological date Subgingival plaque was sampled ot the level of the mesiobuccal and me- siolingual or mesiopalotal ine angles ‘according to the following technique: fist, every trace of supragingival plague was removed with a Gracey ‘curette; then, store cones (size M) |were introduced in the gingival sulcus ‘and left in su for 10 seconds. These points, imbued with exudate ond subgingival debris, were cut and sus- pended in a 0.85% NaC! solution which, dispersed by a vibrator for 15 seconds, was examined with @ dark field microscope within 2 hours at 1,200 magnification. Bacterial forms were classilied according to a mod- ifcotion of Listgorten and Helleden’s method; in foct, only four microbicl forms were taken into occount: coc, mobile forms, spirochetes, and oth- es." “Others” comprised sticight ‘and curved rods, filaments, ond fu- siform boctero. Anolysis of the biopsies The bioptic preparation of the soft tssues thot was exacted with the roots permited (1) 0 cytomorsho- metic analysis using on image ona Iyzer, and (2) a cytomorphologic evaluation aimed at characterizing the inflammatory intitate. The morphometiic evaluation was performed in the following way: 1, The total area /TA/ of each sec- ton was meosued for every cose Reread es ae flommotory infiltrote (lA) wos evaluated. 3. The percentage of inflammatory infiltrate in the area (PIA) was rolodad bi mee weeten th the formule minal x00 ™ For each case, the cyomorpho- Inge slosh es ipa as wt Marginal adaptation of the crowns The marginal adaptation of the crowns was analyzed using a stereo- microscope with ¢ measuring grid. ‘The root of each exacted tooth wos cut at the level of the junction be- ween crown and root fo enable the operator to measure the marginal ‘opening perpendicularly fo the ex- mined surface. The circumference of ‘each crown was divided in four ports, ‘and each part was divided in three sections. In each section, the mxi- mum and minimum openings were coluicted by three different opera: tors for o total of 72 measurements for each crown and 360 meosure- ments for each group (Figs 7 and 8} \otune 1, Number 1, 199046 Fig 7 The wot of each extracted tooth was cut af the level ofthe yncton be- ween crown and root, and the cium (nee woe dived in four pars Stofsicol analysis ‘An analysis of variance taking into account patients and tooth status (experimental or controll was used to compare numerical densily percent age of infitraied connective tssve, precision of the prosthetic margin, fond the mean percent compostion of the subgingival microflora in the experimental and control groups. The maximum and minimum openings of the prosthetic margin were measured by three different operators in 12 po: sions {zones} for each tooth, Anh ysis of variance was then performed fn the 12 zone averages for each tooth, toking into account potients cond tooth status. Fig 8 An eniargsment ofthe marginal ara showing the ad Sdlokon of he Boner the reonds opsring oF 25 fen gies ‘on kdea OF the precision of the margin. Ploque index, gingival index, pock- et depth, and attachment level were analyzed as follows: comparisons between times of observation in the same group were made with respect fo the number of sutaces thot im- proved, remained stable, and de- generated by mecns of o fest similar to the MeNemor test’ Comparisons between groups at the some time were performed by means of the chi squared test The intematons Jourolo Poon & Restore Dentey Results Table 1 shows the ploque index scores in the experimental group and in the control group. The anolysis of variance coried out by comparing the two groups during the 0 to 60 doy, 180 to 210 doy, and 210 10 240 doy periods did not show statistically significant diferences (Fig 9). Similar resuits were also observed for the gingival index scores (Table 2; Fig 10} ‘Average initiol probing depth measurements were 3.86 mm for the experimental group (Fig 11a) ond 4.56 mm for the control group (Fig Tb}. Alter preliminary preperation (dey 60), there was © slight statisa7 Toble 1 Plague index (PI) scores in experimental (Exp!) and control (Cont) sites Pl Day 0 Day 60 Doy 180 Doy 210 Doy 240 Exp. Cont Exp. Cont Exp. Cont Exp. Cont Exp. Cont 0 eee 2 3 307 0 w 6 = 1 ieee - - 3 ee Pee Bi eae - - = - = 15 18 3 ect sos ae = Pees x MOST aos 0 a) 0 008 13 16 Fig. Plaque index. Percent of sies tht improved (), remained stoble (0, and worsened (—) in the two groups fom doy 0 to day 8 fram day 180 10 day 210, and rom day 210 to doy 240 Plaque Index a contro [a Experimenta 80% NS. 210-240 Volvo 10, Nurer 1, 199048 Table 2 Gingivol index (Gi) scores in experimental (Exp) and control (Cont) sites Gi Day 0 Doy 60 Doy 180 Doy 210 Day 240 Exp. Cont Exp. Cont Exp. Cont Exp. Cont Exp. Cont 0 ae 2a OW 30 20 30 30 eitce 1 7 6 7 6 - 10 as 1 15 2 me. - 5 ae eee 2° 2 3 oe a eet ae eee z 161.13 023 053 0 03 o a os 13 fig 10, Gingival dex. Percent of ses that improved (+), remoined stable (0), and wersened (=) in the wo groups day 0 0 day 60, For day 180 0 doy 210, ond fom coy 210 fe coy SG oe Gingival Index conte HBB experimental NS. NS. 0-60 180-210 The neater Jounal of Patents & Retortve Dentsa Probing Depths — Experimental | Fig Na Probing depth measurements the exparmantal group (mean ves) Fig 1b Probing depth measurements in the conto! croup (mean values) Probing Depths — Control Nolure 10, Number 1, 199050 Attachment Levels contoi (BD experimental cally significant (? <.02} decrease in the probing depth measurements of the expermental group only, from 3.86 to 3.43 mm. After periodontal surgery, the de crease in probing depth measure ments was significant both from a clinical ond statisical point of view [P <.001}. The mean values were reduced 10 1.33 mm in the expeti- mental group and to 1.6 mm in the control group; such values remcined unchanged lor the month aller ce- mentation. In the month of oral hygiene intemuption there wos @. significant increase [experimental group P <.005; control group P <.001) in the mean probing depth measure- ments: 1.66 mm in the experimental group and 2.06 mm in the contol group, ‘At days 210 and 240 there was ro significant attachment loss in the ‘wo groups (Fig 12). The hrnotonol Jounal ol Petodontcs& Retro Den The onolysis of variance canied out comparing probing depth and atiachment level changes in the ex: perimental group and in the control group did not point out any statist cally significont difference (Figs 13 cand 14}. The microbiological results were similor for both groups: with ode- quate contol of plague accumula- tion, the predominant bacterial mor- pholype was cocci (82.6% in the ex- perimentol group and 4.8% in the contol group). Spirochetes and mo- bile forms were present in limited ‘quonites in both groups [Table 3} Aller 1 month of plaque occu- mulation, the following changes in the morphology of the bacteral flora were noted: cocci population de- creased, shifing to about 65% in both groups; bacterial forms in the category “others” increased fom 11% to about 27%; ond spirochetes ‘and mobile forms together increased to about 9% in both groups (Table 3). An analysis of vatiance of the Fig 12 Attachment lovel gain (11, stabi 1910, end ess) mero groves mean percent composition of the mi crobial flora in the two groups did not show ony significant difference (Toble 3), The densimeic analysi of the connective tissues did not show any statstically significant cifference in the mean percentage density of inflom- matory inflirate between experimen tal end control groups (Table 4| The cylomoxpholagic analysis 1e- vealed @ lymphomonocylic type of infilate in every section exorined in both groups. The average values of marginal ‘opening of the crowns were 38.6 jim in the experimental group and 57:2 im in the control group. These values differ significantly (P <.001} [Fig 15)51 fig 13. Probing depth. Percent of ses ther improved (+, ramained stable 0), ‘and worsened (=) in the ho groups om day 810 day 80, hom doy 180 fo doy 210, and am doy 210 10 day 240 Fig 14 _Anachment lovel Percent of sles that mproved (+, remained stoble (0), ‘ond worsened (~) nthe hwo groups fom ay 180 19 coy 210 and! hom dey 210 fo doy 240 Probing Depths cont BEB experimental 0-60 —~=«180-210—=~=S«N0=240. Days Attachment Levels BR conver [BED Experimental sam 28% AQ 28.17% Ns. NS. 180-210 210-240 Yolume 19, Numb 1, 1990,Table 3 Percent composition of subgingival microflora in control ond exper- imental groups: mean valve with standard deviation in parentheses Bocteriol Doy 210 ee Control Cocei 826 (54) 4.8 (3.6) Spirochetes 40 (20) 3.2 (0.8) Mobile forms 2.4 (0.8) 1.2 (0.8) Others 10 27) 108 (37) Doy 240 Experimental Control Experimental 64.4 (17.05) 56 (3.4) 3.4 (3.05) 26.6 (11.6) 642 (17.4) 48 3.4) 38 (2.1) 27.2 (19) NS ANOVA NS Table 4 Density of infitrated connective tissue in the control and experimental groups Tooth Control group Tooth Experimental group. 15.30 11.86 21.46 6.46 637 ¥= 1229 SD = 637 F 0312 (NS) 1441 13.52 9.98, 21.10 1474 1 = 1476 SD = 4.02 Te iterational Joumal of Peconic Rasorave Dakig 15 _ Mean opening valves of the ‘on margins # the MO grOURS. Discussion. To analyze the results of this study it can be useful to divide the study in wo periods: 1, From day 60 time of surgery 10 day 210, wih special attention to the month following cementation 2. From day 210 10 day 240, to eval- uate in the control and experi- mental groups the course of the inflammatory state in absence of corel hygiene The low probing depth meosure- ments obtained in both groups after, periodantal surgery were maintained throughout the month following ce- mentation; during this period there was no loss of attachment. After ce- mentation of the crowns, it was easy for the patient to mointain a good level of plaque control, ond in both groups there wos no change in the Crown Margin Openings dinicol periodontal condition, which ‘was unoifected by the lype of prep- ‘ration or the presence of the pros: thes’s itself During the period in which patients interupted oral hygiene measures, from day 210 to day 240, there was fan increase in the ploque index scores ond a retuin of the gingival index score to values similor to the oseline in both groups. A slight in- crease in probing depth scores, be- couse of the formation of pseudo- pockets (there was in fact no signifi- cont attachment loss}, also was re- corded in both groups. Similor results were obicined with the microbiological analysis. Only four microbial fons were taken into ceccount+ that is, cocci, mobile forms, spirochetes, ond “othess.” Skaight and curved rods, ond fla- ments and fusiform bacteria were in- cluded in the “others” category and ‘were not individually considered be- cause they ore rarely sensiive 10 changes in cinicol situations.*!°"" In @ heokhy condiion, the pre- dominant boctesil form wos repre: sented by cocci wih no difference between the two groups. The per- centage of spirochetes wos 4% in the experimental group ond 3:2% in the contol group. Adding mobile forms to spiracheles (MF + SP}, 64% in the experimental group and 4.4% in the contral group are obtained. Comparing the present microbio- logical results fo data obteined som- ping gingiva in healthy conditions shows that the percentage of spiro chetes plus mobile forms is greater thon that reported by Lisigarten and Helleden® (SP + MF = 2%) but sim- ilorto those reported by Lindhe etal {SP + MF = 5%) ond Singletary et al (SP + MF = 5%) If the percentage of spirochetes plus mobile forms obtained inti re- search is compared io the results ob: toned in analogous papers by other couthors2"3" where good oral hy- giene was maintsined offer per ‘odontcl sugery, then icon be noted Vole 10, Nebr 1, 1990thot the percentages recorded by these outhors [14% to 20%) ore higher. This finding may be due to the residual probing depth after ther- apy, whichis greater inthe preceding research, rather than being coused by disease present at a subclinical level, os suggested by Listgorten The increase in spirochetes plus mobile forms obtained with inade- uate oral hygiene was clso not rel: evont, possibly becouse of the limited increase in probing depth to which the percentage of spirochetes plus mobile forms is generally assoc: oted,""? ‘The mean value of margincl open ing of the crowns in the experimental group (36.6 um) ond that ofthe con: trol group (57.2 Hm} ore similar to those reported by Belser et al! (30 0 46 j1m after cementation], and by Eames et ol” (33 10 45 jim ater ce- mentation) for in vo studies, but they ‘are smaller then those reported by Poscos"* (91.51 pm afer cemento- tion). The difference between exper: imental and control groups can be related to the different geomeiry of the preparations,” and although sta- tistcally significant, have no practical consequence, as shown by the clin ico, histological, and microbiological onalysis. Te Inersotonl Jounal of Paiodontcs & Resort Dery Conclusion The results ofthis research ore in oc cordance with those of a rerospec- tive analysis of 510 teeth in 109 po. tients exomined from 1 to 9 yeors ‘fier treatment, but they ore not in ‘accordance with the conclusions of Morignoni and Schénenberger who state that the different ongulo- tion between the prosthesis and the root surtace, obtained atter tooth re- preparation during periodontal sur ‘gery, can cause periodontal disease. Itis not the geometry of the crown preparation that influences the health fr disease of the periodontium but the obiity of the patient to perform ‘oral hygiene measures and the pre- Cision of the crown morgin