Periosteal Pocket Flap for Horizontal Bone Regeneration: A Case Series

2. Combination Flap Surgery
with Resin-Modified Glass
Ionomer for the Treatment of
Radicular Lesions: A Long-
Term Follow-up
Luis A et al, Int J Periodontics
Restorative Dent 2013.
Shilpa Shivanand
II MDS

3. Introduction
• Subgingival radicular lesions and non-carious cervical lesions
(NCCLs) present a great challenge to clinicians.
• Current treatment for NCCLs varies from conservative
subgingival restoration to a more advanced periodontal flap.
• Nonsurgical treatment of subgingival lesions is challenging
due to limited visualization and moisture contamination of
restorative materials.
• Amalgam and composite resin, although frequently elected
as the restorative materials to treat subgingival lesions, elicit
a severe gingival inflammatory response and do not allow
periodontal attachment on their surface.
Gomes SC, Miranda LA et al, 2005.

4. Introduction….
• Periodontal attachment loss and furcation involvement
are common adverse side effects of using restorative
materials that are not biocompatible.
Valderhaug J, 1980
• Surgical crown lengthening compromises periodontal
attachment and the overall esthetic results.
• As a result, some of these teeth affected by radicular
lesions may be extracted because of the overwhelming
restorative and surgical challenges of saving the tooth.

5. Why RMGI ?
• Resin-modified glass ionomer has been advocated for
treating radicular lesions.
• This material consists of a hybrid of traditional glass
ionomer with a small portion of light-curing composite
resin, resulting in intermediate properties between glass
ionomers and resins.
Sidhu SK, Watson TF 1995
• RMGI was developed to overcome the problems of low
initial mechanical strength and moisture sensitivity
exhibited by conventional glass ionomers.
Burgess JO et al 1993, Hinoura K et al 1991

6. Why RMGI ? ..
• Resistance to microleakage of RMGI is an important feature
in a surgical field where contamination with blood and oral
fluid is inevitable.
Tjan AH, Dunn JR 1990, Sidhu SK 1992
• RMGI possesses antibacterial properties through its fluoride
release that contribute to the prevention of recurrent caries
which is particularly important in a subgingival environment
where plaque control is difficult.
Williams et al JA 2001, Dhondt CL et al 2001
• Moreover, periodontal attachment through long junctional
epithelium and hemidesmosomes to this material has been
shown.
Dragoo MR 1997

7. Aim
• The present clinical study was undertaken to evaluate
the clinical effectiveness and biocompatibility of RMGI
in conjunction with flap surgery to treat subgingival
radicular lesions.

8. Materials and Methods
• A review of clinical cases pertaining to the use of an
RMGI was performed.
• Patients were treated in a private practice between 1997
and 2010.
• All surgical and restorative procedures as well as clinical
measurements were performed by two periodontists.
• This study was approved by the University of Michigan
Health Sciences Institutional Review Board.

9. Clinical Measurements
• Demographic data and clinical parameters were recorded
including probing pocket depth (PPD), gingival recession,
clinical attachment level (CAL), bleeding on probing
(BOP)- as present / absent within 30 sec after probing.
• All measurements were performed using a Marquis
periodontal probe (Marquis Dental) and were rounded up
to the nearest millimeter.
• The retention of the RMGI in the restorative cavity was
also recorded as present or absent.
• All measurements were recorded at baseline (ie, prior to
surgery) and at follow-up (ie, following surgery).

10. Surgical Procedure
• Surgical procedures performed were categorized as
either open flap debridement (OFD) or coronally
advanced flap with or without connective tissue graft
(CAF ± CTG).
• CAF ± CTG was performed in cases that exhibited
gingival recession with minimal keratinized gingiva and
attached gingiva.
• All procedures were performed following the same basic
surgical protocol.

11. Surgical procedure…
• Subjects were anesthetized with a local anesthetic
containing vasoconstrictor.
• A full-thickness mucoperiosteal flap was reflected
following sulcular incision.
• The radicular defect was reshaped using round carbide
burs to remove caries if present and to decontaminate
the root surface.
• Hemostasis of the surgical site was achieved using the
local anesthetic.
• The RMGI (Geristore, Den-Mat) was placed according to
the manufacturer’s recommendations.

12. Surgical procedure…
• Acid etching with phosphoric acid gel was applied on the
root surface for 30 seconds and rinsed off with every
attempt to prevent the gel from contacting the bone
and connective tissue.
• Multipurpose bonding system (Den-Mat) was applied
prior to placement of the RMGI.
• A and B paste were mixed with a syringe tip and gun.
• The material was placed using a plastic instrument while
ensuring that all margins were well sealed.
• RMGI was then light cured using a conventional halogen
light for 30 seconds.

13. Surgical procedure…
• Finishing and polishing of the restoration were achieved
with a fine-grit flame-shaped diamond bur and curettes.
• The flap was either replaced at its original position in the
OFD group or coronally positioned in the CAF ± CTG
group and sutured with 4-0 silk and 5-0 gut sutures.
• N-butyl cyanoacrylate was used as needed to achieve
additional flap closure and stability.

14. Conventional OFD + RMGI

15. CAF ± CTG + RMGI

17. Post-op Instructions
• Patients were instructed to take analgesics (400 mg
ibuprofen every 4 to 6 hours for 3 days) and to discontinue
oral hygiene, including tooth brushing and flossing around
the surgical areas, for 10 days.
• No antibiotics were prescribed.
• Patients were instructed to rinse twice daily with 0.12%
chlorhexidine mouthwash for 2 weeks.
• Sutures were removed after 10 days.
• Periodontal maintenance was performed every 3 to 4
months.

18. • Cases were considered successful if they exhibited the
following:
• (1) periodontal pocket depth ≤ 4 mm
• (2) no progressive clinical attachment loss of more than
2 mm between baseline and follow-up
• (3) absence of symptoms and
• (4) retention of the restorative material.

19. Statistical Analysis
• Descriptive statistics were expressed as means ±
standard error (SE) for parameters collected at baseline
and follow-up.
• Radicular lesions were used as the unit of measurement.
• The t test was performed on all clinical parameters (ie,
PPD, recession, CAL, BOP) to compare values at
baseline to follow-up. (P < 0.05 - statistically significant)
• Chi-square test was used to compare success rates for
individual practitioners as well as the association
between baseline and follow-up clinical parameters (ie,
PPD, CAL, and BOP) with success of the cases.

20. Results
• The study population consisted of 142 patients (66 men
and 76 women, mean age: 63.0 ― 0.9 years) with 188
subgingival radicular defects including external root
resorption, root caries, endodontic perforation,
periapical lesions, and non-carious cervical lesions.
• Patients were followed up for a mean of 4.2 ±0.2 years
(up to 13.4 years).
• No adverse events were reported during the observation
period.

21. Results…
• Of the patients, 30.3% (n = 43) were smokers and 14.1%
(n = 20) were diagnosed with diabetes.
• OFD alone was used to treat 90.4% (n = 170) of cases,
and 9.6% (n = 18) of the cases were treated using the
CAF ± CTG approach.

23. Results…
• After a mean follow-up of 4.2 years, 77.7% (n = 146) of
cases treated with OFD were successful and 94.4% (n =
17) of cases treated with CAF ± CTG were successful.
• The overall success rate was 86.7% (163/188) based on
the total number of radicular defects.
• When patient is used as the unit of analysis, the overall
success rate was 82.4% (117/142).
• Success rates among all operators were similar with no
significant differences.

25. Results…
• Of the 25 cases that failed, 7 (28.0%) were replaced with
RMGI, 2 (8.0%) were replaced with another restorative
material other than RMGI, and 16 (64.0%) were
extracted due to either recurrent caries, vertical
fracture, or a devitalized tooth.
• Hence, 9 (36.0%) cases failed due to a loss of retention
of the restoration.

26. Discussion
• Successful treatment of subgingival radicular lesions
depends greatly on excellent combined restorative and
periodontal procedures.
• Favorable properties of the RMGI were demonstrated by
previous in vitro and histologic studies, including its
biocompatibility and ability to obtain an attachment
through long junctional epithelium and
hemidesmosomes.
Dragoo MR 1997, Al-Sabek F et al 2005.

27. Discussion…
• The current study supports the idea that the attachment on
restored roots can be maintained over a mean period of 4.2
years as demonstrated by shallow PPD and CAL gain despite
its subgingival location.
• The soft tissue healing of successful cases showed
significantly less inflammation, as demonstrated by the
decreased BOP at follow-up.
• The presence of BOP in failed cases could be attributed to
plaque accumulation on the restorative material, which
exacerbates gingival inflammation.
• However, Plaque Index was not measured in this study and,
therefore, oral hygiene performance could not be assessed.

28. Discussion…
• Previous studies have shown good retention of the
RMGI in treating Class V lesions.
Santamaria MP et al 2009, Adballa AI 1997
• In this study, 36.0% of failed cases were due to loss of
retention of the restoration.
• Within the context of subgingival defects, where access
is difficult and contamination is frequent, the
combination therapy generated a success rate of 86.7%
and is a good alternative to extracting the tooth.

29. Discussion…
• Furthermore, the CAF ± CTG group generated a success rate
of 94.4%, which suggests that it is a valuable technique when
presenting options available to treat radicular lesions, despite
the smaller number of patients belonging to this group.
• The authors speculate that retention of the RMGI is enhanced
with a CAF compared to an OFD due to the formation of a
hemidesmosomal attachment to the RMGI and, hence, the
inability to damage the subgingival RMGI with
instrumentation.
• Whereas in the OFD group, the risk of dislodging the RMGI
increases due to mechanical instrumentation during
maintenance therapy, which contributes to its lower success
rate compared to the CAF ± CTG group.

30. Conclusion
• This study confirms the successful placement of RMGI
onto the root surface to restore function and esthetics in
teeth that previously would have been non-restorable.
• The overall success rate of this treatment modality was
86.7%.
• The possibility of achieving clinical attachment gain can
be attributed to the advantageous clinical features of
this material such as biocompatibility.
• The favorable results of this treatment modality were
maintained over a mean period of 4.2 years with a
maximum follow-up of 13 years.

31. Critical Evaluation
• No indices to measure oral hygiene plaque index
• No histologic evaluation done to evaluate soft tissue
attachment
• Not considered etiologic factors of patients causing the
radicular lesion

32. Cross References

33. I. Periodontal Tissue Response to Coverage of
Root Cavities Restored With Resin Materials: A
Histomorphometric Study in Dogs
Thiago M.et al, JOP 2007.
AIM: The purpose of this study was to histomorphometrically evaluate
the response of periodontal tissues covering Class V resin restorations
in dogs.
METHOD: After raising a mucoperiosteal flap, bony defects measuring
5*5 mm were created on the buccal aspect of the canines of five dogs
followed by cavity preparations on the root surface measuring 3*3*1
mm. Before repositioning the flap to cover the bone defect, the cavities
were restored with composite resin (CR) or resin-modified glass
ionomer cement (RMGIC) or were left unrestored as control (C). The
dogs were euthanized 90 days after surgery. Specimens comprising the
tooth and periodontal tissues were removed, processed routinely, cut
into longitudinal serial sections in the buccolingual direction, and
stained with hematoxylin and eosin (H&E) or Masson’s trichrome. The
most central sections were selected for histomorphometric analysis.

34. • RESULTS: Histomorphometric analysis revealed apical
migration of epithelial tissue onto the restorative materials
(RMGIC and CR). The C group presented significantly longer
connective tissue attachment (P <0.05) than the RMGIC and CR
groups and significantly higher bone regeneration (P <0.05)
compared to the RMGIC group. Histologically, the cervical third
(CT) of all groups had the most marked chronic inflammatory
infiltrate.
• CONCLUSION: Within the limits of this study, it can be
concluded that the restorative materials used exhibit
biocompatibility; however, both materials interfered with the
development of new bone and the connective tissue attachment
process.

35. II. Preferential Attachment of Human Gingival
Fibroblasts to the Resin Ionomer Geristore
Al Sabek et al , J Endodontics 2005.
ABSTRACT: The resin ionomer Geristore has been used
extensively for root perforation repairs. The purpose of this
study was to evaluate oral in vitro biocompatibility of the resin
ionomer Geristore compared to two other dental perforation
repair materials, Ketac-Fil and Immediate Restorative Material
(IRM). Growth and morphology of human gingival fibroblasts
(HGFs) was determined using scanning electron microscopy
(SEM) of HGFs cells grown on test materials as well as
cytotoxicity assays using elutes from test materials.

36. CONCLUSION: SEM analysis showed that HGFs attached and
spread well over Geristore with relatively normal morphology.
SEM showed that fibroblasts did not attach and spread well over
Ketac-Fil or IRM as cells appeared much fewer with rounded and
different morphology than fibroblasts grown on Geristore.
Cytotoxicity assays indicated that HGFs proliferated in the
presence of Geristore elutes and not in the presence of Ketac-Fil
or IRM elutes. In vitro interpretation indicates that Geristore is
less cytotoxic to gingival fibroblasts.