Journal of Clinica} Perioclonwlogy 1981: 8: 375-386

Key words: perioiiotKu! ak^cesf •- inirabony de/ecl - ihetspy.

AccepletJ for publication Sepltimbet 22, 1980

Case Report

Therapeutic considerations in themanagement of a periodontal abscess with

an intrabony defect

i. KAREHA, EDWIN S. ROSENBERG AND HAROLD DEHAVEN

Department of Periodontology, School of Dental Medicine, University of Pennsylvania, Philadelphia,PA, U.S.A.

Abstract. A cast report of the clinically successful management ofan intrabony pocket associated with aperiodontal abscess of a lone-standing, functioning tnandibuiar canine utilizing an autogenous,intraoral site cortical and cancellous bone graft concurrently with a lateral pedicle soft tissue graft ispresented. The rationale for the diagnostic, prognostic and therapeutic considerations is discussed inlight of the experimental and observational knowledge gained from the literature to date.

A 58-year-o!d female with a noncontribiitorymedical history was referred to the University ofPennsylvania School of Dental Medicine, with achief complaint of "pus coming from the lowerright canine". A history from the patient re-vealed that she sought emergency care forgingival pain and swelling in ihe lower rightcanine area with the treatment consisting ofestablishment of drainage via a sulcular incisionand drainage procedure and a prescription forerythromycin which the patient took only forthe first five days. Less than one week later thepatient sought treatment at the EmergencyDental Clinic, University of PennsylvaniaSchool of Dental Medicine, because of Ihecontinuing purulent drainage, although all painhad ceased following the emergency therapy bythe previous practitioner. Subsequent to a diag-nosis of a lateral periodontal abscess, treatmentconsisted of curettage to maintain free drainageand a recommendation that the patient registerfor more definitive therapy. After a period ofseveral weeks the patient decided to register atthe School of Dental Medicine and was thenseen in the Dental Hygiene Clinic where severai

visits of scaling, root planing and inadvertentcurettage with anesthesia as well as instructionin plaque control techniques and the necessaryprerequisite motivation resulted onlv in themaintenance of free sulcular drainage of pus.With this lack of improvement the patient wasreferred to the Graduate Periodontic Clinic.

Initial examinaiionThe patient presented to the Graduate Perio-dontic Clinic with a maxillary, removable fulldenture; a mandibular, removable partial dent-ure; and full coverage porcelain fused to goldrestorations on the two remaining teeth in themouth, the mandibular canines, which wereconnected by a Dolber type cast bar. The fixedand removable prostheses were fabricated sixyears earlier, at which time the gold margins ofthe fixed restorations were reportedly subgin-gival. Dental records, including radiographs,prior to the Emergency Dental Clinic visit wereunobtainable. The lower ]eft canine remaineduninvoived having no recession, healthy shal-low sulci and vital pulp responses to boththermal and electric stitnuli. The gingiva and

0303-6979/81/050375-12 S02.50/0 ^ 1981 Munk.'igaard. Copenhagen

KAREHA, ROSENBERG AND DEHAVEN

Fig. I A. Periodontal abscess of the lower right caninein which edema of the gingiva and alveolar mucosacan be noted.

Parodoniaiabzess am imteren Eckzahn. Gingiva undaiveolare Mukosa sind ijdema'os verimden.

Abces parodonial au niveau de la 43. Noler I'oedeme dela gencive et de la muqueuse alveolaire.

alveoiar mucosa overlying the lower right ca-nine appeared edematous and erythem.atous. Inaddition there was slight hypersensitivity toboth vertical and horizontal percussion, andresponse to electric and thermal stimtili wasvital although slightly increased. A thoroughperiodontal exatnination of the lower rightcanine was deferred because of the more im-mediate need to reestablish adequate sulculardrainage. In the short time since the last DentalHygiene Clinic visit the oiifice lo the abscesshad apparently occluded with resultant dis-comfort to the patient, described by her as a dullpain (Figs. 1A,B).

DiagnosisThe diagnosis of a periodontal abscess wasconfirmed although it was felt that endodonticinvolvement such as a root fracture or a lateralaccessory canal couid not be definitely ruled outat this time, despite the vital responses tothermal and electric pulp tests. The pathoge-nesis of a peridontal abscess is most frequentlycited as involving an occlusion of, or trauma to,the orifice of a preexisting periodontal pocketand can result in extension of theinfection fromthe pocket into adjacent periodontal tissues due

Fig. IB. Initial radiograph of the lower right canitie.

Rontgenbild des unieren Eckzahncs. Ausgangssitua-hon-

Radiographie iniiiule de la 43.

to the pressure of suppuration within the pock-et. In addition other etioiogic factors mayinclude a change in bacterial virulence or hostr'esponse (Gottsegen & Darakjian 1979), phys-ical impaction of a foreign object into a sulcusor pocket (Shafer et al. 1974, Goldman &Cohen 1980), infection of lateral periodontaicysts (Trott 1959, Miyasato 1975, Grant et al.1979), occlusal trauma (Gottsegen & Darakjian1979), and an occasional idiopathic occurrence(Holder 1959). The pocket involved as anabscess is frequently characterized by remis-sions and exacerbations (Prichard i953, Car-ranza 1979).

Presurgical phase of therapyThe primary etioiogic role of microbial plaquein the pathogenesis of gingivitis (for review seeSocransky 1970) as well as the experimentalprogression of gingivitis into periodontitis (Sa-xe et al. 1967, Lindhe et al. 1973, I975)has beendocumented. Therefore, one of the prime goalsof periodontal therapy is the elimination of ailtooth surface bacterial deposits and the institu-tion of an optimal leyel of plaque control

MANAGEMENT OF PERIODONTAL ABSCESS 377

Fig. 2A. Gingival shrinkage following curettagt toreestablish sulcular drainage.

Gingivaschrumpfuiig iiach Kurettage zur Wicderi^er-stellung dey Drainage cks Sulkus.

Reirecissemeni gingival sulvant k ci/relagc desiinc arl'iablir un drainage du sulcus.

maintainable by the patient (Lightner et al.

1971, Ramfjord et al. 1973, Lindhe & Nyman

1975, Nyman et al. 1975). Although the rate and

sometimes the sequence of the therapy for a

periodontal abscess varies, of necessity, from

that of the more chronic periodontal lesion, the

goals are identical. Immediately following the

initial cursory examination, the lower right

Fig. 2B. Bleeding from the lesion during probing.

Die Liision blute! beim Sondieren.

Saignement de la lesion au sondage.

canine was thoroughly curetted under local

anesthesia. No periodontal dressing was used,

and the patient was instructed to rinse her

mouth at least four times daily with warm saline

to allow for and encourage drainage. Antibiotics

were not prescribed as the patient was afebrile

and free of regional lymphadenopathy. Plaque

control measures were again reinforced.

In two weeks the patient returned for evalua-

tion and a more complete periodontai examina-

tion (Table 1). Accurate individual mobility

Table i. Presurgical examination of lower right canine*

Uniersuchung ernes uniocii rachlen Eckzahne.-; voi- dey chinirgi.sehen Bt-bamllung. (Die Messergchnisse warden inMillimeiei-n angegeben: KUnische Messung von Millimelerbruchteilen wirdals "naclist-hohcre MillimetcrzahF atis-gedruckf. keine Dircktmessung. sondern Ausdruck da- Summe gingivaler Rezession und der Faschcniiefe)Examen preoperatoirc de la canine inferieure droite (la mesures .•ioni exprimees en mm et les meswes en fractiondes donnec.i eliniques soni arrondie.'i ciu nombre entier superieuv - il ne s'agit pas de mcsures direcies mais d'addi-tions du retrait gingival el dc la profondew de la pochej

Toothlocation

Gingival Pocketdepth

Attachment Keratinizedgingiva

DistolabialLabialMesiolabiaiMesiolingualLingualDistolingual

3

1-0I2

1094.%13

13i i5435

233•3

33

* Measurements expressed in mm; fractional clinical recordings expressed as next highest whole numbert Not a direct measurement but as a summation of gingival recession and pocket depth.

Presurgical examination {Untersuchung vor der chiriirgischen Behandlung. examen preoperatoire), tooth location(Zahnoberfldche, region dentaire). gingival recession (giiigivale Rezession. recession gingivate). pocket depth(Faschentiefe, profondeur des pochesj, attachment loss (Atcachmentverlu.vi, pcrte d'atiache), keralinized gingiva(keratinisierte Gingiva, gencive keratinisee).

378 KAREHA, ROSENBERG AND DEHAVEN

recordings were not possible since the two teethwere permanently sphnted. Subjective assess-ment of the splint showed no perceptible mo-bility. Utilizing the descriptive system proposedby Goldman & Cohen (1958) the morphologyof the distolabial intrabony defect was believedto be that of a combination 1-2-3 wall with theapparent loss of much of the labial plate ofalveolar bone as determined by clinicaJ probing,radiographic examination, and presurgicalbone-sounding {Tibbetts 1969, Greenberg et al.1976). Radiographs throughout the treatmentand fo!iow-up were standardized using thelong-cone-paralleling technique {Updegrave1951) with the same X-ray machine, the samemiUiamperage and the same kilovoltage.

Gingival shrinkage of 2 mm was noted on thedistolabial transitional line ang!e (Fig. 2A), butblood and pus could still be freely expressed(Fig. 2B). Plaque control, supragingival andslightly subgingival, was excellent although thepatient could not negotiate the full extent of thedeep pocket adequately. The failure of scalingand curettage procedures to remove the mostapically located hard and soft bacterial de-posits due to such factors as the depth andtopography of the pocket has been demon-strated by Waerhaug (1952, 1975, I978a,b). Anappointment was made for an evaluative ex-ploratory of the iesion via a flap followed by anappropriate therapeutic procedure.

Literature review of definitive treatment con-siderations

In the treatment of a periodontal abscess as-sociated with an intrabony pocket, therapy forthe intrabony pocket should commence quicklyand definitively following reappraisal of theperiodontal damage after the relief of pain andswelling, that is, emergency management of theinfection (Prichard 1960, Miyasato 1975). Al-though not common sequelae, both ceJIuiitisand osteomyelitis may develop from a perio-dontal abscess under the proper circumstances(for review see Prichard 1972). Definitive ther-apy without further delay was made all the more

important because of the unfortunate delaybetween the patient's Emergency Dental Clinicvisit and registration for more definitive thera-peutic measures. Periodontal surgical proce-dures are available to create a healthy anatom-ical relationship between the tooth and gin-giva as weil as correction of any underlyingosseous defects so that there is a positivecorrelation between the contour of the gingivaand the topography of the underlying alveolarbone. Persisting osseous irregularities may re-sult in residual deep sulpi or pockets making asustainable level of acceptable plaque controlmore difficult and therefore less likely to avoidfurther destruction of the periodontium.

Elimination of these osseous irregularities viaosteoplasty and ostectomy (Schiuger 1949,Friedman 1955, Ochsenbein 1958) in certaincases sacrifices too much crucial periodontalsupport from the tooth. In these cases treatmentconsists of elimination of the intrabony defectsvia new attachment procedures. A prognostica-tion of the therapeutic repair of osseous defectsshould take into account both the morphology(Prichard 1953, 1960) and the chronology of thelesion (Prichard 1953, Nabers et al. 1964). Theacute lesion consisting of predominantly acuteinflammatory elements (polymorphonuclearneutrophilic leukocytes) and of relatively short-term duration tends to differ from the morechronic lesion in that there is a characteristicgenera] lack of epithelium, granulation tissue,and transseptal fibers, postulated to be causedby the recent destruction from the abscess or anexacerbation of the abscess (Prichard 1960).The more acute the inflammatory reaction themore dramatic the healing response to appro-priate therapy. In addition there tends to be amore favorable biological state of the rootsurface following an acute infiammatory de-struction (Nabers et al. 1964) with a prognosticimplication of having a greater probability oftherapeutically achieving an adequate cement-ogenic response.

One new attachment procedure is that ofcurettage with and without the use of various

MANAGEMENT OF PERIODONTAL ABSCESS 379

caustic agents. Reported success with this modeof therapy has varied from outstanding (Car-ranza 1954) to moderate (Schaffer & Zander1953) to poor (Waerhaug 1952). The addition ofa gingivectomy to the curettage was introduced(Goldman 1949) and followed by other reportsof some successful results (Shapiro 1953, Shrei-ber 1961). Partly as a result of an attempt to gainadequate access new attachment proceduresbegan to be carried out by surgical flap proce-dures (Prichard I957a,b, 1960, 1967, Patur &GJickman J962, Wade 1962, 1966). Anothernew attachment procedure modification in-volved the addition of various grafting mate-rials inserted into the intrabony defect for thepurpose of promoting osteogenesis and cemen-togenesis, the first attempt being that of Haege-dus (1923) with autogenous bone grafts. Therehas been a plethora of grafting materials to befound in the literature including autographs ofintraoral site cortical and/or cancellous bone,autographs of extraoral site red marrow/can-celious bone either fresh or frozen, allographs,heterographs and various bone substitutes suchas aOogenic sclera, collagen, plaster of paris,porous ceramics, acrylic amide and mixtures oftooth components (for review see Ellegaard1976, International Conference on Research inthe Biology of Periodontal Disease 1977).

Definitive therapyThe response to the curettage therapy consistedof some predictable soft tissue shrinkage (Schaf-fer & Zander 1953) and Ihe maintenance ofdrainage, although it was apparent that thesource of the infection was sti!! present. Directvisualization of a lesion involves the elevationof mucoperiosteal flaps to gain access to thedefect followed by removal of all of the granula-tion tissue and diseased root surface. Regardlessof whether or not graft material is used, theimportance of this diseased tissue removalcannot be underestimated. The osseous lesionwas exposed via an inverse bevel, mucoperio-steal buccaj flap that extended from a few milli-meters buccal to the crest of the edentulous

Fig. 3. Osseous defect morphology at the time ofsurgical exposure, Gingiva on the crest of ridge leftundisturbed so as not to alter the fit of the removableprosthesis.

Das morphologische Bilddes knochemen Defektes nachchirurgischer Freilegung. Die Gingiva des Kieferkam-mes wurde niehi in den Eingriff einbezogen um diePassfarm der abnehmbaren Proihese nicht zu gefahr-den.

Morphahgie de la lesion osseuse au momeni de lachirurgie. La gencive au sommei de la crete n'est pastauchee pour ne pas deranger Vajustemem de la pro-ihese amovible.

ridge, approximately the width of one toothdistal and one toolh mesial to the lower rightcanine with a vertical releasing incision extend-ing into the alveolar mucosa at the distal borderof the incision. Around the tooth itself asulcular incision was utilized in order to pre-serve all of the existing labial gingiva. Reflectionof the flap revealed a wide combination 1-2-3wall intrabony defect extending from the disto-lingual around to the labial (Fig. 3). As wassuspected a great amount of the labial alveolarplate had resorbed, and the remaining labialalveoiar plate was quite thin wiib probably littleor no cancellous bone. The granulation tissuepresent was of a soft, jeliyiike mass. The rootsurface was not particularly soft nor roughalthough this may well have been a result of tiiepresurgical scaling and curettage procedures.The osseous walls of the lesion were thoroughlycuretted to insure removal of all soft tissue andto produce a bleeding bony surface. Followingdebridement the root surface was thoroughlyand carefully inspected to rule out root fractures

380 KAREHA, ROSENBERG AND DEHAVEN

and/or lateral pulp cana! orifices, none ofwhich was found.

After evaluation of the osseous lesion mor-phology, the question of whether or not toutilize a bone graft arises. Although EUegaard& Loe (197!) and Hiatt & Schallhorn (1973)showed the same amount of new attachmentwith and without the use of bone grafts whilecomparing new attachment in 3- and 2-waillesions, there have been numerous indicationsin later reports that little if any new cementumor new bone fill occurs at nongrafted sites ascompared to grafted sites (Carraro et al. 1976,Froum et al. 1976, Listgarten & Rosenberg1979). Seibert (1980) lists as the rationale forbone grafting the following objectives: promot-ing rapid osteogenesis and cementogenesis,eliminating large blood clots that must be re-sorbed and replaced by bone matrix, supportingthe soft tissue walls of the osseous defects,providing a biologically acceptable scaffold fornew granulation tissue to grow upon from thelateral walls of the defects, and blocking epi-thelial downgrowth via contact inhibition. Itwas decided to utilize an autogenous bone graftof intiaoTal origin. Common intraoral sourcesare the maxillary tuberosity, alveolar processand mandibular retromolar regions, exostoses,edentulous ridges, 6- to 8-week-old extractionsockets, stimulated periosteum or material fromosteopiasty/ostectomy (for review see Seibert1980). Since a portion of edentulous ridge wasalready exposed as well as there being an unevetilevel of iabial alveolar plate, a combination ofcanceilous and cortical bone was chosen. De-bate concerning the best graft material con-tinues although there have been indications thatsimilar levels of osseous regeneration apparent-ly take place in osseous defects, other thanfurcation and dihiscence lesions, no matterwhether an intraoral or extraoral source ofcancellous bone was utilized (Hiatt & ShaUhorn1973, Froum et al. 1975). Regardless of the graftmaterial to be placed, a favorable factor for asuccessful reconstruction of the attachmentapparatus was the fact that the involved tooth

was an anterior tooth without root concavities(EUegaard & Loe 1971). Overall, the two mostimportant factors in preventing the establish-ment of a new attachment are postoperative in-flammation (Bjorn 1961, Bjorn et al. 1965,EUegaard 1976, Rosling et al. 1976a) and epi-thelial migration (Bjorn 1961, Bjorn et at. 1965,EUegaard et al. 1974, EUegaard 1976),

In preparation for the graft, the root of thetooth was lightly root planed to insure completeremoval of all remaining bacterial concretionsand softened root surface. The source of cor-tical bone was some of the uneven portion oflabial alveolar plate, the small l-wall peak ofbone and a portion of the edentulous ridgeremoved to gain access to the underlying can-cellous bone located distal to the lesion. Thecortical and cancellous bone was stored tem-porarily in sterile dappen dishes moistened withlocal anesthesia (2% xylocaine with l/lOO.OOOepinephrine). The graft material was lightlypacked with a large curette to the crest of the 2-and 3-wall defect. The predominantly cancel-lous bone particles were placed in the defect firstcovered at the tooth-graft interface by the par-ticles of cortical origin with the intention ofhelping to retard epithelial downgrowth (EUe-gaard et al. 1974, Rosenberg et al. 1979). Theexpected fate of this type of non-red-marrowgraft is one of graft material resorption andreplacement (Ham & Gordon 1952, Haggerty &Maeda 1971).

The flap was tentatively approximated tomake certain that there was complete coverageof the graft material and close adaptation of thesoft tissue to the tooth to help insure newconnective tissue attachment (Caffesse et al.1968). It has been hypothesized that, in additionto the periodontal ligan:ient and the marrowspaces, the connective tissue of ihe gingiva ofthe soft tissue flap may provide for a number ofcapillaries and undifferentiated mesenchymalcells which may aid the reconstructive process(Rivault et al. 1971). Due to the fact that thelabial plate was at a much more apical level thanthe mesial and distal osseous crests in addition

MANAGEMENT OF PERIODONTAL ABSCESS 381

to the thin and friable condition of the labialgingiva, a lateral pedicle graft, originally in-troduced by Grupe & Warren (1956), wasutilized as the labial flap. The donor site for thepedicle graft was the portion of the flap from themesial edentulous ridge (Corn 1964, Robinson1964). Partial thickness dissection beyond themucogingival junction and a cut-back incisionwere performed to gain adequate release andmobility of the pedicle. The recipient site wasprepared by removing a "V"-shaped wedge ofsoft tissue from the labial of the tooth. Thepurposes of the pedicle graft in descendingorder of priority were: 1) to provide an inde-pendent, apically positioned flap from the distalflap covering tbe graft, 2) to augment the zoneof functional, attached gingiva with a mucogin-gival junction apical to the labial alveolar crest,tbat is, tbe creation of a new dentogingival unit,and 3) to cover as much root structure asdeemed appropriate to satisfy the esthetic val-ues of tbe patient. It must be noted tbat the needfor augmentation is as yet only empirical asthere is still no indication tbat an increase inattached and keratinized gingiva bas any directinfluence upon periodontal bealtb (Hangorsky& Bissada 1980). In attempting lo cover acertain amount of root surface, ibe lateralpedicle graft was found to be superior to freesoft tissue autographs (Smukler 1976). Al-though tbe denuded root surface in questionwas never exposed to tbe oral environment aswith gingival recession, it was still felt that inlight of tbe tbree proposed goals tbe lateralpedicle graft was tbe procedure of cboice.

The flaps were sutured witb individual, inter-rupted 0000 black silk suture (Etbicon®, Etbi-con. Inc., Somerville, New JerseyO8896,U.S.A.)(Fig. 4). A periodontal dressing (Coe-Pak®,Coe Laboratories, Inc., Chicago, Illinois 60658,U.S.A.) was placed over tbe surgical site so tbattbe mandibular removable partial denturecouid be worn concurrently. An oral antibiotic(Pbcnoxymetbyl penicillin, 250 mg. q.i.d) wasprescribed for a week as well as a pain medica-tion (Empirin #3®) to be taken as needed.

fig. 4. Suturing of dista! flap over the osseous grafiindependently of the pedicle flap covering the labialroot surface. Sutures into the connective tissue andperiosteum were utilized to anchor the pedicle flap.

Der distale happen wird. unahhiingig von dem gesiiellenhappen der die labiale Wurzeloberfliiche decki, iiberdem kndchemen Transplaniai vemaki. Die Suluren imBindegewebe und im Periosr warden zur Verankerungdes gesiiellen Lappem benoiigt.

hex suiurex du lambeau distal sur le greffon osseux sefont independammeni de cel/es du lambeau pediculerccouvrani la surface radiculaire vesiibulaire. Le lam-beau pedicule esl anere par des sutures dans le tissucanjonclif el le perioste.

Healing was uneventful, and botb dressingand sutures were removed in one week. Plaquecontrol measures were reinstituted as soon astbe dressing was removed. Tbe patient wasagain seen one week later and reported that onesmall wbite "piece'" came out around tbe tooth -probably some cortical graft exfoliation. Thepatient was tben seen at regular, three-montbintervals during whicb time tbe plaque controlremained impeccable. Tbe recall appointmentsconsisted of a propbylaxis, sulcular cleansingwitb a curette, occasional radiograpbs andplaque control reinforcement.

ReentryIn attempting to evaluate tbe success of newattachment procedures there are four methodscurrently available: radiograpbs, clinical mea-surements, reentry surgical procedures and his-tological examination. In clinical practice tbefirst two methods of assessment are relatively

382 KAREHA, ROSENBERG AND DEHAVEN

Table 2. Thirleen-months pre-reentry examinalion of lower right canine*

Nachuntersuckiing eines unieren Eckzahnes nach 13 Monalen durch chirwgische Inspektivn

Examen de la canine inferieure droiie 13 mois avanl I'mtervation d'evaluation (lei' mesures ioni exprimees en mmef les mesures en fraction des donnees cliniques soril arrondies au nombre entier superieur - il ne s'agii pas demesures direcies maix d'additions du reirait gingival el de la profondeiir de la poche)

Toothlocation

Gingival Pocketdepth

Attachmentlosst

Keratinlzedgingiva

DistolabialLabialMesiolabialMesiolinguaiLingualD is to lingual

573iI2

32I21i

894•3

22

554

33

* Measurements expressed in mm; fractional clinical recordings expressed as next highest whole number.•f Not a direct measurement biit as a summation of gingival recession and pocket depth.13 months pre-reentry examination (chirurgische Inspekiion nach J3 Monaten. examen !3 mois avant la reinler-vention d' evaluation).

routine, whereas reentry surgical procedureswould be less routine and histology rare. This isappropriately substantiated by the number ofreports in the literature of these variousmethods of evaluation.

The first two methods of assessment showedthe treatment to be a success although there arethe obvious limitations to their accuracy. Therewere no sulci deeper than 3 mm, no change inendodontic status nor mobility, an empiricallyadequate zone of attached gingiva, and an

apically positioned dentogingival unit withinthe bounds of the patient's esthetic values(Table 2; Figs. 5A,B,C). Permission wasobtained from the patient to reenter the pre-vious lesion for observational purposes pro-vided the pedicle graft was not disturbed. Sincethis strategic tooth was shown to be successfullytreated upon clinical evaluation after one year,a histologic donation by the patient was out ofthe question.

The timing of the reentry surgical procedure

Eig. 5A. Probing of 3 mm prior to reentry 13 monthsfollowing graft placement.

Sondierung = 3 mm vor der chirurgischen Inspektion,13 Monate nach der Inkarporation des Transplantates.

Sondage de 3 mm avant I'operation d'evaluaiion. 13mois apres la greffe.

Eig. 5B. Probing of 2 mm prior to reentry 13 monthsfollowing graft placement.

Sondierung = 2 mm vor der chirurgischen Inspektion.13 Monate nach der Inkorporation des Transplantates.Sondage de 2 mm avant I'operation d'evaluation, 13mois apres la greffe.

MANAGEMENT OF PERIODONTAL ABSCESS 383

Fig. 5C. Initial (top) and 13 month postgraft radio-graphs (bottom).Ausgangsrontgenbild (oben) und das Rontgenbild 13Monaie nach der Transplantation (unten).Radiogyaphics initiales (au-dessus) et IS mois apres la$reffe (au-dessous).

was chosen to be no sooner than one year(Rosenberg 1971) although complete remodel-ing may not be completed even by five years(Nabers et a!. 1972). Thirteen months followingthe graft placement the area was reentered via afull thickness gingival flap, allowing visualaccess to the former distal lesion (Fig. 6). Due tothe patient's strong wishes not to disturb the

Fig. 6. Surgical reentry of the previous osseous lesion.Chirurgisehe Inspekiion der ursprunglichen knocher-nen Lasion.

Operation devaluation de I'ancienne lesion osseuse.

labial pedicle graft site, the direct labial of thetooth was mmimalJy included in the reflection.The area of the osseous graft was probed andwas found to be solid and resistant to probing.The osseous graft site appeared to have abumpy appearance somewhat similar to thatdescribed previously by Schalihorn( 1967,1968).Next an explorer was used to examine the rootsurfaces for any changes and none were found.Without careful clinical data one cannot say forsure, but it did appear that some percentage ofthe repair of the iesion was made up of osseousresorption. This was not unexpected as intra-bony defect repair has been shown to be acombination of coronal bone regeneration andmarginal bone resorption (Prichard 1957a, Pa-tur & Glickman 1962, Wade 1966, Ellegaard &hoc 197], Carraro et al 1976, Rosling et a],1976a,b, Poison & Heijl 197S).

Finally it must be kept in mind that clinicalevidence of osseous repair does not necessarilyexclude the possibility of concurrent epithelialdowngrowth as there have been a number ofreports of apical proliferation of junctionalepithelium between the tooth and the adjacentperiodontal tissues including grafted bone chips(Caton & Zander 1976, Moskow et a!. 1979,Listgarten & Rosenberg 1979). The obviousconclusion is that the clinical evidence of newlyformed bone does not necessarily imply ap-

384 KAREHA, ROSENBERG AND DEHAVEN

position of new cementum nor the presence of afunctional periodontal ligament, and such judg-ments can be made only through histoiogicstudy. The long-term implication of osseousrepair of intrabony defects without new attach-ment of connective tissue is unknown. Anepithelial attachment appears to be weaker andmay be more likely to facilitate the passage ofmicrobial products into the underlying tissues.

Maintenance phaseThe patient was placed on a recall maintenancesystem consisting of appointments every threemonths for at least one year, at which time therecall interval wiil be routinely reevaluated.During the 17 months following the new attach-ment procedure, the patient's plaque controlhas remained at an excellent level, and thecorrection of the periodontal abscess with anintrabony defect has remained a clinical success.

Acknowledgment

The authors would like to acknowledge theassistance of Mrs. Dianne S. Kareha for manu-script preparation.

Zusammenfassung

Therapeuiische Uberlegungen zur Behandlung einesparodomalen Abzesses mil knochernem DefekiEin FaJlbericht schildert die klinisch erfolgreicheBehandlung einer, mit einem parodontalen Abzessvergesdischafteten, Knochentasche an einem inFunktion befmdlichen Unterkiefereckzahn. Hierbeikam cin autogcnes, mtTaoia! entnommenes Trans-piantat aus kortikalem und spongiosem Knochen,zusammen mit einem gestielten Weichgewebslappen,zur Anwenduiig. Uberlegungen zur Diagnostik, Prog-nostik und zur Therapie werden bei Bcriicksichtigungvon dem Schrifttum entnommenen Beobachtungenund experimentellem Wissen, diskutiert.

Resume

Considerations tkerapeutiques sur k iraitemenx d'unabces paradantal avec lesion infraosseuseUn cas clinique de canine mandibulaire isolee etfonctionnelle avec poche infraosseuse associee a un

abces parodontal a ete traite avec succes grace aTutilisation d'une greffe autogene d'o.s spongieux etcortical d'origLne intrabuccale suivie d'un reposition-nemenl lateral de tissu mou. Les considerationsguidant le diagnostic, ]e prognostic et la th^rapeu-tique soni discutees a la iumiere des connaissancesexperimentaies et d'observations decoulant de lalitterature actuelle.

References

Bjorn, H. (1961) Experimental studies on reattach-vncrM-Demal Pracritioner and Dental Record 11,351-354.

Bjorn, H., Hollender, L. & Lindhe, i. (1965) Tissueregeneration in patients with periodontal disease.Odontohgisk 'Revy 16, 317-J26.

Caffesse, R. G., Ramfjord, S. P. & Nasjieti. C. E.(1968) Reverse bevel periodontal flaps in monkeys.Journal of Periodontology 39, 219-235.

Carranza, F. A. (3954) A technique for reattach-ment. Journal of Periodoiilology 25. 212-211.

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386 KAREHA, ROSENBERG AND D E H A V E N

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Address:Dr. Michael J. KarehaDepartment of PeriodontologySchool of Dental MedicineUniversity of Pennsylvania4001 Spruce StreetPhiladelphiaPennsylvania 19104, U.S.A.