708
Treatment of an Osseous Lesion Associated With a Severe PalatoRadicular Groove: A Case Report Jiiang Huei Jeng, * Hsein-Kun Jackson Lu/ and Lein
Tuan Hou*
This
is a case report that describes the management of a severe periodontal defect associated with a palato-radicular (palato-gingival) groove affecting the maxillary right lateral incisor of a 50 year-old male. The patient presented with pain, gingival swelling, and a 10 mm periodontal pocket on the distopalatal aspect of the right maxillary lateral incisor. The defect was initially treated by scaling and root planing. Several days later a flap was elevated, the osseous defect was debrided, and odontoplasty was performed to eliminate the groove. The root surface was treated with citric acid for 3 minutes, the osseous defect was filled with non-porous hydroxyapatite, a periodontal membrane was placed, and the flap was readapted to the tooth. Postoperative care included systemic (minocycline) and local (Chlorhexidine) antimicrobial therapy. The membrane was removed 6 weeks postoperatively and 14 months postoperatively the gingiva appeared healthy; radiographs suggested substantial resolution of the osseous defect and about 7 mm of probing attachment gain was recorded. Further studies are necessary to determine which of the several modes of therapy used to treat this lesion are necessary for success. J Periodontal 1992; 63:708-712.
Key Words: Guided tissue regeneration; hydroxyapatite surgical flaps; palate surgery;
gingiva/surgery.
developmental anomalies which can the maxillary incisor area. Among these, palatoradicular grooves have been reported with an incidence rate of 2% to .5%1-3 and up to 44.6% in Taiwan.4 Since the grooves may predispose to the accumulation of dental plaque, food debris, and calculus, they often cause localized periodontal destruction.1,5 Prognosis of the teeth depends partly upon the depth and extension of the grooves. Some initial lesions can be corrected by odontoplasty in conjunction with periodontal treatment. However, when the lesions were more advanced, treatment of the teeth was almost always doomed to failure. Here we report a case in which open flap surgery combined with odontoplasty, citric acid root conditioning, hydroxyapatite grafting, and guided tissue regeneration (GTR) There
are numerous
occur at
techniques were successfully employed to treat severe periodontal destruction associated with a deep palato-radicular
groove. The rationale behind the treatment modalities will be discussed.
*Department of Clinical Periodontics, National pital, Taipei, Taiwan, R.O.C. +Clinical Periodontics, Taipei Medical College.
Taiwan
University
Hos-
CASE REPORT The patient was a 50 year-old male, who had suffered from gingival swelling and intermittent dull pain at the palatal side of the right maxillary lateral incisor for about 1 month. Clinical examination disclosed that a deep pocket (10 mm) was localized at the disto-palatal line angle of the tooth, and concomitantly, a palato-radicular groove which extended into the gingival sulcus was present (Fig. 1). The surrounding palatal gingiva appeared bluish-red with purulent pus discharging adjacent to it. Another palato-radicular groove which terminated at the cemento-enamel junction (CEJ) was also noted at the left lateral incisor, although no deep pocket was present. Generally the patient's oral hygiene was fair. The radiograph revealed an advanced bony defect extending to near the apical portion of the root. The lamina dura on the mesial side of the lateral incisor was not apparent (Fig. 2). Horizontal root fracture of the left central incisor was observed concurrently. Electric pulp tests showed that the pulp was still vital. Root planing and subgingival curettage were performed at the initial appointment. Clinical symptoms subsided a few days later, but the deep pocket was still present. Therefore, we decided to do a prophylactic surgery in order to eradicate this underlying problem. After reflecting the mucoperiosteal flap, we found an
Volume 63 Number 8
JENG, LU,
HOU
709
Figure I. Clinical picture of right upper incisor area. Note gingival inflammation and swelling at the palatal side of the lateral incisor. A deep pocket (10 mm) was observed at the disto-palatal line angle of the lateral incisor along with a palato-radicular groove. advanced circumferential angular bony defect which surrounded the distal and palatal side of the right lateral incisor and extended near the root apex (Fig. 3). Granulomatous tissue was removed from the bony defect and a palatoradicular groove which terminated in the middle portion of the root of the lateral incisor was noted. Further root planing was performed and odontoplasty was carried out with a high-speed diamond bur to eliminate the palato-radicular groove completely. No pulpal exposure was observed. The exposed dentinal surface was coated with citric acid (pH 1) for 3 minutes and then gently irrigated with normal saline. Non-porous hydroxyapatite* (HA) mixed with blood coagulum was grafted into the bony defect to the same level of alveolar crest (Fig. 4), after which a periodontal membrane5 was applied over the defect. The flap was readapted, stabilized with sling sutures, and covered with periodontal packing. Minocycline (100 mg, Q 12 hour) was prescribed in adjunct with hibitane (0.1%) oral rinse daily for 1 week. One week following surgery, the sutures were removed and radiographs were taken (Fig. 5). Healing of the wound was uneventful. A small, reddish tissue which extruded from the inner aspect of the membrane was discovered 4 weeks after surgery. The patient did not complain of excessive discomfort. Six weeks later a partial thickness flap was executed to remove the embedded membrane. After the flap was reflected and the periodontal membrane removed, a reddish coronally-grown tissue at the inner surface of membrane was visible along the root surface of the lateral incisor. The grafted HA was firmly packed into the *Orthomatrix HA-500, Inc. Dublin, CA. §GoreTex, W.L. Gore and Associates, Flagstaff, AZ.
Radiographie examination of right upper incisor area before Advanced bony destruction which extended near the apex of the lateral incisor was observed. Lamina dura in the mesial side of the lateral incisor disappeared. Horizontal root fracture was also noted incidentally in the right maxillary central incisor. Figure
2.
treatment.
defect (Fig. 6). After gentle irrigation with normal saline, the flap was sutured without disturbing the underlying new tissue. Fourteen months after the operation, the gingiva appeared healthy. Neither inflammatory signs nor symptoms were observed. During this period, the patient maintained meticulous oral hygiene. Radiographie examination revealed that the density of bony trabeculae had increased and the lost lamina dura in the mesial side of the lateral incisor had regenerated (Fig. 7). An obvious clinical attachment gain (7 mm) was observed by periodontal probing
(Fig. 8).
DISCUSSION There is a considerable amount of information regarding the application of grafted HA in humans to justify its role in the healing dynamics of the periodontium. As a natural mineral component of vertebrate hard tissue, HA has become widely used in clinical practice for repairing periodontal lesions and coating implant fixtures. It has been
710
J Periodontol August 1992
TREATMENT OF A LESION ASSOCIATED WITH A PALATO-RADICULAR GROOVE
Figure 3. Advanced bony destruction was observed surrounding the distal and palatal sides of the right maxillary lateral incisor and mesial side of canine. Concomitantly, a palato-radicular groove was also found in the disto-palatal line angle of the lateral incisor. The groove extended to the middle portion of the root. Figure 5. Radiographic examination of the surgical surgery. Note the defect was filled with grafted HA.
Figure 4. Hydroxyapatite (HA) was utilized to fill the circumferential bony defect to the same level of the alveolar crest.
reported that HA is one of the most bio-inert synthetic substances which are devoid of local and systemic toxicity to hard and soft tissues.6'7 Clinical evaluations have reported that the HA grafting procedure gave better results than did debridement alone in the majority of periodontal defects.810 Although there was little new attachment in the
area
1 week
after
Figure 6. Clinical picture of the right maxillary lateral incisor and canine area during removal ofperiodontal membrane. Note the rubbery-like tissue present in the defect. The grafted HA was packed firmly in the osseous defect and coated by the rubbery-like tissue.
grafted sites, HA may provide a physical matrix suitable for the deposition of new bone and conduct the new bone growth in the area which would not otherwise be occupied.6'11 Our purpose in using the particulated HA, in
Volume 63 Number 8
JENG, LU,
i li
7. Radiographie examination of the surgical area 14 months after surgery. The grafted HA was stationary in the defect. Increasing radiopacity of the previous lesion site and reappearance of the lost lamina dura could be observed.
Figure
Figure 8. Clinical probing of the right maxillary lateral incisor and canine area, 14 months after the multidisciplinary treatment. The gingiva appeared healthy and a 7 mm clinical attachment was gained. addition to was
reducing
the dead space for tissue ingrowth, to protect the overlying membrane from possible
collapse. Although
the ability of citric acid to demineralize the surfaces and provide a substrate suitable for fiber attachment has been questioned, it has been shown that citric acid root conditioning is beneficial in removing scaling debris and exposing collagen substrate which may promote the formation of new connective tissue attachment.1214 root
HOU
711
Minimal epithelial downgrowth was present adjacent to demineralized dentin.15'16 It has been suggested that the development of a fibrin linkage between the exposed collagen fibrils of the demineralized dentin matrix and adjacent connective tissue may inhibit the apical migration of oral epithelium, and simultaneously, enhance the migration of mesenchymal cells toward the surface through a chemotactic effect.17'18 While the role of citric acid in the healing process of the present case is not fully understood, it is possible that it prepared a biologic substrate for the attachment and spreading of connective tissue cells. It has been reported that restoration of cementum, bone, and periodontal ligament can be achieved using GTR techniques in human intrabony defects.19'20 Deep defects with 3 osseous walls may help contain progenitor cells and provide more surface area for bone apposition. Becker et al.21 reported a 6-month re-entry study in which the average bone fill of 3-wall intrabony defects treated with GTR techniques was 3.72 mm. The improvement was significant when compared with flap curettage alone. However, Stahl et al.22 have demonstrated that new attachment was not always achieved by this regenerative procedure. The causes for these different results are not known. But defect morphology and pathology, as well as technical limitations and variations encountered at the specific sites, are considered to be important factors.22'23 In this case, the patient's symptoms were resolved and major clinical improvement has occurred, but the long-term prognosis remains unclear due to the short postoperative observation period. Although the clinical fill and radiographic implications did not speak to the histologie modes of closure, it was suggested that composite HA grafting and citric acid root conditioning, when used in conjunction with GTR procedures, may provide a suitable space and substrate for the adjacent periodontal ligament cells to repopulate, proliferate, and differentiate in the periodontal osseous defects and achieve the goal of periodontal therapy—new attachment. This information, in addition to improved surgical intervention, may help in treating advanced periodontal defects which are associated with a palato-radicular groove and allow patients to preserve teeth which would otherwise be lost. REFERENCES 1. Withers JA, Brunsvold MA, Killoy WJ, 2. 3.
4.
5.
Rabe AJ. The relationship of palato-gingival grooves to localized periodontal disease. / Periodontol 1981; 52:41^14. Kogon SL. The prevalence, location, and conformation of palato-radicular grooves in maxillary incisors. J Periodontal 1986; 57:231-234. Everett FG, Kramer GM. The distolingual groove in the maxillary lateral incisors: A periodontal hazard. J Periodontal 1972; 43:352361. Hou GL, Wu YM, Tsai CC. A study of the palato-radicular groove in Chinese adults. I. Prevalence, location, conformation and symmetry. / Formosan Dent Assoc 1980; 11:349-354. Lee KW, Lee EC, Poon KY. Palato-gingival grooves in maxillary incisors: A possible predisposing factor to localized periodontal disease. Br Dent J 1968; 124:14-18.
712
TREATMENT OF A LESION ASSOCIATED WITH A PALATO-RADICULAR GROOVE
6. Froum
7.
SJ, Kushner L, Scoop IW, Stahl SS. Human clinical and histologie responses to durapatite implants in intraosseous lesions: A case report. / Periodontol 1982; 53:719-725. Gáneles J, Listgarten MA, Evian CI. Ultrastructure of durapatiteperiodontal tissue interface in human intrabony defects. J Periodontol
1986; 57:133-140. 8. Meffert RM, Thomas JR, Hamilton KM, Brownstein CN. Hydroxyapatite as an alloplastic graft in the treatment of periodontal osseous defects. / Periodontol 1984; 55:63-73. 9. Yukna RA, Cassingham RJ, Caudill RF, et al. Six month evaluation of calcitite (hydroxyapatite ceramic) in periodontal osseous defects. Int J Periodontics Restorative Dent 1986; 6:35-45. 10. Krejci CB, Bissada NF, Farah C, Greenwell H. Clinical evaluation of porous and non-porous hydroxyapatite in the treatment of human periodontal bony defect. J Periodontol 1986; 57:521-528. 11. Barney VC, Levin MP, Adams DF. Bioceramic implants in surgical periodontal defects: A comparison study. J Periodontol 1986; 57:764769. 12. Tanaka K, O'Leary TJ, Kafrawy AH. The effect of citric acid on retained plaque and calculus. A short communication. J Periodontol 1989; 60:81-83. 13. Poison AM. The root surface and regeneration: Present therapeutic limitations and future biologic potentials. J Clin Periodontol 1986; 13:995-999. 14. Hanes PJ, Poison AM. Cell and fiber attachment to demineralized cementum from normal root surfaces. J Periodontol 1989; 60:188198. 15. Hanes PJ, Poison AM, Ladenheim S. Cell and fiber attachment to demineralized dentin from normal root surfaces. J Periodontol 1985; 56:752-765.
J Periodontol August 1992
16. Poison AM, Hanes PJ. Cell and fiber attachment to demineralized dentin: A comparison of normal and periodontitis-affected surfaces. J Clin Periodontol 1987; 14:357-365. 17. Poison AM, Caton J. Factors influencing repair and regeneration. J Periodontol 1982; 53:617-626. 18. Poison AM, Frederick GT. Cell processes in dentinal tubules during early phase of attachment to demineralized, periodontitis-affected surfaces. / Clin Periodontol 1985; 12:162-169. 19. Gottlow J, Nyman S, Lindhe J, Karring T, Mernstrom J. New attachment formation in human periodontium by guided tissue regeneration. / Clin Periodontol 1986; 13:604-616. 20. Nyman S, Lindhe J, Karring T, Rylander H. New attachment following surgical treatment of human periodontal disease. / Clin Periodontol 1982; 9:290-296. 21. Becker W, Becker BE, Berg L, Prichard J, Caffesse R, Rosenberg E. New attachment after treatment with root isolation procedures: Report for treated Class III and Class II furcation and vertical osseous defects. Int J Periodontics Restorative Dent 1988; 8:9-23. 22. Stahl SS, Froum S, Tarnow D. Human histologie responses to guided tissue regenerative techniques in intrabony lesions. Case reports on 9 sites. / Clin Periodontol 1990; 17:191-198. 23. Tanner MG, Slot CW, Vuddhakanuk S. An evaluation of new attachment formation using microfibrillar collagen barrier. J Periodontol 1988; 59:524-530.
Send reprint requests to Dr. Jiiang Huei Jeng, Department of Periodontics, Dental Clinics, National Taiwan University Hospital, No. 1, ChangTe Street, Taipei, Taiwan, R.O.C. Accepted for publication March 2, 1992.
Treatment of an Osseous Lesion Associated With a Severe PalatoRadicular Groove: A Case Report Jiiang Huei Jeng, * Hsein-Kun Jackson Lu/ and Lein
Tuan Hou*
This
is a case report that describes the management of a severe periodontal defect associated with a palato-radicular (palato-gingival) groove affecting the maxillary right lateral incisor of a 50 year-old male. The patient presented with pain, gingival swelling, and a 10 mm periodontal pocket on the distopalatal aspect of the right maxillary lateral incisor. The defect was initially treated by scaling and root planing. Several days later a flap was elevated, the osseous defect was debrided, and odontoplasty was performed to eliminate the groove. The root surface was treated with citric acid for 3 minutes, the osseous defect was filled with non-porous hydroxyapatite, a periodontal membrane was placed, and the flap was readapted to the tooth. Postoperative care included systemic (minocycline) and local (Chlorhexidine) antimicrobial therapy. The membrane was removed 6 weeks postoperatively and 14 months postoperatively the gingiva appeared healthy; radiographs suggested substantial resolution of the osseous defect and about 7 mm of probing attachment gain was recorded. Further studies are necessary to determine which of the several modes of therapy used to treat this lesion are necessary for success. J Periodontal 1992; 63:708-712.
Key Words: Guided tissue regeneration; hydroxyapatite surgical flaps; palate surgery;
gingiva/surgery.
developmental anomalies which can the maxillary incisor area. Among these, palatoradicular grooves have been reported with an incidence rate of 2% to .5%1-3 and up to 44.6% in Taiwan.4 Since the grooves may predispose to the accumulation of dental plaque, food debris, and calculus, they often cause localized periodontal destruction.1,5 Prognosis of the teeth depends partly upon the depth and extension of the grooves. Some initial lesions can be corrected by odontoplasty in conjunction with periodontal treatment. However, when the lesions were more advanced, treatment of the teeth was almost always doomed to failure. Here we report a case in which open flap surgery combined with odontoplasty, citric acid root conditioning, hydroxyapatite grafting, and guided tissue regeneration (GTR) There
are numerous
occur at
techniques were successfully employed to treat severe periodontal destruction associated with a deep palato-radicular
groove. The rationale behind the treatment modalities will be discussed.
*Department of Clinical Periodontics, National pital, Taipei, Taiwan, R.O.C. +Clinical Periodontics, Taipei Medical College.
Taiwan
University
Hos-
CASE REPORT The patient was a 50 year-old male, who had suffered from gingival swelling and intermittent dull pain at the palatal side of the right maxillary lateral incisor for about 1 month. Clinical examination disclosed that a deep pocket (10 mm) was localized at the disto-palatal line angle of the tooth, and concomitantly, a palato-radicular groove which extended into the gingival sulcus was present (Fig. 1). The surrounding palatal gingiva appeared bluish-red with purulent pus discharging adjacent to it. Another palato-radicular groove which terminated at the cemento-enamel junction (CEJ) was also noted at the left lateral incisor, although no deep pocket was present. Generally the patient's oral hygiene was fair. The radiograph revealed an advanced bony defect extending to near the apical portion of the root. The lamina dura on the mesial side of the lateral incisor was not apparent (Fig. 2). Horizontal root fracture of the left central incisor was observed concurrently. Electric pulp tests showed that the pulp was still vital. Root planing and subgingival curettage were performed at the initial appointment. Clinical symptoms subsided a few days later, but the deep pocket was still present. Therefore, we decided to do a prophylactic surgery in order to eradicate this underlying problem. After reflecting the mucoperiosteal flap, we found an
Volume 63 Number 8
JENG, LU,
HOU
709
Figure I. Clinical picture of right upper incisor area. Note gingival inflammation and swelling at the palatal side of the lateral incisor. A deep pocket (10 mm) was observed at the disto-palatal line angle of the lateral incisor along with a palato-radicular groove. advanced circumferential angular bony defect which surrounded the distal and palatal side of the right lateral incisor and extended near the root apex (Fig. 3). Granulomatous tissue was removed from the bony defect and a palatoradicular groove which terminated in the middle portion of the root of the lateral incisor was noted. Further root planing was performed and odontoplasty was carried out with a high-speed diamond bur to eliminate the palato-radicular groove completely. No pulpal exposure was observed. The exposed dentinal surface was coated with citric acid (pH 1) for 3 minutes and then gently irrigated with normal saline. Non-porous hydroxyapatite* (HA) mixed with blood coagulum was grafted into the bony defect to the same level of alveolar crest (Fig. 4), after which a periodontal membrane5 was applied over the defect. The flap was readapted, stabilized with sling sutures, and covered with periodontal packing. Minocycline (100 mg, Q 12 hour) was prescribed in adjunct with hibitane (0.1%) oral rinse daily for 1 week. One week following surgery, the sutures were removed and radiographs were taken (Fig. 5). Healing of the wound was uneventful. A small, reddish tissue which extruded from the inner aspect of the membrane was discovered 4 weeks after surgery. The patient did not complain of excessive discomfort. Six weeks later a partial thickness flap was executed to remove the embedded membrane. After the flap was reflected and the periodontal membrane removed, a reddish coronally-grown tissue at the inner surface of membrane was visible along the root surface of the lateral incisor. The grafted HA was firmly packed into the *Orthomatrix HA-500, Inc. Dublin, CA. §GoreTex, W.L. Gore and Associates, Flagstaff, AZ.
Radiographie examination of right upper incisor area before Advanced bony destruction which extended near the apex of the lateral incisor was observed. Lamina dura in the mesial side of the lateral incisor disappeared. Horizontal root fracture was also noted incidentally in the right maxillary central incisor. Figure
2.
treatment.
defect (Fig. 6). After gentle irrigation with normal saline, the flap was sutured without disturbing the underlying new tissue. Fourteen months after the operation, the gingiva appeared healthy. Neither inflammatory signs nor symptoms were observed. During this period, the patient maintained meticulous oral hygiene. Radiographie examination revealed that the density of bony trabeculae had increased and the lost lamina dura in the mesial side of the lateral incisor had regenerated (Fig. 7). An obvious clinical attachment gain (7 mm) was observed by periodontal probing
(Fig. 8).
DISCUSSION There is a considerable amount of information regarding the application of grafted HA in humans to justify its role in the healing dynamics of the periodontium. As a natural mineral component of vertebrate hard tissue, HA has become widely used in clinical practice for repairing periodontal lesions and coating implant fixtures. It has been
710
J Periodontol August 1992
TREATMENT OF A LESION ASSOCIATED WITH A PALATO-RADICULAR GROOVE
Figure 3. Advanced bony destruction was observed surrounding the distal and palatal sides of the right maxillary lateral incisor and mesial side of canine. Concomitantly, a palato-radicular groove was also found in the disto-palatal line angle of the lateral incisor. The groove extended to the middle portion of the root. Figure 5. Radiographic examination of the surgical surgery. Note the defect was filled with grafted HA.
Figure 4. Hydroxyapatite (HA) was utilized to fill the circumferential bony defect to the same level of the alveolar crest.
reported that HA is one of the most bio-inert synthetic substances which are devoid of local and systemic toxicity to hard and soft tissues.6'7 Clinical evaluations have reported that the HA grafting procedure gave better results than did debridement alone in the majority of periodontal defects.810 Although there was little new attachment in the
area
1 week
after
Figure 6. Clinical picture of the right maxillary lateral incisor and canine area during removal ofperiodontal membrane. Note the rubbery-like tissue present in the defect. The grafted HA was packed firmly in the osseous defect and coated by the rubbery-like tissue.
grafted sites, HA may provide a physical matrix suitable for the deposition of new bone and conduct the new bone growth in the area which would not otherwise be occupied.6'11 Our purpose in using the particulated HA, in
Volume 63 Number 8
JENG, LU,
i li
7. Radiographie examination of the surgical area 14 months after surgery. The grafted HA was stationary in the defect. Increasing radiopacity of the previous lesion site and reappearance of the lost lamina dura could be observed.
Figure
Figure 8. Clinical probing of the right maxillary lateral incisor and canine area, 14 months after the multidisciplinary treatment. The gingiva appeared healthy and a 7 mm clinical attachment was gained. addition to was
reducing
the dead space for tissue ingrowth, to protect the overlying membrane from possible
collapse. Although
the ability of citric acid to demineralize the surfaces and provide a substrate suitable for fiber attachment has been questioned, it has been shown that citric acid root conditioning is beneficial in removing scaling debris and exposing collagen substrate which may promote the formation of new connective tissue attachment.1214 root
HOU
711
Minimal epithelial downgrowth was present adjacent to demineralized dentin.15'16 It has been suggested that the development of a fibrin linkage between the exposed collagen fibrils of the demineralized dentin matrix and adjacent connective tissue may inhibit the apical migration of oral epithelium, and simultaneously, enhance the migration of mesenchymal cells toward the surface through a chemotactic effect.17'18 While the role of citric acid in the healing process of the present case is not fully understood, it is possible that it prepared a biologic substrate for the attachment and spreading of connective tissue cells. It has been reported that restoration of cementum, bone, and periodontal ligament can be achieved using GTR techniques in human intrabony defects.19'20 Deep defects with 3 osseous walls may help contain progenitor cells and provide more surface area for bone apposition. Becker et al.21 reported a 6-month re-entry study in which the average bone fill of 3-wall intrabony defects treated with GTR techniques was 3.72 mm. The improvement was significant when compared with flap curettage alone. However, Stahl et al.22 have demonstrated that new attachment was not always achieved by this regenerative procedure. The causes for these different results are not known. But defect morphology and pathology, as well as technical limitations and variations encountered at the specific sites, are considered to be important factors.22'23 In this case, the patient's symptoms were resolved and major clinical improvement has occurred, but the long-term prognosis remains unclear due to the short postoperative observation period. Although the clinical fill and radiographic implications did not speak to the histologie modes of closure, it was suggested that composite HA grafting and citric acid root conditioning, when used in conjunction with GTR procedures, may provide a suitable space and substrate for the adjacent periodontal ligament cells to repopulate, proliferate, and differentiate in the periodontal osseous defects and achieve the goal of periodontal therapy—new attachment. This information, in addition to improved surgical intervention, may help in treating advanced periodontal defects which are associated with a palato-radicular groove and allow patients to preserve teeth which would otherwise be lost. REFERENCES 1. Withers JA, Brunsvold MA, Killoy WJ, 2. 3.
4.
5.
Rabe AJ. The relationship of palato-gingival grooves to localized periodontal disease. / Periodontol 1981; 52:41^14. Kogon SL. The prevalence, location, and conformation of palato-radicular grooves in maxillary incisors. J Periodontal 1986; 57:231-234. Everett FG, Kramer GM. The distolingual groove in the maxillary lateral incisors: A periodontal hazard. J Periodontal 1972; 43:352361. Hou GL, Wu YM, Tsai CC. A study of the palato-radicular groove in Chinese adults. I. Prevalence, location, conformation and symmetry. / Formosan Dent Assoc 1980; 11:349-354. Lee KW, Lee EC, Poon KY. Palato-gingival grooves in maxillary incisors: A possible predisposing factor to localized periodontal disease. Br Dent J 1968; 124:14-18.
712
TREATMENT OF A LESION ASSOCIATED WITH A PALATO-RADICULAR GROOVE
6. Froum
7.
SJ, Kushner L, Scoop IW, Stahl SS. Human clinical and histologie responses to durapatite implants in intraosseous lesions: A case report. / Periodontol 1982; 53:719-725. Gáneles J, Listgarten MA, Evian CI. Ultrastructure of durapatiteperiodontal tissue interface in human intrabony defects. J Periodontol
1986; 57:133-140. 8. Meffert RM, Thomas JR, Hamilton KM, Brownstein CN. Hydroxyapatite as an alloplastic graft in the treatment of periodontal osseous defects. / Periodontol 1984; 55:63-73. 9. Yukna RA, Cassingham RJ, Caudill RF, et al. Six month evaluation of calcitite (hydroxyapatite ceramic) in periodontal osseous defects. Int J Periodontics Restorative Dent 1986; 6:35-45. 10. Krejci CB, Bissada NF, Farah C, Greenwell H. Clinical evaluation of porous and non-porous hydroxyapatite in the treatment of human periodontal bony defect. J Periodontol 1986; 57:521-528. 11. Barney VC, Levin MP, Adams DF. Bioceramic implants in surgical periodontal defects: A comparison study. J Periodontol 1986; 57:764769. 12. Tanaka K, O'Leary TJ, Kafrawy AH. The effect of citric acid on retained plaque and calculus. A short communication. J Periodontol 1989; 60:81-83. 13. Poison AM. The root surface and regeneration: Present therapeutic limitations and future biologic potentials. J Clin Periodontol 1986; 13:995-999. 14. Hanes PJ, Poison AM. Cell and fiber attachment to demineralized cementum from normal root surfaces. J Periodontol 1989; 60:188198. 15. Hanes PJ, Poison AM, Ladenheim S. Cell and fiber attachment to demineralized dentin from normal root surfaces. J Periodontol 1985; 56:752-765.
J Periodontol August 1992
16. Poison AM, Hanes PJ. Cell and fiber attachment to demineralized dentin: A comparison of normal and periodontitis-affected surfaces. J Clin Periodontol 1987; 14:357-365. 17. Poison AM, Caton J. Factors influencing repair and regeneration. J Periodontol 1982; 53:617-626. 18. Poison AM, Frederick GT. Cell processes in dentinal tubules during early phase of attachment to demineralized, periodontitis-affected surfaces. / Clin Periodontol 1985; 12:162-169. 19. Gottlow J, Nyman S, Lindhe J, Karring T, Mernstrom J. New attachment formation in human periodontium by guided tissue regeneration. / Clin Periodontol 1986; 13:604-616. 20. Nyman S, Lindhe J, Karring T, Rylander H. New attachment following surgical treatment of human periodontal disease. / Clin Periodontol 1982; 9:290-296. 21. Becker W, Becker BE, Berg L, Prichard J, Caffesse R, Rosenberg E. New attachment after treatment with root isolation procedures: Report for treated Class III and Class II furcation and vertical osseous defects. Int J Periodontics Restorative Dent 1988; 8:9-23. 22. Stahl SS, Froum S, Tarnow D. Human histologie responses to guided tissue regenerative techniques in intrabony lesions. Case reports on 9 sites. / Clin Periodontol 1990; 17:191-198. 23. Tanner MG, Slot CW, Vuddhakanuk S. An evaluation of new attachment formation using microfibrillar collagen barrier. J Periodontol 1988; 59:524-530.
Send reprint requests to Dr. Jiiang Huei Jeng, Department of Periodontics, Dental Clinics, National Taiwan University Hospital, No. 1, ChangTe Street, Taipei, Taiwan, R.O.C. Accepted for publication March 2, 1992.
