Detection of localized

tooth-related factors that

predispose to periodontal
infections
Debora C. Matthews & Moe Tabesh
Periodontal diseases are bacterial infections that
are present in approximately 70% of the U.S. popu-
lation, with 2030% being severely affected (16).
Over the last century, numerous investigations have
attempted to dene the etiologic agents of these
diseases and it is now clear that specic bacterial
pathogens are the primary etiologic agents. These
bacteria form a biolm at or above the gingival mar-
gin. Supragingival irregularities such as crowding,
calculus and rough restorations enhance the reten-
tion of the supragingival biolm and protect organ-
isms from the action of salivary enzymes and oral
hygiene measures. When the bacteria are left undis-
turbed, the host response is to implement a defense
reaction in the form of gingival inammation, or
gingivitis.
If, for whatever reason, the supragingival biolm is
left undisturbed and the bacteria begin to migrate
subgingivally, the environment changes, allowing
gram-negative anaerobes to ourish. Any irregulari-
ties such as root anatomy, subgingival restorative
margins, overhanging dental restorations and other
aberrations will enhance bacterial adhesion to the
pocket epithelium and the tooth surface, thus allow-
ing the growth of subgingival plaque. While potential
pathogens may colonize a site for decades without
causing disease (105), if the local environment chan-
ges in a manner that upsets the balance between
health and disease, destruction rather than remodel-
ing of the periodontium ensues. ``Local'' factors have
been shown to produce these changes.
Local factors are dened as anything that inu-
ences the periodontal health status at a particular
site or sites, with no known systemic effects. These
may be anomalies in the root anatomy or iatrogenic
features. This paper will review the detection and, to
a limited extent, the role of local factors (66) in the
pathogenesis of periodontal diseases.
Tooth anatomy
Inherent anatomic and morphologic features of teeth
can have a signicant impact on the management
and prognosis of the involved tooth or teeth. To
properly diagnose the severity of attachment loss in
a patient with periodontitis, a thorough understand-
ing of tooth root anatomy is crucial.
Molars
Furcations
Molars, particularly maxillary molars, are the teeth
most frequently lost due to periodontal disease (48,
72, 75). The anatomy of the furcation favors retention
of bacterial deposits and makes periodontal debride-
ment, as well as oral hygiene procedures, difcult.
Teeth that have lost attachment to the level of the
furcation are said to have a furcation invasion, or
involvement. Furcal invasions vary in horizontal
and vertical depth as a result of such features as
cervical enamel pearls, root trunk length, furcation
entrance dimensions, root anatomy and variations in
the anatomy of the roof of the furcation.
Several classication schemes have been devised
to describe the degree of furcation involvement.
Most are based on the amount of horizontal and/or
136
Periodontology 2000, Vol. 34, 2004, 136150 Copyright
#
Blackwell Munksgaard 2004
Printed in Denmark. All rights reserved
PERIODONTOLOGY 2000
vertical probe penetration (38, 39, 44, 86, 95, 113),
and are generally divided into three types:
Grade I: Incipient lesion involving up to 3 mm of
horizontal probing depth (Fig. 1).
Grade II: ``Cul-de-sac'' with >3 mm of horizontal
probing depth, without extending through to the
opposite side (Fig. 1).
Grade III: Through-and-through lesion (Fig. 2).
Detection of furcation involvements is not always
straightforward. Good bitewing and periapical radio-
graphs may aid in the diagnosis, but should not be
used as the sole diagnostic tool (3, 61). For example,
less than one quarter of furcation involvements are
picked up on radiographs (98), although the likeli-
hood of detection does increase with the degree of
attachment loss (45).
Clinically, the degree of furcation involvement can
be determined using any of a number of furcation
probes. These probes are curved to allow access into
the furca and have a blunted end for patient comfort.
Clinical assessment, however, may overestimate the
depth of furcation defects. Moriarty et al. (80) demon-
strated that horizontal probing actually measured the
depth of probe penetration into the inamed connec-
tive tissue, rather than the true pocket depth. This is
especially true the deeper the pockets are.
Position of the furcation entrance, particularly in
maxillary molars, is important to remember. The
mesiopalatal entrance of the maxillary rst molar is
located towards the palatal third of the tooth, while
the distopalatal of the furcation is in the middle. In
order to probe maxillary molars, therefore, a palatal
or buccal approach can be used to detect distal fur-
cation involvements (Fig. 3). To detect mesial furca-
tion involvements, it is easiest to detect if probed
from the palatal aspect.
Transgingival sounding under local anesthesia
may be more accurate than regular probing in deter-
mining furcation anatomy. However, this is best
accomplished at the time of initial periodontal ther-
apy when the patient is anesthetized.
Root trunk length
The severity of furcation involvement is highly
dependent on the relationship between the amount
of attachment loss and the distance from the cemen-
toenamel junction to the furcation entrance - the
root trunk length. Hou et al. (53) developed a classi-
cation scheme that takes into account the length of
the root trunk compared to total root length. Type A
has the shortest root trunks, involving a third, or less,
of the cervical area of the root (Fig. 2). Type B root
trunks include up to half of the length of the root,
while in type C, the furcation entrance is in the cer-
vical two-thirds. This system can give a more realistic
prognosis for the tooth, as it takes into consideration
the vertical as well as the horizontal component
of attachment loss. For example, less horizontal
bone loss is required to expose a type A furca than
either the B or C types. On the other hand, a grade I
Fig. 2. Grade III furcation involvement of mandibular rst
molar, with type A root trunk (furcation entrance in the
cervical third of the root) at time of surgery (a). Radio-
graph of area (b).
Fig. 1. Grade I furcation involvement of maxillary second
molar, grade II furcation involvement of rst molar. The
root proximity between these teeth makes access extre-
mely difcult.
Localized tooth-related factors in periodontal infections
137
furcation invasion on a type C root implies a very
poor prognosis, since less than one-third of the root
surface area remains covered by alveolar bone.
In terms of prevalence, Hou et al. (53) reported that
maxillary rst molars are more likely to exhibit either
type B (47.1%) or type A (41.0%), than type C (11.9%).
Mandibular rst molars usually have type A root
trunk lengths (83.5%), while maxillary and mandib-
ular second molars most often have type B (60.8%
and 52.6%, respectively). Others (93, 99) have con-
rmed this in that they found the mean height of the
root trunk is greater in the maxillary molars (3.6
4.8 mm from the cementoenamel junction) than in
mandibular molars (2.43.3 mm). The most apical
furcations are the distal of the maxillary rst molars.
The shortest distance between the cementoenamel
junction and furcation entrance is found in the man-
dibular rst molars, permitting exposure of the fur-
cation at an early stage of periodontitis.
Size of furcation entrance
The diameter of the furcation entrance is extremely
important in predicting the success of periodontal
therapy. Bower et al. (15) reported the majority of
furcation entrances are less than the width of a
new standard Gracey curette. They found that 81%
of furcation entrances were <1.0 mm and 58% of
were <0.75 mm. These ndings are similar to those
found by Chiu et al. (21), who found that 49% of
furcation entrances were <0.75 mm. This anatomic
feature presents additional challenges in the man-
agement of molar furcations. Even with a surgical
approach, narrow furcations are difcult to comple-
tely debride (Fig. 4).
Bifurcation ridges
Using a stereomicroscope and extracted teeth, Svard-
strom & Wennstrom (110) developed complex topo-
graphic contour maps of the furcation areas of
maxillary and mandibular rst molars. Their study
clearly showed the complexity of the anatomy in the
furcation areas. They found various pits and ridges in
the roof of the furcation that would further compli-
cate therapy. These ridges run from one root to
another and, in some maxillary molars, continue
apically. Intermediate ridges connect the mesial
and distal roots and are composed primarily of
cementum. Buccal and lingual ridges are composed
of dentin with overlying thin layers of cementum (3).
In mandibular molars there may be a central bifur-
cation ridge that forms distinct pits in the roof of the
furcation. Hou & Tsai (52) determined that these
ridges are strongly associated with attachment loss
in furcations. These reports emphasize the complex-
ity of the furcation topography of molars that must
be kept in mind when debriding teeth with furcal
attachment loss.
Root concavities
Fluting of roots, or root concavities, are present to
some degree in all molars. Concavities are present in
the roof of furcations, coronal and apical to furca-
tions and on interproximal root surfaces (Fig. 5).
These are often difcult to diagnose unless the
patient is anesthetized during nonsurgical therapy
or the roots surgically exposed. As with any other
anatomic feature, their presence can affect the pro-
gression of attachment loss by harboring bacterial
plaque.
Fig. 3. Note the position of the distal furcation in this
maxillary molar is in the mid-interproximal area. Distal
furcations can be probed from either the buccal or palatal
aspect of the tooth.
Fig. 4. Extracted mandibular molar showing narrow fur-
cation entrance that complicates plaque removal by
patient and clinician.
138
Matthews & Tabesh
Cervical enamel projections
Ectopic deposits of enamel apical to the level of the
normal cementoenamel junction, with a tapering
form and extending towards or into the furcation
areas, are called cervical enamel projections (66).
As with coronal enamel, connective tissue does not
attach to cervical enamel projections, thus they have
been implicated as etiologic factors in furcation
defects (12, 112). Hou & Tsai (50) reported the pre-
valence of cervical enamel projections in molars with
and without furcation involvement. In molars with
cervical enamel projections, 82.5% exhibited furca-
tion involvement, while this was true for 17.5% of
molars that had no cervical enamel projections.
The inuence of a cervical enamel projection is
dependent on the extent of the projection. Masters
& Hoskins (71) introduced a grading system in 1964
that is still in use today:
Grade 1: Short but distinct change in the contour of
the cementoenamel junction extending towards
the furcation.
Grade II: cervical enamel projection approaches
the furcation, without making contact with it.
Grade III: cervical enamel projection extends into
the furcation (Fig. 5).
Roussa (99) found that Grade I and III projections
are more prevalent, and that cervical enamel projec-
tions are more often observed in mandibular second
molars than either the maxillary or mandibular rst
Table 1. Signicant anatomic features of teeth
Tooth Anatomic feature (ref.) Prevalence (ref.)
Maxillary incisors Palatal groove
98% all grooves found in lateral incisors
0.79 (5)21% (51)
Maxillary first bicuspids Root trunk length; averages 414.6 mm (57)
Furcal concavity on palatal aspect of buccal root
Mesial root concavities
Furcation entrance diameter <0.75 mm
62% (57)
100% (14)
57% (15)
Maxillary molars Furcation entrance diameter <0.75 mm
Root trunk length; averages
Mesial: 3.5 mm (99)4.2 mm (15)
Buccal: 4.0 (99)4.8 mm (15, 93)
Distal: 3.3 (12)
Cervical enamel projections
63% (15)
32.6% (112)
Mandibular molars Furcation entrance diameter <0.75 mm
Root trunk length; averages
Buccal: 2.4 mm (15)3.14 mm (70)
Lingual: 2.5 mm (15)4.17 mm (70)
Cervical enamel projections
First molar
Second molar
Bifurcation ridges
50% (15)
80.4% (52)
48.4% (52)
65.5% (52)76% (18)
Fig. 5. GradeIII cervical enamel projectiononamandibular
rst molar. This projection acts as a lip at the furcation
entrance. Together withthe mesial groove onthe distal root,
these anatomic anomalies compromise plaque removal.
139
Localized tooth-related factors in periodontal infections
molars. These ndings are in line with those of other
studies (see Table 1).
Enamel pearls are less prevalent that cervical
enamel projections. They contribute to the etiology
of furcation involvements nonetheless. Moskow &
Canut (81) reviewed the literature on the prevalence
of enamel pearls and reported a range of 1.19.7%.
Nearly three-quarters of enamel pearls are found on
maxillary third molars. The mandibular third molar
and maxillary second molar are the second most
common sites. Figure 6 is a radiographic example
of an enamel pearl and the resultant periodontal
destruction.
Maxillary bicuspids
Maxillary rst bicuspids often have two roots buccal
and palatal. Joseph et al. (57) examined the furca-
tion anatomy of 100 of these teeth. A furcal concavity
was seen on the palatal aspect of the buccal root
in 62% of bifurcated teeth. This coincides with the
prevalence of 78% reported by Gher & Vernino (35).
The mean furcation width was 0.71 mm; again, less
than the diameter of a new curette. Concavities
were found on the proximal surfaces of all teeth
studied, with a deeper concavity on the mesial than
the distal aspect. Maxillary bicuspids may also dis-
play a V-shaped groove on the proximal surfaces
(Figs 7 and 8). These often persist toward the apical
region, and are associated with a greater loss of
attachment than that found around non-grooved
teeth (67).
Anterior teeth
Palatal grooves
The radicular lingual or palatal groove is a develop-
mental anomaly in which an infolding of the inner
enamel epithelium and Hertwig's epithelial root
sheath create a groove that passes from the cingulum
of maxillary incisors apically onto the root (41).
These grooves usually begin in the central fossa,
Fig. 6. Cervical enamel pearl on the maxillary rst molar
(a). There is alveolar bone loss associated with this anom-
aly that is not present in the contralateral tooth (b).
Fig. 8. Moat-type defect associated with distal and buccal
furcations of maxillary second bicuspid.
Fig. 7. Maxillary rst bicuspid with Grade I buccal furca-
tion involvement. Note the deep mesial groove.
140
Matthews & Tabesh
cross the cingulum and extend apically for various
distances and directions (Figs 9 and 10). Pecora & da
Cruz Filho (90) reported radicular grooves to be pre-
sent in 3.9% of their subjects, primarily on the lingual
surface of the maxillary lateral incisor (3.0%). Less
than 1% of maxillary central incisors showed radicu-
lar grooves on the buccal and/or lingual surfaces.
Others report the prevalence of 0.7921% in both
maxillary incisors (5, 49, 62, 124), and 1.914% in
lateral incisors alone (30, 35, 49, 62, 124).
In contrast to maxillary bicuspids, incisors gener-
ally display a shallow U-shaped groove. Kogon (62)
reported that over half of the grooves extend more
than 5 mm apical to the cementoenamel junction.
These grooves may act as ``funnels'' for the accumu-
lation of microbial plaque in the depth of the groove,
where they are inaccessible to both patient and clin-
ician. The prognosis for teeth with palatal grooves
with apical extension is poor (41).
Dental restorations
The relationship between dental restorations and
periodontal status has been examined for some time.
Research has shown that overhanging dental restora-
tions and subgingival margin placement play an
important role in providing an ecologic niche for
periodontal pathogens.
Overhanging dental restorations
An overhanging dental restoration is primarily found
in the Class II restoration, since access for interdental
cleansing is often difcult in these areas, even for
patients with good oral hygiene habits (Fig. 11).
Many studies have shown that there is more period-
ontal attachment loss and inammation associated
with teeth with overhangs than those without. Over-
hangs cause an increase in plaque formation (55, 59,
60, 68, 89, 94, 97), and a shift in the microbial com-
position (64) from healthy ora to one characteristic
of periodontal disease. In addition to their effect on
the inammatory process, overhangs may also cause
damage by impinging on the interdental embrasure
Fig. 9. Periodontal pocket associated with palatal groove
on mesial of central incisor; without probe in place (a),
with probe in place (b).
Fig. 11. Poor quality restorations with overhanging mar-
gins.
Fig. 10. Surgical view of distal palatal groove of maxillary
lateral incisor.
141
Localized tooth-related factors in periodontal infections
and the biologic width. There appears to be no
statistical relationship between the presence of an
amalgam overhang and patient age (89) meaning
an overhang can be equally destructive to young and
old alike.
Restorative matrices may not always adapt well
interproximally, even with careful placement of the
restorative material and tight wedging. Variations in
root anatomy, particularly root concavities, may
make perfect marginal adaptation impossible. It
has been shown that removal of an overhang results
in improved plaque control (97) and restoration of
gingival health (40).
The prevalence of overhangs has been reported in
many patient populations. The reported range on
restored teeth is between 18% (55) and 87% (68).
Criteria used to determine the presence of an over-
hang differ from study to study, which likely
accounts for most of this variation (see Table 2).
Lervick et al. (68) employed bitewing radiographs, a
microscope and magnifying glass. They reported 96%
of overhangs extended less than 0.5 mm from the
tooth. This indicates that studies using the criterion
of 0.5 mm have most likely underestimated overhang
prevalence. Pack et al. (88) found the use of bitewing
radiographs and clinical exploration detected only
35% of interproximal overhangs. Of these, 74% were
found with radiographs alone, while 62% were found
using only clinical inspection.
These studies conrm that removal of overhanging
margins should be part of initial periodontal therapy.
As well, it is obvious that early detection of overhan-
ging dental restorations is an important part of pre-
ventive dental care. A sensitive tactile instrument,
such as a ne explorer, should be used in conjunc-
tion with radiographs to facilitate this detection.
Subgingival restorative margins and
biologic width
The location of the gingival margin of a restoration is
directly related to the health status of the adjacent
periodontium (116). Numerous studies (56, 58, 87,
96, 101, 115) have shown that subgingival margins
are associated with more plaque, more severe gingi-
val inammation and deeper periodontal pockets
than supragingival ones. In a 26-year prospective
cohort, Schatzle et al. (101) followed middle-class
Scandinavian men for a period of 26 years. Gingival
indices and attachment level were compared
between those who did and those who did not have
restorative margins greater than 1 mm from the gin-
gival margin. After 10 years, the cumulative mean
loss of attachment was 0.5 mm more for the group
with subgingival margins. This was statistically sig-
nicant. At each examination during the 26 years of
the study, the degree of inammation in the gingival
tissue adjacent to subgingival restorations was much
greater than in the gingiva adjacent to supragingival
margins. This is the rst study to document a time
sequence between the placement of subgingival mar-
gins and periodontal attachment loss, conrming
that the subgingival placement of margins is detri-
mental to gingival and periodontal health.
Subgingival margins, in addition to inuencing the
progression of periodontitis, can have other effects
on the attachment apparatus. Several authors have
described the area between the depth of a healthy
gingival sulcus and the alveolar crest as the ``biologic
width'' (25, 26, 42, 54, 74, 84). This constitutes the
junctional epithelium and the supracrestal connec-
tive tissue. Using cadaver specimens, Garguilo et al.
(31) calculated the average distance to be 2.96 mm.
Table 2. Prevalence of overhanging dental restorations (adapted from Brunsvold & Lane, 1990 (17))
Reference Diagnostic method for detection % restored surfaces with overhangs
(n number of subjects)
Gilmore & Sheiham, 1971 (37) Bitewing radiographs 25% (n 1976)
Burch et al., 1976 (19) Bitewing radiographs 30% (n 825)
Hakkrainen & Ainamo, 1980 (43) Orthopantograms 50% (n 85)
Than et al., 1982 (114) Calculus probe 60% (n 240)
Lervik & Riordan, 1984 (68) Bitewing radiographs, microscope 25% (n 175)
Keszthelyi & Szabo, 1984 (60) Bitewing radiographs, microscope 86% (n 176)
Coxhead, 1985 (23) Bitewing radiographs, mirror, probe 76% (n 50)
Claman et al., 1986 (22) Bitewing radiographs 27% (n 826)
Jansson et al., 1994 (55) Bitewing radiographs 18% (n 162)
142
Matthews & Tabesh
This is often rounded up to 3.0 mm when referring to
the amount required for the biologic width. It has
since been shown that this is not a magical number,
and the biologic width may vary between teeth and
individuals. The basis for the biologic width is the so-
called ``radius of inammatory effect'' in which there
is a nite distance of approximately 12 mm over
which the tissue-lytic properties of localized inam-
mation operate (117, 118). In other words, plaque at
the apical margin of a subgingival restoration will
cause periodontal inammation that may in turn
destroy connective tissue and bone approximately
12 mm away from the inamed area.
When it is anticipated that placement of a subgin-
gival margin will impinge on the biologic width (i.e.,
be within 12 mm from the alveolar crest), surgical
crown-lengthening procedures should be consid-
ered. Herrero et al. (47) found that this is not always
easy to achieve, even by experienced clinicians. In
the most difcult areas to access, the lingual and
distolingual, clinicians removed an average 0.4 mm
of bone far short of the 3 mm goal. Determination
of the distance between the restorative margin and
the alveolar crest is often done with bitewing radio-
graphs; however, it is important to remember that a
radiograph is a 2-dimensional representation of
3-dimensional structures. Thus, clinical assessment
and judgment are important adjuncts in determining
if, and how much, bone should be removed to main-
tain adequate room for the dentogingival attach-
ment.
Restorative materials
Although surface textures of restorative materials dif-
fer in their capacity to retain plaque (13), all can be
adequately maintained if they are polished and
accessible to patient care (65). This includes the
underside of pontics. While there is little evidence
to substantiate the use of specic materials or
designs for pontics, Wang et al. (119) found that
metal pontics harbor higher proportions of period-
ontal pathogens than porcelain ones. Although there
is no evidence that subpontic plaque leads to attach-
ment loss on abutment teeth, the accumulation of
subpontic plaque for an extended period of time
should be considered a risk factor.
In a trial of porcelain laminate veneers, Kourkouta
et al. (63) found a decrease in the plaque index and
bacterial vitality between teeth with and without
veneers in the same patients. This nding is consis-
tent with other studies that have shown highly glazed
porcelain retains less plaque than enamel (85, 123).
Composite resins are difcult to nish interproxi-
mally and may be more likely to show marginal
defects than other materials (92). As a result, they
are more likely to harbor bacterial plaque (27).
Intra-subject comparisons of unilateral direct com-
posite ``veneers'' showed a statistically signicant
increase in plaque and gingival indices adjacent to
the composites, 56 years after placement (92). In
addition, when a diastema is closed with composite,
the restorations are often overcontoured in the cer-
vical-interproximal area, leading to increased plaque
retention (91). As more plaque is retained, this could
pose a signicant problem for a patient with moder-
ate to poor oral hygiene.
Prostheses
Several investigations have noted that after the inser-
tion of removable partial dentures, the mobility of
the abutment teeth, gingival inammation and per-
iodontal pocket formation increases (10, 11, 20, 102,
126). This may be because partial dentures, especially
those with gingival coverage, have been shown to
favor plaque accumulation (1, 108). Not only is there
an increase in the amount of bacterial plaque, but a
shift to more pathogenic microbiota, as well (100).
In a large case-control study, Zlataric et al. (126)
examined 205 partial denture wearers. Abutment
teeth had higher plaque scores and more severe gin-
gival inammation than non-abutment teeth. Prob-
ing depths of 2 mm were found on 82% of non-
abutment teeth as compared to 54% of abutments.
Not all studies concur with these ndings. Mullaly &
Linden (83) concluded that among regular dental
attenders, those with partial dentures were no more
likely to have periodontal disease than those who did
not wear a partial. It is likely, however, that the sam-
ple size of 14 was too small to detect any potential
difference.
Effect of crowding and tooth
position
Until the 1960s, the dental literature contained few
reports that examined the relationship between mal-
occlusion/malalignment and periodontal disease.
Many studies have concluded that poorly aligned
teeth themselves are not associated with a greater
degree of gingivitis. Rather, crowding can complicate
oral hygiene procedures, leading to an increased
plaque accumulation and subsequent gingival inam-
mation (2, 34, 103). Although Behfelt et al. (9)
143
Localized tooth-related factors in periodontal infections
reported a direct relationship between tooth displa-
cement and gingival inammation, this was only
evident in patients with moderate or poor plaque
control. Similarly, there appears to be no relationship
between crowding and alveolar bone loss in patients
with excellent plaque control (6, 34, 103). Thus, it
appears that malalignment may be more important
in the patient with less than ideal oral hygiene.
However, if interproximal spaces are reduced as a
result of crowding, root proximity may occur (Fig. 1).
This leads to less effective removal of plaque and
subgingival calculus in the inaccessible interproxi-
mal area. Even surgically, these teeth can be difcult
to treat, leading to a compromised prognosis. None-
theless, a well motivated and dexterous patient will
likely prevent plaque accumulation regardless of
tooth shape or position (106).
In some cases of extreme anterior overbite, direct
trauma to the gingiva from the incisal edges of the
mandibular incisors may result in palatal recession
the maxillary incisors. Similarly, in severe Class II
division 2 malocclusions, functional trauma can
cause marginal recession of the facial gingiva of the
mandibular incisors (33).
Vertical root fractures
Vertical root fractures are, by denition, longitudinal
and conned to the root of the tooth. They may be in
a mesiodistal or buccolingual plane, and may occur
at any point along the root (Figs 12 and 13). The
diagnosis of vertical root fracture is difcult because
several of the associated signs and symptoms are
shared with other dental conditions. In some
instances, there may be a halo appearance at the
fracture site of the affected tooth on a radiograph.
However, unless the fractured segment has sepa-
rated, radiographs are often of little use in localizing
the lesion.
The patient may have masticatory pain, with or
without concomitant pulpal pain. Transillumination
may be helpful, or the diagnosis may be made with
the use of a bite test, where a resilient material is
placed between the teeth during gentle occlusion.
Pathognomonic of a vertical fracture is the occur-
rence of a narrow, isolated periodontal pocket. The
affected teeth may exhibit recurrent periodontal
abscesses.
Teeth with cracked roots usually have a poor prog-
nosis, although some success has been reported
using regenerative membranes (82) or resin cement
(109).
Fig. 12. Isolated deep pocket associated with vertical root
fracture and endodontic-periodontal lesion. Radiograph
of tooth prior to extraction (a); extracted tooth (b).
Fig. 13. Not all vertical fractures are visible on a radio-
graph, particularly if they occur in the buccolingual plane.
144
Matthews & Tabesh
Assessment of mucogingival
deformities
Gingival recession
Assessment of the mucogingival status of a patient is
an essential part of an oral examination, particularly
if there is major restorative or orthodontic work
planned. Mucogingival status refers to the quality
and quantity of keratinized gingival tissue, the
amount of gingival recession, the presence of aber-
rant frena and the depth of the vestibules.
Aberrant frenal attachments may be a problem,
especially in shallow vestibules or areas of minimal
attached gingiva (Fig. 14). When the frenum is
stretched, the muscle attachments may pull the mar-
ginal tissue away from the tooth. This then acts as a
``funnel'', allowing accumulation and apical migra-
tion of bacterial plaque. This can lead to an increase
in gingival recession on that particular tooth.
Gingival recession can be a problem for patients
for esthetic reasons, dentinal hypersensitivity or
interference with normal hygiene procedures. A
number of factors have been implicated in the etiol-
ogy of gingival recession. An extreme buccal or lin-
gual positioning of the tooth in the dental arch,
whether natural or due to orthodontic movement,
can lead to thinning of the alveolar plate and asso-
ciated gingival tissues. This makes the area more
susceptible to recession, either from trauma or
inammation (73). Trauma is usually the result of
vigorous toothbrushing, or the use of a medium to
hard brush. Plaque-induced disease can also cause
recession, particularly in patients with a thin period-
ontium (4).
Recession is measured from the midfacial or mid-
lingual/palatal of each tooth to the most coronal
aspect of the marginal gingiva. In multi-rooted teeth,
recession can be measured for each root. Miller's
classication is the standard in categorizing marginal
tissue recession and in predicting the likelihood of
root coverage with periodontal plastic surgery tech-
niques:
Class I: Recession does not extend to the muco-
gingival junction. There is no loss of interdental
bone or soft tissue (Fig. 15).
Class II: Recession extends to or beyond the muco-
gingival junction. There is no loss of interdental
bone or soft tissue (Fig. 16).
Class III: Recession extends to or beyond the
mucogingival junction. There is loss of interdental
bone and/or soft tissue or malpositioning of the
tooth (Fig. 17).
Class IV: There is advanced loss of interdental bone
and/or soft tissue or severe malpositioning of the
tooth (Fig. 18).
Class I and II can be subclassied as narrow or
wide. After gingival grafting procedures, full root
Fig. 15. Grade I recessionhas the best prognosis interms or
root coverage from periodontal plastic surgery procedures.
Fig. 16. Grade II recession on the facial of mandibular
first bicuspid extends beyond the mucogingival junction.
Fig. 14. Frenal pull in an area of no attached gingiva may
accelerate gingival recession.
145
Localized tooth-related factors in periodontal infections
coverage can usually be expected up to the level of
the interdental bone in Classes I and in Class II nar-
row-type defects. For Class III, only partial coverage
can be expected, while little or no coverage occurs in
Class IV lesions treated with current grafting techni-
ques.
Keratinized gingiva
Keratinized gingiva is differentiated from attached
gingiva in that the former includes both attached
and free gingival tissues. Attached gingiva is deter-
mined by subtracting the periodontal probing depth
from the width of keratinized tissue at a given site. It
is measured at the midfacial of mandibular and max-
illary teeth and the midlingual of mandibular teeth.
The clinical impression is that since the attached
gingiva is rmly bound to the underlying periosteum,
it will provide a protective barrier against inamma-
tion and attachment loss. Augmentation of the
attached gingiva is often recommended on this basis.
Several studies have challenged the view that a
wide zone of attached gingiva is a more effective
barrier against recession than a narrow or nonexis-
tent one. It has been demonstrated that in the
absence of inammation, gingival health and attach-
ment levels can be maintained (28, 121, 122). One
long-term study reported that the incidence of reces-
sion was no greater in areas without keratinized tis-
sue than in areas with a wide zone of keratinized
gingiva (120).
Stetler & Bissada (107) studied the relationship
between the width of keratinized gingiva, the pre-
sence of subgingival margins and inammation.
Teeth with subgingival restorative margins and nar-
row (<2.0 mm) keratinized tissue were more likely to
exhibit gingivitis, while those with restorative mar-
gins at or above the coronal aspect of the free gingiva
showed no difference between wide and narrow
bands of keratinized gingiva. These results suggest
that particular attention should be paid to those sub-
gingival restorations associated with <2.0 mm of ker-
atinized tissue. For patients scheduled to receive
subgingival restorations where narrow zones of ker-
atinized tissue exist, and who cannot maintain opti-
mal plaque control levels, it may be desirable to
increase the width of keratinized tissue about those
teeth.
There are other situations in which a wider zone of
attached gingiva may be necessary. Teeth with a thin
periodontium that are planned for orthodontic
movement, particularly if there will be movement
of teeth labially, are likely to have more recession
in areas of minimal attached gingiva (32). Abutment
teeth for removable prostheses are more likely to
exhibit plaque, and therefore be at higher risk of
gingivitis and attachment loss. These areas may be
considered for gingival augmentation, particularly
for patients with inadequate oral hygiene. Sites
where the patient nds oral hygiene difcult because
of the proximity of the mucosa to the cervical area of
the tooth, may also benet from a wider zone of
keratinized tissue.
Effect of periodontally hopeless
teeth on adjacent teeth
The ability to accurately predict the response of the
dentition to periodontal therapy is essential in devel-
oping a denitive periodontal maintenance and
restorative treatment plan. A prognosis is assigned
to an individual tooth based on a number of factors
including type and degree of bone loss, probing
depths, presence and severity of furcations, mobility,
crownroot ratio, root form and pulpal involvement.
Fig. 18. Grade IV recession on mandibular canine that is
further compromised by iatrogenic dentistry.
Fig. 17. Grade III recessionona mandibular central incisor.
146
Matthews & Tabesh
In addition, systemic factors, patient compliance and
type of periodontal disease are key determinants.
Prognostication is a skill not easily acquired and is
highly dependent upon the experience and skill of
the clinician. There are several classication systems
and denitions of prognoses (7, 8, 24, 48, 75). It is
generally agreed that a tooth with a hopeless prog-
nosis is one that, despite the patient's and clinician's
best efforts, is not going to improve. In these situa-
tions, it is difcult, if not impossible, to arrest the
disease process and restore periodontal health. Some
believe that the presence of a hopeless tooth may
also be detrimental to the health of adjacent teeth
(29, 69, 104). Despite this, patients may choose to
retain periodontally hopeless teeth for a variety of
reasons economics, esthetics or an aversion to
extractions.
Several studies have shown that, when appropriate
treatment is rendered and the patient is in a main-
tenance program, teeth previously diagnosed as
hopeless may survive for many years with little or
no effect on proximal teeth (24, 125). Wojcik et al.
(125) examined periodontal maintenance patients,
8 years after the completion of active therapy. There
was no difference in probing depths or alveolar bone
levels between teeth adjacent to the hopeless tooth
and not. Although a small study (n 14), power
calculations showed these results to be robust.
McGuire (76) and Ghiai & Bissada (36) both con-
cluded that in cases where the prognosis is other
than ``good'', it is difcult to predict the long-term
outcome of individual teeth. In cases of hopeless
teeth, prognostication was no more accurate than
ipping a coin (76). In McGuire's study, 25% of teeth
initially diagnosed as hopeless were reclassied as
having a good or fair prognosis 58 years later. These
ndings suggest that periodontally involved teeth
can be maintained for years in health, comfort and
function (8, 24, 36, 46, 48, 7779, 125).
Summary
The primary goal of periodontal therapy is to pro-
duce an environment that is conducive to oral health.
This is achieved by eliminating the subgingival infec-
tion and implementing supragingival plaque control
measures designed to prevent the re-colonization of
the sulcus (111). Local etiologic factors, as described
above, may prevent the removal of subgingival pla-
que, and may even contribute to destruction of the
periodontal tissues. Thus, it is crucial to be able to
recognize and, when possible, eliminate any plaque-
retentive factor that could contribute to disease
progression. Iatrogenic factors such as subgingival
margins, restorative overhangs, overcontoured resto-
rations and unpolished surfaces can be altered.
Similarly, cervical enamel projections, enamel pearls
and, in certain instances, palatal grooves can be
removed or recontoured to enable the patient to
access the area for good plaque control. There are
some things that we cannot alter. Anatomic anoma-
lies, particularly in posterior teeth, cannot be chan-
ged. However, awareness of potential anatomic
variations and early detection of them may be able
to prevent future attachment loss.
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