2. maintenance o f the " b i o l o g i c w i d t h " ( G a r g i u l o , A .
Forced Eruption: Part II. A Method of Treating Nonrestorable Teeth— Periodontal and Restorative Considerations*
et a l . , 1960) 3. access for impression technics 4. c o n t r o l o f hemorrhage 5. maintenance o f p e r i o d o n t a l health 6. restoration o f function 7. esthetics T r a d i t i o n a l l y two methods are available to manage a fracture at the level o f the gingival m a r g i n . These include: (1) extraction o f the r e m a i n i n g root and
by
subsequent
replacement with a fixed prosthesis or (2) exposure o f sound tooth structure by p e r i o d o n t a l surgery.
J E F F R E Y S. I N G B E R , D . D . s . t
S u r g i c a l exposure o f sound tooth structure is fraught with A N I S O L A T E D nonrestorable tooth m a y be defined as that
c o m p r o m i s e especially in the
anterior
segment
where esthetics is a consideration. G i n g i v a l and osseous
c l i n i c a l c o n d i t i o n in which disease, t r a u m a or iatrogene-
surgery cannot be l i m i t e d to the involved tooth and must
sis
be extended to adjacent
has destroyed the c l i n i c a l c r o w n , c o m p r o m i s i n g or
teeth
in order to blend the
m a k i n g restoration impossible. C a r i e s , accidents, contact
gingival and osseous contours. T h e ultimate result is a
sports, large restorations, n o n v i t a l teeth and the over-
sacrifice
zealous use of restorative pins are but a few o f the
sensitivity, and esthetic deformities in the form o f long
etiologic factors that m a y contribute to the loss o f the
c l i n i c a l crowns and open embrasures.
tooth. C l i n i c a l treatment is further c o m p l i c a t e d due to and
only
manage
o f involvement in the
arch and
bone
on
several teeth,
root
F o r c e d eruption has been suggested in the periodontal
the characteristic isolation of the tooth, i.e., when it is the area
o f supporting
adjacent
structures are either physiologic, show m i n i m u m perio
endodontic literature as an alternative method to
crest.
2,
root fractures
in the
region o f the alveolar
3
d o n t a l changes or require m i n o r restorative procedures. RATIONALE OF F O R C E D ERUPTION
Esthetics plays a major role when the loss o f tooth structure involves the anterior teeth which m a y alter or
The m e c h a n i c a l procedure o f accelerating the eruption of a tooth produces a c o m p l i m e n t a r y alteration o f the gingival and supporting tissues. R e i t a n and o t h e r s have demonstrated that eruptive tooth movement results in a stretching o f the gingival and p e r i o d o n t a l fibers which produces a c o r o n a l shift o f gingiva and bone. A t h e r t o n and K e r r have investigated the c l i n i c a l and histological effects o f orthodontic movements on gingiva in animals and humans. T h i s study indicates distinct
l i m i t our ability to restore form and function. The
THERAPY
object o f this paper is to present the biologic
4 , 5 , 6
r a t i o n a l and c l i n i c a l d o c u m e n t a t i o n which demonstrate the potential of forced eruption as a useful technic to manage the isolated nonrestorable tooth.
7 , 8
R E V I E W OF TRADITIONAL T R E A T M E N T
METHODS
The treatment o f fractured roots where the c o r o n a l segment has not been lost has been reported successful i f the m o b i l e segment is reduced and stabilized. Fractures o c c u r i n g in the m i d d l e and a p i c a l t h i r d o f the root have been shown to heal by b r i d g i n g with either a callus, connective tissue, or bone surrounded by connective tissue ( F i g . 1). 1
W h e n the fracture occurs in the m i d d l e or incisal third of the c r o w n and there is adequate tooth structure available, newer restorative technics such as pins, posts, telescopes and composite resins are usually sufficient to restore form and function. H o w e v e r , i f the loss o f tooth structure occurs at the g i n g i v a l m a r g i n or below the crest of bone, exposure o f sound tooth structure becomes p a r a m o u n t i f we are to achieve the following objectives: 1. P l a c e m e n t o f m a r g i n s on sound tooth structure FIGURE 1. Fracture sites versus treatment options. A and B: Root fractures may be stabilized and successful healing is possible by bridging with a callus, connective tissue, or bone and connective tissue. C : Fractures at the level of cementoenamel junction (CEJ) have been treated by periodontal surgery or forced eruption and subsequent restoration. D: Fractured crowns may be treated by standard restorative technics.
* Presented at the Clinical Research Forum of the Philadelphia Society of Periodontology, January, 1975. † Assistant Professor, Department of Form & Function of the Masticatory System, University of Pennsylvania School of Dental Medicine, 4001 Spruce Street, Phila., Pa. 19174; Assistant Clinical Professor, Department of Dental Medicine, Medical College of Penn sylvania.
203
204
J. Periodontol. April, 1976
Ingber
areas o f new gingiva on the m e s i a l o f a tooth that had been
moved distally. E d w a r d s ,
manage
the
9 , 1 0
i n an attempt
Results o f this experiment led to the conclusion that as a
to
tooth is erupted, the gingiva and alveolar crest w i l l follow
p r o b l e m of o r t h o d o n t i c relapse, studied
and the resultant change in p o s i t i o n o f the soft tissue is
g i n g i v a l changes by u t i l i z i n g tattoos that were placed in
not due to a displacement o f the m u c o g i n g i v a l j u n c t i o n
the g i n g i v a l tissues p r i o r to r o t a t i o n a l orthodontic move
but rather to an increase in the zone o f attached gingiva.
ment. T h e vertically-placed tattoos deviated in the direc tion o f the r o t a t i o n in a l l cases and he concluded that
U t i l i z i n g the results o f these studies and
applying
established orthodontic principles, we m a y hypothesize
"the attached g i n g i v a , especially the m a r g i n a l gingiva, is
that when a root segment is o r t h o d o n t i c a l l y erupted, the
indeed pulled a l o n g w i t h the tooth as it is rotated".
gingiva and supporting structures w i l l follow to a p o s i t i o n
Batenherst
11
investigated the effects on hard and soft
that is further
c o r o n a l than the adjacent
teeth.
The
tissues when teeth are tipped facially in m o n k e y s . T h e
therapist can utilize these g i n g i v a l and osseous changes to
author noted that unexpected extrusion occurred d u r i n g
his c l i n i c a l advantage in order to manage the restorative
the p e r i o d o f s t a b i l i z a t i o n , and measurements c o n f i r m e d
problem.
that the w i d t h o f the attached gingiva increased while the
C o n s i d e r the hypothetical situation as illustrated in
p o s i t i o n o f the m u c o g i n g i v a l j u n c t i o n remained stable.
Figures 2 A through J . A fracture that occurs at the level
FIGURE 2 A . A crown fractured at the level of the gingival or osseous margin necessitates periodontal surgery to expose sound tooth structure for an adequate restoration. B. Osseous surgery results in a sacrifice of bone on adjacent teeth and esthetic deformities may result. C . The final restoration after surgery may produce long clinical crowns and open embrasures. D . A sectional orthodontic appliance is activated by engaging a temporary post that has been cemented in the prepared root canal. E . The gingival margin and root segment have been erupted to a position further coronal relative to the adjacent teeth. The dotted line represents the position of preoperative gingival margin. F . Periodontal surgery is employed after a period of stabilization to reposition the gingival complex to approximate the preoperative state at a level constant with the adjacent teeth. G . A flap is elevated illustrating that the osseous margin has followed the coronal movement of the teeth. Note the "angular crests". H . The "angular crests" are corrected which exposes sound tooth structure without sacrificing bone on the adjacent teeth. I. The Jlap is sutured to approximate the gingival margins on the adjacent teeth. J . The final restoration is placed producing acceptable esthetics.
Volume 47 Number 4
Forced Eruption: Part II
205
of the alveolar bone presents the c l i n i c i a n with a difficult
eruption is initiated after endodontic therapy is complete
p r o b l e m ( F i g . 2 A ) . R e s t o r a t i o n o f f o r m and function
in order to reposition the root segment coronally. A
would necessitate extraction o f the r e m a i n i n g root seg
segmented o r t h o d o n t i c appliance is inserted to engage a
ment and subsequent
t e m p o r a r y post that has been cemented in the prepared
tooth replacement with a fixed
prosthesis or p e r i o d o n t a l surgery to expose sound tooth
root c a n a l ( F i g . 2 D ) . T h e gingival m a r g i n and
structure c o r o n a l to the osseous crest ( F i g . 2 B ) . P e r i o
segment have been erupted to a position more c o r o n a l in
d o n t a l surgery generally results in the loss o f supporting
relation
bone on the involved root segment as well as adjacent
p e r i o d o n t a l surgery m a y now be performed by elevating
teeth resulting in an esthetic d e f o r m i t y ( F i g . 2 C ) . F o r c e d
a flap to expose the u n d e r l y i n g structures ( F i g . 2 F ) . T h e
to the
adjacent
teeth
root
(Fig. 2E). Corrective
FIGURE 3A. The maxillary left central incisor was fractured as a result of trauma. The tooth was prepared for a full crown restoration. B. A root fracture on the lingual aspect extended approximately 5 mm below the gingival margin. C . A metal band temporary restoration was cemented. A sectional appliance was bonded directly to the teeth and activated. Note the relative positions of the mucogingival junction and gingival margin. D . Approximately 4 mm of eruption was obtained in 6 weeks at which time the tooth was stabilized in the appliance. It appears that the position of the mucogingival junction has remained relatively stable while the gingival margin has moved coronally. E . A full thickness flat was elevated to reposition the gingival margin apically to approximate the adjacent teeth. A gingivoplasty was performed on the palatal to expose the fracture. Osseous corrections were not made in this case. F . The final restoration was inserted and adjusted to minimize occlusal stress.
206
J. Periodontol. April, 1976
Ingber
FIGURE 3G. Preoperative radiograph. H . Postoperative osseous
crest
has been
radiograph.
shown to have followed the
with the adjacent teeth. N o attempt at osseous c o r r e c t i o n
c o r o n a l m o v e m e n t o f the tooth ( F i g . 2 G ) and osseous
was made. T h e o r t h o d o n t i c appliance was removed after
surgery is i n i t i a t e d with the objective o f exposing sound
final healing ( F i g . 3 E ) .
t o o t h structure o n the involved root segment ( F i g . 2 H ) . The
soft tissue is sutured to blend with the existing
The tooth was reprepared a n d a p r o v i s i o n a l c r o w n was placed that extended beyond the l i n g u a l fracture. T h e
g i n g i v a l m a r g i n s consistent with the adjacent teeth to
final restoration was inserted and adjusted to m i n i m i z e
produce an acceptable esthetic result ( F i g . 21).
occlusal stress. ( F i g . 3 F )
P o s t o p e r a t i v e l y , an acceptable
restoration is fabri
The
preoperative r a d i o g r a p h shows the t r a u m a t i z e d
cated w h i c h satisfies the p e r i o d o n t a l , restorative and es
central incisor has a short, tapered root relative to the
thetic requirements o f the case ( F i g . 2 J ) .
lateral incisor ( F i g . 3 G ) . T h e r a d i o g r a p h o f the final restoration
CASE
REPORTS
reveals a thickened p e r i o d o n t a l ligament
space. ( F i g . 3 H ) T h e residual m o b i l i t y that was present
Case I
after treatment d i d not affect the functional requirements
T h e patient is a 24-year-old female with a history o f t r a u m a to the m a x i l l a r y left central incisor ( F i g . 3 A ) . E n d o d o n t i c s and a t e m p o r a r y c r o w n were placed by her general dentist w h o referred her to the M e d i c a l C o l l e g e of P e n n s y l v a n i a for further evaluation and treatment. T h e patient had lost the t e m p o r a r y c r o w n p r i o r to the i n i t i a l presentation and the c l i n i c a l e x a m i n a t i o n revealed a large v e r t i c a l root fracture on the l i n g u a l that extended a p p r o x i m a t e l y 5 m m below the g i n g i v a l m a r g i n ( F i g . 3B).
of this case.
A m e t a l a n d a c r y l i c p r o v i s i o n a l c r o w n was placed for esthetic purposes and a sectional o r t h o d o n t i c appliance was inserted w h i c h utilized direct bonded brackets ( F i g . 3C). T h e tooth was erupted a p p r o x i m a t e l y 4 m m in 6 weeks and was stabilized i n the appliance for an a d d i t i o n a l 8 weeks ( F i g . 3 D ) . T h e c l i n i c a l c r o w n was shortened to a c c o m m o d a t e the e r u p t i o n . N o t e that after the eruption the relative p o s i t i o n o f the m u c o g i n g i v a l j u n c t i o n re m a i n e d stable while the g i n g i v a l m a r g i n has m o v e d in a coronal direction. T h e s u r g i c a l a p p r o a c h consisted o f a full thickness flap to reposition the gingival m a r g i n at a level consistent
Case 2 A 16-year-old female presented for treatment with a t r a u m a t i c fracture o f the m a x i l l a r y right lateral incisor ( F i g . 4 A ) . E n d o d o n t i c therapy was completed and a tem porary post with a facial offset was cemented i n the pre pared canal. A sectional o r t h o d o n t i c appliance u t i l i z ing direct bonded brackets was activated to erupt the tooth. A p p r o x i m a t e l y 4 m m o f eruption was produced d u r i n g 5 weeks o f o r t h o d o n t i c treatment ( F i g . 4 B ) . T h e tooth was stabilized for a p p r o x i m a t e l y 8 weeks i n the passive appliance prior to corrective p e r i o d o n t a l surgery which consisted o f a full thickness flap to expose the root segment (Figure 4 C ) . Slight osseous corrections were made and the flap was repositioned consistent w i t h the adjacent teeth. T h e fracture was observed to have ex tended further a p i c a l l y than predicted at the i n i t i a l pres entation and a fenestration was also present. H e a l i n g o f the area was uneventful ( F i g . 4 D ) a n d the final restora tion was inserted 6 weeks after adequate healing was ob served ( F i g . 4 E ) . The preoperative r a d i o g r a p h shows that a s m a l l area
Volume 47 Number 4
Forced Eruption: Part II
207
FIGURE 4 A . A traumatic injury of the maxillary right lateral incisor produced a fracture at the level of the osseous crest. Endodontic therapy was completed and a temporary post was inserted into the prepared canal. A sectional orthodontic appliance was activated to erupt the tooth. B. Approximately 4 mm of eruption was produced. C . Periodontal surgery consisted of a full thickness flap and minimal osseous surgery. Note the root fracture and fenestration. D. Post surgical healing. E . Final restoration.
of the i n t e r p r o x i m a l osseous crest fractured in a d d i t i o n to the tooth ( F i g . 4 F ) . R a d i o g r a p h s are presented o f the active eruption ( F i g . 4 G ) and the final restoration ( F i g . 4H). Case 3 A 32-year-old female had been under treatment at the U n i v e r s i t y o f P e n n s y l v a n i a S c h o o l o f D e n t a l M e d i c i n e at w h i c h time the m a x i l l a r y left second p r e m o l a r had a large deficient restoration ( F i g . 5 A ) . T h e patient left the c l i n i c and returned to her general dentist who placed a pin-retained composite resin restoration in that tooth (Fig. 5B).
T h e patient presented to the clinic a p p r o x i m a t e l y 6 months later with a chief c o m p l a i n t o f pain in the restored tooth. T h e r a d i o g r a p h i c e x a m i n a t i o n revealed that a pin had inadvertently perforated the root and had entered the alevolar bone. ( F i g . 5 C ) . T h e soft tissue was inflamed and p r o b i n g indicated a pocket depth o f a p p r o x i m a t e l y 5 m m on the m e s i a l . T h e defect was curetted under anesthesia and a sectional orthodontic appliance was inserted in order to move the pin to a more favorable position and reduce the osseous defect ( F i g . 5 D ) . T h e tooth was erupted a p p r o x i mately 5 m m and stabilized w i t h i n the appliance for another 6 weeks ( F i g . 5 E ) .
J. Periodontol. April, 1976
2 0 8 Ingber
FIGURE 4F. Preoperative radiograph. G . Radiograph during eruption. H . Postoperative radiograph of the restoration. S u r g i c a l c o r r e c t i o n consisted o f a full thickness flap and osseous surgery ( F i g . 5 F ) . It was noted that the i n t e r p r o x i m a l and facial bone had followed the c o r o n a l m o v e m e n t o f the tooth and the perforation was now accessable. A root fenestration can be noted on the first and second p r e m o l a r s . Osseous c o r e c t i o n was l i m i t e d to leveling the " a n g u l a r crest" on the erupted tooth only and the exposed pin was reduced w i t h d i a m o n d instruments ( F i g . 5 G ) . T h e final restoration was inserted after adequate healing was observed ( F i g . 5 H ) . R a d i o g r a p h i c a l l y , changes in the area o f the alveolar crest are evident d u r i n g active eruption ( F i g . 51). T h e final p o s i t i o n o f the pin was above the crest o f bone and the defect had been e l i m i n a t e d ( F i g . 5J). A n acceptable p e r i o d o n t a l result is evident in the radiograph after
osseous surgery ( F i g . 5 K ) . T h e r a d i o g r a p h o f the final restoration indicates that the area o f the perforation has been covered by the m a r g i n o f the c r o w n ( F i g . 5 L ) . Case 4 A 19-year-old female fractured the m a x i l l a r y right lateral incisor in an a u t o m o b i l e accident. She presented to the clinic at the M e d i c a l C o l l e g e o f P e n n s y l v a n i a where endodontic therapy was administered and a tem porary restoration was placed u t i l i z i n g an endodontic reamer as a post ( F i g . 6 A ) . A sectional o r t h o d o n t i c appliance u t i l i z i n g direct bonded brackets was inserted at a subsequent visit ( F i g . 6 B ) . A p p r o x i m a t e l y 4 m m o f eruption occurred in 4 weeks at w h i c h time the appliance was used for s t a b i l i z a tion ( F i g . 6 C ) . It appears that the position o f the m u c o -
Volume 47 Number 4
Forced Eruption: Part II
209
FIGURE 5A. Preoperative radiograph showing a deficient restoration on the second premolar. B. The restoration was replaced utilizing a pin-retained composite resin. C. The radiograph of the new restoration shows that the pin has perforated the root and has entered the alveolar crest causing an osseous defect. D. A sectional orthodontic appliance was activated to erupt the tooth. E . The final tooth position after eruption and during stabilization. F . Periodontal surgery consisted of a full flap to expose the pin. Note the "angular crests" produced as a result of the tooth movement.
gingival j u n c t i o n remained stable while the zone o f gin giva has increased. T h e radiographs after eruption show that the i n t e r p r o x i m a l bone has followed the c o r o n a l movement o f the tooth ( F i g . 6 D ) . Surgery consisted o f a full thickness flap, and m i n o r osseous corrections were confined to the involved tooth ( F i g . 6 E ) . P o s t s u r g i c a l l y , it was necessary to do a gingivoplasty to correct a gingival m a r g i n that was po sitioned too far c o r o n a l l y . T h e final restoration was inserted 4 weeks after final healing had been observed ( F i g . 6 F ) . There was little residual m o b i l i t y due to a g o o d preoperative c r o w n to root ratio ( F i g . 6 G ) .
Case 5 A 14-year-old female presented to the M e d i c a l C o l l e g e of P e n n s y l v a n i a with a recent fracture o f the m a x i l l a r y left central incisor that extended to the level o f the osseous crest ( F i g . 7 A ) . E n d o d o n t i c therapy was c o m pleted as shown in the preoperative radiograph ( F i g . 7 B ) . T h i s case was selected as a pilot for a p r e l i m i n a r y study o f the effects on the gingiva d u r i n g eruptive tooth movement. Satisfactory o r a l disease c o n t r o l was never accomplished by this patient and i n f l a m m a t i o n is evident in the photographs. T a t t o o s were placed at the m u c o g i n gival m a r g i n a n d at a m i d p o i n t i n the attached gingiva. A sectional orthodontic appliance was inserted u t i l i z i n g
210
J. Periodontol. April, 1976
Ingber
FIGURE 5G. Osseous surgery was limited to the second premolar. The osseous crests were blended and the pin was reduced. H . The final restoration. I. Radiograph during active eruption. Note the activity in the region of the alveolar crest. J . Radiograph during stabilization. The pin has been placed in a more coronal position relative to the osseous crest. The bone has followed the coronal movement of the tooth and the defect has been eliminated. K . The radiograph after osseous correction and reduction of the pin. L . The final restoration.
direct bonded brackets ( F i g . 7 C ) . T h e details o f this ex periment w i l l be presented in a subsequent paper. A p p r o x i m a t e l y 3 m m o f eruption was produced in 3 m o n t h s ( F i g . 7 D ) . N o t e that the position o f the m u c o g i n g i v a l j u n c t i o n appears to have remained relatively stable while the g i n g i v a l m a r g i n followed the c o r o n a l movement of the t o o t h . T h e posteruption r a d i o g r a p h is presented in Fig. 7E. P e r i o d o n t a l surgery consisted o f a full thickness flap w h i c h revealed that the osseous crest followed the c o r o n a l m o v e m e n t o f the tooth ( F i g . 7 F ) . It was noted that the t a t t o o had penetrated the facial bone and a
fenestration was present. T h e altered osseous crests were leveled and healing was uneventful. ( F i g . 7 G ) A p r o v i s i o n a l restoration was placed to restore f o r m and function ( F i g . 7 H ) . DISCUSSION
T h e therapist should be aware that there are certain inherent c l i n i c a l c o m p r o m i s e s with forced eruption de spite its value in alleviating p r o b l e m s resulting from corrective periodontal surgery. Restorative procedures posteruption require great finesse and comprehension by the restorative dentist. A s
Volume 47 Number 4
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211
FIGURE 6D. Radiograph of the stabilized tooth after eruption. Alterations in the osseous crest are evident. E . Periodontal surgery consisted of a full flap and minor osseous corrections were made. A gingivoplasty was also part of the surgical correction. c r o w n must u l t i m a t e l y occupy ( F i g . 8). T h e illustration shows that a tooth preparation in a healthy situation, i.e., at the level o f the cemento-enamel j u n c t i o n , remains proportionate relative to the mesio-distal space. T h i s diameter is consistant with the a n a t o m i c characteristics of the i n d i v i d u a l tooth and restoration is rather u n c o m plicated. FIGURE 6 A . Preoperative radiograph of fractured tooth after endodontic therapy. An endodontic reamer was utilized to retain a temporary crown. B. A sectional orthodontic appliance was activated. Note the relative position of the mucogingival junction and the gingival margin. C . The appliance was utilized to stabilize the tooth after eruption. The position of the mucogingival junction appears to have remained stable while the gingival margin has followed the eruptive movement. a tooth is m o v e d c o r o n a l l y major a n a t o m i c changes occur within the i n d i v i d u a l tooth. G e n e r a l l y a lesser diameter root p o r t i o n is positioned into the same fixed mesio-distal space between the adjacent teeth which the
H o w e v e r , in a tooth that has been erupted the diameter of the root decreases as the preparation moves apically, while the space between the teeth remains constant ( F i g . 8B). T h e final restoration therefore, w i l l exhibit a greater degree of taper from the g i n g i v a l m a r g i n to the incisal edge and w i l l require greater attention to the g i n g i v a l areas to avoid overcontoured margins. In a d d i t i o n , tooth preparation o f the smaller root segment w i l l require m o d i f i c a t i o n i f one is to achieve a healthy blending o f restorative materials, g i n g i v a l health, and esthetics. One must also give serious consideration to the selection o f the surgical procedure i f an acceptable result
212
J. Periodontol. April, 1976
Ingber
eration in order to produce an acceptable esthetic result. The final position o f the g i n g i v a l m a r g i n is difficult to predict and is contingent on several factors: the design o f the flap, suturing technics, dressing placement, the integrity o f the facial alveolar bone a n d restorative t r a u m a . Experience with flap placement has shown that it is wise to err in a c o r o n a l d i r e c t i o n and to compensate for these contingencies with a gingivoplasty i f corrections are required after an adequate p e r i o d o f healing and stabili zation. The author has encountered a high incidence o f fenestration o f the facial bone after e r u p t i o n w h i c h m a y influence the design o f the surgical procedure. Fenestra tions that occur in close p r o x i m i t y to the m a r g i n a l bone w i l l obviously l i m i t the extent to w h i c h osseous correc tions can be made. It is difficult to k n o w whether the defect was present p r i o r to treatment or was a result o f accidental t r a u m a in the case o f a fracture, " c o n t r o l l e d " t r a u m a from the o r t h o d o n t i c therapy, o r merely ana t o m i c variations. In view o f the above findings, a p a r t i a l thickness flap m a y be indicated for the s u r g i c a l technic.
FIGURE 6F. The final restoration. G . Radiograph of the final restoration. is to be achieved. It is the author's contention that r e c o n t o u r i n g the altered osseous crest must be part o f the s u r g i c a l procedure. P o s t e r u p t i o n , the i n t e r p r o x i m a l osse ous crest w i l l exhibit a f o r m that is s i m i l a r to the c o n f i g u r a t i o n that occurs with "uneven m a r g i n a l ridges" ( R i t c h i e and O r b a n , 1953). A l t h o u g h " a n g u l a r crests" m a y not be considered infrabony defects, they m a y be unstable and have been regarded by some clinicians as areas o f potential b r e a k d o w n . A surgical blending o f the angular crests is desirable for achieving a h a r m o n i o u s g i n g i v a l result. A highly scalloped p e r i o d o n t i u m interp r o x i m a l l y m a y result in p a t h o l o g i c resorption o f the a n g u l a r crest w i t h subsequent pocket f o r m a t i o n i f they are v i o l a t e d d u r i n g the restorative procedure. T h e prob lem results when the u n i n f o r m e d dentist does not modify his tooth p r e p a r a t i o n to accomodate for these areas and c r o w n m a r g i n s are placed too deep i n t e r p r o x i m a l l y thereby i m p i n g i n g on the " b i o l o g i c w i d t h " . These rea sons w o u l d suggest that it w o u l d be prudent to level these areas d u r i n g the surgical procedure. 12
F l a p placement after osseous surgery deserves c o n s i d
The question of relapse after o r t h o d o n t i c tooth move ment has received m u c h attention in the literature. T h e " i d e a l " time interval between active tooth movement, stabilization, surgery and the final restorative procedure is difficult to assess. T h e cases presented represent periods o f stabilization that varied between 2 and 6 months p r i o r to surgical intervention. F i n a l restorative procedures were generally delayed u n t i l adequate healing was observed. R e t e n t i o n was not p r o v i d e d after insertion of the restoration and the author has concluded that c l i n i c a l l y orthodontic relapse is not a serious considera t i o n . It m a y be speculated that relapse d i d not occur due to the period o f stabilization and the surgical procedure which i n v a r i a b l y severed the gingival fibers. In a d d i t i o n , it is generally accepted that an eruptive type o f tooth movement produces the least a m o u n t o f o r t h o d o n t i c relapse. C o n c e p t u a l l y it can be demonstrated that the c r o w n to root ratio m a y r e m a i n v i r t u a l l y unchanged or possibly i m p r o v e i f c o m p a r e d to conventional treatment meth ods ( F i g . 9). I f a tooth w i t h a preoperative C / R ratio of 4 to 5 is fractured necessitating r e m o v a l o f one unit o f bone to expose tooth structure, the postsurgical C / R ratio w i l l be 5:4. H o w e v e r , i f the tooth is erupted 1 unit, and surgery returns the osseous level to the preoperative state, the C / R ratio w i l l change to 4 to 4 because the c l i n i c a l c r o w n is also shortened by one unit to a c c o m o date the eruptive tooth movement. M o b i l i t y patterns after treatment show considerable v a r i a t i o n depending upon the a n a t o m i c characteristics o f the root as well as the a m o u n t o f eruption; obviously a longer, g r a d u a l l y tapering root is a better candidate for forced eruption. M o b i l i t y patterns i n v a r i a b l y appeared to be greater than the c o n t r a l a t e r a l t o o t h . H o w e v e r , the residual m o b i l i t y that w o u l d be present after any f o r m o f therapy has not c o m p r o m i s e d function. T h e c l i n i c i a n should m i n i m i z e the influence o f t r a u m a associated w i t h
Volume 47 Number 4
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213
FIGURE 7A. Fractured central incisor. B. Preoperative radiograph after endodontic therapy. C . A temporary post was cemented in order to attach an orthodontic bracket. Tattoos were placed as part of a pilot study. D. Approximately 3 mm of eruption was produced in 3 months. Note that the mucogingival tattoo has remained relatively stable while the tattoo at the gingival margin has moved coronally. E. Radiograph after eruption. Arrows indicate the position of the cemento-enamel junction and interproximal bone.
214
J. Periodontol. April, 1976
Ingber
E n d o d o n t i c treatment o f the r e m a i n i n g root segment was never accomplished under sterile conditions due to the i m p o s s i b i l i t y o f m a i n t a i n i n g a d r y operating field. Retreatment due to new or persistent p e r i a p i c a l p a t h o l ogy has not been encountered with this sample p o p u l a tion. A
significant
question
at
this
time
concerns
the
influence o f eruptive tooth movement on the w i d t h o f attached gingiva and the stability o f the m u c o g i n g i v a l j u n c t i o n ( F i g . 1 0 A ) . A n investigation is in progress to determine the relation o f the amount o f root e r u p t i o n ( C ) necessary to produce alterations i n the g i n g i v a l m a r g i n (B) in relation to the m u c o g i n g i v a l j u n c t i o n ( A ) .
1 3
It is
not clear whether there is an increase i n the w i d t h o f the attached gingiva which w o u l d result i f the m u c o g i n g i v a l j u n c t i o n remained stable as suggested by Batenherst ( F i g . 10B) or whether the m u c o g i n g i v a l j u n c t i o n moves c o r o n a l with the g i n g i v a l m a r g i n m a i n t a i n i n g the o r i g i n a l width o f gingiva ( F i g . IOC). T h e cases presented tend to suggest that the
m u c o g i n g i v a l j u n c t i o n does
remain
stable. Teeth that are erupted in the presence o f soft tissue pocket depth appear to move c o r o n a l l y for a considerable distance before the g i n g i v a l m a r g i n follows. C o n c u r rently the pocket depth is reduced and an
immature-
appearing tissue appears c o r o n a l to the o r i g i n a l g i n g i v a l m a r g i n . It has been suggested that the increase in g i n g i v a in this case m a y be due to an inversion o f the pocket
F I G U R E 7F. The elevated flap showing the altered osseous crests. The coronal shift of the facial and interproximal bone is clearly visible. The tattoo penetrated the facial bone and a fenestration is present. G . Postsurgical healing. H . The provi sional restoration.
n o r m a l function or parafunctional habits by reducing heavy contacts i n m a x i m u m intercuspation and excur sions. T h e o r t h o d o n t i c mechano-therapy varied in m a n y o f the cases that were treated by forced eruption. Interarch elastics were generally unsuccessful due to a lack o f patient c o o p e r a t i o n and inadequate c o n t r o l o f forces. A c o r o n a l movement o f the root segment was difficult to achieve with interarch elastics and quite often buccal or l i n g u a l forces developed. T h e use o f direct bonded attachments u t i l i z i n g segmented arch wires was very successful and reduced the mechano-therapy to rather simple procedures.
F I G U R E 8A. Tooth preparation at the level of the CEJ: the diameter of the preparation is proportionate relative to the fixed amount of space between the teeth. This relationship is constant with the anatomical characteristics of the tooth and restoration is uncomplicated. B. Tooth preparation after erup tion further apically: the diameter of the preparation is small relative to the fixed amount of space between the teeth. This relationship is not constant with normal anatomy and restora tion will require greater attention.
Volume 47 Number 4
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215
FIGURE 9. Conceptualization of the relative crown to root ratios (C/R) with osseous surgery and forced eruption: A preoperative C/R of 4:5 would be reduced to 5:4 if one unit of bone was removed to expose tooth structure. Surgery after forced eruption will also reduce the bone by one unit: however the clinical crown will also be reduced by one unit to accomodate the eruption with a resultant C/R of 4:4.
FIGURE 10A. The effect on the mucogingival junction (A) and gingival margin (B) relative to a coronal shift of the tooth (C). B. Eruption of the tooth may produce a coronal shift of the marginal gingival alone which would increase the zone of gingiva. The dotted line indicates the preoperative gingival margin. C. Eruption of the tooth may produce a coronal shift of the mucogingival junction and the marginal gingiva, therefore, the zone of gingiva would remain constant. The dotted lines indicate the preoperative position of the mucogingival junction and the gingival margin.
216
J. Periodontol. April, 1976
Ingber 6
l i n i n g . T h i s nonkeratinized tissue remains erythematous for a considerable period o f t i m e until it assumes the a p p e a r a n c e o f the surrounding gingiva. SUMMARY
In selected cases, forced eruption m a y be a useful a p p r o a c h i n treating isolated nonrestorable teeth as a result o f t r a u m a , caries, o r iatrogenic dentistry. T h i s paper has presented the biologic rationale, objec tives, technics a n d c l i n i c a l cases to demonstrate the p r i n c i p l e . E v a l u a t i o n has been made o f potential difficul ties w h i c h m a y develop with the technic and areas for future research have been identified. ACKNOWLEDGMENT
The author wishes to acknowledge the following for their assistance in the preparation of this manuscript: Bruce Apfelbaum, D . M . D . , D. Walter Cohen, D.D.S., Louis Rose, D.D.S., M . D . , Harvey Wank, D . M . D . , Edwin Slade, D . M . D . , and M s . Patricia A . Scherer. REFERENCES
1. Andreason, J . D., and Hjirting, E.: Intra-alveolar root fractures: Radiographic and histologic study of 50 cases. J Oral Surg 25: 414, 1967. 2. Ingber, Jeffrey S.: Forced eruption: Part I. A method of
treating isolated one and two wall infrabony osseous defects— rational and case report. J Periodontol 45: 199, 1974. 3. Heithersay, Geoffrey S.: Combined endodontic—ortho dontic treatment of transverse root fractures in the region of the alveolar crest. Oral Surg 36: 404, 1973. 4. Reitan, K.: Clinical and histologic observations on tooth movement during and after orthodontic treatment. Amer J Orthod 53: 721, 1967. 5. Oppenheim, A . : Artificial elongation of teeth. Am J Orthod Oral Surg 26: 931, 1940. 6. Brown, I. Stephen: The effect orthodontic therapy on certain types of periodontal defects. I—Clinical findings. J Periodontol 44: 742, 1973. 7. Athertori, J . D . , and Kerr, N . W . : Effect of orthodontic tooth movement upon the gingivae. Br Dent J 124: 555, 1968. 8. Atherton, J . D.: The gingival response to orthodontic tooth movement. Am J Orthod 58: 179, 1970. 9. Edwards, J . G . : A study of the periodontium during orthodontic rotation of teeth. Am J Orthod 54: 441, 1968. 10. Edwards, J . G . : A surgical procedure to eliminate rotational relapse. Am J Orthod 57: 35, 1970. 11. Batenhorst, K . F., Bowers, G . M . , and Williams, J . E . : Tissue changes resulting from facial tipping and extrusion of in cisors in monkeys. J Periodontol 45: 660, 1974. 12. Amsterdam, M . , and Corn, H . : Graduate Seminar Series, University of Pennsylvania School of Dental Medicine, 1969-1972. 13. Apfelbaum, B . , Ingber, J . S., et al: Forced eruption: Part III. A Quantitative Study of the Clinical Crown and its Associated Attached Gingiva. In Progress.
Abstracts
T H E E A R L Y ESTABLISHMENT OF Streptococcus Mutans IN T H E M O U T H OF INFANTS
A BIOCHEMICAL S T U D Y OF T H E ORIGIN OF ARGININE AMINOPEPTIDASES IN H U M A N GINGIVAL F L U I D
Berkowitz, R. J., Jordan, H . V., and White G. Arch Oral Biol 20: 171, March, 1975.
Makinen, K. K., and Hyyppa, T. Arch Oral Biol 20: 509, August, 1975.
Using a selective medium, Streptococcus mutans was cultured from swab samples from the alveolar ridges, buccal mucosa and tongue of infants 3 weeks to 14 months of age. Of 138 subjects, 91 normal infants showed no Streptococcus mutans, but it was found in two of 10 cases of cleft palate infants with acrylic obturators. Nine of 40 infants with erupted incisors demonstrated Streptococcus mutans in their plaques. Representative Streptococcus mutans isolated from nine mother-child pairs were characterized serologically. Type c was the most common maternal serotype but other maternal types included b, d, E strains. All infant isolates were serotype c. Later samples were of the b sero type. Harvard School of Dental Medicine, Boston, Massachusetts
Gingival fluid and whole saliva were collected from healthy persons between 20 to 40 years of age. The oral hygiene and tissue condition were classed according to state. The sources of the enzymes hydrolysing N-L-arginyl-2-naphthylamine in gingival fluid was determined by fractionation qualities of the enzymes on Sephadex G-100 Superfine columns. It was stated that the probable sources of the enzymes were the serum or plaque, or cellular elements of the blood. There was little evidence that the enzymes are derived from plaque or whole mouth saliva. It was also shown that healthy tissue produced more enzyme than implanted tissue. Institute of Dentistry, University of Turku, SF-20502, Turku 52, Finland
Forced Eruption: Part II. A Method of Treating Nonrestorable Teeth— Periodontal and Restorative Considerations*
et a l . , 1960) 3. access for impression technics 4. c o n t r o l o f hemorrhage 5. maintenance o f p e r i o d o n t a l health 6. restoration o f function 7. esthetics T r a d i t i o n a l l y two methods are available to manage a fracture at the level o f the gingival m a r g i n . These include: (1) extraction o f the r e m a i n i n g root and
by
subsequent
replacement with a fixed prosthesis or (2) exposure o f sound tooth structure by p e r i o d o n t a l surgery.
J E F F R E Y S. I N G B E R , D . D . s . t
S u r g i c a l exposure o f sound tooth structure is fraught with A N I S O L A T E D nonrestorable tooth m a y be defined as that
c o m p r o m i s e especially in the
anterior
segment
where esthetics is a consideration. G i n g i v a l and osseous
c l i n i c a l c o n d i t i o n in which disease, t r a u m a or iatrogene-
surgery cannot be l i m i t e d to the involved tooth and must
sis
be extended to adjacent
has destroyed the c l i n i c a l c r o w n , c o m p r o m i s i n g or
teeth
in order to blend the
m a k i n g restoration impossible. C a r i e s , accidents, contact
gingival and osseous contours. T h e ultimate result is a
sports, large restorations, n o n v i t a l teeth and the over-
sacrifice
zealous use of restorative pins are but a few o f the
sensitivity, and esthetic deformities in the form o f long
etiologic factors that m a y contribute to the loss o f the
c l i n i c a l crowns and open embrasures.
tooth. C l i n i c a l treatment is further c o m p l i c a t e d due to and
only
manage
o f involvement in the
arch and
bone
on
several teeth,
root
F o r c e d eruption has been suggested in the periodontal
the characteristic isolation of the tooth, i.e., when it is the area
o f supporting
adjacent
structures are either physiologic, show m i n i m u m perio
endodontic literature as an alternative method to
crest.
2,
root fractures
in the
region o f the alveolar
3
d o n t a l changes or require m i n o r restorative procedures. RATIONALE OF F O R C E D ERUPTION
Esthetics plays a major role when the loss o f tooth structure involves the anterior teeth which m a y alter or
The m e c h a n i c a l procedure o f accelerating the eruption of a tooth produces a c o m p l i m e n t a r y alteration o f the gingival and supporting tissues. R e i t a n and o t h e r s have demonstrated that eruptive tooth movement results in a stretching o f the gingival and p e r i o d o n t a l fibers which produces a c o r o n a l shift o f gingiva and bone. A t h e r t o n and K e r r have investigated the c l i n i c a l and histological effects o f orthodontic movements on gingiva in animals and humans. T h i s study indicates distinct
l i m i t our ability to restore form and function. The
THERAPY
object o f this paper is to present the biologic
4 , 5 , 6
r a t i o n a l and c l i n i c a l d o c u m e n t a t i o n which demonstrate the potential of forced eruption as a useful technic to manage the isolated nonrestorable tooth.
7 , 8
R E V I E W OF TRADITIONAL T R E A T M E N T
METHODS
The treatment o f fractured roots where the c o r o n a l segment has not been lost has been reported successful i f the m o b i l e segment is reduced and stabilized. Fractures o c c u r i n g in the m i d d l e and a p i c a l t h i r d o f the root have been shown to heal by b r i d g i n g with either a callus, connective tissue, or bone surrounded by connective tissue ( F i g . 1). 1
W h e n the fracture occurs in the m i d d l e or incisal third of the c r o w n and there is adequate tooth structure available, newer restorative technics such as pins, posts, telescopes and composite resins are usually sufficient to restore form and function. H o w e v e r , i f the loss o f tooth structure occurs at the g i n g i v a l m a r g i n or below the crest of bone, exposure o f sound tooth structure becomes p a r a m o u n t i f we are to achieve the following objectives: 1. P l a c e m e n t o f m a r g i n s on sound tooth structure FIGURE 1. Fracture sites versus treatment options. A and B: Root fractures may be stabilized and successful healing is possible by bridging with a callus, connective tissue, or bone and connective tissue. C : Fractures at the level of cementoenamel junction (CEJ) have been treated by periodontal surgery or forced eruption and subsequent restoration. D: Fractured crowns may be treated by standard restorative technics.
* Presented at the Clinical Research Forum of the Philadelphia Society of Periodontology, January, 1975. † Assistant Professor, Department of Form & Function of the Masticatory System, University of Pennsylvania School of Dental Medicine, 4001 Spruce Street, Phila., Pa. 19174; Assistant Clinical Professor, Department of Dental Medicine, Medical College of Penn sylvania.
203
204
J. Periodontol. April, 1976
Ingber
areas o f new gingiva on the m e s i a l o f a tooth that had been
moved distally. E d w a r d s ,
manage
the
9 , 1 0
i n an attempt
Results o f this experiment led to the conclusion that as a
to
tooth is erupted, the gingiva and alveolar crest w i l l follow
p r o b l e m of o r t h o d o n t i c relapse, studied
and the resultant change in p o s i t i o n o f the soft tissue is
g i n g i v a l changes by u t i l i z i n g tattoos that were placed in
not due to a displacement o f the m u c o g i n g i v a l j u n c t i o n
the g i n g i v a l tissues p r i o r to r o t a t i o n a l orthodontic move
but rather to an increase in the zone o f attached gingiva.
ment. T h e vertically-placed tattoos deviated in the direc tion o f the r o t a t i o n in a l l cases and he concluded that
U t i l i z i n g the results o f these studies and
applying
established orthodontic principles, we m a y hypothesize
"the attached g i n g i v a , especially the m a r g i n a l gingiva, is
that when a root segment is o r t h o d o n t i c a l l y erupted, the
indeed pulled a l o n g w i t h the tooth as it is rotated".
gingiva and supporting structures w i l l follow to a p o s i t i o n
Batenherst
11
investigated the effects on hard and soft
that is further
c o r o n a l than the adjacent
teeth.
The
tissues when teeth are tipped facially in m o n k e y s . T h e
therapist can utilize these g i n g i v a l and osseous changes to
author noted that unexpected extrusion occurred d u r i n g
his c l i n i c a l advantage in order to manage the restorative
the p e r i o d o f s t a b i l i z a t i o n , and measurements c o n f i r m e d
problem.
that the w i d t h o f the attached gingiva increased while the
C o n s i d e r the hypothetical situation as illustrated in
p o s i t i o n o f the m u c o g i n g i v a l j u n c t i o n remained stable.
Figures 2 A through J . A fracture that occurs at the level
FIGURE 2 A . A crown fractured at the level of the gingival or osseous margin necessitates periodontal surgery to expose sound tooth structure for an adequate restoration. B. Osseous surgery results in a sacrifice of bone on adjacent teeth and esthetic deformities may result. C . The final restoration after surgery may produce long clinical crowns and open embrasures. D . A sectional orthodontic appliance is activated by engaging a temporary post that has been cemented in the prepared root canal. E . The gingival margin and root segment have been erupted to a position further coronal relative to the adjacent teeth. The dotted line represents the position of preoperative gingival margin. F . Periodontal surgery is employed after a period of stabilization to reposition the gingival complex to approximate the preoperative state at a level constant with the adjacent teeth. G . A flap is elevated illustrating that the osseous margin has followed the coronal movement of the teeth. Note the "angular crests". H . The "angular crests" are corrected which exposes sound tooth structure without sacrificing bone on the adjacent teeth. I. The Jlap is sutured to approximate the gingival margins on the adjacent teeth. J . The final restoration is placed producing acceptable esthetics.
Volume 47 Number 4
Forced Eruption: Part II
205
of the alveolar bone presents the c l i n i c i a n with a difficult
eruption is initiated after endodontic therapy is complete
p r o b l e m ( F i g . 2 A ) . R e s t o r a t i o n o f f o r m and function
in order to reposition the root segment coronally. A
would necessitate extraction o f the r e m a i n i n g root seg
segmented o r t h o d o n t i c appliance is inserted to engage a
ment and subsequent
t e m p o r a r y post that has been cemented in the prepared
tooth replacement with a fixed
prosthesis or p e r i o d o n t a l surgery to expose sound tooth
root c a n a l ( F i g . 2 D ) . T h e gingival m a r g i n and
structure c o r o n a l to the osseous crest ( F i g . 2 B ) . P e r i o
segment have been erupted to a position more c o r o n a l in
d o n t a l surgery generally results in the loss o f supporting
relation
bone on the involved root segment as well as adjacent
p e r i o d o n t a l surgery m a y now be performed by elevating
teeth resulting in an esthetic d e f o r m i t y ( F i g . 2 C ) . F o r c e d
a flap to expose the u n d e r l y i n g structures ( F i g . 2 F ) . T h e
to the
adjacent
teeth
root
(Fig. 2E). Corrective
FIGURE 3A. The maxillary left central incisor was fractured as a result of trauma. The tooth was prepared for a full crown restoration. B. A root fracture on the lingual aspect extended approximately 5 mm below the gingival margin. C . A metal band temporary restoration was cemented. A sectional appliance was bonded directly to the teeth and activated. Note the relative positions of the mucogingival junction and gingival margin. D . Approximately 4 mm of eruption was obtained in 6 weeks at which time the tooth was stabilized in the appliance. It appears that the position of the mucogingival junction has remained relatively stable while the gingival margin has moved coronally. E . A full thickness flat was elevated to reposition the gingival margin apically to approximate the adjacent teeth. A gingivoplasty was performed on the palatal to expose the fracture. Osseous corrections were not made in this case. F . The final restoration was inserted and adjusted to minimize occlusal stress.
206
J. Periodontol. April, 1976
Ingber
FIGURE 3G. Preoperative radiograph. H . Postoperative osseous
crest
has been
radiograph.
shown to have followed the
with the adjacent teeth. N o attempt at osseous c o r r e c t i o n
c o r o n a l m o v e m e n t o f the tooth ( F i g . 2 G ) and osseous
was made. T h e o r t h o d o n t i c appliance was removed after
surgery is i n i t i a t e d with the objective o f exposing sound
final healing ( F i g . 3 E ) .
t o o t h structure o n the involved root segment ( F i g . 2 H ) . The
soft tissue is sutured to blend with the existing
The tooth was reprepared a n d a p r o v i s i o n a l c r o w n was placed that extended beyond the l i n g u a l fracture. T h e
g i n g i v a l m a r g i n s consistent with the adjacent teeth to
final restoration was inserted and adjusted to m i n i m i z e
produce an acceptable esthetic result ( F i g . 21).
occlusal stress. ( F i g . 3 F )
P o s t o p e r a t i v e l y , an acceptable
restoration is fabri
The
preoperative r a d i o g r a p h shows the t r a u m a t i z e d
cated w h i c h satisfies the p e r i o d o n t a l , restorative and es
central incisor has a short, tapered root relative to the
thetic requirements o f the case ( F i g . 2 J ) .
lateral incisor ( F i g . 3 G ) . T h e r a d i o g r a p h o f the final restoration
CASE
REPORTS
reveals a thickened p e r i o d o n t a l ligament
space. ( F i g . 3 H ) T h e residual m o b i l i t y that was present
Case I
after treatment d i d not affect the functional requirements
T h e patient is a 24-year-old female with a history o f t r a u m a to the m a x i l l a r y left central incisor ( F i g . 3 A ) . E n d o d o n t i c s and a t e m p o r a r y c r o w n were placed by her general dentist w h o referred her to the M e d i c a l C o l l e g e of P e n n s y l v a n i a for further evaluation and treatment. T h e patient had lost the t e m p o r a r y c r o w n p r i o r to the i n i t i a l presentation and the c l i n i c a l e x a m i n a t i o n revealed a large v e r t i c a l root fracture on the l i n g u a l that extended a p p r o x i m a t e l y 5 m m below the g i n g i v a l m a r g i n ( F i g . 3B).
of this case.
A m e t a l a n d a c r y l i c p r o v i s i o n a l c r o w n was placed for esthetic purposes and a sectional o r t h o d o n t i c appliance was inserted w h i c h utilized direct bonded brackets ( F i g . 3C). T h e tooth was erupted a p p r o x i m a t e l y 4 m m in 6 weeks and was stabilized i n the appliance for an a d d i t i o n a l 8 weeks ( F i g . 3 D ) . T h e c l i n i c a l c r o w n was shortened to a c c o m m o d a t e the e r u p t i o n . N o t e that after the eruption the relative p o s i t i o n o f the m u c o g i n g i v a l j u n c t i o n re m a i n e d stable while the g i n g i v a l m a r g i n has m o v e d in a coronal direction. T h e s u r g i c a l a p p r o a c h consisted o f a full thickness flap to reposition the gingival m a r g i n at a level consistent
Case 2 A 16-year-old female presented for treatment with a t r a u m a t i c fracture o f the m a x i l l a r y right lateral incisor ( F i g . 4 A ) . E n d o d o n t i c therapy was completed and a tem porary post with a facial offset was cemented i n the pre pared canal. A sectional o r t h o d o n t i c appliance u t i l i z ing direct bonded brackets was activated to erupt the tooth. A p p r o x i m a t e l y 4 m m o f eruption was produced d u r i n g 5 weeks o f o r t h o d o n t i c treatment ( F i g . 4 B ) . T h e tooth was stabilized for a p p r o x i m a t e l y 8 weeks i n the passive appliance prior to corrective p e r i o d o n t a l surgery which consisted o f a full thickness flap to expose the root segment (Figure 4 C ) . Slight osseous corrections were made and the flap was repositioned consistent w i t h the adjacent teeth. T h e fracture was observed to have ex tended further a p i c a l l y than predicted at the i n i t i a l pres entation and a fenestration was also present. H e a l i n g o f the area was uneventful ( F i g . 4 D ) a n d the final restora tion was inserted 6 weeks after adequate healing was ob served ( F i g . 4 E ) . The preoperative r a d i o g r a p h shows that a s m a l l area
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FIGURE 4 A . A traumatic injury of the maxillary right lateral incisor produced a fracture at the level of the osseous crest. Endodontic therapy was completed and a temporary post was inserted into the prepared canal. A sectional orthodontic appliance was activated to erupt the tooth. B. Approximately 4 mm of eruption was produced. C . Periodontal surgery consisted of a full thickness flap and minimal osseous surgery. Note the root fracture and fenestration. D. Post surgical healing. E . Final restoration.
of the i n t e r p r o x i m a l osseous crest fractured in a d d i t i o n to the tooth ( F i g . 4 F ) . R a d i o g r a p h s are presented o f the active eruption ( F i g . 4 G ) and the final restoration ( F i g . 4H). Case 3 A 32-year-old female had been under treatment at the U n i v e r s i t y o f P e n n s y l v a n i a S c h o o l o f D e n t a l M e d i c i n e at w h i c h time the m a x i l l a r y left second p r e m o l a r had a large deficient restoration ( F i g . 5 A ) . T h e patient left the c l i n i c and returned to her general dentist who placed a pin-retained composite resin restoration in that tooth (Fig. 5B).
T h e patient presented to the clinic a p p r o x i m a t e l y 6 months later with a chief c o m p l a i n t o f pain in the restored tooth. T h e r a d i o g r a p h i c e x a m i n a t i o n revealed that a pin had inadvertently perforated the root and had entered the alevolar bone. ( F i g . 5 C ) . T h e soft tissue was inflamed and p r o b i n g indicated a pocket depth o f a p p r o x i m a t e l y 5 m m on the m e s i a l . T h e defect was curetted under anesthesia and a sectional orthodontic appliance was inserted in order to move the pin to a more favorable position and reduce the osseous defect ( F i g . 5 D ) . T h e tooth was erupted a p p r o x i mately 5 m m and stabilized w i t h i n the appliance for another 6 weeks ( F i g . 5 E ) .
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FIGURE 4F. Preoperative radiograph. G . Radiograph during eruption. H . Postoperative radiograph of the restoration. S u r g i c a l c o r r e c t i o n consisted o f a full thickness flap and osseous surgery ( F i g . 5 F ) . It was noted that the i n t e r p r o x i m a l and facial bone had followed the c o r o n a l m o v e m e n t o f the tooth and the perforation was now accessable. A root fenestration can be noted on the first and second p r e m o l a r s . Osseous c o r e c t i o n was l i m i t e d to leveling the " a n g u l a r crest" on the erupted tooth only and the exposed pin was reduced w i t h d i a m o n d instruments ( F i g . 5 G ) . T h e final restoration was inserted after adequate healing was observed ( F i g . 5 H ) . R a d i o g r a p h i c a l l y , changes in the area o f the alveolar crest are evident d u r i n g active eruption ( F i g . 51). T h e final p o s i t i o n o f the pin was above the crest o f bone and the defect had been e l i m i n a t e d ( F i g . 5J). A n acceptable p e r i o d o n t a l result is evident in the radiograph after
osseous surgery ( F i g . 5 K ) . T h e r a d i o g r a p h o f the final restoration indicates that the area o f the perforation has been covered by the m a r g i n o f the c r o w n ( F i g . 5 L ) . Case 4 A 19-year-old female fractured the m a x i l l a r y right lateral incisor in an a u t o m o b i l e accident. She presented to the clinic at the M e d i c a l C o l l e g e o f P e n n s y l v a n i a where endodontic therapy was administered and a tem porary restoration was placed u t i l i z i n g an endodontic reamer as a post ( F i g . 6 A ) . A sectional o r t h o d o n t i c appliance u t i l i z i n g direct bonded brackets was inserted at a subsequent visit ( F i g . 6 B ) . A p p r o x i m a t e l y 4 m m o f eruption occurred in 4 weeks at w h i c h time the appliance was used for s t a b i l i z a tion ( F i g . 6 C ) . It appears that the position o f the m u c o -
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FIGURE 5A. Preoperative radiograph showing a deficient restoration on the second premolar. B. The restoration was replaced utilizing a pin-retained composite resin. C. The radiograph of the new restoration shows that the pin has perforated the root and has entered the alveolar crest causing an osseous defect. D. A sectional orthodontic appliance was activated to erupt the tooth. E . The final tooth position after eruption and during stabilization. F . Periodontal surgery consisted of a full flap to expose the pin. Note the "angular crests" produced as a result of the tooth movement.
gingival j u n c t i o n remained stable while the zone o f gin giva has increased. T h e radiographs after eruption show that the i n t e r p r o x i m a l bone has followed the c o r o n a l movement o f the tooth ( F i g . 6 D ) . Surgery consisted o f a full thickness flap, and m i n o r osseous corrections were confined to the involved tooth ( F i g . 6 E ) . P o s t s u r g i c a l l y , it was necessary to do a gingivoplasty to correct a gingival m a r g i n that was po sitioned too far c o r o n a l l y . T h e final restoration was inserted 4 weeks after final healing had been observed ( F i g . 6 F ) . There was little residual m o b i l i t y due to a g o o d preoperative c r o w n to root ratio ( F i g . 6 G ) .
Case 5 A 14-year-old female presented to the M e d i c a l C o l l e g e of P e n n s y l v a n i a with a recent fracture o f the m a x i l l a r y left central incisor that extended to the level o f the osseous crest ( F i g . 7 A ) . E n d o d o n t i c therapy was c o m pleted as shown in the preoperative radiograph ( F i g . 7 B ) . T h i s case was selected as a pilot for a p r e l i m i n a r y study o f the effects on the gingiva d u r i n g eruptive tooth movement. Satisfactory o r a l disease c o n t r o l was never accomplished by this patient and i n f l a m m a t i o n is evident in the photographs. T a t t o o s were placed at the m u c o g i n gival m a r g i n a n d at a m i d p o i n t i n the attached gingiva. A sectional orthodontic appliance was inserted u t i l i z i n g
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FIGURE 5G. Osseous surgery was limited to the second premolar. The osseous crests were blended and the pin was reduced. H . The final restoration. I. Radiograph during active eruption. Note the activity in the region of the alveolar crest. J . Radiograph during stabilization. The pin has been placed in a more coronal position relative to the osseous crest. The bone has followed the coronal movement of the tooth and the defect has been eliminated. K . The radiograph after osseous correction and reduction of the pin. L . The final restoration.
direct bonded brackets ( F i g . 7 C ) . T h e details o f this ex periment w i l l be presented in a subsequent paper. A p p r o x i m a t e l y 3 m m o f eruption was produced in 3 m o n t h s ( F i g . 7 D ) . N o t e that the position o f the m u c o g i n g i v a l j u n c t i o n appears to have remained relatively stable while the g i n g i v a l m a r g i n followed the c o r o n a l movement of the t o o t h . T h e posteruption r a d i o g r a p h is presented in Fig. 7E. P e r i o d o n t a l surgery consisted o f a full thickness flap w h i c h revealed that the osseous crest followed the c o r o n a l m o v e m e n t o f the tooth ( F i g . 7 F ) . It was noted that the t a t t o o had penetrated the facial bone and a
fenestration was present. T h e altered osseous crests were leveled and healing was uneventful. ( F i g . 7 G ) A p r o v i s i o n a l restoration was placed to restore f o r m and function ( F i g . 7 H ) . DISCUSSION
T h e therapist should be aware that there are certain inherent c l i n i c a l c o m p r o m i s e s with forced eruption de spite its value in alleviating p r o b l e m s resulting from corrective periodontal surgery. Restorative procedures posteruption require great finesse and comprehension by the restorative dentist. A s
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FIGURE 6D. Radiograph of the stabilized tooth after eruption. Alterations in the osseous crest are evident. E . Periodontal surgery consisted of a full flap and minor osseous corrections were made. A gingivoplasty was also part of the surgical correction. c r o w n must u l t i m a t e l y occupy ( F i g . 8). T h e illustration shows that a tooth preparation in a healthy situation, i.e., at the level o f the cemento-enamel j u n c t i o n , remains proportionate relative to the mesio-distal space. T h i s diameter is consistant with the a n a t o m i c characteristics of the i n d i v i d u a l tooth and restoration is rather u n c o m plicated. FIGURE 6 A . Preoperative radiograph of fractured tooth after endodontic therapy. An endodontic reamer was utilized to retain a temporary crown. B. A sectional orthodontic appliance was activated. Note the relative position of the mucogingival junction and the gingival margin. C . The appliance was utilized to stabilize the tooth after eruption. The position of the mucogingival junction appears to have remained stable while the gingival margin has followed the eruptive movement. a tooth is m o v e d c o r o n a l l y major a n a t o m i c changes occur within the i n d i v i d u a l tooth. G e n e r a l l y a lesser diameter root p o r t i o n is positioned into the same fixed mesio-distal space between the adjacent teeth which the
H o w e v e r , in a tooth that has been erupted the diameter of the root decreases as the preparation moves apically, while the space between the teeth remains constant ( F i g . 8B). T h e final restoration therefore, w i l l exhibit a greater degree of taper from the g i n g i v a l m a r g i n to the incisal edge and w i l l require greater attention to the g i n g i v a l areas to avoid overcontoured margins. In a d d i t i o n , tooth preparation o f the smaller root segment w i l l require m o d i f i c a t i o n i f one is to achieve a healthy blending o f restorative materials, g i n g i v a l health, and esthetics. One must also give serious consideration to the selection o f the surgical procedure i f an acceptable result
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eration in order to produce an acceptable esthetic result. The final position o f the g i n g i v a l m a r g i n is difficult to predict and is contingent on several factors: the design o f the flap, suturing technics, dressing placement, the integrity o f the facial alveolar bone a n d restorative t r a u m a . Experience with flap placement has shown that it is wise to err in a c o r o n a l d i r e c t i o n and to compensate for these contingencies with a gingivoplasty i f corrections are required after an adequate p e r i o d o f healing and stabili zation. The author has encountered a high incidence o f fenestration o f the facial bone after e r u p t i o n w h i c h m a y influence the design o f the surgical procedure. Fenestra tions that occur in close p r o x i m i t y to the m a r g i n a l bone w i l l obviously l i m i t the extent to w h i c h osseous correc tions can be made. It is difficult to k n o w whether the defect was present p r i o r to treatment or was a result o f accidental t r a u m a in the case o f a fracture, " c o n t r o l l e d " t r a u m a from the o r t h o d o n t i c therapy, o r merely ana t o m i c variations. In view o f the above findings, a p a r t i a l thickness flap m a y be indicated for the s u r g i c a l technic.
FIGURE 6F. The final restoration. G . Radiograph of the final restoration. is to be achieved. It is the author's contention that r e c o n t o u r i n g the altered osseous crest must be part o f the s u r g i c a l procedure. P o s t e r u p t i o n , the i n t e r p r o x i m a l osse ous crest w i l l exhibit a f o r m that is s i m i l a r to the c o n f i g u r a t i o n that occurs with "uneven m a r g i n a l ridges" ( R i t c h i e and O r b a n , 1953). A l t h o u g h " a n g u l a r crests" m a y not be considered infrabony defects, they m a y be unstable and have been regarded by some clinicians as areas o f potential b r e a k d o w n . A surgical blending o f the angular crests is desirable for achieving a h a r m o n i o u s g i n g i v a l result. A highly scalloped p e r i o d o n t i u m interp r o x i m a l l y m a y result in p a t h o l o g i c resorption o f the a n g u l a r crest w i t h subsequent pocket f o r m a t i o n i f they are v i o l a t e d d u r i n g the restorative procedure. T h e prob lem results when the u n i n f o r m e d dentist does not modify his tooth p r e p a r a t i o n to accomodate for these areas and c r o w n m a r g i n s are placed too deep i n t e r p r o x i m a l l y thereby i m p i n g i n g on the " b i o l o g i c w i d t h " . These rea sons w o u l d suggest that it w o u l d be prudent to level these areas d u r i n g the surgical procedure. 12
F l a p placement after osseous surgery deserves c o n s i d
The question of relapse after o r t h o d o n t i c tooth move ment has received m u c h attention in the literature. T h e " i d e a l " time interval between active tooth movement, stabilization, surgery and the final restorative procedure is difficult to assess. T h e cases presented represent periods o f stabilization that varied between 2 and 6 months p r i o r to surgical intervention. F i n a l restorative procedures were generally delayed u n t i l adequate healing was observed. R e t e n t i o n was not p r o v i d e d after insertion of the restoration and the author has concluded that c l i n i c a l l y orthodontic relapse is not a serious considera t i o n . It m a y be speculated that relapse d i d not occur due to the period o f stabilization and the surgical procedure which i n v a r i a b l y severed the gingival fibers. In a d d i t i o n , it is generally accepted that an eruptive type o f tooth movement produces the least a m o u n t o f o r t h o d o n t i c relapse. C o n c e p t u a l l y it can be demonstrated that the c r o w n to root ratio m a y r e m a i n v i r t u a l l y unchanged or possibly i m p r o v e i f c o m p a r e d to conventional treatment meth ods ( F i g . 9). I f a tooth w i t h a preoperative C / R ratio of 4 to 5 is fractured necessitating r e m o v a l o f one unit o f bone to expose tooth structure, the postsurgical C / R ratio w i l l be 5:4. H o w e v e r , i f the tooth is erupted 1 unit, and surgery returns the osseous level to the preoperative state, the C / R ratio w i l l change to 4 to 4 because the c l i n i c a l c r o w n is also shortened by one unit to a c c o m o date the eruptive tooth movement. M o b i l i t y patterns after treatment show considerable v a r i a t i o n depending upon the a n a t o m i c characteristics o f the root as well as the a m o u n t o f eruption; obviously a longer, g r a d u a l l y tapering root is a better candidate for forced eruption. M o b i l i t y patterns i n v a r i a b l y appeared to be greater than the c o n t r a l a t e r a l t o o t h . H o w e v e r , the residual m o b i l i t y that w o u l d be present after any f o r m o f therapy has not c o m p r o m i s e d function. T h e c l i n i c i a n should m i n i m i z e the influence o f t r a u m a associated w i t h
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FIGURE 7A. Fractured central incisor. B. Preoperative radiograph after endodontic therapy. C . A temporary post was cemented in order to attach an orthodontic bracket. Tattoos were placed as part of a pilot study. D. Approximately 3 mm of eruption was produced in 3 months. Note that the mucogingival tattoo has remained relatively stable while the tattoo at the gingival margin has moved coronally. E. Radiograph after eruption. Arrows indicate the position of the cemento-enamel junction and interproximal bone.
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E n d o d o n t i c treatment o f the r e m a i n i n g root segment was never accomplished under sterile conditions due to the i m p o s s i b i l i t y o f m a i n t a i n i n g a d r y operating field. Retreatment due to new or persistent p e r i a p i c a l p a t h o l ogy has not been encountered with this sample p o p u l a tion. A
significant
question
at
this
time
concerns
the
influence o f eruptive tooth movement on the w i d t h o f attached gingiva and the stability o f the m u c o g i n g i v a l j u n c t i o n ( F i g . 1 0 A ) . A n investigation is in progress to determine the relation o f the amount o f root e r u p t i o n ( C ) necessary to produce alterations i n the g i n g i v a l m a r g i n (B) in relation to the m u c o g i n g i v a l j u n c t i o n ( A ) .
1 3
It is
not clear whether there is an increase i n the w i d t h o f the attached gingiva which w o u l d result i f the m u c o g i n g i v a l j u n c t i o n remained stable as suggested by Batenherst ( F i g . 10B) or whether the m u c o g i n g i v a l j u n c t i o n moves c o r o n a l with the g i n g i v a l m a r g i n m a i n t a i n i n g the o r i g i n a l width o f gingiva ( F i g . IOC). T h e cases presented tend to suggest that the
m u c o g i n g i v a l j u n c t i o n does
remain
stable. Teeth that are erupted in the presence o f soft tissue pocket depth appear to move c o r o n a l l y for a considerable distance before the g i n g i v a l m a r g i n follows. C o n c u r rently the pocket depth is reduced and an
immature-
appearing tissue appears c o r o n a l to the o r i g i n a l g i n g i v a l m a r g i n . It has been suggested that the increase in g i n g i v a in this case m a y be due to an inversion o f the pocket
F I G U R E 7F. The elevated flap showing the altered osseous crests. The coronal shift of the facial and interproximal bone is clearly visible. The tattoo penetrated the facial bone and a fenestration is present. G . Postsurgical healing. H . The provi sional restoration.
n o r m a l function or parafunctional habits by reducing heavy contacts i n m a x i m u m intercuspation and excur sions. T h e o r t h o d o n t i c mechano-therapy varied in m a n y o f the cases that were treated by forced eruption. Interarch elastics were generally unsuccessful due to a lack o f patient c o o p e r a t i o n and inadequate c o n t r o l o f forces. A c o r o n a l movement o f the root segment was difficult to achieve with interarch elastics and quite often buccal or l i n g u a l forces developed. T h e use o f direct bonded attachments u t i l i z i n g segmented arch wires was very successful and reduced the mechano-therapy to rather simple procedures.
F I G U R E 8A. Tooth preparation at the level of the CEJ: the diameter of the preparation is proportionate relative to the fixed amount of space between the teeth. This relationship is constant with the anatomical characteristics of the tooth and restoration is uncomplicated. B. Tooth preparation after erup tion further apically: the diameter of the preparation is small relative to the fixed amount of space between the teeth. This relationship is not constant with normal anatomy and restora tion will require greater attention.
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FIGURE 9. Conceptualization of the relative crown to root ratios (C/R) with osseous surgery and forced eruption: A preoperative C/R of 4:5 would be reduced to 5:4 if one unit of bone was removed to expose tooth structure. Surgery after forced eruption will also reduce the bone by one unit: however the clinical crown will also be reduced by one unit to accomodate the eruption with a resultant C/R of 4:4.
FIGURE 10A. The effect on the mucogingival junction (A) and gingival margin (B) relative to a coronal shift of the tooth (C). B. Eruption of the tooth may produce a coronal shift of the marginal gingival alone which would increase the zone of gingiva. The dotted line indicates the preoperative gingival margin. C. Eruption of the tooth may produce a coronal shift of the mucogingival junction and the marginal gingiva, therefore, the zone of gingiva would remain constant. The dotted lines indicate the preoperative position of the mucogingival junction and the gingival margin.
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l i n i n g . T h i s nonkeratinized tissue remains erythematous for a considerable period o f t i m e until it assumes the a p p e a r a n c e o f the surrounding gingiva. SUMMARY
In selected cases, forced eruption m a y be a useful a p p r o a c h i n treating isolated nonrestorable teeth as a result o f t r a u m a , caries, o r iatrogenic dentistry. T h i s paper has presented the biologic rationale, objec tives, technics a n d c l i n i c a l cases to demonstrate the p r i n c i p l e . E v a l u a t i o n has been made o f potential difficul ties w h i c h m a y develop with the technic and areas for future research have been identified. ACKNOWLEDGMENT
The author wishes to acknowledge the following for their assistance in the preparation of this manuscript: Bruce Apfelbaum, D . M . D . , D. Walter Cohen, D.D.S., Louis Rose, D.D.S., M . D . , Harvey Wank, D . M . D . , Edwin Slade, D . M . D . , and M s . Patricia A . Scherer. REFERENCES
1. Andreason, J . D., and Hjirting, E.: Intra-alveolar root fractures: Radiographic and histologic study of 50 cases. J Oral Surg 25: 414, 1967. 2. Ingber, Jeffrey S.: Forced eruption: Part I. A method of
treating isolated one and two wall infrabony osseous defects— rational and case report. J Periodontol 45: 199, 1974. 3. Heithersay, Geoffrey S.: Combined endodontic—ortho dontic treatment of transverse root fractures in the region of the alveolar crest. Oral Surg 36: 404, 1973. 4. Reitan, K.: Clinical and histologic observations on tooth movement during and after orthodontic treatment. Amer J Orthod 53: 721, 1967. 5. Oppenheim, A . : Artificial elongation of teeth. Am J Orthod Oral Surg 26: 931, 1940. 6. Brown, I. Stephen: The effect orthodontic therapy on certain types of periodontal defects. I—Clinical findings. J Periodontol 44: 742, 1973. 7. Athertori, J . D . , and Kerr, N . W . : Effect of orthodontic tooth movement upon the gingivae. Br Dent J 124: 555, 1968. 8. Atherton, J . D.: The gingival response to orthodontic tooth movement. Am J Orthod 58: 179, 1970. 9. Edwards, J . G . : A study of the periodontium during orthodontic rotation of teeth. Am J Orthod 54: 441, 1968. 10. Edwards, J . G . : A surgical procedure to eliminate rotational relapse. Am J Orthod 57: 35, 1970. 11. Batenhorst, K . F., Bowers, G . M . , and Williams, J . E . : Tissue changes resulting from facial tipping and extrusion of in cisors in monkeys. J Periodontol 45: 660, 1974. 12. Amsterdam, M . , and Corn, H . : Graduate Seminar Series, University of Pennsylvania School of Dental Medicine, 1969-1972. 13. Apfelbaum, B . , Ingber, J . S., et al: Forced eruption: Part III. A Quantitative Study of the Clinical Crown and its Associated Attached Gingiva. In Progress.
Abstracts
T H E E A R L Y ESTABLISHMENT OF Streptococcus Mutans IN T H E M O U T H OF INFANTS
A BIOCHEMICAL S T U D Y OF T H E ORIGIN OF ARGININE AMINOPEPTIDASES IN H U M A N GINGIVAL F L U I D
Berkowitz, R. J., Jordan, H . V., and White G. Arch Oral Biol 20: 171, March, 1975.
Makinen, K. K., and Hyyppa, T. Arch Oral Biol 20: 509, August, 1975.
Using a selective medium, Streptococcus mutans was cultured from swab samples from the alveolar ridges, buccal mucosa and tongue of infants 3 weeks to 14 months of age. Of 138 subjects, 91 normal infants showed no Streptococcus mutans, but it was found in two of 10 cases of cleft palate infants with acrylic obturators. Nine of 40 infants with erupted incisors demonstrated Streptococcus mutans in their plaques. Representative Streptococcus mutans isolated from nine mother-child pairs were characterized serologically. Type c was the most common maternal serotype but other maternal types included b, d, E strains. All infant isolates were serotype c. Later samples were of the b sero type. Harvard School of Dental Medicine, Boston, Massachusetts
Gingival fluid and whole saliva were collected from healthy persons between 20 to 40 years of age. The oral hygiene and tissue condition were classed according to state. The sources of the enzymes hydrolysing N-L-arginyl-2-naphthylamine in gingival fluid was determined by fractionation qualities of the enzymes on Sephadex G-100 Superfine columns. It was stated that the probable sources of the enzymes were the serum or plaque, or cellular elements of the blood. There was little evidence that the enzymes are derived from plaque or whole mouth saliva. It was also shown that healthy tissue produced more enzyme than implanted tissue. Institute of Dentistry, University of Turku, SF-20502, Turku 52, Finland
