Parameters of the Attached Epithelial Reformation Following Gingivectomy

Loyola University Chicago Loyola eCommons

Master's Theses Theses and Dissertations

1978

Carl J. Laudando Loyola University Chicago

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Recommended Citation Laudando, Carl J., "Parameters of the Attached Epithelial Reformation Following Gingivectomy" (1978). Master's Theses. 2983. https://ecommons.luc.edu/luc_theses/2983

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EPITHFLIAl REFO~~TION FOLLOWING

GINGIVECT01'~1Y

Carl J. Laudando PARAMETERS OF TI-!F ATTArnED

EPITHELIAL REFO~~TION

FOLL01VING GINGIVECTOJvfY

By Carl J. Laudando, B.S., D.D.S.

A Thesis Submitted to the Faculty of the Graduate School of Loyola University in Partial Fulfillment of the Requirements for the Degree of

~/faster of Science in Oral Biology May

1978

T ~·' • DEDICATION

To my mother and father, Ignatius and Rose Laudando, for their never ending encouragement, love and understanding.

To my wife, Nancy, for her love, sacrifice, and patience.

] ACKNOWLFDGJvlF.t,rrs

I would like to express my appreciation to the members of my advisory committee: Doctor Lawrence Jenkins, Doctor Anthony W. Gargiulo, Doctor Patrick Toto, Doctor Hal McReynolds, and Doctor Daniel Grant for their assistance and recommendations during the research and writting of this thesis. Their recommendations in the preparations of this thesis were most helpful. In particular, I would like to thank Doctor Jenkins for his constant guidance and direction during the many months of preparation, or ganization, and writing of this research project.

ii TARLF. OF CONTF~~S

CHAPTER PAGE

I I,I\;'TRODUCTION ...... •.•.....•...... 1

II RFVIEW OF THF. LITERATIJRF ...... 3

III MATERIALS Ai'ID l\fETHODS •...... 12

IV RESULTS ..•.....•...... •...... 15 v DISCUSSION ...... •...... 21 VI CONCLUSION ...... 26

VII SUrv1J'-1ARY ...... •...... 2 8

VIII TABLES ...... 31

IX ILLUSTRATIONS ...... •...... 55

BIBLIOGRAPHY ..•...... 60

iii GIAPTIR I

U..,l'TRODUCTION

Various theraputic procedures have been developed aimed at restoring to a healthy state the pathologically altered relationship of the periodon tal tissues to the tooth surface. Many investigators have studied the heal ing patterns of these various procedures.l,2 Most of these investigations have been concerned with histological evaluation of the gingiva and attach ment apparatus of teeth following various theraputic procedures.3,4,5,6,7,8,9

The gingivectomy is one such nrocedure. It is a widely used thera putic procedure aimed at restoring to a healthy state the pathologically altered gingival tissues. The usefulness of the gingivectomy as a technique in the treatment of periodontal disease has been affirmed by many investi gators.l0,11,12,13,14 It results in the excision of a large portion of the gingival connective tissue. The jtmctional and sulcular epithelium are lost with the coronal portion of the oral epithelium. The wound which results consists of an open connective tissue bed limited on one side by the tooth and the other by the cut edge of the severed oral epithelium. The adjacent epithelium will proliferate to form a new lining over the exposed connective tissue and will eventually give rise to a new oral, stilcular and junctional epithelium. Clinical opinion, hm..-ever, varies as to the marginal position and sulcular depth of the newly formed gingival unit following a gingivectomy procedure. Some limited human data and animal studies have been published

1 2 describing the position of the gingival margin.l5,16 Some human stlldies are contradictory as to the healing of the gingival margin. Some indicate an apical shift of the marginl7 while others describe a coronal gain of the gingival margin.l5,18,19,20

To study this nhenomenon it is necessary to measure the shift of the attachment and gingiva from a constant reference point, The use of an acry lic stent has proven to be a reliable means to attain this goal.20,21 The measurement of the attacrunent and pocket depth have been performed using a calabrated periodontal probe. T11e use of the probe as a measuring device has been shown to be a very reliable source for measurement.22,23

It is therefore the intent of this research to study the effect of a gingivectomy on the marginal position and sulcular depth of the newly fo~ ed gingival sulcus. GIAPTER II

LITERATITRE REVIEW

Resection of gingival tissue has been one method of periodontal therapy for the elimination of gingival pockets. As long ago as 1746 and 1757, Pierre Fauchard24 and Bourdet25 respectively described there- section of diseased gingival tissues. Various surgical procedures described in the literature included a gingivectomy but involved, in fact, other procedures as well. It was not until 1912, that Pickerall26 first described in a book an operation for pyorrhea called a gingivectomy. It should be noted that in the earlier literature (prior to 1950) the described gingivectomy procedures, in fact, may not have been merely resection of soft tissue but included other procedures as we11. 27 •28 •29 Actually, there was considerable inconsistency in what exactly was per- 30 f orme d dur1ng . a g1ng1vectomy . . proced ure 1n . t h e ear 1y 1"1terature. Not until 1950, had the term "gingivectomy" been defined. Miller31 defined gingivectomy as the operation of cutting away all loose infected and diseased gingival tissue to eradicate the periodontal pocket. In the same year, Goldrnan10 termed and devised a technique of "gingivoplasty" ernphasing form and function. He defined gingivoplasty as artifically re- sharping the gingiva to create physiologic gingival contours. Thus, in the literature following these definitions, more standar- dization of the technique in reported procedures was achieved. This aware- ness in regard to procedure type is necessary to uroperly interpret especi- ally the early periodontal literature in reference to the surgical technique.

3 4

In the definition of gingivectomy, reference is made to the perio dontal "pocket". In 1953, Cross and Wade32 defined a periodontal pocket as a pathologically deepened gingival crevice. The literature presents a vast number of articles concerned with techniques, indications and contraindications of the gingivectomy~l,33,34,35

The general opinion indicates that the gingivectomy procedure can be utilized in the excision of the soft tissue wall of the pocket not extending beyond the mucogingival junction and not involving infrabony defects. Removal of deposits is recognized as an important aspect of perio dontal care. But whether or not pre-surgical scaling is of value is 1lll certain. Glickman (1956), 36 concluded that pre-scaling exerts no beneficial effect on the outcome of the gingivectomy procedure. Pre-scaling did not improve the healing nor reduce the healing time following periodontal sur gery. Ambrose and Detamore38 (1960) were unable to prove the value of presurgical root planing. Bernier and Kaplan (1947), 39 attributed the more rapid epithelization and consolidation of underlying connection of connective tissue to the presence of the surgical dressing. In consideration of surgical procedures, upon completion of the surgical technique, surgical dressings are often placed. Waerhaug and Loe43 observed that a gingivectomy dressing was slightly irritating but it did not 41 prevent healing and apparently it does not cause any damage. Stahl (1969) observed that the use of a pack did not influence the healing parameters. Anatomical descriptions of surface gingival tissue have been 5 42 described in the early periodontal literature by King (1945) as "matt in texture, just distant from the dental margin." Orban (1948) 43 described the "free gingival groove" distinguishing the free gingiva from

the attached gingiva. Also, stippling, mucogingival line, interdental grooves and folds, and interdental papilla were described. Gingival anatomy was reported by Goldrnan. 14 These represent the literatures' most regarded anatomic description of the gingiva. Histologically, Orban44 described surface epithelium as kera-

tinized. Epithelium of alveolar mucosa as not keratinized without the ridge formation found in the gingiva. Gingiva is plentiful in collagenous fibers without or scant in elastic fibers; while alveolar mucosa is poor in collagen fiber bundles and rich in elastic fibers. Orban also was con-

cerned with the importance of the epithelial attachment. Gottlieb (1921) 45 presented the first evidence of the existence 4 of an epithelial attachment. 1Vaerhaug A in 1952, stated that there was no 47 epithelial attachment just a close apposition. Listgarten in 1966, demonstrated, with the electron microscope, that the presence of an epithe-

lial attachment to the teeth does exist.

There is a considerable arnmmt of research that has been perfonned 48 on the healing of the gingivectomy. In 1929, Lundquist studied the epithelial regeneration after a gingivectomy, finding that ten days after the nro 49 ceclure a layer of epi the1 hun was fotmcl covering the lesion. H. Stone (1932) noted that in gingivectomy (in clogs) epithelium did not commence to cover the wound until after four clays. Mann and Kaplan (1941) 50 found that after 6 four days following a gingivectomy only a thin layer of epithelium covered part of the wound. It was after six days that the whole wound was covered. Orban and Archer51 in 1945, using histologic sections, found that two days after gingivectomy, epithelim begins to invade the blood clot and after fourteen days the epithelialization of the wound was complete. In 1955, Waerhaug 52 concluded that a zero sulcus depth following gingivectomy can- not be maintained for any length of time. The new sulcus develops either by regeneration of the corium and epithelium coronal to the line of in cision or by a down growth along the root apical to the line of incision. 53 Pereson (1959) studied the healing of the marginal periodontium after gingivectomy in dogs, noting that epithelium begins to regenerate at two days postsurgically from the basal layer. By six days the blood clot was converted into granulation tissue swelling against the tooth. From eight to ten days the epithelium covers the blood clot and is attached in some way to the tooth. The blood clot is then removed and the epithelium proliferates coronally up the tooth; some time later a proliferation down the root cementum takes place. Loe and Silness54 in 1961, noted that complete epithelization was noted in nine days. Epithelium then proliferated coronally. Henning and 55 Cran (1967) observed that following a gingivectomy at thirteen days the epithelial attachment to the tooth surface was less secure than the con- trol, and at fourth-five days there appeared to be a form of attachment to the root surface. Henning (1968)56, using a carbon insuffilation technique, noted that reattachment to the root surface was not achieved until 15-2~ 7 days after the wounding and about 15-21 days after completion of epithelization of the wound. Ramfjord and Costich16 noted that the new gingival sulcus, following a gingivectomy, showed to be a result of either epithelium growing down into the crevice made between the tooth and the soft tissue during root planning, or the connective tissue proliferation building up a new 17 free gingiva. Donnenfeld and Glickman noted in the healing following a gingivectomy in humans that there was a coronal migration of the mucogingival line and to a lesser extent by an apical shift in the location of the base of the gingival sulcus. 3 Naves , 1969, presented an interesting time schedule of the healing of gingival tissue afte:- a gingivec~omy in a dog. The time sequc:r:ce is as follows: 0 hours - The epithelium exhibits hemorrhage, Pf.1N' s migrate into the area and an acute inflammatory response is initiated in the deeper layers. 2 hours - Epithelium shows a formation of a serous fibrin eXudate and a blood clot. The connective tissue cells on the surface of the wound show sigs of degeneration. 5 hours - A blood clot covers the wound area. There is an establishment of a band of PJ'v!N's covering the wound. TI1ere is a loss of cementoblasts along the root surface adjacent to the wound area. Sometimes osteoblasts in periosteal layers are lost. The presence or absence of the initial crestal bone reaction depends on the proximity of the incision to the crcstal hone. 8

9 hours - Basophilic epithelial cells accumulate at the margin of the wound, and epithelial migration across the surface of the wolu1d begins. The number of PMN's in the connective tissue in creases. 15 hours - TI1e cells from the prickle and basal cell layers migrate over the wound surface and the P~W's in tensify in the connective tissue. 25 hours - The epithelial cells at margin of wound show an organization consistent with that of stratified squamous epithelium. There is an active migration of cells over wound surface coming from prickle and basal cell layers. The cells of the prickle and basal cell layers immediately adjacent to wound exhibit a greatly increased DNA synthesis. If the cells of the epithelial attachment are present, they also migrate toward the surface. The connective tissue portion of the wound is heavily infiltrated with P~~'s. Below the band of Prvf',Tt s there are many angiohlasts in the walls of blood vessels and in blood vessels. Epithelial cells are actively migrating across wound surface and DNA activity is localized to cells at wolmd margin and to basal cells of the migrating epithelium. The epithelium covers wound at rate of .5mrn/dav. The connective tis sue at the margin of the- advaning epithelium does not contain definite collagen bLmdles. As soon as the epithelium covers the connective tissue, organization of the connective tissue occurs. Cementoblastic activity is seen. 5 days Epithelilun migrating_ across wound and the origi nal woLmd margin is. strarified and rete pegs aTe seen.. The band of PMN' s begins to break up and is replaced hy a more diffuse arrangement of inflammatory cells.

7-10 days- The wound is covered by epithelium the epithelium next to the tooth is only a few cell layers thick. As the epi the 1 iwn reaches tooth, the connect i vc tissue next to the tooth proliferates in an occlu sal direction - creating what will be the gingi\•al sulcus and free gingival margin and new gingival sulcus. The alveolar crest exhibits some osteo clastic activity. 9

12-14 days - Epithelium is keratinized; the gingival sulcus is not completely epithelized and collagen bun dles increase in the area of the free gingiva. 21 days - The epithelium appears normal; the gingival sul cus is still not completely epithelized. Well organized collegan bundles can he seen. 35 days - Healing is essentially complete. The gingival sulcus is completely epithelized and the con nective tissue is completely organized. Some chronic inflammatory cells are present.

Holm-Pederscn n971)18 observed healing after a gingivectomy in both young and old subjects, that the depth of the crevice decreased in both young and old by coronal marginal growth. Growth in the young after a gingivectomy was 97.1% of the original margin length. In the older subjects the growth was 61.9% of the original margin length. 19 Bergstorrn (1974) concluded that 180 days post-surgically there was a 50% coronal remigration of the gingival margin from the pre- to post-surgical state. 57 Rarnfjord et a1 reported on the healing of the connective tis sue and the free gingiva using histologic and radiographic technique. Con- nective tissue healing started .3 to .Srnrn under the wound surface but spread to the rest of the supracrestal tissue after epithelization of the wound. 58 Stahl et al in 1968 reported that following a gingivectomy there appeared to be a lack of influence of age, sex, location of pocket and curettage on the gingival healing sequence and still active connective tissue repair was seen 28 days after the gingivectomy, while surface epithelium was already completed in 14 days after surgery. 10

Gingival soft tissue has been reviewed and broad patterns of similar repair responses have been described. These support rather consistent and predictable repair sequences. Little information concerning

the repair of the soft tissue to tooth attachment was reviewed. Stahl1 et al presented a scheme of gingival repair as follows: The mode of epithelial adherence to tooth surface after scaling, gingivectomy or flap surgery is similar to that seen in non-surgically treated controls. This supports and demonstrates the biologic consistency of the gingival repair 4 5 6 7 phenomenon. ' ' ' However, a gingival injury involving the crevicular epithelium frequently causes apical migration of the epithelial cuff. When the epithelial/periodontal fiber/tooth surface contact is broken, the wound edge epithelium at this peculiar site, often migrates apically. This epithelial migration ceases only when the epithelial/periodontal fiber/ tooth surface interface can again be established. After surgery, epithe-

lium may migrate apically along the root whenever adhering or attached collagen fibers are not present at the root surface. Cessation of the apical migration takes place when epithelium contacts such fibers. Stahl and Afshar-Mohajer20 (1977) attempted to describe the position of the new forming gingival margin by clinically monitoring its formation. It was concluded from the study that the excisional reduction of a crevice to 0 mm depth was altered by gingival remodeling during the healing phase. The remodeling took place within three months after surgery and clinically appeared as a limited coronal pocket closure and gain of marginal height. 11

Despite the widespread use of the periodontal probe as a diag nostic tool to measure the depth of periodontal pockets, the exact lo cation of the probe tip during routine meaSlirements of clinical pocket depth has great importance. Orban 59 , et al believed the probe tip is generally located at the coronal end of the epithelial attachment. Waer haug60 favored the view that the tip passes between the epithelium and the tooth to a level which corresponds to the apical end of the junctional epithelium Silvertson and Burgett22 , concluded that in routine clinical probing of untreated periodontal pockets, a thin periodontal probe will penetrate to the coronal level of the connective tissue attachment which

is the base of the epithelial attachment. Listgarten, Moe and Robinson23 found in their investigation of the most common location of the periodontal pockets, that it tends to measure the apical extent of the junctional epi thelium. Despite the presence of an epithelial attachment connecting the junctional epithelil~ rather than·its coronal level. Through this review of the literature it can be seen that clinical opinion varies regarding the marginal position and sulcular depth relation ship of the newly formed gingiva following gingivectomy. It is therefore the intent of this research to study and further describe the position of the newly formed gingival margin by clinically monitoring its position after formation following up to a six month healing time. CJ-L~PTER II I Material and Methods

A total of thirteen quadrants of gingivectomy were utilized in four patients at the Periodontic Clinic at Loyola College of Dentistry. Fifty-three teeth (14 molars, 13 anteriors, and 26 bicuspids) were utilized. The group contained one male and three females between the ages of twenty-four to thirty-six years of age with the mean age of twenty- nine years of age. Among these patients were one caucasian, two blacks and one hindu. All of*these individuals suffered from periodontitis Class Type II. Medical and dental histories as well as full-mouth perio- pical roentgenograms were taken for each patient. Only patients with normal medical histories were asked to participate in this study. In all cases, presurgical treatment consisted of (1) Oral hygiene instructions, (2) Any necessary adjustment of the occlusion, and (3) Root planning and curettage. After initial therapy, all patients were re-evaluated regarding their need for surgical pocket reduction.

Methods - Surgical Procedures Surgical procedures consisted of a standard gingivectomy with excision of the pocket wall carried out to the base of the clinical pocket

Current Procedural Terminology for Periodontics. Early Periodontities. *Class Type II. Clinical Terminology, American Academy of Periodontics. Progressing of gingival inflammation into the alveolar bone crest and early bone loss resulting in moderate pocket formation.

12 20 (Omm depth at the time of excision). 16 , During the surgical procedure, the surgically exposed tooth surface was planned in a routine manner. In all cases, the surgical site was then covered with a periodontal dressing (Orban Periodontal Pack)* for one week. At the end of this time the periodontal dressing was removed, the tissue and teeth were cleansed of debris and the patient was reinstruc- ted in oral hygiene home care.

Measurements - Study models were constructed during the initial phase of the study. A polyvinyL'(omnivac) _stent was fabricated from .60 thickness tray material on the casts. The polyvinyl was then trimmed so that the occlusal surfaces and the cuspal tips were covered and extended down one quarter of the facial and lingual surfaces of the crown. The tray material provided a frame for establishing a fixed reference point. 20 Three grooves were marked on the stent in an occlusal-apical direction with a "joe-dandy disc.'' Each groove was located at the mesial-facial, facial, and distal-facial line angles of each tooth to be treated. The edge of the stent and the direction of the grooves serve as a fixed reference point and position for taking all measurements. All measurements were recorded at the respective facial surfaces using a Williams periodontal probe** inserted into the groove stent. All measurements were recorded to the nearest .Smm and were performed by the

* Orban Dressing Constituents **Hu-Friedy Instrument Company 14 same operator by paralleling the operator's eyes with the stent, then reading off the calabration on the probe which corresponded with the most apical portion of the stent. Measurements were recorded for each patient: (a) at the initial examination, (b) immediately before surgery, (c) immediately after surgery, and (d) at 2,8,12, and 24 weeks postsurgically. The distances measured were: (1) from the fixed point to the free gingival margin, (2) from the fixed point to the bottom of the gingival crevice and (3) the depth of the sulcus from the bottom the gingival crevice to the free gingival margin. The difference between 1 and 2 represents the depth of the gingival crevice. Number 3 was used to confirm the accuracy of readings 1 and 2.

Statistical Analysis - The teeth were then seperated and categorized into three types,

(1) anteriors, (2) bicuspids and (3) molars. The mean m1d standard devi ation of each category for each measurement interval was determined for crevice depth, stent to marginal tissue a~d stent to the bottom of the gin gival crevice. These values were then compared and evaluated for their significance. rnAPTER IV Results

Data from fifty-three teeth (14 molars, 13 anteriors, and 26 bicuspids) was compiled to obtain the results for this thesis. The ob servations of the results were seuarated into three separate categories: 1) anteriors, 2) bicuspids, and 3) molars. Each category was subdivided into six observation intervals: 1) initial measurement, 2) immediately following surgery, 3) 2 weeks post-surgical, 4) 4 weeks post-surgical, 5) 12 weeks post-surgical and 6) 24 weeks post-surgical. At each of these time intervals, except for immediately fol lowing surgery, measurements were taken at the mesial-facial distal-facial and facial surfaces of each tooth. Three different measurements were taken for each location at each time interval; these were: 1) cervical depth, 2) stent to marginal tissue, and 3) stent to base of cervice. The following results of the mesial-facial, distal-facial, and facial surfaces and the mean results collected for each figure given. The measurements obtained immediately after surgery represent only the cervicular depth at the mesial facial, distal-facial, and facial surfaces. No measurements of stent to base of crevice, or stent to marginal tissue was taken because of the pos sibility of producing an error in the measurements obtained due to the con ditions of taking readings at this time. (bleeding, inability to keep stent dry, inability to accurately obtain measurement due to bleeding).

15 16

Anteriors: Measurements were obtained from intervals of initial (pre.,. gingivectomy, 0 weeks, 2 weeks, 4 weeks, 12 weeks, and 24 weeks for the mesial-facial, distal-facial, and facial surfaces. Measurements were taken from subjects using a Williams periodontal probe * . Observations were recorded from readings of the probe according to crevicular depth, stent to marginal tissue and stent to base of crevice. It was found that the initial measurements had mean crevicular depths of 3.0mm ~ 0.2mm,

3.3rmn ~ O.Smm, and LSmm .:_ 0.6rmn respectively for mesial-facial, distal facial, and facial surfaces. Omm crevicular depth was obtained for each location following surgery at 0 weeks. After 2 weeks there was observed a crevicular depth of 1. 2rmn ;:_ 0 .. 6rmn, 1. 3mm ~ 0. 4mm, and 1. Orrrrn ~ 0. 3rmn respectively for mesial-facial, distal-.facial, and facial surfaces. This denotes a beginning increase in sulcular depth. Between the second and twenty-fourtn week observations there was a further increase in the ere- vicular depth. CFefer to Table 1.} The twenty-four "eek mean observations was Z.Orrrn ~ O.Smm, 2.0rrrn ~ O.Smm, and l.Omm + 0.2mm for the mesial-facial, distal-facial, and facial surfaces respectively. From the data it can be seen that there was a gradual increase in the stent to base of crevice value over the 2-24 week period and at the same time there was a constant value for the stent to marginal tissue value. The initial measurements (pre-gingivectomy) for the mean stent to marginal tissue were 2.7mm ~ l.Omm, 2.8mm + l.lmm, and 6.2mm + 1.3mm

* Hu-Friedy Dental Manufacturing Company 17 respectively for mesial-facial, distal-facial, and facial surfaces. After

2 weeks there was observed a stent to marginal tissue reading of S.lmm ~

0.8mm, 5.2mm ~ 0.9mm, 6.9mm ~ l.Omm respectively for mesial-facial, distal facial, and facial surfaces. Between the second and twenty-fourth week ob servation there was a gradual decrease in the mesial-facial and distal facial surfaces and a fairly constant observation in the facial aspect of the stent to marginal tissue. (Refer to Table 1.) The 24 week mean obser

vations were 3.6mm ~ l.Omm, 3.8mm ~ 0.7rrm, and 7.0mm + 1.3mm for the mesial facial, distal-facial, and facial surfaces respectively. It was found in the initial measurements the mean stent to base

of crevice were 5.7mm ~ 1.6mm, lmm ~ 0.7mm, and 7.0mm ~ 2.1ITm respectively for mesial-facial, distal-facial, and facial surfaces. Between the second and twenty-four week observation there was a gradual decrease in the rnesial facial and distal-facial surfaces and a gradual increase in the facial aspect of the stent to marginal tissue. (Refer to Table 1.) The 24 week obser vations were S.Smm ~ 0.9mm, 5.8mm ~0.9mm, and 8.lmm ~ 0.9mm respectively for mesial-facial, distal-facial, and facial surfaces.

Bicuspids: Measuremnts were obtained from intervals of initial measurement (pre-gingivectomy), 0 weeks, 2 weeks, 4 weeks, 12 weeks and 24 weeks for the mesial-facial, distal-facial, and facial surfaces. Measurements were taken from subjects using a Williams probe. Observations were recorded from readings derived from the crevicular depth, stent to marginal tissue and 18 stent to base of crevice. It was found that in the initial measurements the mean crevicular depths were 3.5mm + O.Smm, 3.lrnm ~ 0.4rnm and 1.9mm ~ O.Srnm respectively for mesial-facial, distal-facial, and facial surfaces.

Omm crevicular depth was obtained for each location following surgery at

0 weeks. After 2 weeks there was observed a crevicular denth of 1.4mm +

O.Smm, l.Smm ~ O.Smm, and l.Omm ~ 0.3mm respectively for mesial-facial, distal-facial and facial surfaces. Between the second and twenty-fourth week observations, there was a steady increase in crevicular deuth. (Refer to Table 2.) The twenty-fourth week mean observations were 2.3rnm ~ O.Srnm,

2.0mm ~ 0.9mm, and 4.5mm ~ 1.3mm respectively for mesial-facial, distal facial and facial surfaces. After 2 weeks, there was observed a stent to marginal tissue reading of 4.8mm ~ 1.3mm, 3mm, 4.6mm ~ 1.2rnw and S.?mm + l.lmm respectively for mesial-facial, distal-facial, and facial surfaces. Between the second and twenty-fourth week observations there was a gradual decrease in mesial and distal surfaces and a more or less constant obser vation on the facial surface of the stent to marginal tissue. (Refer to

Table 2.) The 24 week mean observations were 3.8mm ~ O.?mm, 3.6mm ~ 0.8mm, and 5.7mm + l.lmm for the mesial-facial, distal-facial and facial s11rfaces respectively. It was found in the initial measurements the mean stent to base of crevice were 6.0mm ~ l.lmm, S.Smm ~ 0.9mm, and 6.4mm ~ 1.2mm respectively for mesial-facial, distal-facial, and facial surfaces. Between the second and twenty-fourth week observations there was a gradual increase in the dis tal observations with a fairly consistent observation in the facial and 19 mesial-facial aspect of the stent to base of crevice readings. (Refer to

Table 2.) The 23 week observation were 6.0mm ~ 0.8mm, 5.6mm ~ 0.9mm, and

6.8mm ~ l.lmm respectively for mesial-facial, distal-facial, and facial surfaces.

MOlars:

~reasurements were obtained from intervals of initial measurements (pre-gingivectomy), 0 weeks, 2 weeks, 4 weeks, 12 weeks and 24 weeks for the mesial-facial, distal-facial, and facial surfaces. Measurements were taken from subjects using a Williams periodontal probe. Observations were recorded from readings according to crevicular depth, stent to marginal tissue and stent to base of crevice. It was found that in the initial measurements the mean crevicular depth was 4.0mrn ~ 0.7mrn, 3.8mm ~ 0.7mrn, and 2.8mm ~ 0.8mrn respectively for mesial-facial, distal-facial, and facial surfaces. Ornm crevicular depth was obtained for each location following surgery at 0 week. After 2 weeks there was observed a crevicular depth of 1.8mrn + 0.7rnm, l.Smrn ~ O.Smm, and 1.2mm ~ O.Smm respectively for mesial facial, distal-facial, and facial surfaces. Between the second and twenty fourth week observation there was a gradual increase in crevicular depth.

(Refer to Table 3.) The twenty-four week mean observations were 2.5mm +

0.4rnm, 2.lmm ~ 0.6mm, and 1.6mm ~ 0.6mm respectively. The stent to marginal tissue initial measurements were 2.5mm +

0.9mm, 2.5mm ~ 0.9mm, and 4.0mrn ~ l.Omm respectively for mesial-facial, distal-facial, and facial surfaces. After 2 weeks there was observed a stent to marginal tissue reading of 4.4mm + l.Omrn, 4.4~ + 1.7mm and 5.3mm 20

0.9mm for the mesial-facial, distal-facial, and facial surfaces respec tively. Between the second and twenty-fourth week observations a gradual decrease in the mesial-facial, distal-facial, and facial surfaces was observed (Refer to Table 3.). The 24 week mean observations were 3.8mm

+ 0.8mm, 3.8mm + 1.2mm and S.Omrn + l.Omm respectively for mesial-facial, distal-facial, and facial surfaces. The initial measurements for the stent to base of crevice were found to be 6.5mm ~ 0.8mm, 6.4mm ~ 0.9mm and 6.8mm ~ l.Omm respectively for mesial-facial, distal-facial, and facial surfaces. Between the second and twenty-fourth week there was a gradual increase in mesial-facial and facial surfaces, and a gradual decrease in the distal-facial surface of the stent to base of crevice. (Rever to Table 3.) The 24 week observation were

6.3mm ~ 0.6mm, 5.8mm ~ 0.6mm, and 6.8mm + l.OFm for the mesial-facial, dis tal-facial, and facial surfaces respectively. rnAPTER V

Discussion

The findings from this study suggest that there maybe a difference noted from the facial, mesial-facial, and distal-facial surfaces of the an terior, bicuspid and molar teeth. Interestingly the most consistent measure ment observed, between the 2nd and 24th week for anterior, bicuspids and molar teeth, was the area on the facial of each tooth. It appears that at this lo cation there is a lowering (in an apical direction) of the epithetial attach ment, as determined from the observations utilizing the occlusal stent for dementional changes of stent to base of crevice. During the same period Of 0 to 24 weeks the stent to marginal tissue value varied from anterior, bi cuspids and molars over the stent to base of crevice observations. The anterior facial aspects exhibited a lowering (in an apical direction) of the marginal tissue. Bicuspids exhibited a constant value for the marginal tis sue to stent measurement while the molars demonstrated a raising (in an occlusal direction) of the marginal tissue. The mesial-facial aspect of this measurement vary according to the location of the teeth observed. In other words, anteriors vary from bicuspids which vary from molars. In anteriors there is a gradual decrease in stent to base of crevice (coronal gain). In bicuspids there is a slight decrease (coronal gain) observation and in molars there is an increase in the stent to base of crevice. The distal-facial dimensions were consistent in all three areas with a net coronal gain in the dimensional observations or decrease in stent to base of crevice value.

21 22 A consistent observation is also seen from the anterior, bicuspids and molar teeth when stent to marginal tissue is examined. All mesial-facial and distal-facial surfaces exhibit a decrease in stent to marginal tissue or a net coronal gain in this dimension. In regard to the facial surfaces, and this particular parameter, it was observed that the anterior's exhibit a slight increase (movement in an apical direction). The bicuspid teeth behave with a fairly constant value remaining for the stent to marginal tissue observation. A difference is seen in the molar area where there appears to be a decrease in stent to margin distance or a coronal gain of the tissue. Reduction of pocket depth is a very important aspect of this study. The data obtained from this study supports other findings that a 61 gingivectomy· · does re duce poe ket depth. 15 , Th e resu1 tan t h ea 1·Ing f o 1 - lowing a gingivectomy leads to the formation of a new crevicular sulcus.l6, 20,40,51,52 from this study it has been suggested that the new sulcus is partially reformed within two weeks following a gingivectomy and progres- sively matures and deepens over the next 22 weeks. Therefore it can be seen that although there is a decrease in clinical crevicular depth there is also, a remodeling of the marginal tissue leading to the formation of a new sulcus simultaneously. A scalloping result of tissue dimension was noted in the marginal tissues from facial to interproximal dimensions in all the results. This tends to support the concept of positive architecture.62,63 The character of a gingivectomy produces a more or less horizontal gingival surface, re- moving all extraneous interdental and radicular tissue. It can be seen 23

that this architectural form does not prevail for any length of time. There is a tendency for the healing gingiva to re-establish an archi tectural pattern as described by Ochsenbein and Bohannan63 (1963). In this study there appears to be a tendency for the facial epithelial attachment to migrate apically while the distal interproximal tissue mi grates occlusally and, depending on the location of the tooth, the mesial tissue migrates occlusally or remains constant. This giving Sl~port to the positive architecture concept in tissue but not necessarily in bone. In a study performed in dogs by Wilderman64 alveolar bone was denuded resulting in a net loss of crestal bone and an apical migration of the epithelium at that point. In this study it was observed that the apical migration of the radicular epithelial attachment may have occured. This may be due to various factors. To be considered is the healing potential of the radicular surface of teeth may not be as good as that of the interproximal surface. This could result in the lack of growth or apical shift of the epithelial attachment on the radicular surface. Also due to the thin character of the radicular bone when compared to the inter proximal bone it can be hypothesized that any trauma which would effect bone would have a more profound effect on fragile or weaker structure than on the more stable area. The result would be a down1vard movement of the epithelial tissue at that surface or some other tissue change. The apical movement of bone may also be related to the apical movement of the epithe lial attachment. Our study showed a facial apical movement of all teeth possibly relating the apical movement of bone with the apical movement of the crevicular sulcus. 24 As has long been recognized the teeth move continually toward the midline. This is the so called mesial migration of teeth. 65 Knowing that it takes almost a life time for an entire dental arch to lose .5 to l.'Orrnn in length it is still possible to distinguish the mesial from the

distal side of teeth. It has been stated that it is possible even with this slow movement to distinguish mesial from distal by tissue differences in microscopic specimens. 61 The loose connective tissue areas between the principle bundles of the periodontal ligment on the distal side appear oval

in shape as the result of tension on the fiber bundles. On the mesial side of the same tooth, the fiber bundles in the PDL are rather wavy and less stretched. This indicates that different stimuli may influence the perio dontium on the mesial and distal surfaces of the tooth as a result of physiologic tooth mesial drift. This may be the cause for the discrepency for the difference in the epithelial attachment (measured by the stent to base of crevice value) from migrating occlusally in the same fashion as the distal migration occured. The difference in the bicuspids and molars as compared to the anterior stent to crevice base value's may be due to the age of the sample. Since the mean age of the sample was 29 years of age the amount of mesial drift in the anteriors was at a minimum since most mesial drift occurs in the posterior portion of the dental arch. This area has different physiologic parameters effecting it in a migratory extent. This may have caused the observed increase in both mesial and distal epithelial attachments (decrease in stent to base of crevice values). 25

Our results are consistent in demonstrating a apical migration of the epithelial attachment on the facial surfaces of all teeth tested. There is a discrepency in the movement of the interproximal surface de pending on the location of the tooth in question. It has also been shown that following a gingivectomy there is to be expected gingival recession with the shallowing of the gingival crevice. CJ--lAPTFR VI CONCLUSIONS

1. Clinically there was a difference observed in the healing of the facial, rn.esial-facial and distal-facial surfaces of the anterior, bicus pid and molar teeth. 2. The facial surfaces of the anterior, bicuspid and molar teeth all demonstrated a lowering (in an apical direction) of the epithelial attach ment as observed clinically. 3. The mesial-facial surface of the anterior, bicuspid and molar teeth exhibited variation in the stent to base of crevice measurement depend ing upon the location of the observed teeth. In the anteriors there is a gradual decrease in the stent to base of crevice measurement or a coronal gain in the epithelial attachment. In the bicuspid location there is a slight decrease in the stent to base of crevice measurement or a coronal gain in epithelial attachment. In the molar region there is an increase in the stent to base of crevice measurement or a coronal loss in the epithelial attachment. 4. TI1e distal-facial surfaces of the anterior, bicuspid and molar teeth all demonstrate clinically a rise (in an occlusal direction) of an epithelial attachment. 5. All mesial-facial and distal-facial surfaces exhibit a de crease in stent to marginal tissue or a net coronal gain in the marginal tissue, irregardless of tooth location. 6. The marginal tissue on the facial aspect of the observations varied with tooth location: the anterior and bicuspid teeth behave similarly

26 27 with a fairly constant value remaining for the marginal tissue, in the molar region there appears to be a decrease in the stent to marginal tis sue distance or a coronal gain of the tissue. Q-lAPTF.R VII

Slli'''MARY

A study was conducted to examine clinically the sequential heal ing of the marginal gingiva and epithelial attachment following a gingi vectomy procedure. A total of 53 (fifth-three) teeth (14 molars, 13 anteriors, and 26 bicuspid) were utilized from 13 (thirteen) quadrants in four patients. Three measurements were taken on each tooth: crevicular nenth, stent to marginal tissue, and stent to base of crevice. Fach measurement was taken at three different locations on each tooth: facial, mesial-facial, and distal-facial. Gingivectomies were carried out both buccally and lingually for reduction of supra bony pockets. The mean + standard deviation pre operative pocket depth for anteriors was 3.0mm ~ 0.2mm, 3.3mm ~ O.Smm, and

1. Srrrrn + 0. 6mm for mesial-facial, distal-facial and facial respectively.

For bicuspids the mesial-facial pre-operative pocket depth was 3.5rrrrn +

O.Smm, distal-facial 3.lrrrrn ~ 0.4mm, and facial 1.9rrrrn ~ O.Smm. The molar pre-operative pocket depth was 4.0mm ~ 0.7mm, 3.8rrun ~ 0.7mm and 2.8rrun ~ 0.8mm respectively for mesial-facial, distal-facial and facial surfaces. The remodeling of the gingival margin was monitored by using clinical measure ments with a William's periodontal probe. The technique used to obtain the data was as follows: a poly vinyl stent was constructed for each surgical quadrant. This stent covered the occlusal surface of the involved teeth. Fixed points of reference were placed on each stent, at three seperate locations (mesial-facia1, facial,

28 29

and distal-facial), for each tooth measured. Pre- and post-operatively, the following measurements were taken: a) the distance from the marginal tissue to the base of the crevice, b) the base of the crevice to the mar gin of the stent, and c) the margin of the tissue to the margin of the stent. A standard gingivectomy to the base of the clinical pocket was performed and a periodontal dressing was applied for one week. ~1easure ments utilizing the stent (fixed point of reference) were taken at 2, 4, 12, and 24 weeks post-surgical for the healing margin. The data from all the patients was collected, seperated and categorized into three types: (1) anteriors, (2) bicuspids, and (3) molrs, at three different locations for each measurement interval. The mean and standard deviation of each category for each measurement interval was de termined for crevice depth, stent to marginal tissue and stent to base of gingival crevice. The findings indicate that there is a difference in the anterior, bicuspid and. molar teeth with regard to the marginal tissue and coronal gain or loss of attachment apparatus. The excisional reduction of the gingival crevice to Ormn depth was altered by gingival remodeling during the healing phase. This remodeling took place over a 24 week period after surgery and clinically appeared as a variation in healing, depending on the location of the tooth and surface area examined. This research was intended to be a pilot study to determine the effect of a gingivectomy on the marginal position and sulcular depth of the newly formed gingival sulcus. Ideally furth~r research should be undertaken 30 before any broad conclusions can be made. Additional research with greater sample size, varying controls, and histologic sections should be undertaken to determine more accurately the exact parameters of the attached epithe lial reformation. The findings of this paper does support a value for fur ther investigation. 0-IAPTF.R VI I I TABLES 31

TABLE 1.

,....., ('j ~ ~ •rl 1:'0 b.G Q)'4o !-; Cf) '-' ('j~ ('j ~-<~ ;:E_N PQQ) Clin u ,....., 0 ""''-' O•rl ;::l'-'""' -1-l -1-l> ANTERIORS u Q) Q) •rl ...c: -1-l;::::l -1-l!-< >-1-l ~ Cf) ~c...;; Q)P,. Q) Cf) Q) (Mean .:!:_ S.D.) !-; Q) -1-l ...... -1-llH c...;q (/) f:<. lfJO

Initial mesial-facial 3.0 + 0.2 2.7+1.0 5.7+1.1 Measurements distal-facial 3.3 + 0.5 2.8+1.1 6.1 + 0. 7 facial 1.5+ 0.6 6.2+1.3 7.0 + 2.1

0 Day mesial-facial 0.0 + 0.0 Post-Surgical distal-facial 0.0 + 0.0 facial 0.0 + 0.0

2 Weeks mesial-facial 1.2+ 0.6 5.1 + 0.8 6.3 + 0.8 Post-Surgical distal-facial 1.3+0.4 5.2 + 0.9 6.5 + 0.8 facial 1.0+ 0.3 6.9+1.0 7.8 + 0.9

4 Weeks mesial-facial 1.4+ 0.5 4.8 + 0.8 6.2 + 0.6 - fl Post-Surgical distal-facial 1.5+ 0.4 5.0 + 0.9 or.. .•' Vo -I facial 0.8+0.4 7.0 + 0.8 7.7 + 0.9

12 Weeks mesial-facial 1.8+ 0.4 4.0 + 0.7 5.9 + 0.9 Post-Surgical distal-facial 1.9+0.5 4.3 + 0.7 6.3+1.1 facial 1.1+ 0.3 7.0 + 1.2 7.9 + 1.1

24 Weeks mesial-facial 2.0 + 0.5 3.6 + 1.0 5.5 + 0.9 Post-Surgical distal-facial 2.0 + 0.5 3.8 + 0.7 5.8 + 0.9 facial 1.0+ 0.2 7.0 + 1.3 8.1 + 0.9

All measurements in millimeters. 32

TABLE 2.

,...., ('j !=: •r-1 Q) bil Ul l-o ('j l-o j::Q Q) ~ ('j u rl O·r-1 0 ;::j .j..)> .j..) BICUSPIDS u Q) Q) •r-1 ...c: .j..) l-o .j..) ;::j >.j..)r---. ~Ur---. !=:Ulr---. Q) P..,rl Q) N Q)U)t-r) (Mean ~ S.D.) l-o Q) .j-)~'11= .j..) •r-1 "* Ut=<'----'"* (f)Q'----' WE-<'----'

3.5 + 0.5 6.0 + 1.1 2.5 + 0.9 Initial mesial-facial - Measurements distal-facial 3.1 + 0.4 5. 5 + 0.9 2.4 + 0.9 facial 1.9+ 0.5 6.4 + 1.2 4.5 + 1.3

0 Weeks mesial-facial 0.0 + 0.0 Post-Surgical distal-facial 0.0 + 0.0 facial 0.0 + 0.0

2 Weeks mesial-facial 1.4 + 0.5 6.1 + 1.1 4.8 + 1.3 Post-Surgical distal-facial 1.5+ 0.5 6.0 + 1.0 4.6 + 1.2 facial I.O+ 0.3 6. 7 + 1.1 5.7 + 1.1

4 Weeks mesial-facial 1.7 + 0.4 6.1 + 0.9 4.7 + 1.0 - Post-Surgical distal-facial 1.7 + 0.4 6.1 + 0.9 4.5 + 1.1 facial l.O+ 0.3 6.8 + 1.2 5.9 + 1.2

12 Weeks mesial-facial 2.0 + 0.5 6.2 + 1.0 4.1 + 0.8 Post-Surgical distal-facial 1.9+ 0.5 6.0 + 1.1 4.0 + 0.9 facial 1.0+ 0.2 6.7 + 1.1 5.6 + 1.2

24 Weeks mesial-facial 2.3 + 0.5 6.0 + 0.8 3.8 + 0.7 3.6 + 0.8 Post-Surgical distal-facial 2.0 + 0.4 5.6 -+ 0.9 facial 1.1 + 0.4 6.8 + 1.1 5.7 + 1.1

All measurements in millim2ters. 33

TABLE 3.

r--1 n:l ~ •r-i (].) b.O Ul !-< n:l !-< I=Q (].) ~ n:l u r--1 O·r-i 0 ;::) ~> ~ u (J) (].) MOLARS •r-i ...c: ~!-< ~;::) >~,.-.. ~u,-.. ~U),-.. (].) p,,.....; (].) N (].)U)t-0 !-< (].) ~4-1*' ~ •r-i *' (Mean + S.D.) U~'--'*' U'JO'--' U) E-< '--'

Initial mesial-facial 4.0 + 0.7 6.5 + 0.8 2.5 + 0.9 Measurements distal-facial 3.8 + 0.7 6.4 + 0.9 2.5 + 0.9 facial 2.8 + 0.8 6.8 + 1.0 4.0"+1.0

0 Weeks mesial-facial 0.0 + 0.0 Post-Surgical distal-facial 0.0 + 0.0 facial 0.0 + 0.0

2 Weeks mesial-facial 1.8+0.7 6.1 + 0.7 4.4 + 1.0 Post-Surgical distal-facial L5+o.5 6.0 + 0.8 4.4 + 0.7 facial 1.2 + 0.5 6.5 + 0.8 5.3 + 0.9

4 Weeks mesial-facial 2.1 + 0.6 6.1 + 0.9 4.0 + 1.1 Post-Surgical distal-facial 1.9"+0.4 5.8 + 0.8 3.9 + 0.9 facial 1.3+0.6 6.3 + 1.1 5.0"+1.2

12 Weeks mesial-facial 2.3 + 0.5 6.2 + 0.9 3.9 + 0.7 Post-SuTgical distal-facial 2.3 + 0.6 6.1 + 0.8 3.8 + 0.8 facial 1.5+0.5 6.8 + 1.0 5.3 + 0.9

24 Weeks mesial-facial 2.5 + 0.4 6.3 + 0.6 3.8 + 0.8 Post-Surgical distal-facial 2.1+0.6 5.R + 0.6 3.8+1.2 facial 1.6+ 0.6 6.8 + 1.0 5.o+Lo

All measurements in millimeters. PATIENT #1. 34

Crevicular Depth N

3. mesial-facial 5.0 2.5 3.0 2.5 3.0 distal-facial 4.0 2.0 2.5 1.5 2.0 facial 3.0 1.0 2.0 1.5 2.0

4. mesial-facial 3.0 1.0 2.0 1.0 2.0 distal-facial 3.0 2.0 2.0 2.0 2.0 facial 1.5 1.0 1.0 1.0 1.0

5. mesial-facial 4.0 1.5 2.0 1.5 2.0 distal-facial 2.5 1.5 1.5 1.0 1.5 facial 1.0 1.0 1.0 0.5 1.0

6. mesial-facial 3.0 1.0 2.0 2.0 2.0 distal-facial 4.0 1.0 2.0 1.5 2.0 facial 1.0 1.0 1.0 1.5 1.0

11. mesial-facial 3.0 1.0 1.5 2.0 2.0 distal-facial 3.0 2.0 2.0 2.0 2.5 facial 1.0 1.0 1.0 1.0 1.0

12. mesial-facial 3.0 1.5 2.0 1.5 distal-facial 3.0 1.0 1.5 1.5 facial 1.0 1.0 1. 1.0

13. mesial-facial 4.0 1.5 2. 2.0 distal-facial 4.0 2.0 2.5 1.5 facial 3.0 1.5 2.0 1.0

14. mesial-facial 5.0 1.5 2.5 1.5 distal-facial 4.0 1.5 2.0 2.0 facial 2.5 1.0 1.0 1.0

19. mesial-facial 5.0 2.5 3.0 3.0 3.0 distal-facial 5.0 2.5 2.0 1.5 2.0 faci.'ll 1.0 1.0 2.0 2.0 2.0 35 •r-i fJ Patient #1 ro !-< Ul Ul ,....;

20. mesial-facial 4.0 2.0 2.0 2.0 2.5 distal-facial 4.0 2.5 2.5 2.0 3.0 facial 1.0 1.0 1.0 1.0 1.0

21. mesial-facial 4.0 2.0 2.0 1.5 2.5 distal-facial 3.0 1.0 1.5 1.5 2.0 facial 2.0 1.0 1.0 1.0 1.0

22. mesial-facial 3.0 2.0 2.0 1.5 2.5 distal-facial 4.0 2.0 2.0 2.0 2.0 facial 1.0 1.0 1.0 1.5 1.0

27. mesial-facial 3.0 2.5 2.5 2.0 distal-facial 4.0 1.5 1.5 2.0 facial 1.0 1.5 1.5 1.5

28. mesial-facial 4.0 1.5 2.5 1.5 distal-facial 2.5 1.5 1.5 1.0 facial 1.0 1.0 1.0 1.0

29. mesial-facial 3.0 1.5 2.5 2.0 distal-facial 3.0 2.0 2.5 1.0 facial 2.0 1.5 1.0 1.0

30. mesial-facial 5.0 2.5 3.0 2.0 distal-facial 4.0 1.5 2.5 2.5 facial 2.5 1.5 1.5 2.0

All measurements in millimeters. Q) :> •rl PATIENT #1 36 .f-)ro 1-< VJ VJ ....., Q) VJ VJ ~ ~ Q) ~ ~ Q) .~& Q) Q) Stent to Base .f-) I Q) ~ ~ •rl Q) :s: of Crevice ~ N ~ 1-< ....., HP., N """ """N 3. mesial-facial 6.0 5.5 6.0 5.5 6.0 distal-facial 5.5 5.0 5.0 4.5 5.0 facial 6.0 6.0 6.0 5.5 6.0

4. mesial-facial 5.5 6.0 6.0 5.0 5.5 distal-facial 5.0 6.0 5.5 6.0 5.5 facial 6.0 6.0 6.0 6.0 6.0

5. mesial-facial 6.0 7.0 6.0 5.5 6.0 distal-facial 4.5 6.5 5.5 5.0 5.0 facial 5.0 7.0 7.0 6.0 6.0

6. mesial-facial 5.5 6.0 6.5 6.0 5.5 distal-facial 6.0 6.5 6.5 6.0 5.5 facial 8.0 8.0 8.5 8.0 8.5

11. mesial-facial 7.0 7.0 7.0 7.0 7.0 distal-facial 5.0 7.0 6.5 6.5 7.0 facial 8.0 9.0 8.0 9.0 8.5

12. mesial-facial 5.0 6.5 6.0 6.0 6.0 distal-facial 5.0 6.0 5.5 6.0 4.5 facial 6.0 7.5 7.0 7.5 7.0

13. mesial-facial 6.0 6.0 5.5 6.0 5.5 distal-facial 6.0 5.5 5.5 5.0 5.5 facial 5.5 5.0 6.0 5.5 5.5

14. mesial-facial 7.0 4.5 5.5 5.0 6.0 dist:Il-facial 6.5 5.0 5.0 5.0 5.0 facial 5.0 6.0 5.0 5.0 6.0

19. mesial-facial 7.0 6.5 6.5 6.5 6.0 distal-facial 7.0 7.5 7.0 6.5 5.5 facial 8.0 5.5 6.0 8.0 7.0 37 Q) •r-1> +-l Patient #1 ttl ~ U) U) Continued .-iQ) U) ,..:.:; ,..:.:; ,..:.:; ~ Q) Q) .~6 Q) Q) .j-.)1 Q) Q) ~ ~ Stent to Base •r-1 Q) ;:;::: ;3:: 1=: ~ N '<:!" of Crevice HO,. N '<:!" ...., N

20. mesial-facial 5.0 5.5 6.0 6.0 5.5 distal-facial 6.0 6.5 7.0 6.0 6.0 facial 6.0 7.0 7.0 7.0 6.0

21. mesial-facial 6.0 6.0 7.0 5.5 5.5 distal-facial 4.0 5.0 6.0 5.5 5.0 facial 7.0 7.0 7.0 6.5 6.0

22. mesial-facial 4.0 7.0 7.0 5.0 5.5 distal-facial 5.0 6.0 7.0 6.0 5.0 facial 6.0 7.5 7.5 8.0 7.0

27. mesial-facial 4.0 7.0 5.5 5.0 4.5 distal-facial 5.0 6.5 6.5 6.0 5.0 facial 6.0 7.0 7.5 6.0 7.0

28. mesial-facial 5.0 6.5 6.5 5.5 6.0 distal-facial 4.5 6.0 6.5 6.0 5.5 facial 6.0 8.0 7.5 7.5 7.5

29. mesial-facial 5.0 6.0 6.5 6.5 6.0 distal-facial 5.0 6.0 6.5 5.5 5.5 facial 6.0 7.5 7.0 7.0 7.0

30. mesial-facial 7.0 6.5 7.0 6.5 6.0 distal-facial 7.0 6.0 6.5 5.5 6.0 facial 6.5 7.5 7.0 8.0 7.5

All mesurements in milli~eters. (!) ::> •r-1 ~ 38 Cii !-< PATIENT #1 Ul Ul .-ill) Ul Ul ~ ~ ~ ~ (!) (!) .~5 (!) (!) Stent to Marginal (!) ~ I £ £ •r-1 (!) ;s: £ Tissue ~ !-< N <::t HO... N <::t r-i N

3. mesial-facial 1.0 3.0 3.0 3.0 3.0 distal-facial 1.5 3.0 2.5 3.0 3.0 facial 3.0 4.5 4.0 4.0 4.0

4. mesial-facial 2.5 5.0 4.0 4.0 3.5 distal-facial 2.0 4.0 3.5 4.0 3.5 facial 4.5 5.0 5.0 5.0 5.0

5. mesial-facial 2.0 5.5 4.0 4.0 4.0 distal-facial 2.0 5.0 4.0 4.0 3.5 facial 4.0 6.0 6.0 5.5 5.0

6. mesial-facial 2.5 5.0 4.5 4.0 3.5 distal-facial 2.0 5.5 4.5 4.5 3.5 facial 7.0 7.0 7.5 7.5 7.5

11. mesial-facial 4.0 6.0 5.5 5.0 5.0 distal-facial 2.0 5.0 4.5 4.5 4.5 facial 7.0 8.0 7.0 8.0 7.5

12. mesial-facial 2.0 5.0 4.0 4.5 4.0 distal-facial 2.0 5.0 4.0 4.5 3.0 facial 5.0 6.5 6.0 6.5 6.0

13. mesial-facial 2.0 4.5 3.5 4.0 3.5 distal-facial 2.5 3.0 3.0 3.5 3.0 facial 2.0 4.0 4.0 4.0 3.5

14. mesial-facial 2.0 3.0 3.0 3.5 3.0 distal-facial 2.5 3.5 3.0 3.0 3.0 facial 2.5 5.0 4.0 4.0 3.5

19. mesial-facial 2.0 4.0 3.5 3.5 3.0 distal-facial 2.0 5.0 5.0 5.0 3.5 facial 5.0 4.5 4.0 6.0 5.5 (I) 39 .,.,:> Patient #1 .j....l cd Continued ~ (f) (f) ..-1CI..l (f) ~ ~ Zl ~ (I) (I) .~& (I) (I) (I) (I) Stent to Marginal .j....l I (I) ;?: ;?: .,., (I) ~ ;?: Tissue ~ ~ N "<:~" HP.. N "<:~" .--1 N

20. mesial-facial 1.0 3.5 4.0 4.0 3.0 distal-facial 2.0 4.0 4.5 4.0 3.0 facial 5.0 6.0 6.0 6.0 5.0

21. mesial-facial 2.0 4.0 5.0 4.0 3.0 distal-facial 1.0 4.0 4.5 4.0 3.0 facial 5.0 6.0 6.0 5.5 5.0

22. mesial-facial 1.0 5.0 5.0 4.0 3.0 distal-facial 1.0 4.0 5.0 4.0 3.0 facial 5.0 6.5 6.5 6.0 6.0

27. mesial-facial 1.0 4.0 3.0 3.0 2.5 distal-facial 1.0 5.0 5.0 4.0 3.0 facial 5.0 5.5 6.0 5.5 5.5

28. mesial-facial 1.0 5.0 4.5 4.0 4.0 distal-facial 2.0 4.5 5.0 5.0 4.0 facial 5.0 7.0 6.5 6.5 6.0

29. mesial-facial 2.0 4.5 4.0 4.5 4.0 distal-facial 2.0 4.0 4.0 4.5 4.0 facial 4.0 6.0 6.0 6.0 6.0

30. mesial-facial 2.0 4.0 4.0 4.5 4.0 distal-facial 3.0 4.5 4.0 4.0 4.0 facial 4.0 6.0 5.5 6.0 6.0

All measurements in millimeters. Q) :> PATIENT #2 40 •r-1 +Jco ~ If) If) ,.....;Q) If) If) ~ ~ ~ ~ Q) Q) .~& Q) Q) Q) +J I Q) £ ::s: •r-1 Q) £ ::s: Crevicular Depth ~ ~ N "

3. mesial-facial 4.0 2.0 2.0 2.0 2.0 distal-facial 4.0 1.0 1.5 2.5 2.5 facial 3.0 1.0 1.0 2.0 2.0

4. mesial-facial 3.0 2.0 2.0 1.5 2.0 distal-facial 3.0 2.0 2.0 1.5 2.0 facial 2.0 0.5 1.0 1.0 1.0

5. mesial-facial 3.0 2.0 2.0 1.0 1.5 distal-facial 3.0 2.0 1.5 1.5 2.0 facial 2.5 0.5 1.0 1.0 1.0

6. mesial-facial 3.0 0.5 1.0 1.0 1.5 distal-facial 3.0 1.5 1.5 1.0 1.5 facial 2.0 1.0 1.0 1.0 1.0

7. mesial-facial 3.5 2.0 2.0 2.0 2.5 distal-facial 3.5 1.0 1.5 1.0 1.5 facial 2.0 1.0 . 5 0.5 1.0

8. mesial-facial 2.5 1.0 1.0 1.0 1.5 distal-facial 3.0 1.0 1.5 1.5 2.0 facial 2.5 1.0 0.5 1.0 1.0

12. mesial-facial 4.0 2.5 2.0 3.5 2.0 distal-facial 4.0 1.0 1.5 2.0 2.0 facial 2.0 1.0 1.0 1.0 1.0

13. mesial-facial 3.5 2.5 2.0 2.5 2.5 distal-facial 3.5 2.0 2.0 2.0 2.0 facial 2.5 1.0 1.0 1.5 1.5

14. mesial-facial 4.0 2.5 2.0 2.5 3.0 distal-faci::J.l 5.Q 1.5 1.5 3.0 3.0 facial 3.0 2.5 1.5 2.0 2.0 +J ro 41 Patient #2 h (f) (f) r-i

28. mesial-facial 3.0 1.5 2.0 2.5 2.5 distal-facial 3.0 1.0 2.0 1.5 1.5 facial 2.0 1.5 1.0 1.0 1.0

29. mesial-facial 3.5 1.5 1.5 2.0 2.0 distal-facial 3.0 2.0 2.0 2.0 2.0 facial 2.0 1.5 1.0 1.0 1.0

30. mesial-facial 3.0 2.5 2.0 2.0 2.5 distal-facial 3.0 1.0 2.0 2.5 3.0 facial 3.0 1.5 1.0 1.0 1.0

All measurements in millimeters. Q) 42 !> PATIENT #2 •rl .jJ til 1-o Vl Vl MQ) Vl Vl ~ ~ ~ ~ Q) Q) .~& Q) Q) Q) Stent to Base .j-JI Q) £ ;:;::: •rl Q) ;:;::: £ of Crevice 1=: 1-o N ~ HP, N ~ M N

3. mesial-facial 6.5 6.0 5.0 5.5 5.5 distal-facial 6.0 5.0 4.0 6.0 5.0 facial 6.5 6.0 5.0 7.0 7.0

4. mesial-facial 5.0 4.0 4.5 4.5 4.5 distal-facial 5.0 5.0 5.0 4.5 4.5 facial 5.0 4.5 5.0 5.0 5.0

5. mesial-facial 5.5 5.0 5.0 4.5 4.5 distal-facial 4.5 4.0 4.0 4.0 4.0 facial 5.5 5.0 5.0 5.0 5.0

6. mesial-facial 6.0 5.5 5.5 5.0 4.5 distal-facial 6.0 5.5 5.5 4.5 4.5 facial 7.5 7.0 6.0 7.0 7.0

7. mesial-facial 7.0 6.5 6.5 6.0 6.0 distal-facial 6.5 5.5 5.5 5.0 5.0 facial 7.0 6.5 6.5 6.5 7.5

8. mesial-facial 5.5 5.0 5.0 4.0 4.0 distal-facial 6.5 6.0 6.0 5.5 5.5 facial 7.0 8.0 7.5 8.0 8.0

12. mesial-facial 6.0 5.5 5.0 5.0 6.0 distal-facial 5.0 4.5 4.5 7.0 5.0 facial 5.0 5.0 7.0 7.5 7.5

13. mesial-facial 4.5 4.5 5.0 4.0 5.5 distal-facial 4.5 5.0 4.5 5.5 4.0 facial 3.5 5.5 5.0 5.5 5.5

14. mesial-facial 3.5 6.0 4.5 6.0 5.5 distal-facial 7.0 6.0 4.5 5.5 6.0 facial 5.5 7.0 4.5 6.5 6.5 Q)

•ri> 43 +.J Cli Patient #2 Continued 1--< U) U) ,-1Q) U) U) ~ ~ ~ ~ Q) Q) .;:15 Q) Q) Q) Stent to Base +.J I £ :s: •ri Q) £ £ of Crevice !=! 1--< N "<::t HA., C''i "<::t r-1 N

28. mesial-facial 7.0 6.0 6.0 4.5 6.5 distal-facial 5.0 5.0 5.0 6.5 4.5 facial 7.0 6.5 5.5 6.0 6.0

29. mesial-facial 5.5 5.0 5.0 5.0 5.0 distal-facial 6.0 5.5 6.0 5.0 5.0 facial 6.0 6.0 6.0 5.5 5.5

30. mesial-facial 5.0 5.5 5.0 5.5 5.5 distal-facial 6.0 5.0 6.0 5.0 5.5 facial 6.0 5.5 5.0 5.0 5.0

All measurements in millimeters. 44 PATIENT #2 ~ ell !-< (/) (/) M

3. mesial-facial 2.5 4.0 3.0 3.5 3.5 distal-facial 2.0 4.0 2.5 3.5 2.5 facial 3.5 5.0 4.0 5.0 5.0

4. mesial-facial 2.0 2.0 2.5 3.0 2.5 distal-facial 2.0 3.0 3.0 3.0 2.5 facial 3.0 4.0 4.0 4.0 4.0

5. mesial-facial 2.5 3.0 3.0 3.5 3.0 distal-facial 1.5 2.0 2.5 2.5 2.0 facial 3.0 4.5 4.0 4.0 4.0

6. mesial-facial 3.0 5.0 4.5 4.0 3.0 distal-facial 3.0 4.0 4.0 3.5 3.0 facial 5.5 6.0 6.0 6.0 6.0

7. mesial-facial 3.5 4.5 4.5 4.0 3.5 distal-facial 3.0 4.5 4.0 4.0 3.5 facial 5.0 5.5 6.0 6.0 6.5

8. mesial-facial 3.0 4.0 4.0 3.0 2.5 distal-facial 3.5 5.0 4.5 4.0 3.5 facial 5.5 7.0 7.0 7.0 7.0

12. mesial-facial 2.0 3.0 3.5 3.5 3.5 distal-facial 1.0 3.5 3.0 3.0 3.0 facial 3.0 4.0 6.0 6.5 6.5

13. mesial-facial 1.0 2.0 3.0 3.0 3.0 distal-facial 1.0 3.0 2.5 2.0 2.0 facial 1.0 4.5 3.0 4.0 4.0

14. mesial-facial 1.5 3.5 2.5 3.0 2.5 distal-facial 2.0 4.5 3.0 3.0 3.0 facial 2.5 4.5 3.0 4.5 4.5 (!) 45 •rl> +-' PATIENT #2 ell r-.. (f) (f) Continued M(!) (f) (f) ~ ~ ~ ~ (!) (!) .;:1 g (!) (!) Stent to Marginal +-'I (!) £ £ •rl (!) ::s: £ Tissue ~ r-.. N '<:j- H0... ('~ '<:j- M N

28. mesial-facial 4.0 4.5 4.0 4.0 4.0 distal-facial 2.0 4.0 3.0 3.0 3.0 facial 5.0 5.0 5.5 5.0 5.0

29. mesial-facial 2.0 3.5 3.5 3.0 3.0 distal-facial 3.0 3.5 4.0 3.0 3.0 facial 4.0 4.5 5.0 4.5 4.5

30. mesial-facial 2.0 3.0 3.0 3.0 3.0 distal-facial 3.0 4.0 4.0 3.0 2.5 facial 3.0 4.0 4.0 4.0 4.0

All measurements in millimeters. (]) PATIENT #3 46 .,...;> +.J til tf) ~ tf) .-i

19. mesial-facial 3.0 1.0 2.0 2.0 2.0 distal-facial 4.0 1.0 2.0 2.0 2.0 facial 2.0 0.5 0.5 1.0 1.0

20. mesial-facial 3.0 1.0 1.0 2.0 2.0 distal-facial 3.0 1.0 1.5 2.0 1.5 facial 2.0 0.5 0.5 1.0 0.5

21. mesial-facial 4.0 1.0 1.5 2.5 3.0 distal-facial 3.0 1.0 1.5 2.5 2.0 facial 2.0 0.5 0.5 0.5 1.0

22. mesial-facial 3.0 0.5 1.5 2.0 2.5 distal-facial 4.0 1.0 1.0 2.5 2.5 facial 2.0 0.5 0.5 1.0 1.0

27. mesial-facial 2.5 1.0 1.0 2.0 2.0 distal-facial 3.0 0.5 1.0 2.0 2.0 facial 1.0 0.5 0.5 1.0 1.0

28. mesial-facial 3.0 0.5 1.5 2.0 2.5 distal-facial 3.0 1.5 1.5 2.0 2.0 facial 1.5 0.5 0.5 1.0 2.0

29. mesial-facial 4.0 1.0 1.5 2.0 1.5 distal-facial 3.0 0.5 1.0 2.0 2.0 facial 2.0 0.5 0.5 1.0 0.5

30. mesial-facial 4.0 0.5 1.5 2.5 2.0 distal-facial 3.0 1.0 1.5 2.0 1.5 facial 2.0 0.5 0.5 1.0 1.0

31. m.csiai-iacial 4.0 1.0 2.0 2.0 2.0 distal-facial 3.0 1.0 2.0 3.0 2.0 facial 2.0 0.5 0.5 1.0 0.5 All measurements in millimeters. ~ 47 •r-1> ~ PATIENT #3 C'(j ~ Ul Ul Ul Ul ~ ~ '"'""~ ~ ~ ~ ~ .;215 ~ ~ ~ Stent to Base ~ :s: £ •r-1~· ~ £ ;s: of Crevice ~~ N oo:::t N HP.,. N oo:::t '"'""

19. mesial-facial 6.5 6.5 8.0 7.0 7.0 distal-facial 8.0 6.5 6.5 7.0 7.0 facial 7.0 7.5 7.0 8.0 7.5

20. mesial-facial 6.0 6.5 6.0 6.0 6.0 distal-facial 6.0 6.0 6.0 7.0 6.5 facial 7.0 6.0 6.0 7.0 6.5

21. mesial-facial 6.5 6.5 6.5 6.0 7.0 distal-facial 6.0 6.5 6.5 7.5 6.5 facial 6.5 7.0 6.5 7.0 7.0

22. mesial-facial 5.0 5.5 6.0 5.5 5.5 distal-facial 6.0 6.0 6.5 8.5 6.0 facial 8.0 7.0 7.5 7.5 7.0

27. mesial-facial 5.5 6.0 6.0 6.0 6.0 distal-facial 6.0 6.5 5.5 6.0 5.5 facial 7.0 7.5 7.0 7.0 7.5

28. mesial-facial 5.5 6.0 6.0 5.0 5.5 distal-facial 6.0 6.5 6.5 6.0 6.0 facial 7.0 6.0 6.0 6.0 7.5

29. mesial-facial 7.0 6.0 5.5 6.5 5.0 distal-facial 5.0 5.5 5.5 5.0 6.0 facial 6.0 6.0 6.0 6.0 6.5

30. mesial-facial 6.5 5.5 6.0 6.0 6.0 distal-facial 6.0 6.0 6.0 7.0 6.5 facial 6.5 6.5 6.0 6.5 7.0

31. mesial-facial 7.0 5.0 5.5 5.5 6.5 distal-facial 7.0 6.5 6.0 7.0 6.0 facial 7.5 7.0 6.5 6.5 7.0 All measurements in millimeters. Cl) PATIF.NT #3 48 •rl> +J ttl !-< r.n ,....; Cl) r.n r.n ~ ~ ~ ~ Cl) Cl) Stent to Margin .~5 Cl) Cl) Cl) Cl) +J I Cl) ;?.-: ::s:: Tissue •rl Cl) ~ ;s: ~ !-< N o:::r HP, N o:::r ,....; N

19, mesial-facial 3.5 5.5 6.0 5.0 5.0 distal-facial 4.0 5.5 4.5 5.0 5.0 facial 5.0 7.0 6.5 7.0 6.5

20. mesial-facial 3.0 5.5 5.0 4.0 4.0 distal-facial 3.0 5.0 4.5 5.0 5.0 facial 5.0 5.5 5.5 6.0 6.0

21. mesial-facial 2.5 5.5 5.0 3.5 4.0 distal-facial 3.0 5.5 5.0 5.0 4.5 facial 4.5 6.5 6.0 6.5 6.0

22. mesial-facial 2.0 5.0 4.5 3.5 3.5 distal-facial 2.0 5.0 5.5 3.5 3.5 facial 6.0 6.5 7.0 6.5 6.0

27. mesial-facial 3.0 5.0 5.0 4.0 4.0 distal-facial 3.0 6.0 4.5 4.0 3.5 facial 6.0 7.0 6.5 6.0 6.5

28. mesial-facial 2.5 5.5 4.5 3.0 3.0 distal-facial 3.0 5.0 5.0 4.0 4.0 facial 5.5 5.5 5.5 5.0 5.5

29. mesial-facial 3.0 5.0 4.0 4.5 4.0 distal-facial 2.0 4.5 4.5 3.0 4.0 facial 4.0 5.5 5.5 5.0 6.0

30. mesial-facial 2.5 5.0 4.5 3.5 4.0 distal-facial 3.0 5.0 4.5 5.0 5.0 facial 4.5 6.0 5.5 5.5 6.0

31. mesial-facial 3.0 5.0 3.5 3.5 4.5 distal-facial 4.0 5.5 4.0 4.0 4.0 facial 5.5 6.5 6.0 5.5 6.5

All measurements in mill imeters. 49 +-l ro ~ C/l C/l .-4

3, mesial-facial 3.5 2.0 1.5 3.0 2.5 distal-facial 3.0 1.5 1.5 2.5 2.0 facial 2.0 1.5 1.0 1.0 2.0

4. mesial-facial 3.0 1.5 1.0 2.5 2.5 distal-facial 3.0 1.5 1.5 2.0 1.5 facial 2.0 1.0 1.0 1.0 1.0

5. mesial-facial 4.0 1.0 1.5 2.0 1.5 distal-facial 2.5 1.0 1.0 2.0 2.0 facial 2.0 1.0 1.0 1.0 1.0

6. mesial-facial 3.0 0.5 1.0 2.0 1.0 distal-facial 3.0 1.0 1.0 2.0 2.0 facial 1.5 0.5 0.5 1.0 0.5

11. mesial-facial 3.0 1.0 1.0 2.0 2.5 distal-facial 3.0 1.0 1.0 2.0 2.5 facial 1.0 1.0 . 5 1.0 1.0

12. mesial-facial 5.0 1.0 1.5 2.0 3.5 distal-facial 3.0 1.0 1.0 2.5 2.0 facial 2.0 1.0 1.0 1.0 1.0

13. mesial-facial 3.5 1.0 1.0 2.0 3.0 distal-facial 3.0 1.5 1.5 3.0 2.5 facial 2.0 1.0 1.0 1.0 2.0

14. mesial-facial 3.0 1.5 1.0 2.0 3.0 distal-facial 3.5 2.0 1.5 3.0 2.0 facial 3.0 1.0 2.0 2.0 2.0

19. mesial-facial 3.0 1.0 1.5 2.5 2.0 distal-facial 3.5 1.5 1.5 2.5 1.0 facial 3.0 1.5 1.5 2.0 2.0 Q) 50 .,...,> +-' Cil PATIENT #4 h tf) tf) rl Q) tf) tf) ..:.:: ..:.:: Continued Q) Q) ..:.:: ~ Q) .:S g ·~\ C) ._, ,...... ':> +-' I c :=:. .,..., Q) '<- Crevicular Depth ~ ..- '<:j- ~ h N HP-< N '<:j- rl N

20. mesial-facial 4.0 1.0 1.0 2.5 2.0 distal-facial 2.5 1.0 1.5 2.5 2.5 facial 2.0 1.0 1.0 1.0 1.5

21. mesial-facial 3.0 1.5 1.5 2.0 3.0 distal-facial 3.0 1.0 1.5 2.5 0.5 facial 2.0 1.0 1.0 1.0 1.0

22. mesial-facial 3.0 1.0 1.0 2.0 2.0 distal-facial 3.5 1.5 1.5 2.5 1.0 facial 2.0 1.5 1.5 1.5 1.0

27. mesial-facial 3.0 1.0 1.0 2.0 1.5 distal-facial 2.5 1.5 1.5 2.5 2.5 facial 2.0 1.0 1.0 1.0 1.5

28. mesial-facial 3.0 1.0 1.0 2.0 2.0 distal-facial 4.0 1.5 1.0 2.0 2.5 facial 2.0 1.0 1.0 1.0 0.5

29. mesial-facial 3.5 1.5 1.5 2.5 2.0 distal-facial 3.0 2.0 2.0 2.5 2.0 facial 2.0 1.0 1.0 1.0 1.5

30. mesial-facial 4.0 2.0 2.0 3.0 2.5 distal-facial 4.0 2.0 2.0 3.0 3.0 facial 5.0 1.5 2.0 2.0 2.5

All measurements in millimeters. PATIENT #4 51 (!) > 'M...... C\l ~ U) U) ,..., (!) U) U) ~ ~ ~ ~ (!) (!) Stent to Base .~$ (!) (!) (!) ...... (!) ;s: £ of Crevice 'M (!) ;:;:: £ s:: ~ N o:::t Ht:J.. N o:::t ,..., N

3. mesial-facial 6.5 7.0 6.5 8.0 7.0 distal-facial 5.0 5.5 6.0 6.5 6.0 facial 7.0 7.0 8.0 7.5 8.0

4. mesial-facial 7.0 7.5 6.5 7.5 7.0 distal-facial 5.0 6.0 6.0 6.0 5.5 facial 7.0 7.0 7.5 7.5 7.0

5. mesial-facial 8.5 7.5 8.0 8.0 7.5 distal-facial 7.0 7.0 7.0 7.0 7.0 facial 8.0 8.0 9.0 9.0 8.5

6. mesial-facial 7.0 7.5 7.0 7.5 7.0 distal-facial 7.0 8.0 7.5 7.5 7.0 facial 9.5 9.0 9.0 9.0 10.0

11. mesial-facial 7.0 7.0 6.5 6.5 6.5 distal-facial 6.5 7.0 7.0 7.0 7.0 facial 10.0 9.5 9.0 10.5 10.5

12. mesial-facial 8.0 8.0 7.5 7.5 7.5 distal-facial 6.0 7.5 7.0 6.5 6.0 facial 9.0 8.0 8.5 8.5 8.0

13. mesial-facial 6.0 6.5 6.5 6.5 6.5 distal-facial 5.5 6.5 6.5 7.5 6.5 facial 7.0 7.0 5.5 5.5 8.0

14. mesial-facial 5.5 6.5 5.5 6.5 7.0 distal-facial 6.5 6.0 6.0 6.0 5.0 facial 6.5 6.0 7.0 7.0 6.0

19. mesial-facial 8.0 7.0 7.0 6.5 7.0 distal-facial 5.0 6.5 6.5 6.5 6.0 facial 8.0 7.5 7.5 7.5 8.0 52

(J) •r-1> PATIENT #4 .jJ C\1 Continued ~ lf) r-i (J) lf) lf) ~ ] ~ ~ (J) (J) .~5 (J) (J) (J) (J) Stent to Base "'-' I (J) (J) ;:;:: ;:;:: ·r-1 (J) ;:;:: ;:;:: of Crevice ~ ~ N <::T HP.. N <::T r-i N

20. mesial-facial 6.5 7.0 7.0 7.0 6.5 distal-facial 6.0 6.5 7.0 7.0 6.5 facial 7.0 8.0 8.5 8.0 8.5

21. mesial-facial 6.5 7.5 7.5 7.5 7.0 distal-facial 7.0 7.0 6.5 6.5 7.0 facial 9.0 9.0 8.0 8.0 9.0

22. mesial-facial 5.0 6.0 6.0 6.0 5.0 distal-facial 7.0 8.0 7.5 7.5 6.0 facial 9.0 8.5 9.0 9.0 9.0

27. mesial-facial 5.5 6.0 5.5 6.5 5.0 distal-facial 7.0 6.0 6.5 7.0 6.5 facial 7.0 7.5 8.0 7.5 8.0

28. mesial-facial 7.0 6.0 6.0 6.5 6.0 distal-facial 7.0 8.5 7.5 8.0 7.5 facial 7.0 8.0 7.5 7.0 7.5

29. mesial-facial 6.5 7.0 7.5 8.0 7.0 distal-facial 7.0 7.0 7.0 7.5 6.0 facial 7.0 7.0 7.0 7.0 7.5

30. mesial-facial 7.0 7.0 6.5 7.5 7.0 distal-facial 5.0 6.5 6.0 6.0 6.0 facial 8.5 6.5 7.5 7.5 7.5

All measurements in millimeters. PATIENT #4 53

Q) :> •--! +J ro t/) 1--< t/) rlQ) t/) t/) ,..!:<:; ,..!:<:; ,..!:<:; ,..!:<:; Q) Q) Stent to Margin .~8 Q) Q) Q) Q) +J• Q) Q) ;?.: ;?.: .,..., Q) ;?.: ;s: Tissue N <:::t ~I--< HP,.. N <:::t n N

3. mesial-facial 3.0 5.0 5.0 5.0 4.5 distal-facial 2.0 4.0 4.5 4.0 4.0 facial 5.0 5.5 7.0 6.5 6.0

4. mesial-facial 4.0 6.0 5.5 5.0 4.5 distal-facial 2.0 4.5 4.5 4.0 4.0 facial 5.0 6.0 6.5 6.5 6.0

5. mesial-facial 4.5 6.5 6.5 6.0 6.0 distal-facial 4.5 6.0 6.0 5.0 5.0 facial 6.0 7.0 8.0 8.0 7.5

6. mesial-facial 4.0 7.0 6.0 5.5 6.0 distal-facial 4.0 7.0 6.5 5.5 5.0 facial 8.0 8.5 8.5 8.0 9.0

11. mesial-facial 4.0 6.0 5.5 4.5 4.0 distal-facial 3.5 6.0 8.5 5.0 4.5 facial 9.0 8.5 6.0 9.5 9.5

12. mesial-facial 3.0 7.0 6.0 5.5 4.0 distal-facial 3.0 6.5 6.0 4.0 4.0 facial 7.0 7.0 7.5 7.5 7.0

13. mesial-facial 2.5 5.5 5.5 4.5 3.5 distal-facial 2.5 5.0 5.0 4.5 4.0 facial 5.0 6.0 4.5 4.5 6.0

14. mesial-facial 2.5 5.0 5.5 4.5 4.0 distal-facial 3.0 4.0 4.5 3.0 3.0 facial 3.5 5.0 5.0 5.0 4.0

19. mesial-facial 4.5 6.0 5.5 4.0 5.0 distal-facial 2.0 5.0 5.0 4.0 5.0 facial 5.0 6.0 6.0 5.5 6.0 (!)

•r-i> 54 PATIFNf #4 4-l C'ii ~ Ul Ul Continued M(!) Ul Ul ~ ~ ~ ~ (!) (!) .~& (!) (!) (!) (!) Stent to Margin 4-l I ::s: ;::: •r-i (!) ~ ~ Tissue ~ ~ N <::t H~ N <::t M N

20. mesial-facial 2.5 6.0 6.0 4.5 4.5 distal-facial 3.5 5.5 5.5 4.5 4.0 facial 5.0 7.0 7.5 7.0 7.0

21. mesial-facial 3.5 6.0 6.0 5.5 4.0 distal-facial 4.0 6.0 5.0 4.0 4.5 facial 7.0 8.0 7.0 7.0 8.0

22. mesial-facial 2.0 5.0 5.0 4.0 3.0 distal-facial 3.5 6.5 6.0 5.0 5.0 facial 7.0 7.0 7.5 7.5 8.0

27. mesial-facial 2.5 5.0 4.5 4.5 3.5 distal-facial 4.5 4.5 5.0 4.5 4.0 facial 5.0 6.5 7.0 6.5 6.5

28. mesial-facial 4.0 5.0 5.0 4.5 4.0 distal-facial 3.0 7.0 6.5 6.0 5.0 facial 5.0 7.0 6.5 6.0 7.0

29. mesial-facial 3.0 5.5 6.0 5.5 5.0 distal-facial 4.0 5.0 5.0 5.0 4.0 facial 5.0 6.0 6.0 6.0 6.0

30. mesial-facial 3.0 5.0 4.5 4.5 4.5 distal-facial 1.0 4.5 4.0 3.0 3.0 facial 3.5 5.0 5.5 5.5 5.0

All measurements in millimeters. CHAPTER IX ILLUSTRATIONS 55

Figure 1. Patients master cast with fabricated occlusal stent. 56

Figure 2. Illustration of placement of Williams periodontal probe with occlusal stent on master cast. 57

Figure 3. Postoperative site with stent and Williams probe in place. ~easuring crevicular depth.) 58

Figtire 4. Postoperative site with stent and Williams probe in place. QMeasuring stent to marginal tissue.) 59

Figure 5. Postoperative site with stent in place. BIBLIOGRAPHY 60 BIBLIOGRAPHY

1. Stahl, S.S., Slaukin, H.C., Yamada, L., Levine, S.: Specu lations About Gingival Repair. Journal of Periodontology, 43: 395, 1972. 2. Listgarten, M.A., Melcher, A.H., &Zarb, G.A.: Normal Develop ment, Structure, Physiology, and Repair of Gingival Epithelium. In Gingival Epithelium. Oral Science Review, 1:3, 1972, 3. Novaes, A.B. et al.: Visualization of the Microvascularization of the Healing Periodontal Wound. III. Gingivectomy. Journal of Periodontology, 40: 359, 1969.

4. Listgarten, M.A.: Electron ~1icroscopic Features of the Newly Formed Epithelial Attachment After Gingival Surgery. Journal of Periodontal Research. 2: 46, 1967. 5. Innes, P.B.: An Electron Microscopic Study of the Regeneration of Gingival Epithelium Following Gingivectomy in the Dog. Journal of Periodontal Research. 5: 196, 1967. 6. Thilander, H., Hugoson, A.: The Border Zone Tooth- Enamel and Epithelium After Periodontal Treatment. Acta Odontology Scan dinavia. 28: 147, 1970. 7. Listgarten, M.A.: Periodontal Tissue Repair Over Surgically Ex posed Dentin and Cementum Surfaces. I.A.D.R. Abstr. No. 473, 1971. 8. Stahl, S.S., Weinek, J.N., Benjamin, S. &Yamada, L.: Soft Tissue Healing Following Curettage and Root Planning. J. of Periodontology. 42: 678, 1971. 9. Henning, F.R.: Epithelial Mitotic Activity After Gingivectomy. J. of Periodontal Research. 4: 319, 1969.

10. Goldman, H.M.: The Development of Physiologic Gingival Contour by Gingivoplasty. Oral Srugery, Oral Medicine, and Oral Pathology. 3: 879, 1950.

11. Goldman, A.M. Gingivectomy: Indications, Contraindications~ and Method. American J. Orthodontic and Oral Surgery. 32: 323, 1946 ..

12. Coolidge, E.D.: Elimination of the Periodontal Pocket in the Treat ment of Pyorrhea. J. of American Dental Association. 25: 1627, 1938. 61

13. Goldman, H.M.: Gingivectomy. Oral Surgery. 4: 1136, 1951. 14. Orban, B.: Surgical Gingivectomy. J. of American Dental Association. 32: 701, 1945. 15. Goldman &Cohen. Periodontal Therapy. 8th Edition. Mosby Company, 1973. 16. Ramfjord &Costich. Healing After Simple Gingivectomy. J. of Periodontology. 34: 401, 1963.

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57. Ramfjord, S.P., Engler, W.O. and Hiniker, J.I.: A Radioauto graphic Study of Healing Following Simple Gingivectomy. The Connective Tissue. J. of Periodontology 37: 179, 1966. 58. Stahl, S.S., Witkin, G.J., Cantor, M., and Brown, R.: Gingival Healing. II. Clinical and Histological Repair Sequences Fol lowing Gingivectomy. J. of Periodontology 39: 109, 1968. 59. Orban, B.: Current Concepts Concerning Gingival Anatomy. Epithe lial Attachment (The Attached Epithelial Cuff). Dent. Clinic. N. Am. 705, 1960. 60.. Waerhaug, J.: Current Concepts Concerning Gingival Anatomy: The. Dynamic F~ithelial Cuff. Dent. Clinic. N. Am. 715, 1960. 61. Orban, B.: Periodontics; Grant, Stern, Everett. 4th Edition. C.V. Mosby COP1pany, 1972. 62. Ochsenbein, C.. : Rational for Periodontal Osseous Surgery. Dent. Clinic. North Amer, Phila., Saunders, ~arch, 1960. 63. Ochsenbein, C., and Bohannan, M.: The Palatal Approach to Osseous Surg. J. of Periodontology. 34: 1963. 64. Wilderman, M.N., Wentz, P.M. 0 Orban, B.: Histogenesis of Repair After MUcogingival Surgery. J. of Periodontology 31: 283, 1960. 65. Stein, G. & Weinmann, J.P.: Die Physiologische Wanderuns der Zahne: z Stomat. 23: 733, 1925 .. APPROVAL SHEET

The thesis submitted by Carl J. Laudando has been read and approved by the following committee: Doctor Anthony Gargiulo Chairman, Department of Periodontics Doctor Lawrence Jenkins Assistant Professor, Department of Periodontics Doctor Patrick Toto Professor, Chairman of Oral and General Pathology Doctor Hal MCReynolds Associate Professor, Department of Histology Doctor Daniel Grant Clinical Professor, Department of Periodontics The final copies have been examined by the director of the thesis and the signature which appears below verifies the fact that any necessary changes have been incorporated and that the thesis is now given final approval by the Committee with reference to content and form. The thesis is therefore accepted in partial fulfillment of the requirements for the degree of Masters of Science.

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