Infrabony Pocket

The Infrabony Pocket: Classification and Treatmentfby Henry M. Goldman, d.m.d.* and D. Walter Cohen, d.d.s.**

IN recent years, the principal clinicallesion of periodontal disease, the pocket,has been studied clinically, radiographi-

cally, and histopathologically. As a resultof these investigations it became apparentthat the pocket had to be classified on

the basis of the location of the bottom ofthe pocket in its relationship to the alve-olar crest. Arising from these studies came

the classification of pockets: (1) supra-bony or supracrestal and (2) infrabony or

subcrestal. The suprabony pocket is definedas a pathological sulcus where the baseof the pocket is coronal or occlusal to thealveolar crest, while the infrabony is de-fined as a pathological sulcus where thebottom of the pocket is apical to the alve-olar crest. The suprabony pocket was fur-ther subdivided into the gingival or pseudo-pocket and the periodontal pocket. Thisclassification had merit not only from a

teaching standpoint but also on a therapeu-tic basis.

Much attention has been focused on theinfrabony type of pocket in recent publi-cations and this lesion has been describedas amenable to either the new attachmentprocedure or osseous surgery for its eradi-cation. It became obvious to us from our

observations of clinical as well as humanskull material that a classification of theinfrabony pocket was necessary not onlyfor academic purposes but also to serveas a rational basis for the selection of a

method of treatment.

fPresented at the Academy of PeriodontologyMeeting in Miami, Fla. on October 3 1, 19 57.

Trofessor of Periodontology and Chairman ofDept., Graduate School of Medicine, Univ. ofPenna.; Director of Riesman Dental Clinic, BethIsrael Hospital, Boston, Mass.

**Assistant Professor of Periodontology and ViceChairman of Dept. Graduate School of Medicine,Univ. of Penna.; Assistant Professor of Oral Medi-cine and Oral Pathology, Univ. of Penna. School ofDentistry.

The proposed classification of the infra-bony pocket is on a morphologic basis andis dependent on the location and numberof osseous walls remaining about thepocket. Much of this material studied was

from human skulls where the gingivae andother soft tissues were intact. The locationof the bottom of the pocket was estab-lished, the material radiographed, and thenthe soft tissue was removed. The remainderof the material was taken from clinicalcases under treatment.

The first group of infrabony pockets de-scribed have three osseous walls. Thesetrough-like defects are commonly observedin the interdental areas where one finds an

intact proximal wall as well as the buccaland lingual walls of the alveolar process.Some of these lesions may be shallow witha broad orifice to the osseous part of thepocket while others may be narrow anddeep. Three wall infrabony pockets are oc-

casionally observed on the lingual surfacesof maxillary and mandibular teeth wherethe lingual plate is intact as well as bothproximal walls. Less frequently noted are

infrabony pockets located on the buccalsurfaces of maxillary and mandibular pos-terior teeth. It is not uncommon to findthem extending around the tooth to in-volve 2 or sometimes 3 surfaces. Whenthe infrabony pocket is circumferentialand involves the four surfaces of the tooth,it actually has four osseous walls (buccal,lingual, mesial, distal). This occurs infre-quently.

The determination of the position as wellas the number of osseous walls is of con-

cern to the clinician during his examinationprocedures.

The radiograph can be of great aid indemonstrating the presence of buccal andlingual and proximal walls in a pocket oc-

curring in the interdental area. Placing a

radiopaque object such as a gutta perchapoint, a periodontal probe, or Hirschfeld

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The Infrabony Pocket Page 273

point will enable one to locate the bottomof the pocket. Many times the buccal andlingual walls will register on the radiographand one has to relate the radiographic ob-servations with the clinical picture. Takinga probe and running it buccally and lingu-ally one will engage either soft tissue orthe osseous walls. If there is a doubt a flapcan be laid back to see the outline of thepocket or a fine straight needle can bepassed through the buccal and lingual softtissue to map out the height of the crests.

Two wall infrabony pockets may be seenin the interdental areas. If the buccal andlingual walls are intact, but the proximalwall has been destroyed, the lesion is com-

monly referred to as an intraosseous inter-proximal crater. Because the base of thepocket is apical to either the buccal or

lingual wall, this falls into the classificationas an infrabony pocket. One may find thatthe two walls remaining are the buccalwall and the proximal wall or the lingualwall and the proximal wall. In these situa-tions there is usually just a curtain of softtissue remaining on the surface where theosseous wall has been destroyed.

One of the interesting aspects of theskull material is that when the soft tissuehas been stripped out of the bony defect,the osseous surface may be made of cancel-leous supporting bone especially in the in-terproximal wall. Sometimes a more densesclerotic wall of bone was noted under-neath the soft tissue. This latter situationusually appeared more radioopaque on theradiograph.

The infrabony pocket which has one os-seous wall remaining is usually seen in theinterdental area. Here it is most common toobserve the presence of a proximal wallwith the buccal and lingual walls destroyed.This can be detected clinically by probingor passing a needle through the soft tissue;radiographic examination may also be help-ful. It is much less common to find thebuccal wall intact with loss of the proxi-mal and lingual walls or to have a lingualwall intact with the loss of the proximaland buccal.

In setting up a classification of this sortwe realized that many of these infrabonypockets were not pure examples of eitherone, two, or three walls. It was quite com-

mon to find various combinations of osseous

walls. We frequently observed areas wherethe apical part of the pocket had more

walls than the coronal part. For example,we frequently noted a pocket where thebottom part of the pocket had 3 wallswhile in the coronal part the buccal andlingual walls were destroyed leaving justthe one proximal wall. There are also pock-ets with 3 osseous walls at the apical part

INFRABONY POCKET

THREE OSSEOUS WALLS

a proximal, buccal &> lingual wallsb. buccal, mesial &> distal wallsc. lingual, mesial &. distal wallsFour osseous walls- buccal, lingual,

mesial & distal

TWO OSSEOUS WALLS

a buccal & lingual (crater) wallsb. buccal & proximal wallsC lingual &> proximal walls

ONE OSSEOUS WALL

a. proximal wallb. buccal wallc lingual wall

COMBINATION

a. 3 walls • 2 wallsb- 3 walls • 2 walls * 1 wallc- 3 walls +1 walld- 2 walls 1 wall

Fig. 1. Classification of infrabony pockets.

Fig. 2. Drawing of the various bony topographies associated with infrabony pockets. In the upperdrawing, on the distal aspect of the left lateral incisor, a bony defect can be seen. This defecthas osseous walls on the lingual, labial, and proximal; the latter serves as the mesial housing ofthe cuspid. This is classified as a three-walled infrabony pocket when the soft tissue is present.Distal to the left central incisor, the osseous housing of a two-walled infrabony pocket can be seen.The labial bone has been destroyed ; the palatal and proximal walls remain intact. Mesial to theright lateral incisor the bony topography of a one-walled infrabony pocket is shown. Note that boththe labial and lingual walls have been destroyed, with only the proximal wall remaining. In thecenter of the photograph on the right, the two-walled defect is shown in higher power, while onthe left, the one-walled is illustrated. In the lower portion of the photograph, three bonv walls maybe seen.


Pig. 3. Photograph of a skull showing a bonydefect on the buecal aspect of the second molarassociated with a three-walled infrabony pocket.In the radiograph a probe has been inserted intothe bony defect. Note that the bnccal osseouswall does not show up in the radiograph andonly the base of the bony defect can be determined.

and 2 walls as the cemento-enamel junctionis approached. We have also encounteredsituations in which there were two walls atthe apical portion with one wall coronally.

This classification has served as a basisfor our selection of therapy since we real-ize today that all infrabony pockets cannotbe eliminated by means of new attachment,but one must employ other procedures, aswill be brought out subsequently. This de-termination of which method is to be em-

ployed will usually depend on the topog-raphy of the lesion.

CLINICAL EVALUATION

One of the important aspects in thetreatment of the infrabony pocket is the

visualization of the topography of thepocket. The outermost limits of the de-tached gingival tissue must be explored.Since disease affects the entire circumfer-ence of the tooth in question, therapy mustbe directed toward healing this tissue. Alsothat portion below the bone crest must beoutlined in respect to the surfaces of thetooth. At times this latter defect is con-

fined to a single surface (most usually theproximal aspect) but many times is tortu-ous in nature, the deepest point being lo-cated on a different surface of the tooththan the orifice of the main portion of thepocket. Even in instances where a singlesurface pocket is encountered, small lateralpouches may be found. Not infrequently,what is thought to be an infrabony pocketon the mesial aspect of a maxillary anteriortooth, after probing is found to involve thepalatal aspect as well.

Thus, infrabony pockets assume theshape of various combinations of short-and-deep and narrow-and-broad defects. Theymay be located on a single surface of atooth or may encroach upon adjacent sur-faces. Not uncommonly, one may find an

infrabony pocket which is characterized bya narrow orifice, but at the base the defectis bulbous in form causing the pocket toresemble a bottle.

Radiographic examination of the infra-bony pocket discloses a vertical resorptivelesion but gives no information concerningthe base of the pocket. Actually, therefore,

I'Mg. 4. A three-walled osseous housing of aninfrabony pocket on the palatal aspect of amaxillary molar may be seen. Note the destruc-tion of the distal and mesial proximal walls aswell as the palatal, resulting in a trough extend-ing around the tooth.

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Fig. 5. The clinical photograph and radiographsof a two-walled infrabony pocket on the dislalof Hie maxillary cuspid. Note that once theg'mgival tissue has been removed the bone existsonly on the palatal and proximal aspects, theentire labial wall having been destroyed. Radio-graphically, there is a vertical resorptive lesion.One cannot determine from this radiographwhether the pocket is one, two, or three-walled.Only by clinical examination can this be ascer-tained. Passing a needle through the gingivafrom buccal to palatal, and palatal to bticcal,will give the information desired. Entering fromthe buccal aspect, if the needle cannot penetrateany distance, then a buccal wall exists. If itpasses through then no wall exists at all. If itpasses completely through to the outer surfaceon the palatal aspect, both walls are missing.Thus, in reversing the penetration, one can tellexactly what walls are present.

Fig. 6. Photograph of skull material and itsradiograph. Note that on the distal aspect of thesecond molar there is a crater-like defect. How-ever, the defect slopes towards the distal of thesecond molar and here the destruction takes ona broad resorbed defect. Radiographically, withthe probe in position, one notes that in this areathe bony housing is below that of the proximalwall. This may be classified as a broad, one-walled infrabony pocket defect.

one cannot recognize by radiology the pres-ence of a pocket at all, for a vertical lesionmay be present but the gingival tissue maybe intact with no pocket formation. Radi-ographs taken after opaque materials havebeen inserted into the gingival retractedarea (pocket) disclose the depth and con-tour of the pocket in respect to the boneoutline. Unfortunately, this is one planeand a three dimensional picture cannot bevisualized from this examination. Yet acertain amount of information can be ob-tained. The radioopaque materials are

Hirschfeld points, gutta percha probes,and bismuth solutions impregnated in cot-ton.

Important, therefore, is the recording ofthe size and general topography of the in-


Fig. 7. Photograph and radiograph of skullmaterial showing a mesially tilted third molar.Note that there is a broad resorptive trough onthe mesial aspect of the tooth. This representsthe bony defect associated with a one-walledinfrabony pocket.

Fig. 8. The photograph and radiograph of aone-walled infrabony pocket on the mesial as-pect of a maxillary left central incisor. One canvisualize the bony defect associated with a one-walled infrabony pocket.

Fig. 1). Photograph and radiograph of skullmaterial showing a combination of varioustopographies. At the base of the bony defectthree walls are evident. More occlusally, twowalls are present, while at the occlusal level, onewall, that of the proximal, remains. This typeof defect must be carefully determined in treat-ment. The exact topography of the lesion musthe visualized prior to the operative procedurefor such a combination of walls would necessar-ily change the mode of treatment from that of athree-walled infrabony pocket. Clinical exam-ination, and radiographic examination with radioopaqtie material, are necessary for the diag-nosis. (Courtesy of Dr. John Prichard)

frabony pocket, especially that part sub-merged below the crest of the alveolar proc-ess. This consideration refers to the softtissue portion of this periodontal lesion.Even more important, however, is the to-

pography of the bony housing. Althoughradiographically the defect has been de-scribed as a vertical resorptive lesion, not

always can information concerning thebuccal-lingual walls be derived therefrom.

Infrabony pockets are seen in which thedefect is bordered by three walls althoughmore than one surface of the tooth is in-volved. This is often found on the palatal-

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Fig. 10. Photomicrograph of an infrabonypocket on the mesial aspect of a maxillary cus-

pid. Seen in the photomicrograph is the lateralincisor on the left and the interdental septumand the cuspid on the right. Covering the inter-dental septum is gingival tissue. The base of thepocket Is below the interdental crest of thelateral incisor. Note the pocket depth on thelateral incisor is extremely shallow. This photo-micrograph was taken from a specimen withthree walls.

proximal aspect of the maxillary teeth. Al-though radiographic examination is an aidin determination of the outline of the bonywalls especially if radioopaque materials areinserted into the pockets before the radio-graphs are taken, it by no means givesaccurate information. It is necessary thatthe clinical examination disclose the out-line of the bone crest in relation to thebase of the pocket. Probing in the pocketreveals the point to which detachment hasoccurred in relationship to the tooth.Therefore, in addition, the operator must

probe by a sharp instrument (explorer or

Periodontology

Fig. 11. Photomicrograph of an infrabonypocket on the mesial aspect of a maxillary tiltedmolar. Note the distance between the tooth andbone. This photomicrograph was taken from acase with a two-walled infrabony pocket, thebuccal wall being mesial.

Fig. 12. This is a photomicrograph of an infra-bony pocket on the mesial aspect of a tiltedmaxillary molar. In this instance the specimencontained only a proximal wall, the buccal andpalatal being missing. Because of the wide dis-tance between tooth and bone, this may beclassified as a broad one-walled infrabonypocket.


Fig. 13. Clinical examinations of infrabonypockets are essential in diagnosis. The varioustopographies that may be present can be deter-mined fully by clinical probing. Radiographicexamination, while informative, is not in itselfconclusive. Probing, from the buccal and lingualaspects, to determine whether these walls arepresent, is necessary. Also important is thedetermination of the location of the crestal por-tions of the walls that may be present.

Fig. 14. Radiographs showing the base of aninfrabony pocket. Associated with the infrabonypocket is a vertical resorptive lesion of the boneseen radiographically. One cannot determinefrom this whether the buccal and lingual hous-ing is present. Hence, clinical examination isnecessary. Also, one cannot determine where theepithelial attachment, locating the base of thepocket, exists. By inserting a radioopaque mate-rial into the pocket prior to the taking of theradiograph, this factor can be established. Notethat in this instance the base of the pocket co-incides with the base of the bony defect.

some sort of needle) for the location of thecrest of the alveolar process. Should, forexample, a proximal infrabony pocket beexamined, one can pass a needle bucco-lin-gual from one side and then to the other,to determine whether these walls are pres-ent. Thus by exploration of this nature can

the full outline, both soft tissue and bone,be determined.

ETIOLOGY

Visualization of the topography of theinfrabony pocket is an essential for its clin-ical management, but equally important isan understanding of its causation, for ther-apy without consideration for correction ofthe etiologic factors will probably not yieldfavorable results. Therefore, a detailed clin-ical examination is obligatory. Tooth anat-

omy as well as tooth position should beinspected. Teeth without contour associ-ated with heavy wide alveolar processesoften show infrabony pockets and verticalresorptive lesions of the bone housing be-cause the disease process is focused to thepart directly adjacent to the tooth surface.Mandibular molar teeth are sometimes so

affected. The relative uneven levels of ad-jacent marginal ridges and cemento-enameljunctions with some degree of tilting of the

teeth may result in the infrabony type ofpocket formation should a gingival diseaseprocess be initiated by any local causation(calculus, food impaction, etc.) Thus, theposition of the tooth in respect to the alve-olar housing and buccal bone, the contact

points between teeth and the tilting ofteeth must be considered. These and likeconditions are local environmental factorswhich can initiate the infrabony pocketprocess.

Another important factor in the etiologyof the infrabony pocket is the occlusaltraumatic lesion. It must be emphasized,

Fig. 15. Radiographs of infrabony pockets withradioopaque material inserted. Nute that in thisinstance in contrast to Figure 14 the bases of thepockets do not coincide with the bottom of thebony defect.


Fig. 16. Radiograph of an infrabony pocketassociated with food impaction and an open con-tact between two molars. Although there aremany causes for infrabony pockets, local en-vironmental factors usually contribute to theiretiology.

however, that occlusal traumatism cannot

cause pocket formation, since the latter isessentially a soft tissue lesion. There is nev-

ertheless the possibility of the existence ofthe two factors being present at the same

time; first pocket formation caused by anyof the local factors (calculus being themost prominent) and second, the occlusaltraumatic lesion affecting the attachmentapparatus (cementum-periodontal mem-

brane-bone) in the crestal region. Withthese two factors operating an infrabonypocket will result once the gingival andoriginal transseptal fibers have been de-stroyed by the continuing inflammatoryprocess.

It is therefore necessary for the oper-ator to understand that infrabony pocketsmay result from any combination of factorswhich can allow the base of the pocket to

migrate apically alongside the tooth withthe bone housing being affected only on

one side causing the topographic relation-ship described previously.

Infrabony pockets also occur in thatclinical entity termed periodontosis. Sincethis disease is found so rarely, the operatorshould usually base his examination on theabove factors. The clinical signs and symp-toms of periodontosis are so characteristicthat the diagnosis will be soon entertainedby the examiner.

Fig. 17. Radiograph of an infrabony pocket onthe mesial aspect of a mandibular third molar.In this instance the second molar had been ex-tracted, allowing the third molar to move mesi-ally. Because or occlusal traumatism and localgingival inflammation due to calculus deposits,and an open contact allowing for food impaction,an infrabony pocket developed.

THERAPY

Therapy of the infrabony pocket must

be directed towards the elimination of thesigns and symptoms. For consideration ofthe elimination of the causation of the in-frabony pocket, the following factorsshould be recognized and corrected, if pos-sible:

1. Tooth anatomy-proximity of roots

and width of interdental septum.2. Relative position of adjacent mar-

ginal ridges, cemento-enamel junctions andcrest morphology.

3. Tilting of the tooth in group rela-tionships.

4. Tilting of the solitary tooth.

5. Position of the tooth in respect to

alveolar housing and basal bone.6. Contact points and resultant food

impaction.7. The occlusal relationships of the

tooth.

8. Presence of calculus.

9. Causation by the disease process peri-odontosis.

Therefore, correction of the etiologic fac-tors and methods of alleviating symptomsprior to the therapeutic operative procedure


Fig. 19. Diagrams showing motion which isnecessary to remove tissue at the base of thepocket. A lingual to buccal or buccal to lingualstroke is very effective, as is seen in this dia-gram. It is necessary to remove the entire con-tents of the tooth-bone trough.

may at times be necessary. Tooth anatomyconducive to food impaction, uneven mar-

ginal ridges, tilting of teeth and occlusaltraumatism should be corrected before theoperative procedure to secure a new attach-ment is attempted. Grinding to correct flatfacets, adjustment of the occlusal relation-ships, levelling of the marginal ridges,placement of restorations to close contact

points or to restore physiologic anatomy ofthe marginal ridges, correction of the oc-

clusal anatomy, by the crowning of a toothmay be necessary. Any attempt to treat an

infrabony pocket without regard to theetiologic factor may result in failure.

Should mobility of the tooth be present,temporary splinting should be utilized tostabilize the tooth prior to the operation.Usually orthodontic welded bands are em-

Fig. 20. This is a photomicrograph of an infra-bony pocket illustrating the two zones which canbe set up arbitrarily in infrabony pockets. Thefirst, sulcular epithelium in the underlying tis-sue together with the surface of the tooth, andthe second, the dense collagen fibers which runover the bone. The importance of the removal ofthese collagen fibers cannot be overstressed.

ployed although in the anterior part of thedentition, the stainless steel acrylic splintmay be used. The mobile tooth should not

terminate the temporary splint since thistype of splint results in a cantilever effectof the loose tooth. Greater security is ob-tained by extending the splint from a

strongly held tooth to another secure toothwith the mobile tooth in the center. In thisway the splint is rigid and the affectedtooth cannot be moved by occlusal forces.It must be emphasized that the occlusalrelationship must be checked once thesplint is placed into position, since any pre-maturity in occlusal contact on the teethincorporated in the splint will still cause a

movement of the tooth and even mayloosen the splint itself. Also important isthe fact that occasionally in the cuspidregion the splint must be extended around


Fig. 18. Photographs of a step-by-step procedure of a three-walled infrabony pocket on the

mesial of a maxillary left central incisor. In "A" the pocket is being probed, determining that thebuccal and lingual walls were present. The base of the pocket was established at the location of

the bony defect. In "B" after the gingival tissue above the bony crest had been excised and thefrenum incised, the entire contents of tissue between tooth and bone was removed, results of whichcan be seen in "C" and "D." Note that a trough-like defect remains. Bleeding occurs and is allowedto continue. The defect is covered with tinfoil in "E" and "F" and in "G" and "H" covered withpack. One week later the pack had been removed (I) and one can note the healing which had takenplace. The photograph (J) was taken two weeks after the operation. (K) radiograph taken threemonths after the time of operation. The gingiva was firm, pink, and adherent. A millimeter probewas inserted into the sulcus and only one millimeter of depth is present. Thus, a healthy sulcusexists. Note the radiographic changes which have occurred in this period of time. The teeth are

now in contact, which was not so before operation. Thus, not only was the infrabony pocket elimi-nated but the involved tooth reverted back into its original position.


Fig. 21. Radiographs of an infrabony pocket onthe distal aspect of a maxillary lateral incisor.The base of the pocket could be located at theapex of the tooth, distal of the tooth but notinvolving the pulp tissue. The tooth tested vital.After operative procedure "C" a probe couldnot be inserted. Healing is seen in "D" and "E."Numerous radiographs had been taken through-out the course of ten years, all showing a dis-tinct healing of the bone. A new lamina durahad been established and the tooth was firm andin good position. In "F" the radiograph repre-sents the status of the alveolar supporting struc-tures ten years later.

the corner of the arch, to the posterior andthereby take advantage of bilateral splint-ing action.

SELECTION OF THERAPEUTIC PROCEDURE

The objective of treatment is to elimi-nate the pocket and establish a crevice withas near zero depth as possible.

Two major methods of therapy for theinfrabony pocket have been developed. Thefirst consists of curettment of that portion

Fig. 22. Before-and-after radiographs showingthe healing in the therapy of a three-walledinfrabony pocket. One can superimpose oneradiograph on another, thus establishing thatthe measurement of the length of the teeth areexact. Probe shows that there has been severalmillimeters of regeneration of bone.

below the bone crest with gingivectomyfor the part above the alveolus to enhancethe possibility of formation of new ce-

mentum, bone and periodontal membrane.The entire tissue between tooth and boneis removed by this debridement. The sec-

ond method reduces the alveolus to a pointcoinciding with the base of the pocket; thisconstitutes an osteoectomy. In order to fa-cilitate accessibility a flap may be reflectedto approach the operative site. Of impor-tance in the selection of one of these oper-ative procedures is the evaluation of theamount of remaining alveolus, and thenumber of lateral walls present. As previ-ously stated, the most favorable type fornew attachment is one with the presenceof three walls. With two walls a slantingfill in of bone may be obtained whereaswhen only the proximal wall is present, no

additional attachment for the affectedtooth may be expected, and osseous surgeryis indicated. The length and shape of the

Vage 284 The Journal of Periodontology

Pig. 23. Before-and-after radiographs showingtreatment of an infrahnny pocket on the mesialaspect of the maxillary cuspid. Note the estab-lishment of a lamina dura in the after radio-gra ph.

root must be considered in that when a

short rooted tooth is to be treated no sacri-fice of bony structure may be possible,while should the roots be long and wellformed, osteoectomy may be a rational pro-cedure. The housing to the adjacent toothalso plays a role in evaluating the selectionof the technical procedure to be used.

As indicated in all periodontal therapeu-tic techniques for pocket elimination, scal-ing of the tooth surfaces to remove all de-posits should be performed prior to thecurettage-gingivectomy operation. Re-moval of calculus allows for the inflamma-tory element to be controlled by the repairprocess, and thus with subsequent therapy,complete repair is enhanced. This holds truefor the suprabony portion as well as theinfrabony part.

TREATMENT OF THE INFRABONY POCKET

WITH THREE OSSEOUS WALLS

Curettage-gingivectomy operation fornew attachment. This procedure is carriedout under local anesthesia with a minimumor no vasoconstrictor. It should be pro-found enough to carry out the operationwithout discomfort to the patient, but stillnot interfere with the establishment of a

blood clot.

Fig. 24. Radiographs of a three-walled infra-bony pocket on the distal of a maxillary cuspid.The base of the pocket could he established al-most at the apex of the tooth. Note the lilling-inof bone postoperatively.

The gingivectomy phase is performed.The gingiva above the bone crest is excisedfollowing the principle of gingivectomy.The resultant gingival margin should becorrectly bevelled and the spillways shouldbe accentuated sufficiently. The interdentalareas should be pyramidal since the infra-bony pocket is included in the treatmentof a segment, the adjacent areas will betreated at the same time. Hence the gingi-vectomy procedure will be performed forthe segment; else, the bevelling of the gin-givectomy will have to be blended into theadjacent areas.

The next step in this operation is to

remove the contents of the pocket by usingany curette or sealer. Necessarily the in-strument will have to be small, especially inthe narrow type of pocket. Often, in addi-tion to a vertical stroke, a horizontal cir-cumferential sweep, short and precise, maybe used. Once this has been accomplished,the soft tissue against the osseous wall is


Fig. 25. Photographs and radiographs of a be-fore-and-after case of the therapy of an infra-bony pocket around a left central incisor. Thetooth tested vital despite the fact that there wasan extreme amount of resorption around it. Theanterior occlusion was adjusted by grinding.Maxillary and mandibular teeth were shortenedso as to create almost an end-to-end occlusion.The procedure was done by raising a flap andremoving all the tissue between the tooth andits bony housing. The lateral incisors weremoved surgically into position and the flap wasreadapted. Healing took place rather rapidly.

Fig. 26. Before-and-after radiographs of athree-walled infrabony pocket on the mesial as-pect of a tilted second mandibular molar. Theiirst molar was extracted many years previously.Orthodontic band splints were made to stabilizethe teeth and the operation performed. Note thebone filling in. in the after radiograph (B).

removed with deft, short, cutting strokes.A small sharp curette serves well for this:the circumferential stroke here also workswell. The instrument is worked towardsthe base of the pocket between the toothand bone, removing all the tissue until thebone wall is felt. Small bits of tissue willbe removed easily; at times, a large segmentwill be excised. The strokes against the bonewall should not be too forceful since if itis curetted further resorption may ensue.

Because of the size of the curettes, even

very small ones, the operator should keepthe instrument against the tooth side. Inthis manner the head of the instrument can

be placed to the base of the bone-tooth de-fect. Curettage in this manner will removethe tissue in the portion submerged belowthe osseous process. It must be stressed thatthis area must be completely denuded oftissue, else the formation of an attachmentapparatus will not occur. It can be seen inFigure 10 that a transseptal fiber groupextends to the tooth in the infrabonypocket between tooth and bone. This trans-

septal fiber group is composed of denseconnective tissue fibers running almostparallel to the tooth surface. Hence shouldonly the inner portion of the soft tissuewall be removed leaving these fibers stillattached, a blood clot will ensue with heal-ing of the soft tissue wall covered by epi-thelium. Thus no new attachment takesplace. However, if all the tissue is debridedfrom the area, the blood clot fills the entirearea between tooth and bone: after healingThe after photograph may be seen. The gingivalarchitecture was physiologic and the radiographshowed the bone to have filled in completely.The lateral incisor which showed a periapieallesion previously was treated endodontically.


Fig. 27. Drawing of the therapy of a two-walledpocket (crater). In this instance there are buccaland lingual osseous spines with loss of boneinterdentally. In the upper drawing one notesthe clinical condition, while in the lower one themarkings for the gingivectomy may be seen. Thegingival tissue is excised. These and followingdrawings by Dr. Leonard Adams.

a new attachment can form. Thus in theoperation one does not consider only theremoval of the epithelial attachment: infact this and all the adjacent tissue is re-

moved between tooth and bone up to theregion where a normal lamina dura exists.Debridement of the tissue at the base (nar-row portion of the infrabony pocket) must

be carefully executed since the instrumentmust be deftly placed and removed with a

minimum of trauma to the osseous wall.

Once this phase of the operation is per-formed, attention is then focused to thetooth. With any suitable instrument, thecleanliness of the tooth should be checked.The operator should be sure that there are

no deposits present but also that the surfaceis smooth. It is possible that gouging de-fects in the tooth surface will affect heal-ing. Also, caution should be taken that thearea above the operative site is not dis-turbed since the tooth will become sensi-tive.

When the curettage phase is completed,a trough results, the extent of which de-pends upon the original topography. This

Fig. 28. Continuation of Fig. 27. In the upperdrawing the gingival tissue has been excised.The gingival nap is now retracted by the use ofa periosteal elevator and alveolar bone is ex-posed. The bone crest can be removed in manyways : by burs, diamond stones, or hand chisels.In the lower drawing a bur is being used to cutthe buccal interdental walls. The bur must besmall enough so that it will not engage the toothinterdentally. Also, care must be taken whenusing burs or diamond stones not to overheatthe bone. A wrater spray is advisable.

area can be inspected by sponging the area

or by using suction to remove the blood.The lateral walls below the bone crestshould be checked to ascertain whether anyfragmentary tissue has been left. This sur-

face should appear smooth.Once this procedure has been completed,

the trough-like area is allowed to fill withblood and the surface is covered by a smallstrip of tinfoil or Telfa to prevent any sur-

gical pack from getting into the area. Thistinfoil should be securely placed so that itwill not be dislodged when the packing isdone. The small piece of pack is first in-serted interdentally over the foil and thenthe buccal and lingual packing is placed.

The pack is allowed to remain for one

week after which it is repacked: usually thearea is protected for about three weeks. Af-ter the first packing the area should be filledwith tissue and it's not necessary to protectthe area with tinfoil or Telfa beneath thepack. The pack is replaced until the tissuesurface appears completely epithelialized.At this time the patient is instructed torinse the area vigorously with hot water.


Fig. 29. Continuation of Figs. 27 and 28. Oncethe buccal alveolar wall has been reduced, handchisels can then be utilized to trim the bone todesired form. The crestal portion should bebevelled to conform to the desired topography.In this instance the lingual portion is allowedto remain in situ, bevelling the buccal portionto blend into the lingual slope. In the lowerphotograph a diamond stone is in place showingthe cut for the interdental sluiceway.

TREATMENT OF THE INFRABONY POCKETWITH ONE OR TWO OSSEOUS WALLS BY

OSTEOECTOMY-OSTEOPLASTY TO

ELIMINATE LESION

Successful results by the curettage-gingi-vectomy operation may not be able to beobtained and in many instances should not

be expected (causative agents cannot beeliminated—local environment cannot bechanged—three walls not present). As hasbeen stressed, consideration of the bone ar-

chitecture is important. When three wallsare present, one may expect almost rou-

Fig. 3(1. Continuation of Figs. 27-29 showing thecovering and pack in position. If zinc oxide isused as a pack, it is wise to use some materialadjacent to the bone -either tinfoil or telfa canhe utilized for this. To insure the retention of thepack, tinfoil may be used to cover the occlusalsurface completely.

Fig. 31. Before-and-after diagram of the ob-jectives of the operation seen in Figs. 27-30. Notethe architecture achieved, comprising the inter-dental spillway and the gingival position aroundthe teeth. The curvature of the gingival aroundthe tooth, making for physiologic topograph, isessential.

Fig. 32. This is a diagram of the osteoectomyprocedure to eliminate a one-walled infrabonypocket. In the upper drawing the gingival tissuehas been excised around the premolars at thebase of the pocket as it was distal to the molar.However, on the mesial aspect of the molar, thegingival tissue was removed down to a pointcoincident with the base of the infrabony pocket.This has resulted in the bone, consisting of themesial wall of the infrabony pocket, being ex-posed. In the lower drawing this bone tissue isbeing removed by means of a revolving bonebur. In order to facilitate the removal of thisbone, slots are made so that the greater bulk ofthe osseous structure can be removed by chisel.

Page 288 The Journal of

Fig. 33. This is a continuation of the procedureviewed in Fig. 32 (osteoectomy to eliminate aone-walled infrahony pocket). In this instancethe bone elevations are being removed by smallrongeurs. However, a mallet and chisel or handchisels also may be utilized to remove the bone.For the final contouring, hand chisels or dia-mond stones are best employed.

tinely that a new attachment will ensue.

In a small percentage, failure is encoun-

tered; this may result from faulty operativetechnique, inaccessibility which cannot beovercome or interferences during the heal-ing stage. Often it is wise to reoperate to

try to obtain a new attachment. In orderto eliminate the infrabony pocket with one

or two osseous walls, osteoectomy-osteo-plasty procedures are utilized, although at

times, the operation for a new attachmentmay be advisable for pockets with two

walls. Not infrequently a "fill" may beobtained.

That procedure which trims the bonecrest so that the base of the resultant sulcuswill be occlusal to the new bone crest istermed osteoectomy. When recontouring isnecessary, the term osteoplasty is used. Thedecision to eliminate an infrabony pocketby levelling the bone crest must be on a

rational basis. The major contraindications

Periodontology

Fig. 34. Continuation of the procedure Illus-trated in Figs. 32 and 33 (osteoectomy to elimin-ate a one-walled infrabony pocket). The bonehas been recontoured by a revolving diamondstone. Note that the ridge has been contouredso that after healing an acceptable gingivalarchitecture, mesial to the first molar, will ensue.Also the ridge will be able to accept a pontic.In the lower drawing the exposed bone has beencovered with telfa and the entire area coveredwith surgical pack.

are the excessive weakening of the supportof an adjacent tooth or the creation of a

gingival form not conducive to self-cleans-ing or difficulty in maintaining cleanlinessby oral physiotherapy.

On the other hand, when the pocket isshallow and not too much support is lost,osteoectomy is definitely indicated. An-other indication is when a broad infrabonypocket exists on the proximal surface wherethere is no adjacent tooth present. Occa-sionally an osteoectomy performed on thebuccal crestal bone in the mandibular molar


Fig. 35. Photographs and radiographs of the treatment of a one-walled infrabony pocket distalto the maxillary left lateral incisor may be seen. The prognosis for the one-walled pocket in thisinstance was negative and, hence, an osteoectomy was performed. The gingival tissue was excisedfollowing which the crest of the bone on the cuspid was removed, levelling it off between the twoteeth. The gingival tissue was recontoured so that no food retention would take place. In the afterphotograph (C) the gingival contour may be seen whereas in "D" the final radiograph is shown.

region where an infrabony pocket extendsinto the interradicular area allows for theelimination of the pocket with resultantacceptable architecture. Contouring the bi-furcation area so that food accumulationwill not occur aids cleansing in that area.

Many such examples can be cited; whenindicated this procedure is a very valuableasset in the armamentarium for pocketelimination.

There are two major procedures for osteo-

ectomy-osteoplasty. The first comprisesthe raising of a flap, full or modified, andsubsequent trimming of the bone crest.After reflecting the flap, the base of thepocket is measured and marked off on theouter bone wall. The bone may be chiselledaway with small enamel chisels or may becut away by bur in a dental engine. Oneadvantage for the use of a chisel is that it


can be easily maneuvered interproximallyand thereby reduce the possibility of goug-ing tooth structure which may occur withburs or stones. Another method is to makesmall holes, outline the contour of the bonefor removal, and then uniting the holes bychisel. The bone contour can then be ac-

complished by either the chisel or bur. Theoperator, however, must be warned thatwhen a bur is used, care must be taken thatthe tooth is not engaged less defects bemade. Bone files, necessarily small, are alsouseful: they must be sharp and maneuver-

able. The debris is removed by flushing withwarm saline water. Once the base is reached,

\ M f i

Fig. 36. Radiographs of two infrabony pockets(A) mesial to the maxillary central incisors.These were one-walled pockets and the prognosisfor regeneration was negative. An osteoectomywas performed removing the interdental spur.The gingival tissue was then recontoured creat-ing a saddle area in this region. The gingivaehealed, becoming firm, pink, and well-attached.

the crest should be rounded and smooth-ened by diamond stones so that no de-formity will occur once the gingival flap isreplaced. Mention must be made that theinner wall of the gingival flap must bedebrided before replacement. The flapshould be carefully replaced and tautly andsecurely sutured into place: it is often nec-

essary to trim the gingiva in order not to

have too much tissue in the interdentalareas and not to allow the flaps to be looselyreadapted. A mattress suture is often help-ful.

The other method is to mark off the baseof the pocket on the outer surface by theuse of a modified Crane-Kaplan pocketmarker; a probe can also be used to demar-

cate the outline of the pocket and then torecord the markings on the outer gingivae.A gingivectomy should be outlined so thatno severe deformity results after the opera-tion. Thus, the adjacent areas must be sur-

veyed and contoured for desired results.After removal of the soft tissues the bonecrest is denuded by reflecting the soft tissuewith a periosteal elevator placing a small,sharp chisel at an acute angle against thebone crest, the bone can be trimmed to de-sired proportions. A small mallet may beused for the blow although hand pressurecan be utilized. Telfa is then carefullyadapted over the bone and then a surgicalpack placed.

Each method has its advantages and dis-advantages. The gingivectomy procedureoffers the opportunity for obtaining a bet-ter gingival topography and also any ofthe fold extension operations can be per-formed simultaneously.

The two wall infrabony pocket in whichthe buccal and lingual walls remain whilethe proximal wall is destroyed is referredto as a crater. Osteoectomy is usually per-formed to eliminate this lesion. It is some-times desirable to allow the lingual crest toremain and ramp the crest bucally. Thisdoes not produce too much of a deformityand still allows the patient to cleanse andmassage the interdental area where the tipof the papilla has been placed in the lingualpart of the interproximal area.

The infrabony pocket with one osseouswall is also best treated by the osteoectomy-osteoplasty procedure. The gingivectomy isperformed and then the tissue is reflectedrevealing the infrabony pocket. Usually theone remaining wall is a proximal septumand this is eliminated by chisels or burs.The osseous tissue is smoothed with dia-mond stones before placing the telfa andpack.

TREATMENT OF THE COMBINATION TYPESOF INFRABONY POCKETS

The clinician will encounter infrabonypockets where the number of osseous walls


may vary in different parts of the same

pocket. Most frequently 3 walls will be ob-served at the apical part of the pocket withone and/or two osseous walls at the coronalpart of the pocket. In these situations theone or two wall part of the pocket iseliminated by osseous surgery while thethree wall part is prepared for new attach-ment by the curettage-gingivectomy pro-cedure. Thus combinations of proceduresare selected depending on the morphologyof these combination types of infrabonypockets.

references

Bell, D. G.: A Case of Reattachment? J. Perio-dont. 8:3 0, 1937.

Beube, F.: A Radiographic and Histologie Studyon Reattachment, J. Periodont. 23:1 58, 1952.

Cross, W. G.: Bone Grafts in Periodontal Disease,a preliminary report, The Dental Practitioner, 6:98,1955.

Friedman, N.: Periodontal Osseous Surgery:Osteoplasty and Osteoectomy, J. Periodont. 26:257,1955.

Goldman, H. M. and Cohen, D. W.: Periodontia,4th Edition, C. V. Mosby, St. Louis, 1957.

Goldman, H. M.: A Rationale for the Treatmentof the Intrabony Pocket, J. Periodont. 20:83, 1949.

Goldman, H. M., Schluger, S. and Fox, L.: Perio-dontal Therapy, C. V. Mosby, St. Louis, 1956.

Hirschfield, L.: Calibrated Silver Points forPeriodontal Diagnosis and Recording, J. Periodont.24:9, 1953.

Linghorne, W. J. and O'Connell, D. C.: Studiesin the Reattachment and Regeneration of the Sup-porting Structures of the Teeth, J.D.R. 34:164,1955.

Prichard, J.: The Infrabony Technique as a Pre-dictable Procedure, J. Periodont. 28:202, 1957.

Schaeffer, E. M.: and Zander, H. A.: HistologieEvidence of Reattachment of Periodontal Pockets,Paradent. 7:101, 1953.

Schluger, S.: Osseous Resection—A Basic Principlein Periodontal Surgery, Oral Surg., Oral Med., andOral Path., 2:316, 1949.

Schluger, S.: Surgical Techniques in Pocket Elim-ination, Texas D.J., 70:246, 1952.

"Williams, C. H. M.: Rationalization of PeriodontalPocket Therapy, J. Periodont. 14:66, 1943.

Yuktanandana, I.: Bone Graft in the Treatmentof Intra-bony Periodontal Pockets, Alabama DentalReview, 5:17, 1957.

MRS. LORRIE HILL HONORED

All members of the American Academy of Periodontology are familiar with the efficientmanner in which Mrs. Lorrie Hill assists Dr. Clarke E. Chamberlain in his many activi-ties as Secretary of the American Academy of Periodontology. It was not surprisingtherefore to learn that recently the National Secretaries Association recognized Mrs.Hill's ability, and awarded her their coveted Certified Professional Secretary Award.Congratulations, Mrs. Hill!

Infrabony Pocket

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