Histologie Evaluation of New Attachment Apparatus

Formation in Humans
Part III

Gerald M. Bowers*, Brian Chadrofff, Robert Carnevale^,

James Mellonig§, Rüssel CorioH, Jane Emerson*, Mark StevensU,
and Elaine Romberg#

There is still controversy as to the role of bone grafting materials in the formation of a
new attachment apparatus and component tissues (bone, cementum, and periodontal
ligament). The purpose of this study was to compare the healing of intrabony defects with
and without the placement of decalcified freeze-dried bone allograft (DFDBA) in a nonsub-
merged environment in humans. The most apical level of calculus on the root served as a
histologie reference point to delineate root surfaces exposed to the oral environment and to
measure new attachment apparatus and new component tissue formation. Free gingival
grafts were placed over grafted and nongrafted defects to retard epithelial migration. Biopsies
were obtained at 6 months and regeneration was evaluated histometrically. Data from 12
patients with 32 grafted and 25 nongrafted defects were submitted for statistical analysis.
Results indicate that in nongrafted defects, a long junctional epithelium formed along the
entire length of exposed root surfaces and often extended apical to the calculus reference
notch. Free gingival grafts did not enhance regeneration of a new attachment apparatus,
new cementum, new connective tissue, or new bone in nongrafted defects. The formation
of a new attachment apparatus was observed when intrabony defects were grafted with
DFDBA (xl.21 mm); significantly more new attachment apparatus (P < .005), new
cementum (P < .005), new connective tissue (P < .05), and new bone (P < .0001) formed
in intrabony defects grafted with DFDBA than in nongrafted defects. There was a greater
chance for regeneration of a new attachment apparatus and component tissues in grafted
defects than in nongrafted defects. New cellular cementum formed on old cementum and
dentin but more often formed over both in the same defect). The periodontal ligament was
more frequently oriented perpendicular to the root; there was greater loss in alveolar crest
height in nongrafted than grafted defects (P < .05); and extensive root résorption, ankylosis,
and pulp death were not observed in grafted or nongrafted defects. (Journal ofPeriodontology,
1989;60:683-693)

In a1982 review of the literature, histologie studies
were evaluated to determine evidence of regeneration
of periodontal tissues on previously exposed root sur-
*
Department of Periodontics, Baltimore College of Dental Sur-
gery, University of Maryland, Baltimore, MD.
t Private practice, Kew Gardens, NY.
Private practice, New London, CT.
§ Department of Periodontics, School of Dentistry, University of
Texas. San Antonio, TX; previously, Naval Dental Center, Periodon-
tics Department, Bethesda, MD.
I Department of Oral Pathology, Georgetown University, School
of Dentistry, Washington, DC.
H Department of Removable Prosthetics, Baltimore College of
Dental Surgery, University of Maryland, Baltimore, MD.
# Department of Educational and Instructional Resources.
683
faces.1 The authors concluded that there was evidence
of formation of new bone, cementum, and periodontal
ligament (new attachment apparatus) after placement
of various graft materials.1 In spite of existing studies,
controversy persists. A concern expressed by some in-
vestigators is that most information is based on case
reports which can be misleading.2 Another major ob-
jection has been the failure of previous studies to utilize
reference points that delineate exposed from nonex-
posed root surfaces as described by Cole et al.3 Investi-
gators who failed to demonstrate histologie evidence of
new attachment in humans and animals, with4'5 and
without6 7 bone grafting materials, noted that a junc-
tional epithelium was always interposed between bone
and root surfaces. Listgarten and Rosenberg reported
 J. Periodontol.
684 Bowers, Chadroff, Carnevale, Mellonig, Corlo, Emerson, Stevens, Bömberg December 1989

the formation of a new attachment at the base of grafted 3. Will a new attachment apparatus and component
defects but the junctional epithelium was always apical tissues form more frequently in grafted versus non-
to the alveolar crest.8 grafted defects?
Some authors have reported that new attachment is 4. Will free gingival grafts enhance new attachment
possible if epithelial migration is retarded. Ellegaard et apparatus and component tissue formation on patho-
al.9 recommended the placement of a free gingival logically exposed root surfaces?
autografi over the intrabony defect to retard epithelial 5. Are extensive root résorption, ankylosis, or pulp
downgrowth. The gingival autografi reportedly served death common sequelae of grafting nonsubmerged in-
as a protective bandage for the graft site but did not trabony defects with DFDBA?
provide viable epithelial cells in contact with the root
surface. They proposed that epithelial migration was MATERIALS AND METHODS
retarded, since the only source of epithelial cells was Patient Selection
the wound edge which was some distance away from
the root. Patients were solicited who had 2 or more maxillary
A preliminary histologie report of healing of intra- or mandibular incisors, canines, or premolars recom-
bony defects in humans suggested that demineralized mended for extraction by the Oral Diagnosis Depart-
freeze-dried bone allograft (DFDBA) enhanced the for- ment. Patients were systemically healthy. Teeth chosen
mation of a new attachment apparatus in both sub- for the study demonstrated advanced bone loss, deep
merged and nonsubmerged environments.10 This paper
will present the final results of Part III of this study
and attempt to answer the following questions: follow-
ing flap curettage of intrabony defects and root planing
of pathologically exposed root surfaces in a nonsub-
merged environment
1. Will DFDBA enhance new attachment apparatus
and component tissue formation on pathologically ex-
posed root surfaces?
2. Is there a statistically significant difference be-
tween the amount of new attachment apparatus and
component tissue formation in defects grafted with
DFDBA, versus nongrafted defects?

Table 1
Hlstological Measurements in mm (Comparison of 32 Grafted and
25 Nongrafted Defects in Nonsubmerged Teeth, 12 Patients)

Nonsubmerged
Measurement F P
Grafted Nongrafted
mean mean

NAA 1.21 ±1.12+ 0.00 ± 0.00 14.49 .005

NC 1.24 ±1.11 0.00 ± 0.00 15.16 .005
CT 0.13 ± 0.34 0.02 ± 0.15 5.28 .05
NC and CT 1.35 ±1.13 0.02 ± 0.15 17.00 .005
NB 1.75 ± 1.16 0.05 ± 0.21 53.95 .0001
B- 2.57 ± 1.29 2.19 ± 1.27 2.03 .20
B-AC 1.73 ± 1.13 0.38 ± 1.21 9.93 .05
B-JE 1.36 ± 1.13 0.00 ± 0.00 18.22 .005
A-AC -0.82 ± 1.03 -1.79 ± 1.36 5.51 .05
AC-JE -0.40 ±1.41 -0.60 ± 1.59 5.32 .05
NAA New attachment apparatus.
=

NC New cementum.
=

CT Width of new connective tissue.

=

NC and CT New cementum plus new connective tissue.

=
Figure 1. Grafted defect demonstrating the formation of a new attach-
NB New bone.
=
ment apparatus from calculus reference notch to arrow. Note that
Reference notch at base of calculus.
=
junctional epithelium/cementum interface (arrow) is below reference
A Reference notch at alveolar crest.
=
notch A but approximately level with alveolar crest. Space between
JE Most apical level of junctional epithelium.
=
cementum and root surface is artifact. (Masson's trichrome, original
AC Microscopic location of alveolar crest.
=
magnification 4x) Figures 2 and 3 illustrate higher magnification of
+ mean ± standard deviation (mm). calculus reference notch and region ofarrow.
Volume 60
Number 12 Histologie Evaluation ofNew Periodontal Attachment, III
Figure 2.Higher magnification of Figure 1 at level of calculus refer-
ence notch (B). Periodontal ligament (PL) is oriented perpendicular
to the root surface and Sharpey's fibers are embedded in new bone
(NB) and new cellular cementum (NC). Space between new cementum
and root surface is artifact (AT). (Masson's trichrome, original mag-
nification 40x).
pockets, and associated interproximal intrabony defects
with radiographically visible calculus on the root sur-
faces. All teeth were vital and asymptomatic. Volun-
teers were instructed both orally and in writing as to
the nature of the project to obtain an informed consent.
Surgical Therapy
All surgical procedures and clinical measurements
were performed by the same investigator (GMB). A
gingivoplasty was performed over the interproximal
intrabony defects and the crevicular epithelium was
removed around the necks of the teeth with an inter-
nally beveled incision. Full thickness mucoperiosteal
flaps were reflected on the facial and lingual surfaces
and granulation tissue was carefully removed. With the
aid of magnification and fiber optics, the base of cal-
culus and level of the alveolar crest were marked with
a Vi round bur. Root surfaces were planed with hand
instruments and finishing burs from the calculus refer-
685
'
-JE
Figure 3. Higher magnification of junctional epithelium and new
cementum interface (arrow) shown in Figure 1. Residual hard tissue
fragments (HT) are fibrous encapsulated. Space between new cemen-
tum and old cementum is artifact. (Masson's trichrome, original
magnification 40x).
ence notch coronally. The base of defect was debrided
with an ultrasonic instrument but no attempt was made
to contact the root surface apical to the calculus refer-
ence groove. The type of defects were recorded and
measurements were made with a standardized peri-
odontal probe from the alveolar crest to the calculus
groove and from the calculus groove to the base of the
defect. Measurements from the CEJ to base of the defect
were also made (see Part I, Fig. 1). DFDBA was placed
into preselected defects chosen randomly. Graft mate-
rial was placed level with the alveolar crest. DFDBA
was obtained from the former Navy Tissue Bank, Naval
Medical Research Institute, Bethesda, MD and pre-
pared according to Urist et al." A free gingival graft
was sutured over the gingivoplasty wound of grafted
and nongrafted sites to enhance wound closure and to
retard epithelial migration. Nongrafted defects were
treated identical to experimental defects except no graft
material was placed.
Postoperative maintenance was performed weekly for
 J. Periodontol.
686 Bowers, Chadroff, Carnevale, Mellonig, Corlo, Emerson, Stevens, Romberg December 1989

the first month, every other week for the second month stitute of Pathology and The University of Maryland.
and monthly until biopsy. Plaque and gingival indices12 Biopsies were decalcified in EDTA, embedded in par-
were taken preoperatively and at 4, 6, 8, 12, 16, 20, affin, and serially sectioned at 7 µ . Every ninth section
and 24 weeks postoperatively. Biopsy was performed at was stained with Masson's trichrome or Goldner's stain
6 months and the alveolar ridge was augmented with and every tenth section with hematoxylin and eosin. A
ceramic material* as before.10 The patients were seen blind histologie evaluation of biopsies was conducted
in 10 days to remove the sutures and to debride the by an oral pathologist (RC) and a periodontist (JM).
wound. After the ridges had healed, patients were re- Measurements were made simultaneously using a dual
ferred to the Prosthodontic Department for fabrication attachment binocular microscope, with a micrometer
of permanent prosthetic appliances. reticle, f All serial sections with readily identifiable ref-
Specimens were processed at The Armed Forces In-
t American Optical Corp., Buffalo, NY.
*
Synthograft Johnson & Johnson Corp., New Brunswick, NJ. Table 4
Percent ofDefects Showing Regeneration of Periodontal Ligament
Table 2 in Three Directions
Percent of Sections Showing Regeneration for Each Procedure Percent Percent
Percent
Nonsubmerged Treatment
parallel to tooth perpendicular parallel and
Measurement to tooth perpendicular
Grafted Nongrafted
Grafted 5% 55% 41%
New attachment 68% 0%
New cementum 77% 0%
Nongrafted*
apparatus
New connective tissue 23% 3%
*
No periodontal ligament formed.
New bone 84%
Table 5
Mean Clinical Measurements (mm) at Time ofSurgery
Table 3
Percent ofDefects Showing Regeneration of New Cementum Over 3 Nonsubmerged
Types of Tissue Measurement Grafted Nongrafted
Percent over old Percent over Percent over mean mean
Treatment
cementum dentin both
A-B 3.22 ± 1.18+ 2.99 ± 1.78 0.00 .96
Grafted 24% 19% 57% B-BD 3.69 ± 1.39 3.30 ±1.01 3.44 .11
Nongrafted* A-BD 6.91 ± 2.08 6.29 ± 1.99 0.72 .42
*
No new cementum formed. t Mean ± Standard deviation (mm).

Figure 4. Grafled defect demonstrating new attachment apparatus formationfrom calculus reference notch to reference notch A. New cementum
formed over both dentin and old cementum. The junctional epithelium is located approximately level with the alveolar crest at reference notch A.
Figures 5. 6, and 7 illustrate higher magnification of calculus reference notch B. region of arrow and reference notch A. (H&E, original
magnification 4x).
Volume 60
Number 12 Histologie Evaluation ofNew Periodontal Attachment, III
Figure 5. Higher magnification of calculus notch ( ) in Figure 4
demonstrating the formation of a new attachment apparatus. Note
that new cellular cementum (NC) has formed over old cementum (OC)
and over dentin (D). Periodontal ligamentfibers appear to be oriented
both parallel and perpendicular at this level. (H&E, original magni-
fication 40x).
erence points and suitable hard and soft tissue relation-
ships were selected for evaluation and measurement by
the examiners. Magnification was altered to verify spe-
cific tissue types and relationships but all measurements
were made at 35x. If there was disagreement between
examiners, both measurements were included and av-
eraged. A mean score was determined for each meas-
urement shown in Part I, Figure 2. The examiners also
recorded root résorption, ankylosis, evidence of pulp
death, type and location of new cementum formation
(over old cementum, dentin or both), and the direction
of the new periodontal ligament fibers (parallel, perpen-
dicular, or both).
Statistical Analysis
Data from 32 grafted defects and 25 nongrafted
defects in 12 patients were submitted for statistical
analysis (Table 1). Repeated Measures General Linear
Model Analysis of Variance was used to test for a
significant difference in amount of new attachment
687
Figure 6. Higher magnification of region of arrow in Figure 4. Note
new cellular cementum formation (NC) over old cementum (OC). Also
note perpendicular arrangement of periodontal ligament fibers (PL)
at this level. (H&E, original magnification 40x).
apparatus and component tissue formation in experi-
mental and control sites. Serial sections of each defect
were evaluated for positive regeneration of a new at-
tachment apparatus and component tissue formation.
The percentage of positive regeneration for each tech-
nique was reported. The most frequent location of new
cementum formation, and the most common orienta-
tion of the periodontal ligament fibers were also re-
ported in percentage for each technique.
RESULTS
Will DFDBA Enhance New Attachment Apparatus and
Component Tissue Formation on Pathologically
Exposed Root Surfaces?
A mean new attachment apparatus of 1.21 mm from
the calculus reference notch was observed in grafted
defects (Table 1, Figs. 1, 2, and 3). On the mean, there
was 1.24 mm of new cementum formation, 0.13 mm
of connective tissue attachment, and 1.75 mm of new

688 Bowers, Chadroff, Carnevale, Mellonig, Corlo,
Figure 7. Higher magnification of Figure 4 at level ofreference notch
A demonstratingjunctional epithelium (JE) and new cementum (NC)
interface, (arrows) (H&E, original magnification 40x).
bone formation. The junctional epithelium was located
1.36 mm coronal to the calculus reference notch.
Is There a Statistically Significant Difference Between
the Amount of New Attachment Apparatus and
Component Tissue Formation in Defects Grafted With
DFDBA Versus Nongrafted Defects?
values in Table 1 indicate a significant difference
in the amount of new attachment apparatus formation
in grafted versus nongrafted defects (P < .005). There
was likewise a significant difference in new cementum
(P < .005); new connective tissue (P < .05); new
cementum and new connective tissue {P < .005); and
new bone formation (P < .0001 ). No significant differ-
ence was observed between histological distances from
reference notches B- . There was a significant differ-
ence between the clinical and histologie location of the
alveolar crest ( -AC) between grafted and nongrafted
sites (P < .05). Likewise there was a significant differ-
ence in the location of the junctional epithelium from
reference notch (B-JE) and from the alveolar crest
(AC-JE) between grafted and nongrafted defects.
J. Periodontol.
I, Stevens, Bömberg December 1989
Figure 8. Nongrafted defect demonstrating epithelial migration to
calculus reference notch (B) on lateral incisor (LI) and apical to
calculus reference notch (arrow) on central incisor (CI). Note histologie
location of alveolar crest compared to clinical location (A). (H&E,
original magnification 4x) Figures 9 and 10 illustrate higher magni-
fication of notch in lateral incisor and region of arrow in central
incisor.
Will a New Attachment Apparatus and Component
Tissues Form More Frequently in Grafted Versus
Nongrafted Defects?
The percent positive regeneration indicated that a
new attachment apparatus, new cementum, new con-
nective tissue, and new bone formed more frequently
in grafted versus nongrafted defects (Table 2). When
new cementum formed, it was cellular in nature and
was found more frequently over both cementum and
dentin in the same defect (Table 3, Figs. 4, 5, 6, and 7).
The periodontal ligament was most often oriented per-
pendicular to the tooth (Table 4, Fig. 6).
There was no significant difference between probing
measurements from the highest level of the alveolar
crest to the base of calculus ( -B); base of calculus to
base of defect (B-BD) and from the highest level of the
alveolar crest to base of defect (A-BD) (Table 5). Data
indicate no significant differences between plaque and
Volume 60
Number 12
Figure 9. Higher magnification of calculus reference notch ( ) on
lateral incisor of Figure 8. Arrow denotes junclional epithelium and
cementum interface. (H&E, original magnification 40x).
gingival indices in grafted and nongrafted defects (PI:
F= .001, NS; GI:F 1.70, NS).
=
Will Free Gingival Grafts Enhance New Attachment
Apparatus and Component Tissue Formation on
Pathologically Exposed Root Surfaces?
Formation of a new attachment apparatus was not
observed in any of the 25 nongrafted control sites after
placement of a free gingival graft (Table 1, Figs. 8, 9,
and 10). On the mean, a small amount of new connec-
tive tissue (0.02 mm) and new bone formation (0.05
mm) was noted from the base of calculus reference
notch (B). In no instance, however, did all tissues
regenerate simultaneously to form an attachment ap-
paratus. Mean figures indicate that the junctional epi-
thelium was 0.02 mm coronal to calculus reference
notch B, but it frequently extended some distance api-
cally to the base of calculus (Fig. 10).
Are Extensive Root Resorption and Ankylosis or Pulp
Death Common Sequelae of Grafting Nonsubmerged
Intrabony Defects with DFDBA?
No extensive root résorption, ankylosis, or pulp death
wasobserved in grafted or nongrafted specimens.
Histologie Evaluation ofNew Periodontal Attachment, III 689
Figure 10. Higher magnification region of arrow on central incisor,
Figure 8. Junctional epithelium (JE) has migrated apical to calculus
reference notch (B). (H&E, original magnification 40x).
DISCUSSION
The results of this study support authors who have
reported the formation of a new attachment apparatus
after bone grafting.13"25 The findings also provide ad-
ditional information of clinical importance.
Attachment Apparatus Versus Junctional Epithelium
On the mean, 1.21 mm of new attachment apparatus
formed over pathologically exposed root surfaces when
intrabony defects were grafted with DFDBA. Clinical
data from Table 5 indicate that the mean depth of
defects from the calculus reference notch (B-BD) was
3.69 mm. It can be estimated then that, on the mean,
5 mm of repair and regeneration of the attachment
apparatus occurred from the base of grafted defects. In
one specimen, it was estimated that over 10 mm of
attachment apparatus formed from the base of the
defect (Figs. 11, 12, 13, and 14).
This study does not support the observation of List-
garten and Rosenberg,8 who reported that the junc-
tional epithelium was apical to the alveolar crest in all
grafted specimens and new attachment was only ob-
served at the base of the defect. Grafted defects in our

690 Bowers, Chaciroff, Carnevale, Mellonlg, Corlo, Emerson, Stevens, Romberg
Figure 11. Grafted, one-two wall defect. At surgery, the base of
calculus (B) was located approximately 2 mm apical to the alveolar
crest (A) and the inlrabony defect measured 8 mm from calculus notch
to base of defect. Repair of the inlrabony defect has occurred to level
of calculus notch and new attachment apparatus formation has con-
tinued to the level of the arrow. Dark lines are artifact. Bone particles
(BP) were observed coronal to alveolar crest and demonstrated new
bone formation. (H&E, original magnification 4x) Figures 12, 13,
and 14 illustrate higher magnification of calculus reference notch B;
reference notch A; region of arrow.
study consistently formed a new attachment apparatus
from the base of the defect to the calculus reference
notch and in most defects (68%) some distance beyond
(Table 4). The junctional epithelium proliferated api-
cally, but rarely was observed beyond the level of active
bone formation (Figs. 1, 4, 11, and 14). This was
probably related to the formation of new cementum
which usually paralleled the amount of new bone for-
mation. Junctional epithelium was never observed ex-
tending beyond the level of new cementum formation.
Bone Formation
The results of this study reinforce results of
others1'9 24'25 who noted that the formation of a long
junctional epithelium is to be expected on pathologi-
cally exposed root surfaces after flap curettage and root
J. Periodontol.
December 1989
planing in nongrafted defects. In grafted sites, apposi-
tional bone growth with inserting Sharpey's fibers was
generally noted along the entire bony wall and usually
extended to the alveolar crest. Graft particles were not
commonly observed which is probably due to the rapid
turnover of DFDBA as reported by Mellonig et al.26'27
Bone formation was observed coronal to the alveolar
crest in a few specimens (Figs. 11 and 14). Supracrestal
bone formation, however, was not a common finding
which is likely due to apical displacement of graft
particles during wound closure. The location of the
alveolar crest was significantly lower in nongrafted de-
fects than in grafted sites (A-AC, Table 1, Fig. 8). Based
on these findings, it is probable that placement of
DFDBA results in less crestal résorption than non-
grafted defects which, if true, would provide additional
rationale for utilization of graft materials.
Cementum Formation
New cementum formation over pathologically ex-
posed roots was cellular in nature and formed on den-
tin, old cementum, and old cementum and dentin in
the same defect. Cementum formation over both old
cementum and dentin was the most common finding
(57%) (Table 3, Figs. 5, 11, and 12). It was interesting
that only small amounts of connective tissue attach-
ment (0.13 mm) were noted in grafted defects. It was
more common that new cementum and junctional
epithelium abutted one another with no intervening
connective tissue (Figs. 7 and 14). Sharpey's fibers were
usually noted along the entire length of new cementum
formation.
Periodontal Ligament Formation
The periodontal ligament was most often oriented
perpendicular to the bony wall and root (55%) (Table
4, Fig. 6). It was not uncommon however, that both
parallel and perpendicular orientation was observed in
the same section (41%) (Fig. 5). Both parallel and
perpendicular orientation of the periodontal ligament
was also noted as a common occurrence in Part II of
this study in grafted and nongrafted defects. The rea-
son^) for dual orientation of the periodontal ligament
within the same specimen is not clear. Altered function
could account for incomplete perpendicular orientation
since most teeth required splinting and some teeth had
no antagonist. It is just as likely, however, that fiber
arrangement is not complete at 6 months (time of
biopsy), as suggested by Dragoo.24
Effect of Free Gingival Grafts
Free gingival grafts did not enhance new attachment
apparatus formation in nongrafted intrabony defects.
The role of free gingival autografts in grafted sites could
not be determined in this study. One can only speculate
that the formation of a new attachment apparatus,
Volume 60
Number 12 Histologie Evaluation ofNew Periodontal Attachment, III 691

Figure 12. Higher magnification of Figure 11 at region of calculus reference notch (B) demonstrating new attachment apparatus formation (NAA).
Dark lines are artifact (A). (H&E, original magnification 40x).

Figure 13. Higher magnification of Figure 11 at region of reference notch A demonstrating new attachment apparatus formation. Dark line is
artifact (A). (H&E, original magnification 40x).

cementum, and/or connective tissue should have oc-

curred in nongrafted specimens if this technique re-
tarded epithelial migration. In comparison, a new at-
tachment apparatus and component tissues did form
in nongrafted defects when epithelium was excluded by
vital root submersion in Parts I and II of our study. It
appears then that the free gingival autografi is not a
predictable method of retarding epithelial migration in
grafted or nongrafted defects.
Root Resorption and Ankylosis
Previous authors have reported root résorption after
utilization of fresh iliac-bone autografìa,19'21 a highly
osteogenic material. Osteogenic activity may be a factor
in root résorption since placement of less osteogenic
materials such as intraoral autogenous131517,23 or
freeze-dried bone allografts18'28 have not resulted in
extensive résorption. DFDBA, like fresh iliac bone au-
 J. PeriodonÎol.
692 Bowers, Chadroff, Carnevale, Mellonig, Corlo, Emerson, Stevens, Bömberg December 1989

Figure 14. Higher magnification of Figure 11 at region of arrow. Note large particle of DFDBA (BP) with new bone formation designated by
arrows. Arrow on root surface demarks the most apical level of the junctional epithelium as it abuts the newly formed cementum. Dark line is
artifact. (H&E, original magnification 40x).

tograft, is highly osteogenic.26 27 In this study, all sec-

Figure 15. Isolated areas of surface résorption at site remote from
grafted defect in 4. Resorption bays appear to be undergoing repair
and formation of cementoid. (H&E, original magnification 80x).
tions were evaluated for root résorption and ankylosis.
Surface résorption that appeared to precede cemento-
genesis was a common observation but the extensive
résorption and ankylosis previously associated with il-
iac-bone autografts was not observed. Surface résorp-
tion was also noted in areas of the root apical to the
calculus reference notch on noninvolved root surfaces
(Fig. 15). Such areas appeared to be undergoing physi-
ologic repair similar in appearance to cementogenesis
on exposed root surfaces. Apparently, DFDBA does not
induce root résorption, at least within 6 months. It is
unlikely that utilization of DFDBA will result in ré-
sorption after 6 months since this material has been
used extensively in clinical practice for several years
and there have been no reports of root résorption or
ankylosis.29"31
CONCLUSIONS
Following flap curettage of intrabony defects and root
planing of pathologically exposed root surfaces in non-
submerged environments:
1. The formation of a new attachment apparatus is
possible when intrabony defects are grafted with
DFDBA.
2. Significantly more new attachment apparatus,
new cementum, new connective tissue, and new bone
will form in intrabony defects grafted with DFDBA
than in nongrafted defects.
3. There is a greater chance for regeneration of a new
attachment apparatus, new cementum, new connective
tissue, and new bone in intrabony defects grafted with
Volume 60
Number 12 Histologie Evaluation ofNew Periodontal Attachment, III
DFDBA than in nongrafted defects.
4. New cellular cementum may form on dentin, old
cementum, or both dentin and old cementum in the
same defect.
5. The periodontal ligament is most often oriented
perpendicular to the root at 6 months.
6. There is a significantly greater loss of alveolar
crest height in nongrafted defects than grafted defects.
7. Free gingival grafts do not enhance the regenera-
tion of a new attachment apparatus, new cementum,
new connective tissue, or new bone in nongrafted de-
fects.
8. Extensive root résorption, ankylosis, and pulp
death are not common sequelae of grafting intrabony
defects with DFDBA.
ACKNOWLEDGMENTS
This study was supported by Grant DE 06250 from the National
Institute of Dental Research; Research Grant M0095.001.003, US
Navy Tissue Bank, NMRI, NNMC; and research funds from the
Armed Forces Institute of Pathology.
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1. Bowers GM, Schallhorn RH, Mellonig JT. Histologie evalua-
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2. Gara GG, Adams DF. Implant therapy in human intrabony
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3. Cole RT, Crigger M, Bogle G, et al. Connective tissue regener-
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6. Caton JG, Zander HA. Osseous repair of an infrabony pocket
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7. Caton J, Nyman S. Histometric evaluation of periodontal sur-
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Send reprint requests to: Dr. Gerald M. Bowers, Department of
Periodontics, University of Maryland, Baltimore College of Dental
Surgery, 666 West Baltimore Street, Baltimore, Maryland 21201.
Accepted for publication June 14, 1989.