Healing of Human Periodontal Tissues Following Surgical

Detachment and Extirpation of Vital Pulps

by M E L V I N L . M O R R I S , B . S . , M . A . , D.D.S., New York, N. Y.

S
T U D I E S of surgically created perio- To answer some of these questions i t was
dontal p o c k e t s have demonstrated
1,2
decided to repeat the experimental wounds
healing directly w i t h the dentin of on teeth whose vital pulp contents had pre-
vital teeth and cementum of vital and non- viously been mechanically removed without
vital teeth. use of either chemicals or root canal fillings
of any kind.
Healing did not occur directly w i t h the
dentin of teeth w i t h root canal fillings.
PROCEDURE
When this exposed dentin was connected
w i t h the gingival crevice the epithelial Pulp contents were completely removed
lining grew apically u n t i l the first ce- w i t h broaches, reamers, and files, both ends
mentum was encountered. Denuded dentin of the canals being left open. One week
remote from the gingival crevice showed later the surgical periodontal pockets were
a very slight amount of new cementum
growing i n from the surrounding cemen- TABLE I
tum i n an incomplete attempt to cover the
defect. MM
MM Alveolar
Case Surgical Cementum
no. Reattach- bone
detach- curetted
Several teeth w i t h gangrenous pulps re- ment removed
ment
acted like root-canal filled teeth where ex-
posed dentin was connected w i t h the gingi- 1 4.0 3.0 No No
5 3.5 1.5 No Yes
val crevice but showed profuse cemental
6 5.0 4.0 No No
deposition (as i n vital teeth) on the dentin 7 3.0 3.0 No Yes
remote from the gingival crevice. This con- 8 4.0 3.0 No Yes
firmed a previous observation by Waer- 9 6.0 4.5 No Yes
haug. 4,5 10 4.0 2.5 Yes Yes
11 5.0 4.5 No Yes
12 4.0 2.0 No Yes
M a n y questions remain concerning the 13 2.5 Yes
— No
effects of non-vitality on periodontal 14 6.0 1.0 Yes Yes
wound healing. It is not certain whether 15 6.0 4.5 Yes Yes
pulpal death alone inhibits a connective tis-
sue union w i t h the exposed dentin or
whether the additional complication of a created, removing alveolar bone when nec-
root canal filling and its medications are essary to deepen the wound. The free gingi-
necessary for this effect. It is also possible val r i m was removed to delay epithelial
that residual areas of functioning odonto- invagination. D e n t i n was exposed at the
blasts may be responsible for the new ce- apical end of surgical separation, and i n the
mentai formation i n gangrenous teeth. coronal half of the wound. I n some cases
cementum was curetted. Additional tooth
Associate Clinical Professor of Dentistry, Section
nicks were formed as landmarks at the
of Periodontology, Columbia University.
Part of a paper, "Studies in Periodontal Healing original crevice depth and on the enamel.
and Regeneration," presented at the American Acad- Measurements were recorded from enamel
emy of Periodontology, Dallas, Texas, November 7, nick to gingival margin and gingival at-
1958. tachment before, immediately after crea-
This investigation was supported in part by Public
Health Service Grant D-8 5 5, National Institute of
tion of the pocket, and at the time of the
Dental Research, National Institutes of Health. biopsy. This information made i t possible

Page 23
Page 24 THE J O U R N A L O F PERIODONTOLOGY

Fig. 2. New cellular cementum (NC) has formed

Fig. 1. The epithelial lining- (EL) has grown
past the denuded dentin (D), stopping- at the
remaining- cementum (C). (A) is a separation
artefact.
to determine changes i n gingival attach-
ment level w i t h reference to a fixed point.
Biopsies were performed as previously de-
scribed. 1,2
on dentin (D) in the nick (N) located at the
apical end of surgical separation. (C) is remain-
ing cementum apical to the nick.
thelial lining grew past denuded dentin
connected w i t h the gingival crevice and
stopped where the first cementum was met
(Fig. 1 ) . It made no difference whether
that cementum had been untouched, curet-
ted, or partly removed w i t h a bur.

The material reported on consists of The exposed dentin i n the terminal nicks
eleven maxillary anterior teeth from ap- was, i n the majority of cases, covered w i t h
parently healthy adults. Experimental peri- a pink amorphous cernentoid material often
ods ranged from four to seven weeks. enclosing connective tissue cells ( F i g . 2 ) .
As i n previous s t u d i e s the new material
1,2,3

RESULTS was thickest toward the deeper portions of

A) Clinical:
Table I shows that healing occurred i n
every case but was short of the amount of
surgical detachment by from 0.5 to 5.0
millimeters except case #7 where healing
equaled the amount of detachment.
the nicks. Its thickness varied from .008 to
014 millimeters.
Denuded dentinal surfaces not covered
by new material were marked w i t h many
resorption bays ( F i g . 3) containing con-
nective tissue cells and fibers.

B) Histological: DISCUSSION

The results were consistent in that epi- The results are a curious mixture of past
 PERIODONTAL TISSUES: H E A L I N G
Fig. 3. Resorption bays (R) with enclosed cells are present on the apical or terminal nick
(N). Connective tissue fibers (CT) are seen clinging to the dentin. (A) is a separation
artefact.
studies. N e w cementum was deposited i n
the terminal nick as i n vital teeth but not
2
as i n root-canal filled teeth. O n the other
1
hand, the epithelial lining grew down u n -
til the first cementum was encountered
like the root canal filled teeth but unlike
the vital teeth. N o explanations or con-
jectures are offered at this point for the
apparent contradictions.
However, the results do supply some an-
swers to the questions that prompted this
study.
It is possible that a substance (or sub-
stances) exist in dentin that encourage
union w i t h the surrounding connective tis-
sues and induce cementoblastic activity.
Although they may be elaborated i n the
pulp it is not necessary for a vital pulp to
be present for new cementum to form on
Page 25
dentin. This means that new cementum
could form i n the presence of completely
gangrenous pulps.
The absence of pulp contents does seem
to affect the union of dentin and connec-
tive tissue i n the cervical area where epithe-
lial invagination was not stopped. This
downgrowth accounts for the incomplete
reattachment noted clinically.
A s i n the root-canal filled teeth the re-
maining cementum united w i t h connective
tissue and blocked epithelial downgrowth
whether or not the cementum was u n -
touched, curetted or partly removed leav-
ing even the narrowest strip on the root
where cementocytes are generally necrotic.
This strengthens the idea that inductive
qualities in cementum itself do not depend
on its cellular vitality but reside i n the i n -
tercellular substance.
Page 26 T H E J O U R N A L O F PERIODONTOLOGY

Since the mere absence of pulp does not BIBLIOGRAPHY

prevent cemental formation on dentin i n
the terminal nicks, the lack of new ce-
mentum i n root canal filled teeth may have
been due to the noxious influence of the
medicaments employed, to the blocking of
a diffusion process, or to simply a drying
out of the dentin over a period of many
years.
Appreciation is expressed to the many who helped
to complete this study. This includes D r . William
Savoy, D r . J . Anderson, D r . H . Baurmash, D r . G .
Minervini, D r . P. Vahdat and Mrs. F . Moore, Mrs.
R. Feinman and Miss E . Boyd.
1. Morris, M . L.: Healing of Human Periodontal
Tissues following Surgical Detachment from N o n -
Vital Teeth. Journal Perio., 28:222-23 8, 1957.
2. Morris, M . L.: The Reattachment of Human
Periodontal Tissues following Surgical Detachment:
A Clinical and Histological Study. Journal Perio.,
24:220-228, 1953.
3. Morris, M . L.: Healing of Naturally Occur-
ring Periodontal Pockets about Vital Human Teeth.
Journal Perio., 26:28 5-292, 195 5.
4. Waerhaug, J . : The Gingival Pocket, Odontolo-
gisk Tidskrift, Supplementum I, Oslo, Norway,
60, 1952.
5. Waerhaug, J . : Personal Communication, 1955

W A S H I N G T O N , D.C. GROUP ORGANIZES PERIODONTAL SOCIETY

Several diplomates of the American Board of Periodontology living i n the Nation's

Capital have formed a local organization k n o w n as the Greater Washington Periodontal
Society. T h e Society's general objective w i l l be to exchange, disseminate and evaluate
data on periodontology. Its first meeting was held on November 16.

H a v i n g a current membership of thirty, the Society's eligibility rules require that

members have a teaching or research appointment or have completed graduate work i n
the field of periodontology, and be active participants i n the Society's activities. Meetings
w i l l be held about twice yearly.

A m o n g the Society's founders were D r s . W i l l i a m B . Ingersoll and Francis J . Fabrizio,

both o f the Georgetown University Dental School; C o l . Joseph L . Bernier of the A r m e d
Forces Institute of Pathology and a former President of the American Academy of
Periodontology; and D r . Mildred Dickerson, D . D . S . , of Washington.

Present officers are D r . Paul M . Baer, of the National Institute of Dental Research,
President; M a j . Charles F . Sumner, III, Walter Reed A r m y Medical Center, Vice Presi-
dent; D r . A l b e r t G . Paulsen, Treasurer; L t . C m d r . Perry C . Alexander, U . S. N a v a l
Dental School, Bethesda, Maryland, Secretary; and Capt. A l f r e d L . Raphael, of the U . S.
N a v a l Dispensary i n Washington, Chairman, Membership Committee. The next meeting
is to be held i n A p r i l .