Correlation Analyses Between Clinical and Radiological Indexes of Open Furcations

ORIGINAL PAPERS Dent. Med. Probl. 2007, 44, 2, 198 206 ISSN 1644 387X Copyright by Silesian Piasts University of Medicine in Wrocław and Polish Stomatological Association DOROTA MIERZWA DUDEK¹, MARZENA DOMINIAK¹, TOMASZ KONOPKA² Correlation Analyses Between Clinical and Radiological Indexes of Open Furcations Zależności między wskaźnikami klinicznymi a radiologicznymi otwartych przestrzeni międzykorzeniowych 1 Department of Dental Surgery, Silesian Piasts University of Medicine in Wrocław, Poland 2 Department of Oral Pathology, Silesian Piasts University of Medicine in Wrocław, Poland Abstract Background. Surgical treatment methods of periodontal tissues in interradicular areas need comparative analyses and finding both their positive and negative features in a clinical and radiological evaluation. Objectives. An analysis of the correlation between horizontal (HFD), vertical (VFD) defects in interradicular area, II class acc. Hamp, and clinical and radiological inconstants for open furcations both at the time of qualifications and after the surgical treatment. Material and Methods. 42 patients were qualified for the examination. They were divided into 3 groups accord ing to the surgical treatment method of open furcations: A the flap surgery with the usage of coronally reposi tioned envelope flaps (CREF), B the flap surgery with the usage of CREF together with filling the defect with Bio Oss Collagen, C the flap surgery with the usage CREF together with Bio Oss Collagen and Bio Gide Perio membrane. The following clinical parameters were registered: plaque index acc. Silness and Löe (PI1), modified percentage index of dental surfaces with plaque acc. O Leary (PI2), bleeding index of gingival pockets acc. Mühlemann and Son (SBI), modified bleeding index of gingival pocket (msbi), average depth of periodontal pockets (PD), clinical attachment level (CAL), keratinized tissue height (HKT) and thickness (TKT), recession depth (RD) and width (RW). The digital radiography was used to visualize and measure bone structure. Bone den sity (RG) and its reconstruction in interradicular area were estimated. Results. The significant positive correlations between HFD, VFD and PD, CAL were noticed. The significant neg ative co inconstant PI1 was found only for HFD. The positive correlations with RD and RW and the negative rela tions with RG were noticed for VFD. The results of correlation analyses between HFD and VFD and clinical and radiological variables, in group A, 6 and 12 months after the treatment, were compared. During both control exam inations, there was the significant positive co inconstant found between VFD and the loss of CAL and RD and the negative one between VFD and HKT. 12 months after, there were also positive co inconstant HFD and PI1, CAL, RW, RD and between VFD and PI1 and the negative co inconstant found between HFD and HKT, VFD and TKT. In group B, after 6 and 12 months since the treatment, there were significant positive correlations found between HFD, VFD and CAL, as well as between VFD and PI1. Other important correlations were observed only after 6 months since the treatment and it was positive co inconstant of HFD with msbi and RD, VFD with SBI and msbi and RW. In group C, 12 months after the completion of surgical treatment, the significant positive correlations between HVD, VFD and CAL were observed. Conclusions. During the initial examination, the important positive correlations among vertical, horizontal furca tion dimensions and periodontium pocket depth and the loss of clinical attachment level of molars prove the rela tion between destructive changes during periodontal infection and the existence of interradicular area pathology. The biggest amount of positive correlations after the treatment was noticed in group A, the least amount in group C. Lack of such relations can be the proof of the effectiveness of therapeutic guided bone regeneration method in the treatment of open furcations II class acc. Hamp (Dent. Med. Probl. 2007, 44, 2, 198 206). Key words: furcations, surgical treatment, guided tissue regeneration. Streszczenie Wprowadzenie. Metody chirurgicznego leczenia tkanek przyzębia w przestrzeniach międzykorzeniowych wyma gają analizy porównawczej oraz ustalenia ich zalet i wad w ocenie klinicznej i radiologicznej.

Clinical and Radiological Indices of Open Furcations 199 Cel pracy. Analiza korelacji między poziomym (HFD) i pionowym (VFD) ubytkiem w przestrzeni międzykorze niowej II klasy wg Hampa a zmiennymi klinicznymi i radiologicznymi dla otwartych przestrzeni międzykorze niowych w chwili kwalifikacji oraz po leczeniu chirurgicznym. Materiał i metody. Do badań zakwalifikowano 42 pacjentów, których podzielono na 3 grupy w zależności od me tody chirurgicznej leczenia otwartych przestrzeni międzykorzeniowych: A zabiegi płatowe z zastosowaniem do koronowo przesuniętych płatów kopertowych (CREF), B zabiegi płatowe z zastosowaniem dokoronowo przesu niętych płatów kopertowych w połączeniu z wypełnieniem ubytku Bio Oss Collagenem (CREF BOC), C zabiegi płatowe z zastosowaniem dokoronowo przesuniętych płatów kopertowych w połączeniu z Bio Oss Collagenem i bło ną Bio Gide Perio (CREF BOC + BG). Rejestrowano następujące wskaźniki kliniczne: wskaźnik płytki nazębnej wg Silnessa i Löe (PI1), zmodyfikowany wskaźnik procentowy powierzchni zębowych z płytką nazębną wg O Leary (PI2), wskaźnik krwawienia z kieszonek dziąsłowych wg Mühlemanna i Sona (SBI), zmodyfikowany wskaźnik krwa wienia z kieszonki dziąsłowej (msbi), średnią głębokość kieszonek przyzębnych (PD), kliniczny poziom przyczepu łącznotkankowego (CAL), szerokość (HKT) i grubość (TKT) dziąsła zrogowaciałego, wysokość (RD) i szerokość (RW) recesji przyzębia. Do wizualizacji i dokonania pomiarów struktury kostnej zastosowano radiografię cyfrową. Oceniano gęstości kości (RG) i jej odbudowę w przestrzeni międzykorzeniowej w stosunku do oznacznika. Wyniki. Stwierdzono znamienne dodatnie korelacje między HFD i VFD a PD i CAL. Tylko dla HFD wykazano istotną ujemną współzmienność z PI1. Dla VFD stwierdzono dodatnie korelacje z RD i RW oraz ujemną z RG. Ze stawiono wyniki analizy korelacji między HFD i VFD a zmiennymi klinicznymi i radiologicznymi w grupie A 6 i 12 miesięcy po leczeniu. Na obu wizytach kontrolnych stwierdzono istotną dodatnią współzmienność między VFD a utratą CAL i RD oraz ujemną między VFD i HKT. 12 miesięcy po leczeniu znaleziono dodatkowo dodat nie współzmienności między HFD a PI1, CAL, RW, RD oraz między VFD a PI1 oraz ujemną między HFD a HKT i VFD i TKT. W grupie B po leczeniu, po 6 i 12 miesiącach od leczenia stwierdzono dodatnie istotne korelacje między HFD i VFD a CAL oraz VFD a PI1. Inne istotne korelacje zaobserwowano tylko po 6 miesiącach od le czenia i były to dodatnie współzmienności HFD z msbi i RD oraz VFD z SBI i msbi oraz RW. W grupie C za obserwowano jedynie 12 miesięcy po zakończeniu leczenia chirurgicznego znamienne dodatnie korelacje między HVD i VFD a CAL 12. Wnioski. Istotne dodatnie korelacje w badaniu wyjściowym między pionowym i poziomym wymiarem furkacji a głębokością kieszonek przyzębnych i utratą przyczepu łącznotkankowego zębów trzonowych dowodzą, że zmia ny destrukcyjne w zapaleniu przyzębia są związane z objęciem patologią obszaru międzykorzeniowego. Najwię cej istotnych dodatnich korelacji po leczeniu wykazano w grupie A, a najmniej w grupie C. Brak takich zależno ści może być dowodem na skuteczność terapeutyczną metody sterowanej regeneracji kości w leczeniu otwartych przestrzeni międzykorzeniowych II klasy wg Hampa (Dent. Med. Probl. 2007, 44, 2, 198 206). Słowa kluczowe: otwarte przestrzenie międzykorzeniowe, leczenie chirurgiczne, sterowana regeneracja tkanek. The treatment of periodontal tissue defects in interradicular areas is a serious problem of con temporary periodontology. Methods of a surgical treatment of that pathology need both comparative analyses and finding their positive and negative features in the clinical and radiological estimation. The estimation of method effectiveness should lead to better pre treatment qualifications which takes into consideration specificity of etiological and clinical conditions at every patient. The aim of this work was to analyze correla tions between horizontal (HFD) and vertical (VFD) defects in interradicular area and clinical and radiological inconstants for open furcations at the moment of qualification and after the surgical treatment. There were taken into consideration the methods used in the surgical treatment of open furcations, currently recommended by many authors [1 5]: A flap surgery with the usage of coronally repositioned envelope flaps (CREF), B flap surgery using coronally positioned envelope flaps together with filling the defect with Bio Oss Collagen (CREF BOC), C flap surgery using coronally positioned envelope flaps with Bio Oss Collagen and Bio Gide Perio membrane (CREF BOC+BG). Material and Methods 42 patients (including 26 women) of Perio dontology Department of Silesian Piasts Univer sity of Medicine in Wrocław were qualified for the treatment. Their age ranged from 23 to 67 (at aver age 44 years). All those people were informed about planned treatment and gave their permission signing protocols approved by Bio ethic Com mittee of Silesian Piasts University of Medicine in Wrocław (no KB 124/2001). The patients quali fied for the treatment had no general diseases, showed no infection symptoms and could undergo periodontical surgical treatment. Ten indexes were used to estimate the clinical state of periodontal tissue. All initial measurements were done at the moment of patient s qualification, before any stomatological treatment. Plaque index acc. Silness et al. (PI1) [6] was used to estimate dental hygiene. It was done on the treatment area covering three teeth. The modified percentage index of dental surface with plaque acc. O Leary (PI2) [7] was used for the whole oral cavity. The intensity of gingival infection reaction was estimated with the usage of five degree bleed ing index from gingival pockets acc. Mühlemann

200 D. MIERZWA DUDEK, M. DOMINIAK, T. KONOPKA et al. (SB1) [8]. The index and it was shown as the mean of bleeding from gingival pockets at the treatment area covering three teeth. Modified bleeding index of gingival pocket (msbi) [9] was the second measure of gingival infection state. That index was also shown as the mean of treat ment area covering three teeth. The average pock et depth (PD) and clinical attachment level (CAL) at four surfaces of the molar were also taken into consideration. Out of muco gingival the following parameters were estimated: keratinized tissue height (HKT), distance between gingival margin (GM) and muco gingival junction, keratinized tis sue thickness (TKT) measured in the middle of keratinized tissue width with the usage of a cali brated edodontical tool, recession depth vertical ly measured distance between enamel cement junction (CEJ) and gingival margin (GM), reces sion width horizontally measured distance at the recession bottom. Measurements SBI, PD, CAL, HKT, RD and RW were done with the usage of Williams perio probe with the scale calibrated every 1 mm. The indexes were measured at the moment of qualification for the treatment and next 6 and 12 months after the treatment. The indices PI1 and PI2 were measured at the moment of qual ification and 6 and 12 months after the treatment. Digital radiography done with Digor appara tus (Soredex Orion, Helsinki, Finland) was used in order to visualize and measure bone structure. The measurement concerned bone density in inter radicular area compared to the marker. It was done only at the teeth in a jaw aiming of keeping explic itness of the results. The correct picture of inter radicular area of molars in a jaw was difficult to obtain due to palatal root projection onto the fur cation area. The program measured automatically the average bone density (RG) of a given area. The measurement was done by using the system of overlapping three square shape areas, counting the average value. According to the program, no sin gle values 0 255 were taken into consideration. The visualization of the treatment area was done before the treatment and 6 and 12 months after. The relations between particular features measured at the same time were examined using correlation factors of Spearman (due to the big deviation of some features from standard state). The significance of those correlation factors was verified with the appropriate t test. The level of significance p < 0.02 was assumed. Results The analyses between horizontal (HFD) and vertical (VFD) defects in intarradicular area and clinical and radiological inconstants for all furca tions before the treatment was done (Table 1). The significant positive correlations between horizon tal, vertical furcation dimension and periodontal pocket depth and clinical attachment level were found. Fig. 1 shows a correlative graph between VFD and CAL. The significant negative co incon stant with plaque index PI1 was found only for horizontal defect in interradicular area. For verti cal furcation defect, there were found positive cor relations between recession height and width and a negative one with bone density. Tables 2, 3 show the results of correlations between horizontal, vertical defects in interradicu lar area and clinical and radiological inconstants in a group A, 6 and 12 months after the treatment. Both control examinations proved the existence of the significant positive co variability between ver tical furcation defect and attachment loss and recession height, and the negative one between VFD and keratinized tissue width. Fig. 2 shows a correlative graph between VFD and HKT in A group, 12 months after the treatment. During that period there were found the additional co inconstants between HFD and PI1, CAL, RW, RD and between VFD and PI1 and also the negative one between HFD and HKT, VFD, TKT. Tables 4 and 5 show correlation results between horizontal, vertical furcation defect and clinical inconstants and the bone density in B group, after the treatment. After 6 and 12 months since the treatment, there were found positive, significant correlations between those two defects and clinical attachement level and between vertical defect and plaque index PI1. Fig. 3 shows correlation graph between VFD and PI1 in B group, 12 months after the treatment. Other significant correlations were observed only 6 months since the treatment and they were positive co inconstants of horizontal defect with msbi and RD, and vertical defect with two indexes of an infec tion state (SBI and msbi) and recession height. Tables 6, 7 show correlation results between horizontal, vertical furcation defects and clinical inconstants and the bone density in C group, 6 and 12 months after the completion of surgical treat ment. There were observed only positive, signifi cant correlations between those two parameters of furcation opening and the loss of clinical attach ment level, 12 months after the treatment. Discussion The most often periodontopathy of the grown ups in the shape of chronic periodontal infection occurred at every patient. Its main factor is the presence of dental plague. It was expected to have

Clinical and Radiological Indices of Open Furcations 201 Table 1. Analysis of correlations between horizontal (HFD) and vertical (VFD) defects in interradicular area and clinical and radiological inconstants for 90 furcations before the treatment Tabela 1. Analiza korelacji wielkości poziomego (HFD) dla 90 otwartych furkacji w chwili kwalifikacji do leczenia HFD & PI1 0.27 0.007 HFD & PI2 0.05 0.57 HFD & SBI 0.1 0.33 HFD & msbi 0.07 0.7 HFD & PD 0.3 0.003 HFD & CAL 0.31 0.002 HFD & RD 0.05 0.57 HFD & RW 0.08 0.43 HFD & HKT 0.13 0.2 HFD & TKT 0.08 0.45 HFD & RG 0.14 0.24 VFD & PI1 0.24 0.021 VFD & PI2 0.01 0.99 VFD & SBI 0.11 0.27 VFD & msbi 0.03 0.71 VFD & PD 0.25 0.017 VFD & CAL 0.41 (graph 1) 0.000 VFD & RD 0.26 0.012 VFD & RW 0.26 0.01 VFD & HKT 0.13 0.2 VFD & TKT 0.01 0.91 VFD & RG 0.32 0.008 HFD horizontal defects in interradicular area, VFD vertical defects in interradicular area, PI1 plaque index acc., PI2 modified percentage index of dental surfaces with plaque acc., SBI bleeding index of gingival pock ets acc., msbi modified bleeding index of gingival pocket, PD average depth of periodontal pockets, CAL clinical attachment level, HKT keratinized tissue height, TKT keratinized tissue thickness, RD reces sion depth, RW recession width, RG bone density and its reconstruction in an interradicular area. HFD poziomy ubytek w przestrzeni międzykorzenio wej, VFD pionowy ubytek w przestrzeni międzykorze niowej, PI1 wskaźnik płytki nbazębnej wg Silnessa i Löe, PI2 zmodyfikowany wskaźnik procentowy po wierzchni zębowych z płytką nazębną wg O Leary ego, SBI wskaźnik krwawienia z kieszonek dziąsłowych wg Mühlemanna i Sona, msbi zmodyfikowany wskaźnik krwawienia z kieszonki dziąsłowej, PD średnia głębo kość kieszonek przyzębnych, CAL kliniczny poziom przyczepu łącznotkankowego, HKT szerokość dziąsła zrogowaciałego, TKT grubość dziąsła zrogowaciałego, RD wysokość recesji przyzębia, RW szerokość recesji przyzębia, RG gęstość kości i jej odbudowa w prze strzeni międzykorzeniowej. Table 2. Analysis of correlations between horizontal clinical and radiological inconstants in group A, 6 months after the treatment Tabela 2. Analiza korelacji wielkości poziomego (HFD) w grupie A, 6 miesięcy po leczeniu chirurgicznym HFD & PI1 0.26 0.15 HFD & PI2 0.19 0.31 HFD & SBI 0.1 0.58 HFD & msbi 0.09 0.6 HFD & PD 0.2 0.27 HFD & CAL 0.36 0.046 HFD & RD 0.28 0.12 HFD & RW 0.27 0.14 HFD & HKT 0.4 0.027 HFD & TKT 0.2 0.27 HFD & RG 0.14 0.55 VFD & PI1 0.28 0.12 VFD & PI2 0.17 0.34 VFD & SBI 0.25 0.14 VFD & msbi 0.28 0.12 VFD & PD 0.33 0.066 VFD & CAL 0.5 0.004 VFD & RD 0.44 0.014 VFD & RW 0.35 0.057 VFD & HKT 0.55 0.001 VFD & TKT 0.33 0.069 VFD & RG 0.21 0.36 relations between plague indexes (in the treatment area and the whole oral cavity) and defect parame ters in the interradicular areas. The pre tretment qualifications (0 index PI1 in the treatment area and 20% PI2 in the whole oral cavity) resulted in the lack of any problems with keeping the appro priate dental hygiene by the patients who under went the treatment. That might be the reason of a surprising negative correlation between furcation depth in horizontal dimension (HFD) and index PI1 before the treatment. The relations between destructive changes in dental infections and pathology spread of inter radicular area were proved by the significant posi tive correlations between horizontal, vertical fur cation defects and periodontal pocket depth and clinical attachment loss of molars. The relation between furcation vertical defect (VFD) and reces

202 D. MIERZWA DUDEK, M. DOMINIAK, T. KONOPKA Table 3. Analysis of correlations between horizontal clinical and radiological inconstants in group A, 12 months after the treatment Tabela 3. Analiza korelacji wielkości poziomego (HFD) w grupie A, 12 miesięcy po leczeniu chirurgicznym CAL 0 20 15 10 5 HFD & PI1 0.44 0.013 HFD & PI2 0.19 0.29 HFD & PD 0.39 0.031 HFD & CAL 0.55 0.001 HFD & RD 0.48 0.006 HFD & RW 0.43 0.017 HFD & HKT 0.48 0.007 HFD & TKT 0.27 0.14 HFD & RG 0.33 0.14 VFD & PI1 0.48 0.006 VFD & PI2 0.23 0.21 VFD & PD 0.26 0.15 VFD & CAL 0.55 0.001 VFD & RD 0.52 0.003 VFD & RW 0.39 0.031 VFD & HKT 0.47 (graph 2) 0.007 VFD & TKT 0.43 0.017 VFD & RG 0.37 0.1 0 0 2 4 6 8 10 12 14 VFD 0 Fig. 1. Correlative graph between vertical defects in interradicular area (VFD 0) and clinical attachment level (CAL 0) for 90 furcations before the treatment. Equation of regression: CAL 0 = 0.1681 + 0.7486 VFD 0; correlation index R = 0.41. VFD vertical defects in interradicular area, CAL clinical attachment level Ryc. 1. Wykres rozrzutu wartości pionowego ubytku w przestrzeni międzykorzeniowej (VFD 0) i poziomu przyczepu łącznotkankowego (CAL 0) dla 90 furkacji w chwili kwalifikacji do leczenia. Równanie regresji: CAL 0 = 0,1681 + 0,7486 VFD 0; współczynnik korelacji R = 0,41. VFD pionowy ubytek przestrzeni międzykorzeniowej, CAL kliniczny poziom przyczepu łącznotkankowego 8 7 6 5 sion height and width is clearly directly propor tional. On the one hand, cleaning teeth too often and too strong might favour periodontal recession development, which after spreading beyond enam el cement margin and with an influence of addi tional anatomic factors may cause exposing of fur cation in interradicular area and re development of an infection state. On the other hand, lack of appropriate cleaning and constant presence of plaque in furcation area leads to periodontosis, characterized by clinical attachment loss, bone resorption of dental process and consequently periodontal recession [10, 11]. Those suggestions can be proven with other research [12] which also showed the positive correlation between furcation presence and periodontal recessions, particularly in case of people over 40. All those relations prove that open interradicular furcation is indeed a symptom of the clinical periodontal infection. That leads to the complex periodontosis treatment as the base of furcation therapy. Radiography is a commonly accepted method HKT 2 4 3 2 1 0 0 2 4 6 8 10 VFD 2 Fig. 2. Correlative graph between vertical defects in interradicular area (VFD 2) and keratinized tissue height (HKT 2) in a group A, 12 months after the treatment. Equation of regression: HKT 2 = 3.427 0.1843 VFD 2; correlation index R = 0.47. VFD vertical defects in interradicular area, HKT keratinized tissue height Ryc. 2. Wykres rozrzutności pionowego ubytku w przestrzeni międzykorzeniowej (VFD 2) i szerokość dziąsła zrogowaciałego (HKT 2) w grupie A, 12 mie sięcy po leczeniu chirurgicznym. Równanie regresji: HKT 2 = 3,427 0,1843 VFD2; współczynnik kore lacji R = 0,47. VFD pionowy ubytek w przestrzeni międzykorzeniowej, HKT szerokość dziąsła zrogo waciałego

Clinical and Radiological Indices of Open Furcations 203 Table 4. Analysis of correlations between horizontal clinical and radiological inconstants in group B, 6 months after the treatment Tabela 4. Analiza korelacji wielkości poziomego (HFD) w grupie B, 6 miesięcy po leczeniu chirurgicznym HFD & PI1 0.41 0.021 HFD & PI2 0.15 0.41 HFD & SBI 0.38 0.038 HFD & msbi 0.44 0.013 HFD & PD 0.06 0.71 HFD & CAL 0.44 0.012 HFD & RD 0.42 0.018 HFD & RW 0.27 0.13 HFD & HKT 0.11 0.54 HFD & TKT 0.16 0.38 HFD & RG 0.00 0.97 VFD & PI1 0.58 0.000 VFD & PI2 0.15 0.42 VFD & SBI 0.49 0.005 VFD & msbi 0.59 0.000 VFD & PD 0.16 0.38 VFD & CAL 0.58 0.000 VFD & RD 0.46 0.01 VFD & RW 0.33 0.071 VFD & HKT 0.04 0.82 VFD & TKT 0.29 0.11 VFD & RG 0.31 0.17 used in diagnostics of interradicular defects but it is of limited value in initial and intermediate phases of those changes. Ross and Thompson [13] claimed that basing just on radiographic picture resulted in discovering only 22% of clinically open furcations in the mandible and only 8% in the upper jaw. Such big discrepancies were one of the reasons of resignation from radiographical meas urement of furcation in a jaw in authors material. However, the obvious negative co inconstant between vertical open furcation dimension and density of abbeus bone in interradicular area in a jaw was confirmed. Horwitz et al. [14] showed that the negative influence on the surgical treat ment effectiveness can have: wide entrance to fur cations, more coronal location of furcation roof vault to abbeus margin and a high root trunk. While analyzing correlations between hori Table 5. Analysis of correlations between horizontal clinical and radiological inconstants in group B, 12 months after the treatment Tabela 5. Analiza korelacji wielkości poziomego (HFD) w grupie B 12 miesięcy po leczeniu chirurgicznym HFD & PI1 0.41 0.022 HFD & PI2 0.35 0.054 HFD & PD 0.34 0.059 HFD & CAL 0.46 0.009 HFD & RD 0.16 0.38 HFD & RW 0.11 0.55 HFD & HKT 0.05 0.78 HFD & TKT 0.03 0.87 HFD & RG 0.24 0.3 VFD & PI1 0.5 (graph 3) 0.004 VFD & PI2 0.35 0.056 VFD & PD 0.4 0.027 VFD & CAL 0.51 0.003 VFD & RD 0.24 0.19 VFD & RW 0.2 0.28 VFD & HKT 0.1 0.59 VFD & TKT 0.06 0.72 VFD & RG 0.39 0.084 zontal, vertical defects in the interradicular area and clinical and radiological inconstants after the treatment in the particular groups, it must be said that patients with coronally repositioned flap (group A) kept perfect dental hygiene during the whole control time after the treatment. No sooner than a year after the treatment you could see a pos itive correlation between plaque index on molars (PI1) and horizontal and vertical furcation dimen sions. Hygiene state in post treatment period at our patients was much better than in Lekovic s et al. [15] who found a slight increase of index PI1 six months after CREF. All this proves that introduc tion of sharp criteria of dental hygiene which had to be accepted by the patient for geting quali fied to surgical treatment, was absolutely right. However, that method did not have stable influence on muco gingival complex, which was proven by the significant increase of periodontal recession height between 6 and 12 months post the treatment, and after 12 months after the treatment the appearance of significant correlations between

204 D. MIERZWA DUDEK, M. DOMINIAK, T. KONOPKA PI1 2 0.2 0.15 0.1 Table 6. Analysis of correlations between horizontal clinical and radiological inconstants in group C, 6 months after the treatment Tabela 6. Analiza korelacji wielkości poziomego (HFD) w grupie C, 6 miesięcy po leczeniu chirurgicznym 0.05 0 0 2 4 6 8 10 VFD 2 Fig. 3. Correlative graph between vertical defects in interradicular area (VFD 2) and keratinized tissue height (PI1 2) in a group B, 12 months after the treat ment. Equation of regression: PI1 2 = 0.004936 + 0.009362 VDF 2; correlation index R = 0.5. VFD vertical defects in interradicular area, PI1 plaque index acc Ryc. 3. Wykres rozrzutu wartości pionowego ubytku w przestrzeni międzykorzeniowej (VFD 2) i wskaźnika płytki nazębnej wg Löe i Silnessa (PI1 2) w grupie B, 12 miesięcy po leczeniu chirurgicznym. Równanie regresji: PI1 2 = 0,004936 + 0,009362 VDF 2; współczynnik korelacji R = 0,5. VFD pionowy uby tek w przestrzeni międzykorzeniowej, PI1 wskaźnik płytki nazębnej horizontal dimension of furcation and recession height and width and negative correlation between HFD and keratinized tissue height. All this corre sponds with research result of Ainamo et al. [16] who claimed that muco gingival surgeries of api cal flap movement are not characterized by stable clinical results in a far term estimation because there exists a tendency of re positioning of muco gingival junction to its original location, probably genetically determined. Close relation between furcation treatment results by coronally flap repos itioning with application of graft material and indices of dental clinical state is proven by signif icant positive correlations of horizontal and verti cal furcation dimensions 6 months after the treat ment with msbi and CAL and 12 months after only with CAL. A very significant reduction of periodontal pocket depth by 2.69 mm (57.9%) and a rebuilding of clinical attachment level by 2 mm (41.6%) after that treatment should be empha sized. Other graft materials caused the following changes of pocket depth and of attachment loca tion during furcation treatment: DFDBA in con nection with CREF and eatching root cement with citric acid reconstruction of CAL by 1.5 mm after 12 months [17], PD reduction after 6 months since filling the furcation with allograft (PerioGlass) by 3.27 mm (49.1%) [18], CAL HFD & PI1 0.13 0.46 HFD & PI2 0.34 0.065 HFD & SBI 0.36 0.045 HFD & PD 0.21 0.24 HFD & CAL 0.25 0.17 HFD & RD 0.15 0.42 HFD & RW 0.13 0.47 HFD & HKT 0.02 0.88 HFD & TKT 0.11 0.54 HFD & RG 0.01 0.92 VFD & PI1 0.14 0.43 VFD & PI2 0.34 0.062 VFD & SBI 0.46 0.045 VFD & PD 0.19 0.31 VFD & CAL 0.2 0.28 VFD & RD 0.12 0.49 VFD & RW 0.14 0.43 VFD & HKT 0.07 0.7 VFD & TKT 0.08 0.66 VFD & RG 0.07 0.73 reconstruction 6 months after filling the furcation with porous hydroxyapatite (Interpore) was 1.8 mm [19]. It is clearly seen that the range of pocket depth reduction and changes of attachment loca tion is alike, no matter what graft material was used to fill the furcation. That method did not influence much the changes of muco gingival complex parameters (recession width and height and keratinized tissue width). The range of post treatment periodontal recession has an influence on furcation treatment results which is proved by an observed directly proportional relation of HFD and VFD with kera tinized tissue thickness, 6 and 12 months after the treatment (increase by about 0.2 mm) and all this in situation when initial gingival thickness was the biggest in furcations undergoing that treatment. Such an increase is difficult to explain. It may be the effect of connective tissue piling up on graft material. This change is of a big significance and

Clinical and Radiological Indices of Open Furcations 205 Table 7. Analysis of correlations between horizontal clinical and radiological inconstants in group C, 12 months after the treatment Tabela 7. Analiza korelacji wielkości poziomego (HFD) w grupie C, 12 miesięcy po leczeniu chirurgicznym HFD & PI1 0.12 0.5 HFD & PI2 0.27 0.14 HFD & PD 0.39 0.031 HFD & CAL 0.48 0.006 HFD & RD 0.21 0.25 HFD & RW 0.14 0.45 HFD & HKT 0.03 0.84 HFD & TKT 0.16 0.38 HFD & RG 0.14 0.5 VFD & PI1 0.12 0.5 VFD & PI2 0.27 0.14 VFD & PD 0.39 0.031 VFD & CAL 0.48 0.006 VFD & RD 0.21 0.19 VFD & RW 0.2 0.25 VFD & HKT 0.03 0.84 VFD & TKT 0.16 0.38 VFD & RG 0.14 0.5 can influence stability of far term clinical results. It was shown in case of periodontal recession cov erage particularly in case of thin gingival biotope [20]. The authors research in group C showed a sta tistically significant improvement of periodonto logical parameters (SBI, msbi, PD and CAL) 6 and 12 months after the treatment. Although the initial pocket depth, in authors research, was the smallest, the percentage shallowness PD (59%) stays in the range obtained by other authors (49 66%) [21 24]. The reconstruction of attach ment position in case of our patients (49.8% after months and 47.7% after a year) was better after hydroxyapatite with membrane eptfe (24.6% after 6 months) [21] and DFDBA with synthetic polimer membrane (29.2% after a year) [25] but worse then after autogenous bone with eptfe (54.8% after 8 9 months) [24]. Just the analyses of those inconstants shows the discrepancies of the obtained clinical results. Oral hygiene of our patients of group C was excellent during the whole post surgery observation period and that s why it had no effect on the obtained treatment results. An interesting authors observation is the lack of sig nificant statistic relations between analysed clinical and radiological parameters after treatment GBR (with exception of CAL 12 months after the treat ment). The lack of such relations may be the proof of therapeutic method effectiveness which in the big number of cases leads to furcation cure. The authors concluded that the significant pos itive correlations of vertical and horizontal furca tion dimension with periodontal pocket depth and clinical attachment loss of molars prove the exis tence of relation of destructive changes in peri odontal infection with pathological covering of interradicular area. The biggest number of the sig nificant positive correlations after the treatment was shown in the group A, the smallest in the group C. The lack of such correlations can be the proof of therapeutic method effectiveness GBR in the treatment of open furcations II class acc. Hamp. References [1] CARNEVALE G., PONTIERO R., HURGELER M.: Managment of furcation involvement. Periodontology 2000, 1995, 9, 69 89. [2] SANZ M., ZABALEGUI I., VILLA A., SICILIA A.: Guide tissue regeneration in human class II furcations and inter proximal infrabony defects after using a bioabsorbable membrane barrier. Int. J. Periodontology Restorative Dent. 1997, 17, 563 573. [3] KARRING T., CORTELLINI P.: Regenerative therapy: furcation defects. Periodontology 2000, 1999, 19, 115 137. [4] MCCLAIN P.K., SCHALLHORN R.G.: Focus on furcation defects guided tissue regeneration in combination with bone grafting. Periodontology 2000, 2000, 22, 190 212. [5] FLEMMIG T.F.: Chirurgische Therapie marginaler Parodontopathien. Dtsch. Zahnärztl. Z. 1999, 54, 360 364. [6] SILNESS J., LÖE H.: Periodontal disease in pregnancy. II. Correlation between oral hygiene and periodontal condi tion. Acta Odont. Scand. 1964, 22, 121 135. [7] O LEARY T.J., DRAKE R.B., NAYLOR J.E.: The plaque control record. J. Periodontol. 1972, 43, 38 41. [8] MÜHLEMANN H.R., SON S.: Gingival sulcus bleeding, a leading symptom in initial gingivitis. Helv. Odont. Acta. 1971, 15, 107 113. [9] KETTERL W.: Parodontologia. Urban & Partner, Wrocław 1995, 21 25.

206 D. MIERZWA DUDEK, M. DOMINIAK, T. KONOPKA [10] HOU G.L., LIN I.C., TSAI C.C., SHIEH T.Y.: The study of molar furcation involvements in adult periodontitis. II. Age, sex, location and prevalence. Kaohsiung J. Med. Sci., 1996, 12, 514 521. [11] CARRAANZA F.A., JOLKOVSKI D.L.: Current status of periodontal therapy for furcation involvements. Dent. Clin. North Am. 1991, 35, 555 570. [12] MIERZWA DUDEK D., DOMINIAK M., ŁAPOTT M., ŁOŚ A., LULA K., KROCZAK W.: Występowanie ubytków w przestrzeniach międzykorzeniowych zębów trzonowych szczęki i żuchwy u pacjentów województwa dol nośląskiego. Badania wstępne. Czas. Stomat. 2006, 59, 337 349. [13] ROSS I.F., THOMPSON R.H.: Furcation involvement in maxillary and mandibular molars. J. Periodontol. 1980, 51, 450 454. [14] HORWITZ J., MACHTEI E.E., REITMEIR P., HOLLE R., KIM T.S., EICKHOLZ P..: Radiographic parameters as prognos tic indicators for healing of class II furcation defects. J. Clin. Periodontol. 2004, 31, 105 111. [15] LEKOVIC V., KLOKKEVOLD P.R., CAMARGO P.M., KENNEY E.B., NEDIC M., WEINLAENDER M.: Evaluation of periosteal membranes and coronally positioned flaps in the treatment of class II furcation defects: a comparative clinical study in humans. J. Periodontol. 1998, 69, 1050 1055. [16] AINAMO A., BERGENHOLTZ A., HUGOSON A., AINAMO J.: Location of the mucogingival junction 18 years after api cally repositioned flap surgery. J. Clin. Periodontol. 1992, 19, 49 52. [17] GANTES B., MARTIN M, GARRETT S, EGELBERG J.: Treatment of periodontal furcation defects. II. Bone regenera tion in mandibular class II defects. J. Clin. Periodontol. 1988, 15, 232 239. [18] ANDEREGG C.R., ALEXANDER D.C., FREIDMAN M.: A bioactive glass particulate in the treatment of molar furcation invasions. J. Periodontol. 1999, 70, 384 387. [19] KENNEY E.B., LEKOVIC V., ELBAZ J.J., KOVACVIC K., CARRANZA F., TAKEI H.H.: The use of a porous hydroxylap atite implant in periodontal defects. II. Treatment of class II furcation lesions in lower molars. J. Periodontol. 1988, 59, 67 72. [20] BALDI C., PINI PRATO G, PAGLIARO U, NIERI M, SALETTA D, MUZZI L, CORTELLINI P.: Coronally advanced flap pro cedure for root coverage. Is flap thickness a relevant predictor to achieve root coverage? A 19 case series. J. Periodontol. 1999, 70, 1077 1084. [21] LEKOVIC V., KENNEY E.B., CARRANZA F.A., DANILOVIC V.: Treatment of class II furcation defects using porous hydroxylapatite in conjunction with a polytetrafluoroethylene membrane. J. Periodontol. 1990, 61, 575 578. [22] ANDEREGG C.R., MARTIN S.T., GRAY J.L., MELLONING J.T., GHER M.E.: Clinical evaluation of decalcified freeze dried bone allograft with guided tissue regeneration in the treatment of molar furcation invasions. J. Periodontol. 1991, 60, 264 268. [23] ROSEN P.S., MARKS M.H., BOWERS G.M.: Regenerative therapy in the treatment of maxillary molar class II furca tion. Case reports. Int. J. Periodont. Restorative Dent. 1997, 17, 517 527. [24] CAMELO M.C., NEVINS M.L., NEVINS M.: Treatment of class II furcations with autogenous bone grafts and e PTFE membranes. Int. J. Periodont. Restorative Dent. 2000, 20, 233 243. [25] LEONARDIS D., GANG A.K., PEDRAZZOL V., PECORA G.E.: Clinical evaluation of the treatment of class II furcation involvements with bioabsorbable barriers alone or associated with demineralized freeze dried bone allografts. J. Periodontol. 1999, 70, 8 12. Address for correspondence: Dorota Mierzwa Dudek Department of Dental Surgery Silesian Piasts University of Medicine 26 Krakowska Street 50 424 Wrocław, Poland Tel: +48 71 784 0 254 E mail:katedra@chirstom.am.wroc.pl Received: 30.11.2006 Revised: 25.01.2007 Accepted: 25.01.2007 Praca wpłynęła do Redakcji: 24.01.2007 r. Po recenzji: 7.02.2007 r. Zaakceptowano do druku: 19.03.2007 r.