Regeneration and repair of
Loma Linda University, Loma Linda, CA,
periodontal tissues
Egelberg J: Regeneration and repair of periodontal tissues. Journal of Periodontal
Research 1987: 22: 233-242.
Chronic periodontitis leads to loss of
the tooth-supporting tissues, eventually
resulting in loss of teeth. Ideal treatment
should involve not only the prevention
of further attachment loss, but the re-
generation of lost supporting tissues,
comprising new alveolar bone and a
new periodontal ligament. This review
is an attempt to describe what we know
about periodontal regeneration and re-
pair in humans and experimental ani-
mals within the confines of the follow-
ing outhne:
1) New connective tissue attachment
to previously diseased root sur-
faces;
2) Clinical studies on regeneration of
human periodontal defects;
3) Healing of the supracrestal root
surface wound;
4) Heahng of the periodontal liga-
ment wound;
5) Root resorption;
6) Future research needs.
Various aspects of periodontal re-
generation and repair have been cover-
ed in previous reviews (1-8).
1. New connective tissue attachment
to previously diseased root surfaces
It has long been questioned whether
new attachment of connective tissue to
root surfaces previously denuded by
periodontitis is at all possible. Over the
years, histological observations from
human biopsies of treated cases have
been reported which suggest that parts
of previously diseased root surfaces
showed a new connective tissue attach-
ment (5, 9-11). However, conclusive evi-
dence was not presented until appropri-
ate reference notches in the root surface
were utilized (12-15).
Despite the reports of successful new
connective tissue attachment, this does
not seem to be the typical outcome of
regenerative attempts in humans. Many
cases that clinically are considered suc-
cessful, including cases of significant re-
generation of alveolar bone, may histo-
logically show an apical regrowth of
junctional epithelium along the treated
root surface (11).
2. Clinical studies on regeneration of
human periodontal defects
Regeneration of periodontal tissues cir-
cumferentially around teeth does not
seem to be possible in humans at this
time. Efforts have primarily been di-
rected at regeneration of localized peri-
odontal lesions. This review will focus
on those periodontal defects where the
root surface lesion is surrounded by re-
maining walls of alveolar bone (in-
frabony/intraosseous defects).
Since biopsies of treated human
lesions are generally not available, ob-
servations on intraosseous defects have
mostly been limited to results from chni-
cal methods of measurement. These
methods are not capable of identifying
new connective tissue attachment and
can only assess apposition of new al-
veolar bone and improved adaptation
of the gingival tissue. However, given
this limitation, each of the following
chnical methods of observation may
yield useful information: 1) probing at-
tachment level measurements; 2) prob-
ing bone level measurements ("bone
sounding"); and 3) direct bone measure-
ments at surgery and at a subsequent
exploratory re-entry procedure (16).
Effect of surgical debridement
A therapy consisting of elevation of mu-
cogingival fiaps, removal of granuloma-
tous tissue from the intraosseous lesion,
debridement and planing of the root
surfaces, and replacement of the surgi-
cal fiaps, can result in significant clinical
improvement. Gains of probing attach-
ment levels and gains of probing bone
levels amounting to 3 mm or more have
been reported. Re-entry observations
have demonstrated that it is possible
Jan Egelberg
U.S.A.
Accepted for publication September 26, 1986
to eliminate most of the intraosseous
defects by significant bone fill combined
with some resorption of the defect crests
(17-19). Other studies, however, report
more limited mean gains in attachment
and bone levels of 1-1.5 mm (20-22).
Effect of osseous grafting
Initial reports by several authors indi-
cated favorable results following use of
various types of osseous grafts:
autogenous cancellous bone; fresh or
frozen ihac crest autogenous cancellous
bone and marrow; frozen allogenic iliac
cancellous bone and marrow; and free-
ze-dried allogenic cortical bone (23-28).
However, more recent studies on oss-
eous grafting have observed more mod-
est results (29-30). In fact, several stud-
ies have observed little or no advantage
to osseous grafting over non-grafted
controls (29, 31, 32).
There is little indication that grafts
of cortical or cancellous bone have any
inductive effect on formation of new
bone (33, 34). Also, there is little reason
to beheve that such bone grafts would
stimulate connective tissue attachment
to the root surface. Therefore, a benefi-
cial effect, if any, may primarily be ex-
plained by the role of these grafts as
"fillers", providing some postoperative,
mechanical support to the surgical fiaps
prior to the gradual resorption or re-
placement of the grafts.
Animal experimentation indicates
that grafts of decalcified bone may have
higher osteogenic potential than other
types of bone graft materials (35, 36).
Again, there is no evidence that such
grafts might facilitate connective tissue
attachment to the root surface. As yet
there are only limited data available in-
dicating that decalcified bone is a su-
perior graft material for periodontal use
(15, 37). Nevertheless, since freeze-
dried, decalcified bone allografts are
commercially available and seem to
have no antigenic side effects, they
234 Egelberg
might constitute an appealing material
for those clinicians and researchers who
want to continue to explore the benefits
of osseous grafts.
Grafts of fresh, iliac cancellous bone
and marrow seem to play a more active
role during healing. Root resorption,
frequently observed in experimental
animals after use of these grafts, has
also been reported in humans (5, 25,
38-42). It is not known if the root re-
sorption is caused by activity originat-
ing from the grafted iliac tissue or if
these grafts somehow may facilitate an
initial connective tissue attachment to
the root surface, initiating resorption
due to "successful" prevention of epi-
thelial migration.
Effect of ceramic grafts
Grafts of ceramic tricalcium phosphate
and hydroxyapatite, including a porous
hydroxyapatite of coral origin, have
been evaluated. These materials seem to
be inert and do not cause an infiamma-
tory tissue reaction. Hydroxyapatite is
non-resorbable and will remain in the
grafted defect. Tricalcium phosphate,
supposed to be resorbable, has still been
observed in defects 9 months after graft-
ing. Bone formation around grafted
particles has been reported, but may not
occur regularly (43-52).
Clinical studies have reported varying
amounts of defect fill following use of
ceramic grafts (53-58). The beneficial
effect of these grafts over bone grafts
or non-graft procedures has not been
convincingly demonstrated. However,
their use as a "filler" in specific situ-
ations may need to be further explored.
Effect of citric acid root conditioning
Encouraged by results from animal
models, clinical investigators have
evaluated the effect of superficial de-
mineralization of the dcbrided and
planed root surfaces with citric acid. In
spite of the fact that several animal stud-
ies have shown that this treatment facili-
tates attachment of connective tissue to
the root surface, clinical studies have
failed to demonstrate that citric acid is
a significant adjuvant to surgical debri-
dement (20, 29, 59-61).
Predictability of regenerative procedures
in human intraosseous defects
There is little doubt that all of the above
methods of regenerative surgery can
provide clinically successful results in
individual cases in terms of defect fill
and improved adaptation of the gingival
tissues. Deep and narrow 3-wall defects
may have the best regenerative potential
(18, 19, 62-64).
Animal experimentation has demon-
strated that new connective tissue at-
tachment over extended portions of the
treated root surfaces is possible. Still, in
spite of an impressive number of clinical
studies, predictable results have not
been obtained in humans. This lack of
success would seem to indicate that
presently used techniques are inad-
equate, and that the focus of attention
in our approach to treating intraosseous
defects in humans needs to be altered.
The lack of suitable animal models
to simulate human intraosseous defects
is probably one of the reasons for the
limited advancement of our clinical re-
generative procedures. In fact, the logi-
cal investigative sequence of initial stud-
ies of a new therapy in a suitable animal
model, followed by the application and
gradual improvement of this therapy in
human studies to finally reach clinical
significance, is yet to be seen. This cir-
cumstance, however, does not deny the
importance of past studies in various
animal models in terms of improving
our knowledge of the healing process.
Such studies, together with a multitude
of experimental approaches to investi-
gate more specific aspects of periodon-
tal healing, form the basis of current
concepts.
3. Healing of the supracrestal root
surface wound
Successful new attachment of connec-
tive tissue to the treated root at the gin-
gival margin requires a healing process
that only allows a limited epithelization
of the interface between the root surface
and the healing granulation tissue. Fol-
lowing mechanical debridement and
root planing, the cementum or dentin
surface is covered by a smear layer
(65-67). The sequence of events leading
to connective fissue attachment, includ-
ing the formation of a layer of new ce-
mentum on this root surface, is not fully
understood. The observation of minor
surface irregularities reminiscent of cla-
stic resorption bays under newly formed
cementum suggests that there is an in-
itial phase of surface resorption. "Denti-
nolytic" type resorption has also been
suggested. However, new cementum can
also be seen on what appears to be a
smooth and unresorbed surface (68-71).
Conceptually, if initial surface re-
sorption occurs, newly formed collagen
fibrils could interdigitate and somehow
link up with collagen fibrils from the
cementum or the dentin matrix being
exposed by the resorptive process. A
subsequent formation of a layer of mi-
neralized cementum would reinforce
this attachment. In the absence of a re-
sorptive process, it appears that the at-
tachment of a layer of mineralization to
the root surface would have to rely upon
interlocking mineral crystals. This con-
cept is supported by the frequent obser-
vation of artifactual splits, located be-
tween the layer of new cementum and
the dentin surface in histological and
ultrastructural preparations. It is also
supported by the fact that these splits
seem to be less frequent against root
surfaces showing resorptive surface ir-
regularities, and against root surfaces
which have been superficially decalci-
fied as part of the treatment procedures
(70-75).
The limited information available on
molecular and cellular interactions dur-
ing the early healing events at the inter-
face between the root surface and the
coagulum/granulafion tissue is surpris-
ing in light of the importance that this
interface would seem to have for pre-
vention of subgingival reepithelization.
It is equally surprising that our lack of
success in previous attempts to manipu-
late the epithelium as the approach to
treatment has not redirected our focus
of interest from the epithehum to the
root surface. It is well known that the
surgical removal of the junctional epi-
thelium, or repeated postoperative epi-
thelial curettage, is inefficient (76-78).
Also, other attempts at surgical manipu-
lation for the purpose of delaying the
apical migration of the oral epithelium
do not seem to have given clinical suc-
cess beyond that of conventional flap
management (63, 79-82).
A recent approach to preventing ep-
ithelization and to facilitate an undis-
turbed connective tissue healing at the
marginal wound interface involves the
use of barrier membranes placed under-
neath the reapposed surgical flap (83).
The interposition of barrier membranes
extending coronal to the flap margin
will prevent the oral epithelium from
migrating over the root surface. Animal
experimentation has indicated the po-
tentials of this approach. Increased
amounts of connective tissue attach-
ment have been obtained following the

use of membranes as compared to non-
membrane controls (84-85). Successful
application of this method in a human
case has also been reported (83).
The traditional concept of a "race"
between epithelial migration and con-
nective tissue attachment supposes that
the oral epithelium will continue to mi-
grate from the margin of the surgical
fiap and apically until it meets resistance
from connective tissue, which somehow
has attached to the root surface. An-
other way of approaching this problem
is to ask questions such as: How can we
make the coagulum adhere to the root
surface to the extent that it would pre-
vent epithelial cells from migrating
along the marginal wound interface?
How can the root surface be prepared
to provide an initial adhesion of the
coagulum and allow a subsequent unin-
terrupted maturation and organization
of the granulation tissue? Perhaps the
prevention of epithehalization is not the
primary issue. It appears that the ad-
hesion of the coagulum/granulation tis-
sue to the root surface is of critical im-
portance. A break in this adhesion may
lead to a renewed contamination of the
root surface and to failure, even in the
absence of epithelium. Eventually, epi-
thelium originating somewhere around
the tooth will cover the granulation tis-
sue which failed to attach to the root.
Root surface preparation
Conditioning of the root surface by top-
ical application of acids, primarily citric
acid, has been used to facilitate new
connective tissue attachment (73, 74,
86). Between 1 and 3 min of treatment
dissolves the smear layer, and causes
a demineralization of the root planed
dentin to a depth of 1-5 /xm, thereby
exposing collagen fibrils of the dentin
matrix (67, 87-90). The acid treatment
may also contribute to detoxification of
any remaining root surface contaminant
following root planing (91, 92). The ex-
posed collagen fibrils may facilitate an
adhesion of fibrin or other blood clot
components to the root surface (93).
The exposed fibrils may also enhance
adhesion, proliferation, and migration
of fibroblasts on the root surface
(94-104). Electron microscopic obser-
vations indicate that the exposed colla-
gen fibrils of the dentin matrix interdigi-
tate with newly formed collagen fibrils
in the healing tissue after 7-14 d (89,
105, 106). Thus, there are several obser-
vations suggesting that acid condition-
Regeneration of periodontal tissues
ing prepares the root surface for im-
proved adhesion and maturation of the
blood clot.
Several studies have demonstrated in-
creased amounts of new connective tis-
sue attachment following acid con-
ditioning compared to non-acid treated
controls (12, 107-119). Other studies
have not been able to confirm the find-
ing of increased connective tissue at-
tachment following acid conditioning
(120-124). These discrepancies may be
explained by the use of different models
for experimentation. Successful results
would seem to require models with a
certain minimum distance from the
margins of the sutured surgical fiap to
the base of the lesions to allow for the
demonstration of a difference between
experimental and control procedures.
Also, the quality of wound closure, fiap
adaptation, and postoperative fiap sta-
bility may be critical to prevent mechan-
ical interference and rupture at the
wound interface (109, 115, 125). These
factors may have differed between stud-
ies observing benefit versus no benefit
from the use of citric acid conditioning.
Furthermore, the difficulties in obtain-
ing adequate wound protection may
also explain why successful results using
citric acid have not been accomplished
in human intraosseous defects.
Superficial demineralization of the
root surface has also been performed
using acids other than citric acid, e.g.
hydrochloric acid and phosphoric acid
(66, 73, 74, 90). Also, acid solutions of
tetracycline and stannous fluoride have
been introduced (126-129). In vitro
studies using tetracycline have demon-
strated that this treatment, compared
to use of citric acid, further enhances
adsorption of fibronectin and sub-
sequent adhesion of fibroblasts
(103-104). Tetracycline may also be
valuable because of its antimicrobial
properties (129-132). Animal studies
have confirmed that tetracycline hy-
drochloride is an alternative to citric
acid to facilitate new connective tissue
attachment (133-134). The use of stan-
nous fiuoride for demineralization may
reduce the potential for root resorption
(128).
In vitro experiments demonstrate that
fibronectin binds more to demineralized
dentin surfaces than to undemineralized
dentin (103-135). The combination of
surface demineralization and appli-
cation of fibronectin has been found to
enhance the in vitro adhesion of fibro-
blasts compared to demineralization
235
alone (96, 103-104). One animal study
resulted in increased connective tissue
attachment following use of fibronectin
as compared to demineralization alone
(117), whilst other experimentation in
animals has failed to demonstrate such
a difference (134).
In spite of the biological grounds po-
inting to the potentials of root surface
preparation, it must be remembered
that the results in experimental animals
are confiicting, and that clinical success
in humans has not been accomplished.
Also, a new connective tissue attach-
ment may subsequently be subjected to
host tissue intervention resulting in root
resorption.
4. Healing of the periodontal
ligament wound
Studies on replantation of teeth indicate
that, once the periodontal ligament is
destroyed around the full circumference
of the root, a new ligament will not
develop. Drying, radiation, or mechan-
ical removal of the periodontal ligament
in freshly extracted teeth prior to their
replantation lead to an aberrant healing
process resulting in ankylosis of the al-
veolar bone to the root surface and to
root resorption. Eventually, the entire
root will disappear by a gradual remod-
elling and resorptive process. This is in
contrast to teeth which are replanted
soon after extraction without any de-
structive treatment of the ligament
(136-145). The critical elements respon-
sible for regrowth of a ligament are ap-
parently located in that part of the peri-
odontal ligament which remains at-
tached to the tooth following
extraction. Apart from this, little is
known about the specific molecular and
cellular determinants for periodontal
ligament reformation. Attempts at re-
plantation of extracted teeth following
in vitro cultivation of periodontal liga-
ment cells on the root surfaces of the
extracted teeth have met with limited
success (146). However, it appears that
this area of research could be expanded,
considering that these tissue elements
could be studied and manipulated out-
side the living animal.
The periodontal ligament may regen-
erate completely following localized in-
jury. Window type defects have been
created by elevation of a mucoperiosteal
fiap and removal of alveolar bone, peri-
odontal ligament, and cementum in an
area over the root apical to the alveolar
crest. During healing, the granulation
236 Egelberg
tissue of such wounds seems to be
gradually replaced by ingrowth of new
ligament, new cementum, and new bone
from the periphery of the lesions (73,
147). Defects beyond a certain size may
not be completely restored. Although
restitution takes place in the periphery,
the healing of the central portions may
be complicated by ankylosis and poss-
ibly also by root resorption (143,
148-150). Dehiscence type defects creat-
ed at the alveolar crest may show partial
restitution, again by ingrowth of liga-
ment, cementum, and bone from the U-
shaped borders of the lesions (85, 124,
151). Horizontal or circumferential re-
duction of periodontal support is
usually followed by a periodontal liga-
ment regeneration limited to 1 or a few
millimeters from the base of the lesion
(123, 152-155).
It appears from the above studies
that: 1) regeneration of periodontal liga-
ment, including new cementum and
bone, requires adjacent intact ligament
tissue from which proliferation and re-
formation can occur; and 2) the re-
generation capacity of the periodontal
ligament is limited. Future research
needs to find answers to several ques-
tions: Is the regeneration capacity of
periodontal ligament tissue so limited
that it will be impossible to obtain an
amount of regeneration which is chn-
ically significant? Can the regeneration
capacity be enhanced by some adjunc-
tive measures to reach clinical signifi-
cance? Would it be possible to create
conditions that would stimulate undif-
ferentiated cells of the granulation tissue
to form a functional periodontal liga-
ment?
Repair cementum
Typically, formation of new cementum
frequently occurs at the base of the
treated defects coronal to the intact
periodontal ligament. It is assumed that
this cementum is formed by cemento-
blasts originating in the periodontal
ligament and capable of some coronal
migration. However, cementum-like de-
posits associated with inserting collagen
fibers have also been observed in areas
remote from the base of the treated de-
fect (156-158). It seems unhkely, be-
cause of the spatial relationships, that
this "cementum" is formed by cemento-
blasts originating from the periodontal
ligament. The observation of a conti-
nuity of such deposits with newly
formed alveolar bone suggests that bone
cells could be responsible for the de-
posits (157, 158). Cells from the perios-
teum on the inside of the surgical fiaps
is another possible source in situations
where the surgical fiaps are proximate
to the root surfaces during wound clos-
ure. It cannot be excluded that gingival
connective tissue cells also may initiate
a mineralization process. Furthermore,
superficial root surface resorption as
part of the early healing response may
expose matrix proteins which may in-
ifiate a phase of mineralization. Such a
process may be accelerated by prior acid
conditioning of the root surface
(159-166).
Thus, different types of cementum-
like deposits may form on the root sur-
face depending upon the available con-
ditions during healing. It is possible that
only cementum formed by cemento-
blasts originating from the periodontal
ligament can serve as a lasting attach-
ment. Other cementum-like deposits
may be subjected to subsequent re-
sorption, exposing the root dentin to
resorption as well. The possibihty of
cementum-like deposits of various gen-
esis needs to be investigated.
Guided cell repopulation
Following replacement of the surgical
fiap in regenerative surgery of dehiscen-
ce type defects, the elements of the peri-
osteum and the connective tissue on the
inner surface of the fiap are approximat-
ing the wound interface. Placement of
barrier membranes, bridging from the
outer surface of the reduced alveolar
crest to the cervical portion of the tooth,
prevents access of the cells of the surgi-
cal fiap to the wound interface. Instead,
a compartment for the blood clot is
created with access for ingrowth of
blood vessels and cells from the borders
of the lesion. Thus, placement of barrier
membranes may facilitate the repopula-
tion of the root surface with ligament
forming elements. Indeed, membrane
experimentation in dehiscence type de-
fects has demonstrated increased re-
generation of cementum, ligament, and
alveolar bone as compared to non-
membrane controls. Also, the amounts
of healing aberrations - ankylosis and
root resorption - have been reduced (85,
167). It remains to be investigated, how-
ever, to what extent there are limits to
the guided cell repopulation concept.
For example, can the membrane ap-
proach, preventing access of cells from
the surgical fiaps, provide a gradual re-
placement (or transformation stimulus)
of the cells of the granulation tissue over
extended root surface areas? Will cen-
tral areas of large wounds, more distant
from the borders of the lesion, resist
replacement (or transformation) and la-
ter be prone to development of clastic
cells leading to a gradual resorption of
the root?
Another approach to the investiga-
tion of guided cell repopulation has
been suggested following observations
of fibroblast orientation and migration
in vitro. Fibroblasts and endogenously
produced collagen fibers have been
found to bridge "interdental spaces" be-
tween dentin particles and between
transversally cut root slices (94, 98). Mi-
gration of cells and orientation of con-
nective tissue cells and fibers in simulat-
ed periodontal spaces have been studied
(168, 169). These studies may represent
initial efforts attempting to find out if
coronal migration of periodontal Hga-
ment cells somehow can be enhanced by
provision of growth promoting spatial
relationships or "scaffolds" to the
treated area?
Progenitor cells in the periodontal
ligament seem to have a paravascular
origin (170-175). It is not known
whether a single paravascular progeni-
tor cell within the ligament gives rise to
daughter cells which differentiate into
fibroblasts, osteoblasts, and cemento-
blasts, or whether there are separate
progenitors.
As mentioned above, in vitro exper-
imentation has demonstrated that
superficial demineralization enhances
the adhesion, migration, and prolifer-
ation of fibroblasts on the surface of
dentin specimens, and that the fibro-
blast adhesion can be further enhanced
by application of fibronectin to the de-
mineralized dentin surface. Investiga-
tions using application of growth pro-
moting proteins have also been sug-
gested, as have applicafions of gels of
collagen (8, 100). These studies rep-
resent attempts at preparing the root
surface to facihtate the initial popula-
tion of connective tissue cells. It is con-
ceivable, however, that such measures
may be undesirable as subsequent infiux
of periodontal ligament cells may be
competitively inhibited. In fact, obser-
vations have been made indicating an
impaired migration of "periodontal H-
gament" cells from the wound margins
of citric acid treated periodontal fen-
estration defects as compared to non-
acid treated controls (176). Also, anky-

losis and root resorption was more
prevalent following acid conditioning
(177).
5. Root resorption
Root resorption as a potential healing
aberration following periodontal regen-
erative surgery seems to be a function
of the magnitude of the surface area
of initial connective tissue attachment
obtained. Two different "types" of root
resorption have been distinguished: that
located more coronally (cervical or su-
prabony resorption), and that located
more apically in areas of newly formed
bone (ankylosis associated resorption).
The cervical resorption may be more
aggressive as evidenced by the frequent
presence of multinucleated cells and the
size of the resorption bays. The anky-
losis associated resorption may become
temporarily arrested, either by bone ap-
position or by a layer of "osteocemen-
tum" (157, 178).
Both suprabony and ankylosis associ-
ated resorption has been observed in
animal studies utilizing submergence of
treated roots under the surgical flaps,
also enabling connective tissue attach-
ment over extended portions of root
surfaces (123, 144, 152-154, 158, 167).
Therefore, root resorption seems to be
the unwanted sequalae to clinically
meaningful amounts of new connective
tissue attachment, and it appears that
regenerative periodontal therapy cannot
be truly successful until we know how
to prevent this complication.
Root resorption during wound heal-
ing following regenerative periodontal
surgery may be of similar nature as the
root resorption occurring following re-
plantation of teeth with a non-vital peri-
odontal membrane. In both situations
the root surface has been deprived of an
attached layer of vital tissue, thereby
allowing multinucleated clastic cells ac-
cess to the root surface.
Clastic activity on the root surface
requires: a) mobilization of precursor
cells with clastic potential into the
wound coagulum, b) chemoattraction,
or possibly random migration of these
cells to the denuded dentin, and c) in-
itiafion of clastic activity. Clastic pre-
cursor cells may be mobilized from
three possible sources: 1) the alveolar
bone at the base of the treated defects;
2) the periosteum or the connective tis-
sue on the inside of the surgical fiaps;
and 3) cells of the monocytic family
brought to the wound by the circulating
Regeneration of periodontal tissues
blood. Chemoattraction for the precur-
sor cells and stimulus for initiation of
clastic activity may be provided by the
exposed elements of the denuded root
surface.
Future research is needed to find out
how to prevent clastic cells from initia-
ting root resorption. It has been sug-
gested that the cells responsible for root
resorption originate from the surgical
fiaps (179-180). If this is true, placement
of barrier membranes between the surgi-
cal flaps and the root surface might pre-
vent resorption. The resorptive poten-
tial of granulation tissue originating
from bone has been demonstrated (181).
Clastic cells may also be blood borne
and barrier membranes may have lim-
ited preventive effect. If this latter is
true, can the root surface be conditioned
to resist clastic activity?
Root resorption has only been oc-
casionally observed following regener-
ative periodontal surgery in humans. It
seems to be most prevalent following
use of grafts of fresh iliac cancellous
bone and marrow (9, 10, 38, 42, 182).
The infrequent occurrence can be ex-
plained by the fact that human regener-
ative attempts generally have resulted in
reepithelialization of the major portion
of the treated root surfaces (5, 10, 11,
15). Also, humans may be less prone to
root resorption than monkeys and dogs.
Available evidence from tooth replan-
tation suggests that root resorption de-
velops slowly in humans as compared
to monkeys and dogs.
Once more, predictable and success-
ful regenerative techniques have been
developed in man, the propensity of
root resorption needs to be carefully in-
vestigated. Treated human teeth need
to be carefully monitored over several
years. If possible, new regenerative tech-
niques should be tested in animal
models for root resorption prior to in-
troduction in humans.
6. Future Research Needs
From a therapeutic point of view future
research could be focused in the follow-
ing three conceptual areas: 1) Methods
to improve protection of the healing
wound at the root surface; 2) Methods
to enhance the adhesion and maturation
of the coagulum at the root surface; and
3) Methods of achieving repopulation
of the root surface by cells originating
from the periodontal ligament.
Surgical techniques need to be de-
veloped that will provide an adequate
237
protection of the treated root surface
around the circumference of the tooth
from mechanical, microbial, and other
injury. This may possibly be ac-
complished by manipulation of existing
surgical fiaps, by use of tissue trans-
plants for wound coverage, or by some
other means of assisted wound protec-
tion. Such methods, minimizing the risk
of mechanical rupture and contami-
nation at the root surface/coagulum
interface, may obviate the need for at-
tempts at preventing the oral epithelium
from early access to this interface.
Methods of root surface conditioning
need to be developed that will improve
immediate adhesion and early matu-
ration of the coagulum, and that will
accelerate the development of connec-
tive tissue attachment. However, it ap-
pears that these methods will need to
stimulate, or at least allow for sub-
sequent repopulation of the root surface
by periodontal ligament cells (resident
or transplanted).
Repopulation of the root surface by
cells originating from the periodontal
ligament may require methods that pre-
vent access to the root surface by com-
petitive cells, e.g. alveolar bone cells and
cells from the periosteum or the connec-
tive tissue of the surgical fiaps. Al-
though repopulation by ligament cells
is not necessary for successful initial
connective tissue attachment and sub-
sequent coronal bone apposition, such
repopulation may be necessary to avoid
the development of root resorption.
The attainment of new functional
periodontal ligament over extensive
portions of the treated root surfaces
may not be realistic. It is possible that
we will have to settle for a compromize
in terms of a "functional scar". Maybe
it will be possible to develop root con-
ditioning methods which will not only
facilitate connective tissue attachment
and bone apposition, but will also make
the root surface resistant to resorptive
activity, thereby allowing for a long-
lasting, non-ligamentous reunion.
As has become apparent from this
review, we may not have enough infor-
mation at this point to approach the
above conceptual research areas in a
logical manner. In spite of the fact that
we know how to obtain new connective
tissue attachment over extended por-
tions of root surfaces in animal models,
we don't understand the healing events
leading to this new attachment. For ex-
ample, we don't know the origin of cells
developing the attachment - or attach-
238 Egelberg
ments - if attachments of different types
or cellular origins exist. We don't know
why some initial attachments are fol-
lowed by root resorption. The concept
of coronal migration of periodontal
ligament cells as a means of achieving a
long-lasting new attachment has emer-
ged from indirect evidence and has not
yet been proven beyond doubt. In other
words, it appears that an increased
understanding of the nature of our pres-
ent accomplishments is needed to en-
hance the possibilities of new achieve-
ments in the future.
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Address:
Jan Egelberg
Loma Linda University
Loma Linda
California 92350
U.S.A.