719

Periodontal Repair in Dogs:

Effect of Wound Stabilization
on Healing*
Ulf . E. Wikesjö and Rolf Nilvéus

This study evaluated a biodegradable polylactic acid matrix as a wound sta-

bilizing implant in reconstructive periodontal surgery. Supra-alveolar circumferential
periodontal defects, 5 to 6 mm large, were surgically created around the mandibular
premolars in 7 beagle dogs. The root surfaces in left and right jaw quadrants were treated
with either heparin or saline. In this model, root surface treatment with heparin compro-
mises periodontal repair and results in a long junctional epithelium and a reduced con-
nective tissue repair to the root surface, whereas saline treatment results in almost complete
connective tissue repair. Following heparin or saline treatment a polylactic acid implant
was placed on 1 premolar in each quadrant. After 4 weeks of wound healing, the dogs
were sacrificed and tissue blocks prepared for histometric analysis. Postoperatively, the
implant became exposed and infected in 3 dogs and had to be removed. Therefore, the
results reflect the 4 dogs in which healing progressed uneventfully. Connective tissue
repair to the root surface in teeth treated with heparin averaged 82% of the defect height.
Mean connective tissue repair in teeth treated with heparin and the implant was signifi-
cantly greater and comprised approximately 99% of the defect height (P < 0.05). Teeth
treated with saline either with or without the implant also healed with almost complete
connective tissue repair. The results support the importance of wound stabilization in
periodontal wound healing. Development of biodegradable implant systems aimed at
stabilizing and supporting the healing wound seems a desirable direction for future re-
search in regenerative periodontal procedures. J Periodontol 1990; 61:719-724.

Key Words: Tooth résorption; root; dental implants; connective tissue; heparin; peri-
odontal diseases/therapy; polylactic acid; biogradation; wound healing.

Experimental studies in dogs have demonstrated that when
mucoperiosteal flaps are elevated and sutured to cover most
of the crown of teeth with extensive periodontal defects,
connective tissue repair to the root surface is predictable.1"5
In contrast, when the flap margins are placed and sutured
slightly above the cemento-enamel junction (CEJ), healing
results in partial epithelialization of the wound.1-6 However,
when the flap margins are "anchored" at this level by
single interdental sutures luted to the crowns of the teeth,
connective tissue repair is comparable to that observed fol-
lowing coronally elevated flaps.6 From these findings it
appears that in addition to adequate primary wound cov-
erage, some other measure must be satisfied to enhance
connective tissue repair to the root surface. The coronally
elevated flap as well as the crown "anchored" flap pro-
cedure may offer this additional measure by contributing
increased stability to the healing wound.
It is generally not feasible to position and secure the flaps
School of Dentistry, Loma Linda University, Loma Linda, ca.
with sutures "anchored" to the teeth except in rare clinical
situations.7 Other means of establishing wound stabiliza-
tion, therefore, need to be explored. Various implant ma-
terials have been used in periodontal reconstructive surgery.8
The graft materials, whether autografts, allografts, or of
alloplastic nature, are mostly granular and may be suitable
for use in infrabony and furcation defects but not for wound
stabilization in reconstructive surgery of supraalveolar peri-
odontal defects.
Polylactic acid is a biodegradable ester polymer devel-
oped by Kulkarni et al.9-10 It has been used in orthopedic
surgery in various configurations; for example, spun into
fibers11 or machined to screws and plates.12 Thin sheets of
polylactic acid have been used in periodontal reconstructive
surgery13-14 and porous cubes or granules used to enhance
the healing of alveolar extraction sites.15'16 The porous ma-
terial is arranged in a network of randomly sized and po-
sitioned interstices which communicate with each other and
the outer boundaries of the material. The material is rigid
and may be carved to almost any shape. These properties
 J Periodontol
720 PERIODONTAL WOUND STABILIZATION December 1990

seem to be valuable in accomplishing adequate wound sta-

bilization for supraalveolar periodontal defects. The pur-
pose of this study was to histologically evaluate the porous
polylactic acid implant material as a wound stabilizing mea-
sure in reconstructive surgery of supraalveolar periodontal
defects in dogs.

MATERIALS AND METHODS

Animals and Surgical Procedures

Seven young adult male beagle dogs were used. Bilateral
circumferential horizontal periodontal defects were sur-
gically created in the 2nd, 3rd, and 4th mandibular pre-
molars (P2, P3, and P4) immediately followed by
reconstructive surgery. The defects measured approxi-
mately 5 to 6 mm from the CEJ to the margin of the alveolar
bone. The defects in P2 were slightly smaller than in P3
and P4. All surgical procedures and dog maintenance fol-
lowed a standard laboratory protocol earlier described.17
This study was part of an institutionally approved protocol
in periodontal wound healing in dogs.

Wound Management
Root surface treatment followed a protocol earlier de-
scribed.18 Briefly, the root surfaces were carefully instru-
mented to remove all cementum. They were then isolated
with rubber dam and treated with either heparin1" or saline
in alternate quadrants. Heparin or saline treatments were
carried out as 5-minute continuous drop applications. Ov-
erflow of the heparin solution or saline was continuously
aspirated. The root surfaces were then allowed to dry for 2
minutes assisted by a gentle stream of air. After removal
of the rubber dam, porous blocks of polylactic acid,* carved
to a profile similar to the removed alveolar bone, were
loosely fitted to either P2 or P4 in heparin and saline treated
quadrants (Figs. 1 and 2). The base of the implant material
rested on the reduced alveolar bone while its coronal border
reached just apical to the CEJ. Every second dog received
the implant around the left and right P2 and every other
around the left and right P4. Thus, 4 experimental condi-
tions were created: 1) heparin treatment; 2) heparin treat-
ment and polylactic acid implant; 3) saline treatment, and
4) saline treatment and polylactic acid implant. The flaps
were sutured to cover the implant, leaving the flap margins
1 to 2 mm coronal to the cemento-enamel junction. Sutures
were removed after 7 to 10 days. A broad spectrum anti-
biotic* was administered daily for 2 weeks following sur-
gery. Daily plaque control was achieved by irrigation with
a 2% Chlorhexidine solution.¡l The dogs were sacrificed 4
weeks after surgery.
-Lock, 10 units/ml, Elkins Sinn Inc., Cherry Hill, NJ (diluted to 1
unit/ml in saline).
*Drilac Cube, Osmed, Costa Mesa, CA (6% polylactic acid, 94% air).
5Combiotic, Pfizer Inc., New York, NY.
:iHibitane, ICI Ltd., Macclesfield, Great Britain.
Figure 1. The polylactic acid implant material before (A) and after (B)
preparation for the implant site. The body of the material is carved to a
U-shape (B:a) to fit one interproximal and the buccal and lingual aspect
of the defect. Separate blocks are carved to fit the furcation (B:b) and to
close the U-shaped block in the remaining interproximal aspect of the
defect (B:c).
Histological Procedures
Block biopsies including experimental teeth and surround-
ing soft and hard tissues were obtained at sacrifice. The
blocks were decalcified, trimmed, dehydrated, and embed-
ded in paraffin. Serial sections, 7 µ thick, were cut in a
bucco-lingual plane throughout each tooth. Every 14th sec-
tion, approximately 100 µ apart, was stained with Mas-
son's trichrome and an adjacent section with hematoxylin
and eosin.
Judged by the size of the root canal and the pulp cham-
ber, the most centrally located section was identified for
both the mesial and the distal root. This section and the 2
adjacent step serial sections on each side were used for
analysis. Measurements were performed at 30X magnifi-
cation using a microscope linked to a computer aided man-
ual data collection system."
The following linear measurements were taken for the
buccal and lingual surfaces of each root of the teeth:
Defect height: the distance between the apical extension
of the root planing and the cemento-enamel junction.
Junctional epithelium: the distance from the apical to
'Videoplan, Carl Zeiss Inc., Kontron, Eching bei München, West Germany.
Volume 61
Number 12
Figure 2. The mandibular premolar teeth (P2, P3, and P4) after surgical
reduction of the bone and root preparation (A); after fitting of the poly-
lactic acid implant material (B); following wound closure and suturing
(C).
the coronal extension of the junctional epithelium along the
root surface.
Connective tissue repair: the distance between the apical
extension of the root planing and the apical termination of
the junctional epithelium.
Cementum formation: the distance between the apical
extension of the root planing and the coronal extension of
a continuous layer of cementum or a cementum-like deposit
on the root surface.
Bone formation : the distance between the apical exten-
sion of the root planing and the coronal extension of newly
formed alveolar bone along the root surface.
Root résorption: the combined linear heights of distinct
résorption lacunae along the root surface.
Ankylosis: the combined linear heights of ankylotic union
of newly formed alveolar bone and the root surface.
Implant height: the distance between the apical exten-
sion of the root planing and the coronal extension of the
polylactic acid implant.
WIKESJÖ, N1LVÉUS 721
Data Analysis
Surface, tooth, and dog means for each of the measure-
ments were calculated using the 5 selected step serial sec-
tions. Differences for treatments between dog means were
analyzed using Student's f-test for paired observations. Dif-
ferences for treatments between dog means relative to con-
nective tissue repair were also analyzed using the
nonparametric Quade test.19 Additionally, the frequency of
teeth presenting with root résorption and ankylosis was cal-
culated. Presence of these features in 1 or more sections
from each tooth resulted in a positive score.
RESULTS
Clinical Observations
Healing proceeded uneventfully in 4 of the 7 dogs. The
gingival margin receded to slightly coronal to the CEJ in
saline treated teeth with or without the adjunctive biode-
gradable implant. Similarly, in heparin-treated teeth with
the polylactic acid implant, the gingival margin maintained
a position coronal to the CEJ. In contrast, in teeth receiving
heparin treatment alone the gingival recession progressed
apical to the CEJ. In 3 dogs the implant became exposed
and the surgical sites infected. The implant had to be re-
moved and the wounds debrided. Thus, the histological
observations were limited to the 4 dogs in which healing
proceeded uneventfully.
Histological Observations
Healing features of heparin and saline treated teeth in this
study were similar to those earlier reported for these treat-
ments. 17·1 Briefly, heparin-treated defects healed partially
with a long junctional epithelium and partially with con-
nective tissue repair. Saline-treated teeth showed almost
complete connective tissue repair to the root surface. Re-
generation of cementum and alveolar bone was limited and
similar for the 2 treatments. Root résorption was observed
in all teeth and was often prominent immediately apical to
the junctional epithelium. Few teeth exhibited ankylosis.
The polylactic acid implant was present in the sections
from all implant sites (Fig. 3). The most coronal part of
the implant had been resorbed and replaced by connective
tissue. The implant often exhibited infiltration of multi-
nucleated giant cells. This cellular activity did not seem to
affect the adjacent root surface. However, regeneration of
bone and cementum from the base of the wound seemed
inhibited in these teeth.
Histometric Observations
Mean defect height for the 4 treatments was similar and
ranged between 5.0 ± 0.2 and 5.6 ±1.3 mm (Table 1).
Mean connective tissue repair to the root surface comprised
98.5% of the defect height, or more, for saline treatment
and for saline or heparin treatment in conjunction with the
polylactic acid implant. Connective tissue repair following

722 PERIODONTAL WOUND STABILIZATION
Figure 3. Bucco-lingual section of a tooth treated with heparin and the
polylactic acid implant (PIA). The defect height from the apical extension
of the root planing (ARP) to the CEJ is approximately 5 mm. The defect
exhibits complete connective tissue repair to the root surface. The poly-
lactic acid implant occupies a major portion of the defect. Granulation
tissue infiltration of the implant can be observed. This expression of heal-
ing was often seen throughout the implants. Root résorption IRR) can be
seen immediately apical to the
junctional epithelium (JE) and further down
along the root surface. Alveolar bone (AB).
J Periodontol
December 1990
heparin treatment was significantly smaller and averaged
81.6% of the defect height (P<0.05, Table 1, Fig. 4).
There was a tendency for the implant material to suppress
cementum and bone formation (Table 1, Fig. 4). This tend-
ency reached statistical significance when the saline treat-
ment was compared to the saline or heparin treatment
supported by the polylactic acid implant. Root résorption
was present in all teeth and ranged between 35.3 and 47.2%
of the defect height for the 4 treatments (Tables 1 and 2).
Ankylosis was limited and was only observed following the
saline treatment (Tables 1 and 2).
DISCUSSION
This study evaluated whether a biodegradable, porous po-
lylactic acid implant material could serve as a wound sta-
bilizing measure following reconstructive surgery in large
supraalveolar periodontal defects. An experimental model
that features surgically created and immediately treated
periodontal defects was used.17 These defects exhibit al-
most complete connective tissue repair to the root surface
following reconstructive surgery. In a recent study using
this model we examined whether measures intended to dis-
rupt the early healing events; i.e., clot adhesion to the root
surface, would alter the outcome of healing.18 Clot adhe-
sion was compromised by treating the root surfaces with
heparin prior to wound closure. This treatment significantly
reduced the connective tissue repair in these defects. The
heparin treatment may have impaired clot adhesion by in-
terfering with the extrinsic clotting cascade at the root sur-
face and/or by altering the adsorption pattern of plasma
proteins to the root surface. An impaired clot adhesion may
weaken the tensile strength of the wound during the very
early healing events and leave the root surface-gingival flap
interface more susceptible to tear from normally occurring
tensile forces on the wound margins. The question arises if
the inferior healing result following the heparin treatment
may be improved by increasing the stability of the wound
by a biodegradable implant. The data in this study suggest
that the polylactic acid implant significantly improved con-
nective tissue repair in heparin treated root surfaces.
There was a greater variability in defect height for the
treatment groups with implants than for the other treatment
groups. This phenomenon is related to the study design.
Mean defect heights for saline and heparin treatments alone
were derived from dog means from P2 and P3 or P3 and
P4, whereas mean defect heights for implant supported teeth
were derived from the smallest and largest periodontal de-
fects (P2 in 2 dogs and P4 in the other 2 dogs). Since
connective tissue repair was almost complete in implant
supported teeth, the variability in mean connective tissue
repair paralleled the variability in defect height. Due to this
variability and the small sample size, nonparametric statis-
tical testing of differences for treatments in connective tis-
sue repair was additionally used.
A smaller reduction in connective tissue repair was found
Volume 61
Number 12 WIKESJÖ, NILVÉUS 723

Table 1: Periodontal Repair of Supraalveolar Periodontal Defects Following Root Surface Treatment
With Heparin or Saline, With or Without Flap Stabilization With a Polylactic Acid Implant (PLA)

Heparin Saline
Defect Heparin + PLA Saline + PLA
Defect Height 5.1 ±0.3 5.4: :1.0 5.0±0.2 5.6: 1.3
Junctional Epithelium 0.8±0.3 0.1 :0.1 0.1 ±0.0 0.1: 0.1
_I
L
Connective Tissue 4.2±0.4 5.3±1.1 4.9 ±0.1 5.5 ± 1.2
Repair
L
Cementum Formation 0.4 ±0.3 0.2 ±0.2 0.8±0.4 0.3 ±0.3
Bone Formation 0.5 ±0.4 0.2 ±0.2 1.4 ±0.7 0.1 ±0.1
Root Resorption 1.9 ±1.1 2.8 ±2.0 2.1 ±0.8 2.2±2.3
Ankylosis 0.0 ±0.0 0.0 ±0.0 0.3 ±0.3 0.0 ±0.0
Residual Implant 3.8 ±1.0 3.7 + 0.4
Height —

*P 0.05 Student's f-test.

<
tP 0.05 Quade test.
<
Mean ± s.d. in mm, N 4. =

Table 2: Proportions of Teeth With Root Resorption and Ankylosis

Following Root Surface Treatment With Heparin or Saline With
and Without Flap Stabilization With a Polylactic Acid Implant
(PLA)
Heparin Saline
Heparin + PLA Saline + PLA

Root Resorption 8/8 4/4 8/8 4/4

Ankylosis 0/8 0/4 4/8 0/4

harbored a polylactic acid implant around one of the teeth

which may have improved the wound stability for the
neighboring tooth or perhaps the entire quadrant and thus
improved the connective tissue repair in the 2 teeth without
the implant.
It should be kept in mind that the polylactic acid material
was designed as a clot supporting matrix for alveolar ex-
traction sites and not for wound stabilization in reconstruc-
tive periodontal surgery. However, the material has some
properties that seemed suitable for regenerative periodontal
procedures. With these reservations, there are some aspects
of the polylactic acid implant that deserve further comment.
The rigid and porous material was easily carved to fit the
supraalveolar periodontal defects. Upon placement, it was
immediately filled with blood and the flaps could be closed
slightly above the CEJ, secured by single interdental su-
tures. These properties seem desirable for flap support and
may be essential for the maintenance and maturation of the
root surface-adhering blood clot into a connective tissue
HEPARIN HEPARIN SALINE SALINE attachment.20
+ PLA + PLA
The biodegradable implant was still present 4 weeks after
Figure 4. Histometric results expressed in percent (%) of the defect height.
The shadowed blocks depict the polylactic acid implant (PLA). surgery. The implant was often infiltrated with multinuclear
giant cells. These findings are in concert with observations
from alveolar extraction sites and orthopedic surgical
following the heparin treatment compared to our other re- sites.11'12'15 For regenerative periodontal procedures, it would
port.18 This difference (81.6% vs. 50%) may be explained be desirable to develop a material with a somewhat faster
by the altered study design. The heparin-treated quadrants rate of degradation and with minimal inflammatory reac-

724 PERIODONTAL WOUND STABILIZATION
tion. In dogs, connective tissue attachment to the root sur-
face seems to have reached sufficient maturity and tensile
strength to resist mechanical challenges already 7 to 10 days
after surgery.21
The expression of connective tissue repair to the root
surface did not significantly differ from our earlier obser-
vations.'7·18-20 However, bone and cementum regeneration
was suppressed when implanted sites were compared to the
saline control. This may be an effect of the inflammatory
reaction and/or the slow degradation rate, the implant pos-
sibly acting as physical barrier to ingrowth of cells from
alveolar bone and periodontal ligament. For periodontal re-
generative purposes, in addition to being more rapidly de-
gradale, an ideal implant may conceivably serve as a vehicle
for Polypeptide growth factors, which may enhance for-
mation of new alveolar bone and new cementum.22-23
The implant sites in 3 out of 7 dogs became exposed and
infected despite postsurgical systemic and topical antimi-
crobial treatment. It is possible that infection control could
be improved by incorporating an antimicrobial agent in the
implant. However, infection control may not solely rest
with antimicrobial therapy. To develop techniques which
may improve the seal of the flap margin to the tooth surface
may be critical for successful results. This may be partic-
ularly important when the implant material is both rigid and
porous.
There are certain limitations to consider when interpret-
ing the results from this study. The data were based on
observations in few animals. The study design included 2
different treatments within each quadrant. This design re-
sulted in improved connective tissue repair in the negative
control (heparin) and left limited room for improvement
following the use of the polylactic acid implant. Neverthe-
less, this study underscores the importance of wound sta-
bilization in periodontal wound healing. The development
of a biodegradable implant system aimed at stabilizing the
wound seems to be a desirable direction for future research
in regenerative periodontal procedures.
Acknowledgments
thanks are due to Grenith Zimmerman, Ph.D. for
Special
statistical advice; Julie Cranfill for secretarial assistance;
Norman Medina, M.S.P.H. for data management; Elwyn
Spaulding and Richard Tinker for illustrations; and Douglas
Chancellor for histotechnical preparation.
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Send reprint requests to: Dr. Ulf .E. Wikesjö, School of Dentistry,
Loma Linda University, Loma Linda, CA 92350.
Accepted for publication May 8, 1990.