The

Infrabony
Pocket: Classification and
Treatmentf
by
Henry M.
Goldman,
d.m.d.* and D. Walter
Cohen,
d.d.s.**
IN
recent
years,
the
principal
clinical
lesion of
periodontal
disease,
the
pocket,
has been
studied
clinically, radiographi-
cally,
and
histopathologically.
As a result
of these
investigations
it became
apparent
that
the
pocket
had to be
classified on
the basis of the
location
of
the bottom of
the
pocket
in its
relationship
to the alve-
olar crest.
Arising
from
these studies came
the classification of
pockets: (1) supra-
bony
or
supracrestal
and
(2) infrabony
or
subcrestal. The
suprabony pocket
is defined
as a
pathological
sulcus where
the base
of
the
pocket
is coronal or occlusal to the
alveolar
crest,
while the
infrabony
is de-
fined
as a
pathological
sulcus where the
bottom of
the
pocket
is
apical
to the
alve-
olar crest. The
suprabony pocket
was fur-
ther subdivided into the
gingival
or
pseudo-
pocket
and
the
periodontal pocket.
This
classification had merit not
only
from a
teaching standpoint
but also on a
therapeu-
tic basis.
Much attention has been focused on the
infrabony type
of
pocket
in recent
publi-
cations and
this lesion has been described
as amenable to either the new attachment
procedure
or osseous
surgery
for its eradi-
cation. It
became obvious to us from
our
observations
of
clinical as well as human
skull material that a classification of
the
infrabony pocket
was
necessary
not
only
for academic
purposes
but also to serve
as a rational
basis
for the selection of a
method of treatment.
fPresented
at the
Academy
of
Periodontology
Meeting
in
Miami,
Fla. on October 3
1,
19 57.
Trofessor of
Periodontology
and Chairman of
Dept.,
Graduate School of
Medicine, Univ. of
Penna.;
Director of Riesman Dental
Clinic,
Beth
Israel
Hospital, Boston,
Mass.
**Assistant Professor of
Periodontology
and Vice
Chairman of
Dept.
Graduate School of
Medicine,
Univ. of
Penna.;
Assistant Professor of Oral Medi-
cine and Oral
Pathology,
Univ. of Penna. School of
Dentistry.
The
proposed
classification
of
the
infra-
bony
pocket
is on a
morphologic
basis and
is
dependent
on the location and number
of osseous walls
remaining
about the
pocket.
Much
of this
material studied was
from
human skulls where the
gingivae
and
other soft tissues were intact. The location
of
the bottom of the
pocket
was estab-
lished,
the material
radiographed,
and
then
the
soft tissue was
removed. The remainder
of the material was
taken
from clinical
cases under treatment.
The first
group
of
infrabony
pockets
de-
scribed
have three osseous walls.
These
trough-like
defects are
commonly
observed
in the interdental areas
where
one finds an
intact
proximal
wall
as well as the buccal
and
lingual
walls
of the alveolar
process.
Some of these lesions
may
be shallow with
a broad orifice to the osseous
part
of
the
pocket
while others
may
be narrow and
deep.
Three wall
infrabony
pockets
are oc-
casionally
observed on the
lingual
surfaces
of
maxillary
and
mandibular teeth where
the
lingual plate
is intact as well as both
proximal
walls. Less
frequently
noted are
infrabony pockets
located on the buccal
surfaces
of
maxillary
and
mandibular
pos-
terior teeth. It is not uncommon to find
them
extending
around
the tooth to in-
volve
2
or sometimes 3 surfaces. When
the
infrabony
pocket
is circumferential
and
involves the four surfaces of the
tooth,
it
actually
has
four osseous walls
(buccal,
lingual,
mesial,
distal).
This occurs infre-
quently.
The determination
of
the
position
as well
as the number of osseous walls is
of con-
cern to the clinician
during
his examination
procedures.
The
radiograph
can be of
great
aid in
demonstrating
the
presence
of buccal and
lingual
and
proximal
walls in a
pocket
oc-
curring
in the interdental area.
Placing
a
radiopaque
object
such as a
gutta
percha
point,
a
periodontal probe,
or Hirschfeld
Page
272
The Infrabony Pocket
Page
273
point
will
enable one to locate
the
bottom
of
the
pocket. Many
times the buccal and
lingual
walls
will
register
on the
radiograph
and one has to relate the
radiographic
ob-
servations with the clinical
picture.
Taking
a
probe
and
running
it
buccally
and
lingu-
ally
one will
engage
either soft tissue or
the osseous walls.
If
there is a doubt a
flap
can be laid
back to see the outline
of
the
pocket
or a fine
straight
needle can be
passed
through
the buccal and
lingual
soft
tissue to
map
out the
height
of
the crests.
Two wall
infrabony
pockets may
be
seen
in the interdental areas. If
the buccal and
lingual
walls
are
intact, but the
proximal
wall
has
been
destroyed,
the lesion is com-
monly
referred to as an intraosseous inter-
proximal
crater.
Because
the
base of
the
pocket
is
apical
to
either
the
buccal or
lingual
wall,
this
falls into the
classification
as an
infrabony pocket.
One
may
find
that
the two walls
remaining
are the buccal
wall and the
proximal
wall or the
lingual
wall and
the
proximal
wall. In these situa-
tions there is
usually just
a curtain of
soft
tissue
remaining
on the surface where the
osseous wall has been
destroyed.
One of
the
interesting aspects
of
the
skull material is that when
the soft tissue
has
been
stripped
out of the
bony
defect,
the osseous surface
may
be made of
cancel-
leous
supporting
bone
especially
in the in-
terproximal
wall. Sometimes
a more dense
sclerotic wall of
bone was noted
under-
neath the soft tissue. This latter situation
usually appeared
more
radioopaque
on the
radiograph.
The
infrabony pocket
which has one os-
seous wall
remaining
is
usually
seen in the
interdental area. Here it is most common
to
observe the
presence
of
a
proximal
wall
with the buccal and
lingual
walls
destroyed.
This can be detected
clinically by probing
or
passing
a needle
through
the soft
tissue;
radiographic
examination
may
also be
help-
ful. It is much
less
common
to
find
the
buccal wall intact with
loss
of
the
proxi-
mal and
lingual
walls
or to have a
lingual
wall intact
with
the
loss of
the
proximal
and
buccal.
In
setting up
a classification of this sort
we realized that
many
of these
infrabony
pockets
were not
pure examples
of either
one, two,
or three
walls. It was
quite
com-
mon to find various combinations of osseous
walls. We
frequently
observed areas where
the
apical part
of
the
pocket
had more
walls than the coronal
part.
For
example,
we
frequently
noted a
pocket
where the
bottom
part
of
the
pocket
had 3 walls
while in the coronal
part
the
buccal
and
lingual
walls were
destroyed leaving just
the one
proximal
wall.
There are also
pock-
ets with 3 osseous
walls at the
apical part
INFRABONY
POCKET
THREE OSSEOUS WALLS
a
proximal,
buccal &>
lingual
walls
b.
buccal,
mesial &>
distal walls
c.
lingual,
mesial &. distal walls
Four osseous walls-
buccal,
lingual,
mesial & distal
TWO OSSEOUS
WALLS
a
buccal &
lingual
(crater) walls
b.
buccal
&
proximal
walls
C
lingual
&>
proximal
walls
ONE OSSEOUS WALL
a.
proximal
wall
b.
buccal wall
c
lingual
wall
COMBINATION
a. 3 walls

2 walls
b-
3
walls

2 walls
*
1 wall
c-
3 walls +1 wall
d-
2 walls

1 wall
Fig.
1.
Classification
of
infrabony pockets.
Fig.
2.
Drawing of the
various
bony topographies
associated with infrabony pockets.
In the
upper
drawing,
on the
distal aspect
of the left lateral
incisor,
a
bony
defect
can be seen. This
defect
has osseous walls on the
lingual, labial,
and
proximal; the
latter serves as the mesial
housing
of
the
cuspid.
This is classified as a three-walled
infrabony pocket
when the
soft
tissue is
present.
Distal to the left
central incisor,
the osseous housing
of a two-walled
infrabony pocket
can be seen.
The
labial
bone has been
destroyed ; the palatal
and
proximal
walls remain intact. Mesial to the
right
lateral incisor the
bony
topography
of a one-walled
infrabony pocket
is shown. Note that both
the
labial
and
lingual
walls have been
destroyed,
with
only
the
proximal
wall
remaining.
In the
center of the
photograph
on the
right,
the two-walled
defect is
shown in
higher power,
while on
the left,
the
one-walled
is illustrated. In the lower
portion
of the
photograph,
three bonv walls may
be
seen.
The Infrabony Pocket
Page
275
Pig.
3.
Photograph
of a skull
showing
a
bony
defect on the buecal
aspect
of the second molar
associated with a three-walled
infrabony pocket.
In the
radiograph
a probe has been
inserted
into
the
bony
defect. Note
that
the
bnccal osseous
wall does not show
up in the
radiograph
and
only
the
base
of the
bony
defect can be deter
mined.
and 2 walls as the cemento-enamel
junction
is
approached.
We have also encountered
situations in which there were two walls at
the
apical portion
with one
wall
coronally.
This
classification has served
as
a basis
for our selection of
therapy
since we real-
ize
today
that all
infrabony pockets
cannot
be
eliminated
by
means of new
attachment,
but one must
employ
other
procedures,
as
will be
brought
out
subsequently.
This
de-
termination
of which method is
to
be
em-
ployed
will
usually depend
on the
topog-
raphy
of the lesion.
CLINICAL EVALUATION
One of the
important aspects
in the
treatment
of
the
infrabony pocket
is the
visualization of
the
topography
of the
pocket.
The outermost limits
of the
de-
tached
gingival
tissue must be
explored.
Since
disease
affects
the entire circumfer-
ence of the tooth in
question, therapy
must
be directed toward
healing
this tissue. Also
that
portion
below the
bone crest must be
outlined in
respect
to
the
surfaces of
the
tooth. At times
this latter defect is con-
fined to a
single
surface
(most
usually
the
proximal aspect)
but
many
times is tortu-
ous in
nature,
the
deepest point being
lo-
cated on a different surface
of the tooth
than the orifice
of the main
portion
of the
pocket.
Even in instances where a
single
surface
pocket
is
encountered,
small lateral
pouches may
be found. Not
infrequently,
what is
thought
to be
an
infrabony pocket
on the mesial
aspect
of a
maxillary
anterior
tooth,
after
probing
is found to
involve the
palatal aspect
as
well.
Thus,
infrabony pockets
assume the
shape
of various
combinations of
short-and-
deep
and
narrow-and-broad defects.
They
may
be
located on a
single
surface of a
tooth
or
may
encroach
upon adjacent
sur-
faces. Not
uncommonly,
one
may
find an
infrabony pocket
which is characterized
by
a narrow
orifice,
but at
the base
the defect
is
bulbous in
form
causing
the
pocket
to
resemble a
bottle.
Radiographic
examination of
the infra-
bony
pocket
discloses a vertical
resorptive
lesion but
gives
no information
concerning
the base of the
pocket. Actually,
therefore,
I'Mg.
4. A
three-walled
osseous
housing
of an
infrabony pocket
on the
palatal aspect
of a
maxillary molar may be seen.
Note the destruc-
tion of the
distal
and
mesial
proximal
walls as
well as the
palatal, resulting
in a
trough
extend-
ing
around the
tooth.
Page
276 The
Journal
of Periodontology
Fig.
5. The clinical
photograph
and
radiographs
of a two-walled
infrabony pocket
on the dislal
of
Hie
maxillary cuspid.
Note that once the
g'mgival tissue
has been removed the
bone
exists
only
on the
palatal and proximal aspects, the
entire labial
wall
having been destroyed.
Radio-
graphically,
there is a vertical
resorptive
lesion.
One cannot determine
from this
radiograph
whether
the
pocket
is
one, two,
or three-walled.
Only by clinical
examination can this be ascer-
tained. Passing
a needle
through
the
gingiva
from buccal to
palatal,
and
palatal
to
bticcal,
will
give
the information
desired. Entering
from
the
buccal aspect, if
the needle cannot
penetrate
any distance,
then a buccal wall exists. If it
passes through
then no
wall exists
at all.
If it
passes completely through
to the outer surface
on the
palatal aspect, both
walls are missing.
Thus,
in
reversing
the
penetration,
one can tell
exactly what
walls are
present.
Fig.
6.
Photograph
of skull material and its
radiograph. Note that on the distal
aspect
of the
second
molar there is a crater-like
defect.
How-
ever,
the defect
slopes
towards the distal of the
second molar and
here
the destruction takes on
a broad
resorbed defect.
Radiographically,
with
the
probe
in
position, one notes that in
this area
the
bony housing is below
that of the
proximal
wall. This
may be
classified as a
broad, one-
walled
infrabony pocket defect.
one cannot
recognize by
radiology
the
pres-
ence
of
a
pocket
at
all,
for
a vertical lesion
may
be
present
but the
gingival
tissue
may
be intact with
no
pocket
formation. Radi-
ographs
taken
after
opaque
materials have
been inserted into the
gingival
retracted
area
(pocket)
disclose the
depth
and con-
tour of the
pocket
in
respect
to the bone
outline.
Unfortunately,
this is one
plane
and a
three dimensional
picture
cannot be
visualized from this examination. Yet a
certain amount
of information can be ob-
tained.
The
radioopaque
materials are
Hirschfeld
points, gutta percha probes,
and
bismuth solutions
impregnated
in cot-
ton.
Important, therefore,
is the
recording
of
the size and
general
topography
of
the in-
The Infrabony Pocket
Page
277
Fig.
7.
Photograph
and
radiograph
of skull
material
showing
a
mesially
tilted
third
molar.
Note that there is a broad resorptive trough
on
the mesial
aspect
of the tooth. This
represents
the
bony
defect
associated with
a one-walled
infrabony pocket.
Fig.
8.
The
photograph
and
radiograph
of
a
one-walled infrabony pocket
on the
mesial as-
pect
of a maxillary left central
incisor.
One can
visualize the
bony
defect
associated with
a one-
walled
infrabony pocket.
Fig.
1).
Photograph
and
radiograph
of skull
material
showing
a combination
of various
topographies.
At the base of the
bony
defect
three walls are evident. More
occlusally, two
walls are
present,
while at the occlusal
level,
one
wall,
that of the
proximal,
remains. This
type
of defect must be
carefully
determined in treat-
ment. The exact
topography
of the lesion must
he
visualized prior
to the
operative
procedure
for such a combination
of walls would necessar-
ily change
the
mode
of treatment from that
of
a
three-walled infrabony pocket.
Clinical exam-
ination,
and
radiographic
examination
with ra
dioopaqtie material,
are
necessary
for the
diag-
nosis.
(Courtesy
of Dr. John
Prichard)
frabony pocket, especially
that
part
sub-
merged
below the crest of
the alveolar
proc-
ess.
This
consideration refers to the soft
tissue
portion
of
this
periodontal
lesion.
Even more
important, however,
is the to-
pography
of the
bony housing. Although
radiographically
the defect
has been
de-
scribed as a vertical
resorptive lesion,
not
always
can information
concerning
the
buccal-lingual
walls be derived therefrom.
Infrabony pockets
are seen in which the
defect is bordered
by
three walls
although
more
than
one
surface of
the tooth is in-
volved. This is often
found on the
palatal-
Page
278 The
Journal
of
Fig.
10.
Photomicrograph
of an infrabony
pocket
on the
mesial aspect of
a
maxillary cus-
pid.
Seen in the
photomicrograph
is the
lateral
incisor on the left
and
the
interdental septum
and
the
cuspid
on the
right.
Covering
the inter-
dental septum
is
gingival
tissue. The
base
of the
pocket
Is below the interdental crest of the
lateral incisor. Note
the
pocket
depth
on the
lateral incisor
is
extremely shallow.
This
photo-
micrograph
was taken from a
specimen
with
three
walls.
proximal aspect
of
the
maxillary
teeth. Al-
though radiographic
examination is an aid
in determination
of the
outline of
the
bony
walls
especially
if
radioopaque
materials are
inserted into the
pockets
before
the
radio-
graphs
are
taken,
it
by
no means
gives
accurate
information. It is
necessary
that
the clinical examination disclose
the out-
line
of the bone crest
in relation to the
base of
the
pocket. Probing
in the
pocket
reveals the
point
to which detachment has
occurred in
relationship
to the tooth.
Therefore,
in
addition,
the
operator
must
probe by
a
sharp
instrument
(explorer
or
Periodontology
Fig.
11.
Photomicrograph of an infrabony
pocket
on the
mesial aspect
of a
maxillary tilted
molar.
Note
the distance between the tooth and
bone. This
photomicrograph
was taken from a
case with a two-walled
infrabony pocket,
the
buccal wall
being mesial.
Fig. 12.
This is a
photomicrograph
of an infra-
bony pocket
on the mesial aspect of a tilted
maxillary
molar. In this instance the
specimen
contained only
a
proximal
wall,
the
buccal
and
palatal being missing.
Because of the
wide dis-
tance between tooth
and
bone,
this
may be
classified as a broad
one-walled
infrabony
pocket.
The Infrabony Pocket
Page
279
Fig.
13.
Clinical examinations of infrabony
pockets
are essential
in
diagnosis.
The
various
topographies
that may
be
present
can be deter-
mined fully by clinical
probing. Radiographic
examination, while informative,
is not in
itself
conclusive. Probing,
from the buccal
and
lingual
aspects,
to determine
whether these walls are
present,
is
necessary. Also
important
is the
determination
of
the location
of the crestal
por-
tions of
the walls that
may
be
present.
Fig.
14.
Radiographs showing the
base of an
infrabony pocket. Associated with
the
infrabony
pocket
is a vertical resorptive
lesion
of
the bone
seen
radiographically.
One
cannot determine
from this whether the
buccal
and lingual
hous-
ing
is
present. Hence, clinical examination
is
necessary. Also, one cannot determine
where the
epithelial attachment, locating
the base
of the
pocket,
exists.
By inserting
a
radioopaque
mate-
rial into the
pocket
prior to the taking
of the
radiograph,
this factor
can be established. Note
that in this instance the base of
the pocket
co-
incides with
the base
of the
bony
defect.
some sort of
needle)
for the location of
the
crest
of
the alveolar
process.
Should,
for
example,
a
proximal infrabony pocket
be
examined,
one can
pass
a needle bucco-lin-
gual
from one
side and
then to the
other,
to determine whether these walls are
pres-
ent. Thus
by exploration
of
this nature can
the
full
outline,
both soft tissue and
bone,
be determined.
ETIOLOGY
Visualization
of the
topography
of
the
infrabony pocket
is an
essential
for its clin-
ical
management,
but
equally important
is
an
understanding
of its
causation, for
ther-
apy
without consideration
for correction of
the
etiologic
factors will
probably
not
yield
favorable results.
Therefore, a detailed clin-
ical examination is
obligatory.
Tooth anat-
omy
as well as tooth
position
should
be
inspected.
Teeth without contour associ-
ated
with
heavy
wide
alveolar
processes
often show
infrabony
pockets
and vertical
resorptive
lesions
of the
bone
housing
be-
cause the
disease
process
is focused to the
part directly
adjacent
to the tooth
surface.
Mandibular molar
teeth
are sometimes so
affected. The relative uneven levels
of ad-
jacent marginal
ridges
and
cemento-enamel
junctions
with some
degree
of
tilting
of the
teeth
may
result in the
infrabony type
of
pocket
formation should a
gingival
disease
process
be initiated
by any
local causation
(calculus,
food
impaction, etc.) Thus,
the
position
of the tooth in
respect
to the
alve-
olar
housing
and buccal
bone,
the contact
points
between teeth and the
tilting
of
teeth must
be considered.
These and
like
conditions are local environmental factors
which can initiate the
infrabony
pocket
process.
Another
important
factor in the
etiology
of the
infrabony
pocket
is the occlusal
traumatic lesion. It must be
emphasized,
Fig.
15.
Radiographs
of
infrabony
pockets
with
radioopaque
material inserted. Nute that in this
instance in contrast to
Figure
14
the bases
of the
pockets
do not coincide
with the bottom of the
bony defect.
Page
280
The
Journal
of Periodontology
Fig. 16. Radiograph
of
an infrabony
pocket
associated
with
food
impaction
and
an
open
con-
tact between two molars.
Although
there
are
many
causes for infrabony
pockets,
local en-
vironmental factors usually contribute
to their
etiology.
however,
that occlusal
traumatism cannot
cause
pocket
formation,
since the latter
is
essentially
a soft tissue lesion. There is nev-
ertheless the
possibility
of
the existence of
the
two factors
being
present
at the same
time;
first
pocket
formation caused
by any
of the local factors
(calculus being
the
most
prominent)
and
second,
the occlusal
traumatic lesion
affecting
the attachment
apparatus (cementum-periodontal
mem-
brane-bone)
in the crestal
region.
With
these
two factors
operating
an
infrabony
pocket
will result once the
gingival
and
original transseptal
fibers
have
been
de-
stroyed
by
the
continuing inflammatory
process.
It is therefore
necessary
for the
oper-
ator to understand that
infrabony
pockets
may
result
from
any
combination
of
factors
which can allow the base of the
pocket
to
migrate apically alongside
the tooth with
the bone
housing being
affected
only
on
one side
causing
the
topographic
relation-
ship
described
previously.
Infrabony pockets
also occur in that
clinical
entity
termed
periodontosis.
Since
this
disease is found so
rarely,
the
operator
should
usually
base
his
examination on the
above
factors. The clinical
signs
and
symp-
toms of
periodontosis
are so characteristic
that the
diagnosis
will be soon entertained
by
the examiner.
Fig. 17.
Radiograph
of an infrabony
pocket
on
the mesial aspect of
a mandibular third
molar.
In this instance
the
second molar had been ex-
tracted, allowing
the third molar to move mesi-
ally. Because or occlusal traumatism and
local
gingival inflammation
due to calculus
deposits,
and an
open
contact
allowing
for
food
impaction,
an infrabony pocket
developed.
THERAPY
Therapy
of the
infrabony
pocket
must
be
directed towards
the elimination
of the
signs
and
symptoms.
For consideration of
the elimination
of
the
causation of the in-
frabony
pocket,
the
following
factors
should be
recognized
and
corrected,
if
pos-
sible:
1. Tooth
anatomy-proximity
of roots
and width of interdental
septum.
2. Relative
position
of
adjacent
mar-
ginal
ridges,
cemento-enamel
junctions
and
crest
morphology.
3.
Tilting
of the tooth in
group
rela-
tionships.
4.
Tilting
of the
solitary
tooth.
5.
Position of
the
tooth in
respect
to
alveolar
housing
and basal bone.
6. Contact
points
and resultant food
impaction.
7. The occlusal
relationships
of the
tooth.
8.
Presence of calculus.
9. Causation
by
the disease
process peri-
odontosis.
Therefore,
correction of the
etiologic
fac-
tors and methods
of
alleviating symptoms
prior
to the
therapeutic operative procedure
The Infrabony Pocket
Page
281
Fig.
19. Diagrams showing motion which
is
necessary
to remove tissue at the base of
the
pocket.
A
lingual
to buccal or buccal to lingual
stroke is
very effective,
as is seen in
this dia-
gram.
It
is necessary
to remove the
entire con-
tents of the tooth-bone trough.
may
at times be
necessary.
Tooth
anatomy
conducive to food
impaction,
uneven mar-
ginal ridges, tilting
of teeth and occlusal
traumatism should
be
corrected
before
the
operative procedure
to secure a new attach-
ment is
attempted.
Grinding
to
correct flat
facets, adjustment
of
the occlusal relation-
ships, levelling
of the
marginal ridges,
placement
of restorations to close contact
points
or to
restore
physiologic
anatomy
of
the
marginal ridges,
correction of
the oc-
clusal
anatomy, by
the
crowning
of
a tooth
may
be
necessary. Any attempt
to treat an
infrabony
pocket
without
regard
to the
etiologic
factor
may
result in failure.
Should
mobility
of
the tooth
be
present,
temporary splinting
should be utilized to
stabilize
the tooth
prior
to the
operation.
Usually
orthodontic welded bands are em-
Fig.
20. This
is a
photomicrograph
of an infra-
bony pocket illustrating
the two zones which can
be set
up arbitrarily
in
infrabony pockets. The
first, sulcular
epithelium
in the
underlying
tis-
sue
together with
the surface of the
tooth,
and
the
second,
the dense
collagen
fibers which run
over the bone. The
importance
of the removal of
these
collagen
fibers cannot be
overstressed.
ployed although
in the anterior
part
of the
dentition,
the stainless steel
acrylic splint
may
be used. The mobile tooth should not
terminate the
temporary splint
since this
type
of
splint
results in a cantilever effect
of the loose tooth. Greater
security
is ob-
tained
by extending
the
splint
from a
strongly
held tooth to another secure tooth
with
the mobile tooth in the center. In this
way
the
splint
is
rigid
and the affected
tooth cannot be moved
by
occlusal
forces.
It must
be
emphasized
that the occlusal
relationship
must be
checked once the
splint
is
placed
into
position,
since
any pre-
maturity
in occlusal contact on the teeth
incorporated
in the
splint
will
still
cause a
movement of the tooth
and even
may
loosen the
splint
itself. Also
important
is
the
fact
that
occasionally
in the
cuspid
region
the
splint
must be extended
around
Page
282 The
Journal
of Periodontology
Fig.
18.
Photographs
of a
step-by-step procedure
of
a three-walled
infrabony pocket
on the
mesial of
a
maxillary
left central incisor. In "A" the
pocket
is
being probed, determining
that the
buccal
and
lingual
walls were
present.
The
base of the pocket
was established at the
location
of
the bony
defect. In "B" after the
gingival
tissue above
the
bony
crest had been
excised
and the
frenum
incised,
the entire contents
of
tissue between tooth and bone was
removed,
results of which
can be seen in
"C"
and "D." Note that a trough-like
defect remains.
Bleeding
occurs and is allowed
to continue.
The defect
is
covered with
tinfoil
in "E"
and
"F"
and
in
"G" and "H" covered with
pack.
One week later the
pack
had been removed
(I)
and one can note the
healing
which had taken
place.
The
photograph
(J)
was taken two weeks after the
operation. (K) radiograph taken
three
months
after
the time of
operation.
The
gingiva
was
firm, pink,
and adherent. A
millimeter probe
was inserted
into
the sulcus and
only
one millimeter of depth is present. Thus,
a
healthy sulcus
exists.
Note
the radiographic changes
which have
occurred
in this
period
of
time. The teeth are
now in
contact,
which was not so before
operation.
Thus,
not
only
was the
infrabony pocket
elimi-
nated but the involved tooth reverted back into its
original position.
The Infrabony Pocket
Page
283
Fig.
21.
Radiographs
of
an
infrabony pocket on
the
distal aspect of
a
maxillary
lateral incisor.
The base of the
pocket
could be located at
the
apex of
the
tooth, distal of
the tooth
but not
involving
the
pulp
tissue. The tooth tested vital.
After
operative procedure
"C" a
probe
could
not be
inserted. Healing is
seen in "D" and "E."
Numerous radiographs
had
been
taken
through-
out the course of ten
years,
all
showing
a dis-
tinct
healing
of the bone. A new lamina dura
had
been established
and the tooth was firm and
in
good position.
In "F" the
radiograph repre-
sents
the
status
of
the alveolar
supporting struc-
tures ten
years
later.
the corner of the
arch,
to the
posterior
and
thereby
take
advantage
of
bilateral
splint-
ing
action.
SELECTION OF THERAPEUTIC PROCEDURE
The
objective
of treatment is to elimi-
nate the
pocket
and
establish a crevice with
as near zero
depth
as
possible.
Two
major
methods
of
therapy
for
the
infrabony
pocket
have been
developed.
The
first consists of curettment
of
that
portion
Fig.
22. Before-and-after
radiographs showing
the
healing
in the
therapy
of a
three-walled
infrabony pocket.
One can
superimpose one
radiograph on
another,
thus
establishing
that
the measurement of the length of
the teeth are
exact.
Probe shows that
there has
been
several
millimeters of regeneration
of bone.
below the bone crest with
gingivectomy
for the
part
above
the alveolus to
enhance
the
possibility
of formation
of
new ce-
mentum,
bone
and
periodontal
membrane.
The entire tissue between
tooth
and bone
is removed
by
this
debridement.
The sec-
ond
method
reduces the
alveolus to a
point
coinciding
with the base of the
pocket;
this
constitutes an
osteoectomy.
In order to fa-
cilitate
accessibility
a
flap
may
be
reflected
to
approach
the
operative
site. Of
impor-
tance in the selection of one of
these
oper-
ative
procedures
is the evaluation of the
amount of
remaining alveolus,
and
the
number
of lateral walls
present.
As
previ-
ously stated,
the most
favorable
type
for
new attachment is one with the
presence
of
three walls.
With two walls a
slanting
fill in of
bone
may
be
obtained whereas
when
only
the
proximal
wall is
present,
no
additional attachment for the affected
tooth
may
be
expected,
and
osseous
surgery
is indicated. The
length
and
shape
of the
Vage
284
The
Journal
of Periodontology
Pig.
23. Before-and-after radiographs showing
treatment
of an
infrahnny pocket
on the mesial
aspect
of the
maxillary cuspid.
Note the estab-
lishment of a lamina dura in the after
radio-
gra ph.
root must be considered in that
when a
short rooted tooth is to be treated no sacri-
fice of
bony
structure
may
be
possible,
while should
the roots be
long
and
well
formed, osteoectomy may
be
a rational
pro-
cedure.
The
housing
to the
adjacent
tooth
also
plays
a
role in
evaluating
the selection
of the technical
procedure
to be
used.
As indicated in all
periodontal therapeu-
tic
techniques
for
pocket
elimination,
scal-
ing
of
the tooth
surfaces to remove all
de-
posits
should be
performed prior
to the
curettage-gingivectomy operation.
Re-
moval of calculus allows for the
inflamma-
tory
element to be controlled
by
the
repair
process,
and
thus with
subsequent therapy,
complete repair
is enhanced.
This
holds true
for
the
suprabony portion
as well as the
infrabony part.
TREATMENT OF THE INFRABONY POCKET
WITH THREE OSSEOUS WALLS
Curettage-gingivectomy operation
for
new attachment.
This
procedure
is carried
out under local anesthesia with a minimum
or no vasoconstrictor. It should
be
pro-
found
enough
to
carry
out the
operation
without
discomfort to the
patient,
but
still
not interfere
with the establishment
of
a
blood clot.
Fig.
24.
Radiographs
of a three-walled infra-
bony pocket
on the distal of a
maxillary
cuspid.
The base of the
pocket
could he established
al-
most at the
apex
of the tooth.
Note
the lilling-in
of bone
postoperatively.
The
gingivectomy phase
is
performed.
The
gingiva
above the bone crest is excised
following
the
principle
of
gingivectomy.
The resultant
gingival margin
should be
correctly
bevelled
and
the
spillways
should
be
accentuated
sufficiently.
The interdental
areas should
be
pyramidal
since the
infra-
bony pocket
is included in the treatment
of
a
segment,
the
adjacent
areas
will be
treated at the same time. Hence the
gingi-
vectomy procedure
will be
performed
for
the
segment; else,
the
bevelling
of the
gin-
givectomy
will
have
to be
blended into the
adjacent
areas.
The next
step
in this
operation
is to
remove the contents of
the
pocket by using
any
curette or sealer.
Necessarily
the in-
strument will have
to be
small,
especially
in
the
narrow
type
of
pocket. Often,
in addi-
tion to a vertical
stroke,
a horizontal cir-
cumferential
sweep,
short
and
precise, may
be used. Once this has
been
accomplished,
the soft tissue
against
the osseous wall
is
The Infrabony Pocket
Page
285
Fig.
25.
Photographs
and
radiographs
of a be-
fore-and-after
case
of
the
therapy
of an infra-
bony
pocket
around a left central incisor. The
tooth tested vital
despite
the
fact
that there was
an extreme amount of
resorption
around it. The
anterior occlusion was
adjusted by grinding.
Maxillary
and
mandibular
teeth were
shortened
so
as to create almost an
end-to-end
occlusion.
The
procedure
was done
by raising a flap
and
removing
all the tissue between the tooth and
its
bony housing. The lateral
incisors were
moved
surgically
into
position
and the
flap
was
readapted.
Healing
took
place
rather
rapidly.
Fig.
26.
Before-and-after
radiographs
of a
three-walled infrabony pocket on the mesial as-
pect
of a tilted second mandibular
molar.
The
iirst molar was extracted many years previously.
Orthodontic band
splints were made to stabilize
the teeth and the
operation performed.
Note the
bone
filling
in.
in the after
radiograph (B).
removed
with
deft, short, cutting
strokes.
A small
sharp
curette serves well for this:
the circumferential stroke
here also
works
well. The instrument is worked towards
the base
of
the
pocket
between the tooth
and
bone, removing
all the tissue until the
bone wall is felt. Small
bits
of tissue will
be
removed
easily;
at
times, a
large segment
will be excised.
The strokes
against
the bone
wall should not be too forceful since if it
is curetted further
resorption may
ensue.
Because of
the size of
the
curettes,
even
very
small
ones,
the
operator
should
keep
the instrument
against
the tooth side. In
this manner the head of
the instrument can
be
placed
to the
base of
the bone-tooth de-
fect.
Curettage
in this manner will remove
the tissue in the
portion submerged
below
the osseous
process.
It must be stressed
that
this area must be
completely
denuded of
tissue,
else
the formation
of
an attachment
apparatus
will not occur. It can be seen in
Figure
10
that
a
transseptal
fiber
group
extends to the tooth in the
infrabony
pocket
between tooth
and
bone.
This trans-
septal
fiber
group
is
composed
of
dense
connective tissue fibers
running
almost
parallel
to the tooth surface. Hence should
only
the inner
portion
of the soft tissue
wall
be removed
leaving
these
fibers
still
attached,
a blood clot
will
ensue
with
heal-
ing
of
the
soft tissue wall
covered
by epi-
thelium.
Thus
no new attachment takes
place.
However,
if
all the tissue is debrided
from the
area,
the blood clot
fills the entire
area between tooth and bone:
after
healing
The after
photograph may
be seen. The
gingival
architecture was
physiologic
and the
radiograph
showed the bone to have
filled
in
completely.
The lateral incisor
which
showed a
periapieal
lesion
previously
was treated
endodontically.
Page
286 The
Journal
of Periodontology
Fig.
27. Drawing
of the
therapy
of a two-walled
pocket (crater).
In this instance there are buccal
and
lingual
osseous spines
with loss of bone
interdentally.
In the
upper drawing
one notes
the clinical condition,
while in the lower one the
markings
for the
gingivectomy may
be seen. The
gingival
tissue
is excised. These and
following
drawings by
Dr. Leonard Adams.
a new attachment can
form.
Thus
in the
operation
one does
not consider
only
the
removal
of
the
epithelial
attachment: in
fact this
and
all
the
adjacent
tissue is re-
moved between tooth
and
bone
up
to the
region
where a normal
lamina dura exists.
Debridement
of
the tissue at the
base
(nar-
row
portion
of
the
infrabony
pocket)
must
be
carefully
executed since the instrument
must be
deftly placed
and
removed
with
a
minimum of
trauma to the osseous
wall.
Once this
phase
of the
operation
is
per-
formed,
attention is then focused to the
tooth. With
any
suitable instrument,
the
cleanliness of the tooth should
be
checked.
The
operator
should be sure
that there
are
no
deposits present
but
also that the surface
is smooth. It is
possible
that
gouging
de-
fects in the tooth
surface will
affect heal-
ing. Also,
caution should be taken that the
area above the
operative
site is not dis-
turbed
since the tooth will become sensi-
tive.
When the
curettage
phase
is
completed,
a
trough
results,
the extent of which de-
pends upon
the
original topography.
This
Fig.
28. Continuation
of Fig.
27. In the
upper
drawing
the
gingival tissue
has been
excised.
The
gingival
nap
is now retracted by
the use of
a
periosteal
elevator and alveolar bone
is
ex-
posed.
The bone crest can be
removed
in
many
ways
:
by
burs,
diamond
stones,
or hand chisels.
In the lower
drawing
a bur is
being
used to cut
the buccal interdental walls. The bur must be
small
enough
so that it will not engage
the tooth
interdentally. Also,
care must be taken when
using
burs or diamond
stones not to overheat
the bone. A wrater
spray
is advisable.
area can be
inspected
by sponging
the area
or
by using
suction to remove the blood.
The lateral walls below the bone crest
should be checked to ascertain whether
any
fragmentary
tissue has been left. This sur-
face
should
appear
smooth.
Once this
procedure
has been
completed,
the
trough-like
area is allowed to fill with
blood
and
the surface is covered
by
a small
strip
of
tinfoil or
Telfa
to
prevent any
sur-
gical
pack
from
getting
into the area. This
tinfoil
should
be
securely placed
so
that it
will not be
dislodged
when the
packing
is
done.
The small
piece
of
pack
is first in-
serted
interdentally
over the foil
and
then
the buccal
and
lingual
packing
is
placed.
The
pack
is allowed to remain for one
week after which it is
repacked: usually
the
area is
protected
for about
three
weeks. Af-
ter the
first
packing
the area should be
filled
with tissue and it's not
necessary
to
protect
the
area with tinfoil or Telfa beneath the
pack.
The
pack
is
replaced
until the tissue
surface
appears completely epithelialized.
At this time the
patient
is instructed to
rinse the area
vigorously
with
hot water.
The Infrabony Pocket
Page
287
Fig.
29. Continuation of Figs. 27
and 28. Once
the buccal
alveolar wall has been
reduced,
hand
chisels can then be utilized to trim the bone to
desired form. The
crestal portion should be
bevelled to conform to the
desired
topography.
In this instance the
lingual portion is allowed
to remain in
situ, bevelling
the buccal
portion
to blend into
the
lingual slope.
In the lower
photograph
a diamond stone is in
place showing
the cut for the
interdental sluiceway.
TREATMENT OF THE INFRABONY POCKET
WITH ONE OR TWO OSSEOUS WALLS BY
OSTEOECTOMY-OSTEOPLASTY
TO
ELIMINATE LESION
Successful results
by
the
curettage-gingi-
vectomy operation may
not be
able to be
obtained
and in
many
instances should
not
be
expected (causative agents
cannot be
eliminatedlocal environment cannot be
changedthree
walls not
present).
As has
been
stressed,
consideration of
the bone ar-
chitecture
is
important.
When three walls
are
present,
one
may expect
almost rou-
Fig.
3(1. Continuation of Figs.
27-29
showing the
covering
and
pack
in
position.
If zinc
oxide is
used as a
pack,
it is wise to use some material
adjacent
to the bone -either
tinfoil or telfa can
he utilized for this.
To
insure
the retention
of
the
pack, tinfoil may
be
used to cover the
occlusal
surface
completely.
Fig.
31.
Before-and-after
diagram
of
the
ob-
jectives
of the
operation
seen in
Figs.
27-30. Note
the
architecture achieved, comprising
the inter-
dental
spillway
and the
gingival
position around
the
teeth.
The curvature of the
gingival around
the
tooth,
making
for
physiologic topograph,
is
essential.
Fig.
32. This is a
diagram
of the
osteoectomy
procedure
to eliminate a one-walled
infrabony
pocket.
In the
upper drawing the gingival tissue
has been excised around the
premolars
at the
base of the
pocket
as it was distal to the molar.
However,
on the mesial
aspect
of the
molar,
the
gingival
tissue was removed down to a
point
coincident with the base
of
the
infrabony
pocket.
This has
resulted
in
the bone,
consisting
of
the
mesial wall
of
the
infrabony pocket, being
ex-
posed.
In the lower
drawing
this bone
tissue
is
being removed
by
means of a
revolving bone
bur. In order to facilitate the removal
of this
bone,
slots are made so that
the
greater bulk
of
the
osseous structure can be removed
by
chisel.
Page
288 The
Journal
of
Fig. 33.
This is
a continuation
of the
procedure
viewed
in
Fig.
32
(osteoectomy
to eliminate a
one-walled infrahony
pocket).
In
this
instance
the
bone
elevations
are being
removed
by
small
rongeurs. However,
a mallet and
chisel or hand
chisels also may
be
utilized
to remove the bone.
For the
final contouring, hand
chisels or dia-
mond
stones are best
employed.
tinely
that a new attachment will ensue.
In a small
percentage,
failure is encoun-
tered;
this
may
result from
faulty operative
technique,
inaccessibility
which cannot
be
overcome or
interferences
during
the
heal-
ing stage.
Often it is wise to
reoperate
to
try
to obtain a new attachment. In order
to eliminate the
infrabony
pocket
with one
or two osseous
walls, osteoectomy-osteo-
plasty procedures
are
utilized,
although
at
times,
the
operation
for a new attachment
may
be advisable
for
pockets
with two
walls. Not
infrequently
a "fill"
may
be
obtained.
That
procedure
which trims the bone
crest so that the base of the resultant sulcus
will
be occlusal to the new
bone
crest is
termed
osteoectomy.
When
recontouring
is
necessary,
the term
osteoplasty
is used. The
decision to eliminate an
infrabony pocket
by
levelling
the bone crest
must be on a
rational
basis. The
major
contraindications
Periodontology
Fig.
34. Continuation
of the
procedure
Illus-
trated
in
Figs.
32 and 33
(osteoectomy
to elimin-
ate a one-walled
infrabony
pocket).
The
bone
has been
recontoured by
a
revolving
diamond
stone. Note
that the
ridge
has been contoured
so that
after
healing
an
acceptable gingival
architecture, mesial to the
first molar, will ensue.
Also the
ridge will be able to accept
a
pontic.
In
the
lower
drawing
the
exposed
bone
has
been
covered
with telfa and the entire
area covered
with
surgical
pack.
are the excessive
weakening
of
the
support
of an
adjacent
tooth or the creation of a
gingival
form
not conducive to self-cleans-
ing
or
difficulty
in
maintaining
cleanliness
by
oral
physiotherapy.
On the other
hand,
when the
pocket
is
shallow
and
not
too much
support
is
lost,
osteoectomy
is
definitely
indicated. An-
other
indication is when a broad
infrabony
pocket
exists on the
proximal
surface where
there is no
adjacent
tooth
present.
Occa-
sionally
an
osteoectomy
performed
on the
buccal crestal
bone in the mandibular
molar
The Infrabony Pocket
Page
289
Fig. 35.
Photographs
and
radiographs
of the treatment of a one-walled infrabony pocket
distal
to the maxillary
left lateral
incisor may
be seen. The
prognosis
for the
one-walled pocket
in
this
instance was
negative and, hence,
an
osteoectomy
was
performed.
The
gingival tissue
was excised
following
which the crest of the bone on the
cuspid
was
removed, levelling
it off between the two
teeth.
The
gingival
tissue
was recontoured
so that no food retention would take
place.
In the after
photograph
(C)
the
gingival
contour may
be seen whereas in
"D"
the final
radiograph
is shown.
region
where an
infrabony
pocket
extends
into the interradicular area allows for the
elimination
of
the
pocket
with resultant
acceptable
architecture.
Contouring
the
bi-
furcation area so that food accumulation
will
not occur aids
cleansing
in that
area.
Many
such
examples
can be
cited;
when
indicated
this
procedure
is a
very
valuable
asset in the
armamentarium for
pocket
elimination.
There are two
major procedures
for osteo-
ectomy-osteoplasty.
The first
comprises
the
raising
of a
flap,
full or
modified,
and
subsequent
trimming
of the bone crest.
After
reflecting
the
flap,
the base of the
pocket
is measured
and
marked
off
on the
outer bone wall. The bone
may
be chiselled
away
with small enamel chisels or
may
be
cut
away
by
bur in a dental
engine.
One
advantage
for the use of a chisel is that it
Page
290 The
Journal
of Periodontology
can be
easily
maneuvered
interproximally
and
thereby
reduce
the
possibility
of
goug-
ing
tooth structure which
may
occur with
burs or stones. Another
method is to make
small
holes,
outline
the contour of the
bone
for
removal,
and
then
uniting
the holes
by
chisel. The bone contour can then be
ac-
complished
by
either the
chisel or bur. The
operator, however,
must be warned that
when a
bur is
used,
care must be
taken that
the tooth is not
engaged
less defects
be
made. Bone
files,
necessarily
small,
are also
useful:
they
must be
sharp
and
maneuver-
able. The debris is removed
by
flushing
with
warm saline water. Once the base is
reached,
\
M
f i
Fig.
36.
Radiographs
of two
infrabony
pockets
(A) mesial to the
maxillary
central incisors.
These were one-walled pockets
and the
prognosis
for regeneration
was
negative.
An
osteoectomy
was
performed removing
the
interdental spur.
The
gingival tissue was then
recontoured creat-
ing
a saddle area in
this
region.
The
gingivae
healed, becoming firm, pink, and well-attached.
the crest should be
rounded
and
smooth-
ened
by
diamond stones so that no de-
formity
will occur once the
gingival flap
is
replaced.
Mention must be made
that
the
inner wall
of the
gingival
flap
must be
debrided before
replacement.
The
flap
should
be
carefully replaced
and
tautly
and
securely
sutured into
place:
it is often
nec-
essary
to trim the
gingiva
in order not to
have too much tissue in the interdental
areas and not to allow
the
flaps
to be
loosely
readapted.
A mattress
suture is
often
help-
ful.
The
other method is to mark
off
the base
of
the
pocket
on the outer surface
by
the
use of a modified
Crane-Kaplan pocket
marker;
a
probe
can also
be used
to demar-
cate the outline
of
the
pocket
and
then to
record
the
markings
on the outer
gingivae.
A
gingivectomy
should
be
outlined so that
no severe
deformity
results after the
opera-
tion.
Thus,
the
adjacent
areas must be sur-
veyed
and
contoured for
desired
results.
After removal of the soft tissues the bone
crest is denuded
by
reflecting
the soft tissue
with a
periosteal
elevator
placing
a
small,
sharp
chisel at an acute
angle against
the
bone
crest,
the bone can be trimmed
to
de-
sired
proportions.
A small mallet
may
be
used for
the blow
although
hand
pressure
can be utilized.
Telfa is then
carefully
adapted
over the bone
and then
a
surgical
pack
placed.
Each method
has its
advantages
and dis-
advantages.
The
gingivectomy procedure
offers
the
opportunity
for
obtaining
a bet-
ter
gingival topography
and
also
any
of
the
fold extension
operations
can be
per-
formed
simultaneously.
The two wall
infrabony pocket
in
which
the
buccal
and
lingual
walls remain
while
the
proximal
wall is
destroyed
is referred
to as a crater.
Osteoectomy
is
usually per-
formed to eliminate this
lesion. It is some-
times desirable to allow the
lingual
crest to
remain and
ramp
the crest
bucally.
This
does not
produce
too
much of a
deformity
and still
allows
the
patient
to cleanse and
massage
the
interdental area where the
tip
of
the
papilla
has
been
placed
in the
lingual
part
of
the
interproximal
area.
The
infrabony pocket
with one osseous
wall is also best treated
by
the
osteoectomy-
osteoplasty
procedure.
The
gingivectomy
is
performed
and then the tissue is reflected
revealing
the
infrabony pocket. Usually
the
one
remaining
wall is a
proximal septum
and this is eliminated
by
chisels or burs.
The osseous tissue is smoothed
with dia-
mond stones before
placing
the telfa and
pack.
TREATMENT OF THE COMBINATION TYPES
OF INFRABONY POCKETS
The clinician
will encounter
infrabony
pockets
where the number of osseous walls
The Infrabony Pocket
Page
291
may vary
in different
parts
of
the same
pocket.
Most
frequently
3 walls
will be ob-
served at the
apical part
of the
pocket
with
one
and/or
two osseous
walls at the coronal
part
of the
pocket.
In these situations the
one or two wall
part
of
the
pocket
is
eliminated
by
osseous
surgery
while
the
three
wall
part
is
prepared
for
new attach-
ment
by
the
curettage-gingivectomy pro-
cedure. Thus combinations of
procedures
are selected
depending
on
the
morphology
of these
combination
types
of
infrabony
pockets.
references
Bell,
D. G.: A Case of Reattachment?
J.
Perio-
dont. 8:3
0,
1937.
Beube,
F.: A Radiographic
and
Histologie Study
on
Reattachment, J.
Periodont. 23:1
58,
1952.
Cross,
W. G.: Bone Grafts in Periodontal
Disease,
a
preliminary report,
The Dental
Practitioner,
6:98,
1955.
Friedman,
N.: Periodontal Osseous
Surgery:
Osteoplasty
and
Osteoectomy, J.
Periodont.
26:257,
1955.
Goldman, H. M. and
Cohen, D. W.:
Periodontia,
4th
Edition,
C. V.
Mosby,
St.
Louis,
1957.
Goldman,
H. M.: A Rationale for the Treatment
of the
Intrabony Pocket, J.
Periodont. 20:83,
1949.
Goldman,
H.
M., Schluger, S. and
Fox,
L.: Perio-
dontal
Therapy,
C. V.
Mosby,
St.
Louis,
1956.
Hirschfield, L.: Calibrated Silver Points for
Periodontal
Diagnosis
and
Recording, J.
Periodont.
24:9,
1953.
Linghorne, W.
J.
and
O'Connell,
D. C.: Studies
in the Reattachment and
Regeneration
of the
Sup-
porting
Structures of the
Teeth, J.D.R. 34:164,
1955.
Prichard, J.:
The
Infrabony Technique
as a Pre-
dictable
Procedure, J.
Periodont. 28:202,
1957.
Schaeffer, E. M.: and
Zander,
H. A.: Histologie
Evidence of Reattachment of Periodontal
Pockets,
Paradent. 7:101,
1953.
Schluger, S.: Osseous ResectionA Basic
Principle
in Periodontal
Surgery,
Oral
Surg.,
Oral
Med.,
and
Oral
Path., 2:316, 1949.
Schluger, S.: Surgical Techniques in Pocket Elim-
ination,
Texas
D.J., 70:246,
1952.
"Williams,
C. H. M.: Rationalization of Periodontal
Pocket
Therapy, J.
Periodont. 14:66,
1943.
Yuktanandana,
I.: Bone Graft in the Treatment
of
Intra-bony
Periodontal
Pockets,
Alabama Dental
Review, 5:17,
1957.
MRS. LORRIE HILL HONORED
All
members of
the American
Academy
of
Periodontology
are familiar with the efficient
manner in which Mrs. Lorrie Hill assists Dr. Clarke E. Chamberlain in his
many
activi-
ties as
Secretary
of the American
Academy
of
Periodontology.
It was not
surprising
therefore
to learn that
recently
the National Secretaries Association
recognized
Mrs.
Hill's
ability,
and
awarded her their coveted Certified Professional
Secretary
Award.
Congratulations,
Mrs. Hill!