BDS 11009 Periodontal Restorative PDF

NEWGIZA UNIVERSITY BDS11009 Periodontal-restorative interface-replacement of teeth and restorative indications Date: / /20 NEWGIZA UNIVERSITY Rationale for therapy Importance of Preparation of the Periodontium for Restorative Dentistry NEWGIZA UNIVERSITY 1. Establishment of stable gingival margins b...

NEWGIZA UNIVERSITY BDS11009 Periodontal-restorative interface-replacement of teeth and restorative indications Date: / /20 NEWGIZA UNIVERSITY Rationale for therapy Importance of Preparation of the Periodontium for Restorative Dentistry NEWGIZA UNIVERSITY 1. Establishment of stable gingival margins before tooth preparation. Gingiva shrinks after periodontal treatment. no bleeding during restorative manipulation allow for a more predictable restorative and esthetic result 2. To provide adequate tooth length for:  retention access for tooth preparation impression making finishing of restorative margins 3. Resolution of inflammation results in repositioning of teeth & soft tissue Rationale for therapy NEWGIZA Importance of Preparation of the Periodontium for Restorative Dentistry 4. Traumatic forces on teeth with periodontitis may increase tooth mobility discomfort the rate of attachment loss. 5. Periodontium with normal (Quality, quantity, and topography) acts as structural defense factors in maintaining periodontal health against orthodontic & restorative therapy. UNIVERSITY Sequence of treatment Control of the active inflammation (periodontal disease) 1. Emergency treatment 2. Extraction of hopeless teeth 3. Oral hygiene measures 4. Scaling and root planning 5. Reevaluation 6. Periodontal surgery 7. Adjunctive orthodontic therapy NEWGIZA UNIVERSITY Pre-prosthetic periodontal surgery 1. Management of mucogingival problems 2. Ridge preservation after tooth extraction 3. Alveolar ridge reconstruction 4. Crown lengthening Sequence of treatment NEWGIZA UNIVERSITY Control of the active inflammation (periodontal disease) Remove the primary etiological factor of the disease Calculus and plaque https://synapse.koreamed.org/Synapse/Data/PDFData/1150JPIS/jpis41-279.pdf Remove secondary local etiological factors Caries/ overhanging margins….. Sequence of treatment Control of the active inflammation (periodontal disease) NEWGIZA UNIVERSITY 1. Emergency treatment Acute infections should be controlled Endodontic emergencies Periapical abscess Periodontal abscess 2. Extraction of hopeless teeth Must be followed by construction of provisional restorations If hopeless teeth are retained they cause loss of bone on adjacent teeth 3. Oral hygiene measures Patients should be instructed to perform the proper tooth brushing technique and use interdental cleaning devices To reduce plaque scores/ reduce inflammation But in deep periodontal pockets (>5mm), self performed oral hygiene measures are insufficient Sequence of treatment NEWGIZA UNIVERSITY Control of the active inflammation (periodontal disease) 4. Scaling and root planning (non surgical periodontal therapy) Ultrasonic device + hand instruments curettes to remove primary etiological factor plaque and calculus 5. Reevaluation 4 weeks after scaling and root planning to evaluate: Adequacy of OH/ soft tissue response/ pocket depth Sufficient time for healing Reduction of inflammation Reduction in PPD and CAL If PPD is still > 5mm then consider periodontal surgery why? For Better accessibility for plaque and calculus removal 6. Periodontal surgery Purpose could be: Treat the active disease / or prepare the periodontium for restorative phase Preparation of periodontium for restorative treatment: NEWGIZA UNIVERSITY Periodontal health is the foundation for successful restorations. The periodontium should be carefully prepared at sites planned to receive restoration. It is well documented that: Diseased periodontium affects the restoration improper restorative procedure also compromise the periodontal health. Therefore adequate preparation of the periodontal tissues before restorative procedure and proper handling and design during restoration ensure the successful long term outcomes of the procedure. Sequence of treatment NEWGIZA UNIVERSITY Control of the active inflammation (periodontal disease) 7. Adjunctive orthodontic therapy If non-surgical periodontal therapy is sufficient to control the periodontal disease As long as teeth are periodontally healthy, teeth can be moved If non-surgical therapy is not sufficient perform orthodontic therapy postpone the periodontal surgical therapy after completion of orthodontic tooth movement. surgical periodontal correction is performed before orthodontic treatment (ex. Deep pockets/ furcation involvement) Why?? To allow for the advantages of positive bone changes that orthodontic tooth movement could provide Failure to control active periodontal disease before orthodontic tooth movement leads to acute exacerbation of the disease + bone loss Sequence of treatment Control of the active inflammation (periodontal disease) 1. Emergency treatment 2. Extraction of hopeless teeth 3. Oral hygiene measures 4. Scaling and root planning 5. Reevaluation 6. Periodontal surgery 7. Adjunctive orthodontic therapy NEWGIZA UNIVERSITY 1. 2. 3. 4. Pre-prosthetic periodontal surgery Management of mucogingival problems Ridge preservation after tooth extraction Alveolar ridge reconstruction Crown lengthening Sequence of treatment NEWGIZA UNIVERSITY Pre-prosthetic periodontal surgery 1. Management of mucogingival problems Purpose: Gingival augmentation Root coverage for purposes of comfort and esthetics. Indications: Before restoration for prosthetic reasons In conjunction with orthodontic tooth movement. At least 2 months of healing is recommended after soft tissue grafting procedures before initiating restorative dentistry Sequence of treatment Pre-prosthetic periodontal surgery 2. Ridge preservation after tooth extraction Alveolar ridge resorption is so common after tooth loss specifically if lost due to periodontal disease This step is important for: implant placement pontic placement for esthetics NEWGIZA UNIVERSITY Sequence of treatment Pre-prosthetic periodontal surgery NEWGIZA UNIVERSITY 3. Alveolar ridge reconstruction To provide adequate anatomic dimensions for the construction of an esthetic pontic or the placement of dental implants small defects / only pontic soft tissue augmentation For larger defects / sites receiving dental implants hard tissue or hard + soft tissue reconstruction. NEWGIZA UNIVERSITY Bone + soft tissue augmentation before implant placement Sequence of treatment NEWGIZA UNIVERSITY Pre-prosthetic periodontal surgery 4. Crown lengthening Crown lengthening is a surgical procedure that involves manipulation of either soft tissue or both soft and hard tissue around a tooth or teeth for esthetic or restorative purposes. Purpose: retention tooth preparation impression procedures restorative margins placement fracture lines or carious lesions (subgingival) esthetics & correcting gummy smile Esthetic crown lengthening Functional crown lengthening indicated in patients with: 1. excessive gingival display (gummy smile) or gingival overgrowth 2. Correct short clinical crowns due to altered passive eruption 3. Correct uneven gingival margins aims to gain retention and resistance form of sound tooth structure above the alveolar crest level in cases of: subgingival caries subgingival restorative margins tooth fracture NEWGIZA UNIVERSITY https://www.kilbyfamilydentistry.com/crown-lengthening-surgery Correct the position of restorative margin when there is violation of the biologic width https://www.wikiwand.com/en/Crown_lengthening Both aim to increase the amount of supragingival tooth structure for esthetic and/or restorative purposes. Biologic Width : The biological width is defined as the dimension of the soft tissue, which is attached to the portion of the tooth coronal to the crest of the alveolar bone. Another definition: the physiologic dimension of the junctional epithelium and connective tissue attachment (without the gingival sulcus depth) NEWGIZA UNIVERSITY Biologic Width NEWGIZA UNIVERSITY It is recommended that there be at least 3.0 mm between the gingival margin and bone crest. to allow for adequate biologic width when the restoration is placed 0.5 mm within the gingival sulcus Infringement on the biologic width by the placement of a restoration within its zone may result in: gingival inflammation pocket formation alveolar bone loss Biologic Width NEWGIZA UNIVERSITY Surgical crown lengthening Reduction of soft tissue only NEWGIZA UNIVERSITY flap procedure and bone recontouring (Soft + hard tissue) adequate attached gingiva and more than 3 mm of tissue coronal to the bone crest by either gingivectomy or flap technique Inadequate attached gingiva and less than 3 mm of soft tissue coronal to alveolar crest Surgical crown lengthening In the case of caries or tooth fracture, to ensure margin placement on sound tooth structure and retention form, the surgery should provide at least 4 mm from the apical extent of the caries or fracture to the bone crest NEWGIZA UNIVERSITY Surgical crown lengthening NEWGIZA UNIVERSITY Decision tree Biologic considerations margin placement and the biological width For healthy periodontium: Restorations margins must be in harmony with their surrounding periodontal tissues For the patient’s esthetic appearance: The tooth–tissue interface must present a healthy natural appearance (masking the junction of the margin with the tooth) NEWGIZA UNIVERSITY NEWGIZA Biologic considerations margin placement and the biological width 3 options: Supragingival Equigingival subgingival Supragingival margins Unaesthetic Good for the periodontium UNIVERSITY Equigingival margins Retain more plaque More gingival inflammation Any recession will cause margin display Nowadays restoration margins can be esthetically blended with the tooth restorations can be finished easily to provide a smooth, polished interface at the gingival margin. Periodontally both supra-gingival and equigingival margins are well tolerated. Biologic considerations margin placement and the biological width Subgingival margins: Not accessible for finishing procedures If placed too far it can violate the biologic width NEWGIZA UNIVERSITY First the periodontal tissues must be healthy (no signs of inflammation) Second: we use the sulcus depth as a guide for margin placement Rule I: If the sulcus probes 1.5 mm or less, place the restoration margin 0.5 mm below the gingival tissue crest. Rule II If the sulcus probes >1.5 mm, place the margin one half the depth of the sulcus below the tissue crest. Rule III If a sulcus >2 mm is found, especially on the facial aspect of the tooth, then evaluate to see whether a gingivectomy could be performed to lengthen the teeth and create a 1.5 mm sulcus. Then the patient can be treated as mentioned in Rule-I. Biologic considerations margin placement guidelines shallow probing depths (1.0 to 1.5 mm) Placing the restoration margin > 0.5 mm subgingivally risks violating the attachment We can only extend the margins 0.5 mm subgingivally Less risk for recession NEWGIZA UNIVERSITY Deeper sulcular probing depths restoration margins can be located farther below the gingival crest. However the deeper the gingival sulcus, the greater is the risk of gingival recession. Evaluation of biologic width violation NEWGIZA UNIVERSITY Radiographic method: identify only interproximal violations of biologic width. Not diagnostic facial & lingual biologic width violation Clinical method tissue discomfort when the restoration margin levels are being assessed with a periodontal probe Clinical signs 1. Chronic progressive gingival inflammation around the restoration. 2. Bleeding on probing 3. Localized gingival minimal bone loss 4. Gingival recession 5. Pocket formation biologic width violation has occurred. hyperplasia with Evaluation of biologic width violation N E W G I Z A Bone sounding The probe is pushed through the anesthetized attachment tissues from the sulcus to the underlying bone. probing to the bone level & subtracting the sulcus depth from the resulting measurement. distance is < 2 mm at one or more locations, a diagnosis of biologic width violation can be confirmed This should be performed on teeth with healthy gingiva for individual variation UNIVERSITY Biologic considerations marginal fit NEWGIZA UNIVERSITY Open margins Leads to harboring large numbers of bacteria http://www.dentalaw.com/news/asmith.htm inflammatory response in the periodontium However The quality of marginal finish and the margin location relative to the attachment are much more critical to the periodontium Biologic considerations crown contours NEWGIZA UNIVERSITY Ideal contour: provides access for hygiene create the desired gingival form has a pleasing visual tooth contour in esthetic areas. overcontouring causes gingival inflammation undercontouring produces no adverse periodontal effect. A flatter contour is always acceptable https://pocketdentistry.com/17-provisional-restorations/ Biologic considerations subgingival debris Subgingival debris can be caused by: retraction cord impression material provisional material temporary or permanent cement. cause Gingival inflammation and should be removed NEWGIZA UNIVERSITY summary 3 mm required from the restoration margin to the alveolar bone crest A minimum of 2 mm keratinized attached gingiva should be kept to protect the attachment In case of badly broken tooth at least 1 mm of sound tooth structure is required for retention of the restoration NEWGIZA UNIVERSITY Managing interproximal embrasures Papillary height is established by: level of the bone biologic width form of the gingival embrasure. NEWGIZA UNIVERSITY NEWGIZA UNIVERSITY Managing interproximal embrasures IDP behaves differently than the free gingival margin on the facial aspect of the tooth: Free gingival margin is 3 mm above the underlying facial bone Tip of IDP is 4.5-5 mm above interproximal bone Same biological width Therefore: sulcus at interproximal area is 1 -1.5 mm deeper than that at facial surface The size and shape of the gingival embrasure Imagine the papilla as a balloon of a certain volume that sits on the attachment Form & height of this balloon is dictated by the gingival embrasure Embrasure is too wide: balloon (IDP) flattens out and assumes a blunted shape/ shallow sulcus Embrasure is too narrow: Balloon (IDP) grows out to the facial and lingual, form a col and become inflamed NEWGIZA UNIVERSITY Managing interproximal embrasures First compare the papilla in question to adjacent papillae 2.If the papilla in question is apical to the adjacent papillae NEWGIZA UNIVERSITY 1.If: papillae are all at same level with no open embrasure at the other sites Then: evaluate the level of interproximal bone 1.If bone level is apical to level of adjacent bone Then the problem is bone loss (periodontal) 2.If bone level is same as adjacent Then the problem is in embrasure form of the teeth So the problem is in gingival embrasure form Managing interproximal embrasures NEWGIZA UNIVERSITY NEWGIZA UNIVERSITY Pontic design 1. Ovate pontic 2. Full ridge-lap pontic 3. Modified ridge-lap pontic ovate pontic most preferred Why??? maintain the interdental papilla next to abutment teeth after extraction. Pontic design Problem after extraction When a tooth is removed The gingival embrasure form is lost. The papilla recede 1.5-2.0 mm, which corresponds to the additional soft tissue that exists above bone on the interproximal versus the facial aspect. However, this recession can be prevented. insert the correct pontic form 2.5 mm into the extraction site the day of extraction thus maintaining the gingival embrasure form and papilla At 4 weeks, the 2.5-mm extension can be reduced to a 1-1.5mm extension to facilitate hygiene. Aim: maintain the papilla next to the abutment teeth (as long as the bone level on the abutment tooth is normal level). NEWGIZA UNIVERSITY Pontic design certain soft-tissue ridge parameters must exist to optimize the ovate pontic form. 1. The ridge height 2. The gingival margin height 3. The ridge tissue must be facial to the ideal cervical facial form of the pontic so that the pontic can emerge from the tissue. If not then Ridge augmentation Soft tissue final impression is taken 4-6 weeks after surgical preparation of the pontic site for constructing the final restoration NEWGIZA UNIVERSITY Pontic design NEWGIZA UNIVERSITY Full ridge-lap pontic Outdated design and not recommended creates an undersurface that is entirely concave and cannot be cleaned. Modified ridge-lap pontic acceptable design In case of inadequate ridge to create an ovate pontic. The pontic follows the convexity of the ridge on the facial aspect but stops on the lingual crest of the ridge without extending down the lingual side of the ridge. the more open lingual form allows adequate access for oral hygiene. Full ridge-lap Modified ridge-lap Ovate Occlusal considerations NEWGIZA UNIVERSITY Some rules even, simultaneous contacts on all teeth during centric closure for force distribution When the mandible moves from centric closure: canine or anterior guidance is desirable, with no posterior tooth contacts. stable vertical dimension of occlusion Centric relation records transferred to the articulator summary Sequence of treatment: Control the inflammation Emergency NEWGIZA UNIVERSITY Pre-prosthetic periodontal surgery Manage mucogingival problems Extraction hopeless teeth Preparation of periodontium for restorative treatment Rational for preparation of the periodontium before restorative therapy Oral hygiene Preserve the ridge after tooth extraction SRP reevaluation Periodontal surgery Orthodontic therapy Alveolar ridge reconstructi on Crown lengthening summary Crown lengthening Biologic width Decision of the Surgical crown lengthening procedure NEWGIZA UNIVERSITY Managing the interproximal embrasures Effect of size & shape of the gingival embrasure Biologic considerations Margin placement and the biologic width Evaluation of biologic width violation Marginal fit Crown contours Subgingival debris Pontic design Ovate pontic Full ridge lap pontic modified ridge lap pontic Occlusal considerations Reading material NEWGIZA UNIVERSITY Carranza`s clinical periodontology, Newman, Takei, Klokkevold, Carranza (Part 2 section VI) Clinical periodontology and implant dentistry, Jan Lindhe and Niklaus P. Lang, volume 2 NEWGIZA UNIVERSITY NEWGIZA UNIVERSITY