Periodontal Assessment and Managment in Fixed Prosthodontics

Dental Clinical Practice 5 Semester 1
Periodontal Assessment and

Management in Fixed Prosthodontics
Dr.Betul Rahman
Periodontal health is a prerequisite of successful

comprehensive dentistry.
Long-term therapeutic targets of restorative dentistry

are:
comfort,
good function,
treatment predictability,
longevity,
ease of restorative and maintenance care
Active periodontal infection must be treated and

controlled before the initiation of restorative, esthetic,
and implant dentistry to achieve above targets
Key Parameters of Success

Critical assessment of periodontal tissues
Establish periodontal health before starting
Crown and Bridge
Images courtesy of Dr. R. Hirsch
Reasons for establishing periodontal health

before performing restorative dentistry
1. Establishment of stable gingival margins before tooth
preparation
2. Provide for adequate tooth length for retention, access
for tooth preparation, impression making, and finishing
of restorative margins
3. Periodontal therapy should be completed before
restorative care. Because the resolution of inflammation
may result in the repositioning of teeth or in soft tissue
and mucosal changes.
Copyright 2008, The University of

Adelaide. All rights reserved.
Reasons for establishing periodontal health

before performing restorative dentistry
4. Traumatic forces placed on teeth with ongoing
periodontitis may increase tooth mobility, discomfort,
and possibly the rate of attachment loss.
5. Successful esthetic and implant procedures may be
difficult or impossible without the specialized periodontal
procedures developed for this purpose.

Sequence of Treatment in Preparing

Periodontium for Restorative Dentistry
Control of Active Disease

Emergency treatment
Extraction of hopeless
teeth
Oral hygiene instructions
Scaling and root planing
Reevaluation
Periodontal surgery
Adjunctive orthodontic
therapy
Preprosthetic Surgery
Management of
mucogingival problems
Preservation of ridge
morphology after tooth
extraction
Crown-lengthening
procedures
Alveolar ridge
reconstruction
Emergency Treatment
Emergency treatment is undertaken to alleviate symptoms and

stabilize acute infection. This includes endodontic and periodontal
conditions
Extraction of Hopeless Teeth
Extraction of hopeless teeth is followed by temporary fixed or

removable prosthetics. Retention of hopeless teeth without
periodontal treatment may result in bone loss on adjacent teeth.
Restorative margins are refined and provisional restorations refitted
after the completion of active periodontal therapy.
Oral Hygiene Measures
Oral hygiene measures reduce plaque scores and gingival

inflammation
in patients with deep periodontal pockets (>5 mm), plaque control
measures alone are insufficient in resolving subgingival infection
and inflammation.
Scaling and Root Planing
Scaling and root planing combined with oral hygiene measures

reduce gingival inflammation and the rate of progression of
periodontitis.
Reevaluation
After 4 weeks the gingival tissues are evaluated to determine:

-oral hygiene adequacy,
-soft tissue response,
- pocket depth .
This permits sufficient time for healing, reduction in inflammation
and pocket depths, and gain in clinical attachment levels.

Periodontal Surgery
In deeper pockets (>5 mm), plaque and calculus removal is

often incomplete. As a result, periodontal surgery to access the
root surfaces for instrumentation and to reduce periodontal
pocket depths must be considered before restorative care may
proceed.
Adjunctive orthodontic therapy
As long as they are periodontally healthy, teeth with preexisting

bone loss may be moved orthodontically without incurring
additional attachment loss.

A, Before treatment. B, After 4 weeks, oral hygiene instructions

and scaling and root planing have improved this patient's
periodontal status

Preprosthetic Surgery
Management of Mucogingival Problems
Periodontal plastic surgical procedures:
to increase gingival dimensions
achieve root coverage before restoration and for
prosthetic reasons, comfort and esthetics.
At least 2 months of healing is recommended after
soft tissue grafting procedures, before initiating
restorative dentistry
Connective tissue graft placed under a double-papilla flap has

been used to provide root coverage for a maxillary right canine.
A, Maxillary canine before therapy.
B, Connective tissue graft placed over denuded root surface.
C, Papilla placed over connective tissue.
D, Final result
Sharjah to insert Chiche & Pinault 1994
In preparation for a removable partial denture, this

canine has received a gingival graft to increase
attached gingiva and deepen the vestibule.
Preservation of Ridge Morphology after

Tooth Extraction
Alveolar ridge
resorption is a
common consequence
of tooth loss.
Ridge preservation
procedures:
for future placement
of a dental implant or
pontic,
to prevent an
unaesthetic deformity
Crown-Lengthening Procedures
Surgical crown-lengthening procedures are performed:

to provide retention form
to allow for proper tooth preparation,
impression procedures,
placement of restorative margins
adjust gingival levels for esthetics.
It is important that crown lengthening surgery is done in
such a manner that the biologic width is preserved.
The biologic width is defined as the

physiologic dimension of the junctional
epithelium and connective tissue
attachment. It is relatively constant at
approximately 2 mm.
The healthy gingival sulcus depth is
0.69 mm

Connective tissue attachment 1.07 mm
Biologic Width
Junctional epithelium 0.97 mm
Gingival sulcus 0.69

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 violation if a

restorative margin is placed within
the zone of the attachment.
On the mesial surface of the
left central incisor, bone has not
been lost, but gingival
inflammation occurs.
On the distal surface of the left
central incisor, bone loss has
occurred, and a normal biologic
width has been reestablished.
it is recommended that there

be at least 3.0mm between the
gingival margin and bone
crest.
This allows for adequate
biologic width when the
restoration is placed 0.5 mm
within the gingival sulcus

Surgical Crown Lengthening
Indications
Subgingival caries or fracture
Inadequate clinical crown length for retention
Unequal or unesthetic gingival heights
Contraindications
Surgery would create an unesthetic outcome.
Deep caries or fracture would require excessive bone
removal on neighboring teeth.
The tooth is a poor restorative risk.


Surgical crown lengthening may include the removal of

soft tissue or both soft tissue and alveolar bone.
Reduction of soft tissue

alone is indicated if
1. There is adequate attached
gingiva
2. There is more than 3 mm of
tissue coronal to the bone
crest .This may be
accomplished by either
gingivectomy or flap
technique

Inadequate attached
gingiva and less than 3
mm of soft tissue
coronal to the bone
crest require a flap
procedure and bone
recontouring
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 4-5 mm from
the apical extent of the caries
or fracture to the bone crest
With the advent of predictable implant dentistry, it is

important to weigh carefully the value of crown lengthening
for restorative reasons as opposed to tooth removal
intracrevicular margin placement

in esthetic area
Rule 1: If the sulcus probes 1.5 mm or less, place the
restoration margin 0.5 mm below the gingival margin. This is
especially important on the facial aspect and will prevent a
biologic width violation in a patient who is at high risk in that
regard.
Rule 2: If the sulcus probes more than 1.5 mm, place the
margin half the depth of the sulcus below the gingival margin.
This places the margin far enough below tissue so that it will still
be covered if the patient is at higher risk of recession.
Rule 3: If a sulcus greater than 2 mm is found, especially
on the facial aspect of the tooth, evaluate to see if a
gingivectomy could be performed to lengthen the
teeth and create a 1.5-mm sulcus. Then the patient
can be treated using Rule 1.
A 78-year-old woman presents with the

maxillary anterior restorations placed 6
months earlier. She is unhappy with the
exposed margins and notes that the
margins were covered the day the
restorations were placed.
Depth from the attachment to the level

of the preparation margin is greater
than 3 mm. This patient had a sulcus
depth of more than 3 mm when these
restorations were placed.

Two options were available to manage

treatment appropriately:
(1) place the original margins to half the
depth of the sulcus, in which case the
recession that occurred would not have
exposed them, or
(2) perform a gingivectomy, creating a
1-mm to 1.5-mm sulcus. The second
option was chosen when the
restorations were redone. The margins
were then placed 0.5 mm below the
tissue after the
gingivectomy.
At 6 weeks after the gingivectomy and
preparation of the teeth. Note the tissue
level and that the tissue is rebounding
coronally over the margins. This is a
common finding when a gingivectomy
is done.

Four-year recall photograph after

placement of the final restorations for
patient . Note the tissue level has been
maintained, with a sulcus depth of 2
mm on the facial surface.

Alveolar Ridge Reconstruction

Patients are frequently seen after tooth loss and
alveolar ridge resorption have occurred.
Alveolar ridge reconstruction is done:

for an esthetic pontic or
for the placement of dental implants.
In the case of esthetic pontic construction, small
defects may be treated with soft tissue ridge
augmentation.
For larger defects and in those sites receiving dental
implants, hard tissue ridge augmentation are used .

Alveolar Ridge Reconstruction
Gingival Management during

Crown and Bridge Procedures
REQUIREMENTS FOR HEALTHY GINGIVA
AROUND RESTORATIONS
Correctly prepared margins
Gingival protection during preparation
procedures
Impression material to reach critical areas
Well-fitting temporary crowns!
Well-finished restoration margins
Moisture control for impressions and
cementation

Tissue Management and Control

of Bleeding
Gingival retraction cord and astringents

Electrosurgery
Chemical cautery (TCA trichloroacetic acid)

Problems with Subgingival

Margins
Poor access for tooth preparation
Poor access for impression

Poor access for cementation of post-core
Nil tooth structure for ferrule

Gingival Hyperplasia
CAUSES
Large open carious lesion

Lost filling
Fractured tooth
Poor fitting RPD or Bridge

Electrosurgery
THERAPEUTIC OBJECTIVES
Electrosection
Electro-coagulation
- White coagulation
- Dessication
- Black coagulation - Fulguration

Dental Applications of ES
Crown lengthening
Gingival recontouring
Excision of hyperplastic gingival tissue
Haemostasis
Exposing of tooth margins

Gingival Recontouring
INDICATIONS
Aesthetics harmonious gingival contour
Elimination of deep gingival pockets, improve
access for crown margins
Crown lengthening
METHODS
Mechanical (Surgical) gingivoplasty, apically
repositioned flap
Mechanical rotary diamonds
Electrosurgery
Electrosurgical Units (ESU)
Monopolar
Bipolar

Monopolar ESU
ESU
Active Electrode
PATIENT
Dispersive Electrode
Path of ESU Current
Current passes from the site of contact through the tissues and
is dissipated
The path the current takes is beyond the operators control
Nerves and blood vessels are more conductive than fat tissue,
bone, enamel, dentine, cementum and air spaces
Contact with teeth and metal fillings should be avoided
Metal directs current towards the pulp
Avoid electrosurgery around implants



What occurs when the ESU probe is

applied to tissue?
Temperature rise from 35 C 45 C reversible tissue changes
Temperature beyond 45 C coagulation of protein, tissue turns white,

cellular forms remain intact
Around 60 C water content of cells driven out dessication.
Haemostasis achieved without long term tissue damage
Above 60 C cellular disintegration. Oxygen, nitrogen, hydrogen,
carbon formation. BLACK COAGULATION, ESCHAR,
CARBONIZATION
400 500 C cells vaporize. White smoke PLUME

Clean the surgical site

with 0.2% Chlorhexidine
solution on cotton pellet.
Remove carbonised
tissue debris
from INACTIVE probe
with alcohol
on gauze

Electrocoagulation
Coagulation of tissues achieves the therepeutic
objective of haemostasis
There are three levels of coagulation:
- White coagulation
- Dessication
- Fulguration

Fulguration
ESU probe held slightly away from tissue
Arc jumps from electrode to the tissue in
a random manner when current density is
enough to overcome the capacitance of the gap
Tissue is left charred/ sloughs off in days

Precautions with ESU

Contraindicated in heart pacemaker patients
Contraindicated in radiation therapy and
acutely immuno-compromised patients
Do not use near alveolar bone
Do not contact alloy restorations
Do not contact tooth
Do not use near flammable vapors/liquids
Do not use with N2O or O2
Do not retract tissues with metal instruments
Avoid prolonged tissue contact
Have good ventilation/ suction (non-metal)
Adjust current for optimal use
Procedure with ESU

Plan
procedure, simulate on diagnostic model

Give LA
Set up ESU, ensure connections are correct
Plastic retractors and suction tips
Good lighting, efficient high volume suction
Test anaesthesia
Rehearse movement/ access
Choose correct probe and settings
Activate
Wipe eschar off with alcohol gauze when probe off
Wipe tissue debris away with chlorhexidine solution
Assess surgical site and re-enter if required

Using electrosurgery, the fine-wire electrode tip

is held parallel to the tooth preparation and rests on the
cord as the tip is moved around the tooth

If it is necessary to use electrosurgery,

the correct inclination of the
electrosurgery tip is important.
A, Electrosurgery tip being held
parallel to the preparation and resting
on the previously placed retraction
cord. This removes a minimal amount
of tissue, and the presence of the
retraction cord protects the
attachment from the electrosurgery.
B, Incorrect inclination of
electrosurgery tip. The tip is
leaning away from the preparation.
This inclination results in excess
tissue removal
electrosurgery
Bipolar ESU
Cuts, coagulates in irrigated,wet or dry
fields
Safe for pacemaker patients
Patient not in the circuit
No ground pads needed
Used with lower voltage
Safer- no electric arcing
Reduced tissue charring
Control more fine tuned
Less heat and current spread
Cuts and coagulates at far lower
wattages than monopolar ESUs
Trichloroacetic Acid (TCA)

Trauma to Periodontal Tissues 1.

Crown Preparation and Impressions
From burs
Deep crown margins
Abrasion from dry retraction cord
Overly large retraction cord
Retraction cord left in gingival crevice too long
Impression material retained in gingival crevice
Chemical burn from low pH astringents
Consequences
Gingival recession
Deepening of periodontal pocket
New biologic width
Chronic gingivitis

Trauma to Periodontal Tissues 2.

Temporisation
Poor surface finish for temporary restorations

Open proximal contacts
Margin overhangs and deficiencies
Insufficient embrasure space
Consequences
Trapping gingiva under crown margin

Gingival recession/ exposure of margins
Electrosurgery
Heating alveolar bone leading to infection/sequestration


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Dental Clinical Practice 5 Semester 1

Periodontal Assessment and

Periodontal health is a prerequisite of successful

Long-term therapeutic targets of restorative dentistry

Active periodontal infection must be treated and

Key Parameters of Success

Images courtesy of Dr. R. Hirsch

Reasons for establishing periodontal health

Copyright 2008, The University of

Reasons for establishing periodontal health

Copyright 2008, The University of

Sequence of Treatment in Preparing

Control of Active Disease

Emergency treatment is undertaken to alleviate symptoms and

Extraction of Hopeless Teeth

Extraction of hopeless teeth is followed by temporary fixed or

Oral Hygiene Measures

Oral hygiene measures reduce plaque scores and gingival

Scaling and Root Planing

Scaling and root planing combined with oral hygiene measures

After 4 weeks the gingival tissues are evaluated to determine:

Copyright 2008, The University of

In deeper pockets (>5 mm), plaque and calculus removal is

Adjunctive orthodontic therapy

As long as they are periodontally healthy, teeth with preexisting

Copyright 2008, The University of

A, Before treatment. B, After 4 weeks, oral hygiene instructions

Copyright 2008, The University of

Connective tissue graft placed under a double-papilla flap has

Sharjah to insert Chiche & Pinault 1994

In preparation for a removable partial denture, this

Preservation of Ridge Morphology after

Surgical crown-lengthening procedures are performed:

The biologic width is defined as the

Copyright 2008, The University of

Connective tissue attachment 1.07 mm

Copyright 2008, The University of

Infringement on the biologic width by the placement of a

Copyright 2008, The University of

Copyright 2008, The University of

Biologic width violation if a

it is recommended that there

Copyright 2008, The University of

Surgical Crown Lengthening

Copyright 2008, The University of

Copyright 2008, The University of

Surgical crown lengthening may include the removal of

Reduction of soft tissue

Copyright 2008, The University of

In the case of caries or

With the advent of predictable implant dentistry, it is

intracrevicular margin placement

A 78-year-old woman presents with the

Depth from the attachment to the level

Copyright 2008, The University of

Two options were available to manage

Copyright 2008, The University of

Four-year recall photograph after

Copyright 2008, The University of

Alveolar Ridge Reconstruction