Periodontal Assessment and Managment in Fixed Prosthodontics

Dental Clinical Practice 5 Dental Clinical Practice 5 Semester 1

Periodontal Assessment and Periodontal Assessment and Management in Fixed ProsthodonticsManagement 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

Critical assessment of periodontal tissues Establish periodontal health before starting Crown and Bridge

Key Parameters of SuccessKey Parameters of Success

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



Biologic Width

Connective tissue attachment 1.07 mm

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 therestoration 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

With the advent of predictable implant dentistry, it isimportant to weigh carefully the value of crown lengtheningfor restorative reasons as opposed to tooth removal

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


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 themaxillary anterior restorations placed 6 months earlier. She is unhappy with the exposed margins and notes that themargins 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 managetreatment 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 secondoption was chosen when the restorations were redone. The margins were then placed 0.5 mm below the tissue after thegingivectomy.

At 6 weeks after the gingivectomy andpreparation of the teeth. Note the tissue level and that the tissue is rebounding coronally over the margins. This is acommon 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 2mm 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 Gingival Management during Crown and Bridge ProceduresCrown 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


Gingival retraction – cord and astringents Electrosurgery Chemical cautery (TCA – trichloroacetic acid)

Tissue Management and ControlTissue Management and Controlof Bleedingof Bleeding


Poor access for tooth preparation Poor access for impression Poor access for cementation of post-core Nil tooth structure for ‘ferrule’

Problems with Subgingival Problems with Subgingival MarginsMargins


CAUSES Large open carious lesion Lost filling Fractured tooth Poor fitting RPD or Bridge

Gingival HyperplasiaGingival Hyperplasia


THERAPEUTIC OBJECTIVES

Electrosection

Electro-coagulation - White coagulation - Dessication - ‘Black coagulation’ - Fulguration

ElectrosurgeryElectrosurgery


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

Dental Applications of ESDental Applications of ES


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

Gingival RecontouringGingival Recontouring


Monopolar Bipolar

Electrosurgical Units (ESU)Electrosurgical Units (ESU)


ESU

PATIENT

Active Electrode

Dispersive Electrode

Monopolar ESUMonopolar ESU


Path of ESU CurrentPath 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




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

What occurs when the ESU probe is What occurs when the ESU probe is applied to tissue?applied to tissue?


Clean the surgical site with 0.2% Chlorhexidine solution on cotton pellet.

Remove carbonised tissue debrisfrom INACTIVE probe with alcoholon gauze


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

ElectrocoagulationElectrocoagulation


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

FulgurationFulguration


Contraindicated in heart pacemaker patientsContraindicated 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

Precautions with ESUPrecautions 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

Procedure with ESUProcedure with ESU


• 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


• electrosurgery

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 restingon 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 isleaning away from the preparation. This inclination results in excess tissue removal


Cuts, coagulates in irrigated,wet or dry fields Safe for pacemaker patients Patient not in the circuit No ground pads neededUsed 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 ESU’s

Bipolar ESUBipolar ESU


Trichloroacetic Acid (TCA)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 spaceConsequences Trapping gingiva under crown margin Gingival recession/ exposure of margins

Electrosurgery Heating alveolar bone leading to infection/sequestration

Documents

Periodontal Assessment and Managment in Fixed Prosthodontics