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INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com

www.indiandentalacademy.com
www.indiandentalacademy.com
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INTRODUCTION
BASIC CONSIDERATIONS
TRAUMA FROM OCCLUSION
OCCLUSION AND ITS EFFECTS ON PERIODONTAL ...
Dentistry has progressed from the times
when a missing tooth was replaced by an
animal tooth to the present when it is bei...
► In the following deliberation I would like to

bring about the various periodontal aspects
to be considered in designing...
BASIC
CONSIDERATIONS
►
The periodontium
is the attachment
apparatus of the teeth
and consists of
cementum, periodontal
lig...
Gingiva:
►
It is divided anatomically into marginal,
attached and interdental areas.
► The attached gingiva extends from t...
Anatomic landmarks of gingiva

www.indiandentalacademy.com
► Mucogingival junction remains stationary

throughout the adult life. Width of the
attached gingiva increases with age an...
Periodontal Ligament
►

It is composed of collagen
fibres arranged in bundles that
are
attached
from
the
cementum of the t...
► In single rooted teeth, the axis of rotation is

located in the area between the apical third
and middle third of the ro...
Functions of Periodontal Ligament
►
Physical


►
►

Resistance to impact occlusal forces.
Transmission of occlusal force...
Probing
►
The thinnest probe is desired that
permits probing the depth of the pocket
without patient discomfort. While pro...
www.indiandentalacademy.com
Mobility
►
It can be determined by holding the tooth
between the handles of two metallic instruments or
with one metallic ...
Trauma from occlusion
►
When the occlusal forces exceed the adaptive
capacity of the tissues, tissue injury results. The
r...
www.indiandentalacademy.com
Trauma from occlusion occurs in the supporting
tissues and does not affect the gingiva.
The changes in TFO consists of
► a...
► Thus, in the absence of inflammation, the

response to TFO is limited to adaptation to
increased forces. In the presence...
►
►
►
►
►
►
►

Radiographs
The radiograph is a valuable aid in the diagnosis,
prognosis and evaluation of the treatment ou...
Occlusion and its effect on periodontium
►
The effect of occlusal forces on the
periodontium is influenced by their severi...
Occlusal Therapy as a Part of Periodontal
Treatment
►
Studies indicate that the gain in the attachment
level after periodo...
► Occlusal therapy is also indicated when

missing teeth need to be replaced or food
impaction needs to be corrected. Occl...
Occlusal Adjustment
► Removing occlusal prematurities in centric relation
and centric occlusion. A ‘long-centric’ or ‘free...
When to perform occlusal therapy in the
sequence of periodontal treatment
►
It is preferable to postpone any procedures
re...
►
►

►

►
►

Splinting
Splinting refers to any joining together of two
or more teeth for stabilization.
Occlusal correctio...
The number of teeth required to stabilize a
loose tooth depends on:





Degree and direction of mobility.
The remaini...
► Reducing mesiodistal mobility is easier than

reducing buccolingual mobility because of
approximating teeth that aid in ...
Splinting methods:
It may classified as
► Temporary or reversible.
► Provisional.
► Permanent.
Some methods of reversible ...
Splinting by Bonding
►
Newer materials have made splinting teeth
easier. The composite resins have greater
strength and li...
► Provisional

splinting with full
coverage acrylics
►
This method is commonly used with
periodontally compromised patient...
www.indiandentalacademy.com
Indications for splinting
►
Splinting is indicated if mobility is increasing
after periodontal and initial occlusal therap...
► PLACEMENT

OF MARGINS OF
RESTORATION
►
Whenever possible margins are
prepared supragingivally on the enamel of
the anato...
► Advantages of supragingivaly placed

margins are:
► Favourable reaction of the gingiva.
► Wider shoulder tooth preparati...
► Intracrevicular

Margin Placement
►
Despite the advantages of supragingival
margins there are clinical situations
requir...
►
►

►

►

Intracrevicular Depth
Accurate estimate of true gingival crevice is important
to ensure that margins do not imp...
► Studies have also demonstrated that a space of

2mm is needed for supracrestal connective tissue
attachment and junction...
Gingival Retraction and Impressions
►
All retraction methods induce transient trauma
to the junctional epithelium and conn...
►

►

Electrosurgery : They have certain limitations.
But when used properly the cellular healing is
comparable to a scalp...
TEMPORARY AND PROVISIONAL
CROWNS
►
Improperly constructed “interim” restorations
may cause periodontal inflammation and gi...
EMBRASURES
►
When teeth are in proximal contact, the spaces
that widen out from the contact are known as
embrasures. Each ...
In health, the gingival embrasure is filled with
soft tissue, but periodontal diseases may
result in attachment loss creat...
► Periodontal diseases cause tissue destruction,

which reduces the level of alveolar bone,
increases the size of the ging...
► In fixed prosthesis and / or multiunit fixed splints,

the interproximal contact and / or soldered joint is
frequently c...
► CROWN

CONTOUR
►
The contours of full and partial coverage
restorations play a supportive role in
establishing a favoura...

►

Gingival Protection Theory:

It advocates that contours of cast restorations
be designed to protect the marginal ging...

►

Gingival stimulation theory:

This concept reasons that as food is
masticated, it will pass over the gingiva
stimulat...
Muscle action theory:
►

This theory advocates that the perioral
musculature (tongue, cheeks) are
responsible for maintain...
Theory of access for oral hygiene
►

This theory is based on the concept that
the prime etiologic factor in caries and
gin...
Four guidelines to contouring crowns are:
Buccal and lingual contours – flat, not fat
►
Plaque retention on the buccal and...
Location of contacts
►
Contacts should be directed incisally or
occlusally and buccally in relation to the central
fossa, ...
► Facial

and Lingual sulcular contours
►
In the patient whose gingival margins are
apical to the CEJ the sulcular morphol...
PONTIC DESIGN
A pontic should meet the following
requirements.
► Be esthetically acceptable.
► Provide occlusal relationsh...
www.indiandentalacademy.com
► The health of the tissues around the fixed

prosthesis depends primarily on the patients
oral hygiene. The material with...
CEMENTATION
►
During cementation it is important that the
restoration be seated as close to the tooth
preparation as possi...
► RESTORATION

OF MOLAR TEETH
WITH FURCATION INVASIONS
►
In long-term studies of tooth longevity,
molars are the teeth tha...
►
►

►

►

Classification of furcation involvement
Grade I – Incipient or early lesion. Radiographic changes
not seen.
Gra...
Glickman (1958)

www.indiandentalacademy.com
If a full coverage restoration is indicated on a
Grade I or early Grade II furcation involved
teeth, the principles are sa...
►
►
►

►

RESTORATION OF ROOT RESECTED MOLARS
Root amputation :
Removal of a root from a
multirooted teeth.
Root resection...
Indications for Root resection or
Hemisection
► Vertical bone loss around one root but not others.

Post surgical healing ...
www.indiandentalacademy.com
www.indiandentalacademy.com
Post and cores
►
Brittleness of the pulpless root resected tooth
is the primary reason for root fractures over time.
Compl...
www.indiandentalacademy.com
Crown Preparation
►
Intracrevicular margins are usually required to
cover portions of root-resected area. The crown
margin...
PRE-PROSTHETIC
PERIODONTAL SURGERY

www.indiandentalacademy.com
►

►
►

►
►

Mucogingival surgery
Teeth with subgingival restorations and narrow
zones of keratinized gingiva have higher
...
► When there is a pocket formation, thick

manageable pocket walls can be used for
an apically displaced flap – this flap ...
Root coverage : Two techniques are recommended.
►
Langer’s technique – use a connective tissue
graft under a partial thick...
►
►

Crown lengthening procedures
In situations in which a tooth has a short clinical crown
that is deemed inadequate for ...
www.indiandentalacademy.com
►

Ridge Augmentation procedures
Aimed at correcting the excessive loss of
alveolar bone that sometimes occurs in
the ante...
Several prosthetic solutions have been
proposed:
 Placement of a thick mucosal autograft obtained
from palate or tuberosi...
►REMOVABLE

PARTIAL
DENTURES AND THE
PERIODONTIUM

www.indiandentalacademy.com
► From the periodontal viewpoint, fixed

prosthesis are the restorations of choice for
replacement of missing teeth, but t...
DESIGN
►
Every effort must be made to retain posterior
teeth for the distal support of edentulous areas.
When posterior te...
Occlusal rests :
► They should be designed so that the
occlusal forces are directed along the
vertical axis of the tooth. ...
Combined Fixed and Removable
prosthesis
►
Isolated teeth with reduced periodontal support
are particularly vulnerable to p...
Major connectors :
► They should not
impinge on the free
gingival margins. The
major connector
should be placed 6mm
away f...
► When periodontally compromised

mandibular anterior teeth require
stabilization, a special design of major
connector sho...
OVERDENTURES
Over dentures have three obvious
advantages
► Increased retention and stability of record
base.
► Propriocept...
► It is important that appropriate periodontal

considerations be a part of the treatment
planning process.

 Presence of...
► One great advantage that the overdenture

concept has for periodontally involved teeth
is that it is possible to improve...
Implant supported restorations
The main principles that determine success or
failure from a periodontal view point for an ...
Force distribution
► Crown implant ratio – This is very important
in the presence of lateral forces. Lateral
forces result...
Other factors to be considered are:
► Bilateral simultaneous contact is mandatory.
► Occlusal vertical dimension must be i...
► Centric vertical contacts should be aligned

with the long axis of the implant whenever
possible.
► Posterior occlusal t...
SUMMARY AND CONCLUSION
One of the primary goals of restorative therapy is to
establish a physiologic periodontal climate a...
In impression making, ginival retraction methods
should be followed deligently keeping the ginival
health in mind. All int...
The occlusal surfaces should be designed to
direct masticatory forces along the long axis of
the tooth. The occlusal table...
REFERENCES
1. Gengers, Snack, Vagels - Over containing in resin bonded
prosthesis Plague accumulation and gingival health ...
8. James Marcum: The effect of crown marginal depth upon
gingival tissues J.P.D. 17:479:1967.
9. Jon Ruel, Peter S., Kenet...
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Perio prostho /certified fixed orthodontic courses by Indian dental academy

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The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.

Indian dental academy provides dental crown & Bridge,rotary endodontics,fixed orthodontics,
Dental implants courses.for details pls visit www.indiandentalacademy.com ,or call
0091-9248678078

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Transcript of "Perio prostho /certified fixed orthodontic courses by Indian dental academy "

  1. 1. INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com
  2. 2. www.indiandentalacademy.com
  3. 3. ► ► ► ► ► ► ► ► ► ► ► ► INTRODUCTION BASIC CONSIDERATIONS TRAUMA FROM OCCLUSION OCCLUSION AND ITS EFFECTS ON PERIODONTAL LIGAMENT SPLINTING PLACEMENT OF MARGINS OF RESTORATION GINGIVAL RETRACTION AND IMPRESSION CROWN CONTOURING PRE PROSTHETIC PERIODONTAL SURGERIES REMOVABLE PARTIAL DENTURE AND PERIODONTIUM CONCLUSION REFERENCES www.indiandentalacademy.com
  4. 4. Dentistry has progressed from the times when a missing tooth was replaced by an animal tooth to the present when it is being replaced with an implant. ► We have moved into a new era in which dentistry can no longer be practiced in isolated specialty divisions to meet the overall needs of the patients. The team approach is replacing the individual approach resulting in more effective patient care. ► www.indiandentalacademy.com
  5. 5. ► In the following deliberation I would like to bring about the various periodontal aspects to be considered in designing a prosthesis which may be called as “Periodontal Restorative Interrelationship www.indiandentalacademy.com
  6. 6. BASIC CONSIDERATIONS ► The periodontium is the attachment apparatus of the teeth and consists of cementum, periodontal ligament, alveolar bone and a portion of the gingiva www.indiandentalacademy.com
  7. 7. Gingiva: ► It is divided anatomically into marginal, attached and interdental areas. ► The attached gingiva extends from the mucogingival junction to the projection on the external surface of the bottom of the gingival sulcus. ► The width of the attached gingiva on the facial aspect differs in different areas of the mouth. It is generally greatest in the incisor region (3.5 to 4.5mm) and less in the posterior segments with the least width in the first premolar area 1.9mm. www.indiandentalacademy.com
  8. 8. Anatomic landmarks of gingiva www.indiandentalacademy.com
  9. 9. ► Mucogingival junction remains stationary throughout the adult life. Width of the attached gingiva increases with age and in supraerupted teeth. ► Keratinized gingiva includes both the attached gingiva as well as the marginal gingiva. ► Clinical gingival sulcus depth normally measures 2-3mm www.indiandentalacademy.com
  10. 10. Periodontal Ligament ► It is composed of collagen fibres arranged in bundles that are attached from the cementum of the tooth to the alveolar bone. In humans the width of the periodontal ligament ranges from 0.15 to 0.38mm. Occlusal loading in function affects the width of the periodontal ligament. If occlusal forces are within physiologic limits, increased function leads to increase in the width of the ligament www.indiandentalacademy.com
  11. 11. ► In single rooted teeth, the axis of rotation is located in the area between the apical third and middle third of the root. In multirooted teeth, the axis of rotation is located in the bone between the roots. ► The ligament is narrowest in the region of axis of rotation. Due to physiologic mesial migration, the periodontal ligament is thinner on the mesial surface than on the distal surface www.indiandentalacademy.com
  12. 12. Functions of Periodontal Ligament ► Physical   ► ► Resistance to impact occlusal forces. Transmission of occlusal forces to bone. Formative and remodeling function. Nutritional and sensory function Pathological deepening of gingival sulcus is termed as periodontal pocket. It is due to the direct extension of gingivitis into the alveolar bone www.indiandentalacademy.com
  13. 13. Probing ► The thinnest probe is desired that permits probing the depth of the pocket without patient discomfort. While probing the dentist must pay attention to the root anatomy. ► Local anesthesia is recommended when the bony contours are probed to establish whether surgery is necessary. This procedure is called Bone Sounding www.indiandentalacademy.com
  14. 14. www.indiandentalacademy.com
  15. 15. Mobility ► It can be determined by holding the tooth between the handles of two metallic instruments or with one metallic instrument and one finger. An effort is made to move the tooth in all directions. Mobility is graded as: ► Grade I – Barely distinguishable tooth movement. ► Grade II – Any movement upto 1mm (Labiolingual or mesiodistal). ► Grade III – Any movement more than 1mm or teeth that can be depressed or rotated in their sockets. www.indiandentalacademy.com
  16. 16. Trauma from occlusion ► When the occlusal forces exceed the adaptive capacity of the tissues, tissue injury results. The resultant injury is termed trauma from occlusion. ► Trauma from occlusion may be caused by altrations in occlusal forces or reduced capacity of the periodontium to withstand occlusal forces. When trauma from occlusion is the result of alterations in occlusal forces, it is called primary trauma from occlusion . When it results from reduced ability of the tissues to resist occlusal forces, it is known as secondary trauma from occlusion . www.indiandentalacademy.com
  17. 17. www.indiandentalacademy.com
  18. 18. Trauma from occlusion occurs in the supporting tissues and does not affect the gingiva. The changes in TFO consists of ► a) increased width of periodontal ligament space, ► b) thickening of laminadura along the lateral aspect of the root, ► c) vertical rather than horizontal destruction of interdental septum, ► d) root resorption, ► e) radiolucence and condensation of alveolar bone. www.indiandentalacademy.com
  19. 19. ► Thus, in the absence of inflammation, the response to TFO is limited to adaptation to increased forces. In the presence of inflammation, the changes in the shape of the crest may be conducive to angular bone loss with infra bony pockets. Most common clinical sign of TFO is increased tooth mobility www.indiandentalacademy.com
  20. 20. ► ► ► ► ► ► ► Radiographs The radiograph is a valuable aid in the diagnosis, prognosis and evaluation of the treatment outcome of periodontal disease. The most useful technique in evaluating the tooth to bone relationship is the long cone technique. A film positioning holder should be used. The areas to be reviewed on the radiographs are: Alveolar crest resorption. Integrity and thickness of laminadura. Evidence of generalized horizontal bone loss. Evidence of vertical bone loss. Widened periodontal ligament space. Density of the trabaculae of both the arches. Size and shape of the roots compared to crown, to determine crown root ratio www.indiandentalacademy.com
  21. 21. Occlusion and its effect on periodontium ► The effect of occlusal forces on the periodontium is influenced by their severity, direction, duration and frequency. When severity increases, the periodontal fibers thicken and increase with the alveolar bone becoming denser. ► Changing the direction of occlusal forces changes the orientation of periodontal ligament fibres. The principal fibres of the periodontal ligament best accommodate occlusal forces along the long axis of the tooth. ► Lateral forces initiate bone resorption in areas of pressure and bone formation in areas of tension. www.indiandentalacademy.com
  22. 22. Occlusal Therapy as a Part of Periodontal Treatment ► Studies indicate that the gain in the attachment level after periodontal therapy is inversely proportional to the degree of mobility. ► Occlusal therapy should be performed as a part of periodontal treatment-whenever there is a functional indication for it. ► A diagnosis of TFO fully justifies occlusal therapy. ► When malocclusion interferes with achievement of stable intermaxillary relationship. E.g. Migrating teeth, diastemas, flaring of anterior teeth. ► Bruxism may require treatment, since it is the basis for every type of dysfunctional manifestation and often is the first evidence of lack of adaptation to occlusion www.indiandentalacademy.com
  23. 23. ► Occlusal therapy is also indicated when missing teeth need to be replaced or food impaction needs to be corrected. Occlusal therapy should not be initiated unless there is evidence to indicate that the system is no longer adapting to the occlusal scheme of the individual www.indiandentalacademy.com
  24. 24. Occlusal Adjustment ► Removing occlusal prematurities in centric relation and centric occlusion. A ‘long-centric’ or ‘freedom in centric’ when cusp tips contact horizontal stops in the fossae. ► Eliminating balancing interferences which will allow the mandible to move freely laterally and protrusively. ► Adjusting working contacts in lateral movements and anterior contacts in protrusion. Depending on the occlusal pattern of the individual no single tooth should be overloaded during excursions with either group function or a cuspid protected occlusion. www.indiandentalacademy.com
  25. 25. When to perform occlusal therapy in the sequence of periodontal treatment ► It is preferable to postpone any procedures related to occlusion until root preparation has been completed and the patient has been instructed in oral hygiene procedures. When inflammation has been controlled, teeth will modify their position within the socket and will be more stable and less mobile. Thus, after controlling inflammation, occlusal therapy is performed when indicated. www.indiandentalacademy.com
  26. 26. ► ► ► ► ► Splinting Splinting refers to any joining together of two or more teeth for stabilization. Occlusal correction and construction of an appliance precede splinting. Splinting has 3 purposes: To protect loose teeth from injury during stabilization in a favourable occlusal relationship. To Distribute occlusal forces for teeth weakened by loss of periodontal support. To prevent a natural tooth from migrating www.indiandentalacademy.com
  27. 27. The number of teeth required to stabilize a loose tooth depends on:     Degree and direction of mobility. The remaining bone. The location of the mobile tooth. Whether the tooth is to be used as an abutment tooth. www.indiandentalacademy.com
  28. 28. ► Reducing mesiodistal mobility is easier than reducing buccolingual mobility because of approximating teeth that aid in support. It is advisable to use more than one firm tooth to stabilize a mobile tooth. ► If the mobile teeth are splinted to adjacent teeth without correction of the occlusal traumatism or parafunctional habits, the entire splint can become unstable www.indiandentalacademy.com
  29. 29. Splinting methods: It may classified as ► Temporary or reversible. ► Provisional. ► Permanent. Some methods of reversible splinting are ligature wire, circumferential wiring, removable appliances and bonding. Removable appliances include the Hawley’s Retainer and a continuous clasp RPD. A swing-lock RPD though costly and can be damaging is used for medically compromised patients. www.indiandentalacademy.com
  30. 30. Splinting by Bonding ► Newer materials have made splinting teeth easier. The composite resins have greater strength and light cured bonding permits better control of contours. Temporary splinting is accomplished with the composite material alone or in combination with extracoronal or intra coronal wires or screen meshes. ► Permanent splinting can also be performed with resin bonded retainers (Maryland bridges) or bars and plates. www.indiandentalacademy.com
  31. 31. ► Provisional splinting with full coverage acrylics ► This method is commonly used with periodontally compromised patients where there is a commitment to fixed splints after periodontal therapy. Before periodontal treatment, the teeth are prepared and heat processed acrylic treatment restorations are constructed and cemented with sedative cements. When the tissue has healed and matured after surgery, cast splints are inserted www.indiandentalacademy.com
  32. 32. www.indiandentalacademy.com
  33. 33. Indications for splinting ► Splinting is indicated if mobility is increasing after periodontal and initial occlusal therapy and the teeth are interfering with chewing ability and comfort. According to Lindhe, candidates for splinting are: ► Progressive (increasing) mobility of a tooth as a result of gradually increasing width of the periodontal ligament in teeth with a reduced height of alveolar bone. ► Increased bridge mobility despite splinting. ► Progressive mobility in situation 1 can often be controlled by unilateral splints. ► Situation 2 requires cross-arch splinting www.indiandentalacademy.com
  34. 34. ► PLACEMENT OF MARGINS OF RESTORATION ► Whenever possible margins are prepared supragingivally on the enamel of the anatomic crown. Any restorative material is a foreign body in the gingival sulcus and unfortunately they provide an area favourable for plaque formation www.indiandentalacademy.com
  35. 35. ► Advantages of supragingivaly placed margins are: ► Favourable reaction of the gingiva. ► Wider shoulder tooth preparations can accommodate an adequate bulk of porcelain without-pulpal injury. ► Metal margin finishing techniques are easier. www.indiandentalacademy.com
  36. 36. ► Intracrevicular Margin Placement ► Despite the advantages of supragingival margins there are clinical situations requiring intracrevicular margin placement. They are: ► Esthetics. ► Severe cervical erosion, restorations or caries extending beyond gingival crest. ► Adequate crown retention in short or broken down clinical crowns. ► Elimination of persistent root sensitivity. www.indiandentalacademy.com
  37. 37. ► ► ► ► Intracrevicular Depth Accurate estimate of true gingival crevice is important to ensure that margins do not impinge on junctional epithelium or connective tissue attachment (biologic width ). This requires the use of an accepted periodontal probe. Position of the probe and probing force are critical for accuracy. In health, the probe is stopped by the junctional epithelium, whereas gingivitis allows penetration of junctional epithelium and connective tissue fibres. Studies have estimated that the ideal intracrevicular depth for margins is 0.5-1mm beneath gingival crest and not more than 0.5mm when the crevice is adjacent to root surfaces www.indiandentalacademy.com
  38. 38. ► Studies have also demonstrated that a space of 2mm is needed for supracrestal connective tissue attachment and junctional epithelium to attach to the tooth. This 2mm band is a physiologic dimension that is required around every tooth in the mouth. It has been called as biologic width. If the restoration infringes on this width, there is no place for attachment apparatus to insert. An inflammatory response results, attachment loss with apical migration occurs and pocket formation ensues www.indiandentalacademy.com
  39. 39. Gingival Retraction and Impressions ► All retraction methods induce transient trauma to the junctional epithelium and connective tissue of gingival sulcus. ► Retraction chord: It usually produces limited gingival recession and can protect the sulcular tissues during preparation. If used carelessly when inadequate attached gingiva is present, injury to gingival fibres occurs. This can allow the impression material to be forced into the gingival connective tissue and bone producing a foreign body reaction. www.indiandentalacademy.com
  40. 40. ► ► Electrosurgery : They have certain limitations. But when used properly the cellular healing is comparable to a scalpel cut. Controlled depth cutting electrode tips avoid bone trauma but injure the gingival fibres, if the tip is not angled properly in the sulcus. Oringer’s solution or surgical pack may enhance healing. In patients with thin covering of gingiva and alveolar bone over the root, electrosurgery should not be used as the loss of tissue from the internal or crevicular surface can result in gingival recession. In these patients, the gingiva should be retracted with retraction chords. www.indiandentalacademy.com
  41. 41. TEMPORARY AND PROVISIONAL CROWNS ► Improperly constructed “interim” restorations may cause periodontal inflammation and gingival recession. The requirements for fit, polish and contour in the interim restoration should be the same as for the final restoration. ► Long-term restorations should not be called as temporary but should be regarded as provisional or treatment restorations. These allow the dentist to assess the effect of final restoration www.indiandentalacademy.com
  42. 42. EMBRASURES ► When teeth are in proximal contact, the spaces that widen out from the contact are known as embrasures. Each interdental space has 4 embrasures. ► An occlusal or incisal embrasure that is coronal to the contact area. ► A facial embrasure. ► A lingual embrasure. ► A gingival embrasure which is the space between the contact area and the alveolar bone. www.indiandentalacademy.com
  43. 43. In health, the gingival embrasure is filled with soft tissue, but periodontal diseases may result in attachment loss creating open gingival embrasures. ► The gingival embrasure : From a periodontal view point, the gingival embrasure is the most significant www.indiandentalacademy.com
  44. 44. ► Periodontal diseases cause tissue destruction, which reduces the level of alveolar bone, increases the size of the gingival embrasure and creates an open interdental space. Restorations may be constructed to preserve the morphologic features of the crown and root and retain the enlarged embrasure space or when esthetic situations dictate, the teeth may be reshaped by the restorations so that the gingival embrasures are relocated close to the new level of the gingiva. ► To relocate the gingival embrasure, the dentist changes the contour of the proximal surfaces and broadens the contact areas more apically. www.indiandentalacademy.com
  45. 45. ► In fixed prosthesis and / or multiunit fixed splints, the interproximal contact and / or soldered joint is frequently carried for too apically so that it invades the embrasure space from its coronal aspect. This leads to inflammation and destruction of periodontal tissues. ► The responsibility of determining the size of the interproximal contact should rest with the dentist, not the technician. www.indiandentalacademy.com
  46. 46. ► CROWN CONTOUR ► The contours of full and partial coverage restorations play a supportive role in establishing a favourable periodontal climate. The theories of crown contouring that have evolved are: ► Gingival protection. ► Gingival stimulation. ► Muscle action. ► Access for oral hygiene. www.indiandentalacademy.com
  47. 47.  ► Gingival Protection Theory: It advocates that contours of cast restorations be designed to protect the marginal gingiva from mechanical injury. In 1962 this concept was challenged by Morris who reported that the response of gingival tissue around teeth prepared for complete artificial crowns but which had lost their temporary crowns were similar to the adjacent unprepared teeth. Schluger stated that the so called protective cervical bulge protects nothing but the microbial plaque www.indiandentalacademy.com
  48. 48.  ► Gingival stimulation theory: This concept reasons that as food is masticated, it will pass over the gingiva stimulating it and causing increased keratinization of the epithelium. Keratinized epithelium would be more resistant to periodontal breakdown. Several authors have shown that the gingival margin is not in the path of masticated food. Even if the food passing over the teeth were to increase keratinization, this stimulating would occur at the buccal and lingual surfaces www.indiandentalacademy.com
  49. 49. Muscle action theory: ► This theory advocates that the perioral musculature (tongue, cheeks) are responsible for maintaining a healthy periodontal environment. They suggest that overcontouring prevents normal cleansing action by the musculature and allows food to stagnate in the overprotected sulcus www.indiandentalacademy.com
  50. 50. Theory of access for oral hygiene ► This theory is based on the concept that the prime etiologic factor in caries and gingivitis is plaque. Thus, crown contour should facilitate plaque removal, not hinder it. www.indiandentalacademy.com
  51. 51. Four guidelines to contouring crowns are: Buccal and lingual contours – flat, not fat ► Plaque retention on the buccal and lingual surfaces occurs primarily at the infrabulge of the tooth. Reduction or elimination of infrabulge would reduce plaque retention. Open embrasures ► Every effort must be made to allow easy access to interproximal area for plaque control. An over contoured embrasure will reduce the space intended for the gingival papilla. www.indiandentalacademy.com
  52. 52. Location of contacts ► Contacts should be directed incisally or occlusally and buccally in relation to the central fossa, except between maxillary first and second molars. This creates a large lingual embrasure space for optimum health of lingual papilla. Furcation involvement ► Furcations that have been exposed owing to loss of periodontal attachment should be ‘fluted’ or ‘barreled out’. It is based on the concept of eliminating plaque traps www.indiandentalacademy.com
  53. 53. ► Facial and Lingual sulcular contours ► In the patient whose gingival margins are apical to the CEJ the sulcular morphology differs from that of a healthy patients whose gingival margins are on enamel. ► The intracrevicular contours of an artificial crown should be as close to the original enamel contour as possible. Wagman has estimated the angle of enamel flare from CEJ to be approximately 22.5 degrees from the vertical axis of gingival housing. www.indiandentalacademy.com
  54. 54. PONTIC DESIGN A pontic should meet the following requirements. ► Be esthetically acceptable. ► Provide occlusal relationships that are favourable to abutment teeth. ► Restore the masticatory effectiveness. ► Be designed to minimize accumulation of irritating dental plaque and food debris. ► Provide embrasures for passage of food www.indiandentalacademy.com
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  56. 56. ► The health of the tissues around the fixed prosthesis depends primarily on the patients oral hygiene. The material with which pontics are constructed make little difference and pontic design is important only to the extent that it enables the patient to keep the area clean. www.indiandentalacademy.com
  57. 57. CEMENTATION ► During cementation it is important that the restoration be seated as close to the tooth preparation as possible. A minimal cement line at the margin reduces plaque formation. It is extremely important that all excess cement be removed from the sulcus after cementation. Removal of cement from the interproximal joints can be facilitated by lightly coating the exterior surfaces of the prosthesis with petroleum jelly prior to cementation www.indiandentalacademy.com
  58. 58. ► RESTORATION OF MOLAR TEETH WITH FURCATION INVASIONS ► In long-term studies of tooth longevity, molars are the teeth that are most often lost. This is due to the complex root anatomy and furcation that make periodontal therapy and plaque control difficult for the patients www.indiandentalacademy.com
  59. 59. ► ► ► ► Classification of furcation involvement Grade I – Incipient or early lesion. Radiographic changes not seen. Grade II – Bone is destroyed on one or more aspects of the furcation, but a portion of alveolar bone and periodontal ligament remains intact, permitting only partial penetration of probe into the furcation. Grade III – Interradicular bone is completely destroyed, but facial or lingual orifices of the furcation are occluded by gingival tissue. Grade IV – Interradicular bone is completely destroyed and gingival tissue is also receded apically so that the furcation opening is clinically visible www.indiandentalacademy.com
  60. 60. Glickman (1958) www.indiandentalacademy.com
  61. 61. If a full coverage restoration is indicated on a Grade I or early Grade II furcation involved teeth, the principles are same as that for a normal tooth except that the preparation has to be fluted or barreled into anatomic depressions www.indiandentalacademy.com
  62. 62. ► ► ► ► RESTORATION OF ROOT RESECTED MOLARS Root amputation : Removal of a root from a multirooted teeth. Root resection : Surgical removal of a root after endodontic treatment. Hemisection : Surgical separation of a multirooted tooth through the furcation area in such a way that a root or roots may be surgically removed along with associated portion of the crown. Bisection : Splitting and retaining the roots and accompanying crowns of a mandibular molar or any two roots of maxillary molar www.indiandentalacademy.com
  63. 63. Indications for Root resection or Hemisection ► Vertical bone loss around one root but not others. Post surgical healing : It is critical when intracrevicular margins have to be placed on resected or hemisectioned teeth. A minimum of 4 to 6 weeks of healing after surgery is required before the soft tissues can resist the trauma of tooth preparation www.indiandentalacademy.com
  64. 64. www.indiandentalacademy.com
  65. 65. www.indiandentalacademy.com
  66. 66. Post and cores ► Brittleness of the pulpless root resected tooth is the primary reason for root fractures over time. Complete coverage of root resected teeth is recommended especially over resection area. ► There is no evidence that post and cores are beneficial in resected teeth and infact they can be detrimental. If a post and core is required because of a coronal damage, a custom cast dowel core is preferable to prefabricated dowel www.indiandentalacademy.com
  67. 67. www.indiandentalacademy.com
  68. 68. Crown Preparation ► Intracrevicular margins are usually required to cover portions of root-resected area. The crown margin should be apical to the pulp chamber or root canal that was exposed by resection. ► To preserve remaining tooth structure and encourage a better fitting restoration a chamfer finish line is recommended. ► The gingival third of the restoration is fabricated with a flat emergence profile from the gingiva to facilitate oral hygiene www.indiandentalacademy.com
  69. 69. PRE-PROSTHETIC PERIODONTAL SURGERY www.indiandentalacademy.com
  70. 70. ► ► ► ► ► Mucogingival surgery Teeth with subgingival restorations and narrow zones of keratinized gingiva have higher gingival inflammation scores than teeth with similar restorations and wide-zones of attached gingiva. Coverage of denuded roots is also another objective of mucogingival surgery. Mucogingival surgery can also create some vestibular depth when it is lacking. Techniques for increasing attached gingiva . Free gingival autografts. Apical displacement flap www.indiandentalacademy.com
  71. 71. ► When there is a pocket formation, thick manageable pocket walls can be used for an apically displaced flap – this flap should be the first choice. ► When the pockets are absent and there is a need for increasing width of attached gingiva, free gingival graft is the technique of choice. www.indiandentalacademy.com
  72. 72. Root coverage : Two techniques are recommended. ► Langer’s technique – use a connective tissue graft under a partial thickness flap. ► Tarnow technique – Semilunar coronally displaced flap. Langer’s technique is an excellent solution in most of the cases, but Tarnow’s technique is the first choice in isolated upper teeth. www.indiandentalacademy.com
  73. 73. ► ► Crown lengthening procedures In situations in which a tooth has a short clinical crown that is deemed inadequate for the retention of a required cast restoration, it is necessary to increase the size of the clinical crown using periodontal surgical procedures. By definition, the clinical crown is that portion of the tooth that is coronal to the alveolar crest. Therefore, to lengthen it bone margin has to be remodeled. This is done with an apically displaced flap and ostectomy. The removal of bone is usually not necessary all around the tooth but if undertaken should be done with great caution. It is essential that there be atleast 2mm of connective tissue attachment between the most apical extension of the restoration margin and alveolar bone crest. www.indiandentalacademy.com
  74. 74. www.indiandentalacademy.com
  75. 75. ► Ridge Augmentation procedures Aimed at correcting the excessive loss of alveolar bone that sometimes occurs in the anterior region as a consequence of advanced periodontal disease. The excessive bone loss may create a difficult esthetic problem and complicate prosthetic reconstruction www.indiandentalacademy.com
  76. 76. Several prosthetic solutions have been proposed:  Placement of a thick mucosal autograft obtained from palate or tuberosity.  Placement of non-porous dense hydroxyapatite under a split thickness flap or a pouch created under a full thickness flap. ► A double flap technique used in conjunction with hydroxyapatite www.indiandentalacademy.com
  77. 77. ►REMOVABLE PARTIAL DENTURES AND THE PERIODONTIUM www.indiandentalacademy.com
  78. 78. ► From the periodontal viewpoint, fixed prosthesis are the restorations of choice for replacement of missing teeth, but there are some clinical situations in which removable partial prosthesis are the only possible way to restore the lost function of the dentition. ► It is unwise consider a removable partial denture in patients whose oral hygiene is inadequate www.indiandentalacademy.com
  79. 79. DESIGN ► Every effort must be made to retain posterior teeth for the distal support of edentulous areas. When posterior teeth cannot be retained, the design for removable partial prosthesis becomes challenging. Clasps: ► Studies have shown that I-bar type of clasps have little or no detrimental effect of periodontal health. This design utilizes a gingivally approach clasp, mesially positioned occlusal rest and a proximal plate. ► Clasps should be passive and exert no force on teeth when the partial denture is at rest. www.indiandentalacademy.com
  80. 80. Occlusal rests : ► They should be designed so that the occlusal forces are directed along the vertical axis of the tooth. The angle formed by the occlusal rest and the vertical minor connector should be less than 90°. Only this way can the occlusal forces be directed along the long axis of the abutment tooth. www.indiandentalacademy.com
  81. 81. Combined Fixed and Removable prosthesis ► Isolated teeth with reduced periodontal support are particularly vulnerable to periodontal injury and loosening when used as abutments in removable partial prosthesis. The isolated teeth should be joined to their nearest neighbours with a fixed prosthesis and then can be used as abutments for removable prosthesis www.indiandentalacademy.com
  82. 82. Major connectors : ► They should not impinge on the free gingival margins. The major connector should be placed 6mm away from the gingival margin www.indiandentalacademy.com
  83. 83. ► When periodontally compromised mandibular anterior teeth require stabilization, a special design of major connector should be used for splinting teeth together. A lingual plate should extend to the middle third of the surface of the mandibular anterior teeth and the coronal border should follow the natural curvature of the supracingula surface www.indiandentalacademy.com
  84. 84. OVERDENTURES Over dentures have three obvious advantages ► Increased retention and stability of record base. ► Proprioception is dramatically improved compared to a patient with complete dentures. ► Reduction of stresses to the edentulous ridges resulting in less bone resorption over time www.indiandentalacademy.com
  85. 85. ► It is important that appropriate periodontal considerations be a part of the treatment planning process.  Presence of adequate zone of attached gingiva is of critical importance around the abutment teeth. ► Any remaining periodontal defects must be treated in the same way as they would be around any periodontally involved tooth prior to fixed restoration www.indiandentalacademy.com
  86. 86. ► One great advantage that the overdenture concept has for periodontally involved teeth is that it is possible to improve the crown root ratio dramatically. This results in a great diminution of forces applied to the remaining root www.indiandentalacademy.com
  87. 87. Implant supported restorations The main principles that determine success or failure from a periodontal view point for an implant supported restoration are: ► Patient selection. ► Investing tissues. ► Force distribution Investing tissues can be defined as including both hard and soft tissue. Both the bone height and width must be adequate for implant placement. In partially edentulous patients it has been observed that keratinized tissue around implants offer the greatest resistance to periimplant infection. www.indiandentalacademy.com
  88. 88. Force distribution ► Crown implant ratio – This is very important in the presence of lateral forces. Lateral forces result in a moment of the force on the implant and an increase in horizontal stresses. Implants placed in the anterior maxilla experience more frequent complications because of lateral stresses. ► The greater the crown-implant ratio, the greater the moment of force under lateral loads www.indiandentalacademy.com
  89. 89. Other factors to be considered are: ► Bilateral simultaneous contact is mandatory. ► Occlusal vertical dimension must be in harmony with the patient’s muscular system. ► All interferences must be eliminated www.indiandentalacademy.com
  90. 90. ► Centric vertical contacts should be aligned with the long axis of the implant whenever possible. ► Posterior occlusal tables may be narrowed in order to prevent inadvertent lateral forces. ► Enameloplasty of the cusp tips of the opposing natural teeth is indicated to help improve to direction of vertical forces www.indiandentalacademy.com
  91. 91. SUMMARY AND CONCLUSION One of the primary goals of restorative therapy is to establish a physiologic periodontal climate and facilitate the maintenance of periodontal health. Traumatic occlusal relationships should be eliminated before restorative procedures are begun and restorations should be constructed in conformity with the newly established occlusal patterns. If this is not done the prostheis will perpetuate occlusal relationship injurious to the periodontium. Subgingival margins should be avoided as far as possible except in cases of caries, extending apically, short crowns hence to obtain retention, and in labial surfaces of anterior maxillary teeth in patients who demand for esthetics as a primary criteria. www.indiandentalacademy.com
  92. 92. In impression making, ginival retraction methods should be followed deligently keeping the ginival health in mind. All interim restorations should be so constructed that they cause no trauma to the gingival during the time they are in the mouth. The teeth should taper away from their proximal contacts to get good healthy embrasures. Over contouring of the facial and lingual surfaces should be avoided. Over contouring in gingival third causes plaque accumulation and gingival inflammation. Pontic design greatly influences gingival health. If esthetics is a primary concern a spheriodal Pontic for the posteriors and a modified ridge lap for the anteriors is ideal. www.indiandentalacademy.com
  93. 93. The occlusal surfaces should be designed to direct masticatory forces along the long axis of the tooth. The occlusal table should not be too wide to prevent undue pressure on the periodontium of the abutment teeth. A sanitary Pontic is the periodontium’s best friend. Lastly the surface of restorations should be as smooth as possible to limit plaque accumulation. But eventually after taking all these precautions, patient education and motivation towards plaque control and healthy oral habits is the secret of every treatment success. www.indiandentalacademy.com
  94. 94. REFERENCES 1. Gengers, Snack, Vagels - Over containing in resin bonded prosthesis Plague accumulation and gingival health J.P.D. 59:17:Jan 88. 2. Cuetis Becker, Wayne Kaldaht: Current theories of crown contour margin placement and pontic design J.P.D. 45:268:1981. 3. Dayton K Periodontal considerations for prosthetic patients J.P.D. 30:15:July73. 4. DominickC.L. Effect of artificial crown margin extensions and tooth brushing frequency on gingival pocket depth. 5. David Koth: Full crown preparation and gingival inflammation in a controlled population. J.P.D. 48:681:1982. 6. Edmand C: Tissue response to fixed partial denture prosthesis. J.P.D. 23:407:1970. 7. Francisco P. John pedar, Periodontal relationship and F.P.D. J.P.D. 387:36:1976. www.indiandentalacademy.com
  95. 95. 8. James Marcum: The effect of crown marginal depth upon gingival tissues J.P.D. 17:479:1967. 9. Jon Ruel, Peter S., Keneth M: Effect of retraction procedures on periodontium in humans J.P.D. 44:508:1980. 10. John Lorensonl6, Micheal N. Gingival enhancement in F.P.D. 65:100-107:1991. 11. Joseph Clayton: Roughness of pontic materials and dental plague - J.P.D. 23:407:1970. 12. Lee M. Jamson,William M: Crown contains and gingival response J.P.D. 47:620:1982. 13. Martin Bermar. The complete coverage restoration and the gingival sulcus - J.P.D.: 29:301:1973. 14. Martin Frelich, Lasy c.: F.P.D. supported by periodontally compromised teeth - J.P.D.65:607:1991. 15. Martin Frelich, C. Riekrash: Periodontal effects of F.P.D. retainer margins: configurment and location J.P.D. 67:184:1992. www.indiandentalacademy.com
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