Periodontal considerations in fpd/ orthodontic straight wire technique

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Periodontal considerations in fpd/ orthodontic straight wire technique

  1. 1. PERIODONTALPERIODONTAL CONSIDERATIONS IN FPDCONSIDERATIONS IN FPD INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.comwww.indiandentalacademy.com
  2. 2. I N T R O D U C T I OI N T R O D U C T I O NN In the fabrication of any fixed prosthesis, theIn the fabrication of any fixed prosthesis, the practitioner must determine the periodontalpractitioner must determine the periodontal status of the involved abutment teeth. Thisstatus of the involved abutment teeth. This allows a reliable and accurate prognosis for theallows a reliable and accurate prognosis for the restoration. Because periodontal disease is arestoration. Because periodontal disease is a major cause of tooth loss in adults, themajor cause of tooth loss in adults, the practitioner must be aware of the basicpractitioner must be aware of the basic concepts and clinical modes of therapyconcepts and clinical modes of therapy available in Periodontics to be able to developavailable in Periodontics to be able to develop an appropriate diagnosis and treatment plan.an appropriate diagnosis and treatment plan. www.indiandentalacademy.comwww.indiandentalacademy.com
  3. 3. ATTACHMENT UNITATTACHMENT UNIT  When discussing a diseased state, it isWhen discussing a diseased state, it is imperative to understand the normalimperative to understand the normal relationship of the tooth to the supportingrelationship of the tooth to the supporting structure. Understanding the deviationstructure. Understanding the deviation from normal, facilitates comprehension offrom normal, facilitates comprehension of the disease. A normal relationship of thethe disease. A normal relationship of the gingival margin to the tooth, the epithelialgingival margin to the tooth, the epithelial attachment, and the fibers attached fromattachment, and the fibers attached from the cementum to the gingival is shownthe cementum to the gingival is shown here.here. www.indiandentalacademy.comwww.indiandentalacademy.com
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  6. 6. ANATOMYANATOMY  The lining of the oral cavity consists of threeThe lining of the oral cavity consists of three types of mucosa, each with a different function :types of mucosa, each with a different function :  Masticatory (keratinized) mucosa – covering theMasticatory (keratinized) mucosa – covering the gingival and hard palategingival and hard palate  Lining or reflecting mucosa – covering the lips,Lining or reflecting mucosa – covering the lips, cheeks, vestibule, alveoli, floor of the mouth,cheeks, vestibule, alveoli, floor of the mouth, and soft palateand soft palate  Specialized (sensory) mucosa- covering theSpecialized (sensory) mucosa- covering the dorsum of the tongue and taste buds.dorsum of the tongue and taste buds. www.indiandentalacademy.comwww.indiandentalacademy.com
  7. 7. GINGIVAGINGIVA  Normal gingival exhibiting no fluid exudates orNormal gingival exhibiting no fluid exudates or inflammation due to bacterial plaque is pink andinflammation due to bacterial plaque is pink and stippled. It varies in width from 1 to 9 mm and extendsstippled. It varies in width from 1 to 9 mm and extends from the free margin of the gingival to the alveolarfrom the free margin of the gingival to the alveolar mucosa. The Gingiva and alveolar mucosa aremucosa. The Gingiva and alveolar mucosa are separated by a demarcation called the mucogingivalseparated by a demarcation called the mucogingival junction (MGJ which marks the differentiation betweenjunction (MGJ which marks the differentiation between stippled keratinized tissue and smooth, shiny mucosa;stippled keratinized tissue and smooth, shiny mucosa; the latter contains more elastic fibers in its connectivethe latter contains more elastic fibers in its connective tissue. Apical to the MGJ, the alveolar mucosa thentissue. Apical to the MGJ, the alveolar mucosa then forms the vestibule and attaches to the muscles andforms the vestibule and attaches to the muscles and fascia of the lips and cheeks.fascia of the lips and cheeks.www.indiandentalacademy.comwww.indiandentalacademy.com
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  9. 9. THE GINGIVA CONSISTS OF THREE PARTS:THE GINGIVA CONSISTS OF THREE PARTS:  Free (marginal ) gingiva – extending from the mostFree (marginal ) gingiva – extending from the most coronal aspect of the gingiva to the epithelialcoronal aspect of the gingiva to the epithelial attachment with the tooth.attachment with the tooth.  Attached gingiva – extending from the level of theAttached gingiva – extending from the level of the epithelial attachment to the junction between theepithelial attachment to the junction between the gingiva and the alveolar mucosa (the MGJ)gingiva and the alveolar mucosa (the MGJ)  Interdental papillae – triangular projections of gingivaeInterdental papillae – triangular projections of gingivae filling the area between adjacent teeth and consistingfilling the area between adjacent teeth and consisting of a buccal and a lingual component separated by aof a buccal and a lingual component separated by a central concavity (the col).central concavity (the col). www.indiandentalacademy.comwww.indiandentalacademy.com
  10. 10. The gingiva consist of dense collagenThe gingiva consist of dense collagen fibers, sometimes referred to as thefibers, sometimes referred to as the gingivodental ligament, which can begingivodental ligament, which can be divided into alveologingival, dentogingival,divided into alveologingival, dentogingival, circular, dentoperiosteal, and transspetalcircular, dentoperiosteal, and transspetal groups. These fibers firmly bind thegroups. These fibers firmly bind the gingiva to the teeth and are continuousgingiva to the teeth and are continuous with the underlying alveolar periosteum.with the underlying alveolar periosteum. www.indiandentalacademy.comwww.indiandentalacademy.com
  11. 11. PERIODONTIUMPERIODONTIUM The Periodontium is a connective tissueThe Periodontium is a connective tissue structure attached to the periosteum of bothstructure attached to the periosteum of both the mandible and the maxilla that anchorsthe mandible and the maxilla that anchors the teeth in the mandubular and maxillarythe teeth in the mandubular and maxillary alveolar processes.alveolar processes. It provides attachment and support, nutrition,It provides attachment and support, nutrition, synthesis and resorption, andsynthesis and resorption, and mechanoreception,mechanoreception, www.indiandentalacademy.comwww.indiandentalacademy.com
  12. 12. The main element of the periodotium isThe main element of the periodotium is the periodontal ligament (PDL,) whichthe periodontal ligament (PDL,) which consist of collagenous fibers embeddedconsist of collagenous fibers embedded in bone and centum, giving support to thein bone and centum, giving support to the tooth in function. These fibers, also knowntooth in function. These fibers, also known as sharpey’s fibers, follow a wavy courseas sharpey’s fibers, follow a wavy course and terminate in either cementum or bone.and terminate in either cementum or bone.  There are five principal fiber groups in theThere are five principal fiber groups in the PDL that traverse the space between thePDL that traverse the space between the tooth root and alveolar bone, providingtooth root and alveolar bone, providing attachment and support.attachment and support. www.indiandentalacademy.comwww.indiandentalacademy.com
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  14. 14.  Transseptal fibersTransseptal fibers – extending interproximally– extending interproximally between adjacent teeth.between adjacent teeth.  Alveolar crest fibersAlveolar crest fibers – beginning just apical to– beginning just apical to the epithelial attachment and extending fromthe epithelial attachment and extending from cementum to the alveolar crestcementum to the alveolar crest  Horizontal fibersHorizontal fibers – coursing at right angles from– coursing at right angles from cementum to the alveolar bone.cementum to the alveolar bone.  Oblique fibersOblique fibers - extending in a oblique direction- extending in a oblique direction apically, attaching cementum to the alveolar boneapically, attaching cementum to the alveolar bone (They are the most numerous fibers)(They are the most numerous fibers)  Apical fibersApical fibers – radiating from cementum into the– radiating from cementum into the alveolar bone at the apex of the root.alveolar bone at the apex of the root.  In addition, the PDL contains elastic fibers as wellIn addition, the PDL contains elastic fibers as well as oxytalan fibersas oxytalan fibers www.indiandentalacademy.comwww.indiandentalacademy.com
  15. 15. DENTOGINGIVAL JUNCTIONDENTOGINGIVAL JUNCTION  At the base of the gingival sulcus (crevice) is theAt the base of the gingival sulcus (crevice) is the epithelium – tooth interface, also known as theepithelium – tooth interface, also known as the dentogingival junction (DGJ).dentogingival junction (DGJ).  The depth of the sulcus varies in healthy individuals,The depth of the sulcus varies in healthy individuals, averaging 1.8mm. In general, the shallower it is theaveraging 1.8mm. In general, the shallower it is the more likely the gingiva will be in a state of health.more likely the gingiva will be in a state of health. Sulcular depths up to 3mm are consideredSulcular depths up to 3mm are considered maintainable.maintainable.  The continued maintenance of the gingiva in a state ofThe continued maintenance of the gingiva in a state of health depends on tight, shallow sulci, which in turnhealth depends on tight, shallow sulci, which in turn depend on optimal plaque control, and will ensure thedepend on optimal plaque control, and will ensure the success of periodontal therapy as well as affording asuccess of periodontal therapy as well as affording a good prognosis for subsequent restorative treatment.good prognosis for subsequent restorative treatment. www.indiandentalacademy.comwww.indiandentalacademy.com
  16. 16.  The general term periodontal disease is toThe general term periodontal disease is to describe any condition of the Periodontium otherdescribe any condition of the Periodontium other than the normal. Periodontal disease must bethan the normal. Periodontal disease must be recognized and treated before fixedrecognized and treated before fixed prosthodontics so that the gingival tissue levelsprosthodontics so that the gingival tissue levels can be determined to proper margin placement,can be determined to proper margin placement, esthetics, and gingival displacement. Only whenesthetics, and gingival displacement. Only when the gingiva and Periodontium are in an optimalthe gingiva and Periodontium are in an optimal state of health can these determination bestate of health can these determination be made with ease or predictability.made with ease or predictability. www.indiandentalacademy.comwww.indiandentalacademy.com
  17. 17. ETIOLOGYETIOLOGY Most gingival and periodontal diseasesMost gingival and periodontal diseases result from microbial plaque, which causesresult from microbial plaque, which causes inflammation and its subsequentinflammation and its subsequent pathologic processes. Other contributorspathologic processes. Other contributors to inflammation include calculus, acquiredto inflammation include calculus, acquired pellicle, materia alba, and food debris.pellicle, materia alba, and food debris. www.indiandentalacademy.comwww.indiandentalacademy.com
  18. 18. MICROBIAL PLAQUEMICROBIAL PLAQUE  Microbial plaque is a sticky substanceMicrobial plaque is a sticky substance composed of bacteria and their by – products incomposed of bacteria and their by – products in an extra cellular matrix; it also containsan extra cellular matrix; it also contains substances from the saliva, diet, and serum. It issubstances from the saliva, diet, and serum. It is basically a product of the growth of bacterialbasically a product of the growth of bacterial colonies and is the initiating factor in gingivacolonies and is the initiating factor in gingiva and periodontal disease. If left undisturbed, it willand periodontal disease. If left undisturbed, it will gradually cover an entire tooth surface and cangradually cover an entire tooth surface and can be removedbe removed only by mechanical meansonly by mechanical means .. calculus can be found on tooth structure in acalculus can be found on tooth structure in a supragingival and / or a sub gingival location.supragingival and / or a sub gingival location. www.indiandentalacademy.comwww.indiandentalacademy.com
  19. 19. CALCULUSCALCULUS  Dental calculus is a chalky or dark deposit attached toDental calculus is a chalky or dark deposit attached to the tooth structure. It is essentially microbial plaquethe tooth structure. It is essentially microbial plaque that has undergone mineralization over time. Calculusthat has undergone mineralization over time. Calculus can be found on tooth structure in a supragingival andcan be found on tooth structure in a supragingival and / or a subgingival location./ or a subgingival location.  As the plaque colony matures and increases itsAs the plaque colony matures and increases its mineral content, calculus forms within the plaquemineral content, calculus forms within the plaque mass. Although gingival inflammation is often mostmass. Although gingival inflammation is often most severe in areas where calculus is present, the calculussevere in areas where calculus is present, the calculus itself is not the most significant source of inflammation,itself is not the most significant source of inflammation, rather, it provides a nidus for plaque accumulation andrather, it provides a nidus for plaque accumulation and retains the plaque in proximity to the gingiva. Dentalretains the plaque in proximity to the gingiva. Dental plaque is the etiologic agent of the inflammation.plaque is the etiologic agent of the inflammation.www.indiandentalacademy.comwww.indiandentalacademy.com
  20. 20. ACQUIRED PELLICLE.ACQUIRED PELLICLE. Pellicle is a thin, brown or gray film ofPellicle is a thin, brown or gray film of salivary proteins that develops on teethsalivary proteins that develops on teeth after they have been cleaned. Itafter they have been cleaned. It frequently forms the interface between thefrequently forms the interface between the tooth surface and dental deposits.tooth surface and dental deposits. www.indiandentalacademy.comwww.indiandentalacademy.com
  21. 21. MATERIA ALBA.MATERIA ALBA. Materia alba is a white coating composedMateria alba is a white coating composed of microorganisms, dead epithelial cells,of microorganisms, dead epithelial cells, and leukocytes that adheres loosely to theand leukocytes that adheres loosely to the tooth. It can be removed from the toothtooth. It can be removed from the tooth surface by water spray or by rinsing.surface by water spray or by rinsing. www.indiandentalacademy.comwww.indiandentalacademy.com
  22. 22. PATHOGENESISPATHOGENESIS The pathogenesis or sequence of eventsThe pathogenesis or sequence of events in the development of a gingivitis-in the development of a gingivitis- periodontitis lesion is very complex. Itperiodontitis lesion is very complex. It involves not only local phenomena in theinvolves not only local phenomena in the gingiva, PDL, tooth surface, and alveolargingiva, PDL, tooth surface, and alveolar bone but also a number of complex hostbone but also a number of complex host response mechanisms modified by theresponse mechanisms modified by the bacterial infection and behavioral factors.bacterial infection and behavioral factors. www.indiandentalacademy.comwww.indiandentalacademy.com
  23. 23.  INITIAL LESIONINITIAL LESION  The initial lesion is localized in the region of theThe initial lesion is localized in the region of the gingival sulcus and is evident after approximatelygingival sulcus and is evident after approximately 2 to2 to 4 days4 days of undisturbed plaque accumulation from aof undisturbed plaque accumulation from a baseline of gingival health.baseline of gingival health.  The vessels of the gingiva become enlarged, andThe vessels of the gingiva become enlarged, and vasculitis occurs, allowing a fluid exudates ofvasculitis occurs, allowing a fluid exudates of polymorphonuclear leukocytes to form in the sulcus.polymorphonuclear leukocytes to form in the sulcus. Collagen is lost perivascularly, and the resultant spaceCollagen is lost perivascularly, and the resultant space is filled with proteins and inflammatory cells. The mostis filled with proteins and inflammatory cells. The most coronal portion of the junctional epithelium becomescoronal portion of the junctional epithelium becomes altered.altered. www.indiandentalacademy.comwww.indiandentalacademy.com
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  25. 25.  EARLY LESION.EARLY LESION.  Although there is noAlthough there is no distinct divisiondistinct division between the stages ofbetween the stages of lesion formation, thelesion formation, the early lesion generallyearly lesion generally appears withinappears within 4 to 74 to 7 daysdays of plaqueof plaque accumulation. Thisaccumulation. This stage of developmentstage of development exhibits further loss ofexhibits further loss of collagen from thecollagen from the marginal gingiva.marginal gingiva. www.indiandentalacademy.comwww.indiandentalacademy.com
  26. 26. ESTABLISHEDESTABLISHED LESION.LESION.  WithinWithin 7 to 21 days7 to 21 days the lesion enters thethe lesion enters the established stageestablished stage located at the apicallocated at the apical portion of the gingivalportion of the gingival sulcus, and thesulcus, and the inflammation isinflammation is centered in acentered in a relatively small area.relatively small area. www.indiandentalacademy.comwww.indiandentalacademy.com
  27. 27. ADVANCED LESION.ADVANCED LESION. It is difficult to pinpoint the time at which theIt is difficult to pinpoint the time at which the established lesion of gingivitis results in aestablished lesion of gingivitis results in a loss of connective tissue attachment to theloss of connective tissue attachment to the tooth structure and becomes an advancedtooth structure and becomes an advanced lesion or overt periodontitis.lesion or overt periodontitis. Upon conversion to the advanced stage, theUpon conversion to the advanced stage, the features of an established lesion persist. Thefeatures of an established lesion persist. The connective tissue continues to lose collagenconnective tissue continues to lose collagen content, and fibroblasts are further altered.content, and fibroblasts are further altered. www.indiandentalacademy.comwww.indiandentalacademy.com
  28. 28.  Periodontal pockets are formed, with increasedPeriodontal pockets are formed, with increased probing depths, and the lesion extends intoprobing depths, and the lesion extends into alveolar bone. The bone marrow converts toalveolar bone. The bone marrow converts to fibrous connective tissue, with a significant lossfibrous connective tissue, with a significant loss of connective tissue attachment to the root of theof connective tissue attachment to the root of the tooth. This is accompanied by thetooth. This is accompanied by the manifestations of immunopathologic tissuemanifestations of immunopathologic tissue reactions and inflammatory responses in thereactions and inflammatory responses in the gingiva.gingiva. www.indiandentalacademy.comwww.indiandentalacademy.com
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  30. 30. PERIODONTITISPERIODONTITIS  When a loss of connective tissue attachmentWhen a loss of connective tissue attachment occurs, the lesion transforms from gingivitis intooccurs, the lesion transforms from gingivitis into periodontitis a disease that may beperiodontitis a disease that may be characterized by alternating periods ofcharacterized by alternating periods of quiescence and exacerbation. The extent toquiescence and exacerbation. The extent to which the lesion progresses before it is treatedwhich the lesion progresses before it is treated will determine the amount of bone andwill determine the amount of bone and connective tissue attachment loss that occurs. Itconnective tissue attachment loss that occurs. It will subsequently affect the prognosis of thewill subsequently affect the prognosis of the tooth with regard to restorative demands.tooth with regard to restorative demands. www.indiandentalacademy.comwww.indiandentalacademy.com
  31. 31. OCCLUSAL TRAUMATISM:OCCLUSAL TRAUMATISM:  Occlusal traumatism is defined as aOcclusal traumatism is defined as a force originating by movement of theforce originating by movement of the maxillary and mandibular teeth in a waymaxillary and mandibular teeth in a way that creates a pathologic lesion.that creates a pathologic lesion. PRIMARY OCCLUSAL TRAUMA:PRIMARY OCCLUSAL TRAUMA:  Primary occlusal trauma is a pathologicPrimary occlusal trauma is a pathologic lesion that has been created by a forcelesion that has been created by a force strong enough to disturb a normal intactstrong enough to disturb a normal intact periodontiumperiodontium www.indiandentalacademy.comwww.indiandentalacademy.com
  32. 32. SECONDARY OCCLUSAL TRAUMA:SECONDARY OCCLUSAL TRAUMA:  Secondary occlusal trauma is a lesionSecondary occlusal trauma is a lesion created by a normal function on a weakenedcreated by a normal function on a weakened periodontium because of periodontalperiodontium because of periodontal disease. This noninflammatory lesion isdisease. This noninflammatory lesion is caused by trauma in the form of pressurecaused by trauma in the form of pressure atrophy; there is eventual necrosis of theatrophy; there is eventual necrosis of the affected area.affected area.  Factors that enhance occlusal traumatismFactors that enhance occlusal traumatism are clenching, grinding(bruxism), tongueare clenching, grinding(bruxism), tongue thrusting, and nail biting, Of these, the onethrusting, and nail biting, Of these, the one that appears to have the greatest effect isthat appears to have the greatest effect is grinding.grinding. www.indiandentalacademy.comwww.indiandentalacademy.com
  33. 33. PERIODONTAL POCKETPERIODONTAL POCKET  A periodontal pocket is defined as aA periodontal pocket is defined as a diseased periodontal attachment unit. Thediseased periodontal attachment unit. The pocket may result from the enlargement ofpocket may result from the enlargement of the gingival tissue.the gingival tissue. It is caused by the apical migration of theIt is caused by the apical migration of the epithelial attachment with the loss ofepithelial attachment with the loss of connective tissue attachment and,connective tissue attachment and, eventually, of osseous support.eventually, of osseous support. www.indiandentalacademy.comwww.indiandentalacademy.com
  34. 34. The clinical significance of a pocket is thatThe clinical significance of a pocket is that if it extends beyond 3 to 4 mm the patientif it extends beyond 3 to 4 mm the patient has increasing difficulty maintaininghas increasing difficulty maintaining normal brushing and flossing techniques.normal brushing and flossing techniques. If an area cannot be maintained andIf an area cannot be maintained and mature plaque is allowed adjacent to themature plaque is allowed adjacent to the epithelium, the disease continues. Theepithelium, the disease continues. The ideal situation is for the entire mouth to beideal situation is for the entire mouth to be free of pockets.free of pockets. www.indiandentalacademy.comwww.indiandentalacademy.com
  35. 35. EXAMINATIONEXAMINATION VISUAL EXAMINATION:VISUAL EXAMINATION:  It is important during the examination toIt is important during the examination to evaluate the color, consistency, texture, andevaluate the color, consistency, texture, and shape of the gingival unit. It is also critical toshape of the gingival unit. It is also critical to recognize the initial stages of a marginal lesionrecognize the initial stages of a marginal lesion through the change of color and consistency.through the change of color and consistency. An adequate light source is essential toAn adequate light source is essential to differentiate between normal and diseaseddifferentiate between normal and diseased tissue. A fiber optic unit is used to examinetissue. A fiber optic unit is used to examine inaccessible areas.inaccessible areas. www.indiandentalacademy.comwww.indiandentalacademy.com
  36. 36. ATTACHED GINGIVA:ATTACHED GINGIVA:  The width of attached gingivaThe width of attached gingiva necessary to maintain gingival health hasnecessary to maintain gingival health has remained controversial.remained controversial. Crown margins can be gingival irritantsCrown margins can be gingival irritants and plaque traps, so enhancing theand plaque traps, so enhancing the attached gingiva is advised forattached gingiva is advised for restorations.restorations. www.indiandentalacademy.comwww.indiandentalacademy.com
  37. 37. Keratinized tissue is often present andKeratinized tissue is often present and mistakenly restored, after which themistakenly restored, after which the dentist and patient are disappointed whendentist and patient are disappointed when recession continues.recession continues.  It must be realized that clinically, the firstIt must be realized that clinically, the first 2 mm of keratinized tissue represents 12 mm of keratinized tissue represents 1 mm of sulcus and 1 mm of epithelialmm of sulcus and 1 mm of epithelial attachment, therefore, only keratinizedattachment, therefore, only keratinized tissue in excess of 2 mm can betissue in excess of 2 mm can be considered attached by connective tissue.considered attached by connective tissue. www.indiandentalacademy.comwww.indiandentalacademy.com
  38. 38. PROBINGPROBING  There are periodontal instrumentsThere are periodontal instruments designed for probing. The thinnest probe isdesigned for probing. The thinnest probe is desired, this permits probing the depth of adesired, this permits probing the depth of a pocket without patient discomfort and allowspocket without patient discomfort and allows the greatest dexterity in differentiating thethe greatest dexterity in differentiating the dimensions of the pocket.dimensions of the pocket.  These probes are generally calibrated inThese probes are generally calibrated in millimeters. Probing can be one of the mostmillimeters. Probing can be one of the most arduous aspects of examination, yet it isarduous aspects of examination, yet it is mistakenly taken for granted because itmistakenly taken for granted because it appears simple.appears simple. www.indiandentalacademy.comwww.indiandentalacademy.com
  39. 39.  The dentist shouldThe dentist should probe six areasprobe six areas around the tooth,around the tooth, paying specificpaying specific attention to rootattention to root anatomy. Evaluationanatomy. Evaluation should includeshould include bifurcation andbifurcation and trifurcation areas ontrifurcation areas on the maxillary andthe maxillary and mandibular molarsmandibular molars and on the maxillaryand on the maxillary first premolars.first premolars. www.indiandentalacademy.comwww.indiandentalacademy.com
  40. 40. The mouth of a patient with poor oral hygieneThe mouth of a patient with poor oral hygiene habits will be difficult to accurately probe.habits will be difficult to accurately probe. Once oral hygiene has been established, theOnce oral hygiene has been established, the patient’s mouth may be probed accurately.patient’s mouth may be probed accurately.  During the probing procedure, the dentistDuring the probing procedure, the dentist should also check for bleeding or exudation,should also check for bleeding or exudation, these are also signs of periodontal disease.these are also signs of periodontal disease. Clinically, the bleeding of the gingiva duringClinically, the bleeding of the gingiva during probing is the sign of ulceration of theprobing is the sign of ulceration of the sulcular epithelium.sulcular epithelium.  There are also special probes that can beThere are also special probes that can be used in the bifurcation or trifurcation areas.used in the bifurcation or trifurcation areas. www.indiandentalacademy.comwww.indiandentalacademy.com
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  42. 42. MOBILITYMOBILITY  Mobility can be determined with theMobility can be determined with the handle of the probe, also, with the handlehandle of the probe, also, with the handle end of the mirror, placed on the buccalend of the mirror, placed on the buccal and lingual surfaces and applyingand lingual surfaces and applying pressure to the tooth with the hand. Thepressure to the tooth with the hand. The extent of mobility is then evaluated whenextent of mobility is then evaluated when pressure is applied.pressure is applied. www.indiandentalacademy.comwww.indiandentalacademy.com
  43. 43. Normal physiologic movement of a healthyNormal physiologic movement of a healthy tooth is barely, if at all, discernible. Atooth is barely, if at all, discernible. A scale commonly used for classifyingscale commonly used for classifying mobility is given below.mobility is given below. Class 1 :Class 1 : A tooth demonstrates greaterA tooth demonstrates greater than normal movement, buy less than 1than normal movement, buy less than 1 mm of movement in any direction.mm of movement in any direction. Class 2:Class 2: A tooth moves 1 mm fromA tooth moves 1 mm from normal position in any direction.normal position in any direction. Class 3:Class 3: A tooth moves more than 2A tooth moves more than 2 mm in any direction, including rotation ormm in any direction, including rotation or depression.depression. www.indiandentalacademy.comwww.indiandentalacademy.com
  44. 44. A change from normal physiologicA change from normal physiologic movement may indicate traumaticmovement may indicate traumatic occlusion or periodontal disease. Teethocclusion or periodontal disease. Teeth exhibiting Class 3 mobility have anexhibiting Class 3 mobility have an extremely poor prognosis and usually willextremely poor prognosis and usually will require extraction.require extraction. Mobility is an indication of the loss of theMobility is an indication of the loss of the tooth’s attachment to the jaw. This can betooth’s attachment to the jaw. This can be seen radio graphically as a widenedseen radio graphically as a widened periodontal ligament space caused byperiodontal ligament space caused by occlusal trauma or orthodontic movement.occlusal trauma or orthodontic movement. www.indiandentalacademy.comwww.indiandentalacademy.com
  45. 45. . It can also be caused by periodontal. It can also be caused by periodontal disease when the amount of the supportdisease when the amount of the support has diminished sufficiently to loosen thehas diminished sufficiently to loosen the tooth or by overloading of a tooth withtooth or by overloading of a tooth with restorative work.restorative work.  It must be emphasized that because aIt must be emphasized that because a tooth is mobile does not mean that thetooth is mobile does not mean that the tooth will be lost. The entire dentition cantooth will be lost. The entire dentition can exhibit a class I mobility and sustain thisexhibit a class I mobility and sustain this form for many years without splinting.form for many years without splinting. However, if the tooth is under secondaryHowever, if the tooth is under secondary occlusal trauma, a number of teeth areocclusal trauma, a number of teeth are splinted for the required support.splinted for the required support. www.indiandentalacademy.comwww.indiandentalacademy.com
  46. 46. RADIOGRAPHSRADIOGRAPHS  Radiographs are essential forRadiographs are essential for diagnosis, treatment, and maintenance indiagnosis, treatment, and maintenance in Periodontics. Although the radiograph isPeriodontics. Although the radiograph is limited by being two dimensional, if it islimited by being two dimensional, if it is accompanied by a three-dimensionalaccompanied by a three-dimensional image it can be visualized.image it can be visualized. www.indiandentalacademy.comwww.indiandentalacademy.com
  47. 47. The areas to be reviewed on the radiographsThe areas to be reviewed on the radiographs are:are: 1.Alveolar crest resorption1.Alveolar crest resorption 2.Intergrity of thickness of the lamina dura2.Intergrity of thickness of the lamina dura 3.Evidence of generalized horizontal bone loss3.Evidence of generalized horizontal bone loss 4.Evidence of vertical bone loss4.Evidence of vertical bone loss 5.Widened periodontal ligament space5.Widened periodontal ligament space 6.Density of the trabeculae of both arches6.Density of the trabeculae of both arches 7.Size and shape of the roots compared to the7.Size and shape of the roots compared to the crown to determine crown-to-root ratio.crown to determine crown-to-root ratio. www.indiandentalacademy.comwww.indiandentalacademy.com
  48. 48. The radiograph can determine the area ofThe radiograph can determine the area of root embedded in bone; this is crucial inroot embedded in bone; this is crucial in determining the patient’s prognosis.determining the patient’s prognosis.  Often a patient with short conical rootsOften a patient with short conical roots will display minimal bone loss but maximalwill display minimal bone loss but maximal mobility, and the prognosis is thusmobility, and the prognosis is thus guarded to poor. Other patients can loseguarded to poor. Other patients can lose 50 percent of the bone but not exhibit50 percent of the bone but not exhibit mobility, and yet have an encouragingmobility, and yet have an encouraging prognosis because they have normal-prognosis because they have normal- shaped roots.shaped roots. www.indiandentalacademy.comwww.indiandentalacademy.com
  49. 49. HABITSHABITS  The major habit to consider is bruxism.The major habit to consider is bruxism. Visual examination of wear facet patternsVisual examination of wear facet patterns and x-ray interpretation of thickenedand x-ray interpretation of thickened lamina dura and widened periodontallamina dura and widened periodontal ligament spaces determines whether aligament spaces determines whether a patient grinds during sleep. It is importantpatient grinds during sleep. It is important to inform the patient of the condition .to inform the patient of the condition .  One condition that indicates bruxism is aOne condition that indicates bruxism is a complete arch that exhibits mobilitycomplete arch that exhibits mobility despite adequate osseous support. Thedespite adequate osseous support. The teeth may not have been worn from theteeth may not have been worn from the pressure of grinding, but may havepressure of grinding, but may have become mobile while resisting this forcebecome mobile while resisting this forcewww.indiandentalacademy.comwww.indiandentalacademy.com
  50. 50. TREATMENT PLANNING:TREATMENT PLANNING:  Before treatment is rendered, all facts andBefore treatment is rendered, all facts and findings related to the patient’s disease statefindings related to the patient’s disease state should be recorded. In general practice, theshould be recorded. In general practice, the data collection, diagnosis, and treatment –data collection, diagnosis, and treatment – planning for a patient’s restorative needs areplanning for a patient’s restorative needs are accomplished at approximately the same time.accomplished at approximately the same time.  The treatment plan should be concise,The treatment plan should be concise, logical, and rational - a realistic approach tological, and rational - a realistic approach to therapy. The timing and sequencing oftherapy. The timing and sequencing of treatment are important to correcting thetreatment are important to correcting the patient’s dental problems as efficiently aspatient’s dental problems as efficiently as possible.possible. www.indiandentalacademy.comwww.indiandentalacademy.com
  51. 51. The following is a viable working model forThe following is a viable working model for periodontal treatment.periodontal treatment. Initial TherapyInitial Therapy  Control of microbial plaqueControl of microbial plaque  ToothbrushingToothbrushing  FlossingFlossing  Other aidsOther aids  Scaling and polishingScaling and polishing  Correction of defective and / or overhangingCorrection of defective and / or overhanging restorationsrestorations  Root planningRoot planning  Strategic tooth removalStrategic tooth removal  Stabilization of mobile teethStabilization of mobile teeth  Minor tooth movementMinor tooth movement  Evaluation of Initial TherapyEvaluation of Initial Therapywww.indiandentalacademy.comwww.indiandentalacademy.com
  52. 52. Surgical TherapySurgical Therapy  Soft tissue proceduresSoft tissue procedures  GingivectomyGingivectomy  Open debridementOpen debridement  Mucosal repairMucosal repair  Hard tissue proceduresBone inductionHard tissue proceduresBone induction  Osseous resectionOsseous resection  Treatment of furcation involvementsTreatment of furcation involvements  Odontoplasty – osteoplastyOdontoplasty – osteoplasty  Root amputationRoot amputation  HemisectionHemisection  ProvisionalizationProvisionalization  RestorationRestoration www.indiandentalacademy.comwww.indiandentalacademy.com
  53. 53. Evaluation of Surgical TherapyEvaluation of Surgical Therapy Guided Tissue RegenerationGuided Tissue Regeneration (Hard and Soft Tissue Procedures)(Hard and Soft Tissue Procedures) RestorationRestoration MaintenanceMaintenance PrognosisPrognosis www.indiandentalacademy.comwww.indiandentalacademy.com
  54. 54. INITIAL THERAPYINITIAL THERAPY Initial therapy consists of all treatmentInitial therapy consists of all treatment carried out in advance of evaluation forcarried out in advance of evaluation for the surgical phases of periodontal therapy.the surgical phases of periodontal therapy. CONTROL OF MICROBIALCONTROL OF MICROBIAL PLAQUE.PLAQUE. The most critical aspect of periodontalThe most critical aspect of periodontal therapy is the control of microbial flora intherapy is the control of microbial flora in the Sulcular area. If the patient does notthe Sulcular area. If the patient does not maintain excellent oral hygiene andmaintain excellent oral hygiene and thereby the optimum condition of soft andthereby the optimum condition of soft and hard tissues, subsequent periodontal andhard tissues, subsequent periodontal and restorative treatments will be jeopardized.restorative treatments will be jeopardized. www.indiandentalacademy.comwww.indiandentalacademy.com
  55. 55. TOOTHBRUSHINGTOOTHBRUSHING  Plaque removal is accomplished with aPlaque removal is accomplished with a toothbrush and other orophysiotherapytoothbrush and other orophysiotherapy aids. Many types of toothbrushes can beaids. Many types of toothbrushes can be used and are classified according to theirused and are classified according to their size, shape, length, bristle arrangement,size, shape, length, bristle arrangement, and whether they are manually orand whether they are manually or electrically powered.electrically powered. www.indiandentalacademy.comwww.indiandentalacademy.com
  56. 56. FLOSSINGFLOSSING  Interproximal plaque can be controlled withInterproximal plaque can be controlled with dental floss. Both waxed and unwaxed typesdental floss. Both waxed and unwaxed types will clean proximal surfaces, but the unwaxedwill clean proximal surfaces, but the unwaxed floss has several advantages.floss has several advantages.  It is smaller in diameter and thus more easilyIt is smaller in diameter and thus more easily passed through interproximal contact areas.passed through interproximal contact areas.  It flattens out under tension, and thus eachIt flattens out under tension, and thus each separate thread effectively covers a largerseparate thread effectively covers a larger surface area.surface area.  It makes a squeaking noise when applied to aIt makes a squeaking noise when applied to a clean tooth surface, which can be used as aclean tooth surface, which can be used as a guide to effective performanceguide to effective performance www.indiandentalacademy.comwww.indiandentalacademy.com
  57. 57. OTHER AIDS.OTHER AIDS.  Plaque may also be controlledPlaque may also be controlled effectively by orophysiotherapy aids sucheffectively by orophysiotherapy aids such as dental tape, yarn, rubber and woodenas dental tape, yarn, rubber and wooden tips, toothpicks, Interdental stimulators,tips, toothpicks, Interdental stimulators, interproximal brushes, and electricinterproximal brushes, and electric toothbrushes.toothbrushes.  When plaque is removed around aWhen plaque is removed around a fixed partial denture or a restorationfixed partial denture or a restoration involving splinted teeth, a floss threaderinvolving splinted teeth, a floss threader may be neededmay be needed www.indiandentalacademy.comwww.indiandentalacademy.com
  58. 58.  Disclosing agents may be used to provide betterDisclosing agents may be used to provide better visualization of areas where plaque control isvisualization of areas where plaque control is difficult or deficient. Erythrosin dye in tablet ordifficult or deficient. Erythrosin dye in tablet or liquid form stains plaque and is readilyliquid form stains plaque and is readily observable.observable.  Ultraviolet light has been used in combinationUltraviolet light has been used in combination with fluorescein dye to reveal plaque deposits,with fluorescein dye to reveal plaque deposits, bypassing the undesirable red stain that remainsbypassing the undesirable red stain that remains after erythrosine use.after erythrosine use.  The most important aspect of plaque controlThe most important aspect of plaque control is patient motivation. Without motivation, allis patient motivation. Without motivation, all orophysiotherapy aids and the knowledge toorophysiotherapy aids and the knowledge to apply them are useless.apply them are useless. www.indiandentalacademy.comwww.indiandentalacademy.com
  59. 59. SCALING AND POLISHINGSCALING AND POLISHING  Removal of supragingival calculus (scaling) andRemoval of supragingival calculus (scaling) and polishing of the coronal portion of the tooth arepolishing of the coronal portion of the tooth are the first definitive steps in debridement of thethe first definitive steps in debridement of the teeth.teeth.  Scaling consists of the removal of deposits andScaling consists of the removal of deposits and accretions from the crowns of teeth and fromaccretions from the crowns of teeth and from tooth surfaces slightly subgingival.tooth surfaces slightly subgingival.  This is accomplished with the use of sharpThis is accomplished with the use of sharp scalers or curettes. The gingiva responds to thisscalers or curettes. The gingiva responds to this removal of supragingival and slightly subgingivalremoval of supragingival and slightly subgingival calculus with a decrease in inflammation andcalculus with a decrease in inflammation and bleeding.bleeding. www.indiandentalacademy.comwww.indiandentalacademy.com
  60. 60. CORRECTION OF DEFECTIVECORRECTION OF DEFECTIVE AND / OR OVERHANGINGAND / OR OVERHANGING RESTORATIONS.RESTORATIONS.  Overhanging restorations, openOverhanging restorations, open interproximal contacts, and areas of foodinterproximal contacts, and areas of food impaction contribute to local irritation ofimpaction contribute to local irritation of the gingiva and impede proper plaquethe gingiva and impede proper plaque control. These deficiencies should becontrol. These deficiencies should be corrected during the initial therapy phasecorrected during the initial therapy phase of treatment by either replacement orof treatment by either replacement or reshaping and / or removal of thereshaping and / or removal of the overhang.overhang. www.indiandentalacademy.comwww.indiandentalacademy.com
  61. 61. ROOT PLANING.ROOT PLANING.  Root planning is the process of debriding theRoot planning is the process of debriding the root surface with a curette. It is a moreroot surface with a curette. It is a more deliberate and more delicately excecuteddeliberate and more delicately excecuted procedure than scaling and requires theprocedure than scaling and requires the administration of a local anesthetic in mostadministration of a local anesthetic in most instances.instances.  Root planning and the incidental curettage ofRoot planning and the incidental curettage of soft issue that accompanies it may be an endsoft issue that accompanies it may be an end point of active periodontal therapy. In manypoint of active periodontal therapy. In many cases the combination of root planning andcases the combination of root planning and improved oral hygiene on the part of the patientimproved oral hygiene on the part of the patient leads to manageable probing depths, and noleads to manageable probing depths, and no further treatment is necessary.further treatment is necessary. www.indiandentalacademy.comwww.indiandentalacademy.com
  62. 62. STRATEGIC TOOTH REMOVAL.STRATEGIC TOOTH REMOVAL. An important part of treatment sequencingAn important part of treatment sequencing is the elimination of teeth that areis the elimination of teeth that are hopelessly involved periodontally and / orhopelessly involved periodontally and / or are nonrestorable.are nonrestorable. www.indiandentalacademy.comwww.indiandentalacademy.com
  63. 63. STABILIZATION OF MOBILESTABILIZATION OF MOBILE TEETH.TEETH. Tooth mobility occurs when a tooth isTooth mobility occurs when a tooth is subjected to excessive forces, especiallysubjected to excessive forces, especially when bony support is lacking.when bony support is lacking. It is not necessarily a sign of disease,It is not necessarily a sign of disease, because it may be a normal response tobecause it may be a normal response to abnormal forces, and it does not alwaysabnormal forces, and it does not always need corrective treatment.need corrective treatment. www.indiandentalacademy.comwww.indiandentalacademy.com
  64. 64. However, it is sometimes a source ofHowever, it is sometimes a source of discomfort to the patient, and in thesediscomfort to the patient, and in these cases it should be treated by reduction ofcases it should be treated by reduction of the abnormal forces after occlusalthe abnormal forces after occlusal evaluation.evaluation. Depending on the patient’s need, the teethDepending on the patient’s need, the teeth may also be treated by splinting withmay also be treated by splinting with provisional restorations or an acid etchprovisional restorations or an acid etch resin technique in conjunction withresin technique in conjunction with occlusal adjustment. Such restorationsocclusal adjustment. Such restorations should be carefully designed so they doshould be carefully designed so they do not impede plaque control.not impede plaque control. www.indiandentalacademy.comwww.indiandentalacademy.com
  65. 65. EVALUATION OF INITIAL THERAPYEVALUATION OF INITIAL THERAPY  The Periodontium recovering from activeThe Periodontium recovering from active disease should be regularly reexamined anddisease should be regularly reexamined and reevaluated to determine the efficacy ofreevaluated to determine the efficacy of treatment.treatment.  Soft tissue responses to the initial therapy areSoft tissue responses to the initial therapy are observed along with the patient’s motivation andobserved along with the patient’s motivation and ability to maintain a relatively inflammation-freeability to maintain a relatively inflammation-free state.state.  Probing depths should be recorded again, andProbing depths should be recorded again, and the location of the mucogingival junction noted inthe location of the mucogingival junction noted in relation to the teeth. Reevaluation gives therelation to the teeth. Reevaluation gives the practitioner a firmer grasp on the progress ofpractitioner a firmer grasp on the progress of treatment, and if necessary, it allows revision oftreatment, and if necessary, it allows revision of the initial treatment planthe initial treatment planwww.indiandentalacademy.comwww.indiandentalacademy.com
  66. 66. SURGICAL THERAPYSURGICAL THERAPY There are a number of surgicalThere are a number of surgical procedures for the improvement of plaqueprocedures for the improvement of plaque removal aimed primarily at reduction orremoval aimed primarily at reduction or eliminating probing depths. Accuratelyeliminating probing depths. Accurately diagnosing and choosing the mostdiagnosing and choosing the most appropriate surgical regimen is crucial forappropriate surgical regimen is crucial for maximum results.maximum results. www.indiandentalacademy.comwww.indiandentalacademy.com
  67. 67. SOFT TISSUESOFT TISSUE PROCEDURESPROCEDURES GINGIVECTOMY.GINGIVECTOMY.  Gingivectomy is the removal of diseased orGingivectomy is the removal of diseased or hypertrophied gingiva. Introduced by G.V.Black,hypertrophied gingiva. Introduced by G.V.Black, it was the first periodontal surgical approach toit was the first periodontal surgical approach to gain widespread acceptance.gain widespread acceptance.  Gingivectomy is essentially the resection ofGingivectomy is essentially the resection of keratinized gingiva only, and it may be applied tokeratinized gingiva only, and it may be applied to the treatment of suprabony pockets and tothe treatment of suprabony pockets and to fibrous or enlarged gingiva, particularly whenfibrous or enlarged gingiva, particularly when they result from diphenyl hydantoin (Dilantin)they result from diphenyl hydantoin (Dilantin) therapy (Drugs causing gingival hyperplasia /therapy (Drugs causing gingival hyperplasia / enlargement).enlargement).  However, it is unsuitable for the treatment ofHowever, it is unsuitable for the treatment of infrabony defectsinfrabony defects www.indiandentalacademy.comwww.indiandentalacademy.com
  68. 68. OPEN DEBRIDEMENTOPEN DEBRIDEMENT (Modified(Modified Widman Procedure)Widman Procedure)  Open debridement or curettage is a surgicalOpen debridement or curettage is a surgical procedure designed to gain better access to rootprocedure designed to gain better access to root surfaces for complete debridement and rootsurfaces for complete debridement and root planning.planning.  The modified Widman approach has beenThe modified Widman approach has been advocated in recent years, because it allowsadvocated in recent years, because it allows good soft tissue flap control, minimum surgicalgood soft tissue flap control, minimum surgical trauma, and good postoperative integrity withouttrauma, and good postoperative integrity without excessive loss of osseous tissue or connectiveexcessive loss of osseous tissue or connective tissue attachment.tissue attachment. www.indiandentalacademy.comwww.indiandentalacademy.com
  69. 69. MUCOSAL REPAIR.MUCOSAL REPAIR. Mucosal reparative surgery is used toMucosal reparative surgery is used to increase the width of the band ofincrease the width of the band of keratinized gingiva. It is particularly usefulkeratinized gingiva. It is particularly useful where complete-coverage restorations arewhere complete-coverage restorations are planned.planned. www.indiandentalacademy.comwww.indiandentalacademy.com
  70. 70. HARD TISSUEHARD TISSUE PROCEDURESPROCEDURES Hard tissue therapy is aimed at modifyingHard tissue therapy is aimed at modifying the Topography of areas where plaquethe Topography of areas where plaque control is difficult or impossible.control is difficult or impossible. Infrabony pockets.Infrabony pockets. Around root furcation.Around root furcation. www.indiandentalacademy.comwww.indiandentalacademy.com
  71. 71. BONE INDUCTION.BONE INDUCTION. Intrabony lesions are categorized as one-Intrabony lesions are categorized as one- walled, two-walled or three walled,walled, two-walled or three walled, depending on the remaining osseousdepending on the remaining osseous topography.topography.  The three-walled defect responds best toThe three-walled defect responds best to inductive or degranulation procedures,inductive or degranulation procedures, with resulting new attachment andwith resulting new attachment and resolution of all or part of the lesion.resolution of all or part of the lesion. The one-walled and two-walled (crater)The one-walled and two-walled (crater) defects respond better to pocketdefects respond better to pocket elimination procedures.elimination procedures. www.indiandentalacademy.comwww.indiandentalacademy.com
  72. 72. www.indiandentalacademy.comwww.indiandentalacademy.com
  73. 73. Many materials have been used to fillMany materials have been used to fill osseous defects: ceramic, sclera,osseous defects: ceramic, sclera, cartilage, bone chips, cementum andcartilage, bone chips, cementum and dentin, osseous coagulum, freezedrieddentin, osseous coagulum, freezedried bone, iliac crest marrow, hydroxyapatite,bone, iliac crest marrow, hydroxyapatite, tricalcium phosphate, and bioactive glasstricalcium phosphate, and bioactive glass materials.materials. www.indiandentalacademy.comwww.indiandentalacademy.com
  74. 74. OSSEOUS RESECTION WITHOSSEOUS RESECTION WITH APICALLY POSITIONED FLAPS.APICALLY POSITIONED FLAPS.  Chronic inflammatory periodontitisChronic inflammatory periodontitis results in the loss of osseous tissue,results in the loss of osseous tissue, destruction of osseous architecture, anddestruction of osseous architecture, and creation of an intrabony lesion.creation of an intrabony lesion.  The osseous tissue has no predictable orThe osseous tissue has no predictable or simple pattern of loss; the resorption maysimple pattern of loss; the resorption may take the form of craters, hemiseptaltake the form of craters, hemiseptal defects, or well-like (troughlike) shapes.defects, or well-like (troughlike) shapes. Craters in the interproximal areas are theCraters in the interproximal areas are the most common type of lesionmost common type of lesionwww.indiandentalacademy.comwww.indiandentalacademy.com
  75. 75. The objective of osseous resection is toThe objective of osseous resection is to shape the bone to form even contours.shape the bone to form even contours. This is accomplished by levelingThis is accomplished by leveling interproximal lesions, reducing osseousinterproximal lesions, reducing osseous recontour lesions that are too wide and /recontour lesions that are too wide and / or shallow for predictable repair or bonyor shallow for predictable repair or bony fill, thinning, bony ledges, and eliminatingfill, thinning, bony ledges, and eliminating or ramping crater defects.or ramping crater defects.  The result is intended to be a soundThe result is intended to be a sound osseous base for gingival attachment andosseous base for gingival attachment and the elimination of pockets and excessivethe elimination of pockets and excessive Sulcular depth.Sulcular depth. www.indiandentalacademy.comwww.indiandentalacademy.com
  76. 76. TREATMENT OF FURCATIONTREATMENT OF FURCATION INVOLVEMENTINVOLVEMENT  Diagnosis and treatment of furcationDiagnosis and treatment of furcation involvement of multirooted teeth is one ofinvolvement of multirooted teeth is one of the more difficult problems encountered inthe more difficult problems encountered in the periodontal – restorative dentistry.the periodontal – restorative dentistry. www.indiandentalacademy.comwww.indiandentalacademy.com
  77. 77. CLASSIFICATION OFCLASSIFICATION OF INVOLVEMENTSINVOLVEMENTS FurcationFurcation involvements can beinvolvements can be classified as Class forclassified as Class for Grade) I, II, III, andGrade) I, II, III, and IV.IV.  The normal positionThe normal position of the osseous crestof the osseous crest is approximatelyis approximately 1.5mm apical to the1.5mm apical to the cementoenamelcementoenamel junction (CEJ) in ajunction (CEJ) in a young, healthy adult.young, healthy adult.www.indiandentalacademy.comwww.indiandentalacademy.com
  78. 78. Class IClass I  If vertical loss ofIf vertical loss of periodontal support isperiodontal support is less than 3mm apicalless than 3mm apical to the CEL this isto the CEL this is considered to beconsidered to be Class I involvementClass I involvement..  There is no gross orThere is no gross or radiographic evidenceradiographic evidence of bone loss.of bone loss. Clinically the furcaClinically the furca can be probed up to 1can be probed up to 1 mm horizontally.mm horizontally. www.indiandentalacademy.comwww.indiandentalacademy.com
  79. 79. Class IIClass II  If vertical loss is greaterIf vertical loss is greater than 3 mm but the totalthan 3 mm but the total horizontal width of thehorizontal width of the furcation is not involvedfurcation is not involved Class II involvementClass II involvement exists.exists.  A portion of the bone andA portion of the bone and Periodontium remainsPeriodontium remains intact, but osseous loss isintact, but osseous loss is evident on radiographs.evident on radiographs. The furca is penetrableThe furca is penetrable more than 1 mmmore than 1 mm horizontally but does nothorizontally but does not extend through – and –extend through – and – through.through. www.indiandentalacademy.comwww.indiandentalacademy.com
  80. 80. Class IIIClass III  A horizontalA horizontal through – and –through – and – thorugh lesion that isthorugh lesion that is occluded by gingivaoccluded by gingiva but allows passage ofbut allows passage of an instrument froman instrument from the busccal, lingual,the busccal, lingual, or palatal surface isor palatal surface is defined as adefined as a Class IIIClass III involvementinvolvement. The. The degree of osseousdegree of osseous loss is grossly evidentloss is grossly evident on radiographs.on radiographs. www.indiandentalacademy.comwww.indiandentalacademy.com
  81. 81. Class IVClass IV  A horizontal through –A horizontal through – and – thorugh leionand – thorugh leion that is not occludedthat is not occluded by gingiva is definedby gingiva is defined as aas a Class IVClass IV involvementinvolvement www.indiandentalacademy.comwww.indiandentalacademy.com
  82. 82. ODONTOPLASTY – OSTEOPLASTY.ODONTOPLASTY – OSTEOPLASTY.  Lesser degrees of furcationLesser degrees of furcation involvement can often be controlled byinvolvement can often be controlled by root planning and scaling, adequate oralroot planning and scaling, adequate oral hygiene, and / or gingivectomy-hygiene, and / or gingivectomy- gingivoplasty.gingivoplasty. However, when the involvement is moreHowever, when the involvement is more extensive, recontouring of the tooth orextensive, recontouring of the tooth or bone may be necessary.bone may be necessary. www.indiandentalacademy.comwww.indiandentalacademy.com
  83. 83. Class I and incipient Class II lesions canClass I and incipient Class II lesions can be treated by reflecting the soft tissue inbe treated by reflecting the soft tissue in the furcation area and recontouring boththe furcation area and recontouring both the tooth structure and the supportingthe tooth structure and the supporting bone to improve access for cleaning.bone to improve access for cleaning.  Pocket elimination in this mannerPocket elimination in this manner provides the best results and the fairestprovides the best results and the fairest prognosis. A minimal amount of toothprognosis. A minimal amount of tooth structure and bone is lost, and the patientstructure and bone is lost, and the patient can easily maintain it.can easily maintain it. www.indiandentalacademy.comwww.indiandentalacademy.com
  84. 84. Class II and Class III involvements can beClass II and Class III involvements can be treated by a procedure known astreated by a procedure known as tunneling.tunneling.  The osseous structure is completelyThe osseous structure is completely removed in the furcation, converting theremoved in the furcation, converting the lesion to a through-and=through defect.lesion to a through-and=through defect.  Teeth suitable for tunneling must haveTeeth suitable for tunneling must have long, divergent roots, which will facilitatelong, divergent roots, which will facilitate penetration by an oral hygiene aid (e.g., apenetration by an oral hygiene aid (e.g., a proximal brush or a pipe cleaner).proximal brush or a pipe cleaner). www.indiandentalacademy.comwww.indiandentalacademy.com
  85. 85. Patient selection is particularly important,Patient selection is particularly important, because oral hygiene and patientbecause oral hygiene and patient motivation are critical. Failure to maintainmotivation are critical. Failure to maintain the furcation in a relatively plaque-freethe furcation in a relatively plaque-free state may lead to caries, which are oftenstate may lead to caries, which are often impossible to correct.impossible to correct. The common location of accessory canalsThe common location of accessory canals in the roof of the furca can also be ain the roof of the furca can also be a problem. Because of irreversible pulpproblem. Because of irreversible pulp damage, endodontic treatment may bedamage, endodontic treatment may be needed at a later date.needed at a later date. www.indiandentalacademy.comwww.indiandentalacademy.com
  86. 86. ROOT AMPUTATIONROOT AMPUTATION  In many patients, Class II and Class IIIIn many patients, Class II and Class III furcation lesions are most effectivelyfurcation lesions are most effectively treated by root amputation, whichtreated by root amputation, which eliminates the furcation completely. Theeliminates the furcation completely. The indications are as follows.indications are as follows. Severe vertical bone loss involving oneSevere vertical bone loss involving one root of a mandibular molar or one or tworoot of a mandibular molar or one or two roots of a maxillary molar.roots of a maxillary molar. Furcation involvement that is not treatableFurcation involvement that is not treatable by odontoplasty – osteoplasty.by odontoplasty – osteoplasty. www.indiandentalacademy.comwww.indiandentalacademy.com
  87. 87. Vertically or horizontally fractured roots orVertically or horizontally fractured roots or teeth from trauma or endodonticteeth from trauma or endodontic procedures.procedures. Unfavourable root proximity precludingUnfavourable root proximity precluding treatment by conservative measures.treatment by conservative measures. Severe cariesSevere caries Internal or external resorptionInternal or external resorption Inability to treat one root canalInability to treat one root canal successfully.successfully. www.indiandentalacademy.comwww.indiandentalacademy.com
  88. 88.  Severe dehiscence and sensitivity of aSevere dehiscence and sensitivity of a root that precludes grafting procedures.root that precludes grafting procedures.  Failure of an abutment in a long-spanFailure of an abutment in a long-span splint or FPD.splint or FPD.  Strategic removal of a root to improveStrategic removal of a root to improve the prognosis of an adjacent tooth.the prognosis of an adjacent tooth. www.indiandentalacademy.comwww.indiandentalacademy.com
  89. 89. Certain roots will not be suitable forCertain roots will not be suitable for amputation. Individual considerationsamputation. Individual considerations include the extent of furcationinclude the extent of furcation involvement, the anatomy and topographyinvolvement, the anatomy and topography of the supporting bone, the anatomy of theof the supporting bone, the anatomy of the root canal, and the periapical health of theroot canal, and the periapical health of the tooth.tooth. www.indiandentalacademy.comwww.indiandentalacademy.com
  90. 90.  The major contraindications to root resection areThe major contraindications to root resection are teeth exhibiting any of the following.teeth exhibiting any of the following.  Closely approximated or fused roots.Closely approximated or fused roots.  Significantly decreased general osseous supportSignificantly decreased general osseous support or an increased crown / root ratio.or an increased crown / root ratio.  Remaining structure that will not provideRemaining structure that will not provide adequate resistance against the forces ofadequate resistance against the forces of mastication.mastication.  Excessive loss of supporting root structureExcessive loss of supporting root structure  Inability to be treated endodonticallyInability to be treated endodontically  Remaining structure that cannot be restored.Remaining structure that cannot be restored. www.indiandentalacademy.comwww.indiandentalacademy.com
  91. 91. HEMISECTION.HEMISECTION.  Hemisection means cutting a tooth inHemisection means cutting a tooth in half. In the case of mandibular molars,half. In the case of mandibular molars, hemisection is followed by removal andhemisection is followed by removal and subsequent restoration of one root orsubsequent restoration of one root or restoration of each half of the tooth. Therestoration of each half of the tooth. The latter procedure is sometimes calledlatter procedure is sometimes called premolarization or bicuspidization.premolarization or bicuspidization.  The individual roots may then beThe individual roots may then be separated orthodontically, if necessary, toseparated orthodontically, if necessary, to gain new interseptal osseous area.gain new interseptal osseous area. www.indiandentalacademy.comwww.indiandentalacademy.com
  92. 92. PROVISIONALIZATION.PROVISIONALIZATION.  Provisional stabilization is indicated inProvisional stabilization is indicated in many cases of root resection to allowmany cases of root resection to allow proper healing, of the surgical site beforeproper healing, of the surgical site before definitive restorations are placed and todefinitive restorations are placed and to stabilize the remaining tooth structurestabilize the remaining tooth structure against masticatory forces.against masticatory forces. www.indiandentalacademy.comwww.indiandentalacademy.com
  93. 93. RESTORATION.RESTORATION.  Teeth with a resected root or roots mayTeeth with a resected root or roots may be restored in a variety of ways. Theybe restored in a variety of ways. They may be involved in a treatment plan asmay be involved in a treatment plan as single units, as fixed or removable partialsingle units, as fixed or removable partial denture abutments, or as vertical stops fordenture abutments, or as vertical stops for an overdenture.an overdenture. www.indiandentalacademy.comwww.indiandentalacademy.com
  94. 94. The most common types of restorationsThe most common types of restorations for teeth with resected roots involve.for teeth with resected roots involve. The remaining root restored as anThe remaining root restored as an individual tooth.individual tooth. The tooth used as an abutment for a fixedThe tooth used as an abutment for a fixed or removable partial denture.or removable partial denture. Premolarization – individual roots of aPremolarization – individual roots of a molar restored with premolar morphology.molar restored with premolar morphology. Minimum treatment – amalgam placed inMinimum treatment – amalgam placed in the root(s) and the occlusion adjusted.the root(s) and the occlusion adjusted. www.indiandentalacademy.comwww.indiandentalacademy.com
  95. 95. EVALUATION OF SURGICAL THERAPYEVALUATION OF SURGICAL THERAPY  The prognosis for a tooth whose root(s) haveThe prognosis for a tooth whose root(s) have been resected and / or amputated depends onbeen resected and / or amputated depends on many factors.many factors.  The manner in which the tooth is to be used inThe manner in which the tooth is to be used in the restorative plan – as an abutment for athe restorative plan – as an abutment for a partial denture or as a single crown – has apartial denture or as a single crown – has a bearing on prognosis.bearing on prognosis.  The amount of residual osseous structure toThe amount of residual osseous structure to support the remaining tooth also influences thesupport the remaining tooth also influences the outlook. Most important, however, are theoutlook. Most important, however, are the motivation and oral hygiene of the patient. Withmotivation and oral hygiene of the patient. With careful diagnosis, treatment planning, and goodcareful diagnosis, treatment planning, and good surgical technique, the tooth with resected rootssurgical technique, the tooth with resected roots may have a favourable prognosis. Plaquemay have a favourable prognosis. Plaque control is critical.control is critical. www.indiandentalacademy.comwww.indiandentalacademy.com
  96. 96. GUIDED TISSUE REGENERATIONGUIDED TISSUE REGENERATION (Hard(Hard and soft Tissue Procedures)and soft Tissue Procedures)  It has long been a goal of periodontalIt has long been a goal of periodontal therapists to replace lost connective tissuetherapists to replace lost connective tissue attachment and bone.attachment and bone.  Many materials have been used in the quest forMany materials have been used in the quest for reattachment to diseased root surfaces. In thereattachment to diseased root surfaces. In the recent past, regaining lost attachment with cellsrecent past, regaining lost attachment with cells from the host has been successful.from the host has been successful.  Through the use of physical barriers that preventThrough the use of physical barriers that prevent cells from the gingival connective tissue andcells from the gingival connective tissue and apically migrating oral epithelium fromapically migrating oral epithelium from contacting the root surface, space is createdcontacting the root surface, space is created over the root surface, which allows selectiveover the root surface, which allows selective repopulation of this space by cells from therepopulation of this space by cells from the residual periodontal ligament. These becomeresidual periodontal ligament. These become the regenerated periodontal ligament.the regenerated periodontal ligament.www.indiandentalacademy.comwww.indiandentalacademy.com
  97. 97. Several types of barriers, both resorbableSeveral types of barriers, both resorbable and non resorbable, as well as nativeand non resorbable, as well as native periosteum, have seen used to regenerateperiosteum, have seen used to regenerate the periodontium about root surfaces, inthe periodontium about root surfaces, in furcations, and with dental implants.furcations, and with dental implants. www.indiandentalacademy.comwww.indiandentalacademy.com
  98. 98. MAINTENANCEMAINTENANCE Continued reexamination and evaluationContinued reexamination and evaluation of periodontal status are necessary toof periodontal status are necessary to verify the treatment’s success.verify the treatment’s success.  The maintenance regimen variesThe maintenance regimen varies greatly among individuals and requiresgreatly among individuals and requires close coordination between the patientclose coordination between the patient and the involved professionalsand the involved professionals www.indiandentalacademy.comwww.indiandentalacademy.com
  99. 99. PROGNOSISPROGNOSIS  The progress, course, and outcome ofThe progress, course, and outcome of gingival and periodontal disease aregingival and periodontal disease are critically dependent on the patient.critically dependent on the patient. Without the ability and desire of the patientWithout the ability and desire of the patient to maintain his or her teeth andto maintain his or her teeth and periodontium, any treatment will ultimatelyperiodontium, any treatment will ultimately fail.fail. www.indiandentalacademy.comwww.indiandentalacademy.com
  100. 100. PERIODONTAL ASPECT OF FIXEDPERIODONTAL ASPECT OF FIXED OCCLUSIONOCCLUSION OCCLUSION AND ITS EFFECT ONOCCLUSION AND ITS EFFECT ON PERIODONTIUMPERIODONTIUM  When there is an increased functional demandWhen there is an increased functional demand upon the periodontium, it commonly accommodatesupon the periodontium, it commonly accommodates these forces. This adaptive capacity varies betweenthese forces. This adaptive capacity varies between persons and, in the same person, varies withpersons and, in the same person, varies with circumstances.circumstances.  The effect of occlusal forces upon the periodontium isThe effect of occlusal forces upon the periodontium is influenced by their severity, direction, duration, andinfluenced by their severity, direction, duration, and frequency. When severity increases, the periodontalfrequency. When severity increases, the periodontal fibers thicken and increase and the alveolar bonefibers thicken and increase and the alveolar bone becomes denser.becomes denser.  www.indiandentalacademy.comwww.indiandentalacademy.com
  101. 101.  Changing the direction of the occlusal forcesChanging the direction of the occlusal forces changes the orientation of the periodontalchanges the orientation of the periodontal ligament fibers. These fibers are oriented toligament fibers. These fibers are oriented to withstand forces in the long axis of the tooth.withstand forces in the long axis of the tooth.  Horizontal or lateral forces are usually locatedHorizontal or lateral forces are usually located in balancing side interferences and arein balancing side interferences and are deleterious to the periodontium. Lateral forcesdeleterious to the periodontium. Lateral forces initiate bone resorption in areas of pressure andinitiate bone resorption in areas of pressure and bone formation in areas of tension.bone formation in areas of tension. www.indiandentalacademy.comwww.indiandentalacademy.com
  102. 102. www.indiandentalacademy.comwww.indiandentalacademy.com
  103. 103.  Rotational forces cause tension and pressure onRotational forces cause tension and pressure on the periodontium and are the most injuriousthe periodontium and are the most injurious forces.forces.  The duration and frequency affect the responseThe duration and frequency affect the response of the alveolar bone to occlusal forces becauseof the alveolar bone to occlusal forces because constant pressure on bone causes resorption,constant pressure on bone causes resorption, but intermittent forces promote bone formation.but intermittent forces promote bone formation.  Recurrent forces over short intervals haveRecurrent forces over short intervals have essentially the same resorbing effect asessentially the same resorbing effect as constant pressure. When occlusal forcesconstant pressure. When occlusal forces exceed the adaptive capacity of theexceed the adaptive capacity of the periodontium, tissue injury results.periodontium, tissue injury results. www.indiandentalacademy.comwww.indiandentalacademy.com
  104. 104.  Periodontal injury caused by occlusal forces isPeriodontal injury caused by occlusal forces is called trauma from occlusion. Occlusalcalled trauma from occlusion. Occlusal traumatism, does not affect the gingival, nortraumatism, does not affect the gingival, nor does it cause bone formation. Inflammationdoes it cause bone formation. Inflammation causes horizontal bone loss.causes horizontal bone loss.  However, inflammation in the presence ofHowever, inflammation in the presence of trauma from occlusion will alter the pathway oftrauma from occlusion will alter the pathway of inflammation to allow it into the periodontalinflammation to allow it into the periodontal ligament space and lead to infraosseousligament space and lead to infraosseous pockets.pockets.  Thus trauma form occlusion does not affect theThus trauma form occlusion does not affect the marginal gingiva, but affects the bone whenmarginal gingiva, but affects the bone when inflammation is present. This is called the zoneinflammation is present. This is called the zone of codestruction: trauma from occlusion in theof codestruction: trauma from occlusion in the presence of inflammation.presence of inflammation.  www.indiandentalacademy.comwww.indiandentalacademy.com
  105. 105. www.indiandentalacademy.comwww.indiandentalacademy.com
  106. 106. With increased axial forces, there is aWith increased axial forces, there is a distortion of the periodontal ligament,distortion of the periodontal ligament, compression of the periodontal fibers, andcompression of the periodontal fibers, and then resorption of the bone in the apicalthen resorption of the bone in the apical areas.areas. Torque or rotational forces cause tensionTorque or rotational forces cause tension and pressure, which, under physiologicand pressure, which, under physiologic conditions, result in bone formation andconditions, result in bone formation and resorption. Torque is the fore most likelyresorption. Torque is the fore most likely to injure the periodontium.to injure the periodontium. www.indiandentalacademy.comwww.indiandentalacademy.com
  107. 107.  Trauma from occlusion occurs in three stages:Trauma from occlusion occurs in three stages: The first is injury, the second is repair, and theThe first is injury, the second is repair, and the third is a change in the morphology of thethird is a change in the morphology of the periodontium.periodontium.  Tissue injury is produced by excessive occlusalTissue injury is produced by excessive occlusal forces. Natural repair of the injury andforces. Natural repair of the injury and restoration of periodontal tissues occur if therestoration of periodontal tissues occur if the force on the tooth diminishes or the tooth driftsforce on the tooth diminishes or the tooth drifts away from the force. Moving away from theaway from the force. Moving away from the injurious force may result in mobility.injurious force may result in mobility.  If the force is chronic, the periodontal tissuesIf the force is chronic, the periodontal tissues are remolded to cushion the traumatic force:are remolded to cushion the traumatic force: the periodontal ligament is widened at thethe periodontal ligament is widened at the expense of the bone, angular (vertical) boneexpense of the bone, angular (vertical) bone defects occur without pockets, and the toothdefects occur without pockets, and the tooth becomes mobile.becomes mobile. www.indiandentalacademy.comwww.indiandentalacademy.com
  108. 108.  OCCLUSAL TRAUMA IN GINGIVITIS ANDOCCLUSAL TRAUMA IN GINGIVITIS AND PERIODONTAL DISEASE;PERIODONTAL DISEASE;  All periodontal tissues are affected by occlusion.All periodontal tissues are affected by occlusion. Occlusion is a critical environmental factor in the life ofOcclusion is a critical environmental factor in the life of the healthy periodontium and its influence expands inthe healthy periodontium and its influence expands in periodontal ligament cannot be separated from theperiodontal ligament cannot be separated from the influence of occlusion.influence of occlusion.  Because occlusion is the constant monitor for theBecause occlusion is the constant monitor for the condition of the periodontium’s health, it affects thecondition of the periodontium’s health, it affects the response of the periodontium to inflammation and is aresponse of the periodontium to inflammation and is a factor in periodontal disease.factor in periodontal disease.  The role of trauma from occlusion in gingivitis andThe role of trauma from occlusion in gingivitis and periodontitis is best understood if the periodontium isperiodontitis is best understood if the periodontium is considered as having two zones, the zone of irritationconsidered as having two zones, the zone of irritation and the zone of codestruction.and the zone of codestruction. www.indiandentalacademy.comwww.indiandentalacademy.com
  109. 109.  The zone of irritation consists of the marginalThe zone of irritation consists of the marginal and interdental gingival, with its boundaryand interdental gingival, with its boundary formed by the gingival fibers. This is whereformed by the gingival fibers. This is where gingivitis and periodontal pockets start.gingivitis and periodontal pockets start.  They are caused by local irritation from plaque,They are caused by local irritation from plaque, bacteria, calculus., and by food impaction. Withbacteria, calculus., and by food impaction. With few exceptions, researchers agree that traumafew exceptions, researchers agree that trauma from occlusion does not cause gingivitis orfrom occlusion does not cause gingivitis or periodontal pockets.periodontal pockets.  In other words, such things as high restoration,In other words, such things as high restoration, orthodontic movement, or the poorly designedorthodontic movement, or the poorly designed rest of any RPD causing tooth trauma can notrest of any RPD causing tooth trauma can not lead to a periodontal pocket because the locallead to a periodontal pocket because the local irritants that start gingivitis and periodontalirritants that start gingivitis and periodontal pockets affect the marginal gingival, but traumapockets affect the marginal gingival, but trauma from occlusion affects only the supportingfrom occlusion affects only the supporting tissues.tissues. www.indiandentalacademy.comwww.indiandentalacademy.com
  110. 110. As long as the inflammation is confined toAs long as the inflammation is confined to the gingiva, it is not affected by occlusalthe gingiva, it is not affected by occlusal forces. When it extends from the gingivalforces. When it extends from the gingival to the supporting periodontal tissues,to the supporting periodontal tissues, inflammation does enter into the zone ofinflammation does enter into the zone of codestruction.codestruction.  The zone of codestruction begins with theThe zone of codestruction begins with the transeptal fibers and consists oftranseptal fibers and consists of supporting periodontal tissues, is pathwaysupporting periodontal tissues, is pathway and the destruction it causes come underand the destruction it causes come under the influence of the occlusion.the influence of the occlusion. www.indiandentalacademy.comwww.indiandentalacademy.com
  111. 111. www.indiandentalacademy.comwww.indiandentalacademy.com
  112. 112. In ordinary inflammation without trauma,In ordinary inflammation without trauma, the inflammation follows the path of leastthe inflammation follows the path of least resistance. Its course is determined byresistance. Its course is determined by the alignment of the transeptal fibers, andthe alignment of the transeptal fibers, and it goes into the crest of the bone byit goes into the crest of the bone by following a path along the circumvascularfollowing a path along the circumvascular spaces.spaces. www.indiandentalacademy.comwww.indiandentalacademy.com
  113. 113.  Trauma from occlusion changes the tissueTrauma from occlusion changes the tissue environment around the inflammatory exudates in twoenvironment around the inflammatory exudates in two way:way:  it alters the alignment of the transeptal and alveolarit alters the alignment of the transeptal and alveolar crest fibers and thus changes the direction of thecrest fibers and thus changes the direction of the pathway of the inflammation so the direction of thepathway of the inflammation so the direction of the pathway of the inflammation so that it extends directlypathway of the inflammation so that it extends directly into the periodontal ligament.into the periodontal ligament.  Excessive occlusal forces produce periodontalExcessive occlusal forces produce periodontal ligament damage and bone resorption whichligament damage and bone resorption which aggravate the tissue destruction caused byaggravate the tissue destruction caused by inflammation. Combined with inflammation, traumainflammation. Combined with inflammation, trauma from occlusion leads to infraosseous pockets; angularfrom occlusion leads to infraosseous pockets; angular vertical), craterlike osseous defects; and excessivevertical), craterlike osseous defects; and excessive tooth mobility.tooth mobility.  Occlusal trauma may be caused by alterations inOcclusal trauma may be caused by alterations in the occlusal forces, reduced capacity of thethe occlusal forces, reduced capacity of the periodontium to withstand occlusal forces.periodontium to withstand occlusal forces.www.indiandentalacademy.comwww.indiandentalacademy.com
  114. 114. PREPARATIONS FORPREPARATIONS FOR PERIODONTALLY WEAKENEDPERIODONTALLY WEAKENED TEETHTEETH Teeth that have been saved byTeeth that have been saved by periodontal therapy often need castperiodontal therapy often need cast restorations. This may occur because ofrestorations. This may occur because of caries or previous damage, or the teethcaries or previous damage, or the teeth may need to be splinted together tomay need to be splinted together to improve their stability. These teeth alsoimprove their stability. These teeth also may be needed as abutments formay be needed as abutments for prostheses replacing missing teeth.prostheses replacing missing teeth.www.indiandentalacademy.comwww.indiandentalacademy.com
  115. 115. PREPARATION FINISHPREPARATION FINISH LINELINE  Restoration of a tooth around which there has been aRestoration of a tooth around which there has been a loss of gingival height or other change in gingivalloss of gingival height or other change in gingival architecture frequently requires modification of thearchitecture frequently requires modification of the tooth preparation.tooth preparation.  The type and location of the finish line may have aThe type and location of the finish line may have a significant impact on the success of the restoration.significant impact on the success of the restoration. An improperly designed preparation can necessarilyAn improperly designed preparation can necessarily damage the tooth and potentially compromise thedamage the tooth and potentially compromise the longevity of the restoration and of the tooth itself.longevity of the restoration and of the tooth itself.  The proximity of the preparation finish line to theThe proximity of the preparation finish line to the furcations can necessitate even further modification offurcations can necessitate even further modification of the tooth preparation.the tooth preparation.www.indiandentalacademy.comwww.indiandentalacademy.com
  116. 116. LOCATIONLOCATION The optimum location for the gingivalThe optimum location for the gingival finish line of a crown preparation is onfinish line of a crown preparation is on enamel, away from the gingival sulcus.enamel, away from the gingival sulcus. However, it is frequently necessary for theHowever, it is frequently necessary for the restoration margin to extend apically torestoration margin to extend apically to cover an expanse of root surface that maycover an expanse of root surface that may have been affected by caries or erosion.have been affected by caries or erosion. www.indiandentalacademy.comwww.indiandentalacademy.com
  117. 117.  If an all-ceramicIf an all-ceramic shoulder is used as theshoulder is used as the gingivofacial margin forgingivofacial margin for a metal-ceramic crown,a metal-ceramic crown, a 1.0-mm-wide shouldera 1.0-mm-wide shoulder will be required as thewill be required as the gingival finish line. Thusgingival finish line. Thus configuration isconfiguration is destructive under thedestructive under the best of circumstancesbest of circumstances when it is placed in thewhen it is placed in the enamel of the clinicalenamel of the clinical crown. Nevertheless, itcrown. Nevertheless, it is generally wellis generally well tolerated in maturetolerated in mature teeth.teeth. www.indiandentalacademy.comwww.indiandentalacademy.com
  118. 118.  A shoulder is a poorA shoulder is a poor choice when thechoice when the margin must bemargin must be placed on the rootplaced on the root surface. Thesurface. The constricted, smallerconstricted, smaller diameter of the rootdiameter of the root will require that thewill require that the axial reduction beaxial reduction be extended into theextended into the tooth to pulp-tooth to pulp- threatening depth tothreatening depth to achieve the same 1.0-achieve the same 1.0- mm-wide shoulder.mm-wide shoulder. www.indiandentalacademy.comwww.indiandentalacademy.com
  119. 119. Aside from possible pulpal encroachment,Aside from possible pulpal encroachment, this gross destruction of axial tooththis gross destruction of axial tooth structure weakens the natural structuralstructure weakens the natural structural durability of the tooth. Additionally, thedurability of the tooth. Additionally, the shoulder has a greater potential forshoulder has a greater potential for concentrating stresses that couldconcentrating stresses that could ultimately lead to fracture of the tooth.ultimately lead to fracture of the tooth. www.indiandentalacademy.comwww.indiandentalacademy.com
  120. 120.  A chamferA chamfer finish line onfinish line on the facialthe facial surface in thissurface in this apicalapical position willposition will result inresult in approximatelyapproximately the samethe same depth of axialdepth of axial reduction asreduction as would awould a shoulder atshoulder at the usualthe usual level.level. www.indiandentalacademy.comwww.indiandentalacademy.com
  121. 121.  A metal-ceramicA metal-ceramic crown fabricated incrown fabricated in such circumstancessuch circumstances should have a wideshould have a wide metal gingival collar.metal gingival collar. Extension of theExtension of the ceramic veneer to theceramic veneer to the gingival margin willgingival margin will create overcreate over contouring or willcontouring or will require use of therequire use of the more destructivemore destructive shoulder.shoulder. www.indiandentalacademy.comwww.indiandentalacademy.com
  122. 122. FABRICATION FLUTESFABRICATION FLUTES  Sometimes the crown margins on a molar mustSometimes the crown margins on a molar must extend far enough apically that the preparation finishextend far enough apically that the preparation finish line approaches the furcation, where the common rootline approaches the furcation, where the common root trunk divides into two or three roots.trunk divides into two or three roots.  The designs of both the tooth preparations and theThe designs of both the tooth preparations and the crowns for these teeth must be different from thosecrowns for these teeth must be different from those customarily used.customarily used.  This is caused by the intersection of the preparationThis is caused by the intersection of the preparation finish line with the vertical flutes or concavities in thefinish line with the vertical flutes or concavities in the common root trunk, extending from the actualcommon root trunk, extending from the actual furcation in the direction of the preparation occlusal tofurcation in the direction of the preparation occlusal to the inversion of the gingival finish line must also havethe inversion of the gingival finish line must also have vertical concavity or flutes.vertical concavity or flutes. www.indiandentalacademy.comwww.indiandentalacademy.com
  123. 123. The axial contours of crowns placed onThe axial contours of crowns placed on teeth whose furcation flutes areteeth whose furcation flutes are intercepted by preparation finish linesintercepted by preparation finish lines must likewise reflect the concavity risingmust likewise reflect the concavity rising from the furcation flute.from the furcation flute. The artificial crown should recreate theThe artificial crown should recreate the contours of the furcation flute and notcontours of the furcation flute and not follow the original crown contours.follow the original crown contours. www.indiandentalacademy.comwww.indiandentalacademy.com
  124. 124.  The facial surface should be invaginated into aThe facial surface should be invaginated into a concavity above the bifurcation that extendsconcavity above the bifurcation that extends occlusally until it meets the facial surface.occlusally until it meets the facial surface.  The concavities usually merge with featuresThe concavities usually merge with features originating on the occlusal surface.originating on the occlusal surface.  There must be no interruption in the verticalThere must be no interruption in the vertical concavity rising at the margin of the restoration.concavity rising at the margin of the restoration.  Any horizontal ridge on the facial or lingualAny horizontal ridge on the facial or lingual surface of the tooth that intersects with thissurface of the tooth that intersects with this concavity and blocks it will result in plaqueconcavity and blocks it will result in plaque retaining area.retaining area. www.indiandentalacademy.comwww.indiandentalacademy.com
  125. 125. PLACE OF MARGINS OFPLACE OF MARGINS OF RESTORATION:RESTORATION:  Except for the risk of subgingivalExcept for the risk of subgingival decay and esthetic consideration, it is bestdecay and esthetic consideration, it is best to terminate preparations above theto terminate preparations above the gingival margin. If periodontal therapygingival margin. If periodontal therapy has been performed and the gingival hashas been performed and the gingival has receded, the preparations should end atreceded, the preparations should end at the cementoenamel junction. Even if thethe cementoenamel junction. Even if the tissue does not recede, the margin of thetissue does not recede, the margin of the tooth preparation should be away fromtooth preparation should be away from the soft tissue.the soft tissue. www.indiandentalacademy.comwww.indiandentalacademy.com
  126. 126. Crown margins, when placedCrown margins, when placed subgingivally, should be located at thesubgingivally, should be located at the base of the gingival sulcus, which is thebase of the gingival sulcus, which is the level reached when a thin blunt probe islevel reached when a thin blunt probe is positioned without pressure into thepositioned without pressure into the gingival sulcus. The gingival fibers cangingival sulcus. The gingival fibers can then brace the gingiva against the tooththen brace the gingiva against the tooth and the margin of the completedand the margin of the completed restoration.restoration. www.indiandentalacademy.comwww.indiandentalacademy.com
  127. 127. Microscopically, the margin is rough andMicroscopically, the margin is rough and an excellent site to harbor bacteria. Sincean excellent site to harbor bacteria. Since the margin of the gingiva rapidly collectsthe margin of the gingiva rapidly collects plaque, this is the site of recurrent decay.plaque, this is the site of recurrent decay. If decay does not result, the plaqueIf decay does not result, the plaque causes periodontal disease at this mostcauses periodontal disease at this most critical area which is not self-cleansing.critical area which is not self-cleansing. www.indiandentalacademy.comwww.indiandentalacademy.com
  128. 128. www.indiandentalacademy.comwww.indiandentalacademy.com
  129. 129.  Conversely,Conversely, restorations shouldrestorations should not be forcednot be forced subgingivally into thesubgingivally into the connective tissue, butconnective tissue, but placed in theplaced in the intracrevicular spaceintracrevicular space without violatingwithout violating biologic width.biologic width. Tearing of theTearing of the epithelial attachmentepithelial attachment causes it to migratecauses it to migrate apically and theapically and the sulcus to deepen intosulcus to deepen into a pocketa pocket www.indiandentalacademy.comwww.indiandentalacademy.com
  130. 130. BIOLOGIC WIDTH EMBRASURES:BIOLOGIC WIDTH EMBRASURES:  The teeth touch in an area called a proximalThe teeth touch in an area called a proximal contact, the spaces below the contact are knowncontact, the spaces below the contact are known as embrasures. In health, the embrasures areas embrasures. In health, the embrasures are usually filled with tissue . Embrasures protectusually filled with tissue . Embrasures protect the gingival from food impaction and deflect thethe gingival from food impaction and deflect the food to massage the gingival surface. Theyfood to massage the gingival surface. They provide spillways for food during mastication andprovide spillways for food during mastication and relieve occlusal forces when resistant food isrelieve occlusal forces when resistant food is chewed.chewed. www.indiandentalacademy.comwww.indiandentalacademy.com
  131. 131.  The ProximalThe Proximal surfaces of dentalsurfaces of dental restorations arerestorations are important becauseimportant because they determine thethey determine the embrasures essentialembrasures essential for gingival healthfor gingival health www.indiandentalacademy.comwww.indiandentalacademy.com

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