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Surgical procedures in fixed partial denture prostheses/ General orthodontics
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Surgical procedures in fixed partial denture prostheses/ General orthodontics

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Indian Dental Academy: will be one of the most relevant and exciting training center with best faculty and flexible training programs for dental professionals who wish to advance in their dental practice,Offers certified courses in Dental implants,Orthodontics,Endodontics,Cosmetic Dentistry, Prosthetic Dentistry, Periodontics and General Dentistry.

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  • 1. INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com
  • 2. Introduction Periodontal Considerations:  Anatomy of the Gingiva and Periodontium  Osseous Defects  Choosing the right graft material  Treatment sequencing for FPD  Sequencing of periodontal therapy ▪ Phase ITherapy  BiologicWidth,Violation of BiologicWidth  Bone Regeneration  Biologic Considerations www.indiandentalacademy.com
  • 3. Hard and Soft tissue defects and their surgical management  Alveolar bone defects  Inadequate tooth structure for restoration of tooth  Recession  Ridge defects  Gingival Overgrowth  Furcation Involvement  Interdental papilla reconstruction Electrosurgery Gingettage, Frenectomy Management of excessive gingival pigmentation www.indiandentalacademy.com
  • 4. Active periodontal disease must be treated and controlled prior to any restorative therapy. Restorative treatment must be performed on a periodontium free of inflammation and pockets, without any mucogingival involvement and with the contour and shape of the periodontium corrected for a good functional and esthetic result. Jan Lindhe,Thorkild Karring, Niklaus P. Lang. Clinical Periodontology and Implant Dentistry, fourth edition www.indiandentalacademy.com
  • 5. Reasons why periodontal disease must be eliminated before Restoration of teeth:  To locate and determine the gingival margins of restorations correctly. Margins of the restorations covered by inflamed gingiva shrinks after periodontal treatment  Position of the teeth are frequently altered due to periodontal disease, and therefore must be corrected before restoration  Inflammation of the periodontium of the abutment teeth effects the load carrying capacity of the abutment.  Discomfort may be caused due to mobility of the abutment teeth, which interferes with mastication and function. Jan Lindhe,Thorkild Karring, Niklaus P. Lang. Clinical Periodontology and Implant Dentistry, fourth editionwww.indiandentalacademy.com
  • 6. www.indiandentalacademy.com
  • 7. Gingiva (G) Periodontal ligament (PL) Root cementum (RC) Alveolar bone(AP) Alveolar bone proper (ABP) Jan Lindhe,Thorkild Karring, Niklaus P. Lang. Clinical Periodontology and Implant Dentistry, fourth editionwww.indiandentalacademy.com
  • 8. The alveolar bone consists of two components:  The alveolar bone proper and,  The alveolar process The alveolar bone proper, also called ‘bundle bone’ is continuous with the alveolar process and forms the thin bone plate that lines the alveolus of the tooth. Jan Lindhe,Thorkild Karring, Niklaus P. Lang. Clinical Periodontology and Implant Dentistry, fourth edition www.indiandentalacademy.com
  • 9. The main function of the periodontium is to  attach the tooth to the bone tissue of the jaws and  to maintain the integrity of the surface of the masticatory mucosa of the oral cavity. The periodontium, constitutes a developmental, biologic, and functional unit which undergoes certain changes with age and is, in addition, subjected to morphologic changes related to functional alterations and alterations in the oral environment. Jan Lindhe,Thorkild Karring, Niklaus P. Lang. Clinical Periodontology and Implant Dentistry, fourth edition www.indiandentalacademy.com
  • 10. The oral mucosa is continuous with the skin of the lips and the mucosa of the soft palate and pharynx.The oral mucosa consists of (1) the masticatory mucosa, which includes the gingiva and the covering of the hard palate, (2) the specialized mucosa, which covers the dorsum of the tongue, and (3) the remaining part, called the lining mucosa. Jan Lindhe,Thorkild Karring, Niklaus P. Lang. Clinical Periodontology and Implant Dentistry, fourth edition www.indiandentalacademy.com
  • 11. The gingiva is that part of the masticatory mucosa which covers the alveolar process and surrounds the cervical portion of the teeth. It consists of an epithelial layer and an underlying connective tissue layer called the lamina propria. The gingiva obtains its final shape and texture in conjunction with eruption of the teeth. Jan Lindhe,Thorkild Karring, Niklaus P. Lang. Clinical Periodontology and Implant Dentistry, fourth edition www.indiandentalacademy.com
  • 12. In the coronal direction the coral pink gingiva terminates in the free gingival margin, which has a scalloped outline. In the apical direction the gingiva is continuous with the loose, darker red alveolar mucosa from which the gingiva is separated by a, usually, easily recognizable borderline called the mucogingival junction or the mucogingival line. Jan Lindhe,Thorkild Karring, Niklaus P. Lang. Clinical Periodontology and Implant Dentistry, fourth edition www.indiandentalacademy.com
  • 13. There is no mucogingival line present in the palate since the hard palate and the maxillary alveolar process are covered by the same type of masticatory mucosa. Jan Lindhe,Thorkild Karring, Niklaus P. Lang. Clinical Periodontology and Implant Dentistry, fourth editionwww.indiandentalacademy.com
  • 14. Two parts of the gingiva can be differentiated: 1. the free gingiva (FG) 2. the attached gingiva (AG) Jan Lindhe,Thorkild Karring, Niklaus P. Lang. Clinical Periodontology and Implant Dentistry, fourth edition www.indiandentalacademy.com
  • 15. The free gingiva is coral pink, has a dull surface and firm consistency. It comprises the gingival tissue at the vestibular and lingual/palatal aspects of the teeth, and the interdental gingiva or the interdental papillae. On the vestibular and lingual side of the teeth, the free gingiva extends from the gingival margin in apical direction to the free gingival groove which is positioned at a level corresponding to the level of the cementoenamel junction (CEJ). The attached gingiva is in apical direction demarcated by the mucogingival junction (MGJ). Jan Lindhe,Thorkild Karring, Niklaus P. Lang. Clinical Periodontology and Implant Dentistry, fourth edition www.indiandentalacademy.com
  • 16. The free gingival margin is often rounded in such a way that a small invagination or sulcus is formed between the tooth and the gingiva When a periodontal probe is inserted into this invagination and, further apically, towards the cementoenamel junction, the gingival tissue is separated from the tooth, and a "gingival pocket" or "gingival crevice" is artificially opened. Thus, in normal or clinically healthy gingiva there is in fact no "gingival pocket“ or "gingival crevice" present but the gingiva is in close contact with the enamel surface. Jan Lindhe,Thorkild Karring, Niklaus P. Lang. Clinical Periodontology and Implant Dentistry, fourth editionwww.indiandentalacademy.com
  • 17. After completed tooth eruption, the free gingival margin is located on the enamel surface approximately 1.5 to 2 mm coronal to the cemento-enamel junction. Jan Lindhe,Thorkild Karring, Niklaus P. Lang. Clinical Periodontology and Implant Dentistry, fourth editionwww.indiandentalacademy.com
  • 18. The shape of the interdental papilla is determined by the contact relationships between the teeth, the width of the approximal tooth surfaces, and the course of the cementoenamel junction. In anterior regions of the dentition, the interdental papilla is of pyramidal form while in the molar regions, the papillae are more flattened in buccolingual direction. Due to the presence of interdental papillae, the free gingival margin follows a more or less accentuated, scalloped course through the dentition. Jan Lindhe,Thorkild Karring, Niklaus P. Lang. Clinical Periodontology and Implant Dentistry, fourth editionwww.indiandentalacademy.com
  • 19. In the premolar/molar regions of the dentition, the teeth have approximal contact surfaces rather than contact points. As the interdental papilla has a shape in conformity with the outline of the interdental contact surfaces, a concavity —a col — is established in the premolar and molar regions. Thus, the interdental papillae in these areas often have one vestibular and one lingual/palatal portion separated by the col region. Jan Lindhe,Thorkild Karring, Niklaus P. Lang. Clinical Periodontology and Implant Dentistry, fourth editionwww.indiandentalacademy.com
  • 20. The col region, as demonstrated in the histological section, is covered by a thin non- keratinized epithelium. This epithelium has many features in common with the junctional epithelium. Jan Lindhe,Thorkild Karring, Niklaus P. Lang. Clinical Periodontology and Implant Dentistry, fourth editionwww.indiandentalacademy.com
  • 21. The attached gingiva is, in coronal direction, demarcated by the free gingival groove. The attached gingiva extends in the apical direction to the mucogingival junction, where it becomes continuous with the lining mucosa. It is of firm texture, coral pink in colour, and often shows small depressions on the surface, called ‘stippling’. Jan Lindhe,Thorkild Karring, Niklaus P. Lang. Clinical Periodontology and Implant Dentistry, fourth edition www.indiandentalacademy.com
  • 22. The free gingiva comprises all epithelial and connective tissue structures located coronal to a horizontal line placed at the level of the cementoenamel junction.The epithelium covering the free gingiva may be differentiated as follows:  oral epithelium, which faces the oral cavity  oral sulcular epithelium, which faces the tooth without being in contact with the tooth surface  junctional epithelium, which provides the contact between the gingiva and the tooth. Jan Lindhe,Thorkild Karring, Niklaus P. Lang. Clinical Periodontology and Implant Dentistry, fourth edition www.indiandentalacademy.com
  • 23. Oral epithelium Oral sulcular epithelium Junctional epithelium Connective tissue Bone www.indiandentalacademy.com
  • 24. The boundary between the oral epithelium and the underlying connective tissue has a wavy course. The connective tissue portions which project into the epithelium are called connective tissue papillae and are separated from each other by epithelial ridges called rete pegs. In healthy gingiva, rete pegs and connective tissue papillae are lacking at the boundary between the junctional epithelium and its underlying connective tissue. Jan Lindhe,Thorkild Karring, Niklaus P. Lang. Clinical Periodontology and Implant Dentistry, fourth edition www.indiandentalacademy.com
  • 25. Jan Lindhe,Thorkild Karring, Niklaus P. Lang. Clinical Periodontology and Implant Dentistry, fourth editionwww.indiandentalacademy.com
  • 26. The oral or outer epithelium covers the crest and outer surface of the marginal gingiva and the surface of the attached gingiva. It is keratinised or parakeratinised. Jan Lindhe,Thorkild Karring, Niklaus P. Lang. Clinical Periodontology and Implant Dentistry, fourth editionwww.indiandentalacademy.com
  • 27. It lines the gingival sulcus. It is a thin non keratinised stratified squamous epithelium without rete pegs and extends from the coronal limit of the junctional epithelium to the crest of the gingival margin. The sulcular epithelium has potential to keratinise, if  It is reflected and exposed to the oral cavity  The bacterial flora of the sulcus is totally eliminated. And conversely, oral epithelium may lose its keratinsation when in contact with tooth. This epithelium is extremely important as it may act as a semipermeable membrane through which injurious bacterial products pass into the gingiva and tissue fluid from the gingiva seeps into the sulcus. Jan Lindhe,Thorkild Karring, Niklaus P. Lang. Clinical Periodontology and Implant Dentistry, fourth editionwww.indiandentalacademy.com
  • 28. It consists of a collarlike band of startified squamous non-keratinised epithelium. It is 3-4 cell layer thick, number of layers increases as age increases.  these cells may be basal or suprabasal Length of the Junctional Epithelium ranges from 0.25 to 1.35 mm. It is formed by the confluence of the oral epithelium and the reduced enamel epithelium during tooth eruption. Jan Lindhe,Thorkild Karring, Niklaus P. Lang. Clinical Periodontology and Implant Dentistry, fourth editionwww.indiandentalacademy.com
  • 29. It is attached to the tooth surface by means of an internal basal lamina, and to the underlying connective tissue layer through an external basal lamina. The attachment of the junctional epithelium to the tooth is reinforced by the ginigival fibres which brace the marginal gingiva against the tooth surface. For this reason, junctional epithelium and gingival fibres are considered a functional unit, referred to as ‘dentogingival unit’. Jan Lindhe,Thorkild Karring, Niklaus P. Lang. Clinical Periodontology and Implant Dentistry, fourth editionwww.indiandentalacademy.com
  • 30. Circular fibres (CF) are fibre bundles which run their course in the free gingiva and encircle the tooth in a cuff- or ring-like fashion. Dentogingival fibres (DGF) are embedded in the cementum of the supra-alveolar portion of the root and project from the cementum in a fan- like configuration out into the free gingival tissue of the facial, lingual and interproximal surfaces. Jan Lindhe,Thorkild Karring, Niklaus P. Lang. Clinical Periodontology and Implant Dentistry, fourth editionwww.indiandentalacademy.com
  • 31. Dentoperiosteal fibres (DPF) are embedded in the same portion of the cementum as the dentogingival fibres, but run their course apically over the vestibular and lingual bone crest and terminate in the tissue of the attached gingiva. In the border area between the free and attached gingiva, the epithelium often lacks support by underlying oriented collagen fibre bundles. In this area the free gingival groove (GG) is often present. Transseptal fibres (TF), extends between the supra- alveolar cementum of approximating teeth.The transseptal fibres run straight across the interdental septum and are embedded in the cementum of adjacent teeth. Jan Lindhe,Thorkild Karring, Niklaus P. Lang. Clinical Periodontology and Implant Dentistry, fourth editionwww.indiandentalacademy.com
  • 32. TF Jan Lindhe,Thorkild Karring, Niklaus P. Lang. Clinical Periodontology and Implant Dentistry, fourth edition www.indiandentalacademy.com
  • 33. The periodontal ligament is the soft, richly vascular and cellular connective tissue which surrounds the roots of the teeth and joins the root cementum with socket wall. In the coronal direction, the periodontal ligament is continuous with the lamina propria of the gingiva and is demarcated from the gingiva by the collagen fibre bundles which connect the alveolar bone crest with the root. Jan Lindhe,Thorkild Karring, Niklaus P. Lang. Clinical Periodontology and Implant Dentistry, fourth edition www.indiandentalacademy.com
  • 34. In radiographs, two types of alveolar bone can be distinguished: 1.The part of the alveolar bone which covers the alveolus, called ‘lamina dura’. 2.The portion of the alveolar process which, in the radiograph, has the appearance of a meshwork.This is called the ‘spongy bone’. Jan Lindhe,Thorkild Karring, Niklaus P. Lang. Clinical Periodontology and Implant Dentistry, fourth edition www.indiandentalacademy.com
  • 35. The tooth is joined to the bone by bundles of collagen fibres which can be divided into the following main groups according to their arrangement:  alveolar crest fibres  horizontal fibres  oblique fibres  apical fibres ACF HF OF APF Jan Lindhe,Thorkild Karring, Niklaus P. Lang. Clinical Periodontology and Implant Dentistry, fourth editionwww.indiandentalacademy.com
  • 36. The periodontal ligament is situated in the space between the roots of the teeth and the lamina dura or the alveolar bone proper.The alveolar bone surrounds the tooth to a level approximately 1 mm apical to the cemento- enamel junction.The coronal border of the bone is called the alveolar crest. The width of the periodontal ligament is approximately 0.25 mm (range 0.2-0.4 mm). Jan Lindhe,Thorkild Karring, Niklaus P. Lang. Clinical Periodontology and Implant Dentistry, fourth edition www.indiandentalacademy.com
  • 37. The periodontal ligament and the root cementum develop from the loose connective tissue (the follicle) which surrounds the tooth bud. Jan Lindhe,Thorkild Karring, Niklaus P. Lang. Clinical Periodontology and Implant Dentistry, fourth edition www.indiandentalacademy.com
  • 38. The various stages in the organization of the periodontal ligament which forms concomitantly with the development of the root and the eruption of the tooth. Jan Lindhe,Thorkild Karring, Niklaus P. Lang. Clinical Periodontology and Implant Dentistry, fourth edition www.indiandentalacademy.com
  • 39. The tooth bud is formed in a crypt of the bone. The collagen fibres produced by the fibroblasts in the loose connective tissue around the tooth bud are, during the process of their maturation, embedded into the newly formed cementum immediately apical to the cemento-enamel junction. The true periodontal ligament fibres, the principal fibres, develop in conjunction with the eruption of the tooth. First, fibres can be identified entering the most marginal portion of the alveolar bone. Later, more apically positioned bundles of oriented collagen fibres are seen. Jan Lindhe,Thorkild Karring, Niklaus P. Lang. Clinical Periodontology and Implant Dentistry, fourth edition www.indiandentalacademy.com
  • 40. The orientation of the collagen fibre bundles alters continuously during the phase of tooth eruption. First, when the tooth has reached contact in occlusion and is functioning properly, the fibres of the periodontal ligament associate into groups of well oriented dentoalveolar collagen fibres Jan Lindhe,Thorkild Karring, Niklaus P. Lang. Clinical Periodontology and Implant Dentistry, fourth edition www.indiandentalacademy.com
  • 41. TF These fibre bundles oriented towards the coronal portion of the bone crypt will later form the dentogingival fibre group, the dentoperiosteal fibre group and the transseptal fibre group which belong to the oriented fibres of the gingiva. Jan Lindhe,Thorkild Karring, Niklaus P. Lang. Clinical Periodontology and Implant Dentistry, fourth edition www.indiandentalacademy.com
  • 42. 1. First, small, fine, brush-like fibrils are detected arising from the root cementum and projecting into the PDL space. 2. Later on, the number and thickness of fibres entering the bone increase.These fibres radiate towards the loose connective tissue in the mid-portion of the periodontal ligament area 3. The fibres originating from the cementum subsequently increase in length and thickness and fuse in the periodontal ligament space with the fibres originating from the alveolar bone. 1 2 3 Jan Lindhe,Thorkild Karring, Niklaus P. Lang. Clinical Periodontology and Implant Dentistry, fourth edition www.indiandentalacademy.com
  • 43. The cells of the periodontal ligament are: fibroblasts, osteoblasts, cementoblasts, osteoclasts, as well as epithelial cells and nerve fibres.The fibroblasts are aligned along the principal fibres, while cementoblasts line the surface of the cementum, and the osteoblasts line the bone surface. Jan Lindhe,Thorkild Karring, Niklaus P. Lang. Clinical Periodontology and Implant Dentistry, fourth edition www.indiandentalacademy.com
  • 44. The cementum is a specialized mineralized tissue covering the root surfaces and, occasionally, small portions of the crown of the teeth. It has many features in common with bone tissue. However, the cementum contains no blood or lymph vessels, has no innervation, does not undergo physiologic resorption or remodeling, but is characterized by continuing deposition throughout life. It attaches the periodontal ligament fibres to the root and contributes to the process of repair after damage to the root surface. Jan Lindhe,Thorkild Karring, Niklaus P. Lang. Clinical Periodontology and Implant Dentistry, fourth edition www.indiandentalacademy.com
  • 45. 1. Acellular, extrinsic fibre cementum (AEFC) is found in the coronal and middle portions of the root and contains mainly bundles of Sharpey's fibres.This type of cementum is an important part of the attachment apparatus and connects the tooth with the alveolar bone proper. 2. Cellular, mixed stratified cementum (CMSC) occurs in the apical third of the roots and in the furcations. It contains both extrinsic and intrinsic fibres as well as cementocytes. 3. Cellular, intrinsic fibre cementum (CIFC) is found mainly in resorption lacunae and it contains intrinsic fibres and cementocytes. Jan Lindhe,Thorkild Karring, Niklaus P. Lang. Clinical Periodontology and Implant Dentistry, fourth edition www.indiandentalacademy.com
  • 46. The alveolar process is defined as the parts of the maxilla and the mandible that form and support the sockets of the teeth. The alveolar process consists of bone which is formed both by cells from the dental follicle (alveolar bone proper) and cells which are independent of tooth development. Together with the root cementum and the periodontal membrane, the alveolar bone constitutes the attachment apparatus of the teeth, the main function of which is to distribute and resorb forces generated during mastication and other tooth contacts. Jan Lindhe,Thorkild Karring, Niklaus P. Lang. Clinical Periodontology and Implant Dentistry, fourth edition www.indiandentalacademy.com
  • 47. The walls of the sockets are lined by cortical bone, and the area between the sockets and between the compact jaw bone walls is occupied by cancellous bone. The cancellous bone occupies most of the interdental septa but only a relatively small portion of the buccal and palatal bone plates.The cancellous bone contains bone trabeculae, the architecture and size of which are partly genetically determined and partly the result of the forces to which the teeth are exposed during function. Jan Lindhe,Thorkild Karring, Niklaus P. Lang. Clinical Periodontology and Implant Dentistry, fourth editionwww.indiandentalacademy.com
  • 48. At the buccal aspect of the jaws, the bone coverage is sometimes missing at the coronal portion of the roots, forming a so-called dehiscence. If some bone is present in the most coronal portion of such an area the defect is called a fenestration. These defects often occur where a tooth is displaced out of the arch and are more frequent over anterior than posterior teeth.The root in such defects is covered only by periodontal ligament and the overlying gingiva. Jan Lindhe,Thorkild Karring, Niklaus P. Lang. Clinical Periodontology and Implant Dentistry, fourth editionwww.indiandentalacademy.com
  • 49. Horizontal bone loss Bone deformities Vertical or angular defects Osseous Craters Bulbous bone contours Reversed architecture Ledges Furcation involvement Newman,Takei, Carranza. Clinical Periodontology, ninth edition.www.indiandentalacademy.com
  • 50. Horizontal bone loss is the most common patterns of bone loss in periodontal disease. The bone is reduced in height, but the bone margin remains roughly perpendicular to the tooth surface, the interdental septa and facial and lingual plates are affected. Newman,Takei, Carranza. Clinical Periodontology, ninth edition.www.indiandentalacademy.com
  • 51. www.indiandentalacademy.com
  • 52. Different types of bone deformities can occur from periodontal disease. Their presence may be suggested on radiographs, but careful probing and surgical exposure of the areas is required to exactly determine their exact conformation and dimensions Newman,Takei, Carranza. Clinical Periodontology, ninth edition.www.indiandentalacademy.com
  • 53. Vertical or angular bone defects are those that occur in an oblique direction, leaving a hollowed out trough in the bone alongside the root; the base of the defect is located apical to the surrounding bone. They have accompanying infra bony pockets. They are classified based on the number of osseous walls.They may have one, two or three walls.The number of walls in the apical portion of the defect may be greater than in its occlusal portion, in which case it is called a combined osseous defect. Newman,Takei, Carranza. Clinical Periodontology, ninth edition.www.indiandentalacademy.com
  • 54. Newman,Takei, Carranza. Clinical Periodontology, ninth edition.www.indiandentalacademy.com
  • 55. Defects interdentally can be seen radiographically. Buccal and lingual defects cannot be visualised radiographically. Three wall vertical bone defect was originally called an intrabony defect, which was later expanded to designate all vertical bone defects. This defect acts most frequently on the mesial aspects of second and third maxillary and mandibular molars. The one wall defect is also called hemiseptum. Newman,Takei, Carranza. Clinical Periodontology, ninth edition.www.indiandentalacademy.com
  • 56. They are concavities in the crest of the interdental bone confined within facial and lingual walls. They form about one thirds of all bone defects and about two thirds of the mandibular bone defects. The high incidence of osseous craters is due to:  Interdental area collects plaque and is difficult to clean  The normal flat or even concave faciolingual shape of the interdental septum in lower molars may favour crater formation  Vascular patterns from the gingiva to the center of the crest may provide a pathway for inflammation. Newman,Takei, Carranza. Clinical Periodontology, ninth edition.www.indiandentalacademy.com
  • 57. They are bony enlargements caused by exostoses, adaptation to function, or buttressing bone formation Found more frequently in the maxilla than the mandible. Newman,Takei, Carranza. Clinical Periodontology, ninth edition.www.indiandentalacademy.com
  • 58. They are plateau like bone margins casued by resorption of thickened bony plates. Newman,Takei, Carranza. Clinical Periodontology, ninth edition.www.indiandentalacademy.com
  • 59. They are produced by loss of interdental bone, including the facial plates, lingual plates or both, without concomitant loss of radicular bone, thereby reversing the normal architecture. Such defects are common in the maxilla. Newman,Takei, Carranza. Clinical Periodontology, ninth edition.www.indiandentalacademy.com
  • 60. It refers to the invasion of the bifurcation and trifurcation of multirooted teeth by periodontal disease. Mandibular molars are the most common site. The denuded furcation may be visible clinically or may be covered by the walls of the pocket. Newman,Takei, Carranza. Clinical Periodontology, ninth edition.www.indiandentalacademy.com
  • 61. Degree 1: Horizontal loss of supporting tissues not exceeding 1/3 of the width of the tooth. Degree 2: Horizontal loss of supporting tissues exceeding 1/3 of the width of the tooth, but not encompassing the total width of the furcation area. Degree 3: Horizontal ‘through-and-through’ destruction of the supporting tissues in the furcation. Newman,Takei, Carranza. Clinical Periodontology, ninth edition.www.indiandentalacademy.com
  • 62. Oral Surgical Procedures Periodontal Surgeries Endodontics Orthodontics Fixed Prosthodontics Removable Prosthodontics Stephen F. Rosensteil, Martin F. Land, Junheo Fujimoto. Contemporary Fixed Prosthodontics, fourth edition. www.indiandentalacademy.com
  • 63. An important part of treatment sequencing is the elimination of teeth with hopeless prognosis, unerupted teeth, residual roots. Periodontally compromised teeth are best extracted at the earliest, so as to enable the sockets to heal faster and also provide better access for plaque control of the adjacent teeth. Also a transitional or provisional partial removable/fixed prosthesis may be fabricated which stabilises the arch and potentially maintains and improves occlusion, function and esthetics. Stephen F. Rosensteil, Martin F. Land, Junheo Fujimoto. Contemporary Fixed Prosthodontics, fourth edition. www.indiandentalacademy.com
  • 64. Periodontal Surgeries are undertaken for pocket elimination, mucogingival procedures, guided tissue regeneration and root resections Stephen F. Rosensteil, Martin F. Land, Junheo Fujimoto. Contemporary Fixed Prosthodontics, fourth edition. www.indiandentalacademy.com
  • 65. Preliminary Phase  Treatment of emergencies: ▪ Dental/periapical ▪ Periodontal ▪ Other  This phase includes the extraction of teeth with hopeless prognosis, and also provisional replacements if needed. Newman,Takei, Carranza. Clinical Periodontology, ninth edition.www.indiandentalacademy.com
  • 66. Phase ITherapy (Etiotropic)  Plaque control and patient education  Diet control  Removal of calculus, root planing  Correction of prosthtic and restorative irritational factors  Excavation of caries and restoration  Antimicrobial therapy  Occlusal therapy  Minor orthodontic movement  Provisional splinting and prosthesis Newman,Takei, Carranza. Clinical Periodontology, ninth edition.www.indiandentalacademy.com
  • 67. Phase IITherapy (Surgical)  Periodontal therapy, including placement of implants  Endodontic therapy Phase IIITherapy (Restorative)  Final Restorations  Fixed and Removable Prosthodontics Phase IVTherapy (Maintenance)  Periodic reevaluation Newman,Takei, Carranza. Clinical Periodontology, ninth edition.www.indiandentalacademy.com
  • 68. This phase of periodontal therapy aims at the controlling the active disease. Obtaining control of periodontal inflammation results in restorations of a much higher quality than would be obtained if restoration were carried out in an environment of gingival inflammation. There is a possibility of continual bleeding and exudation of inflammatory tissue fluid into the gingival crevice and into the environment of restorative dental procedures. Newman,Takei, Carranza. Clinical Periodontology, ninth edition.www.indiandentalacademy.com
  • 69. The removal of etiologic factors causing gingival inflammation results in a return to a healthy gingival state within 1 to 2 weeks. Thus plaque control, calculus removal and the correction of any inadequate dental restorations in the gingival environment should be important initial procedures. Newman,Takei, Carranza. Clinical Periodontology, ninth edition.www.indiandentalacademy.com
  • 70. NewAttachment Long junctional epithelium Root resorption and ankylosis Recurrence of Pocket www.indiandentalacademy.com
  • 71. www.indiandentalacademy.com
  • 72. www.indiandentalacademy.com
  • 73. Periodontal surgical procedures must be carried out with due regard to restorative needs of the patient. The final level of the periodontium should allow good access to all restorative marginal regions, and any necessary increase in clinical crown length should be obtained by postsurgical positioning of periodontal tissues. If restorative procedures necessitate the resolution of mucogingival inadequacies, the appropriate surgical procedure should be completed before restorative therapy begins. Newman,Takei, Carranza. Clinical Periodontology, ninth edition.www.indiandentalacademy.com
  • 74. It is often necessary to carry out a free soft tissue, autograft in the patient who has a mucogingival defect associated with gingival inflammation and requires a dental restoration in the immediate environment of the gingiva. Periodontal plastic surgery must be carried out at least 2 months before the placement of the restorations.This allows for mature tissue to form in the gingival margin so that restorative procedures do not cause a return in clinical inflammation. Augmentation of keratinised gingiva provides stability of the free gingival margin and surrounding gingival tissues so that the dental restoration can be placed in an environment in which gingival health can be maintained. Newman,Takei, Carranza. Clinical Periodontology, ninth edition.www.indiandentalacademy.com
  • 75. In situations where a tooth has a short clinical crown deemed inadequate for the retention of a required cast restoration, it is necessary to increase the size of the clinical crown using periodontal surgical procedures. These procedures enable the dentist performing the restoration to develop an adequate area for crown retention without extending the crown margins deep, encroaching into the biological width. Newman,Takei, Carranza. Clinical Periodontology, ninth edition.www.indiandentalacademy.com
  • 76. The term biologic width describes the junctional epithelium and connective tissue that attach to the tooth surface. Average length is 2 mm The healthy gingiva coronal to the junctional epithelium, which is not attached to the tooth surface, has an average depth of 0.69mm. Newman,Takei, Carranza. Clinical Periodontology, ninth edition.www.indiandentalacademy.com
  • 77. The biologic width usually remains constant. If the restorative margin is placed into this area, the crestal bone will be lost to reestablish the biologic width.The other consequence of margin placement into this area is gingival inflammation and pocket formation. The surgical procedure to expose adequate clinical crown to prevent the placement of the crown margin into the area of the biologic width is termed crown lengthening surgery. A gingivectomy technique can be used to eliminate the tissue that forms the pocket or sulcus wall; such tissue may be overgrown. And may interfere with the intended restorative procedure. Newman,Takei, Carranza. Clinical Periodontology, ninth edition.www.indiandentalacademy.com
  • 78. It is essential that there may be at least 3 mm between the most apical extension of the restoration margin and the alveolar bone crest. This space allows for sufficient tooth for the supracrestal collagen fibres that are a part of the periodontal support mechanism, as well as providing a gingival crevice of 2 to 3 mm. If this guideline is used the margin of the crown is finally positioned at its correct level, approximately half way down the gingival crevice. Newman,Takei, Carranza. Clinical Periodontology, ninth edition.www.indiandentalacademy.com
  • 79. Failure to allow sufficient space between the crown margin and the alveolar crest height means that the finished restoration is positioned deep in the periodontal tissues and results in inflammation and pocket formation. Newman,Takei, Carranza. Clinical Periodontology, ninth edition.www.indiandentalacademy.com
  • 80. These procedures are aimed at correcting the excessive loss of alveolar bone that sometimes occurs in the anterior region as a consequence of advanced periodontal disease, advanced periapical bone loss, traumatic tooth extractions, and external trauma.This excessive bone loss may create a difficult esthetic problem and complicate the prosthetic reconstruction. Newman,Takei, Carranza. Clinical Periodontology, ninth edition.www.indiandentalacademy.com
  • 81. In a fixed restoration, the large space may result in either a long pontic or a space between the apical end of the pontic and resorbed ridge. These defects may occur in a coronoapical or buccolingial direction, or both. The roll technique was reported by Abrams to managemoderate tissue loss in buccolingual direction. In more extensive cases, subepithelial connective tissue grafts may be used. Newman,Takei, Carranza. Clinical Periodontology, ninth edition.www.indiandentalacademy.com
  • 82. Newman,Takei, Carranza. Clinical Periodontology, ninth edition.www.indiandentalacademy.com
  • 83. Newman,Takei, Carranza. Clinical Periodontology, ninth edition.www.indiandentalacademy.com
  • 84. www.indiandentalacademy.com
  • 85. Three options:  Supragingival  Equigingival  Subgingival Supragingical margins have the least impact on the periodontium, this type of margin may be applied in nonesthetic areas due to marked contrast in colour and opacity of traditional restorative materials against the tooth. The use of equigingival margins traditionally was not desirable because they were thought to retain more plaque, and result in greater gingival inflammation. Newman,Takei, Carranza. Clinical Periodontology, ninth edition.www.indiandentalacademy.com
  • 86. With the advent of newer restorative materials have reduced the concerns, not only because the restoration margins can be esthetically blended with the tooth but also because the restoration can be finished easily to provide a smooth, polished interface at the gingival margin. Newman,Takei, Carranza. Clinical Periodontology, ninth edition.www.indiandentalacademy.com
  • 87. Gargiulo,Wentz, Orbans They found that the connective tissue attachment occupies 1.07 mm of space above the crest of the alveolar bone and that the junctional epithelium occupies another 0.97 mm of space above the connective tissue attachment. The combination of these two widths constitute the biologic width. Clinically, this information is applied to diagnose biologic width violations when the restoration mrgin is placed 2 mm or less away from the alveolar bone and the gingival tissues are inflamed with no other etiologic factor. Newman,Takei, Carranza. Clinical Periodontology, ninth edition.www.indiandentalacademy.com
  • 88. Newman,Takei, Carranza. Clinical Periodontology, ninth edition.www.indiandentalacademy.com
  • 89. Restorative considerations often dictate placement of restoration margins beneath the gingival tissue crest. Restorations may need to be extended gingivally to create adequate resistance and retentive form in the preparation, to make significant contour alterations because of caries or other tooth deficiencies, or to mask the tooth/restoration interface by locating it subgingivally. Newman,Takei, Carranza. Clinical Periodontology, ninth edition.www.indiandentalacademy.com
  • 90. When the restoration margin is placed too far below the gingival tissue crest, it impinges on the gingival attachment apparatus and creates a violation of the biologic width. Two different responses may be seen from the gingival tissues: 1. Bone loss of an unpredictable nature and gingival tissue recession occurs as the body attempts to recreate room between the alveolar bone and margin to allow space for tissue reattachment.This is more likely to occur in areas where alveolar bone surrounding the tooth is very thin.Trauma from restorative procedures may play a major role in causing gingival recession. Newman,Takei, Carranza. Clinical Periodontology, ninth edition.www.indiandentalacademy.com
  • 91. Newman,Takei, Carranza. Clinical Periodontology, ninth edition.www.indiandentalacademy.com
  • 92. 2. More common finding with deep margin placement is that the bone level appears to remain unchanged, but gingival inflammation develops and persists.To restore gingival tissue health, it is necessary to clinically establish space between the alveolar bone and the margin, this can be established by surgery to alter the bone level or by orthodontic extrusion to move the margin farther away from the bone level. Newman,Takei, Carranza. Clinical Periodontology, ninth edition.www.indiandentalacademy.com
  • 93. They can be corrected by either surgically removing the cone away from proximity to the restoration margin or orthodontically extruding the tooth and thus moving the margin away from the bone. Surgery is the more rapid of the two treatment options. It Is also preferred if the resulting crown lengthening will create a more pleasing tooth length. In these situations, the bone should be moved away from the margin by the measured distance of the ideal biologic width for that patient with an additional 0.5 mm of bone removed as a safety zone. Newman,Takei, Carranza. Clinical Periodontology, ninth edition.www.indiandentalacademy.com
  • 94. Gingival recession is a potential risk after removal of bone. If interproximal bone is removed, there is a high likelihood of papillary recession and the creation of an unesthetic triangle of space below the interproximal contacts. If the biologic width violation is on the interproximal, or if the violation is across the facial surface and the gingival tissue level is correct, then orthodontic extrusion is indicated. Newman,Takei, Carranza. Clinical Periodontology, ninth edition.www.indiandentalacademy.com
  • 95. When determining where to place restorative margins relative to the periodontal attachment, it is recommended that the patient's existing sulcus depth be used as a guideline in assessing the biologic width requirement for that patient. The base of the sulcus can be viewed as the top of the attachment, and therefore variations in attachment height are accounted for by assuring that the margin is placed in the sulcus and not in the attachment. The variations in sulcular probing depth are then used to predict how deeply the margin can safely be placed below the gingival crest.With shallow probing depths (1 to 1.5 mm), extending the preparation more than 0.5 mm subgingivally will risk violating the attachment. Newman,Takei, Carranza. Clinical Periodontology, ninth edition.www.indiandentalacademy.com
  • 96. This assumes that the periodontal probe penetrates an average of 0.5 mm into the epithelial attachment in healthy gingiva. With shallow probing depths, future recession is unlikely because the free gingival margin is located close to the top of the attachment. Deeper sulcular probing depths provide more freedom in locating restoration margins farther below the gingival crest. However, in most circumstances, the deeper the gingival sulcus, the greater the risk of gingival recession.The first step in using sulcus depth as a guide in margin placement is to manage gingival health. Newman,Takei, Carranza. Clinical Periodontology, ninth edition.www.indiandentalacademy.com
  • 97. Once the tissue is healthy, the following three rules can be used to place intracrevicular margins: 1. If the sulcus probes 1.5 mm or less, place the restoration margin 0.5 mm below the gingival tissue crest.This is especially important on the facial aspect and prevents a biologic width violation in a patient who is at high risk in that regard. 2. If the sulcus probes more than 1.5 mm, place the margin one half the depth of the sulcus below the tissue crest.This places the margin far enough below tissue so that it still is covered if the patient is at higher risk of recession. 3. If a sulcus greater than 2 mm is found, especially on the facial aspect of the tooth, then evaluate to see whether a gingivectomy could be performed to lengthen the teeth and create a 1.5-mm sulcus.Then the patient can be treated using Rule 1. Newman,Takei, Carranza. Clinical Periodontology, ninth edition.www.indiandentalacademy.com
  • 98. The rationale for Rule 3 is that deep margin placement is more difficult and the stability of the free gingival margin is less predictable when a deep sulcus exists. Reducing the sulcus depth creates a more predictable situation in which to place an intracrevicular margin. It is not guaranteed that the tissue will remain at the corrected level, because some gingival rebound can occur after gingivectomy. However, it ensures that the restorative margins are not exposed and visible in the patient's mouth. Newman,Takei, Carranza. Clinical Periodontology, ninth edition.www.indiandentalacademy.com
  • 99. Introduction Periodontal Considerations:  Anatomy of the Gingiva and Periodontium  Osseous Defects  Choosing the right graft material  Treatment sequencing for FPD  Sequencing of periodontal therapy ▪ Phase ITherapy  BiologicWidth,Violation of BiologicWidth  Bone Regeneration  Biologic Considerations www.indiandentalacademy.com
  • 100. Hard and Soft tissue defects and their surgical management  Alveolar bone defects  Inadequate tooth structure for restoration of tooth  Recession  Ridge defects  Gingival Overgrowth  Furcation Involvement  Interdental papilla reconstruction Electrosurgery Gingettage, Frenectomy Management of excessive gingival pigmentation www.indiandentalacademy.com
  • 101. www.indiandentalacademy.com
  • 102. Three different processes are associated with the successful bone grafting:  Osteogenesis  Osteoinduction  Osteoconduction Osteogenesis is the formation and development of bone. As osteogenic graft is derieved from or composed of tissue involved in the natural growth or repair of bone.They can encourage bone formation in soft tissues or activate more rapid bone growth at bone sites. Arun K Garg. Bone Biology. www.indiandentalacademy.com
  • 103. Osteoinduction is the process of stimulating osteogenesis.Osteoinductive grafts can be used to enhance bone regeneration and may even cause bone to grow or extend into an area where it is not normally found. Osteoconduction provides a physical matrix or scaffolding for deposition of new bone.They are conducive to bone growth and allow bone appostion from existing bone, but they do not produce bone by themselves when placed within soft tissues. All bone graft materials possess at least any one of these three modes of action. Arun K Garg. Bone Biology. www.indiandentalacademy.com
  • 104. Autogenous bone Allografts Alloplasts, Xenografts, andTissue- Engineered Materials Arun K Garg. Bone Biology. www.indiandentalacademy.com
  • 105. One of the difficult aspects of ridge preservation is choosing the appropriate graft material for the specific site. To determine the material, the clinician must evaulate the size and configuration of the defect and then calculate the amount of bone needed to replace the missing tissue. Larger defects require autogenous bone because it provides maximum amount of cellularity and structure and contains proteins and cells that can cause osteoinduction of new tissue, Smaller defects may be appropriate candidates for allografts, alloplasts, or xenografts. Arun K Garg. Bone Biology. www.indiandentalacademy.com
  • 106. Classification of osseous defects based on the number of walls remaining in the socket, as the treatment needs are different for each case  Five-wall defect  Four-wall defect  Three-wall defect  Two-wall defect  One-wall defect Arun K Garg. Bone Biology. www.indiandentalacademy.com
  • 107. This case may not require any grafting, if there is a large amount of interseptal bone present. If grafting is however indicated, any of the grafting materials in putty or gel consistency may be used for wall support Xenografts like PepGen P-15 Flow(tissue engineered xenograft bovine material in a hydrogel carrier). It allows for osteo conductive healing and preserves the tissue contour. Arun K Garg. Bone Biology. www.indiandentalacademy.com
  • 108. For a site that is missing one or two socket walls or that has one or more extremely thin walls, bone grafting is generally advised at the time of extraction. If not grafted, the bone typically narrows as the wound heals. Autogenous bone is a good choice for this type of a defect because entire bony walls often must be regenerated. If sufficient amount of autogenous bone is not available then allogeneic bone putty may be used. Arun K Garg. Bone Biology. www.indiandentalacademy.com
  • 109. For a site that has lost two socket walls or that has two or more extremely thin walls, bone grafting is strongly recommended at the time of extraction. If the socket is not grafted, the bone often narrows as the wound heals. Autogenous grafts are the preferred material for these defects because entire bony walls must be regenerated. If insufficient autogenous grafts are available, allogenic bone blocks mortised around the margins and within the socket with putty. Arun K Garg. Bone Biology. www.indiandentalacademy.com
  • 110. The graft material of choice for this group of patients is particulate autogenous bone with a barrier membrane or other stiff membrane secured in place with pins or screws. This type of surgical method requires careful planning and soft tissue flap design is of utmost importance. The small amount of autogenous bone required may be harvested from adjacent sites or from the tuberosity area with the use of a trephine bur. Membranes can and generally should be used to maximise the predictability of this graft. Arun K Garg. Bone Biology. www.indiandentalacademy.com
  • 111. It is often referred to as knife edge defects and requires a two stage treatment with bone grafting technique. Graft material of choice is autogenous block graft from the mandibular ramus or anterior symphysis.The graft is placed in the block rather than particulated form of added structural support. Arun K Garg. Bone Biology. www.indiandentalacademy.com
  • 112. Alveolar bone defects Inadequate tooth structure for restoration of tooth Recession Ridge defects GingivalOvergrowth Furcation Involvement Interdental papilla lost KennethW. Aschheim, Barry G. Dale. Esthetic Dentistry , Second Edition www.indiandentalacademy.com
  • 113. www.indiandentalacademy.com
  • 114. Treatment options:  Retained papilla technique  GuidedTissue Regeneration  Osseous Grafting  Palatal or Lingual Ramping  Open Debridement and with buccal ostectomy KennethW. Aschheim, Barry G. Dale. Esthetic Dentistry , Second Edition www.indiandentalacademy.com
  • 115. Provides adequate access to deep anterior defects, allowing for thorough surgical debridement of the area while maintaining the position of the free gingival margin This is accomplished by including the entire interproximal tissue mass in the surgical flap By including the papillary tissues interproximal tissue height is maintained and there is little or no apical shrinkage. KennethW. Aschheim, Barry G. Dale. Esthetic Dentistry , Second Edition www.indiandentalacademy.com
  • 116. www.indiandentalacademy.com
  • 117. Any procedure that attempts to regenerate lost periodontal structures or alveolar process through differential tissue responses. Barrier techniques, using synthetic materials that may or may not resorb, to exclude epithelial ingrowth (periodontal regeneration) or connective tissue ingrowth (alveolar process regeneration) that is believed to interfere with regeneration. Glossary of ProsthodonticTerms – 8 www.indiandentalacademy.com
  • 118. It aims at pocket elimination through reformation of the periodontal connective tissue attachment It is applicable in both the anterior and posterior sextants Not all defects are amenable to this procedure Class II Furcation defects and deep, narrow three-walled defects offer the best prognosis KennethW. Aschheim, Barry G. Dale. Esthetic Dentistry , Second Edition www.indiandentalacademy.com
  • 119. This method for the prevention of epithelial migration along the cemental wall of the pocket is termed ‘GuidedTissue Regeneration’. This is based on the assumptions of Nyman, Lindhe, Karring and Gottlow that only periodontal ligament cells have the potential for regeneration of the attachment aparatus of the tooth. It consists of placing barriers of different types to cover the bone and periodontal ligament, thus temporarily separating then from the gingival epithelium. Newman,Takei, Carranza. Clinical Periodontology, ninth edition.www.indiandentalacademy.com
  • 120. Prevention of Epithelial Migration: Elimination of junctional and pocket epithelia may not be sufficient because the epithelium from the excised margin may rapidly proliferate to become interposed between the healing connective tissue and cementum. Another method proposed to prevent or retard the migration of the epithelium consists of total removal of the interdental papilla covering the defect and its replacement with a free autogenous graft obtained from the palate. During healing, the epithelium necroses, and its migration is retarded. Newman,Takei, Carranza. Clinical Periodontology, ninth edition.www.indiandentalacademy.com
  • 121. Excluding the epithelium and the gingival connective tissue from the root surface during the postsurgical healing phase not only prevents epithelial migration into the wound but also favours repopulation of the area by cells from the periodontal ligament and the bone. Newman,Takei, Carranza. Clinical Periodontology, ninth edition.www.indiandentalacademy.com
  • 122. Alveolar bone is not always necessary to achieve pocket closure since the dense connective tissue attachment to the root surface can provide fill for the defect KennethW. Aschheim, Barry G. Dale. Esthetic Dentistry , Second Edition www.indiandentalacademy.com
  • 123. Four stages are used to successfully regenerate bone and other tissues, abbreviated with the acronym PASS: 1. Primary closure of the wound to promote undisturbed and uninterrupted healing 2. Angiogenesis to provided necessary blood supply and undifferentiated mesenchymal cells 3. Space creation and maintenance to facilitate space for soft tissue/bone in-growth 4. Stability of the wound to induce blood clot formation and allow uneventful healing www.indiandentalacademy.com
  • 124. www.indiandentalacademy.com
  • 125. Deep angular defects, both in the anterior and posterior sextants,Three walled defects and Craters Two primary materials used are:  DFDCB(Decalcified Freeze-Dried Cortical Bone)  Synthetic materials DFDCB aids in regeneration, and the synthetic materials form a scaffolding to allow for osseous tissue ingrowth The resultant pocket closure occurs through a long junctional epithelium KennethW. Aschheim, Barry G. Dale. Esthetic Dentistry , Second Edition www.indiandentalacademy.com
  • 126. Surgical Access to the defect site is gained via a flap designed to maintain the marginal tissues, defects are debrided, graft materials are placed into the defect, and flaps replaced to achieve a primary closure KennethW. Aschheim, Barry G. Dale. Esthetic Dentistry , Second Edition www.indiandentalacademy.com
  • 127. It is an esthetic procedure that may be used in the posterior sextant. Here, a palatal or lingual ramping of the alveolar defects without involving the buccal boneis carried out. Ostectomy of the crater like defects is done This results in increased crown height on the palatal/lingual aspect of the teeth, with the gingival tissues angled palatally or lingually Buccal height of the tissue remains intact as the buccal bone is spared KennethW. Aschheim, Barry G. Dale. Esthetic Dentistry , Second Edition www.indiandentalacademy.com
  • 128. There is a need for buccal ostectomy in certain cases as in markedly uneven buccal bony profile KennethW. Aschheim, Barry G. Dale. Esthetic Dentistry , Second Edition www.indiandentalacademy.com
  • 129. www.indiandentalacademy.com
  • 130. Causes:  Caries  Trauma KennethW. Aschheim, Barry G. Dale. Esthetic Dentistry , Second Edition www.indiandentalacademy.com
  • 131. Surgical crown lengthening  This involves as apical flap positioning with ostectomy around the involved tooth and adjacent tooth.  At least 3-4 mm of sound root structure must be exposed below the most apical extent of the proposed restoration.  In addition, the alveolar crest of the adjacent teeth must be blended in with the involved tooth, otherwise an uneven unesthetic gingival profile results. KennethW. Aschheim, Barry G. Dale. Esthetic Dentistry , Second Edition www.indiandentalacademy.com
  • 132. Crown lengthening may be required to solve problems such as  Inadequate amount of tooth structure for proper restorative therapy  Subgingival location of fracture lines  Subgingival location of carious lesions Crown lengthening may be done for esthetic or functional reasons Ratnadeep Patil. Esthetic dentistry: An artist's science. www.indiandentalacademy.com
  • 133. When a disparity in the clincial crown length exists between contralateral teeth resulting in a left/right side height discrepancy, esthetic surgical correction can be provided to enhance the cosmetic result before restorative measures. Ratnadeep Patil. Esthetic dentistry: An artist's science. www.indiandentalacademy.com
  • 134. When such a procedure is carried out in order to gain crown length for restorative purposes. The gingiva and bone follow a definite pattern interproximally, facially and palatally. Whenever the functional requirement needs more than 2 mm of bone resection on the facial and palatal osseous crest, a facial and palatal flap must be reflected and osseous resection is done all over including the interproximal region. This helps to maintain the osseous contour around the tooth Ratnadeep Patil. Esthetic dentistry: An artist's science. www.indiandentalacademy.com
  • 135. Ratnadeep Patil. Esthetic dentistry: An artist's science. www.indiandentalacademy.com
  • 136. Uneven free gingival margin Sub marginal Incision Full thickness reflection Ostectomy Apically positioned flap & sutured 3 weeks Post operative An Esthetic restoration after 2 months of healing www.indiandentalacademy.com
  • 137. Forced eruption with fibrotomy  When ostectomy will result in extremely long clinical crowns and significantly weakened periodontal support, or when a surgical procedure is medially contraindicated, orthodontic forced eruption with sulcular fibrotomy may be performed.  Here, orthodontic force is applied to the tooth involved in an occlusal direction while supracrestal connective tissue fibres are severed every 4 days.  The fibrotomy prevents the tooth and alveolar bone from erupting as a unit, exposing sound tooth without changing the position of the alveloar crest or the free gingival margin. KennethW. Aschheim, Barry G. Dale. Esthetic Dentistry , Second Edition www.indiandentalacademy.com
  • 138. www.indiandentalacademy.com
  • 139.  The orthodontics will pull the root out of the bone, exposing the needed 3-4 mm of sound tooth structure, while the fibrotomy will prevent coronal reformation of the alveolar bone and maintain the free gingival margin at its original level.  In addition to achieving the desired results, the crown to root ratio of the adjacent teeth remains intact and decreases for the involved tooth, thus improving the long-term periodontal prognosis. KennethW. Aschheim, Barry G. Dale. Esthetic Dentistry , Second Edition www.indiandentalacademy.com
  • 140. www.indiandentalacademy.com
  • 141. Causes:  Abrasion  Periodontitis  Trauma  Inadequacy of attached gingiva KennethW. Aschheim, Barry G. Dale. Esthetic Dentistry , Second Edition www.indiandentalacademy.com
  • 142. Miller has described a useful classification of recession defects, taking into consideration the anticipated root coverage that it is possible to obtain  Class I: Marginal tissue recession not extending to the mucogingival junction. No loss of interdental bone or soft tissue.  Class II: Marginal tissue recession extends to or beyond the mucogingival junction. No loss of interdental bone or soft tissue.  Class III: Marginal tissue recession extends to or beyond the mucogingival junction. Loss of interdental bone or soft tissue is apical to the cementoenamel junction, but coronal to the apical extent of the marginal tissue recession.  Class IV: Marginal tissue recession extends beyond the mucogingival junction. Loss of interdental bone extends to a level apical to the extent of the marginal tissue recession.www.indiandentalacademy.com
  • 143. www.indiandentalacademy.com
  • 144. While complete root coverage can be achieved in Class I and II defects, only partial coverage may be expected inClass III. Class IV recession defects are not amenable to root coverage. KennethW. Aschheim, Barry G. Dale. Esthetic Dentistry , Second Edition www.indiandentalacademy.com
  • 145. Free gingival grafts Lateral pedicle grafts Subepithelial connective tissue grafts KennethW. Aschheim, Barry G. Dale. Esthetic Dentistry , Second Edition www.indiandentalacademy.com
  • 146. Predictable results for augmentation in the zone of attached gingiva, success in covering exposed root surfaces is less predictable and depends on various factors  Dimension of the root surface to be covered  Lateral probing depth  Position of the tooth in the arch Areas of narrow recession have better root coverage potential than deeper, wider areas of recession. KennethW. Aschheim, Barry G. Dale. Esthetic Dentistry , Second Edition www.indiandentalacademy.com
  • 147. Preoperative Incision to remove wide zone of tissue Graft placed over CE jn. Graft sutured firmly in place 2 months Postoperative www.indiandentalacademy.com
  • 148. Factors to be considered:  Amount of keratinised tissue adjacent to the recipient site  Existence of an adjacent edentulous ridge  Existence of frena that could cause excessive pull  Width of the recipient root surface The pedicle graft procedures are, depending on the direction of transfer, grouped as (1) rotational flap procedures (e.g. laterally sliding flap, double papilla flap, oblique rotated flap) or (2) advanced flap procedures (e.g. coronally repositioned flap, semilunar coronally repositioned flap). KennethW. Aschheim, Barry G. Dale. Esthetic Dentistry , Second Edition www.indiandentalacademy.com
  • 149. While using this type of a graft, a well keratinised edentulous ridge or a wide zone of attached gingiva adjacent to the graft site is ideal. However, if the recipient area to be grafted is wide mesiodistally, excessive pull may occur on the donor tissue, causing strangulation and failure Healing period of 6 weeks is advised before any prosthetic treatment KennethW. Aschheim, Barry G. Dale. Esthetic Dentistry , Second Edition www.indiandentalacademy.com
  • 150. www.indiandentalacademy.com
  • 151. www.indiandentalacademy.com
  • 152. This technique involves the placement of a a strip of connective tissue from the palate under a partial thickness flap.The recipient site is prepared with a split thickness dissection, retaining all epithelium in the flap. An envelope procedure is performed on the palate to obtain the connective tissue. Advantages of this procedure include, no denudation of the donor site, increasing patient comfort during the healing phase, double blood supply to the connective tissue graft (from the underlying periosteum and the overlying connective tissue of the flap). KennethW. Aschheim, Barry G. Dale. Esthetic Dentistry , Second Edition www.indiandentalacademy.com
  • 153. www.indiandentalacademy.com
  • 154. The edentulous ridge's contour and topography should be carefully evaluated during the treatment planning phase. An ideally shaped ridge has a smooth, regular surface of attached gingiva, which facilitates maintenance of a plaque-free environment. Its height and width should allow placement of a pontic that appears to emerge from the ridge and mimics the appearance of the neighbouring teeth. Stephen F. Rosensteil, Martin F. Land, Junheo Fujimoto. Contemporary Fixed Prosthodontics, fourth edition. www.indiandentalacademy.com
  • 155. Facially, it must be free of frenum attachment and of adequate facial height to sustain the appearance of interdental papillae. Loss of residual ridge contour may lead to unesthetic open gingival embrasures ("black triangles“), food impaction, and percolation of saliva during speech. Stephen F. Rosensteil, Martin F. Land, Junheo Fujimoto. Contemporary Fixed Prosthodontics, fourth edition. www.indiandentalacademy.com
  • 156. A deformed ridge may result from tooth extractions, advanced periodontal disease, abscess formations, etc.The deformity that exists in the ridge is directly related to the volume of root structure and associated bone that is missing or has been destroyed. Stephen F. Rosensteil, Martin F. Land, Junheo Fujimoto. Contemporary Fixed Prosthodontics, fourth edition. www.indiandentalacademy.com
  • 157. Causes:  Visible edentulous ridge defects may be caused due to facial trauma.  Violent avulsion of one or more teeth and surrounding buccal or lingual bone segments often occurs.  Healing of such an injury results in collapse of overlying soft tissue into the depression caused by the bone loss.  A jagged bone topography can be seen with severe attachment loss is seen in case with periodontitis. KennethW. Aschheim, Barry G. Dale. Esthetic Dentistry , Second Edition www.indiandentalacademy.com
  • 158. According to Seibert, ridge defects can be divided into three classes:  Class I: Loss of buccolingual width but normal apicocoronal height  Class II: Loss of apicocoronal height but normal buccolingual width  Class III: A combination of loss of both height and width of the ridge. Jan Lindhe,Thorkild Karring, Niklaus P. Lang. Clinical Periodontology and Implant Dentistry, fourth edition www.indiandentalacademy.com
  • 159. Stephen F. Rosensteil, Martin F. Land, Junheo Fujimoto. Contemporary Fixed Prosthodontics, fourth edition. www.indiandentalacademy.com
  • 160. Ridge augmentation procedures should be preceded by a careful surgical-prosthetic treatment planning by joint consultations involving the surgeon and the restorative dentist in order to attain an optimal esthetic result.The following factors should be determined prior to the initiation of therapy:  Volume of tissue required to eliminate the ridge deformity  Type of graft procedure to be used  Timing of various treatment procedures  Design of the provisional restoration  Potential problems with tissue discolorations and matching tissue colour.www.indiandentalacademy.com
  • 161. Although residual ridge width may be augmented with hard tissue grafts, this is usually not indicated unless the edentulous site is to receive an implant Jan Lindhe,Thorkild Karring, Niklaus P. Lang. Clinical Periodontology and Implant Dentistry, fourth edition www.indiandentalacademy.com
  • 162. GinigivalOnlay Grafts ConnectiveTissue Augmentation Ovate Pontics KennethW. Aschheim, Barry G. Dale. Esthetic Dentistry , Second Edition www.indiandentalacademy.com
  • 163. Buccolingual/Occlusoapical defects, class II defects Adaptation of the free gingival graft technique Thick palatal donor tissue Graft healing – 6-8 weeks Provisionalised with an ovate pontic KennethW. Aschheim, Barry G. Dale. Esthetic Dentistry , Second Edition www.indiandentalacademy.com
  • 164. Internal augmentation Buccolingual/Occlusoapical/Papillary defects Subperiosteal tunnel is created under the soft tissue of the defect, and connective tissue from the donor site is placed to ‘plump out’ the defect. Donor connective tissue:  Free augmentation palatal tissue  Roll augmentation adjacent tissue Provisionalisation: Pontic must allow 1-2 mm of clearance to compensate for postoperative tissue swelling KennethW. Aschheim, Barry G. Dale. Esthetic Dentistry , Second Edition www.indiandentalacademy.com
  • 165. www.indiandentalacademy.com
  • 166. www.indiandentalacademy.com
  • 167. www.indiandentalacademy.com
  • 168. Preservation of the alveolar process can be achieved through immediate restorative and periodontal intervention at the time of tooth removal. By conditioning the extraction site and providing a matrix for healing, the pre-extraction gingival architecture (or "socket") can be preserved. Preparing the abutment teeth before the extraction is the preferred technique. A provisional FPD can be fabricated indirectly, ready for immediate insertion. Because socket preservation is dependent on underlying bone contour, the extraction of the tooth to be replaced should be atraumatic and aimed at preserving the facial plate of bone. www.indiandentalacademy.com
  • 169. The scalloped architecture of interproximal bone forming the extraction site is essential for proper papilla form, as are facial bone levels in the prevention of alveolar collapse. If the bone is compromised before or during extraction, the sockets can be grafted with an allograft material (hydroxyapatite, tricalcium phosphate, or freeze-dried bone). www.indiandentalacademy.com
  • 170. Immediately after preparation of the extraction site, a carefully shaped provisional FPD is placed.The tissue- side of the pontic should be an ovate form, and according to Spear's it should extend approximately 2.5 mm apical to the facial free gingival margin of the extraction socket. As the soft tissues of the socket will begin to collapse immediately after the tooth extraction, the pontic will result in tissue blanching as it supports the papillae and facial/ palatal gingiva. The contour of the ovate tissue-side of the pontic is critical and must conform to within 1 mm of the interproximal and facial bone contour to act as a template for healing. www.indiandentalacademy.com
  • 171. Oral hygiene in this area is difficult during the initial healing period, so the provisional should be highly polished to minimize plaque retention. After approximately 1 month of healing, oral hygiene access is improved by recontouring the pontic to provide 1 to 1.5 mm of relief from the tissue. When the gingival levels are stable (approximately 6 to 12 months), the final restoration can be fabricated. Although maintenance of the residual ridge following extraction is meritorious, socket-preservation techniques are technically challenging and require frequent patient monitoring and conscientious patient hygiene. www.indiandentalacademy.com
  • 172. A pontic that is shaped on its tissue surface like an egg in two dimensions, typically partially submerged in a surgically-prepared soft-tissue depression to enhance the illusion that a natural tooth is emerging from the gingival tissues. Glossary of ProsthodonticTerms – 8 www.indiandentalacademy.com
  • 173. After the desired tissue regeneration is achieved, the area can be modified to allow for fabrication of Ovate or bullet pontics. This type of a pontic creates the illusion of a natural appearance to the adjacent papillae. After adequate maturation of the grafted connective tissue, a round depression is placed into the augmented edentulous crest with a round surgical diamond bur, the dimensions dependent on the tooth to be replaced. The provisional restoration is then relined so that the acrylic material fills in the depression and the area heals by epithelialisation around the pontic. KennethW. Aschheim, Barry G. Dale. Esthetic Dentistry , Second Edition www.indiandentalacademy.com
  • 174. In the final prosthesis, will thus have apically tapered and rounded pontics that fit intimately into the tissue depression.This esthetic pontic design creates the appearance of a natural tooth emerging from a sulcus; the contours of the gingival aspects of the pontics are round without and sharp or abrupt edges. Hygiene can be maintained easily by flossing under the pontic. KennethW. Aschheim, Barry G. Dale. Esthetic Dentistry , Second Edition www.indiandentalacademy.com
  • 175. www.indiandentalacademy.com
  • 176. There is some amount of shrinkage involved in these procedures, sometimes necessitating a second procedure. In the case of occlusoapical and buccolingual defects, several procedures may be needed before the desired results are achieved. Long term esthetic results are usually well worth thee surgical time involved, except for in papillary construction, where the results are quite unpredictable. KennethW. Aschheim, Barry G. Dale. Esthetic Dentistry , Second Edition www.indiandentalacademy.com
  • 177. www.indiandentalacademy.com
  • 178. Causes:  Hyperplasia: o Inflammatory o Non-inflammatory – drug induced, irritants  Altered passive eruption KennethW. Aschheim, Barry G. Dale. Esthetic Dentistry , Second Edition www.indiandentalacademy.com
  • 179. Gingivectomy/gingivoplasty Apically positioned flap with or without ostectomy KennethW. Aschheim, Barry G. Dale. Esthetic Dentistry , Second Edition www.indiandentalacademy.com
  • 180. Gingivectomy – excisional removal of gingival tissue for pocket reduction or elimination. Gingivoplasty – reshaping of the gingiva to attain a more physiologic contour. Treatment of choice with drug or genetically induced hyperplasia, although frequency of recurrence must be considered KennethW. Aschheim, Barry G. Dale. Esthetic Dentistry , Second Edition www.indiandentalacademy.com
  • 181. Indications  Non-inflammatory hyperplasia  Irritation-induced overgrowth  Presence of suprabony pockets  An adequate zone of keratinized tissue  Gingival enlargements  Unaesthetic or asymmetrical gingival topography  To facilitate restorative dentistry Contraindications  Inadequate width of keratinized tissue  Pockets beyond mucogingival junction  Presence of intrabony pockets KennethW. Aschheim, Barry G. Dale. Esthetic Dentistry , Second Edition www.indiandentalacademy.com
  • 182. www.indiandentalacademy.com
  • 183. with or without Ostectomy Altered passive eruption is best treated with this technique.This accomplishes two objectives:  Positions the gingival margin at a normal level  Allows evaluation of the alveolar crest If the alveolar crest is at or above the CE junction, ostectomy is required to first achieve a normal physiologic relationship between tooth and bone before apically positioning the soft tissue. A new biological width is thus established KennethW. Aschheim, Barry G. Dale. Esthetic Dentistry , Second Edition www.indiandentalacademy.com
  • 184. www.indiandentalacademy.com
  • 185. www.indiandentalacademy.com
  • 186. Degree 1: Horizontal loss of supporting tissues not exceeding 1/3 of the width of the tooth. Degree 2: Horizontal loss of supporting tissues exceeding 1/3 of the width of the tooth, but not encompassing the total width of the furcation area. Degree 3: Horizontal ‘through-and-through’ destruction of the supporting tissues in the furcation. Newman,Takei, Carranza. Clinical Periodontology, ninth edition.www.indiandentalacademy.com
  • 187. Furcation involvement degree I Scaling and root planing, Furcation plasty. Furcation involvement degree II Furcation plasty.Tunnel preparation, Root resection,Tooth extraction, Guided tissue regeneration at mandibular molars. Furcation involvement degree III Tunnel preparation, Root resection,Tooth extraction. Jan Lindhe,Thorkild Karring, Niklaus P. Lang. Clinical Periodontology and Implant Dentistry, fourth edition www.indiandentalacademy.com
  • 188. Jan Lindhe,Thorkild Karring, Niklaus P. Lang. Clinical Periodontology and Implant Dentistry, fourth edition www.indiandentalacademy.com
  • 189. Tooth substance is removed (odontoplasty) and the alveolar bone crest is remodeled (osteoplasty) at the level of the furcation entrance. Furcation plasty is used mainly at buccal and lingual furcations. At approximal surfaces access is often too limited for this treatment. Jan Lindhe,Thorkild Karring, Niklaus P. Lang. Clinical Periodontology and Implant Dentistry, fourth edition www.indiandentalacademy.com
  • 190. Jan Lindhe,Thorkild Karring, Niklaus P. Lang. Clinical Periodontology and Implant Dentistry, fourth edition www.indiandentalacademy.com
  • 191. Tunnel preparation is a technique used to treat deep degree II and degree III furcation defects in mandibular molars.This type of resective therapy can be offered at mandibular molars which have a short root trunk, a wide separation angle and long divergence between the mesial and distal root.The procedure includes the surgical exposure and management of the entire furcation area of the affected molar. Jan Lindhe,Thorkild Karring, Niklaus P. Lang. Clinical Periodontology and Implant Dentistry, fourth edition www.indiandentalacademy.com
  • 192. Jan Lindhe,Thorkild Karring, Niklaus P. Lang. Clinical Periodontology and Implant Dentistry, fourth edition www.indiandentalacademy.com
  • 193. Root separation involves the sectioning of the root complex and the maintenance of all roots. Root resection involves the sectioning and the removal of one or two roots of a multirooted tooth. RSR is frequently used in cases of deep degree II and degree III furcation involved molars. Jan Lindhe,Thorkild Karring, Niklaus P. Lang. Clinical Periodontology and Implant Dentistry, fourth edition www.indiandentalacademy.com
  • 194. Factors to be considered:  Length of the root trunk  The divergence between the root cones  The length and the shape of the root cones  Fusion between root cones  Amount of remaining support around individual roots  Stability of individual roots  Access for oral hygiene devices Jan Lindhe,Thorkild Karring, Niklaus P. Lang. Clinical Periodontology and Implant Dentistry, fourth edition www.indiandentalacademy.com
  • 195. Root separation and root resection may be performed as part of the preparation of the segment for prosthetic rehabilitation, i.e. prior to periodontal surgery. During the prosthetic preparation it is important to avoid  exposing the interradicular bone to undue mechanical trauma  leaving behind parts of the furcation fornix perforating the root canals  preparing the vertical surfaces of the remaining roots with sharp angles Jan Lindhe,Thorkild Karring, Niklaus P. Lang. Clinical Periodontology and Implant Dentistry, fourth edition www.indiandentalacademy.com
  • 196. Following separation, both roots are maintained.The distal surface of the distal root and the mesial surface of the mesial root must be prepared parallel with each other to increase the retention for a subsequent restoration. The mesial surface of the distal root and the distal surface of the mesial root should be prepared with diverging angles to increase the space available between the separated roots Jan Lindhe,Thorkild Karring, Niklaus P. Lang. Clinical Periodontology and Implant Dentistry, fourth edition www.indiandentalacademy.com
  • 197. Following flap elevation, osseous resective techniques are used to eliminate angular bone defects that may exist around the maintained roots. Bone resection may also be performed to reduce the buccolingual dimension of the alveolar process of the extraction site.The remaining root(s) may be prepared with a bevel cut to the level of the supporting bone.This additional preparation may serve the purpose of  eliminating residual soft and hard deposits and  eliminating existing undercuts to facilitate the final impression Jan Lindhe,Thorkild Karring, Niklaus P. Lang. Clinical Periodontology and Implant Dentistry, fourth edition www.indiandentalacademy.com
  • 198. The provisional restoration is re-lined.The margins of the provisional restoration must end >_ 3 mm coronal of the bone crest.The soft tissue flaps are secured with sutures at the level of the bone crest.The relined provisional restoration is cemented and a periodontal dressing is applied to cover the surgical area. Jan Lindhe,Thorkild Karring, Niklaus P. Lang. Clinical Periodontology and Implant Dentistry, fourth edition www.indiandentalacademy.com
  • 199. Since the prosthetic preparation of the roots was completed during surgery, the clinician concerns him/herself with only minor adjustments.The preparation margins are located supragingivally, which improves the precision of the definitive crown restoration. The framework of the restoration must be rigid to compensate for the compromised abutments (roots) with a compromised periodontal tissue support. The occlusion should be designed to minimize the infliction of lateral deflective forcesJan Lindhe,Thorkild Karring, Niklaus P. Lang. Clinical Periodontology and Implant Dentistry, fourth editionwww.indiandentalacademy.com
  • 200. www.indiandentalacademy.com
  • 201. There may be several factors contributing to the loss of papilla height and the establishment of "black triangles“ between teeth.The most common reason in the adult individual is loss of periodontal support due to plaque-associated lesions. However, abnormal tooth shape, improper contours of prosthetic restorations and traumatic oral hygiene procedures may also negatively influence the outline of the interdental soft tissues. Jan Lindhe,Thorkild Karring, Niklaus P. Lang.Clinical Periodontology and Implant Dentistry, fourth edition www.indiandentalacademy.com
  • 202. Nordland &Tarnow (1998) proposed a classification system regarding the papillary height adjacent to natural teeth, based on three anatomical landmarks:  the interdental contact point, the apical extent of the  facial cemento-enamel junction (CEJ), and the coronal  extent of the proximal CEJ. Jan Lindhe,Thorkild Karring, Niklaus P. Lang.Clinical Periodontology and Implant Dentistry, fourth edition www.indiandentalacademy.com
  • 203. The interdental papilla occupies the entire embrasure space apical to the interdental contact point/area.  Class I: the tip of the interdental papilla is located between the interdental contact point and the level of the CEJ on the proximal surface of the tooth.  Class II: the tip of the interdental papilla is located at or apical to the level of the CEJ on the proximal surface of the tooth but coronal to the level of the CEJ mid-buccally.  Class III: the tip of the interdental papilla is located at or apical to the level of the CEJ mid-buccally. Jan Lindhe,Thorkild Karring, Niklaus P. Lang.Clinical Periodontology and Implant Dentistry, fourth edition www.indiandentalacademy.com
  • 204. Facial CEJ Interproximal CEJ Interdental contact point Facial CEJ Interproximal CEJ Interdental contact point Jan Lindhe,Thorkild Karring, Niklaus P. Lang.Clinical Periodontology and Implant Dentistry, fourth edition www.indiandentalacademy.com
  • 205. Several techniques have been described for the reconstruction of the deficient papillae. However, the predictability of he various procedures has not been documented and no data is available on the long-term stability of the surgically regained papilla. Jan Lindhe,Thorkild Karring, Niklaus P. Lang.Clinical Periodontology and Implant Dentistry, fourth edition www.indiandentalacademy.com
  • 206. Beagle described a pedicle graft procedure utilising the soft tissues palatal of the interdental area. Jan Lindhe,Thorkild Karring, Niklaus P. Lang.Clinical Periodontology and Implant Dentistry, fourth edition www.indiandentalacademy.com
  • 207. Han andTakei proposed an approach for papilla reconstruction ("semi-lunar coronally repositioned papilla") based on the use of a free connective tissue graft. Jan Lindhe,Thorkild Karring, Niklaus P. Lang.Clinical Periodontology and Implant Dentistry, fourth edition www.indiandentalacademy.com
  • 208. Azzi et al. (1998) described a technique in which an envelope-type flap was prepared for coverage of a connective tissue graft. Jan Lindhe,Thorkild Karring, Niklaus P. Lang.Clinical Periodontology and Implant Dentistry, fourth edition www.indiandentalacademy.com
  • 209. www.indiandentalacademy.com
  • 210. Allows for easy, quick, safe alteration or removal of living tissue of the oral cavity with little or no bleeding. Its indications include, gingivoplasty, removal of hyperplastic tissue, mucoperiosteal surgery, excision of overhanging tissue, frenuli removal, sulcus expansion, hemorrhage control, endodontic procedures, bleaching, biopsy excisions, etc. Jan Lindhe,Thorkild Karring, Niklaus P. Lang.Clinical Periodontology and Implant Dentistry, fourth edition www.indiandentalacademy.com
  • 211. Electrosurgery can be used to contour any gingival architecture that is not conducive to good esthetics or periodontal health, if attention is paid to proper probing and respect for the biological width. Electrosurgical units are convert household current into an electromagnetic radio freequency (RF) wave, which oscillates at a rate of 2-4 Mhz. Because it is impossible for a cell to depolarise at this rate, the resistance of the tissue produces localised intracellular heating without the accompanying muscle contraction. Jan Lindhe,Thorkild Karring, Niklaus P. Lang.Clinical Periodontology and Implant Dentistry, fourth edition www.indiandentalacademy.com
  • 212. It is indicated when improper contours results from any of these causes and when the biological width will not be violated.  Excess tissue caused by ectopic eruption or incomplete passive eruption of one or more teeth  Hypertrophied or malpositioned papialla  Inflamed, hypertrophied gingiva during or after orthodontic treatment  Any hypertrophied tissue from drug therapy such as Dilantin  Any hypertrophied tissue of pathologic origin, including poor oral hygiene Jan Lindhe,Thorkild Karring, Niklaus P. Lang.Clinical Periodontology and Implant Dentistry, fourth editionwww.indiandentalacademy.com
  • 213. Contraindications:  Within 16 feet of unknown frequency pacemakers (Coaxially shielded pacemakers allow for safe use)  Patients who have undergone radiation therapy, due to their decreased vascularisation  Presence of certain chemicals like ethanol, chloroform It must be used with caution when used in conjunction with Nitrous OxideAnalgesia. Jan Lindhe,Thorkild Karring, Niklaus P. Lang.Clinical Periodontology and Implant Dentistry, fourth edition www.indiandentalacademy.com
  • 214. Sparking current  localised but superficial destruction Partially rectified current  coagulates tissue Fully rectified current incises and coagulates Fully rectified filtered current  clean incision Jan Lindhe,Thorkild Karring, Niklaus P. Lang.Clinical Periodontology and Implant Dentistry, fourth edition www.indiandentalacademy.com
  • 215. www.indiandentalacademy.com
  • 216. No pressure is needed for tissue separation Incision is smooth Access to remote regions of the oral cavity is easier than with other surgical modalities Tissue separation occurs with less coagulation. And better visibility Little or no scar tissue formed Sterility is more easily controlled, all bacteria in the line of incision are volatilized at the electrode Electroplaning is possible Allows for planned restorative procedures to be completed in the same appointment, if necessary. Jan Lindhe,Thorkild Karring, Niklaus P. Lang.Clinical Periodontology and Implant Dentistry, fourth edition www.indiandentalacademy.com
  • 217. An abnormal maxillary frenum may cause a pulling force on the gingival margin in some cases leading to gingival inflammation and progressive recession of the gingiva. It may also lead to esthetic problems especially in case of gingival smiles. Correction may be required prior to restorative procedures. A resection or a repositioning of the frenum may be necessary. Whenever there is excessive pressure caused by the frenum then a frenectomy may be the treatment of choice; however when esthetics is the only factor, then frenotomy may be chosen to give the desired results. Ratnadeep Patil. Esthetic dentistry: An artist's science. www.indiandentalacademy.com
  • 218. Saturation of melanin pigments causes an unesthetic dark gingival display.This looks even more unesthetic in people with fair skin and high lip lines. It usually occurs in patches, but may also be seen as a continuous area. Techniques:  Gingivo-abrasion technique  Split thickness epithelial excision  Combination technique Ratnadeep Patil. Esthetic dentistry: An artist's science. www.indiandentalacademy.com
  • 219. www.indiandentalacademy.com
  • 220. It is a troughing method, the purpose of which is to produce limited removal of epithelial tissue in sulcus while a chamfer finish line is being created on the tooth structure. It is used with subgingival palcement of margins. The removal of epithelium from the sulcus by rotary curettage is accomplished with little detectable trauma to soft tissues.Although the tactile sensation is significantly reduced for the operator. It must be done only on healthy, inflammation free tissue to avoid the tissue shrinkage that occurs when diseased tissue heals. HerbertT. Shillingburg, Jr., Sumiya Hobo, Lowell D.Whitsett, Richard Jacobi, Susan E. Brackett. Fundamentals of Fixed Prosthodontics,Third Edition.www.indiandentalacademy.com
  • 221. www.indiandentalacademy.com
  • 222. In conjunction with axial reduction, a shoulder finish line is prepared at the level of the gingival crest with a flat-end tapered diamond.Then a torpedo diamond of 15-180 grit is used to extend the finish line apically, 1/2 to 2/3 the depth of the sulcus, converting the finish line to a chamfer. Tupac and Neacy found no significant histological differences between retraction cord and gingival curettage. Tupac RG, Neacy K: A comparison of cord gingical displacement with gingitage technique.J Prosthet Dent 1981; 46:509-515 www.indiandentalacademy.com
  • 223. Surgical procedures enhance the success of an Fixed Partial Denture Prosthesis.The treatment planning phase is critical for the success of the prosthesis. Correct treatment planning and execution of surgical procedures will result in restorations that are esthetic, functionally sound and easy to maintain. www.indiandentalacademy.com
  • 224. 1. Stephen F. Rosensteil, Martin F. Land, Junheo Fujimoto. Contemporary Fixed Prosthodontics, fourth edition. 2. HerbertT. Shillingburg, Jr., Sumiya Hobo, Lowell D. Whitsett, Richard Jacobi, Susan E. Brackett. Fundamentals of Fixed Prosthodontics,Third Edition. 3. Jan Lindhe,Thorkild Karring, Niklaus P. Lang. Clinical Periodontology and Implant Dentistry, fourth edition 4. Newman,Takei, Carranza. Clinical Periodontology, ninth edition. 5. KennethW. Aschheim, Barry G. Dale. Esthetic Dentistry , Second Edition www.indiandentalacademy.com
  • 225. 5. Arun K Garg. Bone Biology. 6. Glossary of Prosthodontics terms – 8, ACP 7. Tupac RG, Neacy K: A comparison of cord gingival displacement with gingittage technique. J Prosthet Dent 1981; 46:509-515 www.indiandentalacademy.com
  • 226. For more details please visit www.indiandentalacademy.com
  • 227. www.indiandentalacademy.com