The presentation shows the relation between the restorative dentistry and the periodontium , explaining the per-prothetic surgeries and the biological consideration including the biological width. Also, mention how to restore the open embrasures between teeth (the black triangle).

1. Preparation of the Periodontium
for Restorative Dentistry
Dr. DIANA ABO EL OLA

2. To achieve the long-term comfort & good functioning predictable treatment.
Active PD infection must be treated before restorative, esthetic, and implant
dentistry
SO, healthy periodontuim ……………… successful comprehensive dentistry

3. 1- To ensure stable GM before tooth preparation avoid shrinkage
& bleeding.
2- To provide adequate tooth length for retention & accessibility.
3- After the resolution of infl., teeth may repositioned or changes
may occur in the ST….. may interfere with prosthetic procedures.
4- The Quality ,quantity & topography of the periodontuim
provides structural defense factors in maintaining health.

4. SEQUENCE OF TREATMENT
The preparation of the periodontium for restorative dentistry can be
divided into 2 phases:
(2) Pre-prosthetic periodontal
surgeries
-Management of Mucogingival
problems.
-Preservation of ridge morphology
after tooth extraction.
-Crown-lengthening procedures.
-Alveolar ridge reconstruction.
(1)Control of PD infl. with or without
surgery
Emergency Rx
Extraction of hopeless teeth
OH instructions
Scaling and root planing
Re-evaluation
Periodontal surgery
Adjunctive orthodontic therapy

5. Management of Mucogingival problems
(plastic surgery)
1. Increase gingival dimensions 2. Root coverage
At least 2 months of healing is
recommended after Soft tissue
grafting, before restorative dentistry.
The most common techniques include:

6. Preservation of Ridge Morphology after Tooth Extraction
Alveolar ridge resorption is a common consequence of tooth loss
Using bone & membrane to preserve ridge
Use of bone graft + ovate pontic to preserve ridge & ID papillae

7. Crown lengthening procedures
It can be done with or without osseous reduction( apical position flap )

8. Alveolar Ridge Reconstruction
Indications:
• to provide adequate anatomic dimensions for esthetic pontic or implants.
For Small defects may be treated with ST ridge augmentation
For larger defects and in those sites receiving dental implants, hard tissue
modalities are used

9. RESTORATIVE- PERIO
INTERRELATIONSHIPS

10. The most important aspects of periodontal – restorative relationship
is
The location of restorative margins to gingiva
Clinician has 3 options???

11. Clinician has 3 options
Supragingival margins
(less contact to GM.)
Equigingival margin
(even with the GM.)
Subgingival margin
(risk of violation of biological
width)

12. • Equigingival margin →not desirable →retain more plaque→ Gingival
inflammation.
FROM A PERIODONTAL VIEW POINT
Supra gingival and
equigingival are well
tolerated
Greatest biological
risk occurs in
subgingival margin

13. • Subgingival margin should be placed not more than 0.5mm into
the sulcus.
(1) to create resistance and retention for restorative prepration (inadequate
clinical crown)
(2) to make significant contour for caries removal or tooth defects or fracture
(3) to mask the tooth/restoration interface(for esthetic purpose)
BUT
BW violation

14. Sulcus =0.69mm
JE=0.97mm
CT=1.07mm
Total distance from GM to bone =3mm
SO

15. (flat G. scallops, thick cortical plates & inc.
thickness of KG.)……… little apical migration and intrabony pocket
formation are observed.
(highly scalloped & ??)……….more susceptible to G.
recession than the thick periodontium.
• When the margin is placed too far below the gingival crest, 2 different responses can
be observed:

16. Biological considerations :
• 1-Evaluation of BW
• 2-Correction of BW Violations
• 3-Margin Placement Guidelines
• 4-Managing Interproximal Embrasures
• 5-Correcting Open G. Embrasures Restoratively
• 6-Managing G. Embrasure Form for Patients with G. Recession
• 7-Pontic Design

17. 1-Biological width evaluation
Radiographically
Can identify interproximal violation of
biological width only, Y?
Using periodontal probe
Pushing probe through attachment
tissue from sulcus to bone
If distance <2mmviolation confirmed If distance <3mmviolation confirmed

18. 2- Correcting Biologic Width Violations
1. Surgically: by crown lengthening
Drawback: high risk of papillary recession and gingival recession.
Indications
1. Subgingival caries or fracture.
2. Inadequate clinical crown length
3. Unaesthetic or unequal gingival
heights.
Contraindications
1. If Unaesthetic results would happen.
2. Very Deep caries or fracture.
3. The tooth is a poor restorative risk.
2. Orthodontically: by extruding the tooth out of the socket,
INDICATIONS
If biologic width violation is on the
interproximal side.
CONTRAINDICATED
1.Inadequate crown: root ratio
2.Lack of occlusal clearance required for
eruption.

19. Gingivectomy
(Soft tissue surgery)
Or
Osseous surgery
Or
Orthodontic treatment
Indicated in case of pseudopockets - gummy smile-
probing depth >3mm
Needs adequate Keratinized gingiva.
Scalloped marginal incision +crestal bone reduction at
least 2mm away from restoration margin+ apically
displaced flap (ADF)/UDF.
Disadv: risk of ID recession (black triangle)
1)Slow ortho. Extrusion + apically positioned flap
Or
2)Rapid ortho. Extrusion (preventing gingiva& bone to
follow the tooth)
Indicated in case of narrow zone of attached gingiva
Crownlengthening

20. • Gingivectomy
ADF with osseous surgery

21. Final crown restorations…….. completed min. 6 weeks after surgery to
minimized further tissue loss.
In esthetic areas  min. 12 weeks after surgery to be sure no further
gingival recession will occur.
Ortho. Treatment

22. • In the case of caries or tooth fracture
The surgery should provide at least 4 mm
from the apical extent of the caries or
fracture to the bone crest.

23. 3-Margin Placement Guidelines
Three rules to place subgingival margins:
• Rule 1: if PD < 1.5mm, place the margin 0.5mm below the gingival crest.
• Rule 2: if PD = 1.5-2 mm, place the margin half the depth of the sulcus.
• Rule 3: if PD > 2 mm, especially on the facial aspect, evaluate possibility of
gingivectomy to create 1.5mm sulcus probes.

24. • To provide a reference for res. margin after
tissue retraction , the margin preparation is
initially done at FGM level.
4- Clinical procedures in marginal replacement

25. 5- Managing interproximal embrasures
Papillary height related to
1.Level of the bone
2.Biologic width
3.Embrasure form
• Too Wide Embrasure Flattened & Blunt Papilla
• Too Narrow Embrasure Inflamed Papilla (papilla may grow out)
• Ideal Embrasure Healthy & pointed Papilla(sulcus 3mm)
Tapered teeth+ wide embrasure Narrow embrasure Ideal embrasure

26. • GM about 3 mm above the facial bone
• Tip of the papilla about 4.5 -5 mm above
interproximal bone.
Same biologic width for both (2mm)
•Interprox. area Sulcus is deeper
than in the facial surface.
Distance from inter proximal contact to bone level ≤ 5mm papilla always filled 6mm (56%) 7mm(37%)
Interproximal tooth contact

27. 6- Correcting Open Gingival Embrasures by
Restoration
• The papilla is inadequate in height because of
(1) Bone loss
(2) Too high interproximal contact coronally(long embrasure)
• If the papilla is apical to the adjacent papillae; the interproximal
bone levels should be evaluated .
• If the bone is apical to the adj. bone levels bone loss is the cause.
at the same level  the open embrasure is the cause.

28. 1- Diverging roots
2- Tapered Tooth shape
It can be corrected by moving the contact point to the tip of the papilla by
restoration OR margins prepared 1-1.5mm below papillae

29. 7-Managing open Embrasure Form for Patients with
Gingival Recession
1. Carry the interproximal contacts apically  to eliminate the open embrasures
2. Multiple-unit restorations tissue-colored ceramics porcelain papillae
directly on the restoration.
The interproximal contacts should be moved apically to
minimize large food traps but still leave enough space for
interdental brush for hygiene.
In esthetic areas:
In the post. areas

30. Correcting the open embrasures by periodontal surgery
preoperative: loss of ID papillae + class IV CT graft from tuberosity +bone from
tuberosity
Coronally positioned flap
Bone graft is fixed by Ti screw &
covered by ST graft

31. 8-Pontic design
SANITARY RIDGE LAP MODIFIED RIDGE OVATE
👍🏻

32. Thank you