Great Basin Academy
Study Club
March 2013
Roseman University of Health Sciences
Preparation of the Periodontium
Iatrogenic Causes and
Restorative Considerations
Supportive Periodontal
Treatment (Maintenance)
Results of Periodontal Treatment
Presented by
Craig M. Ririe, DDS, MS
Restorative Dentistry



Periodontium free of inflammation
Periodontium free of pockets
Periodontium free of Mucogingival
involvement
3
Implant Dentistry



Needs site development
Needs bone augmentation
Needs gingival augmentation
4
Periodontal Disease
must be eliminated prior to
Restorative dentistry.



To determine gingival margins of
restorations properly
Inflammation weakens abutment
teeth stability
Teeth shift in presence of disease
5
Elimination of Periodontal
Disease



Resolution of inflammation in
P.D.L.
Regeneration of P.D.L. fibers,
APICAL to level of attachment
loss
Can cause teeth to shift again
6
Fixed bridge work designed for
teeth BEFORE
the periodontium is treated
may produce
INJURIOUIS
tensions and pressures
on the treated periodontium.
7
Abutment teeth must have
NO periodontal
involvement –
Before and after restoration
is complete.
8
Removable Partial Dentures
Frame work should not be constructed
until periodontal treatment is
complete and healing is complete.
9
A TRUE ADAGE
GARBAGE IN
GARBAGE OUT
10
Tooth Mobility
11
SUMMARY
The goal of periodontal therapy
should be to create the
gingival mucosal environment
and osseous topography
necessary for the proper
function of single tooth
restorations and fixed and
removable partial prosthesis.
12
TREATMENT TO MAKE THIS HAPPEN
Treatment Sequence:
1.
2.
3.
4.
Hopeless teeth are extracted
Construct TEMPORARY partial denture
Construct TEMPORARY crowns with
PROVISIONAL margins
PERIODONTAL THERAPY is performed.
2 months after completion of periodontal
therapy




Gingival health restored
Gingival sulcus mature
Periodontal membrane restored to health
& function
Mobility decreased
13
Treatment Sequence Continued
Preparations modified to relocate margins
in proper relationship to the healthy
gingival sulcus
6. Final restorations (fixed, removable,
implants) are constructed
5.
14
Esthetic Needs
Clinical crown of tooth must be
adequate for retention of
artificial crown.
15
To get enough retention you
may be tempted to place the
margin into the junctional
epithelium and connective
tissue attachment.
16
Result:
Gingival inflammation
Sometimes bone loss
17
Biologic Width Violations
Ramification of
Biologic Width
Violation
margin placed
within the zone of
attachment
18
Biologic Width
19
Clinician has 3 options for crown
margin placement:



Supragingival
Equigingival
Subgingival
20
Biologic Width Concerns
Equigingival margins
21
Biologic
Width
Average
Biologic
Width
Vacek,
et. al.:
can be
up to
4.3 mm
22
Evaluation of biologic width



Radiographs
Symptomatic
“Sounding”
23
Probe to bone level and
subtract sulcus depth
(must be done on teeth with
healthy gingival tissues)
24
Treatment of Biologic Width
Violation


Orthodontics
Surgery
25
Biologic Width Violation
Left central fractured
and restored 12
months ago
26
Biologic Width Violation
Removal of bone
would be
unaesthetic
27
Biologic Width Treatment
Orthodontic
solution
erupted 3mm
then surgery
28
Biologic Width Violation
Orthodontic/Surgical
Before
1 year recall
29
Surgical Crown Lengthening
Before treatment
30
“Golden Proportion”
31
Surgical Crown Lengthening
Ideal gingival
symmetry
32
Surgical Crown Lengthening
Measurement
taken for crown
lengthening
33
Surgical Crown Lengthening
Incision following
Ideal Symmetry
34
Surgical Crown Lengthening

Final Restoration
• Note the ideal
symmetry
35
Biologic
Width
Average
Biologic
Width
 Vacek,
et. al.:
can be
up to
4.3 mm

36
Margin Placement to Avoid Biologic
Width Violation
HISTOLOGIC SULCUS DEPTH
≠PROBING DEPTH
37
Biologic
Width
Average
Biologic
Width
 Vacek,
et. al.:
can be
up to
4.3 mm

38
Iatrogenic Problems


Poor margin
placement
Margins were
covered when
restored on
Periodontally
diseased tissue
39
Electro Surgery

Tissue retraction
for impression
taking
40
Temporary Crowns Critical Areas



Marginal Fit
Contour
Surface Finish
41
Gingival Embrasure
Loss of Papilla
between #8, 9
42
Gingival Embrasure
Method for
altering tooth
form to fill
embrasure
43
Gingival Embrasure
One year after
restoring
#8, 9 mesial
44
Pontic Design




Sanitary Pontic
Ridge Lap Pontic
Modified Ridge Lap
Pontic
Ovate Pontic
45
Ovate Pontic Design
Must be shallow
46
Ovate Pontic in less esthetic area
47
Ridge Consideration
Ridge
augmentation
48
Iatrogenic Problems
Maxillary Partial
Denture
49
Iatrogenic Problems
Partial Denture
Removed
• Not removed and
cleaned often
enough
• Not monitored
by Dental Office
often enough to
check for
plaque/allergic
reaction
50
Iatrogenic Problems
Plaque retention
on poor
restoration
margin/gingival
interface
51
Iatrogenic Problems
Overhanging
margin
• Bone loss
52
Iatrogenic Problems
Inadequate office
maintenance
during
orthodontic care
53
Iatrogenic Problems
Maxillary Left
bridge #8-11
Periodontally
involved
54
Iatrogenic Problems
Periodontal
Surgery
Completed
55
Iatrogenic Problems
Calculus
56
Iatrogenic Problems
Large Cemented
Post
• Root Fracture
57
Iatrogenic Problems
Retentive Screw
Post
• Perforated Distal
• Bone Loss
Repaired
58
Iatrogenic Problems
“Idiopathic” bone
loss
59
Iatrogenic Problems
“Exploratory”
Surgery found
orthodontic
elastic
60
Iatrogenic Problems
Removal of
orthodontic
elastic
61
Iatrogenic Problems
Orthodontic elastic
62
Iatrogenic Problems
Extracted
maxillary molar
open margins
on crown
63
Iatrogenic Problems


Extracted
mandibular
molar
Margin not
adapted into
furcation
64
Iatrogenic Problems
Perforated post
into furcation
65
After cementation of crown:
cement prevented complete
seating of crown.
66
Usually the dentist will not even
be aware of this problem.
67
Therefore: Where possible –
place margins
supra or equigingival.
68
It is best to assume that all of your
subgingival margins look like this
and then maintain your patients
accordingly.
69
Supportive Periodontal
Therapy
“SPT”
Two phases of Treatment:
1.
2.
Elimination of Periodontal
Disease
PRESERVATION of Periodontal
health
BOTH ARE EQUALLY IMPORTANT
71
The patient must understand
the purpose of the
maintenance program.
The dentist MUST emphasize:
preservation of the teeth is
dependent on it.
72
FACT!!
The more often a patient presents
for the recommended
SUPPORTIVE PERIODONTAL
THERAPY (SPT)
the less likely
they are to lose teeth.
73
Tooth loss is 3 times as common
in treated patients who do not
return for regular recall visits
as in those who do.
Lietha Elmer, 1977
74
Patients with inadequate SPT
after successful therapy have
a 50 fold increase in
probing attachment loss as
compared with those with
regular SPT appointments.
-Cortellini 1994
75
The maintenance phase (SPT)
starts immediately after the
completion of the Reevaluation
appointment.
While the patient is in the
maintenance phase (SPT)
the necessary surgical and
restorative procedures are
performed.
76
This ensures that all areas of the
mouth retain a degree of health
attained after phase one therapy
(non-surgical therapy)
77
Zone of
Influence
SUBGINGIVAL
PLAQUE
Zone of
Influence
Clinically, we readily see evidence of the inflammation
caused by Supragingival plaque.
Therefore, we react with plaque control, etc. to resolve
what is OBVIOUSLY EVIDENT.
But what about the subgingival plaque?
The deeper the inflammation –
NOT CLINICALLY EVIDENT.
78
But much more damaging – bone loss – attachment loss
Subgingival scaling alters the
microflora of periodontal
pockets.
79
One study shows that after scaling
the subgingival flora had not
returned to pretreatment
proportions after 3 months.
But this varies greatly
among patients.
Slots, J 1979
80
Episodic Nature of
Periodontitis
Tortuous Topography of
a pocket
Tortuous
Topography of
a pocket
82
Importance of fixed, stable,
predictable recall system
in your office:
Patients tend to reduce their
oral hygiene efforts
between appointments
(Out of sight, out of mind)
83
Interval between SPT visits
initially set it at 3 months
then vary it according to the
patients needs
84
SPT Appointment
Study page 96 in the
Department of Periodontics
Clinic Handbook
2010-2011
85
Referral of Patients to the
Periodontist
Study the Triage
September 2005 article
by Cobb and Callan
86