PERIODONTIUM AND PROSTHODONTICS

1. Dentistry has progressed from the times when a missing tooth was replaced by an animal tooth to the present when it is being replaced with an implant. 2. We have moved into a new era in which dentistry can no longer be practiced in isolated specialty divisions to meet the overall needs of the patients. The team approach is replacing the individual approach resulting in more effective patient care. 3. A prosthesis can be beneficial or detrimental depending on the forethought given to it. The best environment for the prosthesis is obtained by a pretreatment consultation between the periodontist and the prosthodontist. This will prevent needless treatment of teeth that are of questionable value or the needless e traction of teeth that could prove vital to long!range goals. ". This also represents outstanding opportunities for professional cooperation. #. $t is possible to reconstruct an entire mouth decayed to the root% but it is almost insurmountable tas& to maintain the mouth after

advanced periodontal disease. The best way to serve patients for continued dental health is through early recognition and prevention. $n the following deliberation $ would li&e to bring about the various periodontal aspects to be considered in designing a prosthesis which may be called as '(eriodontal )estorative $nterrelationship*.

BASIC CONSIDERATIONS
The periodontium is the attachment apparatus of the teeth and consists of cementum% periodontal ligament% alveolar bone and a portion of the gingiva. Gingiva: $t is divided anatomically into marginal% attached and interdental areas. ! The attached gingiva e tends from the mucogingival +unction to the pro+ection on the e ternal surface of the bottom of the gingival sulcus. ! The width of the attached gingiva on the facial aspect differs in different areas of the mouth. $t is generally greatest in the incisor

region ,3.# to ".#mm- and less in the posterior segments with the least width in the first premolar area 1..mm. ! /ucogingival +unction remains stationary throughout the adult life. Width of the attached gingiva increases with age and in supraerupted teeth. ! 0eratini1ed gingiva includes both the attached gingiva as well as the marginal gingiva. ! 2linical gingival sulcus depth normally measures 2!3mm.

Periodontal Ligament $t is composed of collagen fibres arranged in bundles that are attached from the cementum of the tooth to the alveolar bone. $n humans the width of the periodontal ligament ranges from 3.1# to 3.34mm. 5cclusal loading in function affects the width of the periodontal ligament. $f occlusal forces are within physiologic limits% increased function leads to increase in the width of the ligament. ! $n single rooted teeth% the a is of rotation is located in the area between the apical third and middle third of the root. $n multirooted teeth% the a is of rotation is located in the bone between the roots.

The ligament is narrowest in the region of a is of rotation. Due to physiologic mesial migration% the periodontal ligament is thinner on the mesial surface than on the distal surface. !n"tion# o$ Periodontal Ligament $. (hysical a- )esistance to impact occlusal forces. b- Transmission of occlusal forces to bone. $$. $$$. 6ormative and remodeling function. 7utritional and sensory function. (athological deepening of gingival sulcus is termed as periodontal poc&et. $t is due to the direct e tension of gingivitis into the alveolar bone. Pro%ing The thinnest probe is desired that permits probing the depth of the poc&et without patient discomfort. While probing the dentist must pay attention to the root anatomy. 8ocal anesthesia is recommended when the bony contours are probed to establish whether surgery is necessary. This procedure is called Bone Sounding.

Mo%ilit& $t can be determined by holding the tooth between the handles of two metallic instruments or with one metallic instrument and one finger. An effort is made to move the tooth in all directions. /obility is graded as9 :rade $ ; <arely distinguishable tooth movement. :rade $$ ; Any movement upto 1mm ,8abiolingual or mesiodistal-. :rade $$$ ; Any movement more than 1mm or teeth that can be depressed or rotated in their soc&ets. Tra!ma $rom o""l!#ion When the occlusal forces e ceed the adaptive capacity of the tissues% tissue in+ury results. The resultant in+ury is termed trauma from occlusion. Trauma from occlusion may be caused by altrations in occlusal forces or reduced capacity of the periodontium to withstand occlusal forces. When trauma from occlusion is the result of alterations in occlusal forces% it is called primary trauma from occlusion. When it results from reduced ability of the tissues to resist occlusal forces% it is &nown as secondary trauma from occlusion.

Trauma from occlusion occurs in the supporting tissues and does not affect the gingiva. The changes in T65 consists of a- increased width of periodontal ligament space% b- thic&ening of lamina dura along the lateral aspect of the root% c- vertical rather than hori1ontal destruction of interdental septum% d- root resorption% e- radiolucence and condensation of alveolar bone. Thus% in the absence of inflammation% the response to T65 is limited to adaptation to increased forces. $n the presence of inflammation% the changes in the shape of the crest may be conducive to angular bone loss with infrabony poc&ets. /ost common clinical sign of T65 is increased tooth mobility. Radiogra'(# The radiograph is a valuable aid in the diagnosis% prognosis and evaluation of the treatment outcome of periodontal disease. The most useful technique in evaluating the tooth to bone relationship is the long cone technique. A film positioning holder should be used. The areas to be reviewed on the radiographs are9 1- Alveolar crest resorption.

2- $ntegrity and thic&ness of lamina dura. 3- =vidence of generali1ed hori1ontal bone loss. "- =vidence of vertical bone loss. #- Widened periodontal ligament space. >- Density of the trabeculae of both the arches. ?- @i1e and shape of the roots compared to crown% to determine crown root ratio.

O""l!#ion and it# e$$e"t on 'eriodonti!m The effect of occlusal forces on the periodontium is influenced by their severity% direction% duration and frequency. When severity increases% the periodontal fibers thic&en and increase with the alveolar bone becoming denser. 2hanging the direction of occlusal forces changes the orientation of periodontal ligament fibres. The principal fibres of the periodontal ligament best accommodate occlusal forces along the long a is of the tooth. 8ateral forces initiate bone resorption in areas of pressure and bone formation in areas of tension.

)otational forces cause tension and pressure on the periodontium and are most in+urious forces. O""l!#al T(era'& a# a Part o$ Periodontal Treatment @tudies indicate that the gain in the attachment level after periodontal therapy is inversely proportional to the degree of mobility. 5cclusal therapy should be performed as a part of periodontal treatment!whenever there is a functional indication for it. a- A diagnosis of T65 fully +ustifies occlusal therapy. b- When malocclusion interferes with achievement of stable interma illary relationship. =.g. /igrating teeth% diastemas% flaring of anterior teeth. c- <ru ism may require treatment% since it is the basis for every type of dysfunctional manifestation and often is the first evidence of lac& of adaptation to occlusion. 5cclusal therapy is also indicated when missing teeth need to be replaced or food impaction needs to be corrected. 5cclusal therapy should not be initiated unless there is evidence to indicate that the system is no longer adapting to the occlusal scheme of the individual.

O""l!#al Ad)!#tment 1. )emoving occlusal prematurities in centric relation and centric occlusion. A Along!centricB or Afreedom in centricB when cusp tips contact hori1ontal stops in the fossae. 2. =liminating balancing interferences which will allow the mandible to move freely laterally and protrusively. 3. Ad+usting wor&ing contacts in lateral movements and anterior contacts in protrusion. Depending on the occlusal pattern of the individual no single tooth should be overloaded during e cursions with either group function or a cuspid protected occlusion. When to perform occlusal therapy in the sequence of periodontal treatment $t is preferable to postpone any procedures related to occlusion until root preparation has been completed and the patient has been instructed in oral hygiene procedures. When inflammation has been controlled% teeth will modify their position within the soc&et and will be more stable and less mobile. Thus% after controlling inflammation% occlusal therapy is performed when indicated.

O""l!#al 'attern# in 'eriodontal t(era'& a) Indications for Group function :roup function includes contact of cuspid% bicuspids and perhaps molars on wor&ing side. 1. $f the e isting occlusion is in group function and there is no temperomandibular +oint or muscular dysfunction or tooth mobility% group function relation is acceptable. 2. $f a cuspid is periodontally wea&ened or presents mobility on lateral e cursive contacts% a group function is indicated. =ven if a cuspid is periodontally compromised% it should still be ad+usted to remain in contact!during group function wor&ing relationship. b) Indications for mutual protection $n many mouths with healthy periodontium and minimum wear% the teeth were arranged so that the overlap of the anterior teeth prevented the posterior teeth from ma&ing any contact on either wor&ing or non wor&ing sides% during mandibular e cursions. This separation from occlusion is termed disocclusion. According to this concept of

occlusion% the anterior teeth bear all the load when the posterior teeth are disoccluded in any e cursive position of the mandible. The position of ma imum intercuspation coincides with the optimal condylar position of the mandible. All posterior teeth are in contact with the forces being directed along their long a is. The anterior teeth contact lightly or are very slightly out of contact. As a result of the anterior teeth protecting the posterior teeth in all mandibular e cursions and the posterior teeth protecting the anterior teeth at the intercuspal position% this type of occlusion came to be &nown as mutually protected occlusion. To reconstruct a mouth with mutually protected occlusion it is necessary to have anterior teeth that are periodontally healthy. $n the presence of anterior bone loss or missing canines% the mouth should probably be restored to group function. S'linting @plinting refers to any +oining together of two or more teeth for stabili1ation. 5cclusal correction and construction of an appliance precede splinting.

@plinting has 3 purposes9 iTo protect loose teeth from in+ury during stabili1ation in a favourable occlusal relationship. iiTo Distribute occlusal forces for teeth wea&ened by loss of periodontal support. iiiTo prevent a natural tooth from migrating.

The number of teeth required to stabili1e a loose tooth depends on9 a- Degree and direction of mobility. b- The remaining bone. c- The location of the mobile tooth. d- Whether the tooth is to be used as an abutment tooth.

)educing

mesiodistal

mobility

is

easier

than

reducing

buccolingual mobility because of appro imating teeth that aid in support. $t is advisable to use more than one firm tooth to stabili1e a mobile tooth. $f the mobile teeth are splinted to ad+acent teeth without correction of the occlusal traumatism or parafunctional habits% the entire splint can become unstable. S'linting met(od#:

$t may classified as 1. Temporary or reversible. 2. (rovisional. 3. (ermanent. @ome methods of reversible splinting are ligature wire% circumferential wiring% removable appliances and bonding. )emovable appliances include the CawleyBs )etainer and a continuous clasp )(D. A swing!loc& )(D though costly and can be damaging is used for medically compromised patients. S'linting %& Bonding 7ewer materials have made splinting teeth easier. The composite resins have greater strength and light cured bonding permits better control of contours. Temporary splinting is accomplished with the composite material alone or in combination with e tracoronal or intra coronal wires or screen meshes. (ermanent splinting can also be performed with resin bonded retainers ,/aryland bridges- or bars and plates. Provi#ional #'linting *it( $!ll "overage a"r&li"# This method is commonly used with periodontally compromised patients where there is a commitment to fi ed splints after periodontal

therapy. <efore periodontal treatment% the teeth are prepared and heat processed acrylic treatment restorations are constructed and cemented with sedative cements. When the tissue has healed and matured after surgery% cast splints are inserted. Indi"ation# $or #'linting @plinting is indicated if mobility is increasing after periodontal and initial occlusal therapy and the teeth are interfering with chewing ability and comfort. According to 8indhe% candidates for splinting are9 1. (rogressive ,increasing- mobility of a tooth as a result of gradually increasing width of the periodontal ligament in teeth with a reduced height of alveolar bone. 2. $ncreased bridge mobility despite splinting. (rogressive mobility in situation 1 can often be controlled by unilateral splints. @ituation 2 requires cross!arch splinting.

PLACEMENT O MARGINS O RESTORATION Whenever possible margins are prepared supragingivally on the enamel of the anatomic crown. Any restorative material is a foreign body in the gingival sulcus and unfortunately they provide an area favourable for plaque formation. Advantages of supragingivaly placed margins are9 a- 6avourable reaction of the gingiva. b- Wider shoulder tooth preparations can accommodate an adequate bul& of porcelain without!pulpal in+ury. c- /etal margin finishing techniques are easier. Intra"revi"!lar Margin Pla"ement Despite the advantages of supragingival margins there are clinical situations requiring intracrevicular margin placement. They are9 1. =sthetics. 2. @evere cervical erosion% restorations or caries e tending beyond gingival crest. 3. Adequate crown retention in short or bro&en down clinical crowns. ". =limination of persistent root sensitivity.

Intra"revi"!lar De't( Accurate estimate of true gingival crevice is important to ensure that margins do not impinge on +unctional epithelium or connective tissue attachment ,biologic width-. This requires the use of an accepted periodontal probe. (osition of the probe and probing force are critical for accuracy. $n health% the probe is stopped by the +unctional epithelium% whereas gingivitis allows penetration of +unctional epithelium and connective tissue fibres. @tudies have estimated that the ideal intracrevicular depth for margins is 3.#!1mm beneath gingival crest and not more than 3.#mm when the crevice is ad+acent to root surfaces. @tudies have also demonstrated that a space of 2mm is needed for supracrestal connective tissue attachment and +unctional epithelium to attach to the tooth. This 2mm band is a physiologic dimension that is required around every tooth in the mouth. $t has been called as biologic width. $f the restoration infringes on this width% there is no place for attachment apparatus to insert. An inflammatory response results% attachment loss with apical migration occurs and poc&et formation ensues.

Ade+!ate atta"(ed ,eratini-ed ti##!e To &now the width of attached gingiva% one must first differentiate between attached and unattached gingiva. $n the best of situations% the gingival sulcus will probe atleast 1mm so that this amount of &eratini1ed tissue will be unattached. 7e t we encounter a millimeter of +unctional epithelial cells% accounting for another millimeter of unattached gingiva. Thus inorder to provide atleast 1mm of attached gingiva in an ideal situation of a very shallow probing depth% atleast 3mm of &eratini1ed tissue must be present. $f more than 1mm of gingiva coincides with the sulcus depth% then an even greater amount of &eratini1ed tissue is necessary. <erman has given a method of placing the margins subgingivally with a collar of metal. 6irst step is to prepare the tooth to the crest of the gingiva. :ingival retraction is obtained with a chord or electrosurgery. A diamond point with an angled tip of calibrated length is introduced to prepare the bevel. This instrument eliminates the sharp edge of the shoulder and the undercut which e tends apically from the shoulder.

Gingival Retra"tion and Im're##ion# All retraction methods induce transient trauma to the +unctional epithelium and connective tissue of gingival sulcus. a- )etraction chord9 $t usually produces limited gingival recession and can protect the sulcular tissues during preparation. $f used carelessly when inadequate attached gingiva is present% in+ury to gingival fibres occurs. This can allow the impression material to be forced into the gingival connective tissue and bone producing a foreign body reaction. b- =lectrosurgery 9 They have certain limitations. <ut when used properly the cellular healing is comparable to a scalpel cut. 2ontrolled depth cutting electrode tips avoid bone trauma but in+ure the gingival fibres% if the tip is not angled properly in the sulcus. 5ringerBs solution or surgical pac& may enhance healing. $n patients with thin covering of gingiva and alveolar bone over the root% electrosurgery should not be used as the loss of tissue from the internal or crevicular surface can result in gingival recession. $n these patients% the gingiva should be retracted with retraction chords.

TEMPORAR. AND PRO/ISIONAL CRO0NS $mproperly constructed 'interim* restorations may cause periodontal inflammation and gingival recession. The requirements for fit% polish and contour in the interim restoration should be the same as for the final restoration. 8ong!term restorations should not be called as temporary but should be regarded as provisional or treatment restorations. These allow the dentist to assess the effect of final restoration. EMBRASURES When teeth are in pro imal contact% the spaces that widen out from the contact are &nown as embrasures. =ach interdental space has " embrasures. 1- An occlusal or incisal embrasure that is coronal to the contact area. 2- A facial embrasure. 3- A lingual embrasure. "- A gingival embrasure which is the space between the contact area and the alveolar bone.

$n health% the gingival embrasure is filled with soft tissue% but periodontal diseases may result in attachment loss creating open gingival embrasures. T(e gingival em%ra#!re9 6rom a periodontal view point% the gingival embrasure is the most significant. (eriodontal diseases cause tissue destruction% which reduces the level of alveolar bone% increases the si1e of the gingival embrasure and creates an open interdental space. )estorations may be constructed to preserve the morphologic features of the crown and root and retain the enlarged embrasure space or when esthetic situations dictate% the teeth may be reshaped by the restorations so that the gingival embrasures are relocated close to the new level of the gingiva. To relocate the gingival embrasure% the dentist changes the contour of the pro imal surfaces and broadens the contact areas more apically. Dimensions of gingival embrasure 9 Ceight% width% depth. The pro imal surfaces of crowns should taper away from the contact area facially% lingually and apically. = cessively broad pro imal contacts and bul&y contour in the cervical region crowd out the gingival

papillae. This can ma&e oral hygiene difficult resulting in gingival inflammation and attachment loss. )estorative dental procedures too often result in the restorative materials ta&ing up spce that is normally occupied by the interdental papilla. The problem begins with underpreparation of tooth% so that the technician is left with no choice e cept to place an e cessive amount of restorative material into the interpro imal space. During the preparation of dies for cast restorations% the technician first removes all of the replicated tissue to gain access to the finish lines. Thus it is impossible for him to visuali1e the space available for dental restoration in the interpro imal embrasure area. $f two models are poured from the same impression and the second one is used as an indicator of how much space is currently occupied by gingival tissues% the technician can have a much better understanding of what the contour of the final restorations should be. $n fi ed prosthesis and D or multiunit fi ed splints% the interpro imal contact and D or soldered +oint is frequently carried for too apically so that it invades the embrasure space from its coronal aspect. This leads to inflammation and destruction of periodontal tissues. The responsibility of determining the si1e of the interpro imal contact should rest with the dentist% not the technician.

CRO0N CONTOUR The contours of full and partial coverage restorations play a supportive role in establishing a favourable periodontal climate. The theories of crown contouring that have evolved are9 1- :ingival protection. 2- :ingival stimulation. 3- /uscle action. "- Access for oral hygiene. 12 Gingival Prote"tion T(eor&: $t advocates that contours of cast restorations be designed to protect the marginal gingiva from mechanical in+ury. $n 1.>2 this concept was challenged by /orris who reported that the response of gingival tissue around teeth prepared for complete artificial crowns but which had lost their temporary crowns were similar to the ad+acent unprepared teeth. @chluger stated that the so called protective cervical bulge protects nothing but the microbial plaque. 32 Gingival #tim!lation t(eor&: This concept reasons that as food is masticated% it will pass over the gingiva stimulating it and causing increased &eratini1ation of the epithelium. 0eratini1ed epithelium would be more resistant to

periodontal brea&down. @everal authors have shown that the gingival margin is not in the path of masticated food. =ven if the food passing over the teeth were to increase &eratini1ation% this stimulating would occur at the buccal and lingual surfaces. 42 M!#"le a"tion t(eor&: This theory advocates that the perioral musculature ,tongue% chee&s- are responsible for maintaining a healthy periodontal environment. They suggest that overcontouring prevents normal cleansing action by the musculature and allows food to stagnate in the overprotected sulcus. 52 T(eor& o$ a""e## $or oral (&giene This theory is based on the concept that the prime etiologic factor in caries and gingivitis is plaque. Thus% crown contour should facilitate plaque removal% not hinder it.

o!r g!ideline# to "onto!ring "ro*n# are: 1) Buccal and lingual contours flat, not fat

(laque retention on the buccal and lingual surfaces occurs primarily at the infrabulge of the tooth. )eduction or elimination of infrabulge would reduce plaque retention. 2) Open embrasures =very effort must be made to allow easy access to interpro imal area for plaque control. An overcontoured embrasure will reduce the space intended for the gingival papilla. 3) Location of contacts 2ontacts should be directed incisally or occlusally and buccally in relation to the central fossa% e cept between ma illary first and second molars. This creates a large lingual embrasure space for optimum health of lingual papilla. 4) urcation in!ol!ement

6urcations that have been e posed owing to loss of periodontal attachment should be AflutedB or Abarreled outB. $t is based on the concept of eliminating plaque traps.

a"ial and Ling!al #!l"!lar "onto!r# $n the patient whose gingival margins are apical to the 2=E the sulcular morphology differs from that of a healthy patients whose gingival margins are on enamel. The intracrevicular contours of an artificial crown should be as close to the original enamel contour as possible. Wagman has estimated the angle of enamel flare from 2=E to be appro imately 22.# degrees from the vertical a is of gingival housing. As the gingival margin progresses more apically% the sulcus narrows and the intracrevicular contours of the tooth become the flat contours of the root rather than the conve surface of the anatomic crown. $ntracrevicular contours in such cases depend on the ad+acent gingival morphology. When the intracrevicular margins are ad+acent to thin gingiva on the root% the sulcular contours of the artificial crown should be flat% mimic&ing the shape of the root. 5ften the gingiva ad+acent to a flat root surface develops a thic& free gingival margin when the underlying bone is thic&. $n these situations it may be advisable to create a thic&er intracrevicular crown contour similar to that of a natural crown.

PONTIC DESIGN A pontic should meet the following requirements. 1. <e esthetically acceptable. 2. (rovide occlusal relationships that are favourable to abutment teeth. 3. )estore the masticatory effectiveness. ". <e designed to minimi1e accumulation of irritating dental plaque and food debris. #. (rovide embrasures for passage of food. The health of the tissues around the fi ed prosthesis depends primarily on the patients oral hygiene. The material with which pontics are constructed ma&e little difference and pontic design is important only to the e tent that it enables the patient to &eep the area clean. (laque accumulates to an equal degree under pontics made of gla1ed and ungla1ed porcelain% polished gold and polished acrylic resin. The principles of contours of crowns apply equally well to pontics but with pontics there is an additional concern associated with the contour of the tissue facing surfaces.

$n the mandibular posterior region% esthetics is not a ma+or consideration% so the spheroidal pontic is the design of choice because of its contour. $n the ma illary posterior area% the modified ridge lap satisfies both esthetics and hygiene. /andibular anterior area also requires a ridge lap design. When using a spheroidal design% the pontic contacts without pressure the tip of the ridge or the buccal surface. When there is e cessive bone loss and the rigidity of the connector is suitable ,non!esthetic posterior areas-% the pontic is not required to touch the ridge. There should be atleast 3mm of space so that the patient can maintain hygiene. CEMENTATION During cementation it is important that the restoration be seated as close to the tooth preparation as possible. A minimal cement line at the margin reduces plaque formation. $t is e tremely important that all e cess cement be removed from the sulcus after cementation. )emoval of cement from the interpro imal +oints can be facilitated by lightly coating the e terior surfaces of the prosthesis with petroleum +elly prior to cementation.

RESTORATION O IN/ASIONS

MOLAR TEETH 0ITH

URCATION

$n long!term studies of tooth longevity% molars are the teeth that are most often lost. This is due to the comple root anatomy and

furcations that ma&e periodontal therapy and plaque control difficult for the patients. $n the ma illary molars% the distal furcation is usually more apical on the tooth than the mesial furcation. $t is less frequently involved with periodontal attachment loss than the mesial and buccal furcations. The concavities and root alignments result in a furcation chamber that is wider than the entrances. $n the mandibular molars% the root surfaces facing the furcation% both have a high prevalence of concavities. Cla##i$i"ation o$ $!r"ation involvement Grade I ; $ncipient or early lesion. )adiographic changes not seen. Grade II ; <one is destroyed on one or more aspects of the furcation% but a portion of alveolar bone and periodontal ligament remains intact% permitting only partial penetration of probe into the furcation.

Grade III ; $nterradicular bone is completely destroyed% but facial or lingual orifices of the furcation are occluded by gingival tissue. Grade I" ; $nterradicular bone is completely destroyed and gingival tissue is also receded apically so that the furcation opening is clinically visible. Diagnosis of furcation9 7aberBs probe (robing of mandibular molar furcations is easier because there are only two entrances. $n ma illary molars% the distal and buccal furcations are also accessible as they are located midway buccolingually and mesiodistally. The mesial furcation is however not situated midway buccolingually but towards the palatal side due to wide buccolingual width of the mesiobuccal root. $f a full coverage restoration is indicated on a :rade $ or early :rade $$ furcally involved teeth% the principles are same as that for a normal tooth e cept that the preparation has to be fluted or barreled into anatomic depressions.

RESTORATION O ROOT RESECTED MOLARS )oot amputation 9 )emoval of a root from a multirooted teeth. )oot resection 9 Cemisection 9 @urgical removal of a root after endodontic treatment. @urgical separation of a multirooted tooth through the furcation area in such a way that a root or roots may be surgically removed along with associated portion of the crown. <isection 9 @plitting and retaining the roots and accompanying crowns of a mandibular molar or any two roots of ma illary molar. Indi"ation# $or Root re#e"tion or Hemi#e"tion 1. Fertical bone loss around one root but not others. Post surgical healing# $t is critical when intracrevicular margins have to be placed on resected or hemisectioned teeth. A minimum of " to > wee&s of healing after surgery is required before the soft tissues can resist the trauma of tooth preparation. )oot amputation procedures ; Digramatic ,5C(-

Post and cores <rittleness of the pulpless root resected tooth is the primary reason for root fractures over time. 2omplete coverage of root resected teeth is recommended especially over resection area. There is no evidence that post and cores are beneficial in resected teeth and infact they can be detrimental. $f a post and core is required because of a coronal damage% a custom cast dowel core is preferable to prefabricated dowel. Crown Preparation $ntracrevicular margins are usually required to cover portions of root!resected area. The crown margin should be apical to the pulp chamber or root canal that was e posed by resection. To preserve remaining tooth structure and encourage a better fitting restoration a chamfer finish line is recommended. The gingival third of the restoration is fabricated with a flat emergence profile from the gingiva to facilitate oral hygiene.

PRE6PROSTHETIC PERIODONTAL SURGER. I. Mucogingival surgery Teeth with subgingival restorations and narrow 1ones of &eratini1ed gingiva have higher gingival inflammation scores than teeth with similar restorations and wide!1ones of attached gingiva. 2overage of denuded roots is also another ob+ective of mucogingival surgery. /ucogingival surgery can also create some vestibular depth when it is lac&ing. Techniques for increasing attached gingiva. iii6ree gingival autografts. Apical displacement flap. When there is a poc&et formation% thic& manageable poc&et walls can be used for an apically displaced flap ; this flap should be the first choice. When the poc&ets are absent and there is a need for increasing width of attached gingiva% free gingival graft is the technique of choice.

)oot coverage 9 Two techniques are recommended. i8angerBs technique ; uses a connective tissue graft under a partial thic&ness flap. iiTarnow technique ; @emilunar coronally displaced flap. 8angerBs technique is an e cellent solution in most of the cases% but TarnowBs technique is the first choice in isolated upper teeth. II. Crown lengthening procedures $n situations in which a tooth has a short clinical crown that is deemed inadequate for the retention of a required cast restoration% it is necessary to increase the si1e of the clinical crown using periodontal surgical procedures. <y definition% the clinical crown is that portion of the tooth that is coronal to the alveolar crest. Therefore% to lengthen it bone margin has to be remodeled. This is done with an apically displaced flap and ostectomy. The removal of bone is usually not necessary all around the tooth but if underta&en should be done with great caution. $t is essential that there be atleast 2mm of connective tissue attachment between the most apical e tension of the restoration margin and alveolar bone crest.

III.

Ridge Augmentation procedures Aimed at correcting the e cessive loss of alveolar bone that

sometimes occurs in the anterior region as a consequence of advanced periodontal disease. The e cessive bone loss may create a difficult esthetic problem and complicate prosthetic reconstruction. @everal prosthetic solutions have been proposed9 a- (lacement of a thic& mucosal autograft obtained from palate or tuberosity. b- (lacement of non!porous dense hydro yapatite under a split thic&ness flap or a pouch created under a full thic&ness flap. c- A double flap technique used in con+unction with hydro yapatite. REMO/ABLE PERIODONTIUM 6rom the periodontal viewpoint% fi ed prosthesis are the restorations of choice for replacement of missing teeth% but there are some clinical situations in which removable partial prosthesis are the only possible way to restore the lost function of the dentition. PARTIAL DENTURES AND THE

$t is unwise consider a removable partial denture in patients whose oral hygiene is inadequate. DESIGN =very effort must be made to retain posterior teeth for the distal support of edentulous areas. When posterior teeth cannot be retained% the design for removable partial prosthesis becomes challenging. Cla#'#: @tudies have shown that $!bar type of clasps have little or no detrimental effect of periodontal health. This design utili1es a gingivally approach clasp% mesially positioned occlusal rest and a pro imal plate. 2lasps should be passive and e ert no force on teeth when the partial denture is at rest. O""l!#al re#t#9 They should be designed so that the occlusal forces are directed along the vertical a is of the tooth. The angle formed by the occlusal rest and the vertical minor connector should be less than .3G. 5nly this way can the occlusal forces be directed along the long a is of the abutment tooth.

Com%ined i7ed and Remova%le 'ro#t(e#i# $solated teeth with reduced periodontal support are particularly vulnerable to periodontal in+ury and loosening when used as abutments in removable partial prosthesis. The isolated teeth should be +oined to their nearest neighbours with a fi ed prosthesis and then can be used as abutments for removable prosthesis. Ma)or "onne"tor#9 They should not impinge on the free gingival margins. The ma+or connector should be placed >mm away from the gingival margin. When periodontally compromised mandibular anterior teeth require stabili1ation% a special design of ma+or connector should be used for splinting teeth together. A lingual plate should e tend to the middle third of the surface of the mandibular anterior teeth and the coronal border should follow the natural curvature of the supracingula surface. O/ERDENTURES 5ver dentures have three obvious advantages 1- $ncreased retention and stability of record base. 2- (roprioception is dramatically improved compared to a patient with complete dentures.

3- )eduction of stresses to the edentulous ridges resulting in less bone resorption over time. $t is important that appropriate periodontal considerations be a part of the treatment planning process. a- (resence of adequate 1one of attached gingiva is of critical importance around the abutment teeth. b- Any remaining periodontal defects must be treated in the same way as they would be around any periodontally involved tooth prior to fi ed restoration. 5ne great advantage that the overdenture concept has for periodontally involved teeth is that it is possible to improve the crown root ratio dramatically. This results in a great diminution of forces applied to the remaining root. Im'lant #!''orted re#toration# The main principles that determine success or failure from a periodontal view point for an implant supported restoration are9 1- (atient selection. 2- $nvesting tissues. 3- 6orce distribution

$nvesting tissues can be defined as including both hard and soft tissue. <oth the bone height and width must be adequate for implant placement. $n partially edentulous patients it has been observed that &eratini1ed tissue around implants offer the greatest resistance to peri! implant infection. or"e di#tri%!tion a- $ro%n implant ratio ; This is very important in the presence of lateral forces. 8ateral forces result in a moment of the force on the implant and an increase in hori1ontal stresses. $mplants placed in the anterior ma illa e perience more frequent complications because of lateral stresses. The greater the crown!implant ratio% the greater the moment of force under lateral loads. b) Bone densit&# The density of bone is in direct relationship with the amount of implant bone contact. The very dense bone of a resorbed anterior mandible ,D!1- or the lateral cortical bone in the anterior mandible has the highest percentage of lamellar bone in contact with an endosteal implant. The percentage of bone contact is significantly greater in cortical bone than in trabecular bone. The initial bone density not only

provides mechanical immobili1ation during healing% but also permits better distribution and transmission of stresses from the implant!bone interface. 5pen marrow spaces or 1ones of unorgani1ed fibrous tissue do not permit force dissipation. The sparse trabeculae of bone often found in posterior ma illa ,D!"- offer less areas of contact with the body of the implant. 2onsequently% greater implant surface area is required to obtain the same amount of implant!bone contact as for a mandibular anterior implant. (rogressive bone!loading changes the amount and density of implant!bone contact. The body is given time to respond to a gradual increase in occlusal load. This increases the quantity of bone at the implant surface% improves bone density and improves the overall support system mechanism. Ot(er $a"tor# to %e "on#idered are: <ilateral simultaneous contact is mandatory. 5cclusal vertical dimension must be in harmony with the patientBs muscular system. All interferences must be eliminated. 2entric vertical contacts should be aligned with the long a is of the implant whenever possible.

 (osterior occlusal tables may be narrowed in order to prevent inadvertent lateral forces. =nameloplasty of the cusp tips of the opposing natural teeth is indicated to help improve to direction of vertical forces.