PERIORESTORATIVE RELATIONSHIP

The relationship between periodontal health and restoration of teeth is intimate and inseparable. For periodontium to remain healthy, restoration must be managed in several areas so that they are in harmony with their surrounding periodontal tissues.

BIOLOGIC CONSIDERATIONS
MARGIN PLACEMENT AND BIOLOGIC WIDTH: The primary treatment goal of a restoration is to mask the junction of the margin with the tooth. 3 options for the margin placement are 1. Supragingival 2. Equigingival 3. Subgingival SUPRAGINGIVAL MARGIN: It will have least impact on the periodontiun. Classically this location has been applied in unaesthetic areas because of the marked contrast in color and opacity of traditional restorative materials against the tooth.

 With the advent of more translucent restorative materials and resin cements, these in esthetic areas. Therefore whenever possible, these restorations should be chosen not only for their esthetic advantages ,but for their favorable periodontal impact as well. The use of equigingival margins traditionally was not desirable because they were thought to retain more plaque than supragingival or sub gingival margins resulting in gingival inflammation. The greatest biologic risk occurs when placing sub gingival margins because 1. They are not accessible 2. If the margin is placed too far below the gingival tissue crest, it will violate the gingival attachment aperture.

BIOLOGIC WIDTH
The dimensions of space that the healthy gingival tissues occupy above the alveolar bone is biologic width. Connective tissue attachment occupies 1.07mm of space above the crest of the alveolar bone and that the junctional epithelial attachment below the base of the gingival sulcus occupies another 0.97mm space above the connective tissue attachment. The combination of these two measurements constitutes the biologic width. Restorations may need to be extended gingivally 1. To create adequate resistance and retentive form in the preparation.

2. To make significant contour alterations because of caries or other tooth deficiencies or 3. To mask the tooth/restoration interface by locating if subgingivally.

When restoration margin is placed too far below the gingival tissue crest two different responses can be observed. Bone loss of an unpredictable nature along with gingival recession will occur. Trauma from restorative procedures plays a major role in causing this fragile tissue to recede and highly scalloped,thin gingiva is more prone to recession than a flat periodontum with thick fibrous tissue.

BIOLOGIC WIDTH EVALUATION

Radiographic interpretation can identify interproximal violations of biologic width. If a patient experiences tissue discomfort when the restoration margin levels are being assessed with a periodontal probe,it is a good indication that the margin extends into the attachment and that a biologic width violation has occurred. The biologic width can be identified for the individual patient by probing to the bone level and subtracting the sulcus depth from the resulting measurement. This is done on more than one tooth with healthy gingiva.

CORRECTING BIOLOGIC WIDTH VIOLATIONS

It is done by surgically removing bone away from proximity to the restoration margin or by orthodontically extruding the tooth and thus moving the margin away from the bone. There is a potential risk of gingival recession after removal of bone. If the biologic width violation is on the interproximal side or across the facial

surface and the gingival tissue level is correct, orthodontic extrusion is indicated.

MARGIN PLACEMENT GUIDELINES

Sulcular depth is used as a guideline in assessing the biologic width requirement. The base of the sulcus can be viewed as the top of the attachment, the margin is placed in sulcus and not in the attachment.

 With shallow probing depths(1-1.5mm) extending the preparation more than 0.5mm subgingivally will risk violating the attachment. 3 rules are to be followed in placing intracrevicular margins

Rule 1: if the sulcus probes 1.5mm or less place the restoration margin 0.5mm below the gingival tissue crest. Rule 2: if sulcus probes more than 1.5mm, place the margin half the depth of the sulcus below the tissue crest. Rule 3: if a sulcus greater than 2mm is found especially on the facial aspect of the tooth, evaluate to see if a gingivectomy could be performed to lengthen the teeth and create a 1.5mm sulcus. Now follow rule 1.

TISSUE RETRACTION
Once the supragingival portion of the preparation is completed it is necessary to extend below the tissue.

 The preparation margin must now be extended to the appropriate depth in the sulcus, in this process the tissue must be protected from abrasion which will cause hemorrhage and can adversely affect the stability of the tissue level around the tooth. Access to the margin is required for the final impression. It is achieved with gingival retraction cords of appropriate size.

 For rule 1 margin, the cord should be placed such that the top of the cord will be located in the sulcus at the level where the final margin will be established, which will be 0.5mm below the previously prepared margin. On interproximal aspects of the tooth the cord will usually be 1 to 1.5mm below the tissue height because here the sulcus is often 2.5 to 3mm in depth. With this initial cord is placed, the preparation is extended to the top of the cord with the bur angled to tooth so that no tissue abrasion occurs

 A second cord is pushed so that it displays the first cord apically and sits between the margin and the tissue. For final impression only the top cord is removed, leaving the margins visible and accessible to be recorded with the impression material the initial cord remains in sulcus until the provisional restoration is completed. As an alternative to additional retraction cords, electro surgery can be used to remove any overlying tissue in the retraction process. For rule 2 situations where the sulcus is deeper two large diameter cords are used to deflect the tissue before extending the margin apically.

PROVISIONAL RESTORATIONS
3 critical areas must be effectively managed to produce a favorable biologic response to provisional restoration. They are Marginal fit: it has clearly been implicated in producing an inflammatory response periodontium. Margins that are significantly open(several tenths of a millimeter) are capable of harboring large numbers of bacteria and cause inflammatory response. Crown contour: ideal contour provides access for hygiene, has fullness to create the desired gingival form and has a

pleasing visual tooth contour in esthetic areas.

Over contouring produces gingival inflammation, whereas under contouring produces no adverse periodontal effect. Sub gingival debris: diagnosis of debris as the cause of gingival inflammation can be confirmed by examining the sulcus around the restoration with an explorer, removing any foreign bodies and then monitoring the tissue response In addition to these criteria inflammation can also occur due to plaque accumulation on the rougher surface of restoration

Esthetic tissue management

Managing interproximal embrasures: the ideal interproximal embrasures should house the gingival papilla without impinging on it and should also extend the interproximal tooth contact to the top of the papilla so that no excess space exits to trap food or to be esthetically displeasing Papillary height is established by the level of the bone, the biologic width and the form of gingival embrasure The tip of the papilla averages 4.5 to 5 mm above the interproximal bone and will

have a sulcus 1 to 1.5mm deeper than that found on the facial surface

If the embrasure is of ideal width, the papilla assumes a pointed form has a sulcus of 2.5 to 3 mm and is healthy If the embrasure is too narrow, the papilla may grow out to the facial and lingual ,form a col and become inflamed Correcting the open gingival embrasures restoratively: two causes of this are the papilla is inadequate in height because of bone loss, the interproximal contact is located too high coronolly Correction is done by moving the contact point toward the tip of the papilla. The margins of restoration is designed to move the contact point toward the papilla while blending the contour into the tooth below the tissue

 Managing gingival embrasure form for patients with gingival recession: in anterior region(esthetic areas)it is necessary to carry out the interproximal contacts apically toward the papilla to eliminate the presence of large open embrasures with multiple unit restorations it is also possible with tissue colored ceramics to bake porcelain papillae directly on the restoration In posteriors the contact should be moved far enough apically to minimize any large food traps while still leaving on embrasure of a convenient size to be accessed with an interdental brush for hygiene

PONTIC DESIGN
Classically there are 4 options to consider in evaluating pontic design, sanitary, ridge-lap, modified ridge lap and ovate designs. Regardless of the design, the pontic should provide an occlusal surface that stabilizes the opposing teeth, allows for normal mastication and does not overload the abutment teeth.

 the sanitary and ovate pontics have convex undersurfaces which makes them easiest to clean. The ridge lap and modified ridge lap designs have concave surfaces which are more difficult to access with the dental floss.

 The ovate pontic is the ideal pontic form. The site is shaped to create either a flat or

a concave contour so that when the pontic is created to adapt to the site, it will have a flat or convex outline. In maxillary anterior region it is necessary to create a reception area that is 1 to 1.5mm below the tissue on the facial aspect. This creates the appearance of a free gingival margin and produces optimal esthetics. In posterior region a flat, easily cleanable tissue surface on the pontic is maintained.

 The ovate ponitc helps in maintaining the interdental papilla next to abutment teeth after extraction. This is done by placing a pontic form of 3.5mm into the extraction site the day the tooth is removed, the gingival embrasure and papilla can be maintained. At 4 weeks 2.5mm extension can be reduced to a 1 to 1.5mm extension to facilitate hygiene.

OCCLUSAL CONSIDERATIONS IN RESTORATIVE THERAPY

There should be even, simultaneous contacts on all teeth during centric closure. When mandible moves from centric closure, some form of canine or anterior guidance is desirable, with no posterior tooth contacts. The anterior guidance needs to be in harmony with the patients neuromuscular envelope of function. The occlusion should be created at a vertical dimension that is stable for the patient.

When managing a pathologic occlusion or when restoring a complete occlusion, centric relation should be maintained.

THANK YOU
IV BDS D.Swetha Manasa