Periodontal application of Prosthodontic treatment

Dr Mahesh Verma, Director Principal MAIDS, HOD and

Professor Prosthodontics

Dr Dr Dr Dr Dr Dr Dr

Rekha Gupta Shubhra Gill Sadhana Mate Nidhi Saini Anshum Gupta Aashish Thomas Rajeev Gupta

Shruti Goel Roll No. 34 Final Year BDS

Effect of prosthesis on the periodontium

Relationship between periodontal health and the restoration of teeth is intimate and inseparable. For restorations to survive long term, the periodontium must remain healthy so that the teeth are maintained. For the periodontium to remain healthy, restorations must be critically managed in several areas so that they are in harmony with their surrounding periodontal tissues

Fixed Dental Prosthesis

Occlusal considerations

Biological considerations

Esthetic tissue management

Occlusal considerations

Biological considerations

Esthetic tissue management

Biological Considerations
1. Margin placement
2. Marginal fit

3. Crown Contour

4. Pontic Design

5. Subgingival debris

6. Hypersensitivity to Dental Materials

7. Plaque retention on Dental Materials

8. Secondary Caries

Supragingival

Least impact on periodontium Used traditionally in unaesthetic areas Now with advent of more translucent restorative materials, adhesive dentistry and resin cements, margins can be placed supragingivally in esthetic areas

Equigingival

Traditionally was not desirable because they were thought to retain more plaque. Also that even any slight gingival recession would create an unsightly margin display. these concerns are not valid today because the restoration margins can be esthetically blended with the tooth and also finishing can be done to provide a smooth polished interface

Subgingival

Presents greatest biologic risk Margins are not well accessible for finishing If margin is placed too far below the gingival crest tissue, it will violate gingival attachment apparatus

Types of Margins

What Is The Need Of Subgingival Margins??

To create adequate resistance and retention form in the preparation To make significant contour alterations because of caries or other tooth deficiencies To mask the tooth/restoration interface

Biologic Width

Margin Placement Guidelines

Patients existing sulcular depth used as guideline

Rule 1 Rule 2

If sulcus probes 1.5 mm or less, place the restoration margin 0.5 mm below the gingival tissue crest

If the sulcus probes more than 1.5 mm, place the margin half the depth of the sulcus below the tissue crest

Rule 3

If a sulcus greater than 2 mm is found, especially on the facial aspect of the tooth, evaluate to see if gingivectomy could be performed to lengthen the tooth and create a 1.5 mm sulcus. Then the pt. can be treated using rule 1

Ramifications Of Biologic With Violation

How to find if biologic width violation has occurred??

1.

2.

3.

Radiographic interpretation- for interproximal violations of biologic width. Cant detect on the more common locations- mesiofacial and distofacial line angles of teeth. Subjective symptoms- patient experiences discomfort when the restoration margin levels are assessed with periodontal probe Measure the distance between the bone and the restoration margin using a sterile periodontal probe. The probe is pushed through the anesthetized attachment tissue from the sulcus to the underlying bone. If this distance is less than 2 mm at one or more locations a diagnosis of biologic width violation can de made.

Margins that are open are capable of harboring large number of bacteria and maybe responsible for the inflammatory response. Margins that are open by more than 0.2 mm are always associated with alveolar bone loss. Following placement of restorations with overhanging margins a subgingival microbiota resembling that of chronic periodontitis was detected

Overcontoured restorations

Severely jeopardizes oral hygiene practices Food impaction occurs Preferable to overcontoured restorations Open interproximal areas need not affect the periodontal tissues provided these areas are accessible to cleaning devices Excessively open interproximal areas negatively affect esthetics, impair phonetics and allow excessive lateral food impaction.

Undercontoured restorations

A: Sanitary pontic B: Ridge Lap Pontic C: Modified Ridge Lap Pontic D: Ovate Pontic

Sanitary Pontic

Tissue surface of pontic is 3 mm from the underlying ridge.

Provides easiest access for hygiene procedures but is rarely used because of its unaesthetic form and a variable acceptance of the open contour by the patient

Ovate Pontic

Ideal Pontic form

The pontic form fits into a receptor site within the ridge. This allows the tissue surface to be convex and also optimizes esthetics

Ridge lap Pontic

Tissue surface of the pontic straddles the ridge in a saddlelike fashion. The entire surface of ridge lap pontic is convex and very difficult to clean.

It is never indicated

Modified Ridge lap Pontic

Tissue surface on the facial is concave, following the ridge. However the lingual saddle has been removed to allow access for oral hygiene Used in cases where inadequate ridge exists for creating an ovate pontic

Leaving debris below the tissue can create adverse periodontal response. The cause can be retraction cord, impression material, provisional material, or either temporary or permanent cement.

Inflammatory gingival responses have occurred on use of nonprecious alloys in dental materials especially those containing nickel. In such cases precious alloys can be used.

Rough surfaces enhance the development of gingivitis because they induce accumulation of plaque. Threshold surface roughness for retention of bacteria is 0.2 micrometer, below which no further bacterial accumulation occurs. Glantz demonstrated that dental materials possess a greater capacity to accumulate dental plaque than either enamel or dentin. Highly polished dental gold, porcelain and heat cure acrylic resin irritate the tissues little, if at all. Porosity on the surface increases plaque accumulation and retention. PMMA accumulates plaque faster than gold or porcelain because of the absorption of fluids.

Incidence of secondary caries adjacent to crown margins in relation to their location

Occlusal considerations

Biological considerations

Esthetic tissue management

Managing interproximal embrasures

Correcting open gingival embrasures restoratively

Occlusal considerations

Biological considerations

Esthetic tissue management

Improper occlusion of the restoration causes trauma to the periodontium which manifests as periodontal disease. To manage occlusion the dentist must be able to make accurate casts, use a facebow, and create centric relation records so that the information can be transferred to a suitable articulator. A few guidelines have been made to achieve proper occlusion-

1.

2.

Even, simultaneous contact on all teeth during centric closure. When the mandible moves from centric closure, some form of canine or anterior guidance is desirable, with no posterior tooth contacts. This reduces the ability of the elevator muscles to contract and distributes the force of the movement onto the anterior teeth, which receives less force because of the class III lever system being applied in this situation

3.

4.

The anterior guidance needs to be in harmony with the patients neurovascular envelope of function. Harmony of this relationship is demonstrated by a lack of fremitus and mobility on the anterior teeth, by the ability of the patient to speak clearly and comfortably, and by the patients general sense of comfort with the overbite, overjet, and guidance created during chewing and when holding the head upright. The occlusion should be created at a vertical dimension that is stable for the patient. It is generally accepted that the patients existing vertical dimension is at equilibrium between the eruptive forces of the teeth and the repeated contracted length of the elevator muscles.

5.

When managing a pathologic occlusion or when restoring a complete occlusion, the clinician needs to set the occlusion on the centric relation because it is the only position from which an interference free occlusion can be created.

Hygiene Maintenance

Use of regular tooth brush Use of Floss Use of interdental brush

Implants

Inflammation and Proliferation

Inflammation in perimplant soft tissue is similar to inflammatory response in gingival and other periodontal tissue Known as periimplant mucositis. Characterised by erythema, edema and swelling around the teeth Sometimes unusual, dramatic inflmmatory proliferation is seen which is characteristic around implants It is indicative of loose-fitting implant to abutment connection or trapped excess cement that remains buried within the soft tissue or pocket. The precipitating local factors ultimately become infected with bacterial pathogens, leading to mucosal hypertrophy or proliferation, possible abscess and fistula formation. Correction of the precipitating factors quickly and effectively resolves the lesion

Dehiscence and Recession

Occurs when support for the tissue is lacking or has been lost.

an inflammatory reaction with loss of supporting bone in the tissues surrounding a functioning implant Etiology: The host inflammatory response displayed in some individuals as a result of biofilm adherence to the roughened surface of an implant

Clinical Features

(1) Evidence of vertical destruction of the crestal bone, often saucer shaped (2) Formation of a peri-implant pocket (> 4mm), (3) Bleeding or suppuration after gently probing, (4) Tissue redness and swelling (5) Mobility (insensitive in detecting early implant failure).

Clinical signs of peri-implantitis may not always be evident. Standardized radiographs are suggested one year after fixture placement and every alternate year thereafter

Plastic probes are used when checking for evidence of disease.

Implants are similar to the natural tooth. Implantitis vs. Periodontal disease have similar clinical presentations

Microbiology

Gram negative anaerobic rods, spirochaetes and fusiform bacteria were found in higher proportions at peri-implantitis sites as compared with healthy sites, which were predominantly composed of coccoid forms. Traditional periodontal pathogens such as Porphyromonas gingivalis, Actinomyces actinomycetemcomitans and Prevotella intermedia have been shown to colonize the peri-implant sulcus from 1 to 3 months after exposure to the oral environment The clinical implication is, if traditional periodontal pathogens are found, then the disease process could be similar to periodontal disease and patients with a history of chronic periodontitis may be at increased risk of peri-implantitis. The microbiology associated with implants are related to the bacteria already resident in the oral cavity, that is, that the remaining teeth can act as reservoirs for seeding of bacteria in the peri-

Management
PPD<=3 mm PPD=45mm
BOP= + No Cratering

PPD>5 mm
BOP= + Cratering<= 2mm BOP= + Cratering> 2mm

PI=1 BOP= -

PI=1 BOP= +

Mechanical Debridement, scaling and polishing

Antiseptic 0.1% CHX gel twice daily for 2 weeks

Systemic or local antibiotic therapy

Resective or Regenerative Surgery

Cumulative Interceptive Supportive Therapy

Implant Maintenance Patient Role

Use of interdental brushes, hand an motorized
Interdental brush for maintenance of implant-based fixed prosthesis.

Dip brushes in chlorhexidine, 0.12%

Use of flosses, yarns, tapes, dipped in chlorhexidine accomplished at night before retiring If patient has tooth-colored materials, composites, and so on, use a cotton swab dipped in chlorhexidine

End-tuft brush.

Butler Floss Aid is used to clean the bar including the area contacting the tissue.

Soft bristle brush.

power toothbrush

Yarn

Tufted floss.

Implant Maintenance

Dentists Role
Check for plaque control effectiveness
Check for inflammatory changes If pathology is present, probe gently with plastic probe

Implant Maintenance

Dentists Role
Scale supragingivally only Expose radiographs every 12-18 months if no pathology is present, and as needed if pathology is present If suprastructure is retrievable, remove and clean in ultrasonic every v18-24 months If implant nees repair, degranulate, detoxify and graft with guided bone regeneration if necessary

Implant supported fixed partial denture

Scaler tips are designed to fit the curvature of the standard abutment.

Removable Partial Denture

Ill effects of RPD on the Periodontium

Excessive Stress on Abutment teeth causing loss of abutment

Food lodgment, plaque retention and consequent periodontal disease

Ways to reduce stress on abutment teeth

Use of Stress Breakers Physiologic Basing: Functional impression making Broad Stress Distribution: increase the number of direct retainers, indirect retainers and rests and increase the area of denture base Clasps should be active only during function Minimum required retention should be used. Weak abutment teeth should be splinted together

Hygiene Maintenance

Mouth and RPD should be cleaned after eating and before retiring Use small, soft-bristle brush with non abrasive dentifrice to clean the RPD. Denture cleaning solutions can also be used. Calculus deposits on the RPD should be removed by ultrasonic scaler in the dental office. Substitute toothbrush massage for the normal stimulation of tongue and food contact with areas that will be covered by the denture framework.

Tooth Supported Overdentures

Beneficial effects of overdentures on periodontium

Preservation of alveolar bone Preservation of proprioceptive response
Existence of periodontal membrane gives a sense of discrimination not possible with conventional dentures

Periodontal maintenance
As abutment teeth are easily accessible, the patient is able to undertake homecare to maintain periodontium in optimal state of health

Preserving teeth not only preserves bone supporting the teeth but also the alveolar bone adjacent to the teeth

Ill Effects Of Overdentures On Periodontium

Periodontal breakdown of abutment tooth

Overdenture prevents natural stimulation & cleaning by tongue & cheeks, promotes accumulation of plaque & irritates gingiva Plaque accumulation, inflammation, pocket formation, loss of supporting bone and decrease in attached gingiva are all potential sequelae if overdenture is not maintained properly.

Prevention of periodontal disease due to overdentures

Properly cleaning the abutment teeth and the prosthesis

Fluoride therapy- not only reduces caries activity but also reduces gingival inflammation by reducing bacterial colonization in dental plaque in both quality and quantity.

Thank You