Periodontal considerations

& FDPs

The mouth is the gateway to the rest of the

body, a mirror of our overall well-being.

Restorations should have proper form,

function, and esthetics while promoting
the maintenance of tissue health in the
surrounding areas.

Periodontal tissues form

the foundation for proper

 Esthetics
Function
Comfort
Health
Satisfaction

Anatomy
The lining of the oral cavity consists of three types of
mucosa, each with a different function:
1. Masticatory (keratinized) mucosa, covering the gingiva and
hard palate.

2. Lining mucosa, covering the lips, cheeks, vestibule, alveoli,

floor of the mouth, and soft palate.
3. Specialized (sensory) mucosa, covering the dorsum of the
tongue and taste buds.

Periodontium

The periodontium is a connective tissue

structure attached to the periosteum of
both the mandible and the maxilla that
anchors the teeth in the mandibular and
maxillary alveolar processes

The main element of the periodontium is

the periodontal ligament (PDL), which
consists of collagenous fibers embedded in
bone and cementum, giving support to the
tooth in function.

What is the function of the periodontium

Anchor teeth to their bony alveoli

-Accommodate functional & morphologic
changes: acts as a damper of forces
applied
Allow changes in position of teeth due to
growth
Allow repair of injuries eg, root fractures
Seals bone & CT from infectious agents in
the oral cavity

Components of Periodontium
It consists of four
principal components
namely:
Gingiva
Periodontal ligament
(PDL)
Cementum
Alveolar bone

Gingiva

Normal gingiva is pink and stippled (orang peel). It varies in width

from1 to 9 mm and extends from the free margin of the gingiva to the
alveolar mucosa (mucogingival junction MGJ).

Gingiva
The gingiva consists of three parts:
1.Free (marginal) gingiva.

2. Attached gingiva.
3. Interdental papilla. consisting of a
buccal and a lingual component
separated by a central concavity
(the col).

Gingiva
The gingiva consists of three parts:
1.Free (marginal) gingiva.

2. Attached gingiva.
3. Interdental papilla. consisting of a buccal and a lingual
component separated by a central concavity (the col).

Functions of Periodontal ligament :

It provides a soft tissue casing to protect

the vessels and nerves from injury by
mechanical forces
Attachment of teeth to the bone
Maintenance of gingival tissues in their
proper relationship to the tooth
Resistance to impact of occlusal forces

Principal Fibres

The Alveolar crest fibres extend

obliquely from the cementum to
the alveolar crest
The Horizontal fibres extend at
right angles to the long axis of
the tooth from the cementum to
the alveolar bone
The Oblique fibres extend from
the cementum in a coronal
direction obliquely to the bone
The Apical fibres radiate at the
apical region of the socket from
the cementum to the bone
The Interradicular fibres fan out
from the cementum to the tooth
in the furcation areas of multi
rooted teeth

Dento-gingival Junction

At the base of the gingival sulcus (crevice) is the epithelium-tooth

interface, also known as the dento-gingival junction (DGJ).

Diseases of the periodontium

Etiology

Materia alba:

- is a white coating composed of microorganisms, dead epithelial cells,

and leukocytes that adheres loosely to the tooth. It can be removed
from the tooth surface by water spray or by rinsing.

Etiology
Acquired pellicle:
- is a thin brown or gray film of salivary proteins that develops on teeth
after they have been cleaned. It frequently forms the interface
between
the tooth surface and dental deposits.

Etiology

Microbial plaque:

is a sticky substance composed of bacteria and their by products in an

extracellular matrix; it also contains substances from the saliva, diet,
and serum.

It is basically a product of the growth of bacterial colonies and is the

initiating factor in gingival and periodontal disease.

Etiology

Calculus:

Dental calculus is a chalky or dark deposit attached to the tooth

structure. It is essentially microbial plaque that has undergone
mineralization over time.

Calculus can be found on tooth structure in a supragingival and/or a

subgingival location.

Periodontitis

When a loss of connective tissue attachment occurs, the lesion

transforms from gingivitis into periodontitis.

Treatment

Surgical Therapy
1- Soft tissue procedures
Gingivectomy
Open debridement
2- Hard tissue procedures
Bone induction
Osseous resection
3- treatment of furcation involvement
Odontoplasty-osteoplasty
Root amputation
Hemisection
Provisionalization
Restoration

Surgical Therapy

Soft tissue procedures

Gingivectomy

Is the removal of diseased or hypertrophied gingiva. It is essentially

the resection of keratinized gingiva only, and it may be applied to the
treatment of supra-bony pockets and to fibrous or enlarged gingiva.
bleeding points

Initial incision

Final gingival
contours
6 month later

Open debridement or curettage

(modified Widman procedure)

Open debridement or curettage is a surgical procedure designed to

gain better access to root surfaces for complete debridement and root
planning.

Hard tissue procedures

Crown lengthening
Indications:

1)

Development of Adequate
Crown Preparation

2)

Esthetics

3)

Creating good biological

width before tooth Prep.

Contraindications of Crown lengthening

periodontal tissue compromise is anticipated (No enough attached

gingiva)

Inadequate crown root ratio.

Non-restorable teeth.

Esthetic considerations.

Golden proportion
Width is 75%
of the height

Chapter 23 page 728

Treatment of Furcation Involvement

The normal position of osseous crest is approximately 1.5-2 mm

apical to the cemento-enamel junction (CEJ) in a young, healthy
adult.

Treatment of Furcation Involvement

Classification of furcation involvement:

Class 1: vertical loss of periodontal support that is less than 3 mm

apical to the CEJ.
There is no gross or radiographic evidence of bone loss.
Clinically the furcation can be probed up to 1 mm horizontally .

Class 2: vertical loss greater than 3 mm but without involvement of

the total horizontal width of the furcation.

A portion of the bone and periodontium remains intact, but osseous

loss is evident on the radiographs.

The furca is penetrable more than 1 mm horizontally but does not

extend through and through.

Class 3: A horizontal through-and-through lesion that is occluded by

the gingiva but allows passage of an instrument from the buccal,
lingual, or palatal surface. The degree of osseous loss is greatly
evident on the radiographs..

Class 4: A horizontal through and through lesion that is not

occluded by gingiva.

Hemisection

Hemisection mean cutting a tooth in half. In the case of mandibular

molar, hemisection is followed by removal and subsequent
restoration of one root or restoration of each half of the tooth.

The latter procedure is sometimes called premolarization or

bicuspidation.

FDPs are important factor for

maintaining periodontal health

Contours

smoothness
Proximal relationships

Margins adaptation

plaque accumulation

Other important factors

Oral hygiene

Periodontal disease

Evaluation of biotype

thin

thick

Thin biotype may

cause esthetic
problems in addition
to higher risk of
gingival recession

Occlusal adjustment before restorative care

Traumatic occlusal relationships

should be eliminated before
restorative
procedures
are
started.

restorations
should
be
constructed in conformity with
the newly established occlusal
patterns

Para-physiological habits
The destructive forces created by these parafunctional habits:
Destroy restorations
Create cervical abrasion
Contribute to the progression of periodontal disease

Materials and surface

Biocompatible materials
should be used.
Surfaces should be highly
polished.

Retraction cords
and added ingredients,
technique, and impression
materials: Are very important.

Improper removal & placement

of retraction cords can result in
tissue tearing and inflammation.

Tooth Preparation

Margins of crowns & other

restorations should be
located in a healthy gingival
sulcus

The occlusal surface

It should be designed to direct masticatory
forces along the long axis of the teeth
Occlusal dimensions and cuspal contours
in harmony with the reminder of the
natural dentition after occlusal
abnormalities have been removed by
occlusal adjustment

Pontic Designs
A- Ridge lap

B- Modified ridge lap.

C- Ovate

Modified ridge lap and

Ovate pontic give best
esthetic results

Esthetic treatment plan

should be started before
extraction to preserve
gingival contours and
papillae

Where to put the margin of the

restoration?
Supragingival
Subgingival
Equigingival

Biologic width

Definition
Dimension of the soft tissues
which is attached to the
portion of the tooth coronal
to the crest of the alveolar
bone

Supragingival margins

Advantages:
Disadvantages:
Periodontal conservation Low aesthetics

Subgingival margins
sub gingival restorations demonstrated more quantitative and qualitative changes in
the micro flora, increased plaque index, gingival index, recession, pocket depth and
gingival fluid.

Advantages

Disadvantages:

Aesthetic

Difficulty in impression
taking

Retention

Indecation
Radicular decay
Preexistent filling
Ferulle effect
Cervical abrasion
Root sensitivity
Badly destroyed teeth

When biological width is invaded

BIOLOGICAL FAILURE

POCKET
Thick

RECESSION
Thin

Violation of the biological

width causes:

Gingival inflammation and

rescission

Attachment loss

Bone loss

The signs of biologic width violation

are: Chronic progressive gingival
inflammation around the restoration,
bleeding on probing, localized gingival
hyperplasia with minimal bone loss,
gingival recession, pocket formation,
clinical attachment loss and alveolar
bone loss. Gingival hyperplasia is most
frequently found in altered passive
eruption and subgingivally placed
restoration margins.

Correcting biologic width violation

1. Surgically:
(crown lengthening)

2. Orthodontically:
(extrusion)

Orthodontic extrusion / crown

lengthening

Orthodontic extrusion SHOULD always be

considered first to avoid possible complications with
C.L Such as: recession, poor crown root ratio.. (Ingber et
el (1977).

Teeth with limited tapering in the coronal third of the

root are better candidates for extrusion (Jorgensen et al 2001).

The health of the periodontal tissues is

dependent on properly designed restorations.
Incorrectly placed restoration margin and
unadapted restoration violates the biologic
width. If the margin must be placed
subgingivally, the factors to be taken into
account are: Correct crown contour in the
gingival third; correct polishing and rounding of
the margin; sufficient zone of the attached
gingiva; and, no biologic width violation by the
margin. Repeated maintenance visits, patient
co-operation and motivation are important for
improved success of restorative procedures
with pristine periodontal health

Contemporary Fixed
Prosthodontics
Chapter 5