A comprehensive

prosthodontics
Lawrence J. Calagna,

treatment and periodontics
M.S.*

rationale

combining

D.D.S.,

College of Dentistry, New York, N. Y.

Brookdale

Dental

Center

of

New

York

(Jniuersity,

eriodontally involved dentitions that require restorative treatment should be approached wit h the most comprehensive and precise therapeutic modalities available today. This type of pathologic dentition must be treated with periodontal and restorative measures. In this article, an attempt will be made to present a concept and the rationale for treatment. A combined approach by the prosthodontist and the periodontist toward establishing a treatment plan is necessar)-. A mutual understanding of the etiologic factors present, anticipated therapeutic procedures required, and the final design of the periodontal prosthesis will provide the total control necessary for successful treatment. Results from investigations demonstrate that dental plaque is one of the primary etiologic factors in inflammatory lesions of the periodontium.‘, ’ Soft and hard tissue breakdown is the clinical sign which indicates the extent of the disease j Fig. 1’1. and trauma from occlusion have been Gingival inflammation, pocket formation, citrd as causes of marked changes in the attachment apparatus.” The topography of the infrabony pocket represents the resultant lesion, where local irritants initiate the marginal inflammation and excessive occlusal forces act on the spread of this inflammation.’ Once the etiologic agents responsible for producing disease arc evaluated, a treatment plan can be decided upon. Hopeless teeth are extracted. endodontir therapy is completed where indicated, and any anticipated tooth movement is incorporated into the initial preparation phase of the treatment (Fig. 2).
PROCEDURE

P

Initial preparation. desire and motivation
Presented *Assistant before Clinical the

During initial preparation, the patient will demonstrate his to perform the necessary hygienic duties. The entire dentition
Northeastern Gnathological Department Society, New York, N. Y.

Professor,

of Removable

Prosthodontics. 781

702 C&gnu the remaining abutments are prepared. and heat-cured xrylic resin r-erainers :jn.: .

. Abutment preparations should conform to the repositioned free gingival margin. Upon evaluation. Any type of elastic impression material may be used to satisfactorily capture the finished margin of the preparation (Fig. and (9) physiologic acceptability. in length. Y. and therefore they are justified.5 to 1. Only those procedures which yualitatively fulfill the objectives have merit. Surgical phase. require definitive operative therapy. Products. Los Angeles. During this period.. A bud or flame-shaped carbide bur* creates the necessary trough and also bevels the chamfer margin (Fig. The provisional splint is a template for the final prosthesis (Figs. iTew R Dental York. 5). Inc. The grey area of “physiologic tolerance” has no known measurable limits. 7). 3 and 4). There is no available diagnostic measure which can accurately predict whether or not a dentition will break down. Philadelphia. As a result. a complete list of objectives is reo. In this fashion. (3) bilateral simultaneous occlusal contacts at the correct \. The prepared margin should not extend into the attachment apparatus nor should retraction procedures impinge upon the epithelial attachment. (4) maximum distribution of contacts. complete pocket elimination should be attained. Maintain integrity of periodontal supportive apparatus.0 mm. the patient’s remaining teeth are provided with the best possible means of maintaining their stability. depending upon the depth of the gingival sulcus. these procedures insure that the integrity of the periodontal supportive apparatus will be maintained. The beveled margin need only be 0. In order to properly evaluate a completed clinical procedure. Teeth with a questionable prognosis are carefully evaluated during this phase of treatment. the gingival salcus depth is 0. meaningful evaluations can bc made regarding thf techniques used.uired. Products Calif. (6) limit horizontal forces. Gingival retraction cord? saturated in a hemostatic solution$ is lightly inserted into the trough to insure adequate access to the margins. Premier N. Dentitions classified as “terminal. 6‘1.” as well as the more moderate periodontally involved dentitions. Minimum bleeding takes place since the operative site is in a state of good health. (5) direct vertical forces.5 to 2 mm. (7) maximum efficiency with minimum expenditure of energy. final chamfer margins are prepared to the exact height of the free marginal gingiva (Fig. (8) maintain stability of centric position.ertical dimension of occlusion. Epithelization of tissue is complete six to eight weeks after surgery. tVan $Hemodent.Prosthodontic-periodontic treatment 783 relined to provisionally splint the remaining dentition. and this provides for a healthy environment in which the prosthodontist can complete therapy. Pa. The increase in clinical crown length following periodontal surgery locates the free gingival margin on root surfaces and farther “Pfingst. Biologically contoured restorations. Dental Company. OBJECTIVES OF RESTORATIVE THERAPY The objectives of restorative therapy in periodontally involved dentitions include the following: ( 1) maintain the integrity of the periodontal supportive apparatus. Following completion of periodontal therapy.” At this time. ( 2) biologically contoured restorations.

gl~.lrti:~i-! !MTI’. 9).! lowing osseous surgery becomes exc?ssively op(xned and prizsc’nta a potcnti. exactly tc> the coronal height of the frrkt* margina! .1. full-coverage restoration< arc indicated. ir~l!~11:1::hin. with the root pal lion c.l~c. I!. Once the vertical dimension of oc. thr potential 11. the.ii heq!l~ of contour is relocated on root surfaces. as c-&ted before surgery. tll<.i/o~lt.itltiii. Consequently. Little.i l<ta-(rc3riol: !I[ Ii.IQ’ restorations arc contraindicated. in the periodontal membranes will reflexly condition the nPurnmusculaturc> w th:l: mandibular closure is harmonious and bilaterallv simrtltaneo~~s at the c‘or‘rec’t 1 !sr. food-impaction area.centuatiorr tj!’ ii:ltul.clusiorr lens been established. f2e1lt1 ik holtli~itr c’usJls are th Ill.Ic. Chamfer margins are prepared gival tissue.l.ci. Maximum distribution o/ f orztac‘ts.” natural ccmentoenamel junction. the s. In addition.erltric..qe position is chosc>n as the correct position for c. Proprioccpti\.ontoured rrlari\~eti \i:<llgi:: and the remaining clinical crown possessing subtlr asi. Bilateral . I%ecaustl of t!!i:\ ~. If the reatorcad i.r nerl(’ t:~ldi~~g. 5. the position must be replicabl~~. ‘I‘hr gingiv. 8. a removable partial denturf.id(> .:i! dimension of occlusion. would resmelt lronl this t\.784 Calagna Fig. marginai tiystic. ‘To prevent a potential patholoq-ic. III order to prwisel~~ loratc~ hi\ :xY~I~I ~211 contact position. (‘orives surfacc~ l~orr~tr . if any.ti~r~r . functional rrlntiori5liiJ) 8 protective capacity upon the gingival tissue.important.rI VI~I~~.! is acceptrd as presented by the patient or restored u ith tllr l)rosthesis. and l~.lii.tr~ buccal cusps and thr maxillary lingual cusps.~sp :111c! maxillary lingual cusp contacts.tmc distanc. The occlusal schemes fahricatcd 1:..I .r :ir(’ must be lengthened occlusogin.li.:.~~. i.i.tic.givally and still l)rn\.. rhc% c.?I away from the protective axial convexities of tht~ tooth. “1 pY’~‘i\f :lll(T harmonious contact position must be attained.c from the. condition.IJ?(’ jf.’ orclusion. For tlli5 rcasoI1.tsin. contours found in tooth forms becomes inc~rc.!’ oi ( o:lto:!~ As the distance from the occlusal surface to the fre(l gingival margin iuc W.i from retrusive occlusal discrepancies can be elinlinatt~d. physiologic~ rfTrc.t/m:ri .I(‘[c>I in most instances.WW ir~ar~c~~srl~i~ for cleansing measures.li l~r. relation to i-oirlc~icic* 11iti: centric occlusion or mnximmn intercuspation.SIT tiltnecessity for protective axial convexities dccrfAas?s.I triangular . and thy . 1”1ostheG\ .rlllll.glJlglvui 13tnhI’a411!i’ i\ ill( /I C:III be readily cleansed by c~onvcntional me. better gingival health and improves esthetics (Fig. result Lvould be to creattt . periodontally treated dentitions must providra for both mandibular bucral c.lsIirt~s Fig:.c>rit.rimultaneour occ~lusal rnntartr ut tlrc co/rc’( t i ~j-tzrcl/ !iltf!c.

as well as to the abutment teeth (Fig.’ Because of this. Reversible hydrocolloid impression material is used to record the shape of all prepared margins. esthetics. The lower lip. the protrusive inclination of the condyle path. occlusogingival recreate natural area convexities is lengthened to promote in order better accessibility for sufcular horizontal food contact to prevent should be incorporated into the treatment plan where indicated to further distribute the forces of occlusion to supportive denture-bearing areas. The most precise way to determine the border paths of the mandible is with a pantographic recording. 9. Restored contours hygiene techniques. The patient is premeditated with 15 mg. 8. The use of cusp teeth necessitates the correlation of ridges and groo\. cusp-fossa occlusion should be used whenever possible (Fig. pro-Banthine to maintain a relatively dry field. Fig. the lateral translation of the mandible or Bennett shift. The lingual concavity of the maxillary anterior teeth is influenced by the sagittal displacements of the working condyle. This information can only be obtained from the patient by means of locating the horizontal mandibular .es with mandibular motion. The design and arrangement of the principal periodontal fibers are such that vertical forces directed along the long axis of teeth are best tolerated by the supportive periodontium. 7. Cusp teeth located in fossae must be provided with ridges and grooves in order to harmoniously pass through opposing occlusal surfaces as determined by condyle pathways and the incisal guidance. Fig.Prosthodontic-periodontic treatment 785 Fig. 11) . The impaction. and phonetics determine the length of the masillary anterior teeth. 10). and the intercenter distance or the distance between the vertical axes. Direct vertical forces.

disclusion horizontal by In order to properi).~ti’ cuspid of limiting teeth in lateral from the Since excursions should all hv incorporating farther posterior a lateral immediately and the nonworking mo\.LSI th r):~(. parafunctional protrusive movement. rrlovements is to diqc iudr Stir typ. of ocrfusal sc~hrmlt~.nld xnti IF IILIA~ . oil ti.enwnts.tic iilaio: available is rquircd. force take destructiw In basis .iuaioJi. interpret a fulls the recording> Arcon-typr of level-h .IdjllDtable laws cfhcicnt Limit renctx method posterior cuspid tication encountered capable working tllr tional \vorking posteriorand of of hokontal of the teeth.hr. capabilities.’ lateral the out of oct. physical the mosl escursi\f~ sourw complete . discriminatory forcer. On in the natural forces away teeth.I-10 0C polver elimination onI)- tooth is located ! than are the during tolerating should side teeth from side (thr.otltact. .l~ trrtii posterior ‘Tllis side. teeth oc~clusal l’orws The tllo\i cuspid Perth OII till. . l>otentinlly a cuspid-disrlusiot.~‘-tom-~ iatrrd ttvtll lateral nlandibular is ilzlpossible.~rrti IP. l)o~h arranpement protcx’ts encountered during the anterior 111r-lc.asis and by total pantography.ii‘ trauzll. in c. musc~it5 of thrw 01 rt:.

Since there are no known methods available to determine an indixidual’s physiologic limitations. Restoration of an occlusion lvith a cusp-fossa occlusal scheme is a most efficient method of maintaining stability. Minimum clearance on the Marking side is provided so that the inclination of the lingual cuspid concavity is maintained within its physiologic limitation. comprehensive treatment modalities are considered mandatory when treating the periodontally involved dentition. The muscles are programmed to effect closure without deviation into the maximum intercuspal terminal hinge position. A team effort is required so that maximum control of total therapy can be maintained.1 nondrfinitive approach may be successful for a given patient does not rule out the fact that. Physiologic acceptability. Also. If a “long-centric” or occlusion-possessing minimum cuspal morphology were formed. such therapy may contribute to the continuation of periodontal breakdown. 13). develop a “slide. The effect of these occlusal schemes ~vould be to confuse the neuromuscular system and diminish the efficiency of the mechanism at the expense of increased muscle energy output. the response of the periodontal tissues is the yardstick by lvhich longevity of prosthodontic treatment is measured (Fig.” If the precision of the occlusion is responsible for programming thr neuromusculature and if the system is capable of adaptation. The occlusion is fabricated so that centric relation and centric occlusion coincide. in a period of time. In the final analysis.e nerve endings continuously reinforce closure into this contact position. and based . Once this has b een established.Prosthodontic-periodontic treatment 707 immediately disclude all the posterior teeth. the prerision of the occlusion becomes more important than the position itself. if the cuspid becomes bveakened structurally. The propriocepti\.‘” A precision orclusion fabricated in the terminal hinge position may. The periodontal tissues arc the ultimate testing ground for the validity of all concepts of occlusal function. every possible measure must be taken to provide the crippled dentition with the best chances of survival. Maintain stability of the system.!’ Only in this way can precision occlusion be established. The mere fact that . in another individual. Definitive periodontal and prosthodontic measures can be evaluated. Use of the terminal hinge position is mandatory in order to take advantage of a replicable reference position during reconstruction of the dentition. Periodontally involved dentitions requiring restorative therapy can be diagnosed and treated on a predictable basis. the physiologic limitations have been exceeded. the proprioceptivc n(xr\-c endings in the periodontal membrane would be continuously stimulated b) a \. a posterior group-functional contact arrangement on the working side can be easily attained (Fig. for that individual. The precision of the occlusion becomes extremely important in conditioning the neuromuscular mrchanism. SUMMARY 1.ariety of positions of occlusal contacts. Whatever the etiologic factors present in a patient. then the recurrence of a “slide” can be considered “normal” and within physiologic limits. definitive. via the proprioceptivr system. the fact that periodontal disease has resulted means that. Maximum efficiency with minimum expenditure of energy. 2. On this premise. 12).

5: 543-568. PARK SOUTH hT. P. 20: 21-36. J. P. 1 Z-182. 8. R. Calif. E. D. V. H.IIT pro\tho dontic objcctkw. M.‘.: Physiologic Design Criteria i<~r F&d Dental Restorations. 1972. <. A. Saunders ‘I’wth Positiux:.: Recent Developments Dental Foundation.i 56: 21-33. References 1. DEKT. H.: Effect of Excessive Wclusal Forces L-JXBII ttw Patt!wa\ of Gingival Inflammation in Humans. Dent. 1964.: Personal Communication. Odontol. Philadelphia. 10.: The Canine Teeth--Normal Functional Relation of the Natural Man. and Noble. Argcnt..L rationale for treatmrnr ~-xi be made.I: 383-391. J. F. 1. I. Assoc. Ramfjord. A. 10019 . Periodontol. 26: 49-60. PROSTHET.e. Box. . and Gitnick. j bf Clinical Manifestation> r)f PeriLovdal. Eissmann. .supportivc apparatl:s I\ rhc.4. M. Jr. F. Carranza.: Occlusil>n..: Exprrimental ‘I‘raunutic l. North Am. Oct. 7. H. J. J. Atwood. 2... Dvtl:. 5 6. 196. Asoc. Dent.lickman.. J. Itoiz: M.ith dt~terrniri3xit~ t )’ mandibular motion and within the physiologic limitations of the patient. M’.wion~. A. Jr. ultirna te goal of combined periodontal prosthodontic thr~rapy. Complete elimination of local irritants and pockrt formation is a prriodorrtxr ob.: and Smulow. Celenza.: Incidence odontal Disease in Light of Oral Hygiene and Calculus Formation. A. 14: 343-354.. 1963. Clin. 1966. Arm). Riologic contours and a precision occlusion.ept of Oral Sepsis. 1. South. PKOSTHET. Ontario. . 1958.jecti\. -1. and Ash. K. and Cabrini. Company. 9. Rcxv. VVt-terr. i\m.3. . J. 3. and Waerhaug.. 1968. R.. 36: l-11 -147. J.: A Critique of Research of the Posterior Limit of the Mandibular J. . 197 i. C-I! D’:lmico.788 Calagna upon biologically and mechanically sound objectives. K. in the Cunc. A. 4. in lumony k\.. S. B.. Y. 127-142. DENT.. :30 CENTRAL NEW YORK. 3. W.*iw. F. Radke. 1958. Rosen. . H. 15%.5. Maintenance of the integrity of the periodontal .: Integrating Restorative Prowdurw Into the ~I’rratmcnr 11: Periodontal Disease..

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