J.
Adv Dental Research REVIEW ARTICLE
All Right Res
Prostho-Perio-Restorative Interrelationship: A
Major Junction
B CMuddugangadhar* Tripathi Siddhi**DikshitSuchismita**
*M.D.S, Asst Professor, **Post Graduate Student, Department of Fixed Prosthodontics,M R Ambedkar
Dental College and Hospital,Bangalore, Karnataka.
Email:drbcmuddu@gmail.com
Abstract:
The relationship between periodontal health
and restoration of teeth is intimate and inseparable. For
restoration to survive long term, the periodontium must
be healthy so that the teeth are maintained. The
establishment of periodontal health is therefore a
prerequisite for successful prosthodontic and
restorative procedures. To facilitate this collaboration
the prosthodontist should not only appreciate the
periodontic implications of various procedures but
should also be knowledgeable about the types of
gingival tissue, osseous topography, occlusal effects and
their implications for abutment choice.
Keywords: Periodontal health, gingival tissue, osseous
topography, abutment.
Introduction:
Multidisciplinary approach is the “sine qua non”
for attaining long term therapeutic target of comfort, good
function, treatment predictability, longevity and ease of
restorative and maintenance care.1 Treatment planning
should be evidence based and ideally should preserve the
biologic environment while maintaining or restoring
esthetics, comfort and function. The real art of dentistry is
to co-ordinate and interface these perspectives and provide
the best quality of care to the patient.
Anatomy
The teeth are one of the few structures that penetrate the
integument; i.e., they go from inside the body to the outside
the body. As such, the gingival epithelium and connective
tissue serve as a unique barrier to oral challenges. In
addition the shapes of the teeth are functionally adapted,
and therefore the barrier morphology is adapted to correlate
with the tooth.
Serial Listing: Print ISSN(2229-4112)
Online-ISSN (2229-4120)
Bibliographic Listing: Indian National Medical
Library, Index Copernicus, EBSCO Publishing
Database,Proquest., Open J-Gate.
Journal of Advanced Dental Research VolII : Issue I: January, 2011
The integrity of the dentogingival complex
depends on having an intact epithelial covering, with
junctional epithelium forming a seal in the gingival sulcus.
Dental procedures such as root planing, sub-gingival
restorative procedures and tooth preparation for crown and
bridge fabrication, gingival retraction techniques all
damage both the epithelium and the gingival connective
tissue. It is essential that dental procedures be as atraumatic
as possible.The periodontal ligament has a shock absorbing
quality and hydraulic like tendency to respond to axial
loading with an increased pressure that counteracts the
apically directed tooth movement. When a tooth is
subjected to increased occlusal load, it will be slightly
depressed, and when unloaded, it will have a rebound
effect. Therefore, correction of “high” restorations by
grinding may require two or more checks over two to five
minutes. Also, the use of heavy body materials for crown
and bridge impressions with sustained pressure can cause
intrusion of a tooth followed by rebound extrusion after the
impression is removed. The result will be a restoration that
is high. Being aware of the properties of the periodontal
ligament can allow clinicians to modify their clinical
procedures.
Perio-restorative inter-relationship
The relationship between periodontal health and
restoration of teeth is intimate and inseparable. For
restoration to survive long term, the periodontium must
remain healthy so that the teeth are maintained.
Restorations must be critically managed in several areas so
that they are in harmony with their surrounding periodontal
tissues. To maintain or enhance the patients’ esthetic
appearance, the tooth-tissue interface must present a
healthy natural appearance, with gingival tissues framing
the restored teeth in a harmonious manner.
Understanding the inter-relationship between
endodontic and periodontal diseases is crucial. Both
involve an inflammatory process.2-9There are three main
pathways for communication between the dental pulp and
periodontium viz. dentinal tubules, lateral canals, accessory
canals and apical foramen. Differential diagnosis for
treatment and prognosis of endodontic-periodontic
diseases can be achieved by using the following
classification:
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1. Primary endodontic diseases
2. Primary periodontal diseases
3. Combined diseases
a. Primary endodontic disease with secondary
periodontal involvement
b. Primary periodontal disease with secondary
endodontic involvement
c. True combined lesions
In combined endodontic-periodontic lesions, it is
generally wise to treat the endodontic component first
because in many cases this will lead to complete resolution
of the problem. The loss of tooth structure makes retention
of subsequent loading problematic and increases the
likelihood of fracture during functional loading. Extensive
caries or periodontal diseases dictate removal of teeth
rather than endodontic treatment. However a
multidisciplinary approach becomes important when loss of
tooth will significantly jeopardize the patients’ occlusal
function or the total treatment plan, particularly when
dental implants are not an option. In such condition
prosthodontic treatment can follow after endodontic
treatment has been completed. If coronal structures are
largely intact and loading is favorable, simple filling can be
placed in the access cavity. However, if coronal structure is
severely compromised, post and core is indicated. A post
and core is occasionally used to provide retention and
support for a restoration in an endodontically treated tooth
with extensive loss of crown structure. It should be of
adequate length for good stress distribution but not so long
that it jeopardizes the apical seal. Anterior teeth,
particularly those with flared or elliptical canals, should be
built up with custom cast post and core, which offers great
strength. Esthetic post and core should be considered if a
dark post would prevent fabrication of an esthetic
restoration. Amalgam core material can be used
satisfactorily on posterior teeth when one or more cusps
have been lost, although a casting may be preferred if
substantial coronal structure is missing.
Prostho - perio relationship
Restorative clinicians must understand the role of
biologic width in preserving healthy gingival tissues and
controlling the gingival form around restorations.10, 11They
must also apply this information in the positioning of
restoration margins, especially in the esthetic zone. The
dimension of space that the healthy gingival tissues occupy
above the alveolar bone is identified as biologic width. A
clinician is presented with three options for margin
placement: supra-gingival, equigingival and sub-gingival.
The greatest biologic risk occurs when placing sub-gingival
margins.
With the advent of more translucent restorative
materials, adhesive dentistry, and resin cements, the ability
to place supragingival margins in esthetic areas is now a
reality. Therefore, whenever possible, these restorations
should be chosen, not only for their esthetic advantages, but
for their favorable periodontal health as well. The use of
equigingival margins traditionally was not desirable
because they were thought to retain more plaque than
supragingival or subgingival margins and therefore result in
Journal of Advanced Dental Research VolII : Issue I: January, 2011
8
greater marginal gingivitis. There was also the concern that
any minor gingival recession would create an unsighty
margin display. These concerns are not valid today not only
because the restoration margins can be esthetically blended
with the tooth, but also because restorations can be finished
easily to provide a smooth, polished interface at the
gingival margin.
When determining where to place restorative
margins relative to periodontal attachment, it is
recommended that patients’ existing sulcular depth be used
as guideline in assessing the biologic width requirement for
that patient.12 If the sulcus probes 1.5 mm or less the
restoration margin should be placed 0.5 mm below the
gingival tissue crest. If the sulcus probes more than 1.5
mm, margin should be placed half the depth of the sulcus
below the tissue crest. If sulcus greater than 2mm is found,
gingivectomy can be performed to lengthen the tooth. If a
patient experiences tissue discomfort when the restoration
margin levels are being assessed witha periodontal probe, it
is a good indication that the margin extends into the
attachmentand that a biologic width violation has occurred.
A more positive assessment can bemade clinically by
measuring the distance between the bone and the
restoration margin using a sterile periodontal probe. The
probe is pushed through the anesthetized attachment tissues
from the sulcus to the underlying bone. If this distance is
less than 2mm at one or more locations, a diagnosis of
biologic width violation can be confirmed. This assessment
is completed circumferentially around the tooth to evaluate
the extent of the problem. Biologic width violations can be
corrected either by surgically removing the bone away from
proximity to the restoration margin i.e., crown lengthening
procedure or by orthodontically extruding the tooth and
thus moving the margin away from the bone.13,14
2. Use of retraction cord and effect on periodontium
There is direct relationship between the time that
retraction cord is in the sulcus and the potential for adverse
gingival responses such as recession. It has been suggested
that total cord retraction time ideally should not exceed 15
to 20 minutes. Factors other than time deserve
consideration in using retraction cord and attempting to
minimize soft tissue trauma. Too large a retraction cord or
too many cords can cause excessive trauma. With healthy
tightly adapted anterior gingival tissue, one small diameter
cord usually produces adequate retraction without
excessive trauma. Placing retraction cord in the gingival
sulcus often severes the epithelial attachment, but healing
occurs in a few days with no prolonged harmful effects if
the procedure was carefully executed. The use of excessive
instrument pressure when placing cord into the sulcus can
produce extensive damage and recession.15
3. Impression procedures
An impression must provide detailed information
about the prepared teeth, surrounding teeth, and associated
soft tissues. The impression must record the form of all
prepared surfaces and some of the unprepared tooth
cervical to the finish line. Impression making of tooth
preparations that extend subgingivally with an elastic
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material also has the potential for soft tissue abuse.
Adequate gingival retraction is essential for predictable
impression making. Although techniques for retraction
have often been debated, the use of retraction cord has
proved to be an effective method of soft tissue management
during the impression phase. The placement of retraction
cord and cotton strings into the gingival sulcus may cause
injury to the sulcular epithelium. The damage inflicted to
the soft tissue depends upon the chemical agent with which
the cord has been impregnated, the force used in packing
the cord and the length of time the cord is left in place
within the sulcus. The force used to place the cords should
be minimal to avoid forcing the cord into the subepithelial
connective tissue. Most importantly prior to its removal, the
cord should be moistened to avoid tripping the sulcular
epithelium.16,17
3. The provisional restoration
Provisional restorations serve many purposes, one
of which is to preserve the position, form, and color of the
gingiva while the definitive restoration is being made. To
accomplish this goal, the soft tissue must rest in its normal
location against a provisional restoration that is properly
contoured, is well adapted to the finish line, and has smooth
surface. Provisional fixed partial dentures must exhibit all
of these attributes plus pontic and cervical embrasure forms
that provide access to the soft tissue by oral hygiene aids.
Gingival recession has been associated with improperly
contoured provisional crowns and rough surfaces have been
shown to promote plaque accumulation. After cementation
of the provisional restoration, it is important to remove all
traces of provisional cement be removed from the gingival
sulcus to prevent unfavorable gingival healing. The patient
mustreceive instructions on how to properly clean
provisional restorations; meticulous attention to the
prescribed regimen is necessary.18
4. Pontic design
Pontics and their relationship to soft tissue health
have been described. Pontic design as found to be the
most important factor in obtaining inflammation-free
pontic-ridge relationships.19,20 Minimal soft tissue contact
designs are biologically advantageous and the sanitary or
hygienic design should be used whenever esthetics permit.
Embrasures should be opened as much as practical to
permit access with oral hygiene aids. Stein has described
the ideal pontic design as "modified ridge lap" in the
posterior region and a “lap facing" in the anterior region.
Some authors prefer glazed porcelain for ridge contact
whereas others indicate that after months there is no
difference in soft tissue response to either porcelain gold or
resin.
5. Crown contour
Restoration contour has been described as
extremely important to the maintenance of periodontal
health.21,22 Ideal contours provides access for hygiene, has
the fullness to create the desired gingival form, and has a
pleasing visual tooth contour in esthetic areas. Evidence
from human and animal studies clearly demonstrates a
Journal of Advanced Dental Research VolII : Issue I: January, 2011
9
relationship between overcontouring and gingival
inflammation, whereas undercontouring produces no
adverse periodontal effect. The most frequent cause of
overcontoured restorations is inadequate tooth preparations
by the dentist which forces the technician to produce a
bulky restoration to provide room for the restorative
material. In areas of the mouth where esthetic
considerations are not critical, a flatter contour is always
acceptable.
6. Interproximal papilla and embrasure design
The interproximal embrasure created by
restorations and the form of the interdental papilla have a
unique and intimate relationship.23 The ideal interproximal
embrasure 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 exists to trap food or to be esthetically displeasing.
Embrasure contours might be more important than facial or
lingual crown contours. The interproximal papilla responds
rapidly to overcontouringof the embrasure region. It
becomes inflamed and hypertrophied as a result of poor
oral hygiene when the interproximal embrasure is impinged
upon by overcontoured adjacent crown surfaces. Other
factors may contribute to the papillary inflammation, often
seen as splinted restorations. 24The papilla is likely to be
inflamed because of the presence of subgingival margin on
either side and is often constricted in an occlusal-gingival
direction by the interproximal soldered connection. A study
to determine whether there were embrasure dimensions that
were more favorable to the health of the gingiva and
underlying mucosa concluded that oral hygiene exerted a
more important influence than the height of the embrasure.
The ideal size of the interproximal embrassure is one that
permits the introduction of cleaning aids for the removal of
plaque in this most vital area. Embrasures that are
excessively opened impact negatively upon esthetics,
impair phonetics, and allow excessive lateral food
impaction. The patient with normal clinical crown length
often presents a dilemma when one is designing an ideal
embrasure form. Interproximal height is often not sufficient
to allow space for an interproximal brush without
weakening the interproximal connector. Tufted dental floss
can be used in these situations, especially for anterior teeth.
The patient with advanced periodontal disease usually
presents much more interproximal height, and in some
space problem instances has so much apical migration of
the attachment apparatus that the embrasure is excessively
wide, which leads to esthetic, phonetic, and food impaction.
This predicament can be further complicated by root
proximity problems, cervical concavities, and root anatomy
irregularities. Correct embrasure form often requires a
balancing of all the factors mentioned.
7. Removable partial denture and periodontium
The use of removable partial denture leads to
detrimental changes in periodontal condition of the
abutment teeth. A successful treatment with removable
partial denture necessitates thorough knowledge of
interaction of removable partial denture with oral tissues.
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Oral hygiene appears to be even more crucial for a
removable partial denture patient compared to a patient
with fixed partial denture. The goal of definitive
periodontal treatment is to eliminate periodontal disease,
treat any defects that hinder plaque control and create a
better environment for cleaning. Periodontal pockets should
be eliminated or reduced via surgical or non-surgical
therapy. Crown lengthening is indicated in instances of
altered passive eruption of abutment teeth to establish
better crown contours as well as to create minimum space
required for different components of removable partial
denture.Retentive arms of removable partial denture can be
a source of plaque accumulation and can present an
inflammatory challenge to soft tissues. This is especially in
case of infrabulge retainers like “I” bars. Gingival grafts on
the lingual portion of anterior mandible provide increased
keratinized tissue for placing major connectors. The
relation between the rest and rest seat must be such that the
forces transmitted from the prostheses to the abutment are
directed apically down the long axis of the tooth. In this
manner the stress can be absorbed by the fibers of the
periodontal ligament without damaging the ligament or the
bone. Splinting of abutment tooth is indicated when
periodontal support as been reduced or increased stress is
expected as in use of intra-coronal abutments. Ill-fitting
denture or malocclusion can alter the function of the
removable partial denture and cause undesirable stress on
the remaining teeth and soft tissues.25,26
8. Occlusal considerations
The relation between periodontal disease and
occlusion has been long debated. It is generally accepted
that the inflammatory aspects of the case should be
addressed first and resolved before any occlusal
considerations. The rationale is that resolution of
inflammation will change the tooth-tissue relationship
including relationship of teeth to the opposing dentition.
After resolution of inflammation, the occlusion can be
evaluated and any negative consequences addressed. A
restorative occlusal scheme should provide for periodontal,
neuromuscular and joint stability. The use of centric
relation gives a reproducible, stable position that reduces
the risk of lateral pterygoid muscle hyperactivity and any
condylar movement will be in inferior direction, thus
lessening the risk of occlusal interferences in functional and
para-functional positions.27
Occlusal therapy can be used to decrease loading
of teeth that have lost bone due to periodontal disease.
Clinicians should develop the skills to diagnose occlusal
status, use splints (bonded external appliances, intra-
coronal appliances, or indirect cast restorations) for
occlusal stability and develop techniques for occlusal
adjustment (coronoplasty). Before considering splinting,
the clinician must identify the etiology of the instability.
Excessive occlusal forces from parafunction or deflective
tooth contacts are frequent causes of excessive mobility.
Whenever occlusion is the cause, occlusal therapy is
always performed first. Occlusal therapy on periodontally
involved teeth must produce an occlusal pattern that
differentially loads individual teeth according to each
Journal of Advanced Dental Research VolII : Issue I: January, 2011
10
tooth’s periodontal bone support. In addition, any
inflammation of the periodontal supporting apparatus must
be controlled before making a decision on splinting.
Orthodontic tooth movement may be a substantial
benefit to the adult perio-restorative patient. Many adults
who seek routine restorative dentistry have problems with
tooth malposition that compromise their ability to clean and
maintain their dentition. If these individuals are susceptible
to periodontal disease, tooth malposition may be an
exacerbating factor that could cause premature loss of
specific teeth. Orthodontic treatment is beneficial in such
patients.
Tooth preparation, impression, temporization and
cementation while fabricating a fixed partial denture can
result in pulpal injury. The palpable benefits of implants
have caused a paradigm shift in prosthetic and surgical
dentistry. Placing a dental implant rather than a fixed
partial denture provides a functional stimulus to help
preserve the remaining bone and prevent resorption while
preserving enamel and dentin of adjacent abutment teeth.
The biologic advantages over traditional prosthodontic
needs include preservation of natural dentition and
supporting periodontium, improved esthetics, improved
hygiene accessibility and reduced future maintenance.
Conclusion:
Thus, the opportunities for oral health care in the
twenty first century are enormous. The convergence of the
biological and digital revolution with clinical dentistry and
medicine is changing and transforming diagnostics,
treatment planning, procedures, techniques, therapeutics,
biomaterials and predictable outcome of therapy.
Realization of comprehensive oral health care requires
health literacy, health promotion, risk assessment and
advances in disease and disorder prevention. Clinicians
need to combine periodontal and restorative procedures in
co-ordinated manner to optimize clinical outcome.
Treatment sequencing should be based on logical and
evidence based methodologies, taking into account not only
the disease state encountered but also the psychologic and
esthetic concerns of the patient. Because periodontal and
restorative therapy is situational and specific to each
patient, treatment plan must be adaptable to change
depending on the variables encountered. Indeed, a carefully
constructed interdisciplinary approach, with accurate
diagnosis and comprehensive treatment planning serves as
corner stone for providing a holistic care for the patient.
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Journal of Advanced Dental Research VolII : Issue I: January, 2011 www.ispcd.org