408

The lnlemalior>ol Joumol of PeriodonBc. & Keslofotive Denlistry


Tissue Response Under Hyper-
pressure from Convex Pontics
Ans-felros Tripodakis, DDS, MS, Dr Odont •
A. Conslanlinldes, DDS, MS, Or Odorat.'
Pontics are important ports of fixed
partial denlures and should not be
considered lifeless pieces of pros-
thetic material ihot simply unite the
obutment teeth. The purpose of their
dynomic presence in the oral cavity
is to restore the missing teeth func-
tionally, biologicolly, ond esthetically.
The occlusol surface is mainly re-
sponsible for the functionol require-
ments by reproducing the ocdusal
configuration of natural teeth as
closely as possible. The lobial sur-
face, on the other hond, is respon-
• Lecturer, Department of Fined Prostho-
dontics. University of Athens, Athens,
Greece,
^ Associate Professor, Department of Peri-
odantology. University of Thessaloniki,
Thessdoniki, Greece.
Correspondence Address: Dr Aris Tripo-
dakis, 92, Vas, Sophias Ave, Athens 11528,
Greece.
Presented at the i 2th Annual Meeting of
the European Pro sth odor tic Association,
Oslo, September 9-11,1988,
409
sible for the esthetics, and it should
reproduce lobially the normal height
of the clinical crown of the tooth to
be replaced. Finally, the tissue sur-
face is responsible for the biologic
reaction of the adjacent soft tissues.
This surface, in order to accommo-
date the neighboring residual ridge,
often results in an unfavorable con-
cove configurotion (Fig lo). A con-
covity in this area is biologically un-
acceptable because ploque accu-
mulation is inevitable (Figs 2o ond b).
Therefore, it has been well docu-
mented and thoroughly accepted in
the literature that the tissue surface af
pontics should be convex, smooth,
and well polished with point contoct
without pressure.'"' The convex con-
figuration would allow the dental
floss to mointain continuous contact
throughout the entire surface and
therefore provide thorough ploque
removal (Fig 3).
A convexity in this orea, however,
is not always easily feosible. In cases
wfiere the veriicol space is reduced,
it is impossible to mointoin the occlu-
sal width ond the lobial height, as
determined by occlusal ond esthetic
requirements, without creoting o con-
covity in the tissue surfoce. As a result,
o convex pontic in such a case ends
up being either shorter labially (Fig
Ib) or narrower acclusally (Fig, l c ] .
A third possibility would be to
mointain a convexity in the tissue sur-
face by slightly violating the resilient
onotomy of the residual ridge. The
pontic in fhis case would creofe
hyperpressure on fhe soft tissues
(Fig Id).
The aim of the present investiga-
tion was to evoluate the tissue re-
sponse to hyperpressure from convex
pontics under different conditions of
orol hygiene.
Volume 10, Number 5, 1990
 410

Fig la The occlusal width af the pantic Figs Ib and c In arder to preserve a convexity in the tissue surface, the pontic
is determined by the occlusal require- becomes either shorter labially or narrower occlusaily.
ments. The labial height should reproduce
the normal clinicol crown ai the tooth to
be replaced in order to meet the esthetic
requirements, in order to accammodate
the residual ndge, the tissue surface aften
results in an untavarabie cancove config-
uration.

Fig 2a Fixed portial denture with paar
biolagic response.
Fig 2b A concavity in the tissue surface
fovors plaque accumulation and hinders
oral hygiene.
Fig 3 A convex tissue surface allows the
continous contact of the dentol floss
throughout the entire surface, allowing lor
thorough piague removal

Tial of Periodonlics & Restorotíve DenHstry


Fig ¡d If the normal dimensions ore
preserved, the canvexity would violóte the
resilient anatamy of the residual ridge.
Method
Twelve patients who were performing
excellent ploque control and who
needed prosthodontic treatment to
the posterior dentition were selected
for this clinical study. Metol ceramic
fixed partial dentures involving two or
more continuous pontics were insert-
ed. The well-polished, glazed, and
convex tissue surfoces of the pontics
were adjusted so that they would
generate hyperpressure in ihe soft tís-
sues of the residuol ridge. The pres-
sure was the moximum allowed by
the resilience of the tissues so that the
proper fit of the castings on the abut-
ment teeth would not be hindered.
The bridges were cemented with tem-
porary cement ¡Opotow Temporary
Cement, Teledyne Getz). The po-
tients were divided in two groups.
Fig 4o Metal ceramic fixed partial den-
ture with convex pontics thot generate hy-
perpressure in the soft tissues. Floss was
being passed underneath the panties ot
least once a day.
Fig 5a Edentulous orea that had been
under hyperpressure from convex pontics
for ¡0 months. The areas of the indenta-
tions provided the experimental units,
whereos the areas aut of contoct provid-
ed the control units.
Group 1
This group comprised six patients
who were passing dental floss
(SuperFloss, Orol-B) underneath the
pontics al least once a doy. For this
group, clinical examination was done
after 3 weeks and 10 months. In three
of the patients biopsies were then
taken for qualitative histologie eval-
uation. The soft tissue pieces were
taken in such o way thot areas of
hyperpressure (experimental units)
and adjacent areas that were not in
contoct with the pontics (control units)
411
Fig 4b hiyperpressure after 3 weeks was
fallawed by a morphologic madificatian
of the residuoi ridge with the deveiapment
of shaliaw indentations Na clinical signs
of inflammation were present
Fig 5b The biapsy cantained areas af
both experimentol ond cantrol units
were incorporated (Figs 5a ond b).
The soft tissue pieces were fixed in
10% formalin solution and routinely
histologically examined. Tissues were
stained with hemotoxylin ond eosin.
Croup 2
This group comprised six potients
who were simply using a toothbrush
but were avoiding the use of dental
floss underneath the pontics. Clinical
examination followed after o period
of 3 weeks and 10 months.
• 10, Number 5, 1990
412

Results

Group I
Clinicol exominotion öfter 3 weeks
ond 10 months reveoled no signs of
inflammotion in the oreos of hyper-
pressure in all cases. However, these
oreos presented o morphologic
modification of the residual ridge with
the development of shollow inden-
totions (Figs 4b ond 5a).
Histológico lly, the differences be-
tween the experimental and the con-
trol units involved only the epithelium.
The epithelium wos thinner in the
oreas of hyperpressure ond the rete
pegs were shorter. No differences
were found in the subepitheliol tissues
Pig 6a Histoiogic section: control unit presenting normal epithelium ond rete pegs. IFigs Ó0 ond b).

Croup 2

When dentoi floss wos not used, in-

flommation was prevalent in oil pa-
Fig Ob Experimentol unit presenting thinner epithelium and shorter rete pegs
Subepithelium tissues do not pieient histolagic differences. tients, especially after 10 months. In
the areas of hyperpressure, the tis-
sues were inflomed and presented
redness and bleeding on stimulation
(Fig 7]. A serious morphologic mod-
ificotion was observed with the de-
velopment of deep indentotions. His-
tologie exominotion of the orea wos
ovoided becouse of the very clear
clinical finding of the estoblished in-
flommation.

Discussion

The clinical ond histological findings

of the present study during the ex-
amination period showed that hy-
perpressure from smooth, well-pol-
ished and glozed, convex, metol ce-
romic pontics, under the condition of

The lr>leTotronal Journal ol Penodonfcs & Restorotive Dentis

 413

excellent plaque control (flossing un-

derneath the pontics), does not intro-
duce inflammation in the od¡acent
soft tissues. Fiowever, if flossing in the
areas of hyperpressure does not toke
place, inflammation is inevitable.
Review of the literature reveols that
oil the research reioted to the biol-
ogic response of pontic design was
accomplished in the late 1960s,
Starting with" Stein's classic reseorch
report, the findings of oil the clinical
investigotions done at that time^' ore
those that led to the biologic princi-
ples for pontic design (convex and
smooth tissue surface, v^th point tis-
sue contact, without pressure). Those
principles have been thoroughly ac-
cepted,'--'"
Fig 7 Edentulous orea that had been under hyperpressure from convex pontics for 10
The findings of the present study months, denial flass had not been used. Clinical signs of infiommation were prévalant
seem to disogree with those biologic while the morphologic modification of the residual ridge involved the development of
deep indentations.
principles on the issue of hyperpres-
sure. The effect of hyperpressure was
examined previously in clinical studies
done by Stein^ and Cavazos,*^ How-
ever, comparisons of those investi-
gotions with the present one connot
be made because of the different ex-
perimental design. cast in the oreo of the residuol ridge, properly fulfilled, the results of the
In Stein's^ investigation, hyperpres- and therefore the mild pressure cre- present study lead to the ossumption
sure wos examined under the con- ated on the tissue from the pontics, that mild hyperpressure permitted by
dition of good orol hygiene in ridge would not affect the biologic re- the resilience of the soft tissues, if
lap pontics. This pontic design in- sponse. When the amount oí scrop- needed, can be biologically accept-
volves a concavity m the tissue sur- ing was increased to 1 mm, infiom- able.
foce from which ploque is not easily mation was seen. Nevertheless, orol On the other hond, proper oral
removed. Therefore, in the areas of hygiene was not mentioned in this hygiene in the tissue surfoce of the
hyperpressure, inflammation was experiment. Therefore, hyperpressure pontics requires the use of o floss
prevalent. Loter in the experiment, the was possibly occomponied by the threader in order to pass the dental
pontics were modified by establish- floss through the interdental spaces
presence of plaque ond led to an
ing a convexity in the tissue surface of the bridge. This procedure requires
unfavorable biologic response.
while the hyperpressure was relieved patience, discipline, and skill thot
The biologic response to the pon-
at the same time. As o result, the many patients do not hove. In o sit-
tics of a fixed portial denture de-
inflammation disoppeored, probobly uation of inodequote ploque control,
pends on: ¡Ij The orol hygiene that
due to fhe improved effectiveness of the findings of the present study
is provided by daily flossing and (2!
oral hygiene, showed thot the presence of hyper-
the effectiveness of fhe orol hygiene
pressure would be biologically un-
Cavazos,^ on the other hand, permitted by the convex design of the
acceptable and should be avoided.
found that 0,25 mm scroping of the pontics. If these two conditions are

10, Number 5, 1990

 414
Summary and conclusions
The aim of the present dinical inves-
tigation was to evaluate the biologic
response of the soft tissues to hy-
perpressure from convex ond smooth
metal ceramic pontics under different
conditions of orol hygiene. The con-
clusions can be summorized os fol-
lowing:
1. When the potient flosses under-
neolh the convex pontics, hyper-
pressure does nol promote in-
flammotion.
2. When the patient does not floss
underneoth the convex pontics,
hyperpressure is followed by in-
flammation,
3. Hyperpressure in all sitijations
promotes a morphologic modifi-
cation of the soft tissues with the
appearance of concove inden-
tations.
4. Fiistologically, when floss is being
used, the oreas of hyperpressure
present a thinning of the epithe-
lium and shortening of fhe rete
pegs.
Ttie Inlemahonal Jou,rQl al Periodonlics a Resloralh/e Denlisl
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