FIXED PROSTHODONTICS WITH

PERIODONTALLY COMPROMISED

TEETH
Active periodontal disease must be treated and

controlled prior to any restorative dentistry. If

restorative dentistry is performed on teeth where the

periodontal prognosis is not determined and disease

not treated, the loss of the restored tooth can occur.

 The following are reasons why periodontal
disease must be eliminated prior
to restorative dentistry:

1. To locate and determine the gingival margins of

restorations properly,

Margins of restorations covered by inflamed gingiva

shrinks after periodontal treatment.

2. The position of teeth is frequently altered in periodontal
disease.
Resolution of inflammation and regeneration of
periodontal ligament fibers after treatment cause the
teeth to move again, often back to their original
position.
3. Inflammation of the periodontium impairs the capacity of
abutment teeth to meet the functional demands made on
them.

become a destructive influence when superimposed on

existing periodontal disease, shortening the life of the
teeth and the restoration.
4. Partial prosthesis constructed on cast made from

impression of diseased gingiva and edentulous mucosa

do not fit properly when periodontal health is restored.

5. Discomfort from tooth mobility interferes with

mastication and function.

the aims of periodontal treatment are not limited to

elimination of periodontal pockets and restoration of

gingival health. Treatment should also create the

gingivomucosal environment and osseous topography

necessary for the proper function of single-tooth

restorations and fixed and removable partial prosthesis.

In patients with mutilated dentitions and extensive

periodontal disease, the sequence of treatment can be

modified as follows:

1. "Hopeless” teeth are extracted, followed by

construction of a temporary partial denture.

Temporary crowns are prepared with provisional

margins.

2. Periodontal therapy is performed.

3. Approximately 2 months after periodontal treatment,

when gingival health is restored and the location of

the gingival sulcus is established, the preparations

are modified to relocate the margins in proper relation

to the healthy gingival sulcus, and final restorations

are constructed.
Etiology of periodontal disease:

1) Microbial plaque

2) Calcules

3) Acquired pellicle

4) Materia alba
Examination of periodontal compromised teeth

1- Visual examination
2- Probing

The use of dental probe is one of the most important

aspects of examination. Probing should be done in six

areas around the tooth.

Evaluation should include bifurcation and trifurcation

areas.
During probing bleeding or exudation should be
checked, these are also signs of periodontal disease.
3- Mobility

Mobility can be determined with the handle end of the

mirror placed on the lingual and the buccal surfaces and

applying pressure to the tooth with the handle.

Mobility is an indication of the loss of the tooth's

attachment to the jaw. This can be seen radiographically

as a widened periodontal ligament space. It's worth

mentioning that, because a tooth is mobile doesn't mean

it will be lost.
The mobility is considered physiologic if it is increased,

but not increasing and does not impair function or

cause patient discomfort. As such, it is reversible once

the source of the traumatic forces has been removed.

Lindhe described these conditions as follows:

Situation I: Increased mobility of a tooth with increased

width of the periodontal ligament, but normal height of

the al­veolar bone.

Situation II: Increased mobility of a tooth with increased

width of the periodontal ligament and reduced height of

the alveolar bone.

Situation III: Increased mobility of a tooth with reduced

height of the alveolar bone and normal width of the

periodontal ligament.

Situation IV: Progressive (increasing ) mobility of a tooth

(teeth) as a result of gradually increasing width of the

periodontal ligament in teeth with a reduced height of

the alveolar bone.

Situation V: Increased bridge mobility despite splinting.

Treatment options:

Situation I,II and III: resolution of inflammation by root

planning and reduction of occlusal prematurities.

Splinting is contra indicated.

Situation IV: splinting.

Situation V: Cross arch splint. If the prognosis is poor,

so complete denture is required.

Splinting
Splinting refers to any joining together of two or more

teeth for the purpose of stabilization. So splinting is the

added mechanical factor used to prevent, reduce or

eliminate tooth movement.

To obtain maximum benefits, splinting should be

combined with redesign of the crown surface and the
tooth should be in functional harmony with the
mandibular movements of the patient before the
construction of the splint.
Purposes of splinting:

1. Protect loose teeth from injury while stabilizing

them in a favorable occlusal relationship.

2. To distribute occlusal forces so that teeth

weakened by loss of periodontal support do not

become loose.

3. To prevent natural tooth from becoming loose and

migrating.
The number of teeth required to stabilize a loose tooth
depends on:

1. Degree and direction of mobility.

2. Amount of remaining bone.

3. Location of the mobile tooth in the arch.

4. Whether the mobile tooth is to be used as an

abutment tooth or not.

Types of splints:

I. Temporary and provisional splints.

2. Permanent splints.

Splints can also be classified as:

1. Removable splints.

2. Fixed splints.
Types of fixed splints:

1. Minimal preparation (resin bonded) splints.

2. Intra-coronal splints.

3. Proprietary splints.

4. Partial crown splints.

5. Complete corwn splints.

6. Diodontic splints.
4- Radiographs

They are essential for

1- diagnosis.

2- treatment.

3- maintenance in periodontics.
The areas to be reviewed on the radiographs are:

1. Alveolar crest resorption.

2. Integrity of thickness of the lamina dura.

3. Evidence of generalized horizontal bone loss.

4. Evidence of vertical bone loss.

5. Widened periodontal ligament space.

6. Density of the trabeculae of both arches.

7. Size and shape of the roots compared to the crown

to determine crown / root ratio.

5- Habits

The major habit to consider is bruxism. Visual

examinations of wear facet patterns that noted in areas

where a person doesn't normally chew and x-ray

interpretation of the thickened lamina dura and widened

periodontal ligament spaces determine whether a

patient grinds during sleep. Another condition that

indicates bruxism is a complete arch that exhibits

mobility despite adequate osseous support.

 Treatment planning

Initial therapy Definitive therapy

Surgical treatment Prosthetic

treatment
I. Initial therapy:

1- Control of microbial plaque

Mechanical means of plaque control include:

(a) tooth brushing

(b) flossing, and

(c) others aids like the use of interdental stimulators,

interproximal brushes, and electric toothbrushes.

2- Scaling and polishing

Removal of supragingival calculus (scaling) and
polishing of the coronal portion of the tooth are the first
steps in debridement of the teeth.
3- Correction of defective and/or overhanging
restorations.
Overhanging restorations. open interproximal contacts,
and areas of food impaction contribute to local irritation
of the gingiva and prevent proper plaque control.
corrected by replacement or reshaping
4- Root planning
It is the process of debriding the root surface with a
curette that will lift deposits off the root surface and will
plane it to a glasslike root surface.
Disease progression will continue without root planning
even with effective oral hygiene,
5- Strategic tooth removal:
It is an important part of treatment sequencing is the
elimination of teeth that are hopelessly involved
periodontaly or are non restorable.
Early extraction of teeth and / or roots will allow the
socket areas to heal and can provide better access for
plaque control of adjacent tooth surfaces.

6- Stabilization of mobile teeth

Tooth mobility is not necessarily a sign of disease
because it may be a normal response to abnormal forces
especially when bony support is lacking and it doesn't
always need corrective treatment.
 So depending on the case, the teeth may be
treated either by,
1. Reduction of the abnormal forces through
occlusal adjustment.
2. Splinting, alone.
3. Splinting in conjunction to occlusal adjustment
if needed.
7- Minor tooth movement
Malposed teeth may be realigned orthodontically, to

make them more receptive to periodontal treatment and

to improve the efficacy of plaque control measures.

Evaluation of the initial therapy: The periodontium

recovering from active disease should be regularly

reexamined and revaluated to determine the efficacy of

the treatment. Soft tissue response to the initial therapy

are observed along with the patients motivation and

ability to maintain a relatively inflammation free state.

 II. Definitive therapy:

Surgical Prosthetic
treatment treatment

Soft tissue Hard tissue

procedures procedures
 II. Definitive therapy:
A. Surgical treatment:

After the initial therapy, decisions regarding whether

further treatment of the peridontium, can be made.

There are number of surgical procedures for the

improvement of plaque removal and aimed primarily at

reducing or eliminating probing depths.

1. Soft tissue procedures:

a- Gingivectomy

It 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

suprabony pockets and to fibrous or enlarged gingiva

particularly resulting from dilantin therapy.

b- Open debridement (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.

The modified Widman approach has been advocated

because :

1- It allows good soft tissue flap control.

2- minimal surgical trauma.
3- good access for complete debridement of the root surfaces and
degranulation of any osseous lesions in the filed.
4- good postoperative integrity without excessive loss of osseous
tissue attachment.
A. internal bevel incision, B. flap reflection (the supra crestal
connective tissue and epithelium are to be removed.
E. enamel, S. sulcus, P. the supra crestal connective tissue, R.
root.
c- Mucosal repair: mucosal reparative surgery is
used to:
 Increase the width of the band of attached keratinized
gingiva which may be increased by surgical grafting.
 It is recommended that a tooth to be treated with a
restoration extending into gingival sulcus should have
approximately. 5mm of keratinized gingiva, at least
3mm of which is attached gingiva.
 Where less keratinized gingiva is present grafting or
other gingival augmentation procedures will be
needed.
1- Free autogenous gingival graft:

 The donor site most commonly used is hard palate

although edentulous ridge or retromolar pad may be
suitable.
 Recipient bed site is prepared by making horizontal
split-thickness incision just coronal to mucogingival
junction.
 Graft is removed from donor site and sutured into
place.
Sterile saline is used to keep the graft moist until it is
placed on recipient bed.
 Complete healing requires approximately. 6 weeks.
2- Laterally positioned pedicle graft:
 It is used for area of recession or lack of attached
gingiva on a single tooth, when there are adequate
amounts of keratinized gingiva in adjacent teeth or
edentulous spaces.
 There are certain limitations of this graft:
1- Some recession always occurs at donor site where free
margin of the gingiva is involved. (1mm).
2- Sever recession is possible if donors site uncovers any
bony fenestration.
 An incision is made obliquely towards the site [recipient].
 Releasing incision at the distal of the donor site.
 The graft is rotated into position over the recipient site.
 Flap sutured into position.
3- Coronally positioned pedicle graft:

 It is used when a single tooth exhibits gingival

recession and sensitivity.
 Divergent vertical incisions are most commonly
placed a far apically as possible into the mucosa. This
results in broader apical than coronal portion of the
flap to ensure an adequate blood supply.
 Root surface is planned.
 Graft is sutured in a coronal position to obtain
maximum root coverage.
4- Subepithelial C.T. graft:

 This technique involves the use of subepithelial C.T.

from the palate in a split-thickness fashion, which
allows the wound to be closed after removal of the
graft.
 This technique minimizes the patient discomfort at
donor site.
 Graft is placed at the recipient site between a
minimally reflected split-thickness flap and the
periosteum covering the root.
d- Crown lengthening:(Exposure of sound tooth structure)

Surgical Crown lengthening procedures may be

required to solve problems such as

(1) Excessive gingival display (esthetic).

(2) Inadequate amount of tooth structure for proper

restorative therapy.

(3) Subgingival location of fracture lines.

(4) Subgingival location of carious lesions.

The techniques used to accomplish crown lengthening
include:
1. Apically positioned flap procedure including bone
recontouring,
2. Orthodontic extrusion (forced tooth eruption) with or
without fiberotomy.

At times, it is possible to achieve an effective increase in

crown length by gingivectomy or electrosurgery alone,

although most often osseous recontouring is needed to

prevent encroachment on the biologic width.

1. Esthetics. When surgical crown lengthening is indicated, it
may be difficult to achieve a harmonious transition from the
tissue around the lengthened tooth to that around adjacent
teeth. Alternatives may then be orthodontic extrusion

2. Root length within bone. If there is limited osseous support,

it may be better to remove the tooth and replace it with
prosthesis

3. Effect on adjacent teeth. Often a fracture or defect will be of

such depth that it cannot be eliminated without severely
endangering the adjacent teeth. In these instances removal
or orthodontic extrusion may be preferable.
4. Root furaction exposure in a posterior tooth. If this
situation cannot be remedied by osteoplasty and / or
odontoplasty, the tooth may require removal.
5. Mobility. Posturgical mobility of a tooth with small or
conical roots is a valid concern. If such a tooth cannot
support itself or cannot be supported by the adjacent
teeth, so removal may be necessary.
6. Extent of the defect. The severity and complications of
any fracture, root caries or cervical wear must be
carefully evaluated during the treatment-planning phase.
7. Root perforation. This is uncommon, but if it occurs
during endodontic therapy, its location will determine
whether to remove, orthodontically exterude, or
lengthen the tooth surgically.
e- Gingival recession

lndictions for treatment. Gingival recession can defined

as the exposure of the root surface due to an apical shift
in the position of the gingiva. Normally, the gingival
margin is positioned 1 to 3 mm coronal to the tooth
cemento-enamel junction (CEJ) circumferentially, such
that the coronal portion of the root is totally covered with
gingival tissue. Prominent teeth with a thin periodontium
are subject to gingival recession especially where there
is gingival inflammation.
Exposed roots may cause:
(1) Hypersensitivity.

(2) Esthetic concerns for the patient

Treatment modalities
(A) teeth that are scheduled for crowns may not require
surgical techniques for root coverage where the
prosthesis will cover the sensitive or unesthetic exposed
root.
(B) Surgical correction of gingival recession is often
required, together with restorative therapy and/or
orthodontics.
Causes: Localized gingival recessions

1- Traumatic tooth-cleaning techniques

2- Local irritants such as plaque and calculus

3- severe orthodontic tipping of teeth.

4- trauma from occlusion.

5- temporary crowns.

6- periodontal surgery.

7- mechanical traumatic factors such as fingernail-biting

habits
Miller classified gingival tissue recessions

Class I defects where marginal tissue recession does not

extend to the mucogingival junction and there is no loss of
interproximal periodontium, full coverage of the exposed root
can be predicted as a postsurgicaI outcome.

Total root coverage can also be anticipated for Class II

recessions, which differ only in that they extend to or beyond
the mucogingival junction with interproximal tissues intact.

Partial root coverage can be expected in Class III recessions

where modest interproximal tissue loss decreases the
chance for new attachment

Due to the pronounced severity of interdental bone and

gingival tissue-loss and/or tooth malpositioning in the Class
IV situation, full root coverage cannot be expected.
 2- Hard tissue procedures:
Hard tissue therapy is aimed at modifying the anatomy of
areas where plaque control is difficult or impossible as
in:
1. Areas where an irregular pattern of bone loss had led
to intrabony pockets.
2. Around root furcations
a- Bone induction
1-to fill osseous defects
2- induce new attachment
3- help in resolution of all or part of the lesion.
These include: bone chips, cementum, dentin. Freeze –dried
bone, hydroxylapatite, tricalcium phosphate. Ceramic, sclera,
cartilage, osseouscoagulum, iliac crest marrow and bioactive
glass material
Intrabony lesions are catehorized as:

1- One- walled 2- two-walled

3- There-walled depending on the remaining osseous topog-
raphy.
Technique:

1. Flap is reflected and lesion is thoroughly degranulated .

2. Grafting material is packed firmly into the lesion until it is

slightly over filled.

3. Interrupted sutures are placed.

4. Surgical dressing is applied for 7 to 10 days.

(b) Osseous resection:

Chronic inflammatory peridontitis results in the loss of

osseous tissue, destruction of osseous architecture, and

creation of an intrabony lesion.

 The objective of osseous resection is to shape the bone to
form even contours. The result is intended to be a sound
osseous base for gingival attachment and the elimination of
pockets and excessive sulcular depth.

C- Furcation involvement
The normal position of the osseous crest is approximately 1.5
mm apical to the CEJ in young and healthy adults.
Root complex is the portion of a tooth that is located apical of
the cemento-enamel junction (CEJ), i.e. the portion that
normally is covered with a root cementum. The root complex
may be divided into two parts the root trunk and the root
cone(s).
The root trunk represents the undivided region of the root. The

height of the root trunk is defined as the distance between the

CEJ and the separation line (furcation) between two root cones

(roots). Depending on the position of the separation line the

height of the root trunk may vary from one surface to the next

in one given molar or premolar.

Furcation entrance: the transitional area between the
undivided and the divided part of the root.

Furcation fornix: the roof of the furcation.

Degree separation: the angle of separation between two
roots (cones).
Divergence is the distance between two roots; this distance
normally increases in apical direction.
Classification of furcation involvements

Class I: vertical loss of bone support is less than 3mm apical

to the CRJ no radiographtic evidence of bone loss.

Class II: vertical loss greater than 3mm but the total

horizontal width of the furcation is not involved osseous loss

in evident in x-ray.

Class III: horizontal through-and-through lesion that is

occluded by gingiva but allows passage of an instrument

from the buccal, lingual , or palatal surface.

Class IV: horizontal through-and-through lesion that is not

occluded by gingiva.
 Root amputation is removal of root without touching the
crown.
Hemisection is a procedure in which the tooth is separated
through the crown and furcation, producing two equally-
sized teeth.
each furcation entrance must be examined and each entrance
must be classified according to the above criteria by:
1-Probing
The buccal furcation entrance of the maxillary molars and the

buccal and lingual furcation entrances of the mandibular

molars are normally accessible for examination using a

curved graduated periodontal probe

In maxillary molars the mesial furcation entrance is located
much closer to the palatal than to the buccal tooth surface.
Thus, the mesial furcation should be probed from the palatal
aspect of the tooth.
 The distal furcation entrance of a maxillary molar is generally
located midway between the buccal and palatal surfaces, this
furcation could be probed from either the buccal or the palatal aspect of the
tooth.

In maxillary premolars the root anatomy often varies

considerably. The roots may also harbor irregularities such as
longitudinal furrows, invaginations or true furcations, which
may open at varying distances from the CEJ. So the clinical
assessment of a furcation involvement in maxillary premolars
is often difficult.
2- Radiographs
Radiographs must always be obtained to confirm findings
made during probing of a furcation-involved tooth.
Therapy
Treatment of a defect in the furcation region of multi-rooted tooth
is intended to meet two objectives:
The elimination of the microbial plaque from the exposed
surfaces of the root complex.
The estahlishmenit of an anatomy of the affected surfaces that
facilitates proper self-performed plaque control.

Different methods of therapy are recommended according to

the degree of furcation involvement as following:
Furcation involvement class I
Recommended therapy: Scaling , root planning and Furcation
plasty.
Furcation involvement class II
Recommended therapy: Furcation plasty, Tunnel preparation,
Root resection, Tooth extraction, and Guided tissue regeneration
at mandibular molars.
Furcation involvement class III, IV
Recommended therapy: Tunnel preparation, Root resection,
and Tooth extraction.
 Treatment of furcation involvement:

1. Scaling and root planing

in the furcation entrance of a class I involvement in most
situations result in the resolution of the inflammatory lesion
in the gingiva.

2. Odontoplasty-osteoplasty

This procedure involves recontouring of both the tooth

structure and the supporting bone to improve access for
cleaning. A minimal amount of tooth structure and bone is
lost in this procedure. This can be used in class I and
incipient class II lesions.
Tunnel preparation
Tunnel preparation is a technique used to treat deep class II and
class III furcation defects in mandibular molars. This type of
resective therapy can be offered at mandibular molars, which
have a short root trunk, a wide separation angle and long
divergence between the mesial and distal root.
1. the reflection of buccal and lingual mucosal flaps
2. the granulation tissue in the defect is removed and the
root surfaces are scaled and planned.
3. The furcation area is widened by the removal of some of
the interradicular bone, mesial and distal to the tooth in
the region is also removed.
4. Following hard tissue resection enough space has been
established in the furcation region to allow access for
cleaning devices.
3. Root amputation= [ Root resection]

Root amputation is indicated in:

1. Severe vertical bone loss involving one root of a

mandibular molar or one or two roots of a maxillary
molar.
2. Furcation involvement that is not treatable by
odontoplasty-osteoplasty. [ class II, III].
3. Vertically or horizontally fractured roots.
4. Severe root caries.
5. Internal or external resorption.

6. Inability to treat one root canal successfully.

7. Emrassures that are obliterated

8. Sever dehiscence and sensitivity of a root

9. Failure of abutment in long span splint or FPD.

10. Strategic removal of a root to improve prognosis

of an adjacent tooth.
Before RSR is performed the following factors must be
considered:
A- The length of the root trunk

short root trunk may have an early involvement of the

furcation. Which is a good candidate of RSR; the amount of

remaining periodontal tissue is often sufficient to ensure the

stability of the remaining root cone. If the root trunk is long,

the furcation involvement occurs later in the disease

process,but once established the amount of periodontal

tissue support left apical of the furcation may be insufficient

to allow RSR.
 B-The divergence between the root cones

Roots with a short divergence are technically more difficult

to separate than roots, which are wide apart.

C-The length and the shape of the root cones

Short and small root cones following separation tend to

exhibit an increased mobility.
D- Fusion between root cones
E- Amount of remaining support around individual roots
Which may compromise the long-term prognosis for an
otherwise ideal root.
F- Stability of individual roots
The more mobile the root cone is, the less periodontal
tissue support remains.
4. Hemisection
cutting the tooth in half. In the case of mandibular molars,
when one hemisected root is to be extracted, then
subsequent restoration of the remaining root is done.
Sometimes the roots are to be maintained and each half of
the tooth is restored separately, a procedure known as
bicspidization. The individual roots may then be separated
orthodonticaly.
 Problems that we may face during root resection:

Fracture of the root and loss of root tip in the max. sinus.
Osseous anatomic features e.g.: flat mandibular shelf, flat
palatal area can make access to surgical site difficult.
Root proximity, complicate flap placement, so problem in
separation and removal of sectioned fragment.
Mucoginival anatomy e.g.: lack of keratinized attachment
gingiva.
Tooth preparation and crown configuration
Finish line:
Location:
Optimum location for F.L. of a crown preparation is on enamel,
away from gingival sulcus.
It may be necessary to extend the margin apically to cover on the
expense of root surface to include caries, erosion.

Preparation for a metal-ceramic Preparation for a metal-ceramic

crown on a maxillary premolar crown on a maxillary premolar
with a 1.0-mm shoulder in the with a 1.0-mm shoulder apical to
usual position. the CEJ.
2- Type:
 A shoulder F.L. is a poor choice when the margin must be
placed on the root surface.
a) The axial reduction will be extended into the tooth to a plup-
threatening depth to achieve the same 1mm wide shoulder.
b) This gross destruction of axial tooth structure weakness the
natural structural durability of the tooth.
c) Shoulder has greater potential for concentrating stresses that
could lead to fracture of the tooth.
 A chamfer F.L. in this apical position will result in the same
depth of axial reduction as would a shoulder at the usual level.

Preparation for a metal-ceramic

crown on a maxillary premolar with a
chamfer apical to the CEJ. The
amount of axial reduction is similar to
that required for a shoulder at the
usual position.
3- Furcation flutes:

 Sometimes, the crown margins on a molar must extend

enough apically so that the preparation of F.L.
approaches the furcation, where the common root trunk
divides into two or three roots.
 There will be an intersection of F.L. with vertical flutes
and concavities in common root trunk extending from the
actual furcation in the direction of CEJ. The axial S.
occlusal to this gingival F.L. must also has vertical
concavities or flutes, until it meets the facial groove in
occlusal 1/3 of the facial surface.
Facial furcations for a maxillary (A) and
is mandibular (B) first molar. The
portion of the furcation facing apically
or toward the bone is the vault (vt), or
roof. The vertical concavity on the
common root trunk is the flute (fl).
Anatomic facial groove of this
mandibular first molar merges (arrow)
with the vertical concavity extending
from the furcation flute.
Vertical concavities in the axial walls of
the tooth preparations (arrows) extend
occlusally from invaginations where
the finish lines cross the furcation
flutes on a mandibular (A) and a
maxillary (B) molar.
A horizontal ridge in the gingival third
of the axial surface above the furcation
flute will create a plaque retaining area
that is difficult to keep clean (arrow).
Crown configuration:
1- Maxillary distofacial root:

 Because of its relatively smaller size, the occlusal outline of the

resulting preparation resembles a " lambs chop" when viewed
from occlusal direction.
 The distofacial embrasure is larger than usual. Enabling the
patient to keep the area clean.
 It doesn't create any esthetic problem, because it is
hidden by the mesiofacial cusp in normal tooth alignment.
2. Maxillary mesiofacial root:
 Represents greater loss of support for remaining tooth

 The resulting occlusal outline tends to the more "

triangular “ because of the greater faciolingual
dimension of the root that has been removed.
3- Maxillary palatal root:
 the palatal s. of he preparation will be "flat" reflecting
the general configuration of the remaining root stump.
 Tooth preparation will have an " abbreviated faciolingual
dimension".
 The facial cusps of the preparation will be near normal
faciolingually.
 The lingual cusp will be small, just a narrow ledge lingual
to central groove.
 The presence of lingual cusps would:
a) Produce an area inaccessible to hygiene maintenance,
b) Create a severe torquing moment on the tooth which
could be either tip the tooth lingually OR fracture tooth
under the crown.
Occlusal contacts should
occur on the lingual cusp
tip. There should be minimal
occlusion facial to the
central groove of the crown.
4- Maxillary facial roots:
Preparation of the tooth overlying this root will result in either "oval
or circular: configuration depending upon the shape of the itself.
5- Mandibular hemisection:
Frequently one root is removed, while the other remains.
Saving mesial segment would be desirable if the molar were
the last tooth in the arch.
6- Sky furcation:
To separate the roots of maxillary molar without removing a root.
This is possible only if roots are: - long
- well supported by bone
- distinctly separate
Roots are cut apart and then rejoined by a crown which acts as
interadicular splint with concave connectors from one root to the
other.
d-The deformed edentulous ridge angmentation

A partially edentulous ridge may retain the general shape of the

alveolar process. Such a ridge is traditionally refered to as a
normal ridge. Even though, this normal ridge has retained the
buccolingual and apicoronal dimensions of the alveolar process
The smooth contours of the normal ridge create problems
for the restorative dentist.
In a fixed bridge the pontics frequently give the impression that
they rest on the top of the ridge rather than emerge from within the
alveolar process.
Lack of root eminence.
Lack of marginal gingiva and interdental papillae. so Dark
triangles, which almost interfere with dentofacial esthetics, are
present in the embrasure area between the pontics and between
the abutments and the pontics.
Correction of ridge defect by:
1-Prevention of soft tissue collapse following tooth extraction
by immediate post-extraction placement of an ovate pontic to
support the soft tissues.
2-Correction of ridge defects by the use of soft tissue grafts
A deformed ridge may result from tooth extractions, advanced
periodontal disease, abscess formations, etc.

According to Seibert (1983), ridge defects can be divided

into three classes:
Class I: Loss of buccolingual width but normal apicocoronal
height
Class II: Loss of apicocoronal height but normal buccolingual
width
Class III: A combination of loss of both height and width of
the ridge.
Classification H (horizontal defects)
Class I: ridge defects

Class II: ridge defects

Class III: ridge defects

Class III: ridge defects
GUIDED TISSUE REGENERATION (HARD
AND SOFT TISSUE PROCEDURES)
Many materials have been used in the quest for reattachment to
diseased root surfaces. Recently in regaining lost attachment with
cells from the host has been successful.

Through the use of physical barriers that prevent cells from the
gingival connective tissue and apically migrating oral epithelium from
contacting the root surface, space is created over the root surface,
which allows selective repopulation of this space by cells from the
residual periodontal ligament. These cells become the regenerated
periodontal ligament

The most significant nonresorbable material is

polytetrafluoroethylene (PTFE) barrier (Gore-Tex Periodontal
Material).
B) Prosthetic Treatment:
I- Biologic Considerations
1. Margin Placement and Biologic Width
 Evaluation of biologic Width
 Correction of biologic Width Violations
 Margin Placement Guidelines
 Clinical Procedures in Margin Placement
 Tissue retraction

2. Provisional restorations
3. Marginal Fit
4. Crown Contour
5. Pontic design
6. Subgingival Debris
7. Hypersensitivity to Dental Materials
II- Esthetic Considerations
Interproximal embrasure form
Crown lengthening (excessive gingival display)
Pontic design.
Gingival recession.
III- Occlusal Considerations
The relationship between periodonral health and the restoration of
teeth is intimate and inseparable.

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.
I- Biologic Considerations
a) Margin placement and biologic width
Restorative clinicians must understand the role of biologic width in
preserving healthy gingival tissues and controlling the gingival form
around restorations. They must also apply this information in the
positioning of restoration margins, especially in the esthetic zone
where a primary treatment goal is to mask the junction of the margin
with the tooth. A clinician is presented with three options for
margin placement: 1. supragingival, 2. equigingival (even with the
tissue), and 3. subgingival locations.
The supragingival margin has the least impact on the
periodontium. Classically, this margin location has
been applied in nonesthetic areas while With the advent
of more translucent restorative materials, adhesive
dentistry and resin cements, increase the ability to
place supragingival margins in esthetic areas

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 greater gingival Inflammation. There
was also the concern that any minor gingival recession
would create an unsightly margin display.
From a periodontal viewpoint

both supragingival and equigingival margins are well tolerated.

The greatest biologic risk occurs when placing margins
subgingivally.

1. These margins are not as accessible as supragingival or

equigingival margins for finishing procedures, and in
addition,

2. if the margin is placed too far below the gingival tissue

crest, it violates the gingival attachment apparatus.
The biologic width: is the dimension of space that the
healthy gingival tissues occupy above the alveolar
bone.
Restorative consideration frequently dictates the
placement of restoration margins beneath the gingival
tissue crest. Restorations may need to be extended
gingival:

1. Create adequate resistance and retentive form in the

preparation,

2. To make significant contour alterations

3. To mask the tooth/restoration interface by locating it

subgingivally.
Two different responses can be observed from the involved
gingival tissues. One possibility is that bone loss of an
unpredictable nature and gingival tissue recession.
Other factors is the likelihood of recession. These variables
include whether the gingiva is thick and fibrotic or thin and
fragile and whether the periodontium is highly scalloped or
flat in its gingival form. It has been found that highly
scalloped thin gingiva is more prone to recession than a flat
and’ thick fibrous tissue.

Two the more common finding with

deep margin placement is that the
bone level appears to remain
unchanged, but gingival inflammation
develops and persists.
Evaluation of biologic width:
1. radiographic interpretation:
radiographs are not diagnostic because of tooth superimposition.
2. tissue discomfort
3. sounding to bone
The biologic, or attachment width can be identified for each
individual patient by probing under anesthesia to the bone level
and subtracting the sulcus depth from the resulting
measurement.
Correction of biologic width violations
Biologic width violations can be corrected by either surgically
removing bone away from proximity to the restoration margin or
orthodontically extruding the tooth and thus moving the margin
away from the bone.
Margin placement guidelines
It is recommended that the patient's existing sulcus depth be used
as a guideline in assessing the biologic width requirement for that
patient. The first step in using sulcus depth as a guide in margin
placement and to manage gingival health.
Once is healthy, the following three rules can be to place
intracrevicular margins.

1. If the sulcus probes 1.5 mm or less: place the restoration

margin 0.5 mm below the gingival tissue crest.
2. If the sulcus probes more than 1.5 mm: place the margin one
half the depth of the sulcus below the tissue crest.
3. If a sulcus greater than 2 mm is found: especially on the
facial aspect of the tooth, then evaluate to see whether a
gingivectomy could be performed to lengthen the teeth and
create a 1.5-mm sulcus. Then the patient can be treated using
Rule 1.
Tissue retraction
Tissue management is achieved with gingival retraction cords, using
the appropriate size to achieve the displacement required. Thin,
fragile gingival tissues and shallow sulcus situations usually dictate
that smaller diameter cords be chosen to achieve the desired
tissue displacement.

2. Provisional restorations
Three critical areas must be effective managed to produce a
favorable biologic response to provisional restorations. The
marginal fit, contour, and surface finish

3. Marginal fit
It has been shown that the level of gingival inflammation can
increase, corresponding with the level of marginal opening.
However, the quality of marginal finish and the margin
location relative to the attachment are far more critical to the
periodontium than is the difference between a 20 µm fit.
4. Crown contour

Ideal contour provides access for hygiene and has the fullness to
create the desired gingival form (improving Esthetics)

5. Pontic design
Material
 The need for strength , rigidity and durability has been
established.
 The material must also permit acceptable color, contour
and be biocompatible regarding effect of the material
itself or the effects of the surface finish.
Design
1- Gingival surface:
The demands of esthetics often dictate tissue contact, whereas
hygienic requirements favor tissue clearance.
2- Occlusal surface
3 concepts exist relative to the occlusal surface of a pontic.
a) The reduction of the occlusal table to 1/5-1/3 the bucco-lingual
dimension to control force on the abutment
b) Another maintains the normal occlusal width to provide soft
tissue protective mechanism during mastication and to provide
adequate occlusion with opposing arch.
c) The 3rd tends to minimize the significance of the occlusal
dimensions based upon the importance of the proprioceptive
mechanism in regulating the occlusal forces.
3- Facial and linguial surfaces:
It may differ according to :
 Function
 Ridge morphology
 Esthetic
4- Proximal surface:
 Excessively broad proximal contact areas crowed out the
facial and lingual gingival papillae. These prominent
papillae trap food debris that leads to gingival
inflammation.
 Too narrow proximal contact areas create enlarged facial
and lingual embrasures that don't provide sufficient
protection against interdental food impaction.
6. Subgingival debris
Leaving debris below the tissue during restorative procedures can
create an adverse periodontal response. The cause can be the
retraction cord, impression material, provisional material, or either
temporary or permanent cement.
7. Hypersensitivity to Dental Materials
Inflammatory gingival responses have been reported related to
the use of nonprecious alloys in dental restorations. Typically,
the responses have occurred to alloys containing nickel,
Hypersensitivity responses to precious alloys are extremely rare,
More importantly, that tissues respond more to the
differences in surface roughness of the material rather than
the composition of the material
8. Cementation
Fragments of excess cement in the gingival sulcus are foreign
bodies; they become covered with plaque and lead to
periodontal disease.
II- Esthetic considerations:
a) Interproximal embrasure form
The interproximal embrasure created by restorations and the form
of the interdental papilla has a unique and intimate relationship.
Papillary height is established by the level of the bone, the
biologic width, and the form of the gingival embrasure.

The relationship between gingival embrasure volume

and papillary form.
A. If the gingival embrasure of the teeth is excessively large due
to a tapered tooth form. Because of the large embrasure form,
the volume of tissue sitting on top of the attachment is not
molded to the shape of a normal papilta but rather has blunted
form and a shallower sulcus.
B. An ideal Embrassure form where the same volume of
tissue sits on top of the attachment.
 Methods of altering gingival embrasure form.

A. The typical open gingival embrasure due to excessively tapered tooth form.
B, common method employed by restorative dentists to correct the embrasure,
whereby material is added supragingivally. This closes the embrasure by
moving the contact to the tip of the papilla but results in overhangs that cannot
be cleaned using dental floss. Removing these overhangs restoratively
reopens the embrasure.
C, The correct method of closing the gingival embrasure whereby the margins of
the restoration are carried 1 to 1.5 mm below the tip of the papilla. Note that
this does not encroach on the attachment because the average interproximal
sulcus probes 2.5 to 3 mm. This allows easy cleaning because of the convex
profile. It also reshapes the papilla to a more pleasing profile esthetically.
b) Crown lengthening
Excessive gingival display

The form of the lips and the position of the lips during speech and
smiling cannot be easily changed, but the dentist may, if
necessary, modify/control the form of the teeth and interdental
papillae as well as the position of the gingival margins and the
incsal edges of the teeth. In other words, it is possible by a
combination of periodontal and prosthetic treatment measures to
improve dentofacial esthetics in this category of patient.
a careful analysis of the dentofacial structures and how
they may affect esthetics should be performed and
should include the following features:
 Facial symmetry
 Interpupillary line-even or uneven
 Smile line-(low, median or high).
 Dental midline in relation to facial midline.
 Gingival display during speech and during broad, relaxed
smile
 Harmony of gingival margins.
 Location of gingival margins in relation to the cemento-
enamel junctions.
 Tooth size and proportions/harmony.
 Incisal plane/occlusal plane.
c) Pontic design

Classically, four options should be considered in evaluating

pontic design: sanitary, ridge-lap, modified ridge-lap, and ovate
pontic designs.

The key differences between the four pontic designs relate to the
esthetics and access for hygiene procedures.
III- Occlusal Trauma and therapy
Occlusal trauma is defined as an injury to the attachment
apparatus (periodontal ligament, alveolar bone, and
cementum) as a result of excessive occlusal force.

Occlusal trauma will clinically manifest itself :

Increasing mobility and/or migration of the teeth.
Persistent discomfort or tenderness.
Pain to percussion or upon biting.
 
Radiographic signs of the traumatic lesion may include
The presence of a widened periodontal ligament
space,
Discontinuity of the lamina dura surrounding the tooth
The lesion of occlusal trauma

These lesions may range in histological appearance from slight

derangement of the periodontal ligament to tissue necrosis.

Morphological changes

that occur as a result of traumatic forces in the periodontiuin

are reversible when either the force is discontinued or the
tooth moves away from the influence of the force and
becomes stable in a new position.
Primary and secondary occlusal trauma
The tissue injury associated with occlusal trauma is often divided
into two categories: primary and secondary.
In primary occlusal trauma, a lesion results from application of
excessive occlusal forces to a tooth or teeth with normal
supporting structures:
In secondary occlusal trauma, the lesion is in the periodontium
of a tooth with inadequate or reduced support. The greater the
amount of periodontal support lost due to periodontitis, the more
significant occlusion becomes.
The distinction between primary and secondary forms of occlusal
trauma, based on the amounts of remaining periodontium, serves
as primarily diagnostic purposes.
Occlusal considerations

1. There should be even simultaneous contacts on all

teeth during centric closure.
2. When the mandible moves from centric closure, some
form of canine or anterior guidance is desirable, with
no posterior tooth contacts.
3. The anterior guidance needs to be in harmony with the
patient’s neuromuscular envelope of function.
4. The occlusion should be created at a vertical
dimension that is stable for the patient.
5. When managing a pathologic occlusion or when
restoring a complete occlusion, a repeatable condylar
reference position is needed.