Periodontology

Applied to
Operative
Dentistry
Basic concepts of the
Periodontium Relevant for
Restorative Dentistry
 The location of the bone in relation to CEJ and the muco-gingival junction are the
important parameters.

 They can be determined by bone sounding and clinical and radiographic

examination.

 Gigivectomy may be performed when there is distance of more than 3 mm from

the CEJ to the alveolar crest, there is enough keratinized tissue and there is no
evidence of bone defect.

 Gingivectomy is not advised when the band of keratinized tissue is insufficient

(< 3 mm)

 Surgical intervention is usually beneficial in individuals with thick, fibrotic and

noninflammed gingival tissue with probing depth of 3-4 mm coronal to CEJ.
Flat ginival contour and
squared-shaped anterior
teeth

Uneven gingival
contour

Gingival discrepancy
corrected by
Gingivectomy
 The Gingival

Display
In a healthy smile lip rises to the level of or
slightly apical to the gingival margins of
maxillary anterior teeth revealing 1-2 mm
of gingiva.

 Gummy smile
 More than 2mm of gingival tissue is shown
upon smiling.

 Etiological factors
1. Excessive Maxillary bone growth
2. Altered Passive Eruption
3. Lip hypermobility
 The Gingival
Display
Etiology Treatment Specialty Setting Timeline

Excessive Orthognathic surgery OMFS Hospital / GA 3-4

Maxillary bone Orthodontic Intrusion Orthodontics Dental Surgery months
growth

Altered Passive Gingivectomy Periodontology Dental Surgery One week

Eruption Crown lengthening Restorative
Dentistry

Lip Botox Periodontology Dental Surgery One day

hypermobility Lip repositioning Restorative 2 weeks
Surgery Dentistry
OMFS
The Gingival
Display
 Challenges in Periodontal Health
Affecting Restorative Dentistry
 Periodontal disease is an immune-inflammatory infection of the tooth-supporting structures and a major
cause of tooth loss among adults.

 A healthy periodontium is important to;

1. Achieve long term success, with optimum comfort, function and esthetics.
2. Establish a controlled and clean field and to maintain the integrity and esthetics of restorative dentistry.

 In case of periodontitis or gingivitis periodontal therapy should be performed prior to most restorative
procedures
 Gingivitis may be controlled with adequate oral hygiene and adult prophylaxis
only.

 Periodontitis requires scaling and root planing to remove subgingival plaque and
calculus deposits.

 Severe cases may require concomitant antibiotic therapy and periodontal surgery
to re-establish a healthy periodontium.
The Importance of Maintenance
Therapy
 It can secure the long-term success of periodontal treatment.

 Patients in periodic maintenance therapy preserve more teeth.

 Several risk factors such as smoking, stress and genetic background can influence
disease progression.
Gingival biotype
Gingival biotype
 Furcation involvement
 Hamp classification
 Other factors; size, divergence of roots, root trunk length, crown-root ratio and
volume of remaining bone, are important.

Mangement
I. Grade 1:
 Scaling and Root Planing.
 100% survival rate during 5 year evaluation series.
 Open flap debridment and furcation plasty in some situations where prosthetic
treatment is needed.

II. Grade II and Grade III:

 Intially Scaling and Root Planing.
 Open Flap debridment or guided tissue regeneration, may be indicated to improve
prognosis.
Dreaded BLACK TRIANGLES
Dreaded BLACK TRIANGLES
Dreaded
BLACK
TRIANGLES
Open Proximal contacts

 Related to food impaction, gingival inflammation and higher probing depths.

 To reduce its influence, restore (close) them as long as overhangs are not created.
 Restorative management, with direct or indirect (full coverage or partial coverage)
restorations can be done.
 Orthodontic space closure of healthy tooth structure.
 Adequate Oral hygiene instructions should always be part of the therapy.
Enamel pearls

 Ectopic globules of enamel adherent to tooth

 Found most often in furcation region of max. 2nd and 3rd molars.

 Associated with attachment loss and its removal is therefore indicated.

 Have most of the features of enamel but with less orderly organization.
Cervical enamel projection

 Ectopic deposits of enamel apical to CEJ with tapering form and extending towards or entering
furcation.
 Masters and Hoskins

I. Grade 1: Short but distinct change in

the contour of CEJ extending towards
the furcation
II. Grade 2: CEP approaches the
furcation without making contact
with it
III. Grade 3: CEP extends into furcation.

 Aetiological furcation defects.

 Contributory factor to periodontal disease.
 Its removal or reduction is indicated.
Cemental tears
Treatment involves
• Scaling and root planning
• Root canal treatment
• Periapical/periodontal surgery
• Surgical debridment, removal of the cementum fragment and periodontal
regeneration if indicated.
• GTR, Bone grafting,
• Intentional replantation.
Palato radicular groove

 Developmental anomaly in which infolding of inner enamel epithelium, and Hertwing

epithelial root sheath creating a groove that passes from the cingulum of maxillary
incisors apically onto the root.

 May act as funnel which facilitates accumulation of biofilm in the depth of groove.

 Prognosis for involved teeth, with diagnosed bone loss around the area, is poor.

 Classification based on severity

1. Type 1: Groove is limited to coronal third of root
2. Type 2: Groove is extended beyond the coronal third of root but is shallow and pulp is
not exposed.
3. Type 3: Groove is long, deep and extends beyond the coronal third of root and
involves the root canal system involved.
Treatment when indicated consists of;

1. Steps in periodontal surgery

 Scaling and root planning
 Surgical curettage of periodontal tissue (granulation tissue and irritants) closed
flap or
 In open flap technique, gigivectomy and surgical exposure of flap (apically
positioned)
2. Steps in Endodontic Treatment Plan
 Odontoplasty if required
 Restore or seal the radicular groove with biocompatible material
 Saucerisation of groove with or without RCT (if endodontic lesion is present)

3. Steps in Surgical Technique

 Flattening of groove with or without application of GTR (guided tissue
regeneration) technique

4. Orthodontic Treatment
 Orthodontic extrusion of teeth if required.
Tooth position

 Malposition have been associated with periodontal disease.

 Plaque accumulation, due to difficult hygiene.

Occlusion

 Traumatic occlusion can act as a contributory factor for periodontal disease.

Trauma from occlusion has also been linked with to higher risk for furcation
involvement.

 Occlusal discrepancy is an individual risk factor for periodontal disease.

 Minor occlusal adjustments with the purpose of achieving better periodontal

treatment are recommended.
Biological width
 Combined vertical dimension of of the JE and supra-
alveolar CT.

 Acts as a seal around the cervical portion of the tooth

and has a self-restoration capacity.

 In health, the epithelial attachment terminates at the

apical end of the JE.

 In disease tissue, it terminates at the coronal aspect of

the CT or apical to JE.

 CT zone has the most consistent dimension. The JE was

the most variable area.

 Biological width was greater in posterior teeth, and JE

was significantly longer in teeth with restoration
 Mean BW was 1.91 mm which consisted of:
• Junctional epithelium (1.14 mm)
• Connective tissue attachment (0.77 mm)

 Average values are adequate except in situations in

which the patient has thin tissue biotype and anterior
esthetic restorations will be placed subgingivally.

 By probing through the attachment to the bone level

and subtracting the sulcus depth the dentist can
determine the biological width of that patient.

 The mean sulcus depth was found to be 1.32 mm.

Periodontal procedures relevant
to Restorative Dentistry
Crown Lengthening
 Removal of bone tissue with concomitant removal of or repositioning of the soft
tissue around the tooth.

 Goal of therapy is;

1. Increase the clinical crown and consequently preserve BW.

2. To avoid impingement of BW often occurring due to presence of subgingival

caries or deep restorative margins.

3. To correct esthetic unpleasant situations such as ‘gummy smile’

 Failing to recognize the need of crown lengthening prior to restoration will lead to;

1. Inflammation (gingivitis)
2. Bone loss (periodontitis)
3. Pain associated with inflammatory remodeling of perioontium
4. Local soft and hard tissue defects.
5. Compromised esthetics
6. Problematic retention of restoration
 Periodontium biotype plays a key role in the periodontal response.
 Thin and scalloped – recession will follow the inflammatory process caused by restoration
margin.
 Thick and flat – soft tissue stability is more likely, higher likelihood of a moat-like lesion
around the tooth to appear on the alveolar bone, leading to increased bleeding, sensitivity
on probing and pocket formation.

 Not indicated in situations where limitations are caused by

1. Position of furcation
2. Reduced attachment levels
3. Esthetic issues
4. Teeth with significantly reduced periodontal support
5. Endodontically infected teeth, should not be treated prior to resolution of infection
6. Extensive need for osseous removal, which would compromise the stability of adjacent
teeth
7. Inadequate crown -to- root ratio after surgery
 BW is preserved when restoration is placed allowing for approximately 2 mm for
CT and JE and 1 mm for the sulcus.

 Ideally an additional 0.5 – 1 mm should be added coronally to create a safe

distance from the alveolar bone crest to the restorative margin.

 A 3 – 4 mm distance from gingival margin to the alveolar crest ensures

periodontium healing after tooth preparation with quick re-establishment of JE and
CT integrity, which avoids continuous inflammation around the tooth.
Short root trunk may limit the
 amount of crown lengthening that can be performed
 Procedure may expose furcation and
compromise tooth prognosis.

Crown fracture extending below the CEJ.

 In case of fracture of anterior teeth, crown lengthening will impact tooth
clinical and esthetic display (as well as of the adjacent teeth)

 Due to removal of bone an subsequent apical repositioning of the gingival

margin.
 Orthodontic extrusion
 There are situations where it is indicated, to minimally affect the gingival
margin level in the anterior sextant or esthetic area. Crown lengthening may
follow the orthodontic extrusion.

 A more favorable crown to root ratio for an extensively damaged tooth, where
preparation has no ferrule, can be achieved.

 Root length is effectively shortened, the crown is not lengthened.

 Camargo stated that forced eruption via orthodontic extrusion is the technique
of choice when clinical crown lengthening is necessary on isolated teeth in the
esthetic zone.
 Extent of healing time is dictated by
1. Type of periodontium ( thick and flat vs thin and scalloped)
2. Location (anterior versus posterior)

3. Direct restorations can be made as soon as there is initial tissue shrinkage if the
margin is supraingival and haemostasis/ trauma is not anticipated.

4. Indirect full coverage restorations wait approximately 6 – 8 weeks before

proceeding with final preparation and impression in posterior teeth.

5. In anterior esthetic cases, periodontal biotype needs to be taken into

consideration.
In thick and flat periodontium,
 gingiva tends to bulk postoperatively prior to moving coronally and flattens as
maturation occurs in the first 6 – 8 weeks.
 Further flattening may continue to occur beyond the initial maturation phase.

In thin and scalloped periodontium,

 There is usually recession immediately after surgery and in some cases ‘creeping
attachment’ occurs in the month after initial maturation.

 Probing depths stabilized at 6 weeks but recession ranging from 2 to 4 mm

continued to develop between 6 and 24 weeks.
 In areas of esthetic concern, postponing final margin placement and restoration
for 6 – 8 months may be desirable to ensure gingival marginal stability,
 To better predict results, an accurate diagnosis of thick verses thin biotype should
be done.
Gingivectomy
 Gingival excess removal to expose the clinical crown.

i. In case of gingival overgrowth

 gingival tissue should not rebound provided etiology for overgrowth is addressed
and
 good oral hygiene is exercised.
 Plaque control is critical

ii. Altered passive eruption

 When gingival tissue is removed, but it alters the dimension of sulcus and JE, the
tissue regrows to establish at least approximately 1 mm of JE an 1 mm of sulcus.
1. Subgingival Caries/Access for proper
restoration

At least 3 mm of sound tooth structure are needed

from the margin of the final cavity preparation (not
the caries lesion) to the alveolar bone crest otherwise
crown lengthening is indicated.

Open flap and bone contour correction is warranted if

periodontal breakdown with evidence of osseous
defect is due to caries impinging biological width is
present.
2. Tooth fracture
Crown lengthening is almost always necessary for sub gingival crown – root fractures
to avoid continuous periodontal breakdown

3. Inadequate Retention
1.5 – 2 mm of ferrule is necessary for adequate retention of crowns and protection of
the integrity of remaining tooth structures.

When there is a need to create ferrule in a tooth that will recive a post and core
restoration, crown lengthening may be needed to facilitate it’s placement without
violation of biologic width and adequate retention form.
4. Altered Passive Eruption
Gingivectomy may be performed when there is a distance of more than 3 mm from
the CEJ to the alveolar crest, there is enough keratinized tissue and there is no
evidence of bone defect.

Gingivectomy is not advised when the band of keratinized tissue is insufficient (< 3
mm)
Distal wedge

 The procedure is either ;

 Complete removal of the tissue (if there is abundant amount of keratinized tissue
even after removal) or,
 Partial ablation of tissue (to spare keratinized tissue).
 Afrer tissue removal soft-tissue coverage of the bone and more coronal tooth
exposure is achieved.
 Commonly performed on the distal surface of molars (tuberosity or the retromolar
pad)
 To facilitate hygiene, access and help eliminate periodontal pockets or facilitate
access for proper restorative treatment.
 A direct restoration can be performed immediately after the surgical procedure
provided adequate operating field isolation is achieved.
Effect of restorative treatment on
the Periodontium
 Biological width violation
 The contact of the restorative margin with JE or CT below the gingival sulcus
allows for bacterial colonization of the area.
 Recruitment of inflammatory cells and chronic inflammation of the site follow.
 While polishing of the restoration may alleviate plaque accumulation and
inflammation, there is extensive evidence of inflammation leading to bone
resorption.
 Inflammatory process is usually aggravated with indirect restoration as the
marginal gap of a well-fitted crown is normally larger than that of direct
restoration.
 Sorensen and colleagues found positive correlation between marginal discrepancy
of restorations and periodontal defects.
 Proper placement of the margin of the restoration (direct or indirect) in respect of
the biological width is critical.
Biological width violations

 By placing restorative margin within or apical to JE will lead to

1. Disturbance of biological seal and
2. penetration of bacteria and their by-products leading to
3. gingival inflammation,
4. attachment loss and
5. recession or
6. Pocket formation.

Can only be restored by apical re-establishment of the supracrestal CT.

 Positive correlation between marginal discrepancy of restoration and periodontal
defects.

 The response of BWV as a function of the bone thickness.

 It most frequently occurs at the mesiofacial and distofacial line angles of maxillary
anterior teeth treated with fixed restoration.

 Can only be restored by apical re-establishment of the supracrestal CT.

Materials
Geristore
 Biocompatibile, dual-cure, hydrophilic resin-modified glass ionomer

 Recommended when the periodontium is extensively involved.

 Gupta and colleagues showed it had superior biocompatibility compared to MTA and glass
ionomer when tested on human periodontal ligament cells. Dragoo showed that Geristore
was not different in terms of probing depth and gingival inflammation than other resin
based materials such as Dycat and Photac fil.

 Insoluble in oral fluids, has low coefficient of termal expansion, low polymerization
shrinkage and low microleakage is ideal for subgingival restorations.
Mineral Trioxide Aggregate (MTA)
 It is not the material of choice for situations where the material is close to the
gingiva, as it does not have the mechanical properties required to sustain occlusal
stresses.

 Coronal restoration in contact with soft tissue would not need to promote bone
growth but rather a healthy soft tissue response.

 Resin Modified Glass Cement

Provisional restorations and
Restorative margins
 To minimize the probability of tissue recession or chronic local inflammatory
response a well-adapted provisional restoration should always be placed and
tissue reaction ideally observed for several weeks prior to final impression and
placement of the final restoration.

 A tissue that is healthy after the provisional restoration is in place for several days
or weeks is a good indicator of no biological width violation and that the
periodontium will respond well to the final restoration margins.

 It will also facilitate gingival retraction and final impression and ensure that the
tissue will rebound atraumatically (after impression).
 When there is a need for immediate or early provisionalization after surgery

• the restoration must rest on supragingival margins.

• This can help with the soft tissue contouring and maintenance or papilla regrowth
during the healing phase.

 It is important to correct margins and roughness of any provisional as soon as

detected to prevent and/or to reverse damage leading to loss of periodontal
attachment.
Retraction Cord and Impressions

 Retraction cord
• Cause reversible gingival displacement that is greater than other type of materia

Retraction systems cause some temporary damage to the integrity of gingival

tissues; however the soft tissue heals in a few days provided there is adequate
marginal adaptation of the temporary restoration.