Great Basin Academy Study Club March 2013 Roseman University of Health Sciences

Presented by Craig M. Ririe, DDS, MS Preparation of the Periodontium Iatrogenic Causes and Restorative Considerations Supportive Periodontal Treatment (Maintenance) Results of Periodontal Treatment Presented by Craig M. Ririe, DDS, MS

Restorative Dentistry Periodontium free of inflammation Periodontium free of pockets Periodontium free of Mucogingival involvement

Implant Dentistry Needs site development Needs bone augmentation Needs gingival augmentation

Periodontal Disease must be eliminated prior to Restorative dentistry. To determine gingival margins of restorations properly Inflammation weakens abutment teeth stability Teeth shift in presence of disease

Elimination of Periodontal Disease Resolution of inflammation in P.D.L. Regeneration of P.D.L. fibers, APICAL to level of attachment loss Can cause teeth to shift again

Fixed bridge work designed for teeth BEFORE the periodontium is treated may produce INJURIOUIS tensions and pressures on the treated periodontium.

Abutment teeth must have NO periodontal involvement – Before and after restoration is complete.

Removable Partial Dentures Frame work should not be constructed until periodontal treatment is complete and healing is complete.

A TRUE ADAGE GARBAGE IN GARBAGE OUT

Tooth Mobility

SUMMARY The goal of periodontal therapy should be to create the gingival mucosal environment and osseous topography necessary for the proper function of single tooth restorations and fixed and removable partial prosthesis.

TREATMENT TO MAKE THIS HAPPEN Treatment Sequence: Hopeless teeth are extracted Construct TEMPORARY partial denture Construct TEMPORARY crowns with PROVISIONAL margins PERIODONTAL THERAPY is performed. 2 months after completion of periodontal therapy Gingival health restored Gingival sulcus mature Periodontal membrane restored to health & function Mobility decreased

Treatment Sequence Continued 5. Preparations modified to relocate margins in proper relationship to the healthy gingival sulcus 6. Final restorations (fixed, removable, implants) are constructed

Esthetic Needs Clinical crown of tooth must be adequate for retention of artificial crown.

To get enough retention you may be tempted to place the margin into the junctional epithelium and connective tissue attachment.

Result: Gingival inflammation Sometimes bone loss

Biologic Width Violations Ramification of Biologic Width Violation margin placed within the zone of attachment

Biologic Width

Clinician has 3 options for crown margin placement: Supragingival Equigingival Subgingival

Biologic Width Concerns Equigingival margins

Average Biologic Width Vacek, et. al.: can be up to 4.3 mm

Evaluation of biologic width Radiographs Symptomatic “Sounding”

Probe to bone level and subtract sulcus depth (must be done on teeth with healthy gingival tissues)

Treatment of Biologic Width Violation Orthodontics Surgery

Biologic Width Violation Left central fractured and restored 12 months ago

Biologic Width Violation Removal of bone would be unaesthetic

Biologic Width Treatment Orthodontic solution erupted 3mm then surgery

Biologic Width Violation Orthodontic/Surgical Before 1 year recall

Surgical Crown Lengthening Before treatment

“Golden Proportion”

Surgical Crown Lengthening Ideal gingival symmetry

Surgical Crown Lengthening Measurement taken for crown lengthening

Surgical Crown Lengthening Incision following Ideal Symmetry

Surgical Crown Lengthening Final Restoration Note the ideal symmetry

Biologic Width Average Biologic Width Vacek, et. al.: can be up to 4.3 mm

Margin Placement to Avoid Biologic Width Violation HISTOLOGIC SULCUS DEPTH ≠PROBING DEPTH

Biologic Width Average Biologic Width Vacek, et. al.: can be up to 4.3 mm

Iatrogenic Problems Poor margin placement Margins were covered when restored on Periodontally diseased tissue

Electro Surgery Tissue retraction for impression taking

Temporary Crowns Critical Areas Marginal Fit Contour Surface Finish

Loss of Papilla between #8, 9 Gingival Embrasure Loss of Papilla between #8, 9

Method for altering tooth form to fill embrasure Gingival Embrasure Method for altering tooth form to fill embrasure

One year after restoring #8, 9 mesial Gingival Embrasure One year after restoring #8, 9 mesial

Pontic Design Sanitary Pontic Ridge Lap Pontic Modified Ridge Lap Pontic Ovate Pontic

Ovate Pontic Design Must be shallow

Ovate Pontic in less esthetic area

Ridge Consideration Ridge augmentation

Maxillary Partial Denture Iatrogenic Problems Maxillary Partial Denture

Iatrogenic Problems Partial Denture Removed Not removed and cleaned often enough Not monitored by Dental Office often enough to check for plaque/allergic reaction

Plaque retention on poor restoration margin/gingival interface Iatrogenic Problems Plaque retention on poor restoration margin/gingival interface

Iatrogenic Problems Overhanging margin Bone loss

Inadequate office maintenance during orthodontic care Iatrogenic Problems Inadequate office maintenance during orthodontic care

Maxillary Left bridge #8-11 Periodontally involved Iatrogenic Problems Maxillary Left bridge #8-11 Periodontally involved

Periodontal Surgery Completed Iatrogenic Problems Periodontal Surgery Completed

Iatrogenic Problems Calculus

Iatrogenic Problems Large Cemented Post Root Fracture

Iatrogenic Problems Retentive Screw Post Repaired Perforated Distal Bone Loss Repaired

“Idiopathic” bone loss Iatrogenic Problems “Idiopathic” bone loss

“Exploratory” Surgery found orthodontic elastic Iatrogenic Problems “Exploratory” Surgery found orthodontic elastic

Removal of orthodontic elastic Iatrogenic Problems Removal of orthodontic elastic

Iatrogenic Problems Orthodontic elastic

Iatrogenic Problems Extracted maxillary molar open margins on crown

Iatrogenic Problems Extracted mandibular molar Margin not adapted into furcation

Iatrogenic Problems Perforated post into furcation

After cementation of crown: cement prevented complete seating of crown.

Usually the dentist will not even be aware of this problem.

Therefore: Where possible – place margins supra or equigingival.

It is best to assume that all of your subgingival margins look like this and then maintain your patients accordingly.

Supportive Periodontal Therapy “SPT”

Two phases of Treatment: Elimination of Periodontal Disease PRESERVATION of Periodontal health BOTH ARE EQUALLY IMPORTANT

The patient must understand the purpose of the maintenance program. The dentist MUST emphasize: preservation of the teeth is dependent on it.

FACT!! The more often a patient presents for the recommended SUPPORTIVE PERIODONTAL THERAPY (SPT) the less likely they are to lose teeth.

Tooth loss is 3 times as common in treated patients who do not return for regular recall visits as in those who do. Lietha Elmer, 1977

Patients with inadequate SPT after successful therapy have a 50 fold increase in probing attachment loss as compared with those with regular SPT appointments. -Cortellini 1994

The maintenance phase (SPT) starts immediately after the completion of the Reevaluation appointment. While the patient is in the maintenance phase (SPT) the necessary surgical and restorative procedures are performed.

This ensures that all areas of the mouth retain a degree of health attained after phase one therapy (non-surgical therapy)

But what about the subgingival plaque? The deeper the inflammation – Zone of Influence Zone of Influence Clinically, we readily see evidence of the inflammation caused by Supragingival plaque. Therefore, we react with plaque control, etc. to resolve what is OBVIOUSLY EVIDENT. But what about the subgingival plaque? The deeper the inflammation – NOT CLINICALLY EVIDENT. But much more damaging – bone loss – attachment loss

Subgingival scaling alters the microflora of periodontal pockets.

One study shows that after scaling the subgingival flora had not returned to pretreatment proportions after 3 months. But this varies greatly among patients. Slots, J 1979

Episodic Nature of Periodontitis Tortuous Topography of a pocket

Tortuous Topography of a pocket

(Out of sight, out of mind) Importance of fixed, stable, predictable recall system in your office: Patients tend to reduce their oral hygiene efforts between appointments (Out of sight, out of mind)

Interval between SPT visits initially set it at 3 months then vary it according to the patients needs

Department of Periodontics SPT Appointment Study page 96 in the Department of Periodontics Clinic Handbook 2010-2011

Referral of Patients to the Periodontist Study the Triage September 2005 article by Cobb and Callan