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

2. 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

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

4. Implant Dentistry Needs site development Needs bone augmentation
Needs gingival augmentation

5. 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

6. 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

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

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

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

10. A TRUE ADAGE
GARBAGE IN
GARBAGE OUT

11. Tooth Mobility

12. 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.

13. 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

14. 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

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

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

17. Result:
Gingival inflammation
Sometimes bone loss

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

19. Biologic Width

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

21. Biologic Width Concerns
Equigingival margins

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

23. Evaluation of biologic width
Radiographs
Symptomatic
“Sounding”

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

25. Treatment of Biologic Width Violation
Orthodontics
Surgery

26. Biologic Width Violation
Left central fractured and restored 12 months ago

27. Biologic Width Violation
Removal of bone would be unaesthetic

28. Biologic Width Treatment
Orthodontic solution erupted 3mm
then surgery

29. Biologic Width Violation Orthodontic/Surgical
Before year recall

30. Surgical Crown Lengthening
Before treatment

31. “Golden Proportion”

32. Surgical Crown Lengthening
Ideal gingival symmetry

33. Surgical Crown Lengthening
Measurement taken for crown lengthening

34. Surgical Crown Lengthening
Incision following Ideal Symmetry

35. Surgical Crown Lengthening
Final Restoration
Note the ideal symmetry

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

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

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

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

40. Electro Surgery
Tissue retraction for impression taking

41. Temporary Crowns Critical Areas
Marginal Fit
Contour
Surface Finish

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

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

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

45. Pontic Design Sanitary Pontic Ridge Lap Pontic
Modified Ridge Lap Pontic
Ovate Pontic

46. Ovate Pontic Design
Must be shallow

47. Ovate Pontic in less esthetic area

48. Ridge Consideration
Ridge augmentation

49. Maxillary Partial Denture
Iatrogenic Problems
Maxillary Partial Denture

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

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

52. Iatrogenic Problems
Overhanging margin
Bone loss

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

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

55. Periodontal Surgery Completed
Iatrogenic Problems
Periodontal Surgery Completed

56. Iatrogenic Problems
Calculus

57. Iatrogenic Problems
Large Cemented Post
Root Fracture

58. Iatrogenic Problems Retentive Screw Post Repaired Perforated Distal
Bone Loss
Repaired

59. “Idiopathic” bone loss
Iatrogenic Problems
“Idiopathic” bone loss

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

61. Removal of orthodontic elastic
Iatrogenic Problems
Removal of orthodontic elastic

62. Iatrogenic Problems
Orthodontic elastic

63. Iatrogenic Problems
Extracted maxillary molar
open margins on crown

64. Iatrogenic Problems Extracted mandibular molar
Margin not adapted into furcation

65. Iatrogenic Problems
Perforated post into furcation

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

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

68. Therefore: Where possible – place margins supra or equigingival.

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

70. Supportive Periodontal Therapy
“SPT”

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

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

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

74. 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

75. 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

76. 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.

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

78. 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

79. Subgingival scaling alters the microflora of periodontal pockets.

80. 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

81. Episodic Nature of Periodontitis Tortuous Topography of a pocket

82. Tortuous Topography of a pocket

83. (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)

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

85. Department of Periodontics
SPT Appointment
Study page 96 in the
Department of Periodontics
Clinic Handbook

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