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AGD Biologic Shaping
AGD Biologic Shaping
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This article describes a team approach for periodontal and to trauma and inflammation. The team approach consists of a
restorative treatment intended to produce a predictable, biologi- restorative phase and a surgical phase. The restorative phase
cally sound outcome that preserves more supporting bone and involves preparation with complete caries removal, adhesive core
restores carious and broken down teeth. The goal of periodontal buildups, and provisionalization. The surgical phase involves
treatment, when performed in conjunction with restorative biologic shaping of the roots and judicious osseous resection.
dentistry, is to provide restorative dentists with a high percentage Case studies are used to demonstrate the team approach.
of tooth structure that allows for a supragingival margin. An Received: January 6, 2012
equally important goal is to ensure that an adequate thickness of Final revisions: April 11, 2012
connective tissue exists to create an environment more resistant Accepted: April 16, 2012
O
ver the years, restorative have no idea how much or how the likelihood of future inflam-
materials have become so little bone had to be removed and mation.6,7 At times, a significant
advanced that successful could not even be sure as to which amount of bone must be removed,
periodontal treatment depends teeth were salvageable. which can weaken the stability of
greatly on the work of the restorative Performing adhesive core buildups the tooth or create weakened and
dentist.1 The advent of the adhesive enables clinicians to facilitate thor- vulnerable furcation areas. As more
core buildup and provisionals gives ough caries removal, seal dentinal bone is removed from the furcation,
the periodontist vertical access to tubules prior to the definitive the likelihood of future maintenance
many areas on the tooth surface that restoration, provide ideal prepara- problems increases.8 As a result, it
might cause periodontal breakdown. tion form, eliminate undercuts in is critical to preserve as much bone
It is essential that the restorative the preparation, increase provisional as possible to support the tooth,
dentist place a core buildup prior to retention, allow for a uniform thick- especially in the furcation area.
periodontal correction.2 This step ness of definitive restorative material, Biologic shaping moves the restor-
allows the periodontist to assign minimize distortion or tearing of ative margin away from the bone,
individual tooth prognoses, deter- impressions, and provide the bio- minimizing the amount by which the
mine the apical extent of caries (and logic periodontal surgical template. crown must be lengthened to move
thus establish a definitive margin the bone away from the restorative
before a bone/restorative relationship Biologic shaping margin. Table 1 lists reasons, based
is developed), and establish complete Biologic shaping is an adjunct to on the authors’ experience, when
access for unimpeded treatment. If conventional crown lengthening.3-5 biologic shaping might be necessary.
the core is not completed prior to Conventional crown lengthening This article examines require-
surgery, there would be no way for uses the existing margins of an old ments for successful treatment
the periodontist to determine where restoration or the cementoenamel using a team approach, based on a
the soft tissue and bone should be junction (CEJ) of a non-restored series of comprehensive periodontal
positioned. If surgery is performed tooth to determine the amount of and restorative cases. It will be
prior to caries removal, core bone removal necessary to establish apparent when doing combined
buildups, and provisionalization, adequate space for the biologic periodontal and restorative treat-
the periodontist would, at best, be width. Creating proper space for the ment that the restorative dentist’s
making an educated guess as to the biologic width ensures that a new knowledge of materials and biology
necessary amount of bone removal. margin will not impinge upon the is paramount to the long-term suc-
At worst, the periodontist would periodontal complex and reduces cess of these cases.
Fig. 1. A preoperative view of leaking crowns. Fig. 2. Caries found under existing restorations.
Fig. 3. An occlusal view after the removal of old crowns. Fig. 4. A patient after complete caries removal.
Fig. 5. Adhesive core buildups bonded in place. Fig. 6. An occlusal view of the adhesive cores in Figure 5.
When the provisionals are within the sulcus. The periodontist’s cords are used to facilitate isolation
remade or relined at four weeks, actions should facilitate hygiene and and removed after the adhesive
there should be 1 mm between the maintenance procedures. cores are completed (Fig. 5 and 6).
provisional and soft tissue margins, Before the periodontist even treats At that point, biologic, esthetic,
which will allow the biologic width the patient, the restorative dentist and functional determinants can be
to mature in a coronal direction. must perform caries removal and established. The fixed provisional res-
No preparation or refining of tooth place core buildups and provisional torations not only allow dentists to
surfaces should be performed at this crowns. Patients often have existing test esthetic and occlusal hypotheses,
time. At 14 weeks, chamfer margins restorations that are undermined by they also can be removed to provide
are placed just coronal to the gingi- recurrent decay (Fig. 1–3). All caries 360 degree access (Fig. 7 and 8),
val collar and impressions are taken. must be completely removed without which allows the periodontist to per-
When endodontics are required, concern for extending the prepara- form crown lengthening and biologic
the new margin can be placed tion subgingivally (Fig. 4). Retraction shaping without impedance.
Fig. 13. The patient in Figure 10, following the Fig. 15. The patient in Figure 10, after a super
removal of CEJs, old restorative margins, and Fig. 14. The patient in Figure 10, after the fine bur is used for additional contouring of the
root surface irregularities. periosteum is reflected for osseous contouring. tooth surface.
barreled in all the way to the occlusal margin just coronal to the gingival
surfaces. The soft tissue-to-tooth collar at 12 weeks. Removing
interface was ideal. The patient was the concavity gives the hygienist
placed on a three-month alternating and patient easy access to plaque,
recall schedule between the restor- calculus, and biofilm for long-term
ative dentist and periodontist and has maintenance (Fig. 24). Once the Fig. 24. The patient in Figure 21, following
not demonstrated any further break- restorations have been completed, removal of the mesial concavity.
down since completion of treatment. the patient will be placed on a
three-month alternating recall
Case report No. 2 schedule between the restorative
As is often the case, caries control dentist and the periodontist.
and provisionalization occurred The minimal vertical probing
prior to periodontal surgery Case report No. 3 depth in the furcation can be decep-
(Fig. 21). The provisionals were In this case, teeth No. 19 and 20 tive. When restoring molars with
removed to allow the periodon- were treated using a periodontal- existing restorations, it is critical to
tist unimpeded vertical access restorative approach. Caries evaluate not only the vertical prob-
(Fig. 22). Reflecting the soft tissue was removed and the teeth were ing, but the horizontal component
revealed a mesial concavity on provisionalized (Fig. 25). After the of the furcation as well (Fig. 26).
tooth No. 12, with associated provisionals were removed, the soft While vertical probing was mini-
calculus present (Fig. 23). Remov- tissues showed ideal health, which mal, the horizontal probing depth
ing the mesial concavity made can occur only when provisionals demonstrated significant furcation
it possible to place a restorative are perfectly contoured and fitted. breakdown (Fig. 27). The furcation
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