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Periodontal Considerations in FPD
Periodontal Considerations in FPD
considerations in FPD
Guided by –Dr. Ajaykumar Nayak
Professor
Presented by – Dr. Shilpa Soman (II MDS)
CONTENTS
Introduction
Biological width Margin placement
Periodontal factors in FPD / abutment selection.
-Crown root ratio
Gingival retraction
-PDL area and surface area Pontic design.
-Root configuration
-Tilt Crown contours
-Mobility
-Furcation involvement
-Resection
-Hemisection
Margin placement
Gingival retraction
INTRODUCTION
◦ Dentists face special problems in patients with history of periodontitis requiring crowns
or FPD’s to restore carious or missing teeth.
◦ These problems include poor crown-root ratio, esthetic compromise, furcation invasion,
progressive tooth mobility, migration, inadequate zone of attached gingiva and prominent
root concavities.
◦ Normal crest
◦ High crest
◦ Low crest
NORMAL CREST HIGH CREST LOW CREST
◦ If a patient experiences discomfort when the restoration margin levels are being assessed with a periodontal
probe.
◦ Margin has extended into the attachment and biological width violation has occurred.
◦ Biological width can be identified by probing under local anesthesia and subtracting the sulcus depth from
surrounding measurements.
◦ If this distance is <2mm at one or more locations, a diagnosis of biological width violation can be confirmed.
◦ RADIOGRAPHIC EVALUATION
Bone loss
Indication Non-esthetic areas due to Restorative margins can esthetic demands, root
the marked constrast in be aesthetically blended caries or fracture,
color &opacity of with the tooth &finished clinically short crowns
traditional restorative to provide a smooth,
materials against the polished interface at the
tooth. gingival margin
subgingival restorations were associated with greater
periodontal inflammation in the sites with keratinized gingiva
less than 2mm.
INTRACREVICULAR MARGIN
Clinical situations in periodontally treated teeth requiring these margins are:
1. Esthetics
2. Severe cervical erosion, restorations, caries extending beyond gingival crest
3. Short clinical crowns or broken down crowns
4. Elimination of persistent root hypersensitivity.
◦ Time elapsed after completion of periodontal treatment is crucial for placement of intra crevicular
margins.
◦ 3 months for healing of extensive surgery or more time required.
◦ Margins after periodontal surgery - coronally; scaling and after root planing - recedes
◦ Carranza gave three rules have been suggested for the placement of subgingival restoration margin. To
implement following rules it must be made sure that the gingival tissue is healthy:
RULE 1-
oIf the sulcus probing depth is 1.5mm or less than that, the gingival margin is placed 0.5mm below the
gingival tissue crest.
RULE 2-
oIf sulcus probing depth is >1.5mm,the margin of restoration is placed one half of the depth of the sulcus
below the gingival tissue crest.
RULE 3-
oIf the sulcus depth is >2mm, the gingival tissue is evaluated for going gingivectomy and for crown
lengthening.
oOnce the gingival sulcus depth around 1.5mm is achieved, the restoration margin Is placed following
rule 1.
Healthy crevice depth 2-3mm, so margin placement 0.5-2mm from gingival crest.
Histologic depth 0.5-1mm
0.5mm ideal depth for intracrevicular margins, specially when adjacent to root surface.
Average cervical depth in enamel and root is similar, while crevicular length of junctional epithelium
is 0.5-1mm shorter on root than on enamel.
Thus overextension of margin placement beneath the gingiva on root surfaces impinges on the gingival
connective tissue fibres and the junctional epithelium
Chamfer or knife edge margins are indicated in cases where gingival margins have receded to root
levels.
◦ The chosen finish line design must have –
◦ a predictable degree of marginal honesty.
◦ Place smooth materials in the sulcus to prevent plaque buildup
◦ Maintain a pleasing appearance.
conservative finish lines such as the feather edge and knife edge result in overcontoured restorations,
which cause periodontal problems such as gingival recession, unattractive black triangular holes, and
alveolar bone loss.
◦ Different studies have demonstrated conclusively that periodontal tissues show more signs of
inflammation around crowns with intracrevicular or subgingival margins than those with supragingival
margins.
◦ Orkin et al demonstrated that subgingival restorations had a greater chance of bleeding and exhibiting
gingival recession than supragingival restorations.
◦ Flores-de-Jacoby et al studied the effects of crown margin location on periodontal health and bacterial
morphotypes in human 6-8 weeks and 1 year postinsertion. Subgingival margins demonstrated increased
plaque, gingival index score and probing depths. Furthermore, more spirochetes, fusiform, rods and
filamentous bacteria were found to be associated with subgingival margins.
◦ Silness evaluated the periodontal condition of the lingual surfaces of 385 fixed partial denture
abutment teeth. He found that a supragingival position of the crown margin was the most
favorable, whereas margins below the gingival margin significantly compromised gingival health.
PERIODONTAL FACTORS IN ABUTMENT SELECTION
CROWN – ROOT RATIO –
Length of tooth occlusal to the alveolar crest of bone compared with
length of root embedded in bone.
As the level of alveolar bone moves apically, the lever arm of that
portion out of bone increases, and the chance for harmful lateral forces
is increased.
The optimum crown root ratio for tooth to be utilized as a fixed partial
denture abutment is 2:3. A ratio of 1:1 is the minimum ratio that is
acceptable for a prospective abutment under normal conditions (such
as number of teeth being replaced, tooth mobility and overall
periodontal health is good)
However there are situations where a crown –root ratio of greater than
1:1 might be considered adequate.
◦ PDL AREA AND SURFACE AREA –
◦ ANTE suggested in 1926 that it was unwise to provide a FPD when the root surface area
of the abutment was less than the root surface area of the teeth being replaced; this has
been adopted and reinforced by other authors (Johnston, Dykema, Shillinburg, Tylman)
as ANTE’s LAW.
◦ Ante’s Law – “ The total periodontal membrane area of the abutment teeth must equal
or exceed that of the teeth to be replaced."
◦ Newman and Ericsson - demonstrating that teeth with considerably reduced bone support can be
successfully used as FPD abutments.
◦ “The total mesiodistal width of the cusps of abutments should be equal or exceed the width of
cusps of pontics.”
◦ ROOT CONFIGURATION –
◦ Multirooted posterior teeth with widely separated roots will offer better periodontal support
than roots that are short converge, fuse, blunted, or generally present a conical
configuration.
◦ A single rooted tooth with evidence of irregular configuration or with some curvature in the
apical third of the root is preferable to the tooth that has a nearly perfect taper.
Long axis Relationship - The long axis relationship of abutment
teeth should be no more than 25- 30 degree from the parallel.
◦ A severely inclined tooth will not withstand forces as well as one
that is erect.
If mobility is caused by considerable bone loss and more than one tooth is to be replaced, it is
unlikely the tooth to be a suitable abutment unless it can be splinted to another sound tooth.
Splinting – in dentistry the joining of two or more teeth into a rigid unit by means of fixed or
removable restorations or devices (GPT-9)
Splints – a rigid or flexible device that maintains in position a displaced or movable part; also used
to keep in place and protect an injured part. (GPT-9).
A periodontal splint is an appliance used for maintaining or stabilising mobile teeth in their
functional position.
Mobile tooth/ teeth is splinted to adjacent healthy teeth and act as a unit and redirects the
masticatory forces to the whole unit .
Also augments crown root ratio and a net decrease of force on individual teeth.
Types –
Temporary splints / Provisional splints
Permanent splints
◦Furcation flutes
◦Sometimes the crown margins on a molar must extend far enough apically that the preparation finish line
approaches the furcation, where the common root trunk divides into two or three roots.
◦The designs of both the tooth preparations and the crowns for these teeth must be different from those
customarily used.
◦caused by the intersection of the preparation finish line with the vertical flutes or concavities in the
common root trunk, extending from the actual furcation in the direction of the cementoenamel junction.
◦The axial contours of crowns placed on teeth whose furcation flutes are intercepted by preparation finish
lines must likewise reflect the concavity rising from the furcation flute.
◦The facial surface should be invaginated into a concavity above the bifurcation that extends occlusally until
it meets the facial groove in the occlusal one-third of the facial surface.
◦There must be no interruption in the vertical concavity rising at the margin of the restoration .
Preparations for Root Resections
◦ One or more roots of a molar may be removed to eradicate areas of the tooth that create problems in
the maintenance of good hygiene and plaque control.
◦ One or more roots can be eliminated because of an invasion or uncovering of the furcation by severe
vertical bone loss.
◦ The severe loss of bone or attachment around one root may also necessitate the removal of a root .
◦ When a root has been removed from a tooth, both the tooth preparation and the contours of the
crown will be different because of the altered tooth shape.
◦ Intracrevicular margin placement may be required to cover portions of the root resected area.
◦ Crown margin should be apical to pulp chamber floor or root canal that was exposed by
resection, especially if these structures have not been sealed by amalgam.
◦ To prevent impingement of biologic width; intracrevicular margins to cover the pulpal canal
structures should be no close than 3mm to the alveolar crest.
◦ Gingival third is fabricated with flat emergence profile from gingiva for hygiene and cleansing.
◦ Open embrasures between crowns and apical to rigid connectors allow proximal cleansing with
interdental brushes
◦ MANDIBULAR HEMISECTION
The roots are cut apart and then rejoined by a “crown” that in reality is a very short interradicular splint
with concave connectors from one root to the other. The occlusal configuration of the splint is pretty
much that of an ordinary molar.
This procedure, in effect, makes the furcation metal and moves it occlusally while separating the roots.
This improves access to the furcation and protects a caries-prone area.
◦ The contours for full and partial coverage restorations play a supportive role in
establishing a favorable periodontal climate.
◦ Three prominent theories of crown contour have evolved:
◦ (1)Gingival protection,
◦ (2) Muscle actions, and
◦ (3)Access for oral hygiene.
◦ Self-cleansing contours. This concept asserts that, as food passes over the tooth
during mastication, the tooth will be cleansed. While certain prominent buccal
and lingual surfaces of teeth do not accumulate plaque even in neglected mouths,
◦ 2-Muscle action theory
◦ Lindhe and Wicen - stated in absence of oral hygiene , “self cleansing mechanisms do nothing to prevent gingivitis.
Even if there was some self cleansing of the buccal and lingual surfaces from muscle action, interproximal
cleansing wuld still not occur.
◦ These authors strive for an intermediate design of crown contour which allows for both gingival protection and
muscular action.
◦ If a shoulder is prepared for a metal ceramic crown axial walls converge towards pulp
chamber with serious consequences : even if axial walls are parallel.
2. In case of anterior bone loss or missing canines, mouth should be restored to group function.
Based on tissue contact two types-
PONTIC DESIGN
◦ The ridge lap and modified ridge lap designs have concave surfaces that are
more difficult to access with dental floss.
◦ A modified ridge lap design can be given where there is inadequate ridge to
place an ovate pontic. Whereas the facial aspect of the undersurface has a
concave shape, adequate access for oral hygiene is allowed by the more open
lingual form.
◦ Chemical agents as well as the mechanical force of retraction cords could trigger temporary gingival
recession and gingival inflammation.
◦ The proper manipulation of different gingival retraction techniques such as materials and time-control
are the key factors to avoid permanent tissue damage while impression-taking process is made.
◦ Kaiser and Newell stated – margins not to be placed over 1.0mm subgingivally to the retracted level of
the free gingival margin to ensure that the margin is hidden under healthy tissue.
◦ Emphasised potential for tissue recession is greatly dependant on its health before preparation.
◦ Best way to avoid irritation is to extend gingival margin into the sulcus after cord retraction.
◦ Retraction cord –
If intracrevicular margins are adjacent to thin gingiva on the root, sulcular contours of
the artificial crown should be flat mimicking shape of the root , to prevent
overcontouring.
If thick free gingiva is present against a flat root it often presents with a slight ,
chronic, marginal gingivitis .
Advisable to create thicker intracrevicular crown contour similar to natural crown.
◦ PROXIMAL CONTOURS
◦ Inter dental site is frequently the first site for gingivitis and periodontitis.
◦ Instead of single interdental papilla, interdental gingiva has separate facial and
lingual peaks with connecting valley under contact area called Col (thin,
nonkeratinized permeable to toxins).
Embrasures:
For restorations to survive long-term, the periodontium must remain healthy so that the
teeth are maintained.
Direct and frequent communication between the periodontist and restorative dentist is
a prerequisite for predictable and satisfactory results
REFERECES
◦ Malone WF, Tylman SD, Koth DL. Tylman's theory and practice of fixed prosthodontics.
Ishiyaku EuroAmerica, Incorporated; 1989.
◦ Shillingburg HT, Hobo S, Whitsett LD, Jacobi R, Brackett SE. Fundamentals of fixed
prosthodontics. Quintessence Publishing Company; 1997 Jan.
◦ Hsu YT, Huang NC, Wang HL. Relationship between periodontics and prosthodontics: The
two-way street. Journal of Prosthodontics and Implantology. 2015;4(1):4-11.
◦ Becker CM, Kaldahl WB. Current theories of crown contour, margin placement, and pontic design. The
Journal of prosthetic dentistry. 1981 Mar 1;45(3):268-77.
◦ Shenoy A, Shenoy N, Babannavar R. Periodontal considerations determining the design and location of
margins in restorative dentistry. Journal of Interdisciplinary Dentistry. 2012 Jan 1;2(1):3.
THANK YOU
◦ The mesial one half crown requires an unblemished distal surface on the molar abutment. The non rigid attachment must not be used
indiscriminately. Because of mesial component of force, the female portion of attachment is usually placed on distal surface of mesial abutment.
◦ The cantilever effect on the non- rigid design can pace additional stress on the abutment with the rigid connector, therefore rigid connector is only
placed on a strong abutment, and the non rigid design is avoided altogether with long span pontics. Telescopic prosthesis requires radical tooth
preparation to provide adequate space for the telescopic coping and the overcasting.
◦ The mesial one- half crown preparation, the non - rigid attachment (semi- precision or stress breaker) and the telescopic prosthesis have been
suggested to solution to the problem.
◦ The mesial one half crown requires an unblemished distal surface on the molar abutment. The non rigid attachment must not be used
indiscriminately. Because of mesial component of force, the female portion of attachment is usually placed on distal surface of mesial abutment.
◦ The cantilever effect on the non- rigid design can pace additional stress on the abutment with the rigid connector, therefore rigid connector is only
placed on a strong abutment, and the non rigid design is avoided altogether with long span pontics. Telescopic prosthesis requires radical tooth
preparation to provide adequate space for the telescopic coping and the overcasting