Periodontal Considerations in Restorative Dentistry Part 1+2

PRESENTED BY:
DR.WALID AL ANESI.
RATIONALE
FOR PERIODONTAL
THERAPY
• Stable gingival margins before tooth
preparation(kois 2000)
• Perio treatment should antecede restorative c are.
• Quality, quantity and topography of the

periodontium provides structural defense factors in
maintaining health.
NORMAL
PERIODONTIUM
• Gingiva
• Gingival
crevice.
• Biologic width.
Clinical Periodontology - 9th edition, Carranza

IRRITATING FACTORS
FOR
• Prior to PERIODONTIUM
procedure
✓Caries
✓Teeth
separation
✓Rubber dam
Interactions between the gingiva and the margin of restorations, J Clin Periodontol 2003;
30: 379–385.
IRRITATING FACTORS FOR
PERIODONTIUM CONTI..
• During the procedure: meticulous instrumentation.

• Preparation instrumentation
✓Vibration
✓preserving proximal plate of enamel-during gross
cavity preparation- avoid injury to gingiva.
✓Wedges below contact area- before proximal
box preparation
• Matricing
Interactions between the gingiva and the margin of restorations, J Clin Periodontol
2003; 30: 379–385.
IRRITATING FACTORS FOR
PERIODONTIUM CONTI..
• Long after the procedure: restoration in close

proximity to soft tissue.
• Gingival retrac tion

✓Physic al retrac tion methods
✓C hemic al retraction methods
✓Elec tro surgic al proc edures
• Impression procedures
• Temporary restorations & fabric ation

Interactions between the gingiva and the margin of restorations, J Clin Periodontol
2003; 30: 379–385.
PERIODONTAL-
RESTORATIVE
INTERRELATIONSHIP
Seven characteristics of restorations and partial
dentures are important from a periodontal point of
view:
•Margins of restorations
•Contours
•Occlusion
•Materials
•Bridge design
•Design of Removable Partial Dentures
•Procedures of Restorative Dentistry themselves.
Periodontal-Restorative Interactions: A Review, shaveta sood, shipra Gupta, Indian

INTERRELATIONSHIP CONTD…
Margins of restoration
•location of restorative margins is determined by
many factors
1.Esthetic c oncerns.
2.Need for increased retention
form 3.Refinement of pre-existing
margins. 4.Root c aries.
5.C ervic al
abrasion 6.Root
sensitivity.
• Orkin et al 1986 demonstrated that sub gingival

restorations had a greater chance of bleeding
and exhibiting gingival recession then supra
gingival restoration
• Waerhaug 1978 stated that sub gingival

restorations are plaque retentive areas that are
inaccessible to sc aling instruments.
The restorative periodontal interface: biological parameters. Perio2000

2001;25:100
Contours
•Over c ontouring and under c ontouring
•The most common error in recreating the contours of
the tooth in dental restorations is over contouring of
the facial and lingual surfaces, generally in the gingival
third.
•Apparently, under c ontouring is not nearly as
damaging to the gingiva as the over c ontouring.
Preparation of tooth surface. Schmid MO,

clinical periodontology, 8th edition.
• Occlusion
• Restorations that do not c onform to the occ lusion
patterns of mouth c ause occ lusal disharmonies
that may be injurious to the supporting periodontal
tissues.
The restorative periodontal interface:

biological parameters. Perio2000 2001;25:100
Materials
•Restorative materials are not themselves injurious to
the periodontal tissues.
•The surface of restorations should be as smooth
as possible to limit plaque ac c umulation.
•Resins are highly polishable, but have deficiencies
in strength, porosity and wear.
•Glass ceramics and porcelain veneers offer a clear
advantage over any other type of restorative
materials in the maintenance of gingival health.
•There are clinical situations in which the full crown is
indicated prior to restoration. It fulfills requirements
that c an be met in no other type of restoration.
The effect of cervical sub gingival restoration margins on the degree of
inflammation of the neighbouring gingiva, Schweiz 1974.
Bridge design
•The health of the tissues around fixed prostheses
depends primarily on the patient’s oral hygiene; the
materials with which bridges are constructed appear
to make little differenc e.
•Ridge lap pontics, the least desirable design.
•Bridge design with the least effect on the
periodontium is the sanitary or hygienic pontic .
Periodontal conditions and carious lesions following the insertion of fixed
prosthesis, Int Dent Journal 1980.
Design of Removable Partial Dentures

•partial dentures favor the accumulation of
plaque, partic ularly if they c over the gingival
tissue.
Periodontal and prosthetic conditions in patients treated with removable partial

dentures and artificial crowns, Acta Odontol Scand, 1971
Restorative Dentistry
Procedures
Periodontal-Restorative Interactions: A Review,

shaveta sood, shipra Gupta, Indian Journal of Clinical
Practice , Vol. 23, No. 11, April 2013
BIOLOGIC
CONSIDERATIONS
Contour
•Convexity on facial & lingual surfaces: provides
protection & stimulation to supporting struc tures
during mastication.
•Becker and Kaldahl opined that the buccal and

lingual crown contour should be ‘flat’ and not ‘fat’,
usually < 0.5 mm, wider than the C EJ.
•Yondelis et al demonstrated that greater the amount

of facial and lingual bulge of an artificial crown, the
more the plaque retained at the cervical margins.
BIOLOGIC CONSIDERATIONS
CONTD…
Interproximal contacts
•There must be a positive contact relation mesially
and distally of one tooth with another in each
dental arch.
•The c ontac t points should be located
inc isially or occlusally and buccally.
•Labio Lingual Location
Hazards of broad contact when placed
•Occluso gingivally
•Narrow Contact
•Contact too far gingivally
Contact
••Too too far occlusally
far buccal/ The restorative periodontal interface: biological
lingual parameters, periodontology 2000 2001
CONTD…
Embrasures/spillways
•V shaped spaces originate at the proximal contact
area between adjacent teeth.
Functions
•Serve as spillways for escape of food during
mastication- force brought on the tooth is reduc ed.
•Prevents forcing of food into c ontac t area.
The restorative periodontal interface: biological parameters,

periodontology 2000 2001
CONTD…
Restoration over hangings
•Overhanging restorations contribute to gingival

inflammation due to their retentive capacity for
bacterial plaque.
•Gilmore and Sheiham 1971 illustrated interproximal

radiographic bone loss adjacent to posterior teeth
with overhanging restoration.
The restorative periodontal interface: biological parameters,

periodontology 2000 2001
CONTD…
• Jeffcoat and Howell 1980 demonstrated a link to the

severity of the overhang and the amount of
periodontal destruc tion. Based upon radiographic
evaluation of 100 teeth with overhang and 100
without, they reported greater bone loss around
teeth with large over hangs. The severity of bone
loss was direc tly proportional to the severity of the
overhang.
• Spinks et al 1986 demonstrated that a motor

driven diamond tip is faster for removing over
hangs and led to smoother restorations compared
to Sonic Scalers and C urettes respec tively.
CONTD…
MARGIN PLACEMENT AND BIOLOGIC WIDTH
•Supragingival
•Equigingival
•Subgingival
Biologic width and its importance in periodontal and restorative dentistry, Babitha
Nugala, Journal of Conservative Dentistry,Jan-Mar 2012,Vol 15.
CONTD…
Supragingival margin
•least impac t on the periodontium.
•Preparation of the tooth and finishing of the margin
is easiest
•Duplication of the margins with impressions c an be
done with ease.
•Fit and finish of the restoration and removal of
excess material is easiest
•Verification of the marginal integrity of the restoration
is easiest.
CONTD…
Equigingival margin
•Previous thought: retains more plaque than supra &
sub gingival margins therefore results in greater
gingival inflammation.
CONTD…
Subgingival margin
•Greatest biologic risk.
•Not as ac c essible as supra or equi for
finishing procedures.
CONTD…
Biologic width
Kois proposed three c ategories of biologic width
based on the total dimension of attac hment and
the sulc us depth following bone sounding
measurements.
•Normal c rest patient
•High c rest patient
•Low c rest patient.
Biologic width and its importance in periodontal and restorative dentistry, Babitha
Nugala, Journal of Conservative Dentistry,Jan-Mar 2012,Vol 15.
CONTD…
Normal crest patient
•Normal C rest occ urs approximately 85% of time.
•The gingival tissue tends to be stable for a long

term.
CONTD…
High crest patient
•High C rest is an unusual finding and

occ urs approximately 2% of the time.
•Oc c urs more often in a proximal surfac e adjac ent

to an edentulous site.
CONTD…
Low crest patient
•Low C rest occ urs approximately 13% of the time.
•Traditionally, the Low Crest patient has been

described as more susceptible to recession secondary
to the placement of an intracrevicular crown margin.
CONTD…
Importance of determining the crest category
•This allows the operator to determine the optimal

position of margin plac ement, as well as inform the
patient of the probable long-term effects of the
c rown margin on gingival health and esthetic
CONTD…
Margin placement
guidelines
•Rule I
•Rule II
•Rule III
Margin of restorations-from view point of

crown and bridge making, 1972
CONTD…
• Orkin et al demonstrated that subgingival

restorations had a greater chance of bleeding
and exhibiting gingival recession than supragingival
restorations.
• Renggli et al showed that gingivitis and plaque
accumulation were more pronounced in interdental
areas with well-adapted subgingival amalgam
fillings c ompared to sound tooth struc ture.
• 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 post-
insertion. Subgingival margins demonstrated
increased plaque, gingival index score and probing
depths
CONTD…
Evaluation of biologic width

violation
•Clinical method
•Bone sounding
•Radiographic evaluation
CONTD…
Clinical method
•Signs of biologic width violation are:
✓Chronic progressive gingival inflammation around
the restoration,
✓Bleeding on probing,
✓Localized gingival hyperplasia with minimal bone
loss,
✓Gingival recession,
✓Pocket formation,
✓C linic al attac hment loss and alveolar bone loss.
CONTD…
Bone sounding
•The biologic width can be identified by probing

under local anesthesia to the bone level and
subtrac ting the sulcus depth from the resulting
measurement. If this distance is less than 2 mm at
one or more locations, a diagnosis of biologic width
violation can be confirmed.
CONTD…
Radiographic evaluation
•Sushama and Gouri have desc ribed a new

innovative parallel profile radiographic (PPR)
technique to measure the dimensions of the dento
gingival unit (DGU).
CONTD…
CONTD…
Surgical crown lengthening
•C rown lengthening surgery is designed to

inc rease clinical crown length.

Journal of Clinical Practice , Vol. 23, No. 11, April 2013
CONTD…
INDICATIONS
•Inadequate clinical crown for retention due to
extensive caries, subgingival caries or tooth fracture,
•Short c linic al c rowns.
•Placement of sub gingival restorative margins.
•Unequal, excessive or unaesthetic gingival levels for
esthetics.
•Planning veneers or c rowns on teeth with the gingival
margin c oronal to the c emeto enamel junction (delayed
passive eruption).
•Teeth with excessive occ lusal wear or inc isal wear.
•Restorations which violate the biologic width.
•Assist with impression accuracy by placing crown
margins more supragingivally.
CONTD…
Contraindications
•Deep c aries or frac ture requiring exc essive
bone removal.
•Post surgery c reating unaesthetic outc omes.
•Tooth with inadequate c rown root ratio (ideally 2:1
ratio is preferred)
•Non restorable teeth.
•Tooth with increased risk of furcation involvement.
•Unreasonable c ompromise of esthetics.
•Unreasonable c ompromise on adjac ent alveolar
bone support.
CONTD…
Gingivectomy
•External bevel
gingivectomy
•Internal bevel
gingivectomy

CONTD…
Apically positional flap surgery
Indication
•C rown lengthening of multiple teeth in a quadrant
or sextant of the dentition, root caries, fractures.
Contraindication
•Apical repositioned flap surgery should not be used
during surgical crown lengthening of a single tooth in
the esthetic zone.
CONTD…
Apically repositioned ﬂap without osseous resection
•This procedure is done when there is no adequate

width of attac hed gingiva, and there is a biologic
width of more than 3 mm on multiple teeth.
CONTD…
Apical repositioned ﬂap with osseous reduction
•This technique is used when there is no adequate

zone of attached gingiva and the biologic width is
less than 3 mm.
•The alveolar bone is reduced by ostectomy and

osteoplasty, to expose the required tooth length in a
scalloped fashion, and to follow the desired contour
of the overlying gingiva.
CONTD…
• Sugumari et al. in a report on surgical crown

lengthening with apical repositioned flap with bone
resection performed in the fractured maxillary
anterior teeth region, showed satisfac tory results
both in terms of functional (restoring biologic width)
and esthetic outcomes.
• Most authors agree that a minimum distance of
3mm is required from the osseous crest to the final
restorative margin following a c rown – lengthening
procedures to allow the margin to finish supra
gingivally (Bragger et al 1992).
CONTD…
Orthodontic techniques
•Heithersay and Ingber were the first to suggest the
use of “forced eruption” to treat “non-restorable” or
previously “hopeless” teeth.
•Forced eruption with minimal osseous resection,
and forced eruption combined with fiberotomy
(starr).
•Frank et al. desc ribed forced eruption of multiple
teeth.
Contraindications
•Inadequate c rown-to-root ratio
•Lac k of occ lusal c learance for the required
CONTD…
Tissue retraction
•Retraction cord
•Tissue management is achieved with gingival
retraction c ords, using the appropriate size to
ac hieve the displacement required.
•Rule 1 margin
•Rule 2 margin
CONTD…
Various c hemicals used for the treatment of

c hords include:
•0.1% and 8% rec emic epinephrine
•100% aluminum solution (potassium aluminum
sulfate)
•5% and 25% aluminum chloride solution
•Ferric subsulfate (Monsel’s solution)
•13.3% ferric sulfate solution
•8% and 40% zinc c hloride solution
•20% and 100% tannic ac id solution
•45% negatol solution.
CONTD…
Recent
Advances
Merocel
•Made of a synthetic material that is specifically
chemically extracted from a biocompatible polymer
(hydroxylate polyvinyl acetate) that creates a net
like strip (2 mm thick)
Expasyl
•Composed of micronized kaolin, aluminum chloride
and water
CONTD…
Electrosurgical
Means
CONTD…
• Surgical Means
• Surgery with a knife is the preferred method

for providing access to the margin of the
preparation.
CONTD…
Rotary curettage:
•It is troughing technique.
•This technique is usually followed by insertion
of retrac tion c ord.
Cryosurgery
•Uses a sharp, c old knife to remove the
tissues conservatively.
CONTD…
Periodontal evaluation of restorative materials

Amalgam
•Surfac e roughness
•Marginal disc repanc ies
•Galvanism
•Chemical irritation
The Effect of Dental Restoration Type and Material on Periodontal Health, Khansa
Taha Ababneh, Oral Health Prev Dent 2011; 9: 395-403.
CONTD…
Zinc Oxide Eugenol

•High solubility in oral ac ids
•Surfac e roughness
•Marginal inadequac ies
Zinc Phosphate Cement

•Inadvertently leaving attached or
unattached set cement within the gingival
crevice
The Effect of Dental Restoration Type and Material on Periodontal Health, Khansa
Taha Ababneh, Oral Health Prev Dent 2011; 9: 395-403.
CONTD…
Direct gold restoration

•Lacerations and contusions which can occur
during condensation.
Ceramic restorations
•Most c hemic ally inert of all materials
•Most biologically ac c eptable to the
periodontium.
Composite restorations
•No evidence of any clinical problems resulting in
soft tissue changes with the use of composite.
CONTD…
Hypersensitivity To Dental Materials

•About 30% of those patients with a known nickel
allergy develop a reaction to an intraoral nickel
chromium dental alloy.
•Phosphate cements and silicates are slightly irritants.
•Ac rylic is highly irritant, although the material itself
is not irritant when fully polymerized.
•Tissues respond more to the differenc es in
surfac e roughness of the material rather than
its c omposition.
ESTHETIC
CONSIDERATIONS IN
GINGIVAL TISSUE
Ideal interproximal embrasure.
MANAGEMENT
•House gingival papilla without impinging on it.
•Extend interproximal tooth contact to top of papilla –
no excess space to trap food or esthetically
displeasing.
•Ideal interproximal tooth contact: 2-3 mm coronal
to epithelial attachment.
Restorative correction of open gingival embrasure.
•Moving the contact to tip of papilla.
•Direc t bonded restorations:
•Margins of restoration carried subgingivally 1-1.5 mm.
•Designing emergence profile: moving contact point
towards papilla while blending c ontour into tooth
below tissue.
Indirect restorations:
•Desired contour & embrasure form established
in provisional restoration.
•Gingival tissues are allowed to adapt for 4-6 weeks
with temporary, before tissue contour information is
relayed to laboratory to be used in final restoration
CONCLUSIO
N
• The health of the periodontal tissues is dependent on
properly designed restorative materials. Overhanging
restorations and open interproximal contacts should
be addressed and remedied during the disease
control phase of periodontal therapy.
Thank you

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PRESENTED BY:

• Perio treatment should antecede restorative c are.

• Quality, quantity and topography of the

Clinical Periodontology - 9th edition, Carranza

• During the procedure: meticulous instrumentation.

• Long after the procedure: restoration in close

• Gingival retrac tion

• Temporary restorations & fabric ation

Periodontal-Restorative Interactions: A Review, shaveta sood, shipra Gupta, Indian

• Orkin et al 1986 demonstrated that sub gingival

• Waerhaug 1978 stated that sub gingival

The restorative periodontal interface: biological parameters. Perio2000

Preparation of tooth surface. Schmid MO,

The restorative periodontal interface:

Design of Removable Partial Dentures

Periodontal and prosthetic conditions in patients treated with removable partial

Periodontal-Restorative Interactions: A Review,

•Becker and Kaldahl opined that the buccal and

•Yondelis et al demonstrated that greater the amount

•Prevents forcing of food into c ontac t area.

The restorative periodontal interface: biological parameters,

Restoration over hangings

•Overhanging restorations contribute to gingival

•Gilmore and Sheiham 1971 illustrated interproximal

The restorative periodontal interface: biological parameters,

• Jeffcoat and Howell 1980 demonstrated a link to the

• Spinks et al 1986 demonstrated that a motor

MARGIN PLACEMENT AND BIOLOGIC WIDTH

•Normal c rest patient

•High c rest patient

•Low c rest patient.

Normal crest patient

•Normal C rest occ urs approximately 85% of time.

•The gingival tissue tends to be stable for a long

High crest patient

•High C rest is an unusual finding and

•Oc c urs more often in a proximal surfac e adjac ent

Low crest patient

•Low C rest occ urs approximately 13% of the time.

•Traditionally, the Low Crest patient has been

Importance of determining the crest category

•This allows the operator to determine the optimal

Margin of restorations-from view point of

• Orkin et al demonstrated that subgingival

Evaluation of biologic width

•The biologic width can be identified by probing

•Sushama and Gouri have desc ribed a new

Surgical crown lengthening

•C rown lengthening surgery is designed to

Periodontal-Restorative Interactions: A Review, shaveta sood, shipra Gupta, Indian

Periodontal-Restorative Interactions: A Review, shaveta sood, shipra Gupta, Indian

Apically positional flap surgery

Apically repositioned ﬂap without osseous resection

•This procedure is done when there is no adequate

Apical repositioned ﬂap with osseous reduction

•This technique is used when there is no adequate

•The alveolar bone is reduced by ostectomy and