great basin academy study club march 2013 roseman university of health sciences

Great Basin Academy Great Basin Academy Study ClubStudy Club

March 2013March 2013

Roseman University of Health Sciences

Presented byPresented byCraig M. Ririe, DDS, MSCraig M. Ririe, DDS, MS

Preparation of the PeriodontiumPreparation of the Periodontium

Iatrogenic Causes and Iatrogenic Causes and Restorative ConsiderationsRestorative Considerations

Supportive Periodontal Supportive Periodontal Treatment (Maintenance)Treatment (Maintenance)

Results of Periodontal TreatmentResults of Periodontal Treatment

Restorative DentistryRestorative Dentistry

Periodontium free of inflammationPeriodontium free of inflammation Periodontium free of pocketsPeriodontium free of pockets Periodontium free of Mucogingival Periodontium free of Mucogingival

involvementinvolvement

33

Implant DentistryImplant Dentistry

Needs site developmentNeeds site development Needs bone augmentationNeeds bone augmentation Needs gingival augmentationNeeds gingival augmentation

44

Periodontal DiseasePeriodontal Disease must be eliminated prior to must be eliminated prior to

Restorative dentistry.Restorative dentistry. To determine gingival margins of To determine gingival margins of

restorations properlyrestorations properly Inflammation weakens abutment Inflammation weakens abutment

teeth stabilityteeth stability Teeth shift in presence of diseaseTeeth shift in presence of disease

55

Elimination of Periodontal Elimination of Periodontal DiseaseDisease

Resolution of inflammation in Resolution of inflammation in P.D.L.P.D.L.

Regeneration of P.D.L. fibers, Regeneration of P.D.L. fibers, APICAL to level of attachment APICAL to level of attachment lossloss

Can cause teeth to shift againCan cause teeth to shift again

66

Fixed bridge work designed for Fixed bridge work designed for teeth BEFORE teeth BEFORE the periodontium is treated the periodontium is treated

may produce INJURIOUIS may produce INJURIOUIS tensions and tensions and

pressures on the treated pressures on the treated periodontium.periodontium.

77

Abutment teeth must have Abutment teeth must have NO periodontalNO periodontal

involvement –involvement –

Before and after restoration Before and after restoration

is complete.is complete.

88

Removable Partial DenturesRemovable Partial Dentures

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

99

A TRUE ADAGEA TRUE ADAGE

GARBAGE INGARBAGE IN

GARBAGE OUTGARBAGE OUT

1010

Tooth MobilityTooth Mobility

1111

SUMMARYSUMMARY

The goal of periodontal therapy The goal of periodontal therapy should be to create the should be to create the

gingival mucosal environment gingival mucosal environment and osseous topography and osseous topography necessary for the proper necessary for the proper function of single tooth function of single tooth

restorations and fixed and restorations and fixed and removable partial prosthesis.removable partial prosthesis.

1212

TREATMENT TO MAKE THIS HAPPENTREATMENT TO MAKE THIS HAPPENTreatment Sequence:Treatment Sequence:1.1. Hopeless teeth are extractedHopeless teeth are extracted2.2. Construct TEMPORARY partial denture Construct TEMPORARY partial denture

Construct TEMPORARY crowns with Construct TEMPORARY crowns with PROVISIONAL marginsPROVISIONAL margins

3.3. PERIODONTAL THERAPY is performed.PERIODONTAL THERAPY is performed.4.4. 2 months after completion of periodontal 2 months after completion of periodontal

therapytherapy Gingival health restoredGingival health restored Gingival sulcus matureGingival sulcus mature Periodontal membrane restored to health & Periodontal membrane restored to health &

functionfunction Mobility decreasedMobility decreased

1313

Treatment Sequence ContinuedTreatment Sequence Continued

5. 5. Preparations modified to relocate margins Preparations modified to relocate margins in proper relationship to the healthy in proper relationship to the healthy gingival sulcusgingival sulcus

6. Final restorations (fixed, removable, 6. Final restorations (fixed, removable, implants) are constructedimplants) are constructed

1414

Esthetic NeedsEsthetic Needs

Clinical crown of tooth must be Clinical crown of tooth must be adequate for retention of adequate for retention of

artificial crown.artificial crown.

1515

To get enough retention you To get enough retention you may be tempted to place the may be tempted to place the

margin into the junctional margin into the junctional epithelium and connective epithelium and connective

tissue attachment.tissue attachment.

1616

Result:Result:

Gingival inflammationGingival inflammation

Sometimes bone lossSometimes bone loss

1717

Biologic Width ViolationsBiologic Width Violations

Ramification of Ramification of Biologic Width Biologic Width

Violation Violation

margin placed margin placed within the zone of within the zone of

attachmentattachment

1818

Biologic WidthBiologic Width

1919

Clinician has 3 options for crown Clinician has 3 options for crown margin placement:margin placement:

SupragingivalSupragingival Equigingival Equigingival SubgingivalSubgingival

2020

Biologic Width ConcernsBiologic Width Concerns

Equigingival marginsEquigingival margins

2121

BiologicBiologic Width Width

Average Average Biologic Biologic WidthWidth

Vacek,Vacek,

et. al.:et. al.:

can be can be up to 4.3 up to 4.3

mmmm

2222

Evaluation of biologic widthEvaluation of biologic width

RadiographsRadiographs SymptomaticSymptomatic ““Sounding”Sounding”

2323

Probe to bone level and Probe to bone level and subtract sulcus depthsubtract sulcus depth

(must be done on teeth with (must be done on teeth with healthy gingival tissues)healthy gingival tissues)

2424

Treatment of Biologic Width Treatment of Biologic Width ViolationViolation

OrthodonticsOrthodontics SurgerySurgery

2525

Biologic Width ViolationBiologic Width Violation

Left central fractured Left central fractured and restored 12 and restored 12 months agomonths ago

2626

Biologic Width ViolationBiologic Width Violation

Removal of bone Removal of bone would be would be

unaestheticunaesthetic

2727

Biologic Width TreatmentBiologic Width Treatment

Orthodontic Orthodontic solution solution

erupted 3mm erupted 3mm

then surgerythen surgery

2828

Biologic Width Violation Biologic Width Violation Orthodontic/SurgicalOrthodontic/Surgical

Before 1 year recallBefore 1 year recall

2929

Surgical Crown LengtheningSurgical Crown Lengthening

Before treatmentBefore treatment

3030

““Golden Proportion”Golden Proportion”

3131


Ideal gingival Ideal gingival symmetrysymmetry

3232


Measurement Measurement taken for crown taken for crown

lengtheninglengthening

3333


Incision following Incision following Ideal SymmetryIdeal Symmetry

3434


Final RestorationFinal Restoration• Note the ideal Note the ideal

symmetrysymmetry

3535

Biologic Biologic WidthWidth


Vacek,Vacek,

et. al.:et. al.:

can be can be up to up to 4.3 mm4.3 mm

3636

Margin Placement to Avoid Biologic Margin Placement to Avoid Biologic Width ViolationWidth Violation

HISTOLOGIC SULCUS DEPTH HISTOLOGIC SULCUS DEPTH ≠PROBING DEPTH≠PROBING DEPTH

3737

Biologic Biologic WidthWidth


Vacek,Vacek,

et. al.:et. al.:

can be can be up to 4.3 up to 4.3 mmmm

3838

Iatrogenic ProblemsIatrogenic Problems

Poor margin Poor margin placementplacement

Margins were Margins were covered when covered when restored on restored on Periodontally Periodontally diseased tissuediseased tissue

3939

Electro SurgeryElectro Surgery

Tissue retraction Tissue retraction for impression for impression takingtaking

4040

Temporary Crowns Critical AreasTemporary Crowns Critical Areas

Marginal FitMarginal Fit ContourContour Surface FinishSurface Finish

4141

Gingival EmbrasureGingival Embrasure

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

4242


Method for Method for altering tooth altering tooth

form to fill form to fill embrasureembrasure

4343


One year after One year after restoring #8, restoring #8,

9 mesial9 mesial

4444

Pontic DesignPontic Design

Sanitary PonticSanitary Pontic Ridge Lap PonticRidge Lap Pontic Modified Ridge Lap Modified Ridge Lap

PonticPontic Ovate PonticOvate Pontic

4545

Ovate Pontic DesignOvate Pontic Design

Must be shallowMust be shallow

4646

Ovate Pontic in less esthetic areaOvate Pontic in less esthetic area

4747

Ridge ConsiderationRidge Consideration

Ridge Ridge augmentationaugmentation

4848


Maxillary Partial Maxillary Partial DentureDenture

4949


Partial DenturePartial Denture RemovedRemoved• Not removed and Not removed and

cleaned often cleaned often enoughenough

• Not monitored by Not monitored by Dental Office often Dental Office often enough to check enough to check for plaque/allergic for plaque/allergic reactionreaction

5050


Plaque retention Plaque retention on poor on poor

restoration restoration margin/gingival margin/gingival

interfaceinterface

5151


Overhanging Overhanging marginmargin

• Bone lossBone loss

5252


Inadequate office Inadequate office maintenance maintenance

during during orthodontic careorthodontic care

5353


Maxillary Left Maxillary Left bridge #8-11 bridge #8-11 Periodontally Periodontally

involvedinvolved

5454


Periodontal Periodontal Surgery Surgery

CompletedCompleted

5555


CalculusCalculus

5656


Large Cemented Large Cemented PostPost

• Root FractureRoot Fracture

5757


Retentive Screw Retentive Screw PostPost• Perforated DistalPerforated Distal• Bone LossBone Loss

RepairedRepaired

5858


““Idiopathic” bone Idiopathic” bone lossloss

5959


““Exploratory” Exploratory” Surgery found Surgery found

orthodontic orthodontic elasticelastic

6060


Removal of Removal of orthodontic orthodontic

elasticelastic

6161


Orthodontic Orthodontic elasticelastic

6262


Extracted Extracted maxillary molarmaxillary molar

open margins open margins on crownon crown

6363


Extracted Extracted mandibular mandibular molarmolar

Margin not Margin not adapted into adapted into furcationfurcation

6464


Perforated post Perforated post into furcationinto furcation

6565

6666

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

seating of crown.seating of crown.

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

6767

Therefore: Where possible – Therefore: Where possible –

place margins place margins

supra or equigingival.supra or equigingival.

6868

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

6969

Supportive Periodontal Supportive Periodontal TherapyTherapy

““SPT”SPT”

Two phases of Treatment:Two phases of Treatment:

1.1. Elimination of Periodontal Elimination of Periodontal DiseaseDisease

2.2. PRESERVATION of Periodontal PRESERVATION of Periodontal healthhealth

BOTH ARE EQUALLY IMPORTANTBOTH ARE EQUALLY IMPORTANT

7171

The patient must understand The patient must understand the purpose of the the purpose of the maintenance program.maintenance program.

The dentist MUST emphasize: The dentist MUST emphasize: preservation of the teeth is preservation of the teeth is dependent on it.dependent on it.

7272

FACT!!FACT!!

The more often a patient presents The more often a patient presents for the recommended for the recommended

SUPPORTIVE PERIODONTAL SUPPORTIVE PERIODONTAL THERAPY (SPT) the THERAPY (SPT) the less likely they are less likely they are

to lose teeth.to lose teeth.

7373

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

Lietha Elmer, 1977Lietha Elmer, 1977

7474

Patients with inadequate SPT Patients with inadequate SPT after successful therapy have after successful therapy have

a 50 fold increase in a 50 fold increase in probing attachment loss as probing attachment loss as compared with those with compared with those with regular SPT appointments.regular SPT appointments.

-Cortellini 1994-Cortellini 1994

7575

The maintenance phase (SPT) The maintenance phase (SPT) starts immediately after the starts immediately after the

completion of the Reevaluation completion of the Reevaluation appointment.appointment.

While the patient is in the While the patient is in the maintenance phase (SPT) the maintenance phase (SPT) the

necessary surgical and necessary surgical and restorative procedures are restorative procedures are

performed.performed.7676

This ensures that all areas of the This ensures that all areas of the mouth retain a degree of health mouth retain a degree of health attained after phase one therapy attained after phase one therapy

(non-surgical therapy)(non-surgical therapy)

7777

Clinically, we readily see evidence of the inflammation Clinically, we readily see evidence of the inflammation caused by Supragingival plaque. caused by Supragingival plaque.

Therefore, we react with plaque control, etc. to resolve Therefore, we react with plaque control, etc. to resolve what is OBVIOUSLY EVIDENT. what is OBVIOUSLY EVIDENT.

But what about the subgingival plaque?But what about the subgingival plaque?The deeper the inflammation –The deeper the inflammation – NOT CLINICALLY EVIDENT. NOT CLINICALLY EVIDENT. But much more damaging – bone loss – attachment lossBut much more damaging – bone loss – attachment loss

Zone of Influence

Zone of Influence

SU

BG

ING

IVA

L

PLA

QU

E

7878

Subgingival scaling alters the Subgingival scaling alters the microflora of periodontal microflora of periodontal

pockets.pockets.

7979

One study shows that after scaling One study shows that after scaling the subgingival flora had not the subgingival flora had not

returned to pretreatment returned to pretreatment proportions after 3 months. But proportions after 3 months. But

this varies greatly among this varies greatly among patients.patients.

Slots, J 1979Slots, J 1979

8080

Episodic Nature of Episodic Nature of Periodontitis Periodontitis

Tortuous Topography of Tortuous Topography of

a pocketa pocket

8282

Tortuous Topography of

a pocket

Importance of fixed, stable, Importance of fixed, stable, predictable recall system in predictable recall system in

your office: Patients your office: Patients tend to reduce their oral tend to reduce their oral

hygiene efforts between hygiene efforts between appointmentsappointments

(Out of sight, out of mind)(Out of sight, out of mind)

8383

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

8484

SPT AppointmentSPT AppointmentStudy page 96 in the Study page 96 in the

Department of Periodontics Department of Periodontics

Clinic Handbook 2010-Clinic Handbook 2010-20112011

8585

Referral of Patients to the Referral of Patients to the Periodontist Periodontist

Study the Study the TriageTriage September 2005 article by September 2005 article by

Cobb and CallanCobb and Callan

8686

great basin academy study club march 2013 roseman university of health sciences

Documents

periodontal involvement

gingival inflammation

goal of periodontal

hopeless teeth

healthy gingival tissues

treatment sequence continued5

healthy gingival sulcus6

bone level