great basin academy study club march 2013 roseman university of health sciences
TRANSCRIPT
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
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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
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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.
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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.
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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
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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
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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.
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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.
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Result:Result:
Gingival inflammationGingival inflammation
Sometimes bone lossSometimes bone loss
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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
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Biologic WidthBiologic Width
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Clinician has 3 options for crown Clinician has 3 options for crown margin placement:margin placement:
SupragingivalSupragingival Equigingival Equigingival SubgingivalSubgingival
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Biologic Width ConcernsBiologic Width Concerns
Equigingival marginsEquigingival margins
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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
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Evaluation of biologic widthEvaluation of biologic width
RadiographsRadiographs SymptomaticSymptomatic ““Sounding”Sounding”
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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)
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Treatment of Biologic Width Treatment of Biologic Width ViolationViolation
OrthodonticsOrthodontics SurgerySurgery
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Biologic Width ViolationBiologic Width Violation
Left central fractured Left central fractured and restored 12 and restored 12 months agomonths ago
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Biologic Width ViolationBiologic Width Violation
Removal of bone Removal of bone would be would be
unaestheticunaesthetic
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Biologic Width TreatmentBiologic Width Treatment
Orthodontic Orthodontic solution solution
erupted 3mm erupted 3mm
then surgerythen surgery
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Biologic Width Violation Biologic Width Violation Orthodontic/SurgicalOrthodontic/Surgical
Before 1 year recallBefore 1 year recall
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Surgical Crown LengtheningSurgical Crown Lengthening
Before treatmentBefore treatment
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““Golden Proportion”Golden Proportion”
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Surgical Crown LengtheningSurgical Crown Lengthening
Ideal gingival Ideal gingival symmetrysymmetry
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Surgical Crown LengtheningSurgical Crown Lengthening
Measurement Measurement taken for crown taken for crown
lengtheninglengthening
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Surgical Crown LengtheningSurgical Crown Lengthening
Incision following Incision following Ideal SymmetryIdeal Symmetry
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Surgical Crown LengtheningSurgical Crown Lengthening
Final RestorationFinal Restoration• Note the ideal Note the ideal
symmetrysymmetry
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Biologic Biologic WidthWidth
Average Average Biologic Biologic WidthWidth
Vacek,Vacek,
et. al.:et. al.:
can be can be up to up to 4.3 mm4.3 mm
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Margin Placement to Avoid Biologic Margin Placement to Avoid Biologic Width ViolationWidth Violation
HISTOLOGIC SULCUS DEPTH HISTOLOGIC SULCUS DEPTH ≠PROBING DEPTH≠PROBING DEPTH
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Biologic Biologic WidthWidth
Average Average Biologic Biologic WidthWidth
Vacek,Vacek,
et. al.:et. al.:
can be can be up to 4.3 up to 4.3 mmmm
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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
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Electro SurgeryElectro Surgery
Tissue retraction Tissue retraction for impression for impression takingtaking
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Temporary Crowns Critical AreasTemporary Crowns Critical Areas
Marginal FitMarginal Fit ContourContour Surface FinishSurface Finish
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Gingival EmbrasureGingival Embrasure
Loss of Papilla Loss of Papilla between #8, 9between #8, 9
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Gingival EmbrasureGingival Embrasure
Method for Method for altering tooth altering tooth
form to fill form to fill embrasureembrasure
4343
Gingival EmbrasureGingival Embrasure
One year after One year after restoring #8, restoring #8,
9 mesial9 mesial
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Pontic DesignPontic Design
Sanitary PonticSanitary Pontic Ridge Lap PonticRidge Lap Pontic Modified Ridge Lap Modified Ridge Lap
PonticPontic Ovate PonticOvate Pontic
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Ovate Pontic DesignOvate Pontic Design
Must be shallowMust be shallow
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Ovate Pontic in less esthetic areaOvate Pontic in less esthetic area
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Ridge ConsiderationRidge Consideration
Ridge Ridge augmentationaugmentation
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Iatrogenic ProblemsIatrogenic Problems
Maxillary Partial Maxillary Partial DentureDenture
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Iatrogenic ProblemsIatrogenic Problems
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
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Iatrogenic ProblemsIatrogenic Problems
Plaque retention Plaque retention on poor on poor
restoration restoration margin/gingival margin/gingival
interfaceinterface
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Iatrogenic ProblemsIatrogenic Problems
Overhanging Overhanging marginmargin
• Bone lossBone loss
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Iatrogenic ProblemsIatrogenic Problems
Inadequate office Inadequate office maintenance maintenance
during during orthodontic careorthodontic care
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Iatrogenic ProblemsIatrogenic Problems
Maxillary Left Maxillary Left bridge #8-11 bridge #8-11 Periodontally Periodontally
involvedinvolved
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Iatrogenic ProblemsIatrogenic Problems
Periodontal Periodontal Surgery Surgery
CompletedCompleted
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Iatrogenic ProblemsIatrogenic Problems
CalculusCalculus
5656
Iatrogenic ProblemsIatrogenic Problems
Large Cemented Large Cemented PostPost
• Root FractureRoot Fracture
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Iatrogenic ProblemsIatrogenic Problems
Retentive Screw Retentive Screw PostPost• Perforated DistalPerforated Distal• Bone LossBone Loss
RepairedRepaired
5858
Iatrogenic ProblemsIatrogenic Problems
““Idiopathic” bone Idiopathic” bone lossloss
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Iatrogenic ProblemsIatrogenic Problems
““Exploratory” Exploratory” Surgery found Surgery found
orthodontic orthodontic elasticelastic
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Iatrogenic ProblemsIatrogenic Problems
Removal of Removal of orthodontic orthodontic
elasticelastic
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Iatrogenic ProblemsIatrogenic Problems
Orthodontic Orthodontic elasticelastic
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Iatrogenic ProblemsIatrogenic Problems
Extracted Extracted maxillary molarmaxillary molar
open margins open margins on crownon crown
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Iatrogenic ProblemsIatrogenic Problems
Extracted Extracted mandibular mandibular molarmolar
Margin not Margin not adapted into adapted into furcationfurcation
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Iatrogenic ProblemsIatrogenic Problems
Perforated post Perforated post into furcationinto furcation
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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.
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Therefore: Where possible – Therefore: Where possible –
place margins place margins
supra or equigingival.supra or equigingival.
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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.
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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.
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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.
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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
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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)
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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.
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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
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Episodic Nature of Episodic Nature of Periodontitis Periodontitis
Tortuous Topography of Tortuous Topography of
a pocketa pocket
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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
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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