April 16, 2009 periodontal lec.

8#

Perio-restorative inter-relationships

Today we are going to talk about the relationships○

.between perio. & restorative dentistry
So we as a periodontists if we don't care & don't know○
that the restorations will going to hurt the gingival and
going to do bad things, we "periodontist" can't do a
.good work
So we have to understand what is the sulcular or the○
sulcus when we place end-fitting margins of crown or
.any restoration
We all know the main etiology of periodontal disease○
which is the dental plaque, and any things that will
favor accumulation of the dental plaque will be called
.as contributing factors

What is the secondary etiology contributing

?factors for perio. Disease
:Restorative issues•
those people Who had crown rest. Have more"
."tendency than neutral dentition
.Overhangs✔
.Open contact✔
.Open margins✔
Occlusal trauma. "High rest. + direct damage•
"to teeth

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 April 16, 2009 periodontal lec. 8#

?What is the biologic width

It is a histological term; consist of tow structure which
.is epithelium & connective tissue
Dimension of junctional epithelium plus the"
"dimension of connective tissue attachment

FROM PIC." , we all know that there is a bone housing by the"✔

tooth, above the bone there is a connective tissue, above the CT
there is a junctional epithelium which is attach not separated to
tooth surface by hemi-desmosomes and finally there is a
.marginal gingival or sulcus

These dimensions if we take any normal healthy teeth○

we will find that , the sulcus tip basically about "0.5 mm
- .69mm" , junctional epithelium "0.97mm-1mm" and
."connective tissue "1.07 mm

so when you measured the probing depth "PD" in○

normal teeth without force or heavy pressure you will
take & find the normal dimension, BUT some times
when I use force more than 25gm. May I
goes down until the base of "JE", and the
"PD"=1.5mm ((sulcus + JE)) , but when
the CT is very healthy it is hard to goes
through the "CT"; cos. the fiber's

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 April 16, 2009 periodontal lec. 8#

orientation is perpendicular ((supra-crestal fiber &

.collagen fiber)), so there will be more resistance

in case of periodontal disease there will be collagen○

destruction so you can probe easy through the CT
down to the bone ,and if there is a
bone loss it will be intra-bony defect
and that's how the periodontal
.pocket form

so now to establish health we must○

keep these supra structure (CT-JE-
SULCUS) which is the biological
."width "BW

: .So the important thing in "B.W" is like immune sys ○

"Sulcus. "Gingival Crevicular Fluid , Neurtophils.i

CT. "the perpendicular fibers that prevent invade by.ii
."bact. , plaque and inflammation

So we want these supra structure "b.w" which is

the essential structure that help protect the
tooth, so if this "B.W" had been invaded by
anything (e.g. marginal rest.), the accumulation of
,,,plaque will occur and finally bone loss. Soooo

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 April 16, 2009 periodontal lec. 8#

Q. how can I know in my preparation that if reach

"the B.W or not? "q. by student
A: when we prepare for crown, in the tooth contour we
.have "CEJ" which separate the crown from root
If we don’t reach to the "CEJ" we suppose to have✔
.a normal gingival and bone
generally in population the bone is away apically✔
from the CEJ up to 2 mm if I put my finish line in
.CEJ exactly it might be still ok

BUT. if we go beyond it here the point, , in case of✔

short crown like example we loss the retention &
resistance we go down the CEJ . ((if the root is
long cos. C&R ratio)) to gain adequate resistance
& retention. So by this issue we r so close to the
bone and we loss main of the B.W. so here I must
"do 1-CRWON LENGTHINING."CL
CL: which is I will start cutting this healthy bone✔
to make it far away to my new margin. Cos. this
bone will go to get disease so fast. So by this way
I keep the bone healthy cos. if it gets disease it
.will be so fast & I can't deal with it

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 April 16, 2009 periodontal lec. 8#

Or 2-extrusion here we elongate the crown but ✔

.it will affect C&R ratio

Study in 50's said that; the BONE FOLLOW THE CEJ, 

and it far 2mm from CEJ, so the shape of the CEJ in the
ant. Teeth is scallop, thus; if you make flap and raised
it, and see the shape of the bone is scallop too., and as
.will as in the post. Teeth it will be flat as the CEJ
And another thing the study said GINGIVA LOVES
BONE, if the bone goes down the gingival follow it. And
make gingival recession, but if the bone stay the
gingival stay away to make the biological width. So if I
cut bone I must cut from the gingival too cos. if I don’t
cut from the gingival, it will be higher than bone so
.periodontal pocket form

VARIATION OF BIOLOGIC WIDTH

M
UCOGINGIVAL\RESTORATIVE CONSIDERATION

.Clinical judgment is necessary

Pg. 2-slide2"/ less keratinized gingival, so it"✔
.very susceptible to gingival recession

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 April 16, 2009 periodontal lec. 8#

MAYNARD & WILSON(79) said: "if there is a

restoration ((e.g. class II or crown)) in the teeth is like a
permanent calculus, and you must maintain 3mm
attached gingival (AG), and 5mm required prior to
."restoration
Settler& bissada (87): "subG margins with less
than 2mm KG show significant inflammation.
Compare teeth with or without 2mm KG with or
without full coverage subG restorations. Teeth with
narrow zone of KG with a subG restoration exhibited
a greater gingival inflammatory response compared
."to the other 3 groups
."Corn (80): "supports grafting prior to RPD's
However, farther studies showed that health can be
.maintained with less than 2mm attached gingival
Conclusion: it may be desirable to augment these 
areas if the patient is having trouble controlling the
.inflammation of the site

OPTIONS FOR PLACEMENT OF MARGINS

SUPRA -GINGIVAL. ((POOR AESTHETIC , PREFER TO BE IN POST ..i

((TEETH TO BE MORE CLEANSABLE
.EQUI-GINGIVAL.ii
.SUB-GINGIVAL.iii
."SEE PIC. PAGE 2– SLIDE 4, 5, 6"

REACTION OF GINGIVA & BONE TO SUB-GINGIVAL

MARGINS PLACEMENT
GINGIVAL RECESSION ○
.INFLAMMATION DEVELOPS AND PERSISTS ○
.Bone loss○

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 April 16, 2009 periodontal lec. 8#

THE NATURE OF SOFT TISSUE

:We have 2 kind of gingival biotype

DR. DENNIS P. TARNOW IN SAOUDI ARABIA

‫دراسته كانت تتكلم عن احتمالية‬..‫تارنو واحد من علماء البريو‬.‫هذا د‬

‫ عن طريق انه في بابيلل‬BLACK TRI-ANGLE ‫حدوث شغلة اسمها‬
‫؟‬..‫بتعبي الجنجفا ول ل‬

contact point & crest ‫ف راح جاب ناس كثير وقاس المسافه ما بين‬
of the bone

mm or less 5 ‫وبعدين لقى انه كل الناس اللي عندهم المسافه‬

‫ اما الناس‬,"‫ بابيل مليانه وما بيصير عندهم "بلك تراي انجل‬%100 ‫عندهم‬
‫ واللي‬, %50 ‫ صار عندنا فقدان البابيل ل‬mm 6 ‫اللي طلعت المسافه‬
‫( بابيل‬%27 ‫ )في السليد‬%10- %20 ‫ نزلت النسبة‬mm.7 ‫المسافه‬
.‫تعبي الجينجفا‬

(CROWN LENGTHENING(CL

:(The indication for (CL

Insufficient tooth structure(ITS): e.g. wear,.i
.trauma or caries and int.-ext. resorption
By expose sound tooth structure✔
.3 mm
:(Insufficient biological width(IBW.i
.Reestablish✔
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 April 16, 2009 periodontal lec. 8#

Esthetics. E.g. gummy smile or square tooth.i

!.shape
:Retention of restoration.ii
.Severely worn dentition✔
.Loss of vertical dimension✔
.Extensively perio-pros treatment✔

PRE-OPERATIVE REQUIREMENTS
.RECENTLY RADIOGRAPH○
.RECENT CHARTING○
.RECENT STUDY CASTS○
.RECENT CONSULTATION WITH THE ATTENDING PERIODONTIST○

PER-OPERATIVE EVALUATION

TREATMENT SEQUENCE REVIEW

TYPES OF SURGERY FOR CROWN LENGTHENING

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 April 16, 2009 periodontal lec. 8#

:GINGIVECTOMY(1
JUST BY REMOVING SOFT TISSUE , BUT WE HAVE MAKE

SURE THAT THE BONE IS FAR AWAY WHEN WE REMOVE THE

.GINGIVA
YOU MAKE THIS SURGERY , LIKE PATIENT WITH GINGIVAL

.OVERGROWTH
OR WHEN SOUND TOOTH STRUCTURE IS 3MM OR MORE
SUPRACRESTAL . AND WE HAVE ADEQUATE ZONE OF

.KERATINIZED GINGIVA

.APICALLY POSITION FLAP WITH OSSEOUS RECONTOURING(1

THIS IS SOFT & HARD TISSUE REMOVAL , WE USE IT WHEN

THE BONE IS GOING TO BE VERY CLOSE TO THE MARGIN OF

.(THE GINGIVA (<3-2MM

:THE COMPROMISES OF THIS SURGERY

.SACRIFICE BONE ON ADJACENT TEETH○

.ROOT SENSITIVITY ○

.ALTERED GINGIVAL CONTOURS○

.LONG CLINICAL CROWN○
.OPEN EMBRASURES ○

WHEN WE CUT OFF THE BONE THERE IS 2

:PHYSIOLOGICAL ARCHITECTURE

:OSTEOPLASTY
RESHAPING OF ALVEOLAR BONE WITHOUT REMOVING✔

(SUPPORTING BONE .(E .G . LEDGE , PROJECTION

OSTEO

:Y CTOM

.REMOVAL OF SUPPORTING ALVEOLAR BONE✔

POST-OPERATIVE MANAG EMENT

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 April 16, 2009 periodontal lec. 8#

TIMING OF RESTORATIVE

WHEN I'M SUPPOSE TO DO REST. ON THE TOOTH "

AFTER (CL)" ROLE OF THUMB

:weeks TO 6 weeks 3-4✔

.in posterior teeth

:month 6✔
(In
the anterior. (esthetic
To be sure everything is
stable
HOW MAINTENANCE THE RESTORED TEETH

inter-proximal brush, irrigators and any device anything make the teeth
.clean use it

DONY BY/ SALEH ALYFEAI…23

…GOOD LUCK IN F. exams

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