Periodontal considerations in fpd/ orthodontic straight wire technique

PERIODONTALPERIODONTAL
CONSIDERATIONS IN FPDCONSIDERATIONS IN FPD
INDIAN DENTAL ACADEMY
Leader in continuing dental education
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I N T R O D U C T I OI N T R O D U C T I O
NN
In the fabrication of any fixed prosthesis, theIn the fabrication of any fixed prosthesis, the
practitioner must determine the periodontalpractitioner must determine the periodontal
status of the involved abutment teeth. Thisstatus of the involved abutment teeth. This
allows a reliable and accurate prognosis for theallows a reliable and accurate prognosis for the
restoration. Because periodontal disease is arestoration. Because periodontal disease is a
major cause of tooth loss in adults, themajor cause of tooth loss in adults, the
practitioner must be aware of the basicpractitioner must be aware of the basic
concepts and clinical modes of therapyconcepts and clinical modes of therapy
available in Periodontics to be able to developavailable in Periodontics to be able to develop
an appropriate diagnosis and treatment plan.an appropriate diagnosis and treatment plan.

ATTACHMENT UNITATTACHMENT UNIT
 When discussing a diseased state, it isWhen discussing a diseased state, it is
imperative to understand the normalimperative to understand the normal
relationship of the tooth to the supportingrelationship of the tooth to the supporting
structure. Understanding the deviationstructure. Understanding the deviation
from normal, facilitates comprehension offrom normal, facilitates comprehension of
the disease. A normal relationship of thethe disease. A normal relationship of the
gingival margin to the tooth, the epithelialgingival margin to the tooth, the epithelial
attachment, and the fibers attached fromattachment, and the fibers attached from
the cementum to the gingival is shownthe cementum to the gingival is shown
here.here. www.indiandentalacademy.comwww.indiandentalacademy.com

ANATOMYANATOMY
 The lining of the oral cavity consists of threeThe lining of the oral cavity consists of three
types of mucosa, each with a different function :types of mucosa, each with a different function :
 Masticatory (keratinized) mucosa – covering theMasticatory (keratinized) mucosa – covering the
gingival and hard palategingival and hard palate
 Lining or reflecting mucosa – covering the lips,Lining or reflecting mucosa – covering the lips,
cheeks, vestibule, alveoli, floor of the mouth,cheeks, vestibule, alveoli, floor of the mouth,
and soft palateand soft palate
 Specialized (sensory) mucosa- covering theSpecialized (sensory) mucosa- covering the
dorsum of the tongue and taste buds.dorsum of the tongue and taste buds.

GINGIVAGINGIVA
 Normal gingival exhibiting no fluid exudates orNormal gingival exhibiting no fluid exudates or
inflammation due to bacterial plaque is pink andinflammation due to bacterial plaque is pink and
stippled. It varies in width from 1 to 9 mm and extendsstippled. It varies in width from 1 to 9 mm and extends
from the free margin of the gingival to the alveolarfrom the free margin of the gingival to the alveolar
mucosa. The Gingiva and alveolar mucosa aremucosa. The Gingiva and alveolar mucosa are
separated by a demarcation called the mucogingivalseparated by a demarcation called the mucogingival
junction (MGJ which marks the differentiation betweenjunction (MGJ which marks the differentiation between
stippled keratinized tissue and smooth, shiny mucosa;stippled keratinized tissue and smooth, shiny mucosa;
the latter contains more elastic fibers in its connectivethe latter contains more elastic fibers in its connective
tissue. Apical to the MGJ, the alveolar mucosa thentissue. Apical to the MGJ, the alveolar mucosa then
forms the vestibule and attaches to the muscles andforms the vestibule and attaches to the muscles and
fascia of the lips and cheeks.fascia of the lips and cheeks.www.indiandentalacademy.comwww.indiandentalacademy.com

THE GINGIVA CONSISTS OF THREE PARTS:THE GINGIVA CONSISTS OF THREE PARTS:
 Free (marginal ) gingiva – extending from the mostFree (marginal ) gingiva – extending from the most
coronal aspect of the gingiva to the epithelialcoronal aspect of the gingiva to the epithelial
attachment with the tooth.attachment with the tooth.
 Attached gingiva – extending from the level of theAttached gingiva – extending from the level of the
epithelial attachment to the junction between theepithelial attachment to the junction between the
gingiva and the alveolar mucosa (the MGJ)gingiva and the alveolar mucosa (the MGJ)
 Interdental papillae – triangular projections of gingivaeInterdental papillae – triangular projections of gingivae
filling the area between adjacent teeth and consistingfilling the area between adjacent teeth and consisting
of a buccal and a lingual component separated by aof a buccal and a lingual component separated by a
central concavity (the col).central concavity (the col).

The gingiva consist of dense collagenThe gingiva consist of dense collagen
fibers, sometimes referred to as thefibers, sometimes referred to as the
gingivodental ligament, which can begingivodental ligament, which can be
divided into alveologingival, dentogingival,divided into alveologingival, dentogingival,
circular, dentoperiosteal, and transspetalcircular, dentoperiosteal, and transspetal
groups. These fibers firmly bind thegroups. These fibers firmly bind the
gingiva to the teeth and are continuousgingiva to the teeth and are continuous
with the underlying alveolar periosteum.with the underlying alveolar periosteum.

PERIODONTIUMPERIODONTIUM
The Periodontium is a connective tissueThe Periodontium is a connective tissue
structure attached to the periosteum of bothstructure attached to the periosteum of both
the mandible and the maxilla that anchorsthe mandible and the maxilla that anchors
the teeth in the mandubular and maxillarythe teeth in the mandubular and maxillary
alveolar processes.alveolar processes.
It provides attachment and support, nutrition,It provides attachment and support, nutrition,
synthesis and resorption, andsynthesis and resorption, and
mechanoreception,mechanoreception,

The main element of the periodotium isThe main element of the periodotium is
the periodontal ligament (PDL,) whichthe periodontal ligament (PDL,) which
consist of collagenous fibers embeddedconsist of collagenous fibers embedded
in bone and centum, giving support to thein bone and centum, giving support to the
tooth in function. These fibers, also knowntooth in function. These fibers, also known
as sharpey’s fibers, follow a wavy courseas sharpey’s fibers, follow a wavy course
and terminate in either cementum or bone.and terminate in either cementum or bone.
 There are five principal fiber groups in theThere are five principal fiber groups in the
PDL that traverse the space between thePDL that traverse the space between the
tooth root and alveolar bone, providingtooth root and alveolar bone, providing
attachment and support.attachment and support.

 Transseptal fibersTransseptal fibers – extending interproximally– extending interproximally
between adjacent teeth.between adjacent teeth.
 Alveolar crest fibersAlveolar crest fibers – beginning just apical to– beginning just apical to
the epithelial attachment and extending fromthe epithelial attachment and extending from
cementum to the alveolar crestcementum to the alveolar crest
 Horizontal fibersHorizontal fibers – coursing at right angles from– coursing at right angles from
cementum to the alveolar bone.cementum to the alveolar bone.
 Oblique fibersOblique fibers - extending in a oblique direction- extending in a oblique direction
apically, attaching cementum to the alveolar boneapically, attaching cementum to the alveolar bone
(They are the most numerous fibers)(They are the most numerous fibers)
 Apical fibersApical fibers – radiating from cementum into the– radiating from cementum into the
alveolar bone at the apex of the root.alveolar bone at the apex of the root.
 In addition, the PDL contains elastic fibers as wellIn addition, the PDL contains elastic fibers as well
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DENTOGINGIVAL JUNCTIONDENTOGINGIVAL JUNCTION
 At the base of the gingival sulcus (crevice) is theAt the base of the gingival sulcus (crevice) is the
epithelium – tooth interface, also known as theepithelium – tooth interface, also known as the
dentogingival junction (DGJ).dentogingival junction (DGJ).
 The depth of the sulcus varies in healthy individuals,The depth of the sulcus varies in healthy individuals,
averaging 1.8mm. In general, the shallower it is theaveraging 1.8mm. In general, the shallower it is the
more likely the gingiva will be in a state of health.more likely the gingiva will be in a state of health.
Sulcular depths up to 3mm are consideredSulcular depths up to 3mm are considered
maintainable.maintainable.
 The continued maintenance of the gingiva in a state ofThe continued maintenance of the gingiva in a state of
health depends on tight, shallow sulci, which in turnhealth depends on tight, shallow sulci, which in turn
depend on optimal plaque control, and will ensure thedepend on optimal plaque control, and will ensure the
success of periodontal therapy as well as affording asuccess of periodontal therapy as well as affording a
good prognosis for subsequent restorative treatment.good prognosis for subsequent restorative treatment.

 The general term periodontal disease is toThe general term periodontal disease is to
describe any condition of the Periodontium otherdescribe any condition of the Periodontium other
than the normal. Periodontal disease must bethan the normal. Periodontal disease must be
recognized and treated before fixedrecognized and treated before fixed
prosthodontics so that the gingival tissue levelsprosthodontics so that the gingival tissue levels
can be determined to proper margin placement,can be determined to proper margin placement,
esthetics, and gingival displacement. Only whenesthetics, and gingival displacement. Only when
the gingiva and Periodontium are in an optimalthe gingiva and Periodontium are in an optimal
state of health can these determination bestate of health can these determination be
made with ease or predictability.made with ease or predictability.

ETIOLOGYETIOLOGY
Most gingival and periodontal diseasesMost gingival and periodontal diseases
result from microbial plaque, which causesresult from microbial plaque, which causes
inflammation and its subsequentinflammation and its subsequent
pathologic processes. Other contributorspathologic processes. Other contributors
to inflammation include calculus, acquiredto inflammation include calculus, acquired
pellicle, materia alba, and food debris.pellicle, materia alba, and food debris.

MICROBIAL PLAQUEMICROBIAL PLAQUE
 Microbial plaque is a sticky substanceMicrobial plaque is a sticky substance
composed of bacteria and their by – products incomposed of bacteria and their by – products in
an extra cellular matrix; it also containsan extra cellular matrix; it also contains
substances from the saliva, diet, and serum. It issubstances from the saliva, diet, and serum. It is
basically a product of the growth of bacterialbasically a product of the growth of bacterial
colonies and is the initiating factor in gingivacolonies and is the initiating factor in gingiva
and periodontal disease. If left undisturbed, it willand periodontal disease. If left undisturbed, it will
gradually cover an entire tooth surface and cangradually cover an entire tooth surface and can
be removedbe removed only by mechanical meansonly by mechanical means ..
calculus can be found on tooth structure in acalculus can be found on tooth structure in a
supragingival and / or a sub gingival location.supragingival and / or a sub gingival location.

CALCULUSCALCULUS
 Dental calculus is a chalky or dark deposit attached toDental calculus is a chalky or dark deposit attached to
the tooth structure. It is essentially microbial plaquethe tooth structure. It is essentially microbial plaque
that has undergone mineralization over time. Calculusthat has undergone mineralization over time. Calculus
can be found on tooth structure in a supragingival andcan be found on tooth structure in a supragingival and
/ or a subgingival location./ or a subgingival location.
 As the plaque colony matures and increases itsAs the plaque colony matures and increases its
mineral content, calculus forms within the plaquemineral content, calculus forms within the plaque
mass. Although gingival inflammation is often mostmass. Although gingival inflammation is often most
severe in areas where calculus is present, the calculussevere in areas where calculus is present, the calculus
itself is not the most significant source of inflammation,itself is not the most significant source of inflammation,
rather, it provides a nidus for plaque accumulation andrather, it provides a nidus for plaque accumulation and
retains the plaque in proximity to the gingiva. Dentalretains the plaque in proximity to the gingiva. Dental
plaque is the etiologic agent of the inflammation.plaque is the etiologic agent of the inflammation.www.indiandentalacademy.comwww.indiandentalacademy.com

ACQUIRED PELLICLE.ACQUIRED PELLICLE.
Pellicle is a thin, brown or gray film ofPellicle is a thin, brown or gray film of
salivary proteins that develops on teethsalivary proteins that develops on teeth
after they have been cleaned. Itafter they have been cleaned. It
frequently forms the interface between thefrequently forms the interface between the
tooth surface and dental deposits.tooth surface and dental deposits.

MATERIA ALBA.MATERIA ALBA.
Materia alba is a white coating composedMateria alba is a white coating composed
of microorganisms, dead epithelial cells,of microorganisms, dead epithelial cells,
and leukocytes that adheres loosely to theand leukocytes that adheres loosely to the
tooth. It can be removed from the toothtooth. It can be removed from the tooth
surface by water spray or by rinsing.surface by water spray or by rinsing.

PATHOGENESISPATHOGENESIS
The pathogenesis or sequence of eventsThe pathogenesis or sequence of events
in the development of a gingivitis-in the development of a gingivitis-
periodontitis lesion is very complex. Itperiodontitis lesion is very complex. It
involves not only local phenomena in theinvolves not only local phenomena in the
gingiva, PDL, tooth surface, and alveolargingiva, PDL, tooth surface, and alveolar
bone but also a number of complex hostbone but also a number of complex host
response mechanisms modified by theresponse mechanisms modified by the
bacterial infection and behavioral factors.bacterial infection and behavioral factors.

 INITIAL LESIONINITIAL LESION
 The initial lesion is localized in the region of theThe initial lesion is localized in the region of the
gingival sulcus and is evident after approximatelygingival sulcus and is evident after approximately 2 to2 to
4 days4 days of undisturbed plaque accumulation from aof undisturbed plaque accumulation from a
baseline of gingival health.baseline of gingival health.
 The vessels of the gingiva become enlarged, andThe vessels of the gingiva become enlarged, and
vasculitis occurs, allowing a fluid exudates ofvasculitis occurs, allowing a fluid exudates of
polymorphonuclear leukocytes to form in the sulcus.polymorphonuclear leukocytes to form in the sulcus.
Collagen is lost perivascularly, and the resultant spaceCollagen is lost perivascularly, and the resultant space
is filled with proteins and inflammatory cells. The mostis filled with proteins and inflammatory cells. The most
coronal portion of the junctional epithelium becomescoronal portion of the junctional epithelium becomes
altered.altered.

 EARLY LESION.EARLY LESION.
 Although there is noAlthough there is no
distinct divisiondistinct division
between the stages ofbetween the stages of
lesion formation, thelesion formation, the
early lesion generallyearly lesion generally
appears withinappears within 4 to 74 to 7
daysdays of plaqueof plaque
accumulation. Thisaccumulation. This
stage of developmentstage of development
exhibits further loss ofexhibits further loss of
collagen from thecollagen from the
marginal gingiva.marginal gingiva.

ESTABLISHEDESTABLISHED
LESION.LESION.
 WithinWithin 7 to 21 days7 to 21 days
the lesion enters thethe lesion enters the
established stageestablished stage
located at the apicallocated at the apical
portion of the gingivalportion of the gingival
sulcus, and thesulcus, and the
inflammation isinflammation is
centered in acentered in a
relatively small area.relatively small area.

ADVANCED LESION.ADVANCED LESION.
It is difficult to pinpoint the time at which theIt is difficult to pinpoint the time at which the
established lesion of gingivitis results in aestablished lesion of gingivitis results in a
loss of connective tissue attachment to theloss of connective tissue attachment to the
tooth structure and becomes an advancedtooth structure and becomes an advanced
lesion or overt periodontitis.lesion or overt periodontitis.
Upon conversion to the advanced stage, theUpon conversion to the advanced stage, the
features of an established lesion persist. Thefeatures of an established lesion persist. The
connective tissue continues to lose collagenconnective tissue continues to lose collagen
content, and fibroblasts are further altered.content, and fibroblasts are further altered.

 Periodontal pockets are formed, with increasedPeriodontal pockets are formed, with increased
probing depths, and the lesion extends intoprobing depths, and the lesion extends into
alveolar bone. The bone marrow converts toalveolar bone. The bone marrow converts to
fibrous connective tissue, with a significant lossfibrous connective tissue, with a significant loss
of connective tissue attachment to the root of theof connective tissue attachment to the root of the
tooth. This is accompanied by thetooth. This is accompanied by the
manifestations of immunopathologic tissuemanifestations of immunopathologic tissue
reactions and inflammatory responses in thereactions and inflammatory responses in the
gingiva.gingiva.

PERIODONTITISPERIODONTITIS
 When a loss of connective tissue attachmentWhen a loss of connective tissue attachment
occurs, the lesion transforms from gingivitis intooccurs, the lesion transforms from gingivitis into
periodontitis a disease that may beperiodontitis a disease that may be
characterized by alternating periods ofcharacterized by alternating periods of
quiescence and exacerbation. The extent toquiescence and exacerbation. The extent to
which the lesion progresses before it is treatedwhich the lesion progresses before it is treated
will determine the amount of bone andwill determine the amount of bone and
connective tissue attachment loss that occurs. Itconnective tissue attachment loss that occurs. It
will subsequently affect the prognosis of thewill subsequently affect the prognosis of the
tooth with regard to restorative demands.tooth with regard to restorative demands.

OCCLUSAL TRAUMATISM:OCCLUSAL TRAUMATISM:
 Occlusal traumatism is defined as aOcclusal traumatism is defined as a
force originating by movement of theforce originating by movement of the
maxillary and mandibular teeth in a waymaxillary and mandibular teeth in a way
that creates a pathologic lesion.that creates a pathologic lesion.
PRIMARY OCCLUSAL TRAUMA:PRIMARY OCCLUSAL TRAUMA:
 Primary occlusal trauma is a pathologicPrimary occlusal trauma is a pathologic
lesion that has been created by a forcelesion that has been created by a force
strong enough to disturb a normal intactstrong enough to disturb a normal intact
periodontiumperiodontium

SECONDARY OCCLUSAL TRAUMA:SECONDARY OCCLUSAL TRAUMA:
 Secondary occlusal trauma is a lesionSecondary occlusal trauma is a lesion
created by a normal function on a weakenedcreated by a normal function on a weakened
periodontium because of periodontalperiodontium because of periodontal
disease. This noninflammatory lesion isdisease. This noninflammatory lesion is
caused by trauma in the form of pressurecaused by trauma in the form of pressure
atrophy; there is eventual necrosis of theatrophy; there is eventual necrosis of the
affected area.affected area.
 Factors that enhance occlusal traumatismFactors that enhance occlusal traumatism
are clenching, grinding(bruxism), tongueare clenching, grinding(bruxism), tongue
thrusting, and nail biting, Of these, the onethrusting, and nail biting, Of these, the one
that appears to have the greatest effect isthat appears to have the greatest effect is
grinding.grinding. www.indiandentalacademy.comwww.indiandentalacademy.com

PERIODONTAL POCKETPERIODONTAL POCKET
 A periodontal pocket is defined as aA periodontal pocket is defined as a
diseased periodontal attachment unit. Thediseased periodontal attachment unit. The
pocket may result from the enlargement ofpocket may result from the enlargement of
the gingival tissue.the gingival tissue.
It is caused by the apical migration of theIt is caused by the apical migration of the
epithelial attachment with the loss ofepithelial attachment with the loss of
connective tissue attachment and,connective tissue attachment and,
eventually, of osseous support.eventually, of osseous support.

The clinical significance of a pocket is thatThe clinical significance of a pocket is that
if it extends beyond 3 to 4 mm the patientif it extends beyond 3 to 4 mm the patient
has increasing difficulty maintaininghas increasing difficulty maintaining
normal brushing and flossing techniques.normal brushing and flossing techniques.
If an area cannot be maintained andIf an area cannot be maintained and
mature plaque is allowed adjacent to themature plaque is allowed adjacent to the
epithelium, the disease continues. Theepithelium, the disease continues. The
ideal situation is for the entire mouth to beideal situation is for the entire mouth to be
free of pockets.free of pockets.

EXAMINATIONEXAMINATION
VISUAL EXAMINATION:VISUAL EXAMINATION:
 It is important during the examination toIt is important during the examination to
evaluate the color, consistency, texture, andevaluate the color, consistency, texture, and
shape of the gingival unit. It is also critical toshape of the gingival unit. It is also critical to
recognize the initial stages of a marginal lesionrecognize the initial stages of a marginal lesion
through the change of color and consistency.through the change of color and consistency.
An adequate light source is essential toAn adequate light source is essential to
differentiate between normal and diseaseddifferentiate between normal and diseased
tissue. A fiber optic unit is used to examinetissue. A fiber optic unit is used to examine
inaccessible areas.inaccessible areas.

ATTACHED GINGIVA:ATTACHED GINGIVA:
 The width of attached gingivaThe width of attached gingiva
necessary to maintain gingival health hasnecessary to maintain gingival health has
remained controversial.remained controversial.
Crown margins can be gingival irritantsCrown margins can be gingival irritants
and plaque traps, so enhancing theand plaque traps, so enhancing the
attached gingiva is advised forattached gingiva is advised for
restorations.restorations.

Keratinized tissue is often present andKeratinized tissue is often present and
mistakenly restored, after which themistakenly restored, after which the
dentist and patient are disappointed whendentist and patient are disappointed when
recession continues.recession continues.
 It must be realized that clinically, the firstIt must be realized that clinically, the first
2 mm of keratinized tissue represents 12 mm of keratinized tissue represents 1
mm of sulcus and 1 mm of epithelialmm of sulcus and 1 mm of epithelial
attachment, therefore, only keratinizedattachment, therefore, only keratinized
tissue in excess of 2 mm can betissue in excess of 2 mm can be
considered attached by connective tissue.considered attached by connective tissue.

PROBINGPROBING
 There are periodontal instrumentsThere are periodontal instruments
designed for probing. The thinnest probe isdesigned for probing. The thinnest probe is
desired, this permits probing the depth of adesired, this permits probing the depth of a
pocket without patient discomfort and allowspocket without patient discomfort and allows
the greatest dexterity in differentiating thethe greatest dexterity in differentiating the
dimensions of the pocket.dimensions of the pocket.
 These probes are generally calibrated inThese probes are generally calibrated in
millimeters. Probing can be one of the mostmillimeters. Probing can be one of the most
arduous aspects of examination, yet it isarduous aspects of examination, yet it is
mistakenly taken for granted because itmistakenly taken for granted because it
appears simple.appears simple.

 The dentist shouldThe dentist should
probe six areasprobe six areas
around the tooth,around the tooth,
paying specificpaying specific
attention to rootattention to root
anatomy. Evaluationanatomy. Evaluation
should includeshould include
bifurcation andbifurcation and
trifurcation areas ontrifurcation areas on
the maxillary andthe maxillary and
mandibular molarsmandibular molars
and on the maxillaryand on the maxillary
first premolars.first premolars.

The mouth of a patient with poor oral hygieneThe mouth of a patient with poor oral hygiene
habits will be difficult to accurately probe.habits will be difficult to accurately probe.
Once oral hygiene has been established, theOnce oral hygiene has been established, the
patient’s mouth may be probed accurately.patient’s mouth may be probed accurately.
 During the probing procedure, the dentistDuring the probing procedure, the dentist
should also check for bleeding or exudation,should also check for bleeding or exudation,
these are also signs of periodontal disease.these are also signs of periodontal disease.
Clinically, the bleeding of the gingiva duringClinically, the bleeding of the gingiva during
probing is the sign of ulceration of theprobing is the sign of ulceration of the
sulcular epithelium.sulcular epithelium.
 There are also special probes that can beThere are also special probes that can be
used in the bifurcation or trifurcation areas.used in the bifurcation or trifurcation areas.

MOBILITYMOBILITY
 Mobility can be determined with theMobility can be determined with the
handle of the probe, also, with the handlehandle of the probe, also, with the handle
end of the mirror, placed on the buccalend of the mirror, placed on the buccal
and lingual surfaces and applyingand lingual surfaces and applying
pressure to the tooth with the hand. Thepressure to the tooth with the hand. The
extent of mobility is then evaluated whenextent of mobility is then evaluated when
pressure is applied.pressure is applied.

Normal physiologic movement of a healthyNormal physiologic movement of a healthy
tooth is barely, if at all, discernible. Atooth is barely, if at all, discernible. A
scale commonly used for classifyingscale commonly used for classifying
mobility is given below.mobility is given below.
Class 1 :Class 1 : A tooth demonstrates greaterA tooth demonstrates greater
than normal movement, buy less than 1than normal movement, buy less than 1
mm of movement in any direction.mm of movement in any direction.
Class 2:Class 2: A tooth moves 1 mm fromA tooth moves 1 mm from
normal position in any direction.normal position in any direction.
Class 3:Class 3: A tooth moves more than 2A tooth moves more than 2
mm in any direction, including rotation ormm in any direction, including rotation or
depression.depression.

A change from normal physiologicA change from normal physiologic
movement may indicate traumaticmovement may indicate traumatic
occlusion or periodontal disease. Teethocclusion or periodontal disease. Teeth
exhibiting Class 3 mobility have anexhibiting Class 3 mobility have an
extremely poor prognosis and usually willextremely poor prognosis and usually will
require extraction.require extraction.
Mobility is an indication of the loss of theMobility is an indication of the loss of the
tooth’s attachment to the jaw. This can betooth’s attachment to the jaw. This can be
seen radio graphically as a widenedseen radio graphically as a widened
periodontal ligament space caused byperiodontal ligament space caused by
occlusal trauma or orthodontic movement.occlusal trauma or orthodontic movement.

. It can also be caused by periodontal. It can also be caused by periodontal
disease when the amount of the supportdisease when the amount of the support
has diminished sufficiently to loosen thehas diminished sufficiently to loosen the
tooth or by overloading of a tooth withtooth or by overloading of a tooth with
restorative work.restorative work.
 It must be emphasized that because aIt must be emphasized that because a
tooth is mobile does not mean that thetooth is mobile does not mean that the
tooth will be lost. The entire dentition cantooth will be lost. The entire dentition can
exhibit a class I mobility and sustain thisexhibit a class I mobility and sustain this
form for many years without splinting.form for many years without splinting.
However, if the tooth is under secondaryHowever, if the tooth is under secondary
occlusal trauma, a number of teeth areocclusal trauma, a number of teeth are
splinted for the required support.splinted for the required support.

RADIOGRAPHSRADIOGRAPHS
 Radiographs are essential forRadiographs are essential for
diagnosis, treatment, and maintenance indiagnosis, treatment, and maintenance in
Periodontics. Although the radiograph isPeriodontics. Although the radiograph is
limited by being two dimensional, if it islimited by being two dimensional, if it is
accompanied by a three-dimensionalaccompanied by a three-dimensional
image it can be visualized.image it can be visualized.

The areas to be reviewed on the radiographsThe areas to be reviewed on the radiographs
are:are:
1.Alveolar crest resorption1.Alveolar crest resorption
2.Intergrity of thickness of the lamina dura2.Intergrity of thickness of the lamina dura
3.Evidence of generalized horizontal bone loss3.Evidence of generalized horizontal bone loss
4.Evidence of vertical bone loss4.Evidence of vertical bone loss
5.Widened periodontal ligament space5.Widened periodontal ligament space
6.Density of the trabeculae of both arches6.Density of the trabeculae of both arches
7.Size and shape of the roots compared to the7.Size and shape of the roots compared to the
crown to determine crown-to-root ratio.crown to determine crown-to-root ratio.

The radiograph can determine the area ofThe radiograph can determine the area of
root embedded in bone; this is crucial inroot embedded in bone; this is crucial in
determining the patient’s prognosis.determining the patient’s prognosis.
 Often a patient with short conical rootsOften a patient with short conical roots
will display minimal bone loss but maximalwill display minimal bone loss but maximal
mobility, and the prognosis is thusmobility, and the prognosis is thus
guarded to poor. Other patients can loseguarded to poor. Other patients can lose
50 percent of the bone but not exhibit50 percent of the bone but not exhibit
mobility, and yet have an encouragingmobility, and yet have an encouraging
prognosis because they have normal-prognosis because they have normal-
shaped roots.shaped roots.

HABITSHABITS
 The major habit to consider is bruxism.The major habit to consider is bruxism.
Visual examination of wear facet patternsVisual examination of wear facet patterns
and x-ray interpretation of thickenedand x-ray interpretation of thickened
lamina dura and widened periodontallamina dura and widened periodontal
ligament spaces determines whether aligament spaces determines whether a
patient grinds during sleep. It is importantpatient grinds during sleep. It is important
to inform the patient of the condition .to inform the patient of the condition .
 One condition that indicates bruxism is aOne condition that indicates bruxism is a
complete arch that exhibits mobilitycomplete arch that exhibits mobility
despite adequate osseous support. Thedespite adequate osseous support. The
teeth may not have been worn from theteeth may not have been worn from the
pressure of grinding, but may havepressure of grinding, but may have
become mobile while resisting this forcebecome mobile while resisting this forcewww.indiandentalacademy.comwww.indiandentalacademy.com

TREATMENT PLANNING:TREATMENT PLANNING:
 Before treatment is rendered, all facts andBefore treatment is rendered, all facts and
findings related to the patient’s disease statefindings related to the patient’s disease state
should be recorded. In general practice, theshould be recorded. In general practice, the
data collection, diagnosis, and treatment –data collection, diagnosis, and treatment –
planning for a patient’s restorative needs areplanning for a patient’s restorative needs are
accomplished at approximately the same time.accomplished at approximately the same time.
 The treatment plan should be concise,The treatment plan should be concise,
logical, and rational - a realistic approach tological, and rational - a realistic approach to
therapy. The timing and sequencing oftherapy. The timing and sequencing of
treatment are important to correcting thetreatment are important to correcting the
patient’s dental problems as efficiently aspatient’s dental problems as efficiently as
possible.possible.

The following is a viable working model forThe following is a viable working model for
periodontal treatment.periodontal treatment.
Initial TherapyInitial Therapy
 Control of microbial plaqueControl of microbial plaque
 ToothbrushingToothbrushing
 FlossingFlossing
 Other aidsOther aids
 Scaling and polishingScaling and polishing
 Correction of defective and / or overhangingCorrection of defective and / or overhanging
restorationsrestorations
 Root planningRoot planning
 Strategic tooth removalStrategic tooth removal
 Stabilization of mobile teethStabilization of mobile teeth
 Minor tooth movementMinor tooth movement
 Evaluation of Initial TherapyEvaluation of Initial Therapywww.indiandentalacademy.comwww.indiandentalacademy.com

Surgical TherapySurgical Therapy
 Soft tissue proceduresSoft tissue procedures
 GingivectomyGingivectomy
 Open debridementOpen debridement
 Mucosal repairMucosal repair
 Hard tissue proceduresBone inductionHard tissue proceduresBone induction
 Osseous resectionOsseous resection
 Treatment of furcation involvementsTreatment of furcation involvements
 Odontoplasty – osteoplastyOdontoplasty – osteoplasty
 Root amputationRoot amputation
 HemisectionHemisection
 ProvisionalizationProvisionalization
 RestorationRestoration www.indiandentalacademy.comwww.indiandentalacademy.com

Evaluation of Surgical TherapyEvaluation of Surgical Therapy
Guided Tissue RegenerationGuided Tissue Regeneration
(Hard and Soft Tissue Procedures)(Hard and Soft Tissue Procedures)
RestorationRestoration
MaintenanceMaintenance
PrognosisPrognosis

INITIAL THERAPYINITIAL THERAPY
Initial therapy consists of all treatmentInitial therapy consists of all treatment
carried out in advance of evaluation forcarried out in advance of evaluation for
the surgical phases of periodontal therapy.the surgical phases of periodontal therapy.
CONTROL OF MICROBIALCONTROL OF MICROBIAL
PLAQUE.PLAQUE.
The most critical aspect of periodontalThe most critical aspect of periodontal
therapy is the control of microbial flora intherapy is the control of microbial flora in
the Sulcular area. If the patient does notthe Sulcular area. If the patient does not
maintain excellent oral hygiene andmaintain excellent oral hygiene and
thereby the optimum condition of soft andthereby the optimum condition of soft and
hard tissues, subsequent periodontal andhard tissues, subsequent periodontal and
restorative treatments will be jeopardized.restorative treatments will be jeopardized.

TOOTHBRUSHINGTOOTHBRUSHING
 Plaque removal is accomplished with aPlaque removal is accomplished with a
toothbrush and other orophysiotherapytoothbrush and other orophysiotherapy
aids. Many types of toothbrushes can beaids. Many types of toothbrushes can be
used and are classified according to theirused and are classified according to their
size, shape, length, bristle arrangement,size, shape, length, bristle arrangement,
and whether they are manually orand whether they are manually or
electrically powered.electrically powered.

FLOSSINGFLOSSING
 Interproximal plaque can be controlled withInterproximal plaque can be controlled with
dental floss. Both waxed and unwaxed typesdental floss. Both waxed and unwaxed types
will clean proximal surfaces, but the unwaxedwill clean proximal surfaces, but the unwaxed
floss has several advantages.floss has several advantages.
 It is smaller in diameter and thus more easilyIt is smaller in diameter and thus more easily
passed through interproximal contact areas.passed through interproximal contact areas.
 It flattens out under tension, and thus eachIt flattens out under tension, and thus each
separate thread effectively covers a largerseparate thread effectively covers a larger
surface area.surface area.
 It makes a squeaking noise when applied to aIt makes a squeaking noise when applied to a
clean tooth surface, which can be used as aclean tooth surface, which can be used as a
guide to effective performanceguide to effective performance

OTHER AIDS.OTHER AIDS.
 Plaque may also be controlledPlaque may also be controlled
effectively by orophysiotherapy aids sucheffectively by orophysiotherapy aids such
as dental tape, yarn, rubber and woodenas dental tape, yarn, rubber and wooden
tips, toothpicks, Interdental stimulators,tips, toothpicks, Interdental stimulators,
interproximal brushes, and electricinterproximal brushes, and electric
toothbrushes.toothbrushes.
 When plaque is removed around aWhen plaque is removed around a
fixed partial denture or a restorationfixed partial denture or a restoration
involving splinted teeth, a floss threaderinvolving splinted teeth, a floss threader
may be neededmay be needed

 Disclosing agents may be used to provide betterDisclosing agents may be used to provide better
visualization of areas where plaque control isvisualization of areas where plaque control is
difficult or deficient. Erythrosin dye in tablet ordifficult or deficient. Erythrosin dye in tablet or
liquid form stains plaque and is readilyliquid form stains plaque and is readily
observable.observable.
 Ultraviolet light has been used in combinationUltraviolet light has been used in combination
with fluorescein dye to reveal plaque deposits,with fluorescein dye to reveal plaque deposits,
bypassing the undesirable red stain that remainsbypassing the undesirable red stain that remains
after erythrosine use.after erythrosine use.
 The most important aspect of plaque controlThe most important aspect of plaque control
is patient motivation. Without motivation, allis patient motivation. Without motivation, all
orophysiotherapy aids and the knowledge toorophysiotherapy aids and the knowledge to
apply them are useless.apply them are useless.

SCALING AND POLISHINGSCALING AND POLISHING
 Removal of supragingival calculus (scaling) andRemoval of supragingival calculus (scaling) and
polishing of the coronal portion of the tooth arepolishing of the coronal portion of the tooth are
the first definitive steps in debridement of thethe first definitive steps in debridement of the
teeth.teeth.
 Scaling consists of the removal of deposits andScaling consists of the removal of deposits and
accretions from the crowns of teeth and fromaccretions from the crowns of teeth and from
tooth surfaces slightly subgingival.tooth surfaces slightly subgingival.
 This is accomplished with the use of sharpThis is accomplished with the use of sharp
scalers or curettes. The gingiva responds to thisscalers or curettes. The gingiva responds to this
removal of supragingival and slightly subgingivalremoval of supragingival and slightly subgingival
calculus with a decrease in inflammation andcalculus with a decrease in inflammation and
bleeding.bleeding. www.indiandentalacademy.comwww.indiandentalacademy.com

CORRECTION OF DEFECTIVECORRECTION OF DEFECTIVE
AND / OR OVERHANGINGAND / OR OVERHANGING
RESTORATIONS.RESTORATIONS.
 Overhanging restorations, openOverhanging restorations, open
interproximal contacts, and areas of foodinterproximal contacts, and areas of food
impaction contribute to local irritation ofimpaction contribute to local irritation of
the gingiva and impede proper plaquethe gingiva and impede proper plaque
control. These deficiencies should becontrol. These deficiencies should be
corrected during the initial therapy phasecorrected during the initial therapy phase
of treatment by either replacement orof treatment by either replacement or
reshaping and / or removal of thereshaping and / or removal of the
overhang.overhang. www.indiandentalacademy.comwww.indiandentalacademy.com

ROOT PLANING.ROOT PLANING.
 Root planning is the process of debriding theRoot planning is the process of debriding the
root surface with a curette. It is a moreroot surface with a curette. It is a more
deliberate and more delicately excecuteddeliberate and more delicately excecuted
procedure than scaling and requires theprocedure than scaling and requires the
administration of a local anesthetic in mostadministration of a local anesthetic in most
instances.instances.
 Root planning and the incidental curettage ofRoot planning and the incidental curettage of
soft issue that accompanies it may be an endsoft issue that accompanies it may be an end
point of active periodontal therapy. In manypoint of active periodontal therapy. In many
cases the combination of root planning andcases the combination of root planning and
improved oral hygiene on the part of the patientimproved oral hygiene on the part of the patient
leads to manageable probing depths, and noleads to manageable probing depths, and no
further treatment is necessary.further treatment is necessary.

STRATEGIC TOOTH REMOVAL.STRATEGIC TOOTH REMOVAL.
An important part of treatment sequencingAn important part of treatment sequencing
is the elimination of teeth that areis the elimination of teeth that are
hopelessly involved periodontally and / orhopelessly involved periodontally and / or
are nonrestorable.are nonrestorable.

STABILIZATION OF MOBILESTABILIZATION OF MOBILE
TEETH.TEETH.
Tooth mobility occurs when a tooth isTooth mobility occurs when a tooth is
subjected to excessive forces, especiallysubjected to excessive forces, especially
when bony support is lacking.when bony support is lacking.
It is not necessarily a sign of disease,It is not necessarily a sign of disease,
because it may be a normal response tobecause it may be a normal response to
abnormal forces, and it does not alwaysabnormal forces, and it does not always
need corrective treatment.need corrective treatment.

However, it is sometimes a source ofHowever, it is sometimes a source of
discomfort to the patient, and in thesediscomfort to the patient, and in these
cases it should be treated by reduction ofcases it should be treated by reduction of
the abnormal forces after occlusalthe abnormal forces after occlusal
evaluation.evaluation.
Depending on the patient’s need, the teethDepending on the patient’s need, the teeth
may also be treated by splinting withmay also be treated by splinting with
provisional restorations or an acid etchprovisional restorations or an acid etch
resin technique in conjunction withresin technique in conjunction with
occlusal adjustment. Such restorationsocclusal adjustment. Such restorations
should be carefully designed so they doshould be carefully designed so they do
not impede plaque control.not impede plaque control.

EVALUATION OF INITIAL THERAPYEVALUATION OF INITIAL THERAPY
 The Periodontium recovering from activeThe Periodontium recovering from active
disease should be regularly reexamined anddisease should be regularly reexamined and
reevaluated to determine the efficacy ofreevaluated to determine the efficacy of
treatment.treatment.
 Soft tissue responses to the initial therapy areSoft tissue responses to the initial therapy are
observed along with the patient’s motivation andobserved along with the patient’s motivation and
ability to maintain a relatively inflammation-freeability to maintain a relatively inflammation-free
state.state.
 Probing depths should be recorded again, andProbing depths should be recorded again, and
the location of the mucogingival junction noted inthe location of the mucogingival junction noted in
relation to the teeth. Reevaluation gives therelation to the teeth. Reevaluation gives the
practitioner a firmer grasp on the progress ofpractitioner a firmer grasp on the progress of
treatment, and if necessary, it allows revision oftreatment, and if necessary, it allows revision of
the initial treatment planthe initial treatment planwww.indiandentalacademy.comwww.indiandentalacademy.com

SURGICAL THERAPYSURGICAL THERAPY
There are a number of surgicalThere are a number of surgical
procedures for the improvement of plaqueprocedures for the improvement of plaque
removal aimed primarily at reduction orremoval aimed primarily at reduction or
eliminating probing depths. Accuratelyeliminating probing depths. Accurately
diagnosing and choosing the mostdiagnosing and choosing the most
appropriate surgical regimen is crucial forappropriate surgical regimen is crucial for
maximum results.maximum results.

SOFT TISSUESOFT TISSUE
PROCEDURESPROCEDURES
GINGIVECTOMY.GINGIVECTOMY.
 Gingivectomy is the removal of diseased orGingivectomy is the removal of diseased or
hypertrophied gingiva. Introduced by G.V.Black,hypertrophied gingiva. Introduced by G.V.Black,
it was the first periodontal surgical approach toit was the first periodontal surgical approach to
gain widespread acceptance.gain widespread acceptance.
 Gingivectomy is essentially the resection ofGingivectomy is essentially the resection of
keratinized gingiva only, and it may be applied tokeratinized gingiva only, and it may be applied to
the treatment of suprabony pockets and tothe treatment of suprabony pockets and to
fibrous or enlarged gingiva, particularly whenfibrous or enlarged gingiva, particularly when
they result from diphenyl hydantoin (Dilantin)they result from diphenyl hydantoin (Dilantin)
therapy (Drugs causing gingival hyperplasia /therapy (Drugs causing gingival hyperplasia /
enlargement).enlargement).
 However, it is unsuitable for the treatment ofHowever, it is unsuitable for the treatment of
infrabony defectsinfrabony defects www.indiandentalacademy.comwww.indiandentalacademy.com

OPEN DEBRIDEMENTOPEN DEBRIDEMENT (Modified(Modified
Widman Procedure)Widman Procedure)
 Open debridement or curettage is a surgicalOpen debridement or curettage is a surgical
procedure designed to gain better access to rootprocedure designed to gain better access to root
surfaces for complete debridement and rootsurfaces for complete debridement and root
planning.planning.
 The modified Widman approach has beenThe modified Widman approach has been
advocated in recent years, because it allowsadvocated in recent years, because it allows
good soft tissue flap control, minimum surgicalgood soft tissue flap control, minimum surgical
trauma, and good postoperative integrity withouttrauma, and good postoperative integrity without
excessive loss of osseous tissue or connectiveexcessive loss of osseous tissue or connective
tissue attachment.tissue attachment.

MUCOSAL REPAIR.MUCOSAL REPAIR.
Mucosal reparative surgery is used toMucosal reparative surgery is used to
increase the width of the band ofincrease the width of the band of
keratinized gingiva. It is particularly usefulkeratinized gingiva. It is particularly useful
where complete-coverage restorations arewhere complete-coverage restorations are
planned.planned.

HARD TISSUEHARD TISSUE
PROCEDURESPROCEDURES
Hard tissue therapy is aimed at modifyingHard tissue therapy is aimed at modifying
the Topography of areas where plaquethe Topography of areas where plaque
control is difficult or impossible.control is difficult or impossible.
Infrabony pockets.Infrabony pockets.
Around root furcation.Around root furcation.

BONE INDUCTION.BONE INDUCTION.
Intrabony lesions are categorized as one-Intrabony lesions are categorized as one-
walled, two-walled or three walled,walled, two-walled or three walled,
depending on the remaining osseousdepending on the remaining osseous
topography.topography.
 The three-walled defect responds best toThe three-walled defect responds best to
inductive or degranulation procedures,inductive or degranulation procedures,
with resulting new attachment andwith resulting new attachment and
resolution of all or part of the lesion.resolution of all or part of the lesion.
The one-walled and two-walled (crater)The one-walled and two-walled (crater)
defects respond better to pocketdefects respond better to pocket
elimination procedures.elimination procedures.

Many materials have been used to fillMany materials have been used to fill
osseous defects: ceramic, sclera,osseous defects: ceramic, sclera,
cartilage, bone chips, cementum andcartilage, bone chips, cementum and
dentin, osseous coagulum, freezedrieddentin, osseous coagulum, freezedried
bone, iliac crest marrow, hydroxyapatite,bone, iliac crest marrow, hydroxyapatite,
tricalcium phosphate, and bioactive glasstricalcium phosphate, and bioactive glass
materials.materials.

OSSEOUS RESECTION WITHOSSEOUS RESECTION WITH
APICALLY POSITIONED FLAPS.APICALLY POSITIONED FLAPS.
 Chronic inflammatory periodontitisChronic inflammatory periodontitis
results in the loss of osseous tissue,results in the loss of osseous tissue,
destruction of osseous architecture, anddestruction of osseous architecture, and
creation of an intrabony lesion.creation of an intrabony lesion.
 The osseous tissue has no predictable orThe osseous tissue has no predictable or
simple pattern of loss; the resorption maysimple pattern of loss; the resorption may
take the form of craters, hemiseptaltake the form of craters, hemiseptal
defects, or well-like (troughlike) shapes.defects, or well-like (troughlike) shapes.
Craters in the interproximal areas are theCraters in the interproximal areas are the
most common type of lesionmost common type of lesionwww.indiandentalacademy.comwww.indiandentalacademy.com

The objective of osseous resection is toThe objective of osseous resection is to
shape the bone to form even contours.shape the bone to form even contours.
This is accomplished by levelingThis is accomplished by leveling
interproximal lesions, reducing osseousinterproximal lesions, reducing osseous
recontour lesions that are too wide and /recontour lesions that are too wide and /
or shallow for predictable repair or bonyor shallow for predictable repair or bony
fill, thinning, bony ledges, and eliminatingfill, thinning, bony ledges, and eliminating
or ramping crater defects.or ramping crater defects.
 The result is intended to be a soundThe result is intended to be a sound
osseous base for gingival attachment andosseous base for gingival attachment and
the elimination of pockets and excessivethe elimination of pockets and excessive
Sulcular depth.Sulcular depth.

TREATMENT OF FURCATIONTREATMENT OF FURCATION
INVOLVEMENTINVOLVEMENT
 Diagnosis and treatment of furcationDiagnosis and treatment of furcation
involvement of multirooted teeth is one ofinvolvement of multirooted teeth is one of
the more difficult problems encountered inthe more difficult problems encountered in
the periodontal – restorative dentistry.the periodontal – restorative dentistry.

CLASSIFICATION OFCLASSIFICATION OF
INVOLVEMENTSINVOLVEMENTS FurcationFurcation
involvements can beinvolvements can be
classified as Class forclassified as Class for
Grade) I, II, III, andGrade) I, II, III, and
IV.IV.
 The normal positionThe normal position
of the osseous crestof the osseous crest
is approximatelyis approximately
1.5mm apical to the1.5mm apical to the
cementoenamelcementoenamel
junction (CEJ) in ajunction (CEJ) in a
young, healthy adult.young, healthy adult.www.indiandentalacademy.comwww.indiandentalacademy.com

Class IClass I
 If vertical loss ofIf vertical loss of
periodontal support isperiodontal support is
less than 3mm apicalless than 3mm apical
to the CEL this isto the CEL this is
considered to beconsidered to be
Class I involvementClass I involvement..
 There is no gross orThere is no gross or
radiographic evidenceradiographic evidence
of bone loss.of bone loss.
Clinically the furcaClinically the furca
can be probed up to 1can be probed up to 1
mm horizontally.mm horizontally.

Class IIClass II
 If vertical loss is greaterIf vertical loss is greater
than 3 mm but the totalthan 3 mm but the total
horizontal width of thehorizontal width of the
furcation is not involvedfurcation is not involved
Class II involvementClass II involvement
exists.exists.
 A portion of the bone andA portion of the bone and
Periodontium remainsPeriodontium remains
intact, but osseous loss isintact, but osseous loss is
evident on radiographs.evident on radiographs.
The furca is penetrableThe furca is penetrable
more than 1 mmmore than 1 mm
horizontally but does nothorizontally but does not
extend through – and –extend through – and –
through.through. www.indiandentalacademy.comwww.indiandentalacademy.com

Class IIIClass III
 A horizontalA horizontal
through – and –through – and –
thorugh lesion that isthorugh lesion that is
occluded by gingivaoccluded by gingiva
but allows passage ofbut allows passage of
an instrument froman instrument from
the busccal, lingual,the busccal, lingual,
or palatal surface isor palatal surface is
defined as adefined as a Class IIIClass III
involvementinvolvement. The. The
degree of osseousdegree of osseous
loss is grossly evidentloss is grossly evident
on radiographs.on radiographs.

Class IVClass IV
 A horizontal through –A horizontal through –
and – thorugh leionand – thorugh leion
that is not occludedthat is not occluded
by gingiva is definedby gingiva is defined
as aas a Class IVClass IV
involvementinvolvement

ODONTOPLASTY – OSTEOPLASTY.ODONTOPLASTY – OSTEOPLASTY.
 Lesser degrees of furcationLesser degrees of furcation
involvement can often be controlled byinvolvement can often be controlled by
root planning and scaling, adequate oralroot planning and scaling, adequate oral
hygiene, and / or gingivectomy-hygiene, and / or gingivectomy-
gingivoplasty.gingivoplasty.
However, when the involvement is moreHowever, when the involvement is more
extensive, recontouring of the tooth orextensive, recontouring of the tooth or
bone may be necessary.bone may be necessary.

Class I and incipient Class II lesions canClass I and incipient Class II lesions can
be treated by reflecting the soft tissue inbe treated by reflecting the soft tissue in
the furcation area and recontouring boththe furcation area and recontouring both
the tooth structure and the supportingthe tooth structure and the supporting
bone to improve access for cleaning.bone to improve access for cleaning.
 Pocket elimination in this mannerPocket elimination in this manner
provides the best results and the fairestprovides the best results and the fairest
prognosis. A minimal amount of toothprognosis. A minimal amount of tooth
structure and bone is lost, and the patientstructure and bone is lost, and the patient
can easily maintain it.can easily maintain it.

Class II and Class III involvements can beClass II and Class III involvements can be
treated by a procedure known astreated by a procedure known as
tunneling.tunneling.
 The osseous structure is completelyThe osseous structure is completely
removed in the furcation, converting theremoved in the furcation, converting the
lesion to a through-and=through defect.lesion to a through-and=through defect.
 Teeth suitable for tunneling must haveTeeth suitable for tunneling must have
long, divergent roots, which will facilitatelong, divergent roots, which will facilitate
penetration by an oral hygiene aid (e.g., apenetration by an oral hygiene aid (e.g., a
proximal brush or a pipe cleaner).proximal brush or a pipe cleaner).

Patient selection is particularly important,Patient selection is particularly important,
because oral hygiene and patientbecause oral hygiene and patient
motivation are critical. Failure to maintainmotivation are critical. Failure to maintain
the furcation in a relatively plaque-freethe furcation in a relatively plaque-free
state may lead to caries, which are oftenstate may lead to caries, which are often
impossible to correct.impossible to correct.
The common location of accessory canalsThe common location of accessory canals
in the roof of the furca can also be ain the roof of the furca can also be a
problem. Because of irreversible pulpproblem. Because of irreversible pulp
damage, endodontic treatment may bedamage, endodontic treatment may be
needed at a later date.needed at a later date.

ROOT AMPUTATIONROOT AMPUTATION
 In many patients, Class II and Class IIIIn many patients, Class II and Class III
furcation lesions are most effectivelyfurcation lesions are most effectively
treated by root amputation, whichtreated by root amputation, which
eliminates the furcation completely. Theeliminates the furcation completely. The
indications are as follows.indications are as follows.
Severe vertical bone loss involving oneSevere vertical bone loss involving one
root of a mandibular molar or one or tworoot of a mandibular molar or one or two
roots of a maxillary molar.roots of a maxillary molar.
Furcation involvement that is not treatableFurcation involvement that is not treatable
by odontoplasty – osteoplasty.by odontoplasty – osteoplasty.

Vertically or horizontally fractured roots orVertically or horizontally fractured roots or
teeth from trauma or endodonticteeth from trauma or endodontic
procedures.procedures.
Unfavourable root proximity precludingUnfavourable root proximity precluding
treatment by conservative measures.treatment by conservative measures.
Severe cariesSevere caries
Internal or external resorptionInternal or external resorption
Inability to treat one root canalInability to treat one root canal
successfully.successfully.

 Severe dehiscence and sensitivity of aSevere dehiscence and sensitivity of a
root that precludes grafting procedures.root that precludes grafting procedures.
 Failure of an abutment in a long-spanFailure of an abutment in a long-span
splint or FPD.splint or FPD.
 Strategic removal of a root to improveStrategic removal of a root to improve
the prognosis of an adjacent tooth.the prognosis of an adjacent tooth.

Certain roots will not be suitable forCertain roots will not be suitable for
amputation. Individual considerationsamputation. Individual considerations
include the extent of furcationinclude the extent of furcation
involvement, the anatomy and topographyinvolvement, the anatomy and topography
of the supporting bone, the anatomy of theof the supporting bone, the anatomy of the
root canal, and the periapical health of theroot canal, and the periapical health of the
tooth.tooth.

 The major contraindications to root resection areThe major contraindications to root resection are
teeth exhibiting any of the following.teeth exhibiting any of the following.
 Closely approximated or fused roots.Closely approximated or fused roots.
 Significantly decreased general osseous supportSignificantly decreased general osseous support
or an increased crown / root ratio.or an increased crown / root ratio.
 Remaining structure that will not provideRemaining structure that will not provide
adequate resistance against the forces ofadequate resistance against the forces of
mastication.mastication.
 Excessive loss of supporting root structureExcessive loss of supporting root structure
 Inability to be treated endodonticallyInability to be treated endodontically
 Remaining structure that cannot be restored.Remaining structure that cannot be restored.

HEMISECTION.HEMISECTION.
 Hemisection means cutting a tooth inHemisection means cutting a tooth in
half. In the case of mandibular molars,half. In the case of mandibular molars,
hemisection is followed by removal andhemisection is followed by removal and
subsequent restoration of one root orsubsequent restoration of one root or
restoration of each half of the tooth. Therestoration of each half of the tooth. The
latter procedure is sometimes calledlatter procedure is sometimes called
premolarization or bicuspidization.premolarization or bicuspidization.
 The individual roots may then beThe individual roots may then be
separated orthodontically, if necessary, toseparated orthodontically, if necessary, to
gain new interseptal osseous area.gain new interseptal osseous area.

PROVISIONALIZATION.PROVISIONALIZATION.
 Provisional stabilization is indicated inProvisional stabilization is indicated in
many cases of root resection to allowmany cases of root resection to allow
proper healing, of the surgical site beforeproper healing, of the surgical site before
definitive restorations are placed and todefinitive restorations are placed and to
stabilize the remaining tooth structurestabilize the remaining tooth structure
against masticatory forces.against masticatory forces.

RESTORATION.RESTORATION.
 Teeth with a resected root or roots mayTeeth with a resected root or roots may
be restored in a variety of ways. Theybe restored in a variety of ways. They
may be involved in a treatment plan asmay be involved in a treatment plan as
single units, as fixed or removable partialsingle units, as fixed or removable partial
denture abutments, or as vertical stops fordenture abutments, or as vertical stops for
an overdenture.an overdenture.

The most common types of restorationsThe most common types of restorations
for teeth with resected roots involve.for teeth with resected roots involve.
The remaining root restored as anThe remaining root restored as an
individual tooth.individual tooth.
The tooth used as an abutment for a fixedThe tooth used as an abutment for a fixed
or removable partial denture.or removable partial denture.
Premolarization – individual roots of aPremolarization – individual roots of a
molar restored with premolar morphology.molar restored with premolar morphology.
Minimum treatment – amalgam placed inMinimum treatment – amalgam placed in
the root(s) and the occlusion adjusted.the root(s) and the occlusion adjusted.

EVALUATION OF SURGICAL THERAPYEVALUATION OF SURGICAL THERAPY
 The prognosis for a tooth whose root(s) haveThe prognosis for a tooth whose root(s) have
been resected and / or amputated depends onbeen resected and / or amputated depends on
many factors.many factors.
 The manner in which the tooth is to be used inThe manner in which the tooth is to be used in
the restorative plan – as an abutment for athe restorative plan – as an abutment for a
partial denture or as a single crown – has apartial denture or as a single crown – has a
bearing on prognosis.bearing on prognosis.
 The amount of residual osseous structure toThe amount of residual osseous structure to
support the remaining tooth also influences thesupport the remaining tooth also influences the
outlook. Most important, however, are theoutlook. Most important, however, are the
motivation and oral hygiene of the patient. Withmotivation and oral hygiene of the patient. With
careful diagnosis, treatment planning, and goodcareful diagnosis, treatment planning, and good
surgical technique, the tooth with resected rootssurgical technique, the tooth with resected roots
may have a favourable prognosis. Plaquemay have a favourable prognosis. Plaque
control is critical.control is critical.

GUIDED TISSUE REGENERATIONGUIDED TISSUE REGENERATION (Hard(Hard
and soft Tissue Procedures)and soft Tissue Procedures)
 It has long been a goal of periodontalIt has long been a goal of periodontal
therapists to replace lost connective tissuetherapists to replace lost connective tissue
attachment and bone.attachment and bone.
 Many materials have been used in the quest forMany materials have been used in the quest for
reattachment to diseased root surfaces. In thereattachment to diseased root surfaces. In the
recent past, regaining lost attachment with cellsrecent past, regaining lost attachment with cells
from the host has been successful.from the host has been successful.
 Through the use of physical barriers that preventThrough the use of physical barriers that prevent
cells from the gingival connective tissue andcells from the gingival connective tissue and
apically migrating oral epithelium fromapically migrating oral epithelium from
contacting the root surface, space is createdcontacting the root surface, space is created
over the root surface, which allows selectiveover the root surface, which allows selective
repopulation of this space by cells from therepopulation of this space by cells from the
residual periodontal ligament. These becomeresidual periodontal ligament. These become
the regenerated periodontal ligament.the regenerated periodontal ligament.www.indiandentalacademy.comwww.indiandentalacademy.com

Several types of barriers, both resorbableSeveral types of barriers, both resorbable
and non resorbable, as well as nativeand non resorbable, as well as native
periosteum, have seen used to regenerateperiosteum, have seen used to regenerate
the periodontium about root surfaces, inthe periodontium about root surfaces, in
furcations, and with dental implants.furcations, and with dental implants.

MAINTENANCEMAINTENANCE
Continued reexamination and evaluationContinued reexamination and evaluation
of periodontal status are necessary toof periodontal status are necessary to
verify the treatment’s success.verify the treatment’s success.
 The maintenance regimen variesThe maintenance regimen varies
greatly among individuals and requiresgreatly among individuals and requires
close coordination between the patientclose coordination between the patient
and the involved professionalsand the involved professionals

PROGNOSISPROGNOSIS
 The progress, course, and outcome ofThe progress, course, and outcome of
gingival and periodontal disease aregingival and periodontal disease are
critically dependent on the patient.critically dependent on the patient.
Without the ability and desire of the patientWithout the ability and desire of the patient
to maintain his or her teeth andto maintain his or her teeth and
periodontium, any treatment will ultimatelyperiodontium, any treatment will ultimately
fail.fail.

PERIODONTAL ASPECT OF FIXEDPERIODONTAL ASPECT OF FIXED
OCCLUSIONOCCLUSION
OCCLUSION AND ITS EFFECT ONOCCLUSION AND ITS EFFECT ON
PERIODONTIUMPERIODONTIUM
 When there is an increased functional demandWhen there is an increased functional demand
upon the periodontium, it commonly accommodatesupon the periodontium, it commonly accommodates
these forces. This adaptive capacity varies betweenthese forces. This adaptive capacity varies between
persons and, in the same person, varies withpersons and, in the same person, varies with
circumstances.circumstances.
 The effect of occlusal forces upon the periodontium isThe effect of occlusal forces upon the periodontium is
influenced by their severity, direction, duration, andinfluenced by their severity, direction, duration, and
frequency. When severity increases, the periodontalfrequency. When severity increases, the periodontal
fibers thicken and increase and the alveolar bonefibers thicken and increase and the alveolar bone
becomes denser.becomes denser.
 www.indiandentalacademy.comwww.indiandentalacademy.com

 Changing the direction of the occlusal forcesChanging the direction of the occlusal forces
changes the orientation of the periodontalchanges the orientation of the periodontal
ligament fibers. These fibers are oriented toligament fibers. These fibers are oriented to
withstand forces in the long axis of the tooth.withstand forces in the long axis of the tooth.
 Horizontal or lateral forces are usually locatedHorizontal or lateral forces are usually located
in balancing side interferences and arein balancing side interferences and are
deleterious to the periodontium. Lateral forcesdeleterious to the periodontium. Lateral forces
initiate bone resorption in areas of pressure andinitiate bone resorption in areas of pressure and
bone formation in areas of tension.bone formation in areas of tension.

 Rotational forces cause tension and pressure onRotational forces cause tension and pressure on
the periodontium and are the most injuriousthe periodontium and are the most injurious
forces.forces.
 The duration and frequency affect the responseThe duration and frequency affect the response
of the alveolar bone to occlusal forces becauseof the alveolar bone to occlusal forces because
constant pressure on bone causes resorption,constant pressure on bone causes resorption,
but intermittent forces promote bone formation.but intermittent forces promote bone formation.
 Recurrent forces over short intervals haveRecurrent forces over short intervals have
essentially the same resorbing effect asessentially the same resorbing effect as
constant pressure. When occlusal forcesconstant pressure. When occlusal forces
exceed the adaptive capacity of theexceed the adaptive capacity of the
periodontium, tissue injury results.periodontium, tissue injury results.

 Periodontal injury caused by occlusal forces isPeriodontal injury caused by occlusal forces is
called trauma from occlusion. Occlusalcalled trauma from occlusion. Occlusal
traumatism, does not affect the gingival, nortraumatism, does not affect the gingival, nor
does it cause bone formation. Inflammationdoes it cause bone formation. Inflammation
causes horizontal bone loss.causes horizontal bone loss.
 However, inflammation in the presence ofHowever, inflammation in the presence of
trauma from occlusion will alter the pathway oftrauma from occlusion will alter the pathway of
inflammation to allow it into the periodontalinflammation to allow it into the periodontal
ligament space and lead to infraosseousligament space and lead to infraosseous
pockets.pockets.
 Thus trauma form occlusion does not affect theThus trauma form occlusion does not affect the
marginal gingiva, but affects the bone whenmarginal gingiva, but affects the bone when
inflammation is present. This is called the zoneinflammation is present. This is called the zone
of codestruction: trauma from occlusion in theof codestruction: trauma from occlusion in the
presence of inflammation.presence of inflammation.


With increased axial forces, there is aWith increased axial forces, there is a
distortion of the periodontal ligament,distortion of the periodontal ligament,
compression of the periodontal fibers, andcompression of the periodontal fibers, and
then resorption of the bone in the apicalthen resorption of the bone in the apical
areas.areas.
Torque or rotational forces cause tensionTorque or rotational forces cause tension
and pressure, which, under physiologicand pressure, which, under physiologic
conditions, result in bone formation andconditions, result in bone formation and
resorption. Torque is the fore most likelyresorption. Torque is the fore most likely
to injure the periodontium.to injure the periodontium.

 Trauma from occlusion occurs in three stages:Trauma from occlusion occurs in three stages:
The first is injury, the second is repair, and theThe first is injury, the second is repair, and the
third is a change in the morphology of thethird is a change in the morphology of the
periodontium.periodontium.
 Tissue injury is produced by excessive occlusalTissue injury is produced by excessive occlusal
forces. Natural repair of the injury andforces. Natural repair of the injury and
restoration of periodontal tissues occur if therestoration of periodontal tissues occur if the
force on the tooth diminishes or the tooth driftsforce on the tooth diminishes or the tooth drifts
away from the force. Moving away from theaway from the force. Moving away from the
injurious force may result in mobility.injurious force may result in mobility.
 If the force is chronic, the periodontal tissuesIf the force is chronic, the periodontal tissues
are remolded to cushion the traumatic force:are remolded to cushion the traumatic force:
the periodontal ligament is widened at thethe periodontal ligament is widened at the
expense of the bone, angular (vertical) boneexpense of the bone, angular (vertical) bone
defects occur without pockets, and the toothdefects occur without pockets, and the tooth
becomes mobile.becomes mobile. www.indiandentalacademy.comwww.indiandentalacademy.com

 OCCLUSAL TRAUMA IN GINGIVITIS ANDOCCLUSAL TRAUMA IN GINGIVITIS AND
PERIODONTAL DISEASE;PERIODONTAL DISEASE;
 All periodontal tissues are affected by occlusion.All periodontal tissues are affected by occlusion.
Occlusion is a critical environmental factor in the life ofOcclusion is a critical environmental factor in the life of
the healthy periodontium and its influence expands inthe healthy periodontium and its influence expands in
periodontal ligament cannot be separated from theperiodontal ligament cannot be separated from the
influence of occlusion.influence of occlusion.
 Because occlusion is the constant monitor for theBecause occlusion is the constant monitor for the
condition of the periodontium’s health, it affects thecondition of the periodontium’s health, it affects the
response of the periodontium to inflammation and is aresponse of the periodontium to inflammation and is a
factor in periodontal disease.factor in periodontal disease.
 The role of trauma from occlusion in gingivitis andThe role of trauma from occlusion in gingivitis and
periodontitis is best understood if the periodontium isperiodontitis is best understood if the periodontium is
considered as having two zones, the zone of irritationconsidered as having two zones, the zone of irritation
and the zone of codestruction.and the zone of codestruction.

 The zone of irritation consists of the marginalThe zone of irritation consists of the marginal
and interdental gingival, with its boundaryand interdental gingival, with its boundary
formed by the gingival fibers. This is whereformed by the gingival fibers. This is where
gingivitis and periodontal pockets start.gingivitis and periodontal pockets start.
 They are caused by local irritation from plaque,They are caused by local irritation from plaque,
bacteria, calculus., and by food impaction. Withbacteria, calculus., and by food impaction. With
few exceptions, researchers agree that traumafew exceptions, researchers agree that trauma
from occlusion does not cause gingivitis orfrom occlusion does not cause gingivitis or
periodontal pockets.periodontal pockets.
 In other words, such things as high restoration,In other words, such things as high restoration,
orthodontic movement, or the poorly designedorthodontic movement, or the poorly designed
rest of any RPD causing tooth trauma can notrest of any RPD causing tooth trauma can not
lead to a periodontal pocket because the locallead to a periodontal pocket because the local
irritants that start gingivitis and periodontalirritants that start gingivitis and periodontal
pockets affect the marginal gingival, but traumapockets affect the marginal gingival, but trauma
from occlusion affects only the supportingfrom occlusion affects only the supporting
tissues.tissues. www.indiandentalacademy.comwww.indiandentalacademy.com

As long as the inflammation is confined toAs long as the inflammation is confined to
the gingiva, it is not affected by occlusalthe gingiva, it is not affected by occlusal
forces. When it extends from the gingivalforces. When it extends from the gingival
to the supporting periodontal tissues,to the supporting periodontal tissues,
inflammation does enter into the zone ofinflammation does enter into the zone of
codestruction.codestruction.
 The zone of codestruction begins with theThe zone of codestruction begins with the
transeptal fibers and consists oftranseptal fibers and consists of
supporting periodontal tissues, is pathwaysupporting periodontal tissues, is pathway
and the destruction it causes come underand the destruction it causes come under
the influence of the occlusion.the influence of the occlusion.

In ordinary inflammation without trauma,In ordinary inflammation without trauma,
the inflammation follows the path of leastthe inflammation follows the path of least
resistance. Its course is determined byresistance. Its course is determined by
the alignment of the transeptal fibers, andthe alignment of the transeptal fibers, and
it goes into the crest of the bone byit goes into the crest of the bone by
following a path along the circumvascularfollowing a path along the circumvascular
spaces.spaces.

 Trauma from occlusion changes the tissueTrauma from occlusion changes the tissue
environment around the inflammatory exudates in twoenvironment around the inflammatory exudates in two
way:way:
 it alters the alignment of the transeptal and alveolarit alters the alignment of the transeptal and alveolar
crest fibers and thus changes the direction of thecrest fibers and thus changes the direction of the
pathway of the inflammation so the direction of thepathway of the inflammation so the direction of the
pathway of the inflammation so that it extends directlypathway of the inflammation so that it extends directly
into the periodontal ligament.into the periodontal ligament.
 Excessive occlusal forces produce periodontalExcessive occlusal forces produce periodontal
ligament damage and bone resorption whichligament damage and bone resorption which
aggravate the tissue destruction caused byaggravate the tissue destruction caused by
inflammation. Combined with inflammation, traumainflammation. Combined with inflammation, trauma
from occlusion leads to infraosseous pockets; angularfrom occlusion leads to infraosseous pockets; angular
vertical), craterlike osseous defects; and excessivevertical), craterlike osseous defects; and excessive
tooth mobility.tooth mobility.
 Occlusal trauma may be caused by alterations inOcclusal trauma may be caused by alterations in
the occlusal forces, reduced capacity of thethe occlusal forces, reduced capacity of the
periodontium to withstand occlusal forces.periodontium to withstand occlusal forces.www.indiandentalacademy.comwww.indiandentalacademy.com

PREPARATIONS FORPREPARATIONS FOR
PERIODONTALLY WEAKENEDPERIODONTALLY WEAKENED
TEETHTEETH
Teeth that have been saved byTeeth that have been saved by
periodontal therapy often need castperiodontal therapy often need cast
restorations. This may occur because ofrestorations. This may occur because of
caries or previous damage, or the teethcaries or previous damage, or the teeth
may need to be splinted together tomay need to be splinted together to
improve their stability. These teeth alsoimprove their stability. These teeth also
may be needed as abutments formay be needed as abutments for
prostheses replacing missing teeth.prostheses replacing missing teeth.www.indiandentalacademy.comwww.indiandentalacademy.com

PREPARATION FINISHPREPARATION FINISH
LINELINE
 Restoration of a tooth around which there has been aRestoration of a tooth around which there has been a
loss of gingival height or other change in gingivalloss of gingival height or other change in gingival
architecture frequently requires modification of thearchitecture frequently requires modification of the
tooth preparation.tooth preparation.
 The type and location of the finish line may have aThe type and location of the finish line may have a
significant impact on the success of the restoration.significant impact on the success of the restoration.
An improperly designed preparation can necessarilyAn improperly designed preparation can necessarily
damage the tooth and potentially compromise thedamage the tooth and potentially compromise the
longevity of the restoration and of the tooth itself.longevity of the restoration and of the tooth itself.
 The proximity of the preparation finish line to theThe proximity of the preparation finish line to the
furcations can necessitate even further modification offurcations can necessitate even further modification of
the tooth preparation.the tooth preparation.www.indiandentalacademy.comwww.indiandentalacademy.com

LOCATIONLOCATION
The optimum location for the gingivalThe optimum location for the gingival
finish line of a crown preparation is onfinish line of a crown preparation is on
enamel, away from the gingival sulcus.enamel, away from the gingival sulcus.
However, it is frequently necessary for theHowever, it is frequently necessary for the
restoration margin to extend apically torestoration margin to extend apically to
cover an expanse of root surface that maycover an expanse of root surface that may
have been affected by caries or erosion.have been affected by caries or erosion.

 If an all-ceramicIf an all-ceramic
shoulder is used as theshoulder is used as the
gingivofacial margin forgingivofacial margin for
a metal-ceramic crown,a metal-ceramic crown,
a 1.0-mm-wide shouldera 1.0-mm-wide shoulder
will be required as thewill be required as the
gingival finish line. Thusgingival finish line. Thus
configuration isconfiguration is
destructive under thedestructive under the
best of circumstancesbest of circumstances
when it is placed in thewhen it is placed in the
enamel of the clinicalenamel of the clinical
crown. Nevertheless, itcrown. Nevertheless, it
is generally wellis generally well
tolerated in maturetolerated in mature
teeth.teeth.

 A shoulder is a poorA shoulder is a poor
choice when thechoice when the
margin must bemargin must be
placed on the rootplaced on the root
surface. Thesurface. The
constricted, smallerconstricted, smaller
diameter of the rootdiameter of the root
will require that thewill require that the
axial reduction beaxial reduction be
extended into theextended into the
tooth to pulp-tooth to pulp-
threatening depth tothreatening depth to
achieve the same 1.0-achieve the same 1.0-
mm-wide shoulder.mm-wide shoulder.

Aside from possible pulpal encroachment,Aside from possible pulpal encroachment,
this gross destruction of axial tooththis gross destruction of axial tooth
structure weakens the natural structuralstructure weakens the natural structural
durability of the tooth. Additionally, thedurability of the tooth. Additionally, the
shoulder has a greater potential forshoulder has a greater potential for
concentrating stresses that couldconcentrating stresses that could
ultimately lead to fracture of the tooth.ultimately lead to fracture of the tooth.

 A chamferA chamfer
finish line onfinish line on
the facialthe facial
surface in thissurface in this
apicalapical
position willposition will
result inresult in
approximatelyapproximately
the samethe same
depth of axialdepth of axial
reduction asreduction as
would awould a
shoulder atshoulder at
the usualthe usual
level.level.

 A metal-ceramicA metal-ceramic
crown fabricated incrown fabricated in
such circumstancessuch circumstances
should have a wideshould have a wide
metal gingival collar.metal gingival collar.
Extension of theExtension of the
ceramic veneer to theceramic veneer to the
gingival margin willgingival margin will
create overcreate over
contouring or willcontouring or will
require use of therequire use of the
more destructivemore destructive
shoulder.shoulder.

FABRICATION FLUTESFABRICATION FLUTES
 Sometimes the crown margins on a molar mustSometimes the crown margins on a molar must
extend far enough apically that the preparation finishextend far enough apically that the preparation finish
line approaches the furcation, where the common rootline approaches the furcation, where the common root
trunk divides into two or three roots.trunk divides into two or three roots.
 The designs of both the tooth preparations and theThe designs of both the tooth preparations and the
crowns for these teeth must be different from thosecrowns for these teeth must be different from those
customarily used.customarily used.
 This is caused by the intersection of the preparationThis is caused by the intersection of the preparation
finish line with the vertical flutes or concavities in thefinish line with the vertical flutes or concavities in the
common root trunk, extending from the actualcommon root trunk, extending from the actual
furcation in the direction of the preparation occlusal tofurcation in the direction of the preparation occlusal to
the inversion of the gingival finish line must also havethe inversion of the gingival finish line must also have
vertical concavity or flutes.vertical concavity or flutes.

The axial contours of crowns placed onThe axial contours of crowns placed on
teeth whose furcation flutes areteeth whose furcation flutes are
intercepted by preparation finish linesintercepted by preparation finish lines
must likewise reflect the concavity risingmust likewise reflect the concavity rising
from the furcation flute.from the furcation flute.
The artificial crown should recreate theThe artificial crown should recreate the
contours of the furcation flute and notcontours of the furcation flute and not
follow the original crown contours.follow the original crown contours.

 The facial surface should be invaginated into aThe facial surface should be invaginated into a
concavity above the bifurcation that extendsconcavity above the bifurcation that extends
occlusally until it meets the facial surface.occlusally until it meets the facial surface.
 The concavities usually merge with featuresThe concavities usually merge with features
originating on the occlusal surface.originating on the occlusal surface.
 There must be no interruption in the verticalThere must be no interruption in the vertical
concavity rising at the margin of the restoration.concavity rising at the margin of the restoration.
 Any horizontal ridge on the facial or lingualAny horizontal ridge on the facial or lingual
surface of the tooth that intersects with thissurface of the tooth that intersects with this
concavity and blocks it will result in plaqueconcavity and blocks it will result in plaque
retaining area.retaining area.

PLACE OF MARGINS OFPLACE OF MARGINS OF
RESTORATION:RESTORATION:
 Except for the risk of subgingivalExcept for the risk of subgingival
decay and esthetic consideration, it is bestdecay and esthetic consideration, it is best
to terminate preparations above theto terminate preparations above the
gingival margin. If periodontal therapygingival margin. If periodontal therapy
has been performed and the gingival hashas been performed and the gingival has
receded, the preparations should end atreceded, the preparations should end at
the cementoenamel junction. Even if thethe cementoenamel junction. Even if the
tissue does not recede, the margin of thetissue does not recede, the margin of the
tooth preparation should be away fromtooth preparation should be away from
the soft tissue.the soft tissue. www.indiandentalacademy.comwww.indiandentalacademy.com

Crown margins, when placedCrown margins, when placed
subgingivally, should be located at thesubgingivally, should be located at the
base of the gingival sulcus, which is thebase of the gingival sulcus, which is the
level reached when a thin blunt probe islevel reached when a thin blunt probe is
positioned without pressure into thepositioned without pressure into the
gingival sulcus. The gingival fibers cangingival sulcus. The gingival fibers can
then brace the gingiva against the tooththen brace the gingiva against the tooth
and the margin of the completedand the margin of the completed
restoration.restoration.

Microscopically, the margin is rough andMicroscopically, the margin is rough and
an excellent site to harbor bacteria. Sincean excellent site to harbor bacteria. Since
the margin of the gingiva rapidly collectsthe margin of the gingiva rapidly collects
plaque, this is the site of recurrent decay.plaque, this is the site of recurrent decay.
If decay does not result, the plaqueIf decay does not result, the plaque
causes periodontal disease at this mostcauses periodontal disease at this most
critical area which is not self-cleansing.critical area which is not self-cleansing.

 Conversely,Conversely,
restorations shouldrestorations should
not be forcednot be forced
subgingivally into thesubgingivally into the
connective tissue, butconnective tissue, but
placed in theplaced in the
intracrevicular spaceintracrevicular space
without violatingwithout violating
biologic width.biologic width.
Tearing of theTearing of the
epithelial attachmentepithelial attachment
causes it to migratecauses it to migrate
apically and theapically and the
sulcus to deepen intosulcus to deepen into
a pocketa pocket www.indiandentalacademy.comwww.indiandentalacademy.com

BIOLOGIC WIDTH EMBRASURES:BIOLOGIC WIDTH EMBRASURES:
 The teeth touch in an area called a proximalThe teeth touch in an area called a proximal
contact, the spaces below the contact are knowncontact, the spaces below the contact are known
as embrasures. In health, the embrasures areas embrasures. In health, the embrasures are
usually filled with tissue . Embrasures protectusually filled with tissue . Embrasures protect
the gingival from food impaction and deflect thethe gingival from food impaction and deflect the
food to massage the gingival surface. Theyfood to massage the gingival surface. They
provide spillways for food during mastication andprovide spillways for food during mastication and
relieve occlusal forces when resistant food isrelieve occlusal forces when resistant food is
chewed.chewed.

 The ProximalThe Proximal
surfaces of dentalsurfaces of dental
restorations arerestorations are
important becauseimportant because
they determine thethey determine the
embrasures essentialembrasures essential
for gingival healthfor gingival health

PONTIC IN FIXED PROSTHESIS:PONTIC IN FIXED PROSTHESIS:
 A pontic is important to a FPD because itA pontic is important to a FPD because it
alters the functional and environmentalalters the functional and environmental
demands directed onto the teeth and the ridge.demands directed onto the teeth and the ridge.
The pontic mechanically unifies the abutmentThe pontic mechanically unifies the abutment
teeth, covers the residual ridge, assumes ateeth, covers the residual ridge, assumes a
dynamic role in the prosthesis, and is notdynamic role in the prosthesis, and is not
considered to be a lifeless insert of material.considered to be a lifeless insert of material.
 In this role the pontic restores the function ofIn this role the pontic restores the function of
the missing tooth, ensures adequate sanitation,the missing tooth, ensures adequate sanitation,
and is esthetically pleasing, comfortable, andand is esthetically pleasing, comfortable, and
biologically tolerable.biologically tolerable.

PONTIC DESIGN CLASSIFICATION:PONTIC DESIGN CLASSIFICATION:
 Pontic Design are classified in two generalPontic Design are classified in two general
groups those that contact the oral mucosa andgroups those that contact the oral mucosa and
those that do not. Pontic selection dependsthose that do not. Pontic selection depends
primarily on esthetics and oral hygiene. In theprimarily on esthetics and oral hygiene. In the
anterior region, where esthetics is a concern,anterior region, where esthetics is a concern,
the pontic should be well adapted to the tissuethe pontic should be well adapted to the tissue
to make it appear that it emerges from theto make it appear that it emerges from the
gingival. Conversely, in the posterior regionsgingival. Conversely, in the posterior regions
(mandibular premolar and molar areas),(mandibular premolar and molar areas),
esthetics can be compromised in the interest ofesthetics can be compromised in the interest of
designs that are more amenable to oraldesigns that are more amenable to oral
hygiene.hygiene. www.indiandentalacademy.comwww.indiandentalacademy.com

A. MUCOSAL CONTACTA. MUCOSAL CONTACT
1. Ridge lap1. Ridge lap
2. Modified ridge lap2. Modified ridge lap
3. Ovate3. Ovate
4. Conical4. Conical
B. NO MUCOSAL CONTACTB. NO MUCOSAL CONTACT
1. Sanitary (Hygienic)1. Sanitary (Hygienic)
2. Modified sanitary (Hygienic)2. Modified sanitary (Hygienic)

PERIODONTAL SPLINTSPERIODONTAL SPLINTS
Splint (GPT – 7)Splint (GPT – 7)
1.1. A rigid or flexible device that maintainsA rigid or flexible device that maintains
in position a displaced or movable part;in position a displaced or movable part;
also used to keep in place and protect analso used to keep in place and protect an
injured part.injured part.
2.2. A rigid or flexible material used toA rigid or flexible material used to
protect, immobilize, or restrict motion in aprotect, immobilize, or restrict motion in a
part.part.
3.3. To immobilize, support, or brace.To immobilize, support, or brace.

Splinting (GPT – 7)Splinting (GPT – 7)
In dentistry, the joining of two or moreIn dentistry, the joining of two or more
teeth into a rigid unit by means of fixed orteeth into a rigid unit by means of fixed or
removable restorations or devices.removable restorations or devices.
Splint by definition is an appliance usedSplint by definition is an appliance used
for immobilization of injured or diseasedfor immobilization of injured or diseased
parts.parts.
A Periodontal splint is an appliance usedA Periodontal splint is an appliance used
for maintaining or stabilizing mobile teethfor maintaining or stabilizing mobile teeth
in their functional position.in their functional position.

Since functional movement of the tooth withinSince functional movement of the tooth within
the socket is necessary for maintaining thethe socket is necessary for maintaining the
health of periodontal tissues it may not behealth of periodontal tissues it may not be
advisable to immobilize teeth with the help ofadvisable to immobilize teeth with the help of
splints. Since mobile teeth are splinted tosplints. Since mobile teeth are splinted to
adjacent healthy teeth, abnormal tooth mobilityadjacent healthy teeth, abnormal tooth mobility
during mastication is prevented.during mastication is prevented.

The splinted teeth act as a unit andThe splinted teeth act as a unit and
redirect the masticatory forces to theredirect the masticatory forces to the
whole unit rather than individual teeth.whole unit rather than individual teeth.
Inclusion of healthy teeth in theInclusion of healthy teeth in the
splinted segment results insplinted segment results in
augmentation of crown-root ratio and aaugmentation of crown-root ratio and a
net decrease in the force on individualnet decrease in the force on individual
tooth.tooth.
Splinting mobile teeth increasesSplinting mobile teeth increases
patients comfort and function,patients comfort and function,
significantly.significantly. www.indiandentalacademy.comwww.indiandentalacademy.com

CLASSIFICATION OFCLASSIFICATION OF
SPLINTSSPLINTS
 Splints may be classified based on theSplints may be classified based on the
length of time they are used as:length of time they are used as:
 Temporary splintsTemporary splints
Provisional splints andProvisional splints and
Permanent splintsPermanent splints

Temporary splint :Temporary splint :
 A temporary splint is used for aA temporary splint is used for a
short period of time to stabilise theshort period of time to stabilise the
teeth and allow normal healing to taketeeth and allow normal healing to take
place. It is generally used followingplace. It is generally used following
traumatic episodes to maintain thetraumatic episodes to maintain the
mobile teeth in normal position duringmobile teeth in normal position during
healing. Temporary splints are alsohealing. Temporary splints are also
used following periodontal therapyused following periodontal therapy
inorder to achieve uneventful healinginorder to achieve uneventful healing
or regeneration.or regeneration.

Provisional splints:Provisional splints:
Sometimes Clinician may anticipateSometimes Clinician may anticipate
reduction in the mobility of teeth followingreduction in the mobility of teeth following
periodontal therapy but may not beperiodontal therapy but may not be
confident of the degree of reduction inconfident of the degree of reduction in
mobility. In such cases a provisionalmobility. In such cases a provisional
splint is utilised during periodontalsplint is utilised during periodontal
therapy and the mobile teeth aretherapy and the mobile teeth are
stabilised permiting healing to take place.stabilised permiting healing to take place.

After a reasonable period of time theAfter a reasonable period of time the
splint is removed and the status of thesplint is removed and the status of the
teeth is evaluated. If the mobility hasteeth is evaluated. If the mobility has
reduced significantly so as to permitreduced significantly so as to permit
the teeth to function normally, thethe teeth to function normally, the
splint is discarded. Such splints aresplint is discarded. Such splints are
termed provisional splints.termed provisional splints.

Permanent Splints :Permanent Splints : In certainIn certain
cases retention of the mobile teethcases retention of the mobile teeth
may be important from esthetic ormay be important from esthetic or
functional point of view. A permanentfunctional point of view. A permanent
splint may be delivered in such casessplint may be delivered in such cases
provided the patient is motivated wellprovided the patient is motivated well
enough to maintain meticulous oralenough to maintain meticulous oral
hygiene and follow the instructionshygiene and follow the instructions

BIBLIOGRAPHYBIBLIOGRAPHY
Contemporary Fixed ProsthodonticsContemporary Fixed Prosthodontics
–– RosenstielRosenstiel
Theory and Practice of FixedTheory and Practice of Fixed
ProsthodonticsProsthodontics –– Tylman.Tylman.
Fundamental of Fixed ProsthodonticsFundamental of Fixed Prosthodontics
–– ShillingburgShillingburg
Clinical PeriodontologyClinical Periodontology
–– GlickmanGlickman

Periodontal considerations in fpd/ orthodontic straight wire technique

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