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Periodontics

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Combining perio-restorative protocols


to maximize function
Lloyd M. Tucker, DMD, MSD   n  Daniel J. Melker, DDS   n  Howard M. Chasolen, DMD

This article describes a team approach for periodontal and to trauma and inflammation. The team approach consists of a
restorative treatment intended to produce a predictable, biologi- restorative phase and a surgical phase. The restorative phase
cally sound outcome that preserves more supporting bone and involves preparation with complete caries removal, adhesive core
restores carious and broken down teeth. The goal of periodontal buildups, and provisionalization. The surgical phase involves
treatment, when performed in conjunction with restorative biologic shaping of the roots and judicious osseous resection.
dentistry, is to provide restorative dentists with a high percentage Case studies are used to demonstrate the team approach.
of tooth structure that allows for a supragingival margin. An Received: January 6, 2012
equally important goal is to ensure that an adequate thickness of Final revisions: April 11, 2012
connective tissue exists to create an environment more resistant Accepted: April 16, 2012

O
ver the years, restorative have no idea how much or how the likelihood of future inflam-
materials have become so little bone had to be removed and mation.6,7 At times, a significant
advanced that successful could not even be sure as to which amount of bone must be removed,
periodontal treatment depends teeth were salvageable. which can weaken the stability of
greatly on the work of the restorative Performing adhesive core buildups the tooth or create weakened and
dentist.1 The advent of the adhesive enables clinicians to facilitate thor- vulnerable furcation areas. As more
core buildup and provisionals gives ough caries removal, seal dentinal bone is removed from the furcation,
the periodontist vertical access to tubules prior to the definitive the likelihood of future maintenance
many areas on the tooth surface that restoration, provide ideal prepara- problems increases.8 As a result, it
might cause periodontal breakdown. tion form, eliminate undercuts in is critical to preserve as much bone
It is essential that the restorative the preparation, increase provisional as possible to support the tooth,
dentist place a core buildup prior to retention, allow for a uniform thick- especially in the furcation area.
periodontal correction.2 This step ness of definitive restorative material, Biologic shaping moves the restor-
allows the periodontist to assign minimize distortion or tearing of ative margin away from the bone,
individual tooth prognoses, deter- impressions, and provide the bio- minimizing the amount by which the
mine the apical extent of caries (and logic periodontal surgical template. crown must be lengthened to move
thus establish a definitive margin the bone away from the restorative
before a bone/restorative relationship Biologic shaping margin. Table 1 lists reasons, based
is developed), and establish complete Biologic shaping is an adjunct to on the authors’ experience, when
access for unimpeded treatment. If conventional crown lengthening.3-5 biologic shaping might be necessary.
the core is not completed prior to Conventional crown lengthening This article examines require-
surgery, there would be no way for uses the existing margins of an old ments for successful treatment
the periodontist to determine where restoration or the cementoenamel using a team approach, based on a
the soft tissue and bone should be junction (CEJ) of a non-restored series of comprehensive periodontal
positioned. If surgery is performed tooth to determine the amount of and restorative cases. It will be
prior to caries removal, core bone removal necessary to establish apparent when doing combined
buildups, and provisionalization, adequate space for the biologic periodontal and restorative treat-
the periodontist would, at best, be width. Creating proper space for the ment that the restorative dentist’s
making an educated guess as to the biologic width ensures that a new knowledge of materials and biology
necessary amount of bone removal. margin will not impinge upon the is paramount to the long-term suc-
At worst, the periodontist would periodontal complex and reduces cess of these cases.

280 July/August 2012 General Dentistry www.agd.org


Responsibilities of be relined or remade to provide
the periodontist ideal fit and the proper relationship Table 1. Reasons for biologic
When treating combined periodontal to the new soft tissue margin. The shaping.
and restorative cases, the periodontist final restoration must have proper
must create a final margin location contours and perfect marginal fit Replacing or supplementing the current
(either supragingival or just into to enable long-term maintenance. indications for clinical crown lengthening
the sulcus), improve tissue health Finally, the restorative dentist must Minimizing ostectomy
to guarantee an ideal impression, support the periodontist by moti- Facilitating supragingival or just slightly
and provide an abundance of dense, vating the patient to proceed with intrasulcular margins to preserve the
biologic width
thick connective tissue bound to proper comprehensive care.
Eliminating developmental grooves
the root surface and bone to protect
the underlying periodontal support. Comprehensive periodontal Eliminating previous subgingival
restorative margins
This abundance of tissue is essential and restorative procedures
Reducing or eliminating furcation
for taking impressions and placing All previous restorative materials and
anatomy, thus facilitating margin
final restorations, since restorations decay should be removed. A core placement
alter the environment and increase buildup of composite bonded resin Allowing supragingival or intrasulcular
the likelihood of inflammation, should be placed (where necessary) impression techniques
while a mucosal margin can remain to add volume to the teeth. The Removing all CEJs
inflammation-free when it is adjacent core helps to determine where the
to a non-restored natural tooth.9 final margin of the new restoration
For esthetic surgical procedures, will be placed. Acrylic provisionals
the periodontist must provide ideal should be luted. The authors recom-
clinical anterior crown length so mend using Durelon (3M ESPE) as should be used to help decrease
that the restorative dentist can pro- a temporary cement, due to its anti- postsurgical sensitivity. The liquid is
vide patients with the highest level microbial properties and ability to applied to the root surface for 45–60
of esthetic treatment. The periodon- help decrease sensitivity. Provisional seconds and lightly air-dried. This
tist also must make every attempt to restorations must be removed at the step should be repeated two or three
avoid black triangles when carrying time of surgery to improve access. times. The provisional prosthesis
out surgical procedures and support The roots must be shaped and the should be secured with a polycarbox-
the restorative dentist by motivating old margins removed; also, cervical ylate cement such as Tylok (Dentsply
patients to accept the comprehen- enamel projections must be reduced Caulk) or Durelon. Both of these
sive treatment plan. or eliminated. The ideal restorative cements have an antimicrobial effect
emergence profile (flat is better than due to the zinc oxide present in their
Responsibilities of the convex contours) should be estab- formulations. Other polycarboxylate
restorative dentist lished; diamond burs are recom- cements can be used depending on
As part of the team approach, the mended for this process. Any reverse the operator’s comfort level.
restorative dentist must remove architecture should be corrected; Home care instructions include
all caries and place core buildups, where biologic width violation is rinsing with chlorhexidine twice
which provide landmarks that will anticipated, bone removal might daily (morning and evening) and
allow the periodontist to establish be necessary. If the surgical site has brushing with a prescription, high
the proper location for margin insufficient keratinized tissue, the concentration fluoride toothpaste
placement. Provisionals must be connective tissue thickness must be at bedtime to help decrease ther-
placed wherever an old crown is to augmented, which will make the mal sensitivity. After meals, the
be replaced or decay might impede marginal tissues less prone to inflam- patient should rinse with water to
the location of the final margin. mation and protect the supporting remove any food particles. If the
These provisionals will provide the bone. In addition, the connective patient prefers an over-the-counter
surgeon with vertical access so that tissue protects underlying periodon- mouthrinse instead of water, the
all root surface irregularities can be tal tissues from irritation by impres- authors recommend Listerine
treated and harmony can be created sion materials and cementation. (Johnson & Johnson Healthcare
between bone and tooth surface. At Once the flaps are adapted and Products) due to its demonstrated
four weeks, the provisionals must sutured, liquid potassium oxalate anti-gingivitis properties.

www.agd.org General Dentistry Special Periodontics Section 281


Periodontics  Combining perio-restorative protocols to maximize function

Fig. 1. A preoperative view of leaking crowns. Fig. 2. Caries found under existing restorations.

Fig. 3. An occlusal view after the removal of old crowns. Fig. 4. A patient after complete caries removal.

Fig. 5. Adhesive core buildups bonded in place. Fig. 6. An occlusal view of the adhesive cores in Figure 5.

When the provisionals are within the sulcus. The periodontist’s cords are used to facilitate isolation
remade or relined at four weeks, actions should facilitate hygiene and and removed after the adhesive
there should be 1 mm between the maintenance procedures. cores are completed (Fig. 5 and 6).
provisional and soft tissue margins, Before the periodontist even treats At that point, biologic, esthetic,
which will allow the biologic width the patient, the restorative dentist and functional determinants can be
to mature in a coronal direction. must perform caries removal and established. The fixed provisional res-
No preparation or refining of tooth place core buildups and provisional torations not only allow dentists to
surfaces should be performed at this crowns. Patients often have existing test esthetic and occlusal hypotheses,
time. At 14 weeks, chamfer margins restorations that are undermined by they also can be removed to provide
are placed just coronal to the gingi- recurrent decay (Fig. 1–3). All caries 360 degree access (Fig. 7 and 8),
val collar and impressions are taken. must be completely removed without which allows the periodontist to per-
When endodontics are required, concern for extending the prepara- form crown lengthening and biologic
the new margin can be placed tion subgingivally (Fig. 4). Retraction shaping without impedance.

282 July/August 2012 General Dentistry www.agd.org


Fig. 7. An occlusal view of the cemented fixed provisional restoration. Fig. 8. An anterior view of the provisional restoration in Figure 7.

Four weeks after periodontal cor-


rection, the provisional restoration
in the illustrated case is relined
1 mm shy of (or coronal to) the
soft tissue margin (Fig. 9). The
provisional could have been entirely
remade, but nothing more than a
simple reline was necessary. There is Fig. 9. The provisional restoration is relined 1 mm coronal to the tissue margin.
still no defined restorative margin on
the tooth. The biologic shaping has
completely removed any restorative
margin and all undercuts from bone
to the occlusal/incisal surface. From areas (Fig. 11). If crown lengthening The periodontist started by
an occlusal view, one sees only a per- is done prior to provisionalization, removing all CEJs and irregu-
fectly smooth tube of tooth structure the periodontist’s access is severely larities on the root surfaces. Most
coming through the soft tissues. impaired. Split-thickness flap reflec- importantly, the old margins of
tion allows for easy visualization of the restorations were removed,
Case report No. 1 the core-to-bone relationship and creating a root surface free from
The patient came to the perio- demonstrates that the periodontist any landmarks that dictate bone
dontist with provisionals already has ideal working conditions for removal to provide space for the
in place (Fig. 10). Removing the performing a treatment that will biologic width. A C847-016 bur
provisionals gives the periodontist produce a stable periodontal envi- (Axis Dental) was used initially for
vertical access to all interproximal ronment (Fig. 12). tooth surface contouring (Fig. 13).

Fig. 10. A patient after caries removal,


core buildup, and provisionalization of the Fig. 11. The patient in Figure 10, following the
mandibular right posterior area. removal of provisionals. Fig. 12. Reflection of a split thickness.

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Periodontics  Combining perio-restorative protocols to maximize function

Fig. 13. The patient in Figure 10, following the Fig. 15. The patient in Figure 10, after a super
removal of CEJs, old restorative margins, and Fig. 14. The patient in Figure 10, after the fine bur is used for additional contouring of the
root surface irregularities. periosteum is reflected for osseous contouring. tooth surface.

Fig. 17. With the periosteum repositioned over


Fig. 16. The patient in Figure 10, after biologic the bone, palatal connective tissue is sutured Fig. 18. A connective tissue graft is covered by
shaping and osseous contouring. in place. an overlying flap.

and dense, thick connective tissue


(Fig. 17). Suturing should position
the tissue just coronal to the bone so
that the patient experiences minimal
discomfort when attempting to
Fig. 20. The furcation contours of the final achieve primary closure. The connec-
Fig. 19. An occlusal view shows barreled-in restorations mimic the underlying tooth tive tissue graft was covered by the
furcations. structure. overlying flap and 5-0 chromic gut
sutures were used to close the buccal
flap to the lingual flap (Fig. 18).
The occlusal view showed barreled-
in furcations. Overhanging tooth
The periosteum was reflected from no undercuts in the preparations structure and all heights of contour
the bone to allow for osseous con- and the bone demonstrated positive were removed from bone level to the
touring. A C801L-023 bur (Axis architecture (Fig. 16). occlusal table of the tooth (Fig. 19).
Dental) was used for the critical With the periosteum repositioned The final restorations consisted
step of creating a parabolic archi- over the bone, connective tissue of an all-ceramic crown on tooth
tecture for ideal approximation taken from the palate was sutured No. 28 and porcelain-fused-to-gold
of soft tissue over bone (Fig. 14). in place to increase the support crowns on teeth No. 29–32. It
Using a super fine bur (F847-016, and protection for the underlying should be noted that the furcal con-
Axis Dental), additional contour- periodontal foundation. The authors tours of the restorations mimic the
ing and refining was performed believe that connective tissue is underlying tooth structure, which
to create a smooth root surface the key to long-term maintenance was prepared at the time of surgery
(Fig. 15). After biologic shaping of periodontal restorative cases, (Fig. 20). No heights of contour
and osseous contouring, there were because it has very few blood vessels were placed and the furcations were

284 July/August 2012 General Dentistry www.agd.org


Fig. 21. A patient with provisionals placed in Fig. 22. The patient in Figure 21, after the Fig. 23. Reflected tissue shows a mesial concav-
advance of periodontal correction. removal of provisionals. ity on tooth No. 12, with associated calculus.

barreled in all the way to the occlusal margin just coronal to the gingival
surfaces. The soft tissue-to-tooth collar at 12 weeks. Removing
interface was ideal. The patient was the concavity gives the hygienist
placed on a three-month alternating and patient easy access to plaque,
recall schedule between the restor- calculus, and biofilm for long-term
ative dentist and periodontist and has maintenance (Fig. 24). Once the Fig. 24. The patient in Figure 21, following
not demonstrated any further break- restorations have been completed, removal of the mesial concavity.
down since completion of treatment. the patient will be placed on a
three-month alternating recall
Case report No. 2 schedule between the restorative
As is often the case, caries control dentist and the periodontist.
and provisionalization occurred The minimal vertical probing
prior to periodontal surgery Case report No. 3 depth in the furcation can be decep-
(Fig. 21). The provisionals were In this case, teeth No. 19 and 20 tive. When restoring molars with
removed to allow the periodon- were treated using a periodontal- existing restorations, it is critical to
tist unimpeded vertical access restorative approach. Caries evaluate not only the vertical prob-
(Fig. 22). Reflecting the soft tissue was removed and the teeth were ing, but the horizontal component
revealed a mesial concavity on provisionalized (Fig. 25). After the of the furcation as well (Fig. 26).
tooth No. 12, with associated provisionals were removed, the soft While vertical probing was mini-
calculus present (Fig. 23). Remov- tissues showed ideal health, which mal, the horizontal probing depth
ing the mesial concavity made can occur only when provisionals demonstrated significant furcation
it possible to place a restorative are perfectly contoured and fitted. breakdown (Fig. 27). The furcation

Fig. 25. A patient with provisionals on teeth


No. 19 and 20 in advance of periodontal Fig. 26. The patient in Figure 25, with minimal Fig. 27. The horizontal probing depth
correction. vertical probing depth in the furcation. demonstrates significant furcation breakdown.

www.agd.org General Dentistry Special Periodontics Section 285


Periodontics  Combining perio-restorative protocols to maximize function

Fig. 28. The patient in Figure 25, following


complete removal of the furcal roof and any Fig. 29. Tissue positioned just coronal to bone Fig. 30. The final restorations, with equigingi-
heights of contour. for development of a new biologic width. val margin placement.

to perform long-term maintenance. results, is unrealistic. A combined


In the present case, the porcelain periodontal/restorative protocol
furcation could have been carried to termed biologic shaping has been
the occlusal surface to prevent any documented to address these issues
unnecessary height of contour in the with predictable, reproducible clini-
final restoration (Fig. 30). A one-year cal precision and long-term success.
Fig. 31. Tooth No. 19, as seen in a postopera- postoperative radiograph verified that
tive radiograph of the patient in Figure 25. the pulp of tooth No. 19 was healthy Disclaimer
and that there was no indication for The authors have no relationship
endodontic treatment (Fig. 31). with any of the manufacturers men-
tioned in this article.
Summary
was removed and any furcal roof Many of today’s patients have Author information
was eliminated to create an environ- restorative needs that often require Dr. Tucker is in private practice
ment for a crown that fit well with the replacement of existing den- limited to periodontics and implant
no areas where plaque and calculus tistry. Often, caries removal and surgery in Seattle, Washington. He
could accumulate. After osseous the establishment of a new restor- is a faculty member at the Pikos
recontouring, the periosteum was ative margin places the anticipated Implant Institute, Palm Harbor,
positioned in place (Fig. 28). The new restorations in an apical or Florida. Dr. Melker is in private
tissue was positioned just coronal to more subgingival position, which practice limited to periodontics
the bone to allow for ideal develop- presents a number of biologic and in Clearwater, FL. Dr. Chasolen
ment of a new biologic width. mechanical problems that could is in private practice limited to
To promote more rapid healing downgrade the long-term prognosis prosthodontics in Sarasota, FL. He
and decrease patient discomfort, one of both the periodontal health and is also an affiliate clinical instructor,
must always attempt to gain primary the restorations. In order to achieve Department of Graduate Prostho-
closure of the soft tissue when sutur- superior restorative results, perio- dontics, University of Florida
ing flaps. Due to the location of pulp dontal corrective procedures are School of Dentistry, Gainesville.
chambers, endodontic treatment is necessary to return the foundation
not usually necessary when barreling to a healthy state. Traditionally, References
out furcations. (Fig. 29). The goal crown lengthening was indicated 1. Vaidyanathan TK, Vaidyanathan J. Recent ad-
vances in the theory and mechanism of adhe-
of the periodontist is to provide the for deep subgingival margins— sive resin bonding to dentin: A critical review. J
restorative dentist with a tooth sur- not only to facilitate impression Biomed Mater Res Part B Appl Biomater 2009;
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2. Strupp WC Jr. Crown & Bridge Update 1999;4(1):
a margin just coronal to the gingival width impingement. Attempting 1-7.
collar. A feldspathic porcelain crown to take impressions or to cement 3. DiFebo G, Carnevale G, Sterrantino SF. Treatment
with proper contours in the furcation or bond restorations in this septic of a case of advanced periodontitis: Clinical pro-
cedures utilizing the “combined preparation”
area allows the patient and hygienist environment, and expecting good

286 July/August 2012 General Dentistry www.agd.org


technique. Int J Periodontics Restorative Dent
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5. Strupp WC Jr, Melker DJ. Maximizing aesthetics
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6. Gargiulo AW, Wentz FM, Orban B. Dimensions
and relations of the dentogingival junction in
humans. J Periodontol 1961;32:261-267.
7. Vacek JS, Gher ME, Assad DA, Richardson AC,
Giambarresi LI. The dimensions of the human
dentogingival junction. Int J Periodontics Restor-
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8. Dibart S, Capri D, Kachouh I, Van Dyke T, Nunn
ME. Crown lengthening in mandibular molars:
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J Periodontol 2003;74(6):815-821.
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Manufacturers
Axis Dental, Coppell, TX
800.355.5063, www.axisdental.com
Dentsply Caulk, Milford, DE
800.532.2855, www.caulk.com
Johnson & Johnson Healthcare Products, Skillman, NJ
888.222.0182, www.listerine.com
3M ESPE, St. Paul, MN
888.364.3577, solutions.3m.com

Published with permission by the Academy of


General Dentistry. © Copyright 2012 by the
Academy of General Dentistry. All rights reserved.

www.agd.org General Dentistry Special Periodontics Section 287