PERIODONTAL

CONSIDERATIONS IN FPD
Jojo Quinitio, DDM
 Learning Outcomes
2

 By the end of the lecture, the student must be able

to
1. Understand the importance of periodontal health in ensuring the
success of fixed prosthodontic service
2. Review the anatomy and histology of the periodontal tissues
3. Understand the importance of preserving the biologic width
when restoring a tooth
4. Discuss the etiology and progression of periodontal disease
5. Discuss how to perform a thorough periodontal examination
6. Discuss some procedures that are done to prepare the tooth
and periodontal tissues prior to prosthodontic treatment
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 In fixed prosthodontics, the periodontal health of

the abutment teeth must be ensured

 An abutment tooth that has a healthy periodontal

status has a better chance of success than that with a
poor periodontal status

 A basic understanding of periodontics and its

relation to restorative dentistry is therefore essential
 Anatomy of the Periodontium
4

1. Gingiva
 Normal healthy gingiva is pink and stippled
 Extends from the free gingival margin to the alveolar
mucosa
 The gingivae and the alveolar mucosa are separated by a
line called the mucogingival junction (MCJ)
 Apical to the MCJ is the vestibule
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 Gingiva consists of 3 parts:

a. Free gingiva (marginal gingiva) – extends from the most
coronal part of the gingiva to the epithelial attachment with
the tooth

b. Attached gingiva – extends from the level of the epithelial

attachment to the junction between the gingiva and alveolar
mucosa (MCJ)

c. Interdental papillae – triangular projections of gingivae filling

the area between adjacent teeth
*col – central concavity connecting the buccal and lingual parts
of the papillae
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 A V-shaped depression on the facial surface of the gingiva

and apical to the level of the epithelial attachment is called
the free gingival groove (it divides the free gingiva from the
attached gingiva)
 MG – marginal gingiva
FGG – free gingival groove
AG – attached gingiva
MGJ – mucogingival junction
AM – alveolar mucosa
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 Alveolar
mucosa MCG

Attached Marginal
gingiva gingiva

8
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2. Periodontium
 Periodontium is a connective tissue structure attached to the
periosteum of maxilla and mandible that anchors the teeth
to the alveolar process

 It provides attachment and support, nutrition, synthesis and

resorption and mechanoreception to the teeth

 Main element of the periodontium is the periodontal

ligament (PDL) which consists of collagen fibers embedded
in bone and cementum giving support to the teeth
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3. Dentinogingival junction
 At the base of the sulcus is the dentinogingival junction
 Depth of the sulcus varies but the average is about 1.8 mm
 The alveolar crest should be found approximately 2 mm
apical to the base of the sulcus

 Biologic Width = epithelial attachment (1 mm) +

connective tissue attachment (1 mm)

 Average BW = 2 mm
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 Biologic Width
12

 Biologic width varies:

Incisors and canines – 1.75 mm
Premolars – 1.97 mm
Molars – 2.08 mm

 Methods of accurately determining BW:

a. Tactile – bone sounding
b. Soft tissue cone beam computed tomography
 What is the Importance of the Biologic
13
Width?
 Biologic width – acts as a barrier and prevents
penetration of microorganisms into the periodontium

 Biologic width must always be maintained to

preserve the periodontal health

 Restorative/crown margins should never be placed

within the biologic width
 What is the Importance of the Biologic
14
Width?
 A minimum of 3 mm space between the restoration
margin and the alveolar bone is required to
maintain a healthy periodontium
 What is the Importance of the Biologic
15
Width?
 Consequences of violating the biologic width
1. Gingival inflammation
2. Attachment loss
3. Bone loss
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 Crown Lengthening
17

 Surgical procedure to expose a greater amount of

tooth structure for the purpose of restoring the tooth

 This is done by removing gingival tissue, bone or

both
 Crown Lengthening
18
 Crown Lengthening
19
 Periodontal Disease
20

 Periodontal disease must be recognized and treated

before fixed prosthodontics so that the gingival tissue
levels can be determined for proper margin placement,
esthetics and proper retraction

 Periodontal disease is an inflammatory disease of the

gingiva and the deeper tissues of the periodontium

 It is characterized by pocket formation and bone loss

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 Etiology of periodontal disease: microbial plaque

which causes inflammation

 Dental plaque – consists mainly of microorganisms,

leukocytes, enzymes, food debris, epithelial cells
and macrophages in an intracellular matrix

 Matrix – 70% is bacteria; 30% is carbohydrates,

proteins, calcium and phosphate ions
 Periodontal Diseases
22

1. Gingivitis – inflammation of the gingiva

 Caused mainly by plaque
 Changes in the gingiva characterized by redness, swelling,
tenderness and bleeding
 There may be deepening of the sulcus or pocket formation
due to inflammation of the gingiva
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2. Periodontitis – advanced stage of periodontal

disease
 Due to chronic inflammation, deeper layers of the
connective tissue become involved
 There is breakdown of the alveolar process – bone loss
 Periodontal pocket formation due to apical migration of
the epithelial attachment with loss of bone support
 Patient will have a difficult time in cleaning the pockets
because of its depth
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 Periodontal Examination
25

1. Visual examination of the gingiva

 Color – healthy is pink; inflammed is red
 Consistency – healthy is firm; inflammed is
 Texture – healthy is stippled; inflammed, there is loss of
stippling
 Shape – healthy is firmly attached to tooth, knife-edged,
sharply pointed papillae fill the interproximal space;
inflammed is swollen, puffy, blunted papillae
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2. Probing
 The periodontal probe is one of the most useful diagnostic
tools for examining the periodontium
 It provides a measurement of the depth of periodontal
pockets and sulci on all surfaces of each tooth
 6 areas are probed around each tooth
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 Measure from the top of the marginal gingiva to the bottom

of the sulcus
 Normal sulcus is about 2 mm
 Anything more than 5 mm is considered a pocket
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3. Mobility
 Mobility test is an indication of the loss of attachment of
the tooth
 Radiographically seen in the form of a widened PDL space
 Grade 1 – slightly more than normal (<0.2 mm horizontal
movement)
 Grade 2 – moderately more than normal (1-2 mm
horizontal movement)
 Grade 3 – severe mobility (>2 mm horizontal or any
vertical movement)
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4. Radiographic examination
 Check alveolar crest for signs of resorption
 Integrity of the lamina dura
 Evidence of horizontal and vertical bone loss
 Widened periodontal ligament
 Density of the trabeculae of both maxilla and mandible
 Size and shape of the roots compared to the crown –
important for analysis of crown-root ratio
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6. Presence of parafunctional habits

 Bruxism
 Check for wear facets on teeth
 Radiographs – widened periodontal ligament spaces
 Tooth mobility
 Periodontal Treatment
40

1. Oral physiotherapy – oral hygiene instructions; most

important aspect of periodontal therapy is control of
plaque; if the patient doesn’t maintain excellent oral
hygiene, subsequent periodontal and restorative
treatments will be jeopardized

2. Scaling and polishing

3. Chemotherapy – mouthrinse, antibiotics
4. Periodontal surgery
 Periodontal Treatment
41

 Surgery
1. Gingivectomy – removal of diseased or hypertrophied
gingiva
2. Mucogingival procedures
3. Mucoperiosteal flap entry with osseous recontouring – aim
is to modify the shape of the bone where plaque control is
difficult or impossible
 Periodontal Treatment
42

 Advanced Surgery Technique:

1. Hemisection – cutting tooth in half; used to treat furcation
involvement
2. Bone grafting or transplantation
3. Root amputation or resection – removal of a root in a
multirooted molar; used to treat Class II and III furcation
lesions
4. Guided tissue regeneration
 Hemisection
43
 Hemisection
44

Tooth 46 is hemisected due to furcation involvement (before any hemisection

is done, the tooth should be endodontically treated).
 Hemisection
45

The mesial half is extracted while the distal half is retained

and prepared like a premolar.
 Hemisection
46

The distal half of tooth 46 will now serve as an abutment for

a 3-unit bridge with tooth 45.
 Root Amputation or Resection
47
 Root Amputation or Resection
48

A 79 years old petite woman

was referred for an evaluation of
tooth #36. Her medical history
included a hypertension and type II
diabetes controlled by medications.
She reported no pain, occasional
bad taste and discomfort when
eating. Clinical examination
revealed alveolar bone loss around
the distal root of #36.
 Root Amputation or Resection
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TREATMENT OPTIONS:

1. Extraction and tooth

replacement

2. Root canal treatment and distal

root amputation
 Root Amputation or Resection
50

After RCT was completed on the

mesial root, composite resin was
placed into the distal root and a
root amputation was completed.
When considering a root
amputation, one must evaluate the
face type, the musculature (how
strong are the masseters, angle of
the jaw, etc.), occlusion. This
procedure may not work for a 30
y/o with bradycephalic face,
however in older individual with
weaker muscles of mastication, it
can last a lifetime.
 Occlusion and Periodontal Health
51

 Occlusal trauma – an injury to the periodontal

attachment as a result of excessive occlusal force

 3 types of Occlusal Trauma:

1. Primary occlusal trauma – injury resulting from
excessive occlusal forces applied to a tooth or teeth
with normal periodontal support

Examples: high restorations, bruxism, drifting or extrusion into

edentulous spaces and orthodontic movement
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2. Secondary occlusal trauma – injury resulting from normal

occlusal forcess applied to a tooth or teeth with inadequate
periodontal support

3. Combined occlusal trauma – injury from an excessive

occlusal force on a diseased periodontium

*occlusal trauma doesn’t cause periodontitis but it exacerbates it

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 Signs and symptoms of occlusal trauma:

1. Mobility
2. Pain on chewing or percussion
3. Fremitus
4. Occlusal prematurities
5. Wear facets
6. Tooth migration
7. Chipped or fractured teeth
8. Thermal sensitivity
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 Radiographic features:
1. Widened PDL space
2. Bone loss – usually vertical
bone loss
3. Root resorption
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 Treatment for occlusal trauma:

1. Occlusal adjustment – adjust any high restorations
2. Management of parafunctional habits
3. Stabilization of mobile teeth with splints
4. Orthodontic tooth movement
5. Occlusal reconstruction
6. Extraction of selected teeth
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