Anatomy of gingiva & periodontium -prosthodontic significance

DILIP KUMAR SINGH

GUIDEPROF(DR.)SAIBAL KUMAR SEN DEPARTMENT OF PROSTHODONTICS GNIDSR

Contents
1. 2. 3. 4. 5. 6. a. b. c. 7. 8.

Introduction to periodontium Different elements of periodontium Occlusal forces & periodontium Concept of BIOLOGICAL WIDTH Pathologies of periodontium Prosthodontic importance of periodontium RPD and periodontium FPD and periodontium Implant and periodontium Conclusion References

Introduction
Periodontium is an indispensible part of any Prosthodontic treatmentRPD, FPD, Implant, It serves as the foundation on which any prosthodontic treatment stands on .

Periodontium
Gingiva Periodontal ligament Cementum Alveolar process

The Gingiva
The Gingiva is the part of the oral mucosa that

covers the alveolar processes of the jaws and surrounds the necks of the teeth. Mainly of three types Marginal Attached Interdental

COL

PAPILLA JUNCTIONAL EPITHELIUM FREE GINGIVA ATTACHED GINGIVA MUCOGINGIVAL JUNCTION ALVEOLAR MUCOSA CEMENTUM PERIODONTAL LIGAMENT ALVEOLAR BONE/CRIBIFORM PLATE LINGUAL PLATE TRABECULAR/CANCELOUS BONE

Marginal/margin/free/ unattached gingiva

Attached Gingiva
Extends from base of the pocket to the mucogingival junction The width of attached & keratinized Gingiva is often narrower in periodontal diseases

Gingiva:Interdentalpapilla

 Lang,N.P, and loe,H :the relationship between the

width of keratinized gingiva & gingival health. J. periodontal 43:623-627, 1979 2mm of keratinized Gingiva , including 1mm of attached Gingiva , is adequate to maintain gingival health
Wilson,R.D & Maynard, J.G:the relationship of

restorative dentistry to periodontic.J.periodontal 1979 5mm of keratinized Gingiva (2mm of free Gingiva +3mm of attached Gingiva) is essentials for placing sub gingival margins

Gingival Fibres
The gingival fibres are arranged in three group Gingivodental Circular transseptal Functions: To brace the marginal gingiva firmly against the tooth. To provide the rigidity necessary to withstand the forces of mastication without being deflected away from the tooth surface. To unite the free marginal Gingiva with the Cementum of the root and the adjacent attached Gingiva.

Color
The colour of the attached and marginal gingiva is generally described as "coral pink" and is produced

by
the vascular supply, the thickness and degree of keratinisation of the epithelium, and the presence of pigment-containing cells.

The alveolar mucosa is red, smooth, and shiny rather than pink and stippled.
The epithelium of the alveolar mucosa is thinner, is

non keratinized, and contains no rete pegs The connective tissue of the alveolar mucosa is loosely arranged, and the blood vessels are more numerous

Size
The size of the gingiva corresponds with the

sum total of the bulk of cellular and intercellular elements and their vascular supply. Alteration in size is a common feature of gingival disease

Contour
The contour or shape of the gingiva varies

considerably and depends on the shape of the teeth their alignment in the arch, the location and size of the area of proximal contact

The marginal gingiva envelops the teeth in collar like

fashion and follows a scalloped outline on the facial and lingual surfaces.

It forms a straight line along teeth with relatively

flat surfaces. On teeth with pronounced mesiodistal convexity (e.g., maxillary canines) or teeth in labial version, the normal arcuate contour is accentuated, and the gingiva is located farther apically

Consistency
The gingiva is firm and resilient and, with the

exception of the movable free margin, tightly bound to the underlying bone. The collagenous nature of the lamina propria and its contiguity with the mucoperiosteum of the alveolar bone determine the firmness of the attached gingiva. The gingival fibres contribute to the firmness of the gingival margin

Position
The position of the gingiva refers to the level at which

the gingival margin is attached to the tooth. When the tooth erupts into the oral cavity, the margin and sulcus are at the tip of the crown; as eruption progresses, they are seen closer to the root. During this eruption process, the junctional epithelium, oral epithelium, and reduced enamel epithelium undergo extensive alterations and remodeling The distance between the apical end of the junctional epithelium and the crest of the alveolus remains constant throughout continuous tooth eruption (1.07 mm).

Periodontal ligament
The periodontal ligament is the connective tissue that surrounds the root and connects it with the bone. It is continuous with the connective tissue of the gingiva and communicates with the marrow spaces through vascular channels in the bone. The average width is about 0.2 mm

Principal fibres of the periodontal ligament

Primarily composed of bundles of type I collagen fibrils. Classified into several groups on the basis of their anatomic location 1. Alveolar crest fibres 2. Horizontal fibres 3. Oblique fibres 4. Periapical fibres 5. Interradicular fibres Also contains oxytalan fibres Also contains cell rests of Malassez

Functions of the Periodontal Ligament

Physical Function Formative and Remodeling Function Nutritional and Sensory Functions

Physical Functions
Provision of a soft tissue "casing" to protect

the vessels and nerves from injury by mechanical forces Transmission of occlusal forces to the bone. Attachment of the teeth to the bone. Maintenance of the gingival tissues in their proper relationship to the teeth. Resistance to the impact of occlusal forces (shock absorption)

Change in PDL during mastication

According to Biancu et.al 1995 & kaneko et al 2001 Histologically , PDL adapts to occlusal load by thickening of PDL space at stress point whereas loss of occlusal function is manifested by narrowing of PDL space
According to Davies et al 2001 PDL physiologically adapts to accumulated occlusal loading by resorption of alveolar structures & resultant tooth mobility, which is actual occlusal trauma & is reversible if the occlusal load is reduced

Cementum
Cementum is the calcified mesenchymal tissue that forms the outer covering of the anatomic root There are two main types of root cementum: acellular (primary) and cellular (secondary) Both consist of a calcified interfibrillar matrix and collagen fibrils.

Ankylosis
Fusion of the cementum and alveolar bone Resorption of the root and its gradual

replacement by bone tissue Implants

ALVEOLAR PROCESS
The alveolar process is the portion of the

maxilla and mandible that forms and supports the tooth sockets Consists of Compact bone cortical bone alveolar bone proper (also known as the cribriform plate or lamina dura) and Cancellous bone

Alveolar process
1 Alveolar bone a) Cribiform plate b) Alveolar wall c) Lamina dura 2 Trabecular bone 3 Compact bone

Occlusal Forces and the Periodontium

occlusal forces Abutment tooth PDL Alveolar bone

Changes in Periodontium due to Occlusal Forces

Alveolar bone undergoes constant physiologic remodeling in response to occlusal forces. When occlusal forces are increased, the cancellous bony trabecular increase in number and thickness, and bone may be added to the external surface of the labial and lingual plates.

The periodontal ligament can accommodate increased function with an increase in width, a thickening of its fiber bundles, and an increase in diameter and number of Sharpey's fibers. Forces that exceed the adaptive capacity of the periodontium produce injury called trauma from occlusion.

When occlusal forces are reduced, the number and thickness of the trabeculae are reduced. The periodontal ligament also atrophies, appearing thinned, and the fibers are reduced in number and density, disoriented and ultimately arranged parallel to the root surface

Concept of BIOLOGICAL WIDTH

Biological width is defined

as the physiologic dimension of juncjtional epithelium and connective tissue attachment It is approximately-2.04mm (0.97mm-junctional epithelium +1.07-connective tissue) For any Prosthodontic treatment to be successful the biologic width should be preserved

Clinical importance of biological width

Placement of the restorative margin 0.5mm into the sulcus allows for the maintenance of the

biologic width If the biologic width is not preserved ,it may result in Gingival inflammation Pocket formation Loss of alveolar bone So any interference to the biologic width should be considered before planning any prosthesis

 Greater than 3.0mm of soft tissue b/w the bone & gingival margin, with adequate attached gingiva allows crown

lengthening by gingivectomy

 With less than 3.0mm of soft tissue b/w the bone & gingival margin

,or less than adequate attached gingiva , a flap procedure & osseous recontouring are required for crown lengthening

 In case of caries or fracture , at least 1.0mm of sound tooth structure should be provided above the

gingival margin for proper restoration

Pathologies of periodontium
Gingival diseasesGingivitis Chronic periodontitis Aggressive periodontitis Necrotizing periodontal diseases NUG NUP Abscesses of periodontium

Gingivitis
Most common gingival

diseases Its nothing but the inflammation of gingiva resulting in bleeding on slight probing Mainly due to the local irritating factors-plaque but may be sometimes associated with non plaque induced factors

Gingivitis
NO PROSTHESIS can be placed in such an

inflamed and swollen condition of gingiva because it not only affects the fit but also will irritate the tissue more , hence will aggravate the condition Margins of the restoration cannot be placed properly

PERIODONTITIS
It is the inflammation of the supporting tissues of the teeth It results in progressive destruction of PDL &

Alveolar bone with pocket formation & gingival recession or both Here clinical sign of attachment loss is seen

PERIODONTITIS
Periodontitis is directly associated with the support of ABUTMENT TEETH It weakens the

supporting structures of the teeth making them mobile & incapable to bear the occlussal load transmit the same to alveolar bone

Any pathology in periodontium Inflammation of gingiva Loss of attachment Destruction of PDL &Ultimately bone loss Supporting structures of teeth are weakened Abutment teeth fails to bear the required Occlusal load & transfer the same to the bone

Support for any prosthesis will be COMPROMISED

Eventually leads to TREATMENT FAILURE

RPD and PERIODONTIUM

The ultimate success of RPD directly depends on the health &

integrity of supporting structures of the teeth esp those to be used as the ABUTMENT following factor should be evaluated carefully before fabricating a RPD Periodontal diseases Degree of gingival recession Loss of epithelial attachment Furcation involment Tooth mobility Amount of bone loss to be assessed by radiograph

McGivney GP, Castleberry DJ ;McCrackens RPD 8th ed

The above factors decide the status of abutment teeth &the remaining structures Support for the prosthesis
Treatment outcome

 Frechette A. Influence of partial denture

design on distributionof forces on abutment teeth. J Prosthet Dent 1956;6:195212 The forces occurring with the RPD can be widely distributed & directed & can be minimized by appropriate design of RPD The design of RPD requires both mechanical & biological consideration Rigid major connector & max coverage of the denture bearing areas with denture bases are of great importance in reducing stress on the abutment teeth

Chamrawy E. Qualitative changes in dental plaque formation related to removable partial dentures. J Oral Rehabil 1979;6:183188 The use of RPDs leads to detrimental changes in the quality and quantity of plaque. Implementing meticulous hygiene of both the oral cavity and dentures can offset these changes.
Isidor F et al J. Periodontal 1990 ; 61 :21-26 Oral hygiene is considered to be one of the most imp factor in RPD prothesis Maintenance of oral hygiene is more crucial for RPD than for FPD a/c to z lahaviz DK, celebric A, valentio peruzovic: Appropriate design & good oral hygiene may decrease the incidence of periodontal disease
(Jour. Oral rehabit 2001)

Possible movements of partial denture

There are three possible movements

depending upon the differences in the support characteristics of the abutment teeth &the soft tissue covering the residual ridges Rotation around the fulcrum line passing through the most posterior abutments when denture base moves vertically towards or away from the supporting residual ridges Rotation around the longitudinal axis formed by the crest of residual ridge

 Rotation around the vertical axis located near the centre of the arch The 1st two movements

do not occur in tooth supported partial dentures whereas the 3rd possible movement occurs in all partial dentures

Vertical vs horizontal forces

More periodontal fibers are activated to resist forces directed vertically on the tooth than are activated to resist horizontal forces Therefore , stabilizing components against horizontal movements must be incorporated in any partial denture design

McGivney GP, Castleberry DJ ;McCrackens RPD 8th ed

Design of RPD components & periodontium

While designing RPD components also, the gingiva & periodontium

is taken care of a/c to stewart & Rudd 1968 Broad distribution of stress through the use of rigid major & minor connector, multiple rests or guiding plane helps in preservation of underlying periodontium (jour of prosthodent 1968)
McHenry KR, Johansson OE, Christersson LA. The effect of

removablepartial denture framework design on gingival inflammation:A clinical model. J Prosthet Dent 1992;68:79980

Gingival areas that are covered by parts of RPD without relief

shows more adverse reaction both clinically & Histologically whereas the uncovered areas are least affected Increased tissue coverage by lateral major connector causes more plaque accumulation

Designing of RPD
The maxillary major

connectors are placed 6.Omm away from the gingival margins It is called as INTENTIONAL RELIEF ,given to avoid any injury to the gingiva uniformly distribute the occlusal forces acting on any part of the prosthesis without undergoing distortion

Should be rigid enough to

Designing of RPD
Mandibular major

connectors are placed 4 mm away from the marginal gingiva

Lingual bar should be

tapered superiorly with a half pear shape in crosssection & should be relieved sufficiently Lingual plate is used in case of periodontically weakened lower anterior teeth

 Borders of major connectors should be parallel to the gingival contours The metal framework should cross the

gingival margins at an sharp angle of 90

 the other components minor connectors ,rests ,direct & indirect retainers etc are placed on the abutment teeth &hence directly

depends on the periodontal support of the same for their proper functioning

 Becher CM , Kaldahl W ( jour of prosthodent

1982) Additional design should be considered viz stabilization of all compromised teeth, potential for addition of artificial teeth if natural teeth are lost & a minimum of soft tissue coverage spl those tissue at the gingival margin of the remaining teeth

Minor connector
Connecting link b/w major

connector or denture base and other components of RPD Function: Transfer forces acting on the artificial teeth to the abutment teeth Forces acting on the abutment teeth are also transferred uniformly throughout the prosthesis

 Chou T-M, Caputo AA, Moore DJ, Xiao B. Photoelastic analysis and comparison of force-

transmission characteristics of intracoronal attachments with clasp distal-extension removable partial dentures. J Prosthet Dent 1989;62:313319.

Clasp retained designs produces less torque on abutment teeth than intra coronal design RPI design produces lowest torquing forces on

the abutment teeth

RPI Clasp Assembly

Clasp assembly consists: A mesioocclusal rest with the minor connector placed into the mesiolingual embrasure A distal guiding plane, extending from the marginal ridge to the junction of the middle and gingival thirds of the abutment tooth, prepared to receive pp The proximal plate, in conjunction with the minor connector supporting the rest, provides the stabilizing and reciprocal aspects of the clasp assembly. The I-bar should be located in the gingival third of the buccal or labial surface of the abutment in 0.01inch undercut

Proximal plate minor connector

Proximal plate minor

connector Width=1/2 distance b/w tips of adj buccal & lingual cusps of the abutment tooth Length=area of the abutment from marginal ridge to 2/3rd the length of enamel crown Shape=triangular with apex located buccally & the base lingually McCrackens removable partial denture 11th edition

Guiding plane
Guiding plane-two or more

parallel vertical surfaces of abutment teeth, so shaped to direct a prosthesis during placement and removal More vertical walls that are made parallel , the fewer the possibilities that exist for dislodgement If some degree of parallelism does not exist during placement & removal, trauma to the teeth & supporting structures & strain on the denture parts are inevitable

Guiding plane & design of Minor connector

There are three basic approaches to the application of RPI system
Guiding plane &corresponding

proximal plate MC extends entire length of the proximal tooth surface . physiologic relief is required to prevent impingement of gingival tissue during function This directs the functional forces in horizontal direction thus teeth are loaded more than edentulous ridge

 Guiding plane & pp extends from

marginal ridge to junction of middle & gingival thirds of the proximal tooth surface This decrease in the contact area of pp on guiding plane more evenly distributes the functional forces b/w tooth & edentulous ridge
Here there is no contact b/w pp &

prepared guide plane, resulting in uncontrolled stress to the abutment McCrackens removable partial denture 11th edition

Stress breaker
A device which relieves the abutment

teeth of all or part of the occlusal forces A type of hinge joint placed within the denture framework ,which allows two parts of the framework on either side of the joint to move freely Soft tissue are more compressible than the abutment teeth In tooth-tissue supported partial denture , when occlusal force is applied , the denture tends to rock due the difference in the compressibility of the abutment tooth & soft tissue .As the tissue are more compressible, the amount of stress acting on the abutment tooth is increased. This can have harmful effect on the abutment To protect the abutment tooth from such condition , a stress breaker is incorporated in the denture

FPD & PERIODONTIUM

Success of FPD

Health of abutment teeth

Periodontal health of the teeth
Any pathology of periodontium will weaken

the support of the abutment teeth , hence the prosthesis will be compromised

 a/c johnson et al 1986,macguire & nunn 1996 & grossman & sadan 2005 A periodontally compromised tooth can be diagnosed from probing depth, mobility , supporting bone volume, crown to root ratio, root form , periodontal ligament area Reduction in periodontal support

Worsens the prognosis of the tooth

Radiographic evaluation of periodontal bone loss greatly influences Prosthodontic decision making (moser et al 2002)

Abutment selection & periodontium

Abutment refers to a tooth or a part of tooth

that supports FPD It is the abutment tooth that takes the maximum Occlusal load which is then transmitted through the long axis to the basal bone Selection of abutment is an important criteria for the designing of FPD

Abutment selection
The supporting tissues surrounding the abutment teeth must be healthy, free from

inflammation before any prosthesis can be contemplated. Normally abutment teeth should not exhibit mobility, since they will be carrying an extra load. The roots & their supporting tissue should be evaluated for three factors: crown root ratio root configuration periodontal ligament area

Crown root ratio

Measured as length of tooth

Occlusal to the alveolar crest compared with length of root embedded in bone. As the level of alveolar bone moves apically, the lever arm of that portion out of bone increases, and the chances of lateral forces is increased The optimum crown root ratio is 2:3 . A ratio of 1:1 is the minimum ratio that is acceptable for a prospective abutment under normal circumstance

Root configuration
Important criteria to evaluate

abutment tooth from periodontal point of view Roots that are broader labiolingually than they are mesiodistally are preferable than that are round in crosssection Multirooted posterior teeth with divergent roots will offer better periodontal support than the roots that converge , fuse or with conical configuration Single rooted tooth with irregular pattern is preferred to one that is tapers uniformly

Periodontal ligament area

Another important factor in

the evaluation of the abutment teeth is the root surface area or the area of periodontal attachment of the root to the bone Larger teeth have a greater surface area and are better able to bear added stress When supporting bone has been lost due to periodontal disease, the involved teeth have lessened capacity to serve as abutments.

ANTES LAW
JOHNSTON et al 1986 gives Antes law According to it sum of the pericemental area of the abutment teeth should be equal to or greater than the pericemental area of the teeth being replaced

Pontic design & periodontium

Pontic or artificial tooth is derived from the latin, pons =bridge, it is not a simple replacement,bcoz placing an exact anatomic replica of the tooth in space would be

hygienically unmanageable Pontic-component of FPD that replaces a missing tooth & restores its function & appearance (GPT, 8th edition 2005) Acc to parkinson &schaberg 1984 The design of pontic will be dictated by Esthetics Function Ease of cleansing Maintenance of healthy tissue on the edentulous ridge Patients comfort J.prosthet dent 1984;51:51-54

Design considerations

Acc to j.prosthet dent 1966;16:251-284 Stein RS stated Extent & shape of the pontic contact with the ridge is very important Excessive tissue contact-major factor in the failure of FPD Should have minimum contact area b/w pontic & the ridge The gingival surface of the pontic should be convex

Tjan AH :biologic pontic design Gen Dent 1983 ;31:4044 Pontic should not encroach on unattached mucosa or otherwise an ulcer will form The tip must be restricted to keratinized gingiva

Acc to j prosthet dent 1966;16:937-947 The mesial, distal & lingual gingival embrasures should be wide open to allow the easy access for cleaning Contact b/w pontic &tissue must allow the passage of floss from one retainer to other

Types of pontic design

Ridge lap (saddle) Modified Ridge lap Hygienic or sanitary Conical ovate

Ovate pontic
Ovate pontic
Most esthetics Convex tissue surface

resides within the socketgives perfect emergence profile Not easy to clean Requires surgical process Modified ovate pontic Less convex-easy to clean requires little or no surgery

Occlusal forces
Reducing the buccolingual width of the pontic by as much as 30% has been suggested as a way to lessen occlusal forces, thus the loading to abutment teeth. Analysis reveals that This practice has little scientific basis. Forces are lessened only when chewing food of uniform consistency .

12% increase in chewing efficiency can be expected from a onethird reduction of pontic width.
JPD1975,Vol33

Pre-treatment assessment
Loss of residual ridge contour may lead to unesthetic open gingival embrasures ("black triangles") food impaction and percolation of saliva during speech.

GINGIVAL ARCHITECTURE PRESERVATION

The concept of atraumatic extraction followed by socket grafting and placement of an ovate pontic to preserve gingival architecture was presented by Schlar. Ridge augmentation procedures can be more invasive and less successful than the results obtained by preserving the patients original ridge and gingival contours.
The Journal of Contemporary Dental Practice, Volume 5,, 2004

Gingival architecture preservation

Atraumatic extraction is done interim FPD(ovate pontic) is prefabricated

PR is placed immediately inside socket(ovate pontic is being extended 2.5mm into the socket blanching of Interdental papilla
restoration after 12 months Interdental papilla is preserved

Finish lines
Placement of FINISH LINES of the restoration is also guided by the contour &the position of gingiva Depending on it finish lines can be placed either supragingivally-least impact on the periodontium equigingival more plq accu sub-gingivally-most impact on the periodontium Ideally the margins of the restoration should be placed supragingivally if possible-LEAST IMPACT ON PERIODONTIUM

INDICATIONS OF SUB GINGIVAL FINISH LINES (JPD 1973;29:301-304 & JPD1982; 47:625-632) Short clinical crowns Sub gingival caries Root sensitivity Aesthetic purpose Additional retention etc....

Acc to ReevesWG 1991 (JPD 1991;66:733-736) Deeper the restoration margin resides in the gingival sulcus , greater is the inflammatory responses Sub gingival finish lines usually results in PERIODONTITIS Acc to IngberJS ,RoseLF 1977 Finish lines placed at a distance of less than 2.0mm can cause Gingival inflammation Pocket formation Loss of alveolar bone (The biologic width-a concept in periodontics and restorative dentistry Alpha omegan 1977; 10:62-65 )

FURCATION INVOLVEMENT
Glickman I: clinical

periodontology, ed 2 , philadelphia, 1958, W.B.Saunders co..,pp694696

Classified furcation in 4

grades Normal Furcation No bone or attachment loss No flute detected on clinical probing

 Grade I involvement Incipient lesion Supra bony pocket Flute concavity

detected on probing Slight bone loss in Furcation area Radiograph changes unusual

 Grade II involvement Lesion is cul-de-sac Bone is destroyed on one

or more aspect of Furcation but a portion of the alveolar bone and PDL remains intact Clinically gingival recession may be present but the Furcation entrance is not visible

 Grade III involvement Interradicular bone is completely absent horizontally Lesion is through and

through Furcation entrance is still not visible and is occluded by the gingival tissue

 Grade IV furcation Loss of attachment within the furca through one entrance to the other, with apical gingival recession Clinically visible

Depending on Class of Furcation involvement Extent configuration of bone loss Other anatomic factors There can be two therapeutic approaches Non-surgical-(for grade I &II cases) Maintaining oral hygiene Scaling & root planning Odontoplasty & osteoplasty

 surgical (late grade II ,

III & IV) Root resection surgical removal of all or portion of the root Hemi section-surgical separation of a multirooted tooth through Furcation area such that root or roots ,may be surgically removed along with the associated crown portion

Crown modification

Implant & periodontium

Implant a substance that is

placed in the jaw to support a crown or a FPD or RPD INDICATIONCompletely edentulous pt with excessive ridge resorption Partially edentulous teeth where RPD will weaken the abutment teeth & provides reduced masticatory efficencey Single tooth replacement where FPD cannot be placed Patients desire

mechanism
When an implant is first

placed in the bone there should be a close fit to ensure stability. The space between implant and bone is initially filled with a blood clot and serum/bone proteins. the initial response to the surgical trauma is resorption, which is then followed by bone deposition

 The stability of the implant at the time of

placement is very important and is dependent upon bone quantity and quality Following the loss of a tooth, the alveolar bone resorbs in width and height

Classification of implant
Based on the placement of implants within the tissue

Epiosteal-it is placed on the surface Endosteal-placed within the basal bone Transosteal-penetrates both the cortical plates

osseointegration
Proposed by P.I Branemark in 1982 Implants integrate with the bone such that the

bone is laid very close to the implant material without intervening connective tissue
Stated that implant should not be loaded &

must be kept out of function during the healing period for osseous integration Commonly used-commercially pure Ti (CPTi)

 Early loading:

High initial load on an implant immediately following placement results in the formation of fibrous capsule rather than OI Late loading: Excessive mechanical load on an OI implant can result in the breakdown of the interface with resultant implant failure & therefore overload should be avoided

Fibro-osseous integration
Proposed by Weiss in 1985 Stated that a fibro-osseous ligament is formed

b/w the implant & the bone & this ligament is considered as the peri-implant ligament found in the gomphosis
He defends the presence of collagen fibres at

bone-implant interface he advocates the early loading of the implant

Importance of bone quality & quantity implant prosthesis

Both quality & quantity influences osseointegration & hence success of implants Many attempts have been made to classify different bone densities to aid surgeons in selecting appropriate implants, surgical technique/procedure, and predict future success rates Lekholm and Zarb(1985) classified bone quality into four categories Type I bone -homogenous compact bone Type II bone -a core of dense trabecular bone with a thick layer of compact bone surrounding it

 Type III bone -a thin layer of cortical bone

surrounding dense trabecular bone of favourable strength Type IV bone - a thin layer of cortical bone surrounding a core of low-density trabecular bone It is recommended that acid-etched titanium implants be used on Type I, TPS implants in Type II and Type III bone, and Type IV bone receive HAcoated implants Espositpo M et al. Biological factors contributing to failure of osseointegrated oral implants: Eur J Oral Sci. 1998;106: 721-764

Scortecci G, Misch C, Benner K. Implants and RestorativeDentistry. London:Martin Dunitz Ltd. 2001. pg59-87 Bone quantity: The available bone at edentulous & future implant site Volume of available bone is evaluated by Bone height Bone width Bone length Bone angulation Crown implant ratio Requirement for the ideal placement of implant: Minimum bone height-10mm Minimum bone width-5mm Minimum bone length-7mm

Transmucosal abutment (TMA)

used to link the implant body to the prosthesis Also know as implant abutment basically of four types: cylindrical, shouldered, angled and customizable Made up of CPTi cylindrical designs :are employed where the

mucosal aspect of the prosthesis is to be placed some distance above the oral mucosa to aid cleaning, the so-called 'oil rig' design.

 Shouldered designs: permit the prosthesis to

finish at or below the 'gingival margins', providing a more natural-appearing emergence profile for the superstructure.

Healing abutment
temporary implant-connecting part placed on the implant body to create a channel through the

mucosa while the adjacent soft tissues heal. normally wider than the corresponding regular abutment to compensate for some tissue collapse into the space when placing the regular abutment They also allow for a period of resolution of tissue swelling before selecting the final abutment so as to ensure its optimum height

Recent advancements

Gingival prosthesis
Gingivl resession II. Gingival prosthesis III. Periodontal acrylic veeners
I.

Gingival porcelain
Dental esthetics is based

not only on the white component of the restoration but also on the pink component. Gingival pink colored prosthesis are used to replace missing gingival tissues. Materials: Pink autocure acrylics. Heat cure acrylics. porcelain

Conclusion
So we have seen how & why the knowledge of

a periodontium is important for a prosthodontist Knowing the basic anatomy of gingiva & periodontium helps a prosthodontist to correlate the available conditions in the pts mouth & to classify the same as normal & abnormal which eventually helps the dentist in better diagnosis & treatment planning the related problem

Referances

Carranzas clinical periodontolgy,10th edition mcCrackens removable partial prosthodntics,11th edition Shillingburg, fundamentals of fixed prosthodontics 3rd edition

Biancu S, Ericsson I, Lindhe J (1995). Periodontal ligament tissue reactions to trauma and gingival inflammation. An experimental study in the beagle dog. J Clin Periodontol 22:772779.

Biewener AA (1993). Safety factors in bone strength. Calcif Tissue Int 53(Suppl 1):S68 S74.

Brunski JB (2003). Biomechanical aspects of oral/maxillofacial implants. Int J Prosthodont 16(Suppl):3032.

Cattaneo PM, Dalstra M, Melsen B (2005). The finite element method: a tool to study orthodontic tooth movement. J Dent Res 84:428433. Davies SJ, Gray RJ, Linden GJ, James JA (2001). Occlusal considerations in periodontics. Br Dent J 191:597

 Scortecci G, Misch C, Benner K. Implants and Restorative

Dentistry. London:Martin Dunitz Ltd. 2001. pg59-87. Renouard F, Rangert B.Risk Factors in Implant Dentistry. Chicago:Quintessence Publishing Co Inc. 1999. pg 143-145. Misch C. Contempory Implant Dentistry. St. Louis: MosbyYear Book Inc. 1993.pg123-156. Rangert B et al. Forces and Moments on Branemark Implants:The International Journal of Oral & Maxillofacial Implants. 1989; 4(3): 241-247 Wohrle P. Single-tooth Replacement in the Aesthetic Zone with Immediate Provisionalization: Fourteen Consecutive Case Report: Pract Periodont Aesthet Dent.1998;10(9): 1107-1114

Thanks for your attention