perio restorative

Presented By
DDrr.. MM.. SShhiivvaa SShhaannkkeerr
II Year Post Graduate Student ,
Dept of Periodontics, Mamata Dental College.

CONTENTS
• Introduction
• Rationale for periodontal
therapy
• Normal periodontium
• Gingiva
• Gingival crevice
• Biologic width
• Irritating factors for the
periodontium.
• Periodontal-Restorative
interrelationship
• Biologic considerations:
• Contour.
• Contact areas
• embrasures/spillways.
• Overhanging margin.
•Margin placement & biologic width.
• evaluation of violation of
biologic width.
• correction of biologic width
violation.
• margin placement
guidelines.
• clinical procedures in
margin placement
•Tissue retraction.
•Hypersensitivity to dental materials
• Esthetic considerations:
• interproximal embrasure form.
• Restorative correction of open
gingival embrasure.
• Conclusion

RATIONALE FOR
PERIODONTAL THERAPY
• Stable gingival margins before tooth preparation(kois
2000)
• Perio treatment should antecede restorative care.
• Quality, quantity and topography of the periodontium
provides structural defense factors in maintaining
health.

NORMAL PERIODONTIUM
• Gingiva
• Gingival crevice.
• Biologic width.
Clinical Periodontology - 9th edition, Carranza

IRRITATING FACTORS FOR
PERIODONTIUM
• Prior to procedure
Caries
Teeth separation
Rubber dam
Interactions between the gingiva and the margin of restorations, J Clin Periodontol 2003;
30: 379–385.

PERIODONTIUM CONTI..
• During the procedure: meticulous instrumentation.
• Preparation instrumentation
Vibration
preserving proximal plate of enamel-during gross cavity
preparation- avoid injury to gingiva.
Wedges below contact area- before proximal box
preparation
• Matricing
Interactions between the gingiva and the margin of restorations, J Clin Periodontol
2003; 30: 379–385.

PERIODONTIUM CONTI..
• Long after the procedure: restoration in close proximity
to soft tissue.
• Gingival retraction
Physical retraction methods
Chemical retraction methods
Electro surgical procedures
• Impression procedures
• Temporary restorations & fabrication
Interactions between the gingiva and the margin of restorations, J Clin Periodontol
2003; 30: 379–385.

PERIODONTAL-RESTORATIVE
INTERRELATIONSHIP
Seven characteristics of restorations and partial dentures
are important from a periodontal point of view:
•Margins of restorations
•Contours
•Occlusion
•Materials
•Bridge design
•Design of Removable Partial Dentures
•Procedures of Restorative Dentistry themselves.
Periodontal-Restorative Interactions: A Review, shaveta sood, shipra Gupta, Indian
Journal of Clinical Practice , Vol. 23, No. 11, April 2013

INTERRELATIONSHIP CONTD…
Margins of restoration
•location of restorative margins is determined by many
factors
1.Esthetic concerns.
2.Need for increased retention form
3.Refinement of pre-existing margins.
4.Root caries.
5.Cervical abrasion
6.Root sensitivity.

• Orkin et al 1986 demonstrated that sub gingival
restorations had a greater chance of bleeding and
exhibiting gingival recession then supra gingival
restoration
• Waerhaug 1978 stated that sub gingival restorations
are plaque retentive areas that are inaccessible to
scaling instruments.
The restorative periodontal interface: biological parameters. Perio2000
2001;25:100

Contours
•Over contouring and under contouring
•The most common error in recreating the contours of the
tooth in dental restorations is over contouring of the
facial and lingual surfaces, generally in the gingival third.
•Apparently, under contouring is not nearly as damaging
to the gingiva as the over contouring.
Preparation of tooth surface. Schmid MO,
clinical periodontology, 8th edition.

• Occlusion
• Restorations that do not conform to the occlusion
patterns of mouth cause occlusal disharmonies that
may be injurious to the supporting periodontal tissues.
The restorative periodontal interface:
biological parameters. Perio2000 2001;25:100

Materials
•Restorative materials are not themselves injurious to the
periodontal tissues.
•The surface of restorations should be as smooth as
possible to limit plaque accumulation.
•Resins are highly polishable, but have deficiencies in
strength, porosity and wear.
•Glass ceramics and porcelain veneers offer a clear
advantage over any other type of restorative materials in
the maintenance of gingival health.
•There are clinical situations in which the full crown is
indicated prior to restoration. It fulfills requirements that
can be met in no other type of restoration.
The effect of cervical sub gingival restoration margins on the degree of
inflammation of the neighbouring gingiva, Schweiz 1974.

Bridge design
•The health of the tissues around fixed prostheses
depends primarily on the patient’s oral hygiene; the
materials with which bridges are constructed appear to
make little difference.
•Ridge lap pontics, the least desirable design.
•Bridge design with the least effect on the periodontium
is the sanitary or hygienic pontic.
Periodontal conditions and carious lesions following the insertion of fixed
prosthesis, Int Dent Journal 1980.

Design of Removable Partial Dentures
•partial dentures favor the accumulation of plaque,
particularly if they cover the gingival tissue.
Periodontal and prosthetic conditions in patients treated with removable partial
dentures and artificial crowns, Acta Odontol Scand, 1971

Restorative Dentistry Procedures
Periodontal-Restorative Interactions: A Review,
shaveta sood, shipra Gupta, Indian Journal of Clinical
Practice , Vol. 23, No. 11, April 2013

BIOLOGIC
CONSIDERATIONS
Contour
•Convexity on facial & lingual surfaces: provides
protection & stimulation to supporting structures during
mastication.
•Becker and Kaldahl opined that the buccal and lingual
crown contour should be ‘flat’ and not ‘fat’, usually < 0.5
mm, wider than the CEJ.
•Yondelis et al demonstrated that greater the amount of
facial and lingual bulge of an artificial crown, the more
the plaque retained at the cervical margins.

BIOLOGIC CONSIDERATIONS CONTD…
Interproximal contacts
•There must be a positive contact relation mesially and
distally of one tooth with another in each dental arch.
•The contact points should be located incisially or
occlusally and buccally.
•Labio Lingual Location
Hazards of broad contact when placed
•Occluso gingivally
•Narrow Contact
•Contact too far gingivally
•Contact too far occlusally
•Too far buccal/ lingual
•Open Contact
The restorative periodontal interface: biological
parameters, periodontology 2000 2001

Embrasures/spillways
•V shaped spaces originate at the proximal contact area
between adjacent teeth.
Functions
•Serve as spillways for escape of food during mastication-force
brought on the tooth is reduced.
•Prevents forcing of food into contact area.
The restorative periodontal interface: biological parameters,
periodontology 2000 2001

Restoration over hangings
•Overhanging restorations contribute to gingival
inflammation due to their retentive capacity for bacterial
plaque.
•Gilmore and Sheiham 1971 illustrated interproximal
radiographic bone loss adjacent to posterior teeth with
overhanging restoration.
The restorative periodontal interface: biological parameters,
periodontology 2000 2001

• Jeffcoat and Howell 1980 demonstrated a link to the
severity of the overhang and the amount of
periodontal destruction. Based upon radiographic
evaluation of 100 teeth with overhang and 100 without,
they reported greater bone loss around teeth with
large over hangs. The severity of bone loss was directly
proportional to the severity of the overhang.
• Spinks et al 1986 demonstrated that a motor driven
diamond tip is faster for removing over hangs and led
to smoother restorations compared to Sonic Scalers
and Curettes respectively.

MARGIN PLACEMENT AND BIOLOGIC WIDTH
•Supragingival
•Equigingival
•Subgingival
Biologic width and its importance in periodontal and restorative dentistry, Babitha
Nugala, Journal of Conservative Dentistry,Jan-Mar 2012,Vol 15.

Supragingival margin
•least impact on the periodontium.
•Preparation of the tooth and finishing of the margin is
easiest
•Duplication of the margins with impressions can be done
with ease.
•Fit and finish of the restoration and removal of excess
material is easiest
•Verification of the marginal integrity of the restoration is
easiest.

Equigingival margin
•Previous thought: retains more plaque than supra & sub
gingival margins therefore results in greater gingival
inflammation.

Subgingival margin
•Greatest biologic risk.
•Not as accessible as supra or equi for finishing
procedures.

Biologic width
Kois proposed three categories of biologic width based
on the total dimension of attachment and the sulcus
depth following bone sounding measurements.
•Normal crest patient
•High crest patient
•Low crest patient.
Biologic width and its importance in periodontal and restorative dentistry, Babitha
Nugala, Journal of Conservative Dentistry,Jan-Mar 2012,Vol 15.

Normal crest patient
•Normal Crest occurs approximately 85% of time.
•The gingival tissue tends to be stable for a long term.

High crest patient
•High Crest is an unusual finding and occurs
approximately 2% of the time.
•Occurs more often in a proximal surface adjacent to an
edentulous site.

Low crest patient
•Low Crest occurs approximately 13% of the time.
•Traditionally, the Low Crest patient has been described
as more susceptible to recession secondary to the
placement of an intracrevicular crown margin.

Importance of determining the crest category
•This allows the operator to determine the optimal
position of margin placement, as well as inform the
patient of the probable long-term effects of the crown
margin on gingival health and esthetic

Margin placement guidelines
•Rule I
•Rule II
•Rule III
Margin of restorations-from view point of
crown and bridge making, 1972

• Orkin et al demonstrated that subgingival restorations
had a greater chance of bleeding and exhibiting
gingival recession than supragingival restorations.
• Renggli et al showed that gingivitis and plaque
accumulation were more pronounced in interdental
areas with well-adapted subgingival amalgam fillings
compared to sound tooth structure.
• Flores-de-Jacoby et al studied the effects of crown
margin location on periodontal health and bacterial
morphotypes in human 6-8 weeks and 1 year post-insertion.
Subgingival margins demonstrated increased
plaque, gingival index score and probing depths

Evaluation of biologic width violation
•Clinical method
•Bone sounding
•Radiographic evaluation

Clinical method
•Signs of biologic width violation are:
Chronic progressive gingival inflammation around the
restoration,
Bleeding on probing,
Localized gingival hyperplasia with minimal bone loss,
Gingival recession,
Pocket formation,
Clinical attachment loss and alveolar bone loss.

Bone sounding
•The biologic width can be identified by probing under
local anesthesia to the bone level and subtracting the
sulcus depth from the resulting measurement. If this
distance is less than 2 mm at one or more locations, a
diagnosis of biologic width violation can be confirmed.

Radiographic evaluation
•Sushama and Gouri have described a new innovative
parallel profile radiographic (PPR) technique to measure
the dimensions of the dento gingival unit (DGU).

Surgical crown lengthening
•Crown lengthening surgery is designed to increase
clinical crown length.

INDICATIONS
•Inadequate clinical crown for retention due to extensive
caries, subgingival caries or tooth fracture,
•Short clinical crowns.
•Placement of sub gingival restorative margins.
•Unequal, excessive or unaesthetic gingival levels for esthetics.
•Planning veneers or crowns on teeth with the gingival margin
coronal to the cemeto enamel junction (delayed passive
eruption).
•Teeth with excessive occlusal wear or incisal wear.
•Restorations which violate the biologic width.
•Assist with impression accuracy by placing crown margins
more supragingivally.

Contraindications
•Deep caries or fracture requiring excessive bone
removal.
•Post surgery creating unaesthetic outcomes.
•Tooth with inadequate crown root ratio (ideally 2:1 ratio
is preferred)
•Non restorable teeth.
•Tooth with increased risk of furcation involvement.
•Unreasonable compromise of esthetics.
•Unreasonable compromise on adjacent alveolar bone
support.

Gingivectomy
•External bevel gingivectomy
•Internal bevel gingivectomy

Apically positional flap surgery
Indication
•Crown lengthening of multiple teeth in a quadrant or
sextant of the dentition, root caries, fractures.
Contraindication
•Apical repositioned flap surgery should not be used
during surgical crown lengthening of a single tooth in the
esthetic zone.

Apically repositioned flap without osseous resection
•This procedure is done when there is no adequate width
of attached gingiva, and there is a biologic width of
more than 3 mm on multiple teeth.

Apical repositioned flap with osseous reduction
•This technique is used when there is no adequate zone
of attached gingiva and the biologic width is less than 3
mm.
•The alveolar bone is reduced by ostectomy and
osteoplasty, to expose the required tooth length in a
scalloped fashion, and to follow the desired contour of
the overlying gingiva.

• Sugumari et al. in a report on surgical crown
lengthening with apical repositioned flap with bone
resection performed in the fractured maxillary anterior
teeth region, showed satisfactory results both in terms
of functional (restoring biologic width) and esthetic
outcomes.
• Most authors agree that a minimum distance of 3mm is
required from the osseous crest to the final restorative
margin following a crown – lengthening procedures to
allow the margin to finish supra gingivally (Bragger et al
1992).

Orthodontic techniques
•Heithersay and Ingber were the first to suggest the use
of “forced eruption” to treat “non-restorable” or
previously “hopeless” teeth.
•Forced eruption with minimal osseous resection, and
forced eruption combined with fiberotomy (starr).
•Frank et al. described forced eruption of multiple teeth.
Contraindications
•Inadequate crown-to-root ratio
•Lack of occlusal clearance for the required amount of
eruption

Tissue retraction
•Retraction cord
•Tissue management is achieved with gingival retraction
cords, using the appropriate size to achieve the
displacement required.
•Rule 1 margin
•Rule 2 margin

Various chemicals used for the treatment of chords
include:
•0.1% and 8% recemic epinephrine
•100% aluminum solution (potassium aluminum sulfate)
•5% and 25% aluminum chloride solution
•Ferric subsulfate (Monsel’s solution)
•13.3% ferric sulfate solution
•8% and 40% zinc chloride solution
•20% and 100% tannic acid solution
•45% negatol solution.

Recent Advances
Merocel
•Made of a synthetic material that is specifically
chemically extracted from a biocompatible polymer
(hydroxylate polyvinyl acetate) that creates a net like
strip (2 mm thick)
Expasyl
•Composed of micronized kaolin, aluminum chloride and
water

Electrosurgical Means

• Surgical Means
• Surgery with a knife is the preferred method for
providing access to the margin of the preparation.

Rotary curettage:
•It is troughing technique.
•This technique is usually followed by insertion of
retraction cord.
Cryosurgery
•Uses a sharp, cold knife to remove the tissues
conservatively.

Periodontal evaluation of restorative materials
Amalgam
•Surface roughness
•Marginal discrepancies
•Galvanism
•Chemical irritation
The Effect of Dental Restoration Type and Material on Periodontal Health, Khansa
Taha Ababneh, Oral Health Prev Dent 2011; 9: 395-403.

Zinc Oxide Eugenol
•High solubility in oral acids
•Surface roughness
•Marginal inadequacies
Zinc Phosphate Cement
•Inadvertently leaving attached or unattached set
cement within the gingival crevice
The Effect of Dental Restoration Type and Material on Periodontal Health, Khansa
Taha Ababneh, Oral Health Prev Dent 2011; 9: 395-403.

Direct gold restoration
•Lacerations and contusions which can occur during
condensation.
Ceramic restorations
•Most chemically inert of all materials
•Most biologically acceptable to the periodontium.
Composite restorations
•No evidence of any clinical problems resulting in soft
tissue changes with the use of composite.

Hypersensitivity To Dental Materials
•About 30% of those patients with a known nickel allergy
develop a reaction to an intraoral nickel chromium
dental alloy.
•Phosphate cements and silicates are slightly irritants.
•Acrylic is highly irritant, although the material itself is not
irritant when fully polymerized.
•Tissues respond more to the differences in surface
roughness of the material rather than its composition.

ESTHETIC CONSIDERATIONS IN
GINGIVAL TISSUE MANAGEMENT
Ideal interproximal embrasure.
•House gingival papilla without impinging on it.
•Extend interproximal tooth contact to top of papilla – no
excess space to trap food or esthetically displeasing.
•Ideal interproximal tooth contact: 2-3 mm coronal to
epithelial attachment.

Restorative correction of open gingival embrasure.
•Moving the contact to tip of papilla.
•Direct bonded restorations:
•Margins of restoration carried subgingivally 1-1.5 mm.
•Designing emergence profile: moving contact point
towards papilla while blending contour into tooth below
tissue.

Indirect restorations:
•Desired contour & embrasure form established in
provisional restoration.
•Gingival tissues are allowed to adapt for 4-6 weeks with
temporary, before tissue contour information is relayed to
laboratory to be used in final restoration

CONCLUSION
• The health of the periodontal tissues is dependent on
properly designed restorative materials. Overhanging
restorations and open interproximal contacts should be
addressed and remedied during the disease control
phase of periodontal therapy.

REFERENCES
• Clinical Periodontology - 9th edition, Carranza.
• Clinical periodontology and implant dentistry, 5th
edition, Jan Lindhe.
• Interactions between the gingiva and the margin of
restorations, J Clin Periodontol 2003; 30: 379–385.
• Biologic width and its importance in periodontal and
restorative dentistry, Babitha Nugala, Journal of
Conservative Dentistry,Jan-Mar 2012,Vol 15.
• Periodontal and Restorative Considerations with Clear
Aligner Treatment to Establish a More Favorable
Restorative Environment, Robert L. Boyd, June
2009,Volume 30, Number 5.

• Periodontal-Restorative Interactions: A Review, shaveta
sood, shipra Gupta, Indian Journal of Clinical Practice ,
Vol. 23, No. 11, April 2013.
• Physiologie Dimensions of the Periodontium Significant
to the Restorative Dentist, J. Gary Maynard, JOP,
Volume 50 Number 4.
• Periodontalconsiderationsin
restorativeandimplanttherapy, perryv. Goldberg,
Periodontology 2000, Vol. 25, 2001, 100–109.
• Periodontal-restorative interrelationships, Roxana
Vacaru, OHDMBSC - 2003 - 3 (5).
• The Effect of Dental Restoration Type and Material on
Periodontal Health, Khansa Taha Ababneh, Oral Health
Prev Dent 2011; 9: 395-403.

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