PERIODONTAL CONSIDERATIONS

It is the Major Obstacle in the Prevention of Tooth Loss

COST of Care

A Strong Correlation exist between

Poverty
Lack Of Eduation And,
Presence Of Periodontal Disease

PATHOGENESIS OF PERIODONTAL DISEASE

The Pathogenesis of Periodontal Disease is complex and involve the following
Local Phenomena in the Gingiva,
the Periodontal Ligament,
the Tooth Surface,
the Alveolar Bone
a Series of Complex Host Response Mechanisms modified by the bacterial infection and,
Patient Behavioral Factors.

Implicated in the Pathogenic Mechanism(Periodontal Disease) are

Phagocytic Cells,
the Lymphoid System,
Antibodies & Immune Complexes,
Complement & Clotting Cascades,
Immune Reactions, &
the Microcirculation.

The initial plaque-induced lesion in periodontal disease is termed

Gingivitis
it(Gingivitis) can be divided into overlapping stages:
Initial,
Early,
Established,
Advanced.

The Initial Lesion is

localized in the region of the gingival sulcus and is
evident after approximately 2 to 4 days of undisturbed plaque accumulation from the baseline of
gingival health.
vessels of the gingiva become enlarged, and local vasculitis occurs, allowing a fluid exudate of
polymorphonuclear leukocytes(PMNs) to form in the sulcus.
Collagen is lost perivascularly
resultant space is filled with proteins and inflammatory cells

Early Lesion
Generally appears within 4 to 7 days of plaque accumulation.
involves further loss of collagen from the marginal gingiva
gingival sulcular fluid flow increases, with higher numbers of inflammatory cells and
accumulation of lymphoid cells subjacent to the junctional epithelium
basal cells of the junctional epithelium begin to proliferate
significant alterations are visible in the connective tissue fibroblasts

Established Lesion
Generally appears Within 7 to 21 days after plaque accumulation,
It is still located at the apical portion of the gingival sulcus, and the inflammation is centered in a
relatively small area
Loss of connective tissue continues , with persistence of the features of the early lesion.
This stage involves a predominance of
plasma cells,
presence of immunoglobulins in the connective tissue, and
proliferation of the junctional epithelium
No Pocket Formation

ADVANCED LESION
Also referred to as Overt Periodontitis
It is difficult to pinpoint the time at which the established lesion of gingivitis results in a loss of
connective tissue attachment to the tooth structure and becomes an advanced lesion
Upon conversion to the advanced stage, the features of an established phase persist.
The connective tissue continues to lose collagen content, and
fibroblasts are further altered.
Periodontal Pockets Are Formed, with increased probing depths, and
the lesion extends into the alveolar bone.
bone marrow converts to fibrous connective tissue, with a significant CAL to the root of the tooth.
This conversion is accompanied by the manifestations of
immunopathologic tissue reactions and,
Inflammatory responses in the gingiva

PERIODONTITIS
Periodontal disease is site specific;
The logical implication is that diagnosis and treatment must also be site specific
Periodontitis is a disease that may be characterized by alternating periods of quiescence and
exacerbation

The extent to which the lesion progresses before it is treated determines the following:
amount of Alveolar bone & Connective Tissue Attachment Loss that occurs.

The following subsequently affects the prognosis of the tooth with regard to Restorative Demands.
Amount of ALveolar Bone Loss
Amount of CAL
The predominant inflammatory cells in the early lesion of gingivitis-periodontitis are
lymphocytes(subjacent to the junctional epithelium).
The epithelium is beginning to proliferate into the rete ridges(in the early lesion of gingivitis-
periodontitis).

There is a predominance of this cells in the beginning stages of the inflammation.

PMNs
PolyMorphoNuclear leukocytes

Effective Periodontal Care incorporates three components:

(1) effective Daily Plaque Removal by the patient,
(2) Active Therapy to remove calculus and pathologic bacteria from the root surfaces and pocket,
(3) Preventive Periodontal Maintenance Therapy (Supportive Periodontic Therapy-SPT) every 2 to 6
months.

The time interval for frequent SPT varies according to the individual patient.
Treatment at each SPT(SUPPORTIVE PERIODONTAL THERAPY) appointment should be based on
COMPARISONS of the FOLLOWING at the current appointment with those of the previous appointment
pocket depths,
attachment levels,
presence of BOP,
mobility

This has been shown to be able to compensate for the presence of some residual plaque.
healthy immune system

Enhanced salivary diagnostic testing has the ability to

indicate active bone loss and
detect pathologic bacteria

The most cost-effective, reliable, site-specific indicators of periodontal health are Comparison of
the following over time
pocket depths,
Clinical attachment levels,
bleeding on probing(BOP)
tooth mobility

This periodontic procedure remains the foundation of periodontal treatment

Scaling and Root Planing(SC/RP)
What is the objective of Scaling and Root Planing(SC/RP)?
achieve a clean root surface

The following statements are true about Scaling and Root Planing(SC/RP)
remains the foundation of periodontal treatment
has been shown to be cost effective, and
minimal negative side effects(in comparison with those of all other techniques)

During active therapy, Scaling and Root Planing(SC/RP) results in

the greatest gain in CAL(of all possible therapeutic techniques)
reasonable pocket depth reduction,
decreased BOP,
Improvement in microbial composition

Scaling and Root Planing(SC/RP) can be accomplished with

hand instrumentation,
ultrasonic scaler,
laser.

They are often useful in eliminating pathogenic bacteria not accessible with mechanical therapy.
AntiBiotics

Examples of Periodontal therapies that will result to Gingival Recession(IF BONE HAS BEEN LOST)
improved oral hygiene,
antibiotic therapy,
SC/RP
laser therapy,
surgery

The most frequent Indications For Surgical Periodontal Therapy are

-CONTINUED BONE LOSS in a patient who has had SC/RP and is on a 2-3-month periodontal
maintenance schedule
-NEED for FIXED PROSTHODONTIC TREATMENT in the POSTERIOR quadrants(that will result in either a
subgingival crown inaccessible for cleaning or a short clinical crown that will have inadequate retention
or resistance form).

THEY are designed to allow meticulous cleaning of the root surfaces and to reduce pockets through
removal of gingiva or regrowth of bone.
SURGICAL(Periodontal) PROCEDUREs

unless SURGICAL(Periodontal) PROCEDUREs is followed by frequent SPT, the following will occur
Plaque will reaccumulate in the surgical sites,
periodontal disease will recur,
further loss of significant CAL

This is a reliable INDICATOR that Continued Periodontal Destruction is occurring

increase of pocket depths or loss of attachment of 2mm

this is a reliable Indicator of (Periodontal)Health

absence of BOP

this is the Best Predicator of Future Attachment Loss.

Continued BOP at the same site

This Indicates the Need for Careful Analysis of the Occlusion and/or Endodontic Status of the
Tooth if pocket depths and attachment levels have not changed
Increasing Mobility
NB: Obtaining complete periodontal data at every SPT appointment changes the appointment from a
nonspecific teeth cleaning to a site-specific program to maintain periodontal health.

It is an Overlooked Benefit of SPT

the concurrent reduction in dental caries(that occurs with frequent periodontal maintenance)

This is regarded as reasonable approach to prevent future decay and periodontal disease
a 2-3month SPT Interval for all patients who exhibit active decay or periodontal disease.
What is the the key component of SPT ?
the Meticulous Record Keeping in which decay, pocket depths, attachment levels, BOP, and mobility
at the current appointment was compared with those at the previous appointment;

PROGNOSIS
The prognosis is the best guess of the course/outcome of the periodontal disease
Prognosis comprises
(1) the prognosis for the overall dentition
(2) the prognosis for individual tooth.
The various guidelines available to predict the future of a tooth with a poor or questionable prognosis
are unreliable
The dentist refines the prognosis after observing the response to initial periodontal therapy.

it is the Prognosis made after a thorough review of the patient’s medical & dental histories and clinical
findings
tentative prognosis

It is a Poor Prognosis if it had

50% attachment loss or
class II furcation;

a tooth had a Questionable Prognosis if it had the following

more than 50% attachment loss,
class II/class III furcation, or
poor crown-root ratio or
poor root form

The dentist refines the prognosis when?

after observing the response to initial periodontal therapy.

The following are included in/characteristic of Initial(Periodontal) Therapy.

SC/RP,
Improvement In Oral Hygiene,
Replacement/Recontouring of Defective Restorations(that compromise plaque removal)

Initial(periodontal) therapy serves the following Beneficial(therapeutic) functions

reduce the bacteria in the sulcus,
detoxifies the root surface,
eliminates microenvironments that harbor bacteria(such as calculus and defective restorations

What happens if defective restorations are not corrected during initial therapy?
healing response will be stunted.

All of the following should be corrected before or at the time of SC/RP for maximum gingival healing
response
Decay near the gingiva,
marginal overhangs
open contacts
In patients who respond to initial therapy with significant reductions in pocket depths and in BOP, the
prognosis is significantly more positive

When other problems allow, patients should undergo SPT at what interval during the first year after
initial phase therapy
2-3 months
All urgent dental needs are addressed, and the patient’s oral hygiene and maintenance compliance are
evaluated during this year.

This enables much more accurate planning, allowing comprehensive restorative therapy to be initiated
at that time.
3rd refinement of prognosis

Only teeth with the following prognosis can be used to support a prosthesis that replaces missing teeth
teeth or implants with a good or fair prognosis
It may be possible to maintain the teeth in a periodontally compromised but otherwise intact dentition
for an extended period of time.
However, if that same patient is missing teeth and now requires comprehensive restorative dentistry,
STRATEGIC EXTRACTIONS may be necessary to Improve Prosthetic Predictability

The following factors usually considered whenever Strategic Extractions are indicated
whether such teeth can serve as interim abutments or
for implant site development through orthodontic forced eruption (OFE)
NB: Both procedures(ABOVE) may Enhance Bone & Gingival Tissue Augmentation.

Tooth Extraction(as indicated above) is always followed by

some Loss of Crestal Bone & Gingiva

Before the advent of implants, teeth with a hopeless prognosis were simply extracted.
In contrast, retention of teeth, even if temporary, can
help retain & augment tissue in anticipated implant sites(improving future esthetics & implant
considerations)

The following must be CORRECTED during the Initial Phase Of Periodontal Therapy to promote
maximum gingival healing after scaling and root planing,
open contacts,
defective restorations, &
decay

Criteria(FACTORs) for Consideration in Determining a Periodontal Prognosis

Overall Clinical Factors
Local Factors
Tooth Mobility
Systemic & Environmental Factor
Anatomical Factor
Prosthetic & Restorative Factor

Overall Clinical Factors

Patient’s Age
Disease Severity
Plaque Control
Patient Compliance
Finances Available

Local Factors
Plaque & Calculus
Subgingival Restorations
Tooth Crowding
Root Resorption

Tooth Mobility

Systemic and Environmental Factors

Smoking
Systemic Disease(or Condition)
Genetic Factors
Stress
Dry Mouth

Anatomic Factors(Tooth Anatomy)

Short, Conical Roots
Root Concavities
Developmental Grooves
Root Proximity
Furcation Involvement

Prosthetic and Restorative Factors

Abutment Selection
Caries
Nonvital Teeth
BIOLOGIC WIDTH
The normal gingival attachment consists of 1 mm of connective tissue attachment to the root and 1
mm of epithelial adhesion(Junctional Epithelium) to the root.

What is biologic width?

The combination of connective tissue attachment and epithelial adhesion(Junctional Epithelium)

What is the minimum amount of space that the gingiva needs to attach to the root?
2mm

How can the dentist can Determine the Biologic Width of a specific patient.?
By probing through the attachment to the bone level & subtracting the sulcus depth
(or) By measuring the distance between the apical extent of the probing depth and the CEJ

MARGING PLACEMENT(During Preparation)

preparation Margin can be placed
Supragingival
At the Crest
Subgingival

Which preparation Margins are easier to prepare, impress, and finish to a smooth polished surface?
Supragingival Margins
Crestal Margins

Advantages of Supragingival & Crestal(Preparation)Margins

Easier to Prepare, Impress & Finish to a Smooth Polished Surface
Facilitates Effective Plaque Removal
Facilitates Maintenance of Gingival Health.

In Simple term, Biologic Width is the addition of the following

Junctional Epithelium(0.97mm)
CT Attachment(1.078mm)

In some circumstances, the following FACTORs dictate a subgingival(preparation Margin)

previous restorations,
existing decay,
esthetics, or
retention/resistance needs

In comparison with an intact tooth surface, All Restorations Exhibit Open, Rough Margins that
favor plaque retention.
The Clinical Significance of a farther Margin is from the Gingiva, is;
easier access for plaque removal
the healthier gingival tissue
This Preparation Margin Location allows the healthiest gingival response.
supragingival Margin location

A toothbrush can clean only 0.5 mm subgingivally,

floss can clean up to 2.5 mm below the gingiva,and a
water irrigation device can clean up to 4 mm below the gingiva

This Preparation Margin is said to be problematic and should be AVOIDED when possible
SubGingival Margin

Periodontally, this Margin always results in a gingival inflammatory response

Subgingival Margin

This inflammatory Response include the following

mild, subclinical inflammation
overt inflammatory response(with swelling, redness, tenderness, bleeding)
possibly Bone Loss.

The two(2) FACTORS(Beyond a Dentist’s Control) that is associated with degree of Inflammatory
Response(elicited by Subgingival Margin) are
patient’s Overall Systemic Health
patient’s Gingival Biotype,

The AWARENESS of these two(2) FACTORs can help the dentist make choices before The Decision To
Place a Subgingival Restoration.
patient’s Overall Systemic Health
patient’s Gingival Biotype,

The following are the FACTORS(UNDER a Dentist’s Control) that is associated with degree of
Inflammatory Response(elicited by Subgingival Margin) are
extent to which the preparation margin is placed farther apically,
Quality of the Marginal Fit
Smoothness of the Subgingivally Placed Restorative Material

Preparation Margins that fit in the acceptable range and that are placed in a cleansable area provoke
this type of response
mild, subclinical inflammatory response.

Preparation Margins that are significantly Open More Than 200 mm provoke the following response
Harbor a Large Number of Bacteria and
provoke a Larger Inflammatory Response

What is the Clinical Significance of an encroachment into 2.04-mm(Biologic Width) space?

Inflammatory Response

The Emergency profile of the(planned) restoration should follow the tooth anatomy apical to the
margin.
Gingival health is better maintained if the crown is slightly undercontoured rather than overcontoured.

What is the most frequent reason for Overcontouring Restoration?

insufficient tooth reduction(which forces the technician to overbuild the restoration)

What is the minimum width of attached keratinized tissue should be present for gingival health when a
restorative margin will be placed subgingivally.
3mm

Guidelines for Subgingival Margin Placement

What is the general guideline for Subgingival Margin Placement?
Subgingival margins be placed NO MORE THAN Half(1/2) The Depth Of The Gingival Sulcus
In a Healthy Periodontal Sulcus, the tip of a probe extends approximately 0.5 mm into the Epithelial
Attachment.
If the sulcus probe extends 1 mm, the restoration cannot extend any more than 0.5 mm subgingivally
without invading the attachment (biologic width).
For Instance; A 3mm Healthy Interproximal Sulcus allows the Margin to be placed 1.0-1.25 mm
Subgingivally

NB: The deeper the sulcus is, the greater is the potential for gingival recession after any treatment.
Margins

This is an acceptable compromise between maintaining gingival health and achieving the esthetic and
functional requirements of the restoration
(preparation)Margins at the Gingival Crest

It is the most coronal portion of the attachment, and the restorative margin cannot encroach into
this attachment.
Base of the Healthy Sulcus

The following are Restorative considerations that Dictate Placement of Margins below the Gingiva
(1) Creating Adequate Resistance & Retention Form,
(2) Allowing the Margin to be Placed on Sound Tooth Structure(below any decay or existing restoration)
(3) Masking the Tooth/Restoration Interface(in order to mask a color change between the restoration
and the tooth)
The following difficulties are associated with Margins placed deeper than 1mm
greater difficulty in preparing a smooth margin,
Difficulty in obtaining an accurate impression,
Difficulty in evaluating the marginal fit of the final restoration;

What are the Clinical Significance of the difficulties are associated with Margins Placed deeper than
1mm hindering of Future Plaque Removal
Impinging on the Biologic Width.

Tooth preparation margins that are within the attachment create

Biologic Width Violation(BWD)

The response to the Biologic Width Violation(BWV) is regarded as a function of

the Bone Thickness

The Biologic Width Violation(BWV) frequently occur

the MESIOFACIAL or DISTOFACIAL LINE ANGLES of Maxillary Anterior Teeth treated with Fixed
Restorations.

DEPTHS OF PLAQUE REMOVAL FOR VARIOUS ORAL HYGIENE DEVICES.

Subgingival irrigation with water is more effective than supragingival rinsing with chlorhexidine.

Study results show that to reduce Marginal Bleeding & Bleeding on Probing,
Oral Irrigation (OI) with Chlorhexidine (CHX)/Water (H2O) IS BETTER THAN Rinsing with Chlorhexidine

Gingival Biotype
Variable responses to biologic width invasion are among many responses by different gingival biotypes
to trauma.
The inflammatory response results in swelling, edema, redness, and bleeding
A thick gingival biotype characterizes two thirds(3/3rd) of the population, and
most people with a Thick Biotype are MEN
most people with a Thin Biotype are WOMEN

The Inflammatory Response associated with THIN BIOTYPES are

gingival recession
bone loss,
new biologic width established at a More Apical Level.

This is a combination of thin bone with thin gingiva overlying the bone
Thin(Gingival)Biotype

Patients with this type of gingival biotypes are at High Risk For Gingival Recession during any Dental
Procedures
Thin Gingival Biotype

NB: If a probe is placed within the gingival sulcus, and if the biotype is thin, the tip of the probe can be
visualized through the sulcus

Correcting or Preventing Biologic Width Violations

Biologic Width Violations can be corrected by
Surgical Removal Of Bone (from below the restorative margin) and movement of the attachment
apically
Orthodontic Movement of the tooth (and preparation margin) coronally away from the attachment
NB: Surgical correction of a BWV is more rapid.
The new gingival position is reasonably stable at 3 Months.
In the posterior quadrants, new margins can be successfully placed
3months after surgery.
In the anterior areas, it is advisable to Wait 6Months before final margin placement due to
Increased esthetic demands)
NB: In the anterior esthetic zone, surgery is often contraindicated unless all teeth would benefit from a
longer tooth length

What is the Treatment of Choice for Biologic Width violation in the posterior quadrants?
surgical correction

This is responsible for the retention and/or resistance challenges often encountered in the Posterior
Tetth
short clinical crowns

The gradual correction of bone over three teeth(regarding surgical correction of BWVs) helps increase
crown length and moves many margins from a subgingival position to a crestal or supragingival
position, where oral hygiene is more accessible.

Determining the Best Treatment Technique

These techniques have been introduced for Selected Anterior Crown Lengthening
Lasers
closed surgical techniques

This tissue must be adequate for a gingivectomy to be performed as needed

Keratinized Tissue

This is regarded as an adjunct to Surgical Crown Lengthening is

biologic reshaping of the roots during an open-flap approach to crown lengthening.

This adjunct to Surgical Crown Lengthening technique allows smoothing of rough cement enamel
junctions and minimizes root proximities, root grooves, and furcation.
biologic reshaping of the roots during an open-flap approach to crown lengthening.

Major advantages of biologic reshaping of the roots during an open-flap approach to crown
lengthening( adjunct to Surgical Crown Lengthenin)
allows smoothing of rough cement enamel junctions(CEJ)
minimizes root proximities, root grooves,& furcation

Teeth requiring surgical crown lengthening must fulfil the following pre-requisite have
all caries eliminated,
foundation restorations & interim crowns must be placed before surgery

Complete caries removal is necessary for the following reason

so that the surgeon need not guess where to place the final restorative margin.

This allows the surgeon complete access to the interproximal bone after the interim restoration is
removed
An interim crown over a solid foundation restoration
Crown-lengthening procedures result in
a tooth with a thinner cross section at the point where the now-exposed root emerges from the bone
a decreased crown-root ratio(both of which leave the tooth more susceptible to fracture)

In the esthetic zones, this can minimize the risk for significant gingival changes while correcting BWVs
orthodontic extrusion

PAPILLA
The ideal Interdental Gingival Papilla fills an interproximal embrasure created the following
(1) by the lateral walls of adjacent teeth,
(2) coronally by the base of the interproximal contact,
(3) apically by the coronal aspect of the attachment.

The clinician can change teeth #1 and #2 with the following

restorative dentistry,
orthodontics,
both.
Spear and Clooney suggested the following
“… viewing the papilla as a balloon of a certain volume sitting on the attachment.
The balloon of tissue has a form and height dictated by the gingival embrasure of the teeth.
With an embrasure that is too wide, the balloon flattens out, assumes a blunted shape and has a
shallow sulcus.
If the embrasure is ideal width, the papilla
assumes a pointed form,
has a sulcus of 2.5 to 3.0 mm
Is healthy.
If the embrasure is too narrow, the papilla may
grow out to the facial & lingual,
form a col,
become inflamed.”

This analogy can be applied in evaluating a papilla that does not adequately fill the interproximal
embrasure.
Spear and Clooney Analogy

Orthodontic movement to parallel the roots will improve the contact location, narrow the embrasure,
and result in a taller, more pointed papilla

In general; Early recognition of these difficult situations allows the clinician to plan alternative care to
minimize the damage.

OVATE PONTICS
This entails Removal Of The Contact Point and Half The Interproximal Embrasure; as a
consequence,the papilla is not compressed but flattens out, and esthetics are compromised.
Extraction of a Tooth

The papilla can be maintained if at the time of extraction an ovate pontic is created that will provide
the contact point and lateral embrasure support that the papilla needs
An ovate pontic is inserted 2.5 mm into the extraction site.
The size and shape of the ovate pontic should be the same as the tooth that was extracted.
A well-formed ovate pontic will seal the extraction socket and aid in retaining the bone graft within the
socket.
Adequate edentulous ridges can be shaped to support an ovate pontic.
The receptor site is created with a diamond rotary instrument, an electrosurgery or radiosurgery
unit, or a laser.
The receptor site is carved concave in the anterior aspect and slightly flatter in the posterior aspect.
The thickness of the gingival tissue between the bone and the newly created site for the ovate pontic
must be at least 2 mm, or rebound of the gingiva will occur.

IMPLANT SITE MAINTENANCE AND DEVELOPMENT

CONSEQUENCES OF AN EXTRACTION
After a routine extraction, the average bone and gingival loss for a maxillary anterior tooth is
2.0 to 3.5 mm of vertical bone and gingival tissue(along with 1 to 2 mm of buccolingual bone and
gingival loss)
This loss will cause alterations in gingival margin levels between the prosthetic replacement tooth and
the adjacent teeth..
Patients with a thin biotype will develop more recession and bone loss, up to 7.5 mm;
Patients with thick biotype will have LESS bone and gingival loss.

What is a (tooth Extraction)site preservation?

Various techniques(including bone grafts alone, or in combination with barrier membranes) employed
at the time of extraction to prevent bone and gingival loss;
In the best-case scenario, a patient with a thick biotype will lose only 1 to 2 mm of vertical bone and
gingiva after site preservation techniques in maxillary anterior teeth.
A patient with a thin biotype may lose a severe amount of bone and gingiva (5-7mm) after an
atraumatic extraction of a maxillary anterior tooth, in spite of a site preservation procedure.

Treatment Planning
It consists of developing a logical sequence of treatment designed to restore the patient’s dentition to
good health, optimal function, and optimal appearance.
Treament Planning
Good Communication with the patient is critical as the plan is formulated
The plan should be presented in writing and discussed in detail with the patient

In appropriate proper planning, the patient is informed about the following:

current conditions and problems,
extent of dental treatment that is proposed,
time and cost of treatment,
level of home care and professional follow-up necessary for success

This is regarded as the foremost among necessary decisions usually considered in planning fixed
prosthodontic treatment.
identification of patients’ needs & preferences
For long-term success, when a fixed dental prosthesis (FDP) is being considered, the Abutment Teeth
must be carefully evaluated

Identification Of Patients’ Need

Successful treatment planning is based on proper identification of the patient’s needs.

Treatment Objectives include the following:

correcting an existing disease,
preventing future disease,
restoring function,
improving appearance.

Correction of Existing Disease

Existing disease is revealed during the clinical examination

Active disease can usually be halted by the following

identification & reduction of the initiating factors,
Identification & improvement of the resistive factors,
Both

Prevention of Future Disease

The likelihood of future disease can be predicted from the patient’s disease experience and from the
prevalence of the disease in the general population.
Treatment should be proposed if future disease seems likely in the absence of such intervention.
One of the First Phases Of Treatment Is To Stabilize Active Disease(which often includes)
replacement of defective restorations
treatment of carious lesions.

Restoration of Function
Treatment may be proposed to correct impaired function (e.g., mastication or speech).
Prerequisite treatment may include:
-Mandibular Repositioning(Through Occlusal Reshaping Before Fixed Prosthodontic Treatment)
-Orthodontically Repositioning Teeth(In More Favorable Locations) Before Missing Teeth Are Replaced.

Improvement of Appearance
Patients often seek dental treatment because they are Dissatisfied With Their Appearance.
NB: If the existing appearance is far outside socially accepted values, the feasibility (and limitations) of
corrective procedures should be brought to the patient’s attention.

AVAILABLE MATERIALS AND TECHNIQUES

Plastic materials (e.g.,silver amalgam or composite resin)
Cast metal(IntraCoronal & ExtraCoronal Restoration)
Metal-Ceramic Material
Complete Ceramic
Fiber-Reinforced Resin

(Techniques)
Fixed Dental Prostheses
Implant-Supported Prostheses
Partial Removable Dental Prosthesis
Complete Dentures

Plastic Materials
Plastic materials (e.g., Silver Amalgam Or Composite Resin) are the most commonly used dental
restoratives.
They allow simple and conservative restoration of damaged teeth
Their mechanical properties are inferior to those of cast metal or metal-ceramic restorations.
Their longevity depends on the strength and integrity of the remaining tooth structure.
When the tooth structure needs reinforcement, a cast metal restoration should be fabricated, often
with amalgam or composite resin as the foundation or core

Cast Metal
Cast metal crowns are fabricated in the dental laboratory and are cemented with a luting agent.
To minimize exposure of the luting agent to oral fluids, a long-lasting crown must fit the tooth well.
Replication of optimal anatomic form in crowns helps maintain periodontal health and good occlusal
function.

Intracoronal Restorations
An intracoronal cast metal restoration, or Inlay, relies on the strength of the remaining tooth structure
for support and retention, just as a plastic restoration does.
this restoration is contraindicated in a significantly weakened tooth
in a tooth with a minimal proximal carious lesion, an inlay usually necessitates greater removal of tooth
structure than does an amalgam preparation.

Extracoronal Restorations
An extracoronal cast metal restoration, or crown, encircles all or part of the remaining tooth structure
and the occlusal surface.
NB: Crowns strengthen and protect teeth weakened by caries or trauma
The margins of an extracoronal restoration often must be near or below the crest of the free gingiva,
which can make maintenance of tissue health difficult.

Metal-Ceramic Material
Metal-ceramic crowns consist of a toothcolored layer of porcelain bonded to a cast metal substructure.
They are used when a complete crown is needed to restore appearance and function.
Preparation Design for a metal-ceramic crown is among the least conservative, although tooth
structure can be conserved if only the most visible part of the restoration is veneered.

Fiber-Reinforced Resin
they are very useful as long-term interim restorations.
Involves the use of indirect composite resin restorations for inlays, crowns, and FDPs.
Excellent marginal adaptation and esthetic results are achievable

Fixed Dental Prostheses

An FDP is often indicated when one or more teeth must be removed or are missing. Such teeth are
replaced by pontics that are designed to fulfill the functional and often the esthetic requirements of the
missing teeth.
Pontics are attached with connectors to the FDP retainers, which are the restorations on prepared
abutment teeth.
Principles of Occlusion
Most restorative procedures affect the shape of the occlusal surfaces.
Proper dental care ensures that functional occlusal contact relationships are restored in harmony with
both dynamic and static conditions.

Maxillary and mandibular teeth should contact uniformly on closing for the following reasons
allow optimal function,
minimize trauma to the supporting structures,
allow for uniform load distribution throughout the dentition
NB: Positional stability of well-aligned teeth is crucial if arch integrity and proper function are to be
maintained over time.
As an aid to the diagnosis of occlusal dysfunction, it is helpful to evaluate the condition of specific
anatomic features and functional aspects of a patient’s occlusion with reference to a concept of
“optimum” or “ideal” occlusion
Deviation from this concept can then be measured objectively and may prove to be a useful guide
during
-treatment planning
-active treatment phases.

malocclusion may be associated with undesirable changes to the following

teeth,
Musculature,
temporomandibular joints (TMJs)
periodontium

ANATOMY
Temporomandibular Joints
The major components of the TMJs are the following
cranial base,
mandible,
muscles of mastication(with their innervation and vascular supply)

What does it means to say the TMJs are GinglymoArthrodial,

it means that they are capable of both a Hinging & a Gliding Articulation.

This separates the mandibular fossa and the articular tubercle of the temporal bone from the condylar
process of the mandible.
Articular disk
NB: The articulating surfaces of the condylar processes and fossae are covered with avascular fibrous
tissue (in contrast to most other joints, which have hyaline cartilage).
The articular disk consists of dense connective tissue;
It also is avascular and devoid of nerves in the area where articulation normally occurs.
Posteriorly, it is attached to loose highly vascularized & innervated connective tissue:
the retrodiscal pad/bilaminar zone
(called bilaminar because it consists of two layers:
an elastic superior layer
a collagenous inelastic inferior layer).

This connects to the posterior wall of the articular capsule surrounding the joint
retrodiscal pad

Anteriorly, it fuses with the capsule and with the superior lateral pterygoid muscle.
Superior and inferior to the articular disk are of two spaces:
the superior Synovial cavity
inferior synovial cavity
NB: Because of its firm attachment to the poles of each condylar process, the articular disk follows
condylar movement during both hinging and translation, which is made possible by the loose
attachment of the posterior connective tissues.

Ligaments
The body of the mandible is attached to the base of the skull by muscles and three paired ligaments:
temporomandibular(lateral) Ligament,
sphenomandibular Ligaments,
stylomandibular ligaments
NB: Ligaments cannot be stretched significantly,

what is the major function(s) of Temporomandibular Ligament?

restrict rotation of the mandible,
limit border movements,
protect the structures of the joint

The sphenomandibular and stylomandibular ligaments perform the following Functions?

limit separation between the condylar process and the articular disk;
(the stylomandibular ligaments also limit forward (protrusive) movement of the mandible)

Musculature
Several muscles responsible for mandibular movements are grouped as follows
muscles of mastication
suprahyoid muscles

muscles of mastication include the following

temporal
masseter,
medial pterygoid muscles
Latera pterygoid muscles

suprahyoid muscles include the following

geniohyoid,
mylohyoid,
digastric muscles.

Muscular Function
these Three(3) paired muscles of mastication provide elevation and lateral movement of the mandible:
temporal muscles
masseter muscles
medial pterygoid muscles

The lateral pterygoid muscles each have two bellies that function as two separate muscles, which
contract in the horizontal plane during opening and closing and they are:
inferior belly (inferior lateral pterygoid muscle)
superior belly (superior lateral pterygoid muscle)

Which lateral ptrygoid muscle is active during protrusion, depression, and lateral movement of the
mandible?
inferior belly (inferior lateral pterygoid muscle)

Which lateral ptrygoid muscle is active during closure?

superior belly (superior lateral pterygoid muscle)

What are the dual functions of he suprahyoid muscles?

elevate the hyoid bone
depress & retract the mandible.
NB: When the muscles of mastication are in a state of contraction, the suprahyoid muscles elevate the
hyoid bone.
when the infrahyoid muscles (which anchor the hyoid bone to the sternum and clavicle) are contracted,
the suprahyoid muscles depress and retract the mandible.

These muscles initiate the opening movements of the Mandible

geniohyoid and mylohyoid muscles

This muscle completes mandibular depression.

anterior belly of the digastric

Dentition
The relative positions of the maxillary and mandibular teeth influence mandibular movement.
Ideally, in the fully bilateral seated position of the condyle–articular disk assemblies, the maxillary and
mandibular teeth exhibit maximum intercuspation.
This(above) means that the maxillary lingual and mandibular buccal cusps of the posterior teeth are
evenly distributed and in stable contact with the opposing occlusal fossae.

This is defined as the complete intercuspation of the opposing teeth, independent of condylar
position
Maximum Intercuspation.
NB: this is sometimes considered the best fit of the teeth regardless of condylar position.

this orthodontic relationship is considered If(when) the mesiobuccal cusp of the maxillary first molar is
aligned with the buccal groove of the mandibular first molar.
Angle class I
(this is considered normal occlusion)
This position is defined as the dental relationship in which the anteroposterior relationship of the jaws is
normal, as indicated by correct intercuspation of maxillary and mandibular molars
NB: Empirically, dentitions with greater vertical overlap of the anterior teeth appear to have a better
long-term prognosis than do dentitions with minimal vertical overlap.

Centric Relation
Centric relation is defined as the maxillomandibular relationship in which the condyles articulate with
the thinnest avascular portion of their respective articular disks with the complex in the anterosuperior
position against the shapes of the articular eminences
NB: This position is independent of tooth contact.
Centric relation is considered a Reliable & Reproducible Reference (and treatment) Position.
If maximum intercuspation coincides with the centric relation position, restorative treatment is often
straightforward.

This occlusal relationis clinically discernible when the mandible is directed superior and anterior and is
restricted to a purely rotary movement about the transverse horizontal axis.
Centric Relation

Mandibular Movement
The complex three(3)-dimensional mandibular movement can be divided into two basic components:
Translation(in which all points within a body have identical motion)
Rotation(in which the body is turning about an axis)

It is easier to understand mandibular movement when the components are described as projections in
three perpendicular planes:
Sagittal
horizontal
Frontal

Reference Planes
Sagittal Plane
In the sagittal plane, the mandible is capable of a purely Rotational movement, as well as
Translation.
Rotation occurs around the terminal hinge axis, an imaginary horizontal line through the rotational
centers of the left and right condylar processes.
Rotational Movement is limited to about 12mm of incisor separation before the temporomandibular
ligaments and structures anterior to the mastoid process force the mandible to translate.
The initial rotation or hinging motion occurs between the condylar process and the articular disk.
During translation, the inferior lateral pterygoid muscle contracts and moves the condyle–articular disk
assembly forward along the posterior incline of the tubercle.
Rotation in the horizontal plane occurs during lateral movement of the mandible.

Horizontal Plane
In the horizontal plane, the mandible is capable of rotation around several vertical axes

This movement consists of rotation around an axis situated in the working(laterotrusive) condylar
process with relatively little concurrent translation.
Lateral Movement

Term used for a slight lateral translation of the condyle on the working side in the horizontal plane(that
is frequently )present.
LateroTrusion(Bennett movement or mandibular side shift)
Term used for a slight lateral translation of the condyle(in a slightly forward direction) on the working
side in the horizontal plane
LateroProtrusion

Term used for a slight lateral translation of the condyle(in a slightly backward direction) on the working
side in the horizontal plane
LateroRetrusion

Frontal Plane
In a lateral movement in the frontal plane, the nonworking (mediotrusive) condyle moves down and
medially, whereas the working (laterotrusive) condyle rotates around the sagittal axis perpendicular to
this plane

Border Movements
Mandibular movements are limited by the following
Tmjs & Ligaments,
NeuroMuscular System,
Teeth

This term is used to decsribe the movement of the mandibular at(to) the limits dictated by
anatomic structures, as viewed in a given plane,
Border Movement
NB: All possible mandibular movements occur within its boundaries
Starting from the maximum intercuspation position, in the protrusive pathway, the lower incisors are
initially guided by the lingual concavity of the maxillary anterior teeth.

Posterior and Anterior Determinants of Mandibular Movement

These determinants are the anatomic structures that dictate or limit the movements of the mandible.
They are
Anterior Determinants
Posterior Determinants

This determinant of mandibular movement is the articulation of the teeth.

anterior determinant

This determinants of mandibular movement are the temporomandibular controls and their associated
structures
posterior determinants

The following posterior determinants—cannot be altered by the dentist, and the neuromuscular
responses of the patient can be influenced only indirectly (e.g., through changes in the shape of the
contacting teeth or with an occlusal device).
shape of the articular eminences,
anatomy of the medial walls of the mandibular fossae,
configuration of the mandibular condylar processes
NB: The anatomy of the joint dictates the actual path and timing of condylar movement.
Laterotrusive movement of the working condylar process is influenced predominantly by the anatomy
of the lateral wall of the mandibular fossa.

They are the vertical and horizontal overlaps of the anterior teeth and the form of the lingual
concavities of the maxillary anterior teeth.
anterior determinants
NB: These can sometimes be altered by restorative and orthodontic treatment.

Functional Movements
This mandibular Movement is defined as all normal, proper, or characteristic movements of the
mandible made during speech, mastication, yawning, swallowing, and other associated activities.
Functional mandibular movement
NB: Most functional movement of the mandible (as occurs during mastication and speech) takes place
inside the physiologic limits established by the following
the teeth,
the TMJs,
the muscles & ligaments of mastication

Chewing
During Mastication; The direction of the mandibular path of closure is influenced by the inclination of
the occlusal plane with the teeth apart and by the occlusal guidance as the mandible approaches
maximum intercuspation.
NB: The chewing pattern observed in children differs from that found in adults. Until about age 10,
children begin the chewing stroke with a lateral movement. After the age of 10, they start to chew
increasingly like adults, with a more vertical stroke
Stimuli from the PressoReceptors play an important role in the development of functional chewing
cycles.

Speaking
The following oral structures form the resonance chamber that affects pronunciation.
teeth
tongue
lips
floor of the mouth
soft palate
NB: During speech, the teeth are generally not in contact, although the anterior teeth may come very
close together during soft “c,” “ch,” “s,” & “z” sounds, forming the “speaking space:

This is the space that occurs between the incisal and/or occlusal surfaces of the maxillary and
mandibular teeth during speech.”
Speaking Space

it is a useful diagnostic guide for correcting Vertical Dimension & Tooth Position during Fixed and
Removable Prosthodontic Treatment
Phonetics

Parafunctional Movements
This movements of the mandible may be described as sustained activities that occur beyond the
normal functions of mastication, swallowing, and speech.
Parafunctional Movements(of the mandible)

Few of the many forms of parafunctional activities, include

Bruxism
clenching
nail biting
pencil chewing.
NB: Parafunction is typically manifested by long periods of increased Muscle Contraction &
Hyperactivity and is associated with the following
excessive occlusal pressure
prolonged tooth contact

Over a protracted period, parafunction(which is inconsistent with the normal chewing cycle) can result
in the following:
excessive wear;
widening of the periodontal ligament;
Teeth mobility,
teeth migration,
teeth fracture

Examples of Muscle Dysfunction that may result from Parafunctional Activities of the jaw
elevated muscle tone
myospasm
Myositis
myalgia,
referred pain (headaches) from trigger point tenderness

What are the two most common forms of parafunctional activities

bruxism
clenching

which of the following radiographic features is often increased in patients with a history of sustained
parafunctional activity.
Radiographic bone density (f the alveolar process)

Bruxism
It is the term used for the group of Involuntary rhythmic or spasmodic nonfunctional gnashing,
grinding, or clenching of teeth, in other than chewing movements of the mandible(that may lead to
Occlusal Trauma)
Bruxism
(This activity may be diurnal, nocturnal, or both)

This type of bruxism is potentially more harmful because the patient is not aware of it during sleep
and as such; difficult to detect but should be suspected in any patient exhibiting abnormal tooth wear
or pain.
Nocturnal Bruxism

causes of bruxism are often unclear but some theories relate its occurrence to the following or a
combination of these factors
malocclusion,
neuromuscular disturbances,
responses to emotional distress
Genetics
Sleep Disturbance
Altered Mastication
NB: According to one theory, bruxism is performed on a subconscious reflex-controlled level in relation
to emotional responses and occlusal interferences.
Patients with bruxism can exert considerable forces on their teeth, and much of this may have a lateral
component.
Posterior teeth do not tolerate lateral forces as well as vertical forces in their long axes. Buccolingual
forces, in particular, appear to cause rapid widening of the periodontal ligament space and increased
mobility.

Clenching
Clenching is defined as the pressing and clamping of the jaws and teeth together frequently in
association with
acute nervous tension or physical effort

The Causes of Clenching can be associated with the following( rather than an occlusal disorder).
stress
anger
physical exertion
intense concentration(on a given task)
NB: In contrast to bruxism, clenching does not necessarily result in damage to the teeth because the
concentration of pressure is directed more or less through the long axes of the posterior teeth without
the involvement of detrimental lateral forces.
Abfractions(cervical defects at the CEJ))—may result from sustained Clenching.
Also, the increased load(during Clenching) may result in damage to the following
periodontium,
TMJs
muscles of mastication
The following may progress,(as a result of Clenching) causing the patient to seek treatment.
Muscle splinting,
myospasm
myositis
NB: In most patients, maximum tooth contact occurs anterior to the centric relation position of the
mandible. Often, this maximum intercuspation position anterior to centric relation is referred to as
Centric Occlusion

Bilaterally Balanced Articulation

This requires having a maximum number of teeth in contact in maximum intercuspation & all excursive
positions.
In complete denture fabrication, this tooth arrangement helps maintain denture stability because the
nonworking
contact prevents the denture from being dislodged.

Unilaterally Balanced Articulation(Group Function)

In a unilaterally balanced articulation, excursive contact occurs between all opposing posterior teeth on
only the laterotrusive side. This occlusal arrangement is also referred to as group function.
On the mediotrusive side, no contact occurs until the mandible has reached centric relation.

Optimum Occlusion
In an ideal occlusal arrangement, the load exerted on the dentition should be distributed optimally.
Any restorative procedures that adversely affect occlusal stability may affect the timing and intensity of
elevator muscle activity
The features of a mutually protected articulation are as follows
Uniform contact of all teeth around the arch when the mandibular condylar processes are in their most
superior position
Contact of stable posterior teeth with vertically directed resultant forces
Centric relation coincident with maximum intercuspation (intercuspal position)
No contact of posterior teeth in lateral or protrusive movements
Harmonizing of anterior tooth contacts with functional mandibular movements
To achieve these criteria, it is assumed that
(1) a full complement of teeth exists,
(2) the supporting tissues are healthy,
(3) there is no reverse articulation (crossbite),
(4) the occlusion is Angle class I.

PATIENT ADAPTABILITY
PATHOGENIC OCCLUSION
A pathogenic occlusion is an occlusal relationship capable of producing pathologic changes in the
stomatognathic system.
Signs and Symptoms of Pathogenic Occlusion
Teeth
Periodontium
Musculature
Temporomandibular Joints
Myofascial Pain Dysfunction

Teeth
The teeth may exhibit hypermobility, open contacts, or abnormal wear. Hypermobility of an individual
tooth or an opposing pair of teeth is often an indication of excessive occlusal force.
This may result from premature contact in centric relation or during excursive movements.
Open Proximal Contacts may be the result of tooth migration because of an unstable occlusion

Periodontium
a widened periodontal ligament space (detected radiographically) may indicate premature occlusal
contact and is often associated with tooth mobility
Isolated Or Circumferential Periodontal Defects are often associated with Occlusal Trauma

Musculature
Acute or chronic muscular pain on palpation can indicate habits associated with tension, such as
bruxism or clenching.
Chronic muscle fatigue can lead to muscle spasm and pain.

Temporomandibular Joints
Pain, clicking, or popping in the TMJs can indicate temporomandibular disorders.
patient may complain of TMJ pain that is actually of muscular origin and is referred to the joints.
Clicking may also be associated with internal derangements of the joint.
A patient with unilateral clicking during opening and closing (reciprocal click) in conjunction with a
midline deviation may have a Displaced Articular Disk.

Myofascial Pain Dysfunction

The myofascial pain dysfunction (MPD) syndrome manifests as diffuse unilateral pain in the preauricular
area, with muscle tenderness, clicking, or popping noises in the contralateral TMJ and limitation of
mandibular function.
Often the muscles, and not the TMJ, are the primary sites, but over time the functional problem may
lead to organic changes in the joint.
Patients with MPD may require multidisciplinary treatment involving occlusal therapy, medications,
biofeedback, and physical therapy.

OCCLUSAL TREATMENT
When a patient exhibits signs and symptoms that appear to be associated with occlusal interferences,
occlusal treatment should be considered.
Such treatment can include the following:s
tooth movement through orthodontic treatment,
elimination of deflective occlusal contacts through selective reshaping of the occlusal surfaces of teeth,
missing tooth restoration
replacement that result in more favorable distribution of occlusal force.

What are the objectives of occlusal treatment?

To direct the occlusal forces along the long axes of the teeth
To attain simultaneous contact of all teeth in centric relation
To eliminate any occlusal contact on inclined planes to enhance the positional stability of the teeth
To have centric relation coincide with the maximum intercuspation position
To arrive at the occlusal scheme selected for the patient (e.g., unilateral balanced versus mutually
protected)

Occlusal Device Therapy

Occlusal devices (sometimes referred to as occlusal splints, occlusal appliances, or orthotics) are used
extensively in the management of temporomandibular disorders and bruxism