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Problem Based Learning
Pre-prosthetic Periodontal Surgery
Maha A. Bahammam, BDS, MSc, CAGS,
EdM, DSc
Diplomate of the American Board of Periodontology
Case: 1
• 45 years old. Female patient
• Healthy
• Her chief complaint: ( my crowns on my
lower RT back teeth always come off, I need
good cement this time)
• What do you think the reason is? And how
would you manage that case?
Note where the gingival margin is!
Preoperative
Postoperative
What is the effect of a restorative
margin on the development and
health of the supracrestal attachment
apparatus?
Success is in the details!
Goals of Osseous Resective Surgery
• Establish physiologic probing depth
• Exposing sound tooth structure or correcting
an un-esthetic gingival contour
Supracrestal Gingival Tissue (SGT)
• Bilogic Width: the juctional epithelium and
connective tissue elements of the
dentogingival contiuum that occupy the space
between the base of the gingival crevice and
the alveolar crest (Cohen, 1962)
Biologic Width
• Gargiulo et al. described the dimensions and
relation of the dentogingival junction in human.
Their study established that there is a
proportionate dimensional relationship between
the crest of the alveolar bone, the connective
tissue attachment, junctional epithelium, and the
sulcus.
• The biologic width is
that zone of root
surface coronal to the
alveolar crest, to which
the connective tissue
and junctinal epithelum
are attached.
•Gargiulo A, Wantz F, Orban B. 1961. Dimentions of the
dentogindival junction in Humans. J Periodontol., 32, 261.
Biologic Width
• Sulcus depth- 0.69mm
• Junctional epithelium0.97mm
• Connective tissue
attachment- 1.07mm
• Total (from the osseous
crest to the gingival
margin): 2.73mm
• These are averages!!!
A small amount can make
a BIG difference!
How much is enough?
• Estimated dimention of the biologic width as
being in vicinity of 2.04 mm (Gargiulo et al.,
1961) ≈ 2 mm
• Therefore the total dimensions of SGT
(Biologic Zone) would be in vicinity of 2.73
mm. ≈3mm
Based on these dimensions of the SGT
• Ingber et al., 1977; states that during clinical
crown lengthening surgery, sufficient bone
should be resected to permit 3 mm of sound
tooth structure above the crest of the bone
• Rosenberg et al., 1980; preferred 4 mm of
tooth exposure
• This bone resection is necessary to
accommodate the SGT, which will develop in
the surgical site, and yet leave sufficient tooth
exposed to complete the tooth preparation
• When the attachment levels are within normal
limits, soft tissue excision alone will result in
reformation of the predestined amount of SGT
and no real gain in clinical crown length
The decision to restore a tooth
depends on the following factors:
• Degree of periodontal support lost form
adjacent tooth during crown lengthening
procedure
• Location of furcation relative to biologic width
• Ability to perform effective plaque control
following placement of restoration
Continue
• Crown to root ratio
• Position of tooth in the
arch
• Predictability of
treatment procedure
• Strategic value of tooth
• Esthetic and phonetic
consideration
• Endodontic
consideration
• Root anatomy and
morphology as it relates
to post placement
• Restorative requirement
• Cost/ Risk/ Benefit
ration relative to
alternative treatment
(Case 4)
Indications: surgical removal of healthy periodontal
tissue is sometimes necessary to facilitate a restorative
treatment for the following reason:
• Tooth decay at or apical to the gingival margin that
prevent adequate finish line preparation
• Tooth fracture bellow the gingival margin, with
adequate remaining periodontal support and
attachment
• Teeth with insufficient interocclusal space
• Mechanical retention is inadequate
• Displeasing esthetics of short or uneven clinical
crown lengths following excessive attrition or
delayed passive eruption
Cost/ Risk/ Benefit Ration
•
•
•
•
•
What are the costs of each treatment?
What is the length of time involved?
How many visits are involved?
What is the long term prognosis?
How predictable is the procedure?
How do we treat this case?
What do we tell the patient?
How do we treat this case?
What do we tell the patient?
Contraindications for Crown
Lengthening Procedures
• Teeth that are not restorable, when adjacent
teeth would be compromised either
functionally or esthetically
• When the importance of the tooth is not
comparable with the extent of the procedure
required to save it.
Post Operative Treatment
•
•
•
•
•
•
•
Perio packing
Medication
NSAID
Antibiotics
Analgesics
Suture removal
Completion of restoratioin
Possible Complication
•
•
•
•
•
Bleeding
Pain
Swelling
Root sesitivity
Loss of flap
How long to wait for healing?
 Healing should proceed uneventfully, with the attachment
of the flap to the underlying bone being completed by 14 to
21 days. Maturation and remodeling can continue for up to
6 months.
 It is usually advisable to wait a minimum period of 6 weeks
after the completion of the last surgical area before
beginning dental restorations.
 For those patients with a major cosmetic concern, it is wise
to wait as long as possible to achieve a postoperative soft
tissue position and sulcus that is stable.
The Art of Communication
Explaining the Procedure
What words do we use?
• Cut away tissue
• Grind bone
• surgery
Weighing the choices
Cost/ Risk/ Benefit Ratio
• What alternative treatment exists?
• Extraction
Bridge
Implant
Cost/ Risk/ Benefit Ratio
• What alternative treatment exists?
Extraction
Orthodontic extrusion
Forced Eruption and Flap Surgery
• This accomplished by moderate orthodontic
force of 25 to 35 g.
Indications:
• When the amount of surgical bone reduction
around the affected tooth and the adjacent
teeth would be excessive
Contraindication:
• Short root length which result in inadequate
crown/ root ration following extrusion
• Poor root form
• Following forced eruption, a flap procedure
usually is necessary to reduce any extruded
alveolar bone and to apically position the
gingiva that moved coronally during
extrusion
• However, if a gingival supracrestal fibrotomy
is performed during the extrusion process,
the gingiva should not erupt with the tooth,
and the need for periodontal surgery maybe
eliminated
Advantages of Forced Eruption
• Supporting bone of the adjacent teeth not
sacrificed
• Surgical treatment phase maybe reduced or
eliminated
Summary
• In establishing a biologic basis for crown
lengthening; we should consider the following:
– Finish line of the restoration should be
determined prior to the surgery
– If not possible, the finish line should be
anticipated at surgery
– Sufficient alveolar bone should be removed to
permit the development of an acceptable
dimension of SGT between the actual and
anticipated finish line of the preparation and
the alveolar crest
– Circumferential transgingival probing (bone
sounding) prior to surgery, in healthy areas in
the operation site, should be the gauge for
estimating the SGT compatible with individual
patient requirements
– The degree and configuration of osseous
scalloping is determined by the surface
topography of the tooth
– Gingival form is dictated both by osseous
configuration and the surface anatomy of the
tooth
– Restorative procedures must not disrupt the
epithelial attachment and the SGT
Conclusions
• Dental restorations and periodontal health are
interrelated
• The adaptation of the margins, the contours
of the restoration, the proximal relationships,
and the surface smoothness have a critical
biologic impact on the gingiva and supporting
periodontal tissues
• Dental restorations therefore play a significant
role in maintaining periodontal health
Thank You!