Restorations and Periodontal Health

Question 1

Biological width

Answer 1

The combined width of connective tissue and junctional epithelial attachment formed adjacent to a tooth and superior to the crystal bone

Question 2

Biological width =

Answer 2

Biological width = connective tissue attachment + junctional epithelium

Question 3

Importance of the biological width

Answer 3

The mean dimensions of biological width 2.15mm 50 2.30mm

This concept establishes a healthy state of the periodontium and any violations to it, while providing treatment, will hinder the healthy state of the periodontium resulting in gingivitis / periodontitis.

Therefore its important to try to preserve it whilst providing treatment

Question 4

Why do we get periodontal problems in restorative dentistry?

Answer 4

2 main causes

1. Plaque retentive factors
   - Created by the shape (3D contour) of the restoration with overhangs or ledges
   - Deficiencies or voids at the margin or in the restoration surface
   - Roughness of the restorative surface causing plaque retention
2. Food impaction
   - poor / no contact point
   - incorrect 3D contour of the supragingival bulge in the restoration
   - over/under built embrasures (spillways)

Question 5

Contact points and embrasures

Answer 5

Question 6

Prior health status of the periodontium and teeth

Answer 6

Always undertake prevention first
- diet analysis/advice … smoking cessation
- OHI advice, indicies, interdental cleaning aids
- exposure to and the use of fluoride toothpaste

If food packing inter proximally is a problem, the examine the occlusion for:
- ‘plunger cusps’ abnormal cusp contact between marginal ridges, not into the normal cusp and fossae arrangement
- open or poor contact points between tooth and restoration or poor embrasure design, leading to the trapping of food

Question 7

Disease promotion: iatrogenic (clinician controlled) factors

Answer 7

Before you cut, alter or deface enamel, and dentine remember

1. Teeth are hard tissue held in a vital and dynamic tissue matrix
2. Lost hard tissues can be replaces with other materials but wont be as good in terms of contour, surface, smoothness, strength, aesthetics, biocompatibility or longevity)
3. Tooth tissue loss may affect the vital supporting hard and soft tissues in both the shorter and longer terms

Question 8

Iatrogenic damage to gingival/periodontal health

Incorrect placement of matrix band and no wedges leads to..

Answer 8

• gross overhangs (material extrusion) and ledges
• plaque retention and caries and/or gingival / periodontal disease

Question 9

How to maintain gingival / periodontal health

Answer 9

Correct placement of matrix band and wedges leads to…

• tight contact points and correct vertical positioning of contact points minimise plaque/food trapping and correct 3D contour of the restoration
• minimises voids or deficiencies in the restoration resulting in les plaque retention / caries and gingival inflammation
• no overhangs or ledges or gross material displacement

Question 10

Are the soft tissues healthy enough to allow all necessary procedures?

Answer 10

Is gingivitis present?
- is there spontaneous haemorrhaging on.. preparation / or when a matrix band or strip is being placed
- bleeding prevent adequate moisture control

Is periodontitis present?
- will pocketing and bone loss mean poor restoration contours and aesthetics (black triangle disease - punched out interdental papilla)
- deep subgingival floor of the restoration because of root caries
- if so, how deep before sound tissue is found, or the pulp exposed?

Question 11

The long term consequence of gingival and periodontal inflammation

Answer 11

Plaque retaining factor / plaque will increase in pocket formation, pocket depth, with further loss of clinical attachment

• may cause localised alveolar bone loss
• gingival recession
• secondary caries at the restoration margin
• associated with poor plaque control, high consumption of fermentable carbohydrates and low exposure to fluoride

Question 12

Clinical relevance

Answer 12

• prevention comes first
• check and review baseline gingival / periodontal disease
• correctly address any disease
• correct faulty restoration / refurbish / modify / replace
• plan and carry out restorative treatment by respecting the biological width, natural tooth morphology and anatomical contact relationship

Question 13

Faulty restorations - what to do?

Answer 13

Question 14

Prior to restorative procedures think about

Answer 14

Gingival bleeding
Increased GCF flow
Poor soft tissue contours
Hyperplasticity tissue

Immediate impact following the procedure
- trauma from burns
- matrix strips / wedges
- chemical burns from phosphoric gel

How does your restoration impact upon the long term heath of the gingival and periodontal tissues