W6 - Interdisciplinary Perio - Sharma Flashcards
What can perio therapy help achieve in multi-disciplinary approach (4)
Stable gingival margins before tooth prep
Adequate tooth length / Crown lengthening
Perio tx after ortho mvmt and restorations causing mvmt
Esthetic and implant procedures usually require specialized perio
What is Perio specialty’s role in preprosthetic surgery (4)
After control of active disease:
Mgmt of mucogingival problems
Preservation of ridge after exo
Crown lengthening
Alveolar ridge reconstruction
Example of preservation of ridge
GBR - not squeezing socket after exo, rather pack it to not lose anatomy
Describe how the resto margins are tolerated by perio tissues (3)
Supragingival: no effect on perio but unaesthetic in anterior
Equigingival- well tolerated
Subgingival - Can affect SCAT and lead to BL
What is SCAT (+ measurement)
Supracrestal attached tissues AKA biologic width
Junctional epithelium + connective tissue attachment
2.04 mm
How to evaluate if you violated SCAT + BEST way
Radiograph - can SUGGEST it
Pt discomfort when probing around resto margins
Histological evaluation is definitive (but not clinically possible)
BEST WAY: Bone sounding
What is bone sonding and what is it used to indicate
Probe is pushed through attachment tissues to underlying bone after LA
- Can be done on healthy gingival tissues
- <2 mm indicated SCAT violation
Management of SCAT violation (2)
Surgically removing bone away from proximity of resto margin (faster)
or
Ortho extrusion
Rules for managing clinical margin placement (3)
Rule 1: Sulcus is ≤ 1.5 mm, resto margin no more than 0.5 mm subgingival
Rule 2: Sulcus ≥ 1.5mm margin at half the depth of the sulcus
Rule 3: Sulcus >2mm, gingivectomy to create a 1.5mm sulcus, then use rule 1
Indications for surgical crown lengthening (3)
Subgingival caries or fracture
Inadrquate clinical crown for retetion
Unequal or unesthetic gingival heights
Why do we use crown lengthening? (2)
To expose adequate clinical crown to prevent margins impacting SCAT
At least 3 mm between the most apical extension of the restorative margin and alveolar bone.
Contraindication of surgical crown lengthening (3)
If surgery would create unaesthetic outcome
If deep caries or fracture would require excessive bone removal on adjacent teeth
Tooth has poor restorative prognosis
Guideline/rule for soft tissue crown lengthening vs osseous reduction CL
When is ortho extrusion necessary (2)
Violation is on interproximal side or is across the facial surface with ideal gingival tissue level
Slow force vs rapid force ortho extrusion
Slow force - takes months
- Bone and teeth move
- Surgical correction
Rapid force - weeks
- Teeth only
- Supracrestal fibrotomy
Interproximal tooth contact to bone distance relationship with Black triangles
≤ 5mm or less → papilla always fill space
6mm → 56% of papillae fill the space
7mm → 37% of the papillae fill the space
Relationship between contact point and embrasure impacting papilla shape
- Embrasure too wide, papilla flattens out, assumes a blunted shape.
- Embrasure ideal width, papilla assumes a pointed form, normal sulcus
- Embrasure too narrow, papilla grows out to the facial and lingual, and become inflamed.
2 options for black triangles
- Tissue coloured ceramics to mimic papillae
- Resin - carry the interproximal contact apically towards papilla
How can a good emergence profile be developed in pontic receptor site
Provisional prosthesis placed to develop the ovate pontic receptor site
- Maintains interdental papilla
- Develops the pontic receptor site
Interdisciplinary treatment case objectives
Example
Benefits of ortho tx in perio pts (6)
Fix crowding for better OH
Intrusion to improve osseous defects
Improve gingival margin esthetics
Crown lengthening fractured teeth
Corrected embrasures to regain lost papilla
Adjust adjacent tooth positions before implant
What is pathologic tooth migration (PTM)
change in tooth position that occurs when there is a disruption of forces that maintain teeth in a normal relationship
Ex. Perio, occlusal forces, oral habits, soft tissues
Major factors affecting tooth position (4)
Perio tissues
Soft tissues inc cheek, tongue, lips
Occlsual forces
Oral habits
Example of ortho tx of osseous defects
Hemiseptal defects
- One or two walled defects usually found in mesial tipped or supraerupted teeth
- Treated by up righting or intrusion
- Supra-erupted teeth managed by intrusion
Indications for surgical crown lengthening (3)
Subgingival caries or fracture
Inadequate clinical crown length for retention
Unequal or unaesthetic gingival heights
2 types of ortho extrusion and features
Rapid force - takes weeks, tooth movement only, supracrestal fibrotomy → releasing fibres with scalpel every few weeks as force is applied
Slow force - takes months, bone AND teeth move, need surgical correction after tx to remove excess bone
When is alveolar ridge reconstruction done?
Prior to fixed prosthesis or implant therapy in the form of soft or hard tissue augmentation.
How is papillary height established?
Contact area
Level of bone
Biological width
Form of gingival embrasure
What is an osseous crater?
IP 2-wall defect that does not improve with orthodontic treatment—surgical reshaping is required
How is a class III furcation defect commonly managed?
Hemisecting crown and root of tooth
Sequence: endo-perio-ortho-pros
What is is the length of gingival sulcus + junction epithelium + connective tissue
3mm
What is an example of when soft tissue augmentation is required?
May be used to correct black triangles
Why can the papilla appear inadequate?
Bone loss or IP contact located too high coronally
What is most common pontic?
Modified ridgelap
- Used anteriorly and posteriorly
- Balance of aesthetics and hygiene
What is the issue with this patients dentition
- Significant recession
- Extrusion/supraeruption of teeth
- Pathological migration
- Multiple teeth missing
- Open bite
What are factors to consider for tx of fractured teeth (crown lengthening and forced eruption)?
- Root length (fracture to level of bone, erupt at least 4mm)
- Root form (broad and non-tapering)
- Level of fracture (too deep from bone makes difficult)
- Relative importance of tooth (pt age)
- Aesthetics (high lip line)
- Endo/perio prognosis (perio defect and vertical fractures have poor prognosis)
What is required before orthodontics?
- Perio assessment
- Hx: prev perio disease, drug hx, systemic diseases
- Clinical exam: BOP, mobility, thin fragile gingiva, pockets
What happens when an extruded tooth with vertical bone defect is intruded with orthodontics?
Bone can fill in the defect (may need to do bone graft before ortho)
What are some common ways ortho is a useful adjunct to perio management?
- Managing vertical bone defect
- Managing pathological tooth migration
