Surgical procedures in fixed partial denture prostheses/ General orthodontics

INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com

Introduction
Periodontal Considerations:
 Anatomy of the Gingiva and Periodontium
 Osseous Defects
 Choosing the right graft material
 Treatment sequencing for FPD
 Sequencing of periodontal therapy
▪ Phase ITherapy
 BiologicWidth,Violation of BiologicWidth
 Bone Regeneration
 Biologic Considerations

Hard and Soft tissue defects and their surgical
management
 Alveolar bone defects
 Inadequate tooth structure for restoration of tooth
 Recession
 Ridge defects
 Gingival Overgrowth
 Furcation Involvement
 Interdental papilla reconstruction
Electrosurgery
Gingettage, Frenectomy
Management of excessive gingival pigmentation

Active periodontal disease must be treated
and controlled prior to any restorative
therapy.
Restorative treatment must be performed on
a periodontium free of inflammation and
pockets, without any mucogingival
involvement and with the contour and shape
of the periodontium corrected for a good
functional and esthetic result.
Jan Lindhe,Thorkild Karring, Niklaus P. Lang. Clinical Periodontology and Implant Dentistry, fourth edition

Reasons why periodontal disease must be
eliminated before Restoration of teeth:
 To locate and determine the gingival margins of
restorations correctly. Margins of the restorations
covered by inflamed gingiva shrinks after periodontal
treatment
 Position of the teeth are frequently altered due to
periodontal disease, and therefore must be corrected
before restoration
 Inflammation of the periodontium of the abutment
teeth effects the load carrying capacity of the abutment.
 Discomfort may be caused due to mobility of the
abutment teeth, which interferes with mastication and
function.
Jan Lindhe,Thorkild Karring, Niklaus P. Lang. Clinical Periodontology and Implant Dentistry, fourth editionwww.indiandentalacademy.com

Gingiva (G)
Periodontal ligament
(PL)
Root cementum (RC)
Alveolar bone(AP)
Alveolar bone proper
(ABP)

The alveolar bone consists of two
components:
 The alveolar bone proper and,
 The alveolar process
The alveolar bone proper, also called ‘bundle
bone’ is continuous with the alveolar process
and forms the thin bone plate that lines the
alveolus of the tooth.

The main function of the periodontium is to
 attach the tooth to the bone tissue of the jaws and
 to maintain the integrity of the surface of the
masticatory mucosa of the oral cavity.
The periodontium, constitutes a developmental,
biologic, and functional unit which undergoes
certain changes with age and is, in addition,
subjected to morphologic changes related to
functional alterations and alterations in the oral
environment.

The oral mucosa is continuous with the skin
of the lips and the mucosa of the soft palate
and pharynx.The oral mucosa consists of
(1) the masticatory mucosa, which includes
the gingiva and the covering of the hard
palate,
(2) the specialized mucosa, which covers the
dorsum of the tongue, and
(3) the remaining part, called the lining
mucosa.

The gingiva is that part of the masticatory
mucosa which covers the alveolar process
and surrounds the cervical portion of the
teeth.
It consists of an epithelial layer and an
underlying connective tissue layer called the
lamina propria.
The gingiva obtains its final shape and texture
in conjunction with eruption of the teeth.

In the coronal direction the coral pink gingiva
terminates in the free gingival margin, which has a
scalloped outline. In the apical direction the gingiva is
continuous with the loose, darker red alveolar
mucosa from which the gingiva is separated by a,
usually,
easily recognizable
borderline called the
mucogingival junction or the
mucogingival line.

There is no mucogingival line present in the
palate since the hard palate and the maxillary
alveolar process are covered by the same
type of masticatory mucosa.

Two parts of the gingiva can be differentiated:
1. the free gingiva (FG)
2. the attached gingiva (AG)

The free gingiva is coral pink, has a dull surface
and firm consistency.
It comprises the gingival tissue at the vestibular
and lingual/palatal aspects of the teeth, and the
interdental gingiva or the interdental papillae.
On the vestibular and lingual side of the teeth, the
free gingiva extends from the gingival margin in
apical direction to the free gingival groove which is
positioned at a level corresponding to the level of
the cementoenamel junction (CEJ).
The attached gingiva is in apical direction
demarcated by the mucogingival junction (MGJ).

The free gingival margin is often rounded
in such a way that a small invagination or
sulcus is formed between the tooth and
the gingiva
When a periodontal probe is inserted into
this invagination and, further apically,
towards the cementoenamel junction, the
gingival tissue is separated from the
tooth, and a "gingival pocket" or "gingival
crevice" is artificially opened.
Thus, in normal or clinically healthy
gingiva there is in fact no "gingival
pocket“ or "gingival crevice" present but
the gingiva is in close contact with the
enamel surface.

After completed tooth eruption, the free
gingival margin is located on the enamel
surface approximately 1.5 to 2 mm coronal to
the cemento-enamel junction.

The shape of the interdental papilla is
determined by the contact
relationships between the teeth, the
width of the approximal tooth surfaces,
and the course of the cementoenamel
junction.
In anterior regions of the dentition, the
interdental papilla is of pyramidal form
while in the molar regions, the papillae
are more flattened in buccolingual
direction.
Due to the presence of interdental
papillae, the free gingival margin
follows a more or less accentuated,
scalloped course through the dentition.

In the premolar/molar regions of the
dentition, the teeth have approximal
contact surfaces rather than contact
points. As the interdental papilla has a
shape in conformity with the outline of
the interdental contact surfaces, a
concavity —a col — is established in the
premolar and molar regions.
Thus, the interdental papillae in these
areas often have one vestibular and one
lingual/palatal portion separated by the
col region.

The col region, as demonstrated in the
histological section, is covered by a thin non-
keratinized epithelium.
This epithelium has many features in common
with the junctional epithelium.

The attached gingiva is, in coronal
direction, demarcated by the free
gingival groove.
The attached gingiva extends in
the apical direction to the
mucogingival junction, where it
becomes continuous with the
lining mucosa.
It is of firm texture, coral pink in
colour, and often shows small
depressions on the surface, called
‘stippling’.

The free gingiva comprises all epithelial and
connective tissue structures located coronal to a
horizontal line placed at the level of the
cementoenamel junction.The epithelium
covering the free gingiva may be differentiated
as follows:
 oral epithelium, which faces the oral cavity
 oral sulcular epithelium, which faces the tooth without
being in contact with the tooth surface
 junctional epithelium, which provides the contact
between the gingiva and the tooth.

Oral
epithelium
Oral sulcular
epithelium
Junctional
epithelium
Connective
tissue
Bone

The boundary between the oral epithelium and the
underlying connective tissue has a wavy course.
The connective tissue portions which project into
the epithelium are called connective tissue papillae
and are separated from each other by epithelial
ridges called rete pegs.
In healthy gingiva, rete pegs and connective tissue
papillae are lacking at the boundary between the
junctional epithelium and its underlying connective
tissue.

The oral or outer epithelium covers the crest
and outer surface of the marginal gingiva and
the surface of the attached gingiva.
It is keratinised or parakeratinised.

It lines the gingival sulcus.
It is a thin non keratinised stratified squamous epithelium
without rete pegs and extends from the coronal limit of
the junctional epithelium to the crest of the gingival
margin.
The sulcular epithelium has potential to keratinise, if
 It is reflected and exposed to the oral cavity
 The bacterial flora of the sulcus is totally eliminated.
And conversely, oral epithelium may lose its keratinsation
when in contact with tooth.
This epithelium is extremely important as it may act as a
semipermeable membrane through which injurious
bacterial products pass into the gingiva and tissue fluid
from the gingiva seeps into the sulcus.

It consists of a collarlike band of startified
squamous non-keratinised epithelium.
It is 3-4 cell layer thick, number of layers
increases as age increases.
 these cells may be basal or suprabasal
Length of the Junctional Epithelium ranges
from 0.25 to 1.35 mm.
It is formed by the confluence of the oral
epithelium and the reduced enamel
epithelium during tooth eruption.

It is attached to the tooth surface by means of an
internal basal lamina, and to the underlying
connective tissue layer through an external basal
lamina.
The attachment of the junctional epithelium to
the tooth is reinforced by the ginigival fibres
which brace the marginal gingiva against the
tooth surface. For this reason, junctional
epithelium and gingival fibres are considered a
functional unit, referred to as ‘dentogingival unit’.

Circular fibres (CF) are fibre bundles which run
their course in the free gingiva and encircle the
tooth in a cuff- or ring-like fashion.
Dentogingival fibres (DGF) are embedded in the
cementum of the supra-alveolar portion of the
root and project from the cementum in a fan-
like configuration out into the free gingival
tissue of the facial, lingual and interproximal
surfaces.

Dentoperiosteal fibres (DPF) are embedded in the same
portion of the cementum as the dentogingival fibres, but
run their course apically over the vestibular and lingual
bone crest and terminate in the tissue of the attached
gingiva. In the border area between the free and attached
gingiva, the epithelium often lacks support by underlying
oriented collagen fibre bundles. In this area the free
gingival groove (GG) is often present.
Transseptal fibres (TF), extends between the supra-
alveolar cementum of approximating teeth.The
transseptal fibres run straight across the interdental
septum and are embedded in the cementum of adjacent
teeth.

TF

The periodontal ligament is the soft, richly
vascular and cellular connective tissue which
surrounds the roots of the teeth and joins the
root cementum with socket wall.
In the coronal direction, the periodontal
ligament is continuous with the lamina
propria of the gingiva and is demarcated from
the gingiva by the collagen fibre bundles
which connect the alveolar bone crest with
the root.

In radiographs, two types
of alveolar bone can be
distinguished:
1.The part of the alveolar
bone which covers the
alveolus, called ‘lamina
dura’.
2.The portion of the
alveolar process which, in
the radiograph, has the
appearance of a
meshwork.This is called
the ‘spongy bone’.

The tooth is joined to
the bone by bundles of
collagen fibres which
can be divided into the
following main groups
according to their
arrangement:
 alveolar crest fibres
 horizontal fibres
 oblique fibres
 apical fibres
ACF
HF
OF
APF

The periodontal ligament is situated in the
space between the roots of the teeth and the
lamina dura or the alveolar bone proper.The
alveolar bone surrounds the tooth to a level
approximately 1 mm apical to the cemento-
enamel junction.The coronal border of the
bone is called the alveolar crest.
The width of the periodontal ligament is
approximately 0.25 mm (range 0.2-0.4 mm).

The periodontal ligament and the root
cementum develop from the loose
connective tissue (the follicle) which
surrounds the tooth bud.

The various stages in the organization of the
periodontal ligament which forms
concomitantly with the development of the
root and the eruption of the tooth.

The tooth bud is formed in a crypt of the bone.
The collagen fibres produced by the fibroblasts in
the loose connective tissue around the tooth bud
are, during the process of their maturation,
embedded into the newly formed cementum
immediately apical to the cemento-enamel
junction.
The true periodontal ligament fibres, the principal
fibres, develop in conjunction with the eruption of
the tooth. First, fibres can be identified entering
the most marginal portion of the alveolar bone.
Later, more apically positioned bundles of
oriented collagen fibres are seen.

The orientation of the collagen fibre bundles
alters continuously during the phase of tooth
eruption. First, when the tooth has reached
contact in occlusion and is functioning
properly, the fibres of the periodontal
ligament associate into groups of well
oriented dentoalveolar collagen fibres

TF
These fibre bundles
oriented towards the
coronal portion of the
bone crypt will later
form the dentogingival
fibre group, the
dentoperiosteal fibre
group and the
transseptal fibre group
which belong to the
oriented fibres of the
gingiva.

1. First, small, fine, brush-like fibrils are detected arising from
the root cementum and projecting into the PDL space.
2. Later on, the number and thickness of fibres entering the
bone increase.These fibres radiate towards the loose
connective tissue in the mid-portion of the periodontal
ligament area
3. The fibres originating from the cementum subsequently
increase in length and thickness and fuse in the periodontal
ligament space with the fibres originating from the
alveolar bone.
1 2 3

The cells of the periodontal ligament are:
fibroblasts, osteoblasts, cementoblasts,
osteoclasts, as well as epithelial cells and nerve
fibres.The fibroblasts are aligned along the
principal fibres, while cementoblasts line the
surface of the cementum, and the
osteoblasts line the bone surface.

The cementum is a specialized mineralized tissue
covering the root surfaces and, occasionally, small
portions of the crown of the teeth. It has many
features in common with bone tissue.
However, the cementum contains no blood or lymph
vessels, has no innervation, does not undergo
physiologic resorption or remodeling, but is
characterized by continuing deposition throughout
life.
It attaches the periodontal ligament fibres to the root
and contributes to the process of repair after damage
to the root surface.

1. Acellular, extrinsic fibre cementum (AEFC) is found in
the coronal and middle portions of the root and
contains mainly bundles of Sharpey's fibres.This
type of cementum is an important part of the
attachment apparatus and connects the tooth with
the alveolar bone proper.
2. Cellular, mixed stratified cementum (CMSC) occurs in
the apical third of the roots and in the furcations. It
contains both extrinsic and intrinsic fibres as well as
cementocytes.
3. Cellular, intrinsic fibre cementum (CIFC) is found
mainly in resorption lacunae and it contains intrinsic
fibres and cementocytes.

The alveolar process is defined as the parts
of the maxilla and the mandible that form
and support the sockets of the teeth.
The alveolar process consists of bone which
is formed both by cells from the dental
follicle (alveolar bone proper) and cells
which are independent of tooth
development.
Together with the root cementum and the
periodontal membrane, the alveolar bone
constitutes the attachment apparatus of
the teeth, the main function of which is to
distribute and resorb forces generated
during mastication and other tooth
contacts.

The walls of the sockets are lined by
cortical bone, and the area between the
sockets and between the compact jaw
bone walls is occupied by cancellous bone.
The cancellous bone occupies most of
the interdental septa but only a
relatively small portion of the buccal and
palatal bone plates.The cancellous bone
contains bone trabeculae, the architecture
and size of which are partly genetically
determined and partly the result of the
forces to which the teeth are exposed
during function.

At the buccal aspect of the jaws, the
bone coverage is sometimes missing
at the coronal portion of the roots,
forming a so-called dehiscence.
If some bone is present in the most
coronal portion of such an area the
defect is called a fenestration.
These defects often occur where a
tooth is displaced out of the arch and
are more frequent over anterior than
posterior teeth.The root in such
defects is covered only by periodontal
ligament and the overlying gingiva.

Horizontal bone loss
Bone deformities
Vertical or angular defects
Osseous Craters
Bulbous bone contours
Reversed architecture
Ledges
Furcation involvement
Newman,Takei, Carranza. Clinical Periodontology, ninth edition.www.indiandentalacademy.com

Horizontal bone loss is the
most common patterns of
bone loss in periodontal
disease.
The bone is reduced in
height, but the bone
margin remains roughly
perpendicular to the tooth
surface, the interdental
septa and facial and
lingual plates are affected.

Different types of bone deformities can occur
from periodontal disease.
Their presence may be suggested on
radiographs, but careful probing and surgical
exposure of the areas is required to exactly
determine their exact conformation and
dimensions

Vertical or angular bone defects are
those that occur in an oblique
direction, leaving a hollowed out
trough in the bone alongside the
root; the base of the defect is located
apical to the surrounding bone.
They have accompanying infra bony
pockets.
They are classified based on the
number of osseous walls.They may
have one, two or three walls.The
number of walls in the apical portion
of the defect may be greater than in
its occlusal portion, in which case it is
called a combined osseous defect.

Defects interdentally can be seen
radiographically. Buccal and lingual defects
cannot be visualised radiographically.
Three wall vertical bone defect was originally
called an intrabony defect, which was later
expanded to designate all vertical bone defects.
This defect acts most frequently on the mesial
aspects of second and third maxillary and
mandibular molars.
The one wall defect is also called hemiseptum.

They are concavities in the crest of the
interdental bone confined within facial and
lingual walls.
They form about one thirds of all
bone defects and about two thirds
of the mandibular bone defects.
The high incidence of osseous craters is due to:
 Interdental area collects plaque and is difficult to clean
 The normal flat or even concave faciolingual shape of
the interdental septum in lower molars may favour
crater formation
 Vascular patterns from the gingiva to the center of the
crest may provide a pathway for inflammation.

They are bony enlargements caused by
exostoses, adaptation to function, or
buttressing bone formation
Found more frequently in the maxilla than
the mandible.

They are plateau like bone margins casued by
resorption of thickened bony plates.

They are produced by loss
of interdental bone,
including the facial plates,
lingual plates or both,
without concomitant loss of
radicular bone, thereby
reversing the normal
architecture.
Such defects are common
in the maxilla.

It refers to the invasion of the bifurcation and
trifurcation of multirooted teeth by
periodontal disease.
Mandibular molars are the most common site.
The denuded furcation may be visible
clinically or may be covered by the walls of the
pocket.

Degree 1:
Horizontal loss of supporting tissues not
exceeding 1/3 of the width of the tooth.
Degree 2:
Horizontal loss of supporting tissues exceeding
1/3 of the width of the tooth, but not
encompassing the total width of the furcation
area.
Degree 3:
Horizontal ‘through-and-through’ destruction of
the supporting tissues in the furcation.

Oral Surgical Procedures
Periodontal Surgeries
Endodontics
Orthodontics
Fixed Prosthodontics
Removable Prosthodontics
Stephen F. Rosensteil, Martin F. Land, Junheo Fujimoto. Contemporary Fixed Prosthodontics, fourth edition.

An important part of treatment sequencing is
the elimination of teeth with hopeless
prognosis, unerupted teeth, residual roots.
Periodontally compromised teeth are best
extracted at the earliest, so as to enable the
sockets to heal faster and also provide better
access for plaque control of the adjacent teeth.
Also a transitional or provisional partial
removable/fixed prosthesis may be fabricated
which stabilises the arch and potentially
maintains and improves occlusion, function and
esthetics.

Periodontal Surgeries are undertaken for
pocket elimination, mucogingival procedures,
guided tissue regeneration and root
resections

Preliminary Phase
 Treatment of emergencies:
▪ Dental/periapical
▪ Periodontal
▪ Other
 This phase includes the extraction of teeth with
hopeless prognosis, and also provisional
replacements if needed.

Phase ITherapy (Etiotropic)
 Plaque control and patient education
 Diet control
 Removal of calculus, root planing
 Correction of prosthtic and restorative irritational
factors
 Excavation of caries and restoration
 Antimicrobial therapy
 Occlusal therapy
 Minor orthodontic movement
 Provisional splinting and prosthesis

Phase IITherapy (Surgical)
 Periodontal therapy, including placement of
implants
 Endodontic therapy
Phase IIITherapy (Restorative)
 Final Restorations
 Fixed and Removable Prosthodontics
Phase IVTherapy (Maintenance)
 Periodic reevaluation

This phase of periodontal therapy aims at the
controlling the active disease.
Obtaining control of periodontal inflammation
results in restorations of a much higher quality
than would be obtained if restoration were
carried out in an environment of gingival
inflammation.
There is a possibility of continual bleeding and
exudation of inflammatory tissue fluid into the
gingival crevice and into the environment of
restorative dental procedures.

The removal of etiologic factors causing
gingival inflammation results in a return to a
healthy gingival state within 1 to 2 weeks.
Thus plaque control, calculus removal and the
correction of any inadequate dental
restorations in the gingival environment
should be important initial procedures.

NewAttachment
Long junctional epithelium
Root resorption and ankylosis
Recurrence of Pocket

Periodontal surgical procedures must be carried
out with due regard to restorative needs of the
patient.
The final level of the periodontium should allow
good access to all restorative marginal regions,
and any necessary increase in clinical crown length
should be obtained by postsurgical positioning of
periodontal tissues.
If restorative procedures necessitate the resolution
of mucogingival inadequacies, the appropriate
surgical procedure should be completed before
restorative therapy begins.

It is often necessary to carry out a free soft tissue,
autograft in the patient who has a mucogingival defect
associated with gingival inflammation and requires a
dental restoration in the immediate environment of the
gingiva.
Periodontal plastic surgery must be carried out at least 2
months before the placement of the restorations.This
allows for mature tissue to form in the gingival margin so
that restorative procedures do not cause a return in
clinical inflammation.
Augmentation of keratinised gingiva provides stability of
the free gingival margin and surrounding gingival tissues
so that the dental restoration can be placed in an
environment in which gingival health can be maintained.

In situations where a tooth has a short
clinical crown deemed inadequate for the
retention of a required cast restoration, it is
necessary to increase the size of the clinical
crown using periodontal surgical procedures.
These procedures enable the dentist
performing the restoration to develop an
adequate area for crown retention without
extending the crown margins deep,
encroaching into the biological width.

The term biologic width
describes the junctional
epithelium and connective
tissue that attach to the
tooth surface.
Average length is 2 mm
The healthy gingiva coronal
to the junctional epithelium,
which is not attached to the
tooth surface, has an
average depth of 0.69mm.

The biologic width usually remains constant. If the
restorative margin is placed into this area, the crestal
bone will be lost to reestablish the biologic width.The
other consequence of margin placement into this area is
gingival inflammation and pocket formation.
The surgical procedure to expose adequate clinical crown
to prevent the placement of the crown margin into the
area of the biologic width is termed crown lengthening
surgery.
A gingivectomy technique can be used to eliminate the
tissue that forms the pocket or sulcus wall; such tissue
may be overgrown. And may interfere with the intended
restorative procedure.

It is essential that there may be at least 3 mm
between the most apical extension of the
restoration margin and the alveolar bone crest.
This space allows for sufficient tooth for the
supracrestal collagen fibres that are a part of the
periodontal support mechanism, as well as
providing a gingival crevice of 2 to 3 mm.
If this guideline is used the margin of the crown is
finally positioned at its correct level,
approximately half way down the gingival
crevice.

Failure to allow sufficient space between the
crown margin and the alveolar crest height
means that the finished restoration is
positioned deep in the periodontal tissues
and results in inflammation and pocket
formation.

These procedures are aimed at correcting
the excessive loss of alveolar bone that
sometimes occurs in the anterior region as a
consequence of advanced periodontal
disease, advanced periapical bone loss,
traumatic tooth extractions, and external
trauma.This excessive bone loss may create a
difficult esthetic problem and complicate the
prosthetic reconstruction.

In a fixed restoration, the large space may result
in either a long pontic or a space between the
apical end of the pontic and resorbed ridge.
These defects may occur in a coronoapical or
buccolingial direction, or both.
The roll technique was reported by Abrams to
managemoderate tissue loss in buccolingual
direction.
In more extensive cases, subepithelial
connective tissue grafts may be used.

Three options:
 Supragingival
 Equigingival
 Subgingival
Supragingical margins have the least impact on
the periodontium, this type of margin may be
applied in nonesthetic areas due to marked
contrast in colour and opacity of traditional
restorative materials against the tooth.
The use of equigingival margins traditionally was
not desirable because they were thought to retain
more plaque, and result in greater gingival
inflammation.

With the advent of newer restorative
materials have reduced the concerns, not
only because the restoration margins can be
esthetically blended with the tooth but also
because the restoration can be finished easily
to provide a smooth, polished interface at
the gingival margin.

Gargiulo,Wentz, Orbans
They found that the connective tissue
attachment occupies 1.07 mm of space above the
crest of the alveolar bone and that the junctional
epithelium occupies another 0.97 mm of space
above the connective tissue attachment.
The combination of these two widths constitute
the biologic width.
Clinically, this information is applied to diagnose
biologic width violations when the restoration
mrgin is placed 2 mm or less away from the
alveolar bone and the gingival tissues are
inflamed with no other etiologic factor.

Restorative considerations often dictate
placement of restoration margins beneath
the gingival tissue crest. Restorations may
need to be extended gingivally to create
adequate resistance and retentive form in
the preparation, to make significant contour
alterations because of caries or other tooth
deficiencies, or to mask the tooth/restoration
interface by locating it subgingivally.

When the restoration margin is placed too far below the
gingival tissue crest, it impinges on the gingival
attachment apparatus and creates a violation of the
biologic width.
Two different responses may be seen from the gingival
tissues:
1. Bone loss of an unpredictable nature and gingival
tissue recession occurs as the body attempts to
recreate room between the alveolar bone and margin
to allow space for tissue reattachment.This is more
likely to occur in areas where alveolar bone
surrounding the tooth is very thin.Trauma from
restorative procedures may play a major role in causing
gingival recession.

2. More common finding with deep margin
placement is that the bone level appears to
remain unchanged, but gingival inflammation
develops and persists.To restore gingival tissue
health, it is necessary to clinically establish
space between the alveolar bone and the
margin, this can be established by surgery to
alter the bone level or by orthodontic extrusion
to move the margin farther away from the
bone level.

They can be corrected by either surgically removing
the cone away from proximity to the restoration
margin or orthodontically extruding the tooth and
thus moving the margin away from the bone.
Surgery is the more rapid of the two treatment
options. It Is also preferred if the resulting crown
lengthening will create a more pleasing tooth length.
In these situations, the bone should be moved away
from the margin by the measured distance of the
ideal biologic width for that patient with an additional
0.5 mm of bone removed as a safety zone.

Gingival recession is a potential risk after
removal of bone. If interproximal bone is
removed, there is a high likelihood of
papillary recession and the creation of an
unesthetic triangle of space below the
interproximal contacts. If the biologic width
violation is on the interproximal, or if the
violation is across the facial surface and the
gingival tissue level is correct, then
orthodontic extrusion is indicated.

When determining where to place restorative margins
relative to the periodontal attachment, it is
recommended that the patient's existing sulcus depth
be used as a guideline in assessing the biologic width
requirement for that patient.
The base of the sulcus can be viewed as the top of the
attachment, and therefore variations in attachment
height are accounted for by assuring that the margin is
placed in the sulcus and not in the attachment.
The variations in sulcular probing depth are then used
to predict how deeply the margin can safely be placed
below the gingival crest.With shallow probing depths (1
to 1.5 mm), extending the preparation more than 0.5
mm subgingivally will risk violating the attachment.

This assumes that the periodontal probe penetrates
an average of 0.5 mm into the epithelial attachment
in healthy gingiva. With shallow probing depths,
future recession is unlikely because the free gingival
margin is located close to the top of the attachment.
Deeper sulcular probing depths provide more
freedom in locating restoration margins farther below
the gingival crest. However, in most circumstances,
the deeper the gingival sulcus, the greater the risk of
gingival recession.The first step in using sulcus depth
as a guide in margin placement is to manage gingival
health.

Once the tissue is healthy, the following three rules can
be used to place intracrevicular margins:
1. If the sulcus probes 1.5 mm or less, place the restoration
margin 0.5 mm below the gingival tissue crest.This is
especially important on the facial aspect and prevents a
biologic width violation in a patient who is at high risk in that
regard.
2. If the sulcus probes more than 1.5 mm, place the margin one
half the depth of the sulcus below the tissue crest.This
places the margin far enough below tissue so that it still is
covered if the patient is at higher risk of recession.
3. If a sulcus greater than 2 mm is found, especially on the
facial aspect of the tooth, then evaluate to see whether a
gingivectomy could be performed to lengthen the teeth and
create a 1.5-mm sulcus.Then the patient can be treated
using Rule 1.

The rationale for Rule 3 is that deep margin
placement is more difficult and the stability of the
free gingival margin is less predictable when a
deep sulcus exists.
Reducing the sulcus depth creates a more
predictable situation in which to place an
intracrevicular margin.
It is not guaranteed that the tissue will remain at
the corrected level, because some gingival
rebound can occur after gingivectomy.
However, it ensures that the restorative margins
are not exposed and visible in the patient's mouth.

Three different processes are associated with
the successful bone grafting:
 Osteogenesis
 Osteoinduction
 Osteoconduction
Osteogenesis is the formation and development
of bone. As osteogenic graft is derieved from or
composed of tissue involved in the natural
growth or repair of bone.They can encourage
bone formation in soft tissues or activate more
rapid bone growth at bone sites.
Arun K Garg. Bone Biology. www.indiandentalacademy.com

Osteoinduction is the process of stimulating
osteogenesis.Osteoinductive grafts can be used to
enhance bone regeneration and may even cause bone
to grow or extend into an area where it is not normally
found.
Osteoconduction provides a physical matrix or
scaffolding for deposition of new bone.They are
conducive to bone growth and allow bone appostion
from existing bone, but they do not produce bone by
themselves when placed within soft tissues.
All bone graft materials possess at least any one of
these three modes of action.

Autogenous bone
Allografts
Alloplasts, Xenografts, andTissue-
Engineered Materials

One of the difficult aspects of ridge preservation is
choosing the appropriate graft material for the
specific site.
To determine the material, the clinician must evaulate
the size and configuration of the defect and then
calculate the amount of bone needed to replace the
missing tissue.
Larger defects require autogenous bone because it
provides maximum amount of cellularity and
structure and contains proteins and cells that can
cause osteoinduction of new tissue,
Smaller defects may be appropriate candidates for
allografts, alloplasts, or xenografts.

Classification of osseous defects based on the
number of walls remaining in the socket, as
the treatment needs are different for each
case
 Five-wall defect
 Four-wall defect
 Three-wall defect
 Two-wall defect
 One-wall defect

This case may not require any grafting, if there is
a large amount of interseptal bone present.
If grafting is however indicated, any of the
grafting materials in putty or gel consistency
may be used for wall support
Xenografts like PepGen P-15 Flow(tissue
engineered xenograft bovine material in a
hydrogel carrier).
It allows for osteo conductive healing and
preserves the tissue contour.

For a site that is missing one or two socket walls
or that has one or more extremely thin walls,
bone grafting is generally advised at the time of
extraction.
If not grafted, the bone typically narrows as the
wound heals.
Autogenous bone is a good choice for this type
of a defect because entire bony walls often must
be regenerated.
If sufficient amount of autogenous bone is not
available then allogeneic bone putty may be
used.

For a site that has lost two socket walls or that
has two or more extremely thin walls, bone
grafting is strongly recommended at the time of
extraction.
If the socket is not grafted, the bone often
narrows as the wound heals.
Autogenous grafts are the preferred material for
these defects because entire bony walls must be
regenerated.
If insufficient autogenous grafts are available,
allogenic bone blocks mortised around the
margins and within the socket with putty.

The graft material of choice for this group of patients
is particulate autogenous bone with a barrier
membrane or other stiff membrane secured in place
with pins or screws.
This type of surgical method requires careful planning
and soft tissue flap design is of utmost importance.
The small amount of autogenous bone required may
be harvested from adjacent sites or from the
tuberosity area with the use of a trephine bur.
Membranes can and generally should be used to
maximise the predictability of this graft.

It is often referred to as knife edge defects
and requires a two stage treatment with bone
grafting technique.
Graft material of choice is autogenous block
graft from the mandibular ramus or anterior
symphysis.The graft is placed in the block
rather than particulated form of added
structural support.

Alveolar bone defects
Inadequate tooth structure for restoration of
tooth
Recession
Ridge defects
GingivalOvergrowth
Furcation Involvement
Interdental papilla lost
KennethW. Aschheim, Barry G. Dale. Esthetic Dentistry , Second Edition

Treatment options:
 Retained papilla technique
 GuidedTissue Regeneration
 Osseous Grafting
 Palatal or Lingual Ramping
 Open Debridement and with buccal ostectomy

Provides adequate access to deep anterior
defects, allowing for thorough surgical
debridement of the area while maintaining
the position of the free gingival margin
This is accomplished by including the entire
interproximal tissue mass in the surgical flap
By including the papillary tissues
interproximal tissue height is maintained and
there is little or no apical shrinkage.

Any procedure that attempts to
regenerate lost periodontal structures or
alveolar process through differential tissue
responses. Barrier techniques, using
synthetic materials that may or may not
resorb, to exclude epithelial ingrowth
(periodontal regeneration) or connective
tissue ingrowth (alveolar process
regeneration) that is believed to interfere
with regeneration.
Glossary of ProsthodonticTerms – 8

It aims at pocket elimination through
reformation of the periodontal connective tissue
attachment
It is applicable in both the anterior and posterior
sextants
Not all defects are amenable to this procedure
Class II Furcation defects and deep, narrow
three-walled defects offer the best prognosis

This method for the prevention of epithelial
migration along the cemental wall of the pocket
is termed ‘GuidedTissue Regeneration’.
This is based on the assumptions of Nyman,
Lindhe, Karring and Gottlow that only
periodontal ligament cells have the potential for
regeneration of the attachment aparatus of the
tooth.
It consists of placing barriers of different types
to cover the bone and periodontal ligament,
thus temporarily separating then from the
gingival epithelium.

Prevention of Epithelial Migration:
Elimination of junctional and pocket epithelia may
not be sufficient because the epithelium from the
excised margin may rapidly proliferate to become
interposed between the healing connective tissue
and cementum.
Another method proposed to prevent or retard
the migration of the epithelium consists of total
removal of the interdental papilla covering the
defect and its replacement with a free autogenous
graft obtained from the palate. During healing,
the epithelium necroses, and its migration is
retarded.

Excluding the epithelium and
the gingival connective tissue
from the root surface during
the postsurgical healing phase
not only prevents epithelial
migration into the wound but
also favours repopulation of
the area by cells from the
periodontal ligament and the
bone.

Alveolar bone is not always necessary to
achieve pocket closure since the dense
connective tissue attachment to the root
surface can provide fill for the defect

Four stages are used to successfully regenerate
bone and other tissues, abbreviated with the
acronym PASS:
1. Primary closure of the wound to promote
undisturbed and uninterrupted healing
2. Angiogenesis to provided necessary blood
supply and undifferentiated mesenchymal cells
3. Space creation and maintenance to facilitate
space for soft tissue/bone in-growth
4. Stability of the wound to induce blood clot
formation and allow uneventful healing

Deep angular defects, both in the anterior and posterior
sextants,Three walled defects and Craters
Two primary materials used are:
 DFDCB(Decalcified Freeze-Dried Cortical Bone)
 Synthetic materials
DFDCB aids in regeneration, and the synthetic materials
form a scaffolding to allow for osseous tissue ingrowth
The resultant pocket closure occurs through a long
junctional epithelium

Surgical Access to the defect site is gained via
a flap designed to maintain the marginal
tissues, defects are debrided, graft materials
are placed into the defect, and flaps replaced
to achieve a primary closure

It is an esthetic procedure that may be used in
the posterior sextant.
Here, a palatal or lingual ramping of the alveolar
defects without involving the buccal boneis
carried out.
Ostectomy of the crater like defects is done
This results in increased crown height on the
palatal/lingual aspect of the teeth, with the
gingival tissues angled palatally or lingually
Buccal height of the tissue remains intact as the
buccal bone is spared

There is a need for buccal ostectomy in
certain cases as in markedly uneven buccal
bony profile

Causes:
 Caries
 Trauma

Surgical crown lengthening
 This involves as apical flap positioning with ostectomy
around the involved tooth and adjacent tooth.
 At least 3-4 mm of sound root structure must be
exposed below the most apical extent of the proposed
restoration.
 In addition, the alveolar crest of the adjacent teeth
must be blended in with the involved tooth, otherwise
an uneven unesthetic gingival profile results.

Crown lengthening may be required to solve
problems such as
 Inadequate amount of tooth structure for proper
restorative therapy
 Subgingival location of fracture lines
 Subgingival location of carious lesions
Crown lengthening may be done for esthetic
or functional reasons
Ratnadeep Patil. Esthetic dentistry: An artist's science.

When a disparity in the clincial crown length
exists between contralateral teeth resulting in a
left/right side height discrepancy, esthetic
surgical correction can be provided to enhance
the cosmetic result before restorative measures.

When such a procedure is carried out in order to
gain crown length for restorative purposes.
The gingiva and bone follow a definite pattern
interproximally, facially and palatally. Whenever
the functional requirement needs more than 2
mm of bone resection on the facial and palatal
osseous crest, a facial and palatal flap must be
reflected and osseous resection is done all over
including the interproximal region.
This helps to maintain the osseous contour
around the tooth

Uneven free gingival margin Sub marginal Incision Full thickness reflection
Ostectomy Apically positioned flap & sutured 3 weeks Post operative
An Esthetic restoration after
2 months of healing

Forced eruption with fibrotomy
 When ostectomy will result in extremely long clinical
crowns and significantly weakened periodontal
support, or when a surgical procedure is medially
contraindicated, orthodontic forced eruption with
sulcular fibrotomy may be performed.
 Here, orthodontic force is applied to the tooth involved
in an occlusal direction while supracrestal connective
tissue fibres are severed every 4 days.
 The fibrotomy prevents the tooth and alveolar bone
from erupting as a unit, exposing sound tooth without
changing the position of the alveloar crest or the free
gingival margin.

 The orthodontics will pull the root out of the bone,
exposing the needed 3-4 mm of sound tooth
structure, while the fibrotomy will prevent coronal
reformation of the alveolar bone and maintain the
free gingival margin at its original level.
 In addition to achieving the desired results, the
crown to root ratio of the adjacent teeth remains
intact and decreases for the involved tooth, thus
improving the long-term periodontal prognosis.

Causes:
 Abrasion
 Periodontitis
 Trauma
 Inadequacy of attached gingiva

Miller has described a useful classification of recession
defects, taking into consideration the anticipated root
coverage that it is possible to obtain
 Class I: Marginal tissue recession not extending to the
mucogingival junction. No loss of interdental bone or soft
tissue.
 Class II: Marginal tissue recession extends to or beyond the
mucogingival junction. No loss of interdental bone or soft
tissue.
 Class III: Marginal tissue recession extends to or beyond the
mucogingival junction. Loss of interdental bone or soft tissue
is apical to the cementoenamel junction, but coronal to the
apical extent of the marginal tissue recession.
 Class IV: Marginal tissue recession extends beyond the
mucogingival junction. Loss of interdental bone extends to a
level apical to the extent of the marginal tissue recession.www.indiandentalacademy.com

While complete root coverage can be
achieved in Class I and II defects, only partial
coverage may be expected inClass III. Class IV
recession defects are not amenable to root
coverage.

Free gingival grafts
Lateral pedicle grafts
Subepithelial connective tissue grafts

Predictable results for augmentation in the zone
of attached gingiva, success in covering exposed
root surfaces is less predictable and depends on
various factors
 Dimension of the root surface to be covered
 Lateral probing depth
 Position of the tooth in the arch
Areas of narrow recession have better root
coverage potential than deeper, wider areas of
recession.

Preoperative Incision to remove
wide zone of tissue
Graft placed over CE jn.
Graft sutured
firmly in place
2 months
Postoperative

Factors to be considered:
 Amount of keratinised tissue adjacent to the recipient site
 Existence of an adjacent edentulous ridge
 Existence of frena that could cause excessive pull
 Width of the recipient root surface
The pedicle graft procedures are, depending on the
direction of transfer, grouped as (1) rotational flap
procedures (e.g. laterally sliding flap, double papilla flap,
oblique rotated flap) or (2) advanced flap procedures (e.g.
coronally repositioned flap, semilunar coronally
repositioned flap).

While using this type of a graft, a well
keratinised edentulous ridge or a wide zone
of attached gingiva adjacent to the graft site
is ideal. However, if the recipient area to be
grafted is wide mesiodistally, excessive pull
may occur on the donor tissue, causing
strangulation and failure
Healing period of 6 weeks is advised before
any prosthetic treatment

This technique involves the placement of a a strip of
connective tissue from the palate under a partial
thickness flap.The recipient site is prepared with a
split thickness dissection, retaining all epithelium in
the flap.
An envelope procedure is performed on the palate to
obtain the connective tissue.
Advantages of this procedure include, no denudation
of the donor site, increasing patient comfort during
the healing phase, double blood supply to the
connective tissue graft (from the underlying periosteum
and the overlying connective tissue of the flap).

The edentulous ridge's contour and topography
should be carefully evaluated during the
treatment planning phase.
An ideally shaped ridge has a smooth, regular
surface of attached gingiva, which facilitates
maintenance of a plaque-free environment.
Its height and width should allow placement of
a pontic that appears to emerge from the ridge
and mimics the appearance of the
neighbouring teeth.

Facially, it must be free of
frenum attachment and of
adequate facial height to
sustain the appearance of
interdental papillae.
Loss of residual ridge contour
may lead to unesthetic open
gingival embrasures ("black
triangles“), food impaction,
and percolation of saliva during
speech.

A deformed ridge may result from tooth
extractions, advanced periodontal disease,
abscess formations, etc.The deformity that
exists in the ridge is directly related to the
volume of root structure and associated bone
that is missing or has been destroyed.

Causes:
 Visible edentulous ridge defects may be caused due to
facial trauma.
 Violent avulsion of one or more teeth and surrounding
buccal or lingual bone segments often occurs.
 Healing of such an injury results in collapse of
overlying soft tissue into the depression caused by the
bone loss.
 A jagged bone topography can be seen with severe
attachment loss is seen in case with periodontitis.

According to Seibert, ridge defects can be
divided into three classes:
 Class I: Loss of buccolingual width but normal
apicocoronal height
 Class II: Loss of apicocoronal height but normal
buccolingual width
 Class III: A combination of loss of both height and
width of the ridge.

Ridge augmentation procedures should be
preceded by a careful surgical-prosthetic
treatment planning by joint consultations
involving the surgeon and the restorative dentist
in order to attain an optimal esthetic result.The
following factors should be determined prior to
the initiation of therapy:
 Volume of tissue required to eliminate the ridge
deformity
 Type of graft procedure to be used
 Timing of various treatment procedures
 Design of the provisional restoration
 Potential problems with tissue discolorations and
matching tissue colour.www.indiandentalacademy.com

Although residual ridge width may be
augmented with hard tissue grafts, this is
usually not indicated unless the edentulous
site is to receive an implant

GinigivalOnlay Grafts
ConnectiveTissue Augmentation
Ovate Pontics

Buccolingual/Occlusoapical defects, class II
defects
Adaptation of the free gingival graft
technique
Thick palatal donor tissue
Graft healing – 6-8 weeks
Provisionalised with an ovate pontic

Internal augmentation
Buccolingual/Occlusoapical/Papillary defects
Subperiosteal tunnel is created under the soft
tissue of the defect, and connective tissue from
the donor site is placed to ‘plump out’ the
defect.
Donor connective tissue:
 Free augmentation palatal tissue
 Roll augmentation adjacent tissue
Provisionalisation: Pontic must allow 1-2 mm of
clearance to compensate for postoperative
tissue swelling

Preservation of the alveolar process can be achieved
through immediate restorative and periodontal
intervention at the time of tooth removal. By
conditioning the extraction site and providing a
matrix for healing, the pre-extraction gingival
architecture (or "socket") can be preserved.
Preparing the abutment teeth before the extraction is
the preferred technique.
A provisional FPD can be fabricated indirectly, ready
for immediate insertion. Because socket preservation
is dependent on underlying bone contour, the
extraction of the tooth to be replaced should be
atraumatic and aimed at preserving the facial plate of
bone.

The scalloped architecture of interproximal
bone forming the extraction site is essential
for proper papilla form, as are facial bone
levels in the prevention of alveolar collapse.
If the bone is compromised before or during
extraction, the sockets can be grafted with an
allograft material (hydroxyapatite, tricalcium
phosphate, or freeze-dried bone).

Immediately after preparation of the extraction site, a
carefully shaped provisional FPD is placed.The tissue-
side of the pontic should be an ovate form, and
according to Spear's it should extend approximately
2.5 mm apical to the facial free gingival margin of the
extraction socket.
As the soft tissues of the socket will begin to collapse
immediately after the tooth extraction, the pontic will
result in tissue blanching as it supports the papillae and
facial/ palatal gingiva.
The contour of the ovate tissue-side of the pontic is
critical and must conform to within 1 mm of the
interproximal and facial bone contour to act as a
template for healing.

Oral hygiene in this area is difficult during the initial
healing period, so the provisional should be highly
polished to minimize plaque retention.
After approximately 1 month of healing, oral hygiene
access is improved by recontouring the pontic to
provide 1 to 1.5 mm of relief from the tissue.
When the gingival levels are stable (approximately 6
to 12 months), the final restoration can be fabricated.
Although maintenance of the residual ridge following
extraction is meritorious, socket-preservation
techniques are technically challenging and require
frequent patient monitoring and conscientious
patient hygiene.

A pontic that is shaped on its tissue surface
like an egg in two dimensions, typically
partially submerged in a surgically-prepared
soft-tissue depression to enhance the illusion
that a natural tooth is emerging from the
gingival tissues.
Glossary of ProsthodonticTerms – 8

After the desired tissue regeneration is achieved,
the area can be modified to allow for fabrication of
Ovate or bullet pontics.
This type of a pontic creates the illusion of a natural
appearance to the adjacent papillae.
After adequate maturation of the grafted
connective tissue, a round depression is placed into
the augmented edentulous crest with a round
surgical diamond bur, the dimensions dependent
on the tooth to be replaced.
The provisional restoration is then relined so that
the acrylic material fills in the depression and the
area heals by epithelialisation around the pontic.

In the final prosthesis, will thus have apically
tapered and rounded pontics that fit
intimately into the tissue depression.This
esthetic pontic design creates the
appearance of a natural tooth emerging from
a sulcus; the contours of the gingival aspects
of the pontics are round without and sharp or
abrupt edges. Hygiene can be maintained
easily by flossing under the pontic.

There is some amount of shrinkage involved
in these procedures, sometimes necessitating
a second procedure. In the case of
occlusoapical and buccolingual defects,
several procedures may be needed before the
desired results are achieved.
Long term esthetic results are usually well
worth thee surgical time involved, except for
in papillary construction, where the results
are quite unpredictable.

Causes:
 Hyperplasia:
o Inflammatory
o Non-inflammatory – drug induced, irritants
 Altered passive eruption

Gingivectomy/gingivoplasty
Apically positioned flap with or without
ostectomy

Gingivectomy – excisional removal of gingival
tissue for pocket reduction or elimination.
Gingivoplasty – reshaping of the gingiva to
attain a more physiologic contour.
Treatment of choice with drug or genetically
induced hyperplasia, although frequency of
recurrence must be considered

Indications
 Non-inflammatory hyperplasia
 Irritation-induced overgrowth
 Presence of suprabony pockets
 An adequate zone of keratinized tissue
 Gingival enlargements
 Unaesthetic or asymmetrical gingival topography
 To facilitate restorative dentistry
Contraindications
 Inadequate width of keratinized tissue
 Pockets beyond mucogingival junction
 Presence of intrabony pockets

with or without Ostectomy
Altered passive eruption is best treated with this
technique.This accomplishes two objectives:
 Positions the gingival margin at a normal level
 Allows evaluation of the alveolar crest
If the alveolar crest is at or above the CE junction,
ostectomy is required to first achieve a normal
physiologic relationship between tooth and bone
before apically positioning the soft tissue.
A new biological width is thus established

Furcation involvement degree I
Scaling and root planing, Furcation plasty.
Furcation involvement degree II
Furcation plasty.Tunnel preparation, Root
resection,Tooth extraction, Guided tissue
regeneration at mandibular molars.
Furcation involvement degree III
Tunnel preparation, Root resection,Tooth
extraction.

Tooth substance is removed (odontoplasty)
and the alveolar bone crest is remodeled
(osteoplasty) at the level of the furcation
entrance.
Furcation plasty is used mainly at buccal and
lingual furcations. At approximal surfaces
access is often too limited for this treatment.

Tunnel preparation is a technique used to
treat deep degree II and degree III furcation
defects in mandibular molars.This type of
resective therapy can be offered at
mandibular molars which have a short root
trunk, a wide separation angle and long
divergence between the mesial and distal
root.The procedure includes the surgical
exposure and management of the entire
furcation area of the affected molar.

Root separation involves the sectioning of the
root complex and the maintenance of all
roots.
Root resection involves the sectioning and
the removal of one or two roots of a
multirooted tooth.
RSR is frequently used in cases of deep
degree II and degree III furcation involved
molars.

Factors to be considered:
 Length of the root trunk
 The divergence between the root cones
 The length and the shape of the root cones
 Fusion between root cones
 Amount of remaining support around individual
roots
 Stability of individual roots
 Access for oral hygiene devices

Root separation and root resection may be
performed as part of the preparation of the
segment for prosthetic rehabilitation, i.e. prior
to periodontal surgery. During the prosthetic
preparation it is important to avoid
 exposing the interradicular bone to undue
mechanical trauma
 leaving behind parts of the furcation fornix
perforating the root canals
 preparing the vertical surfaces of the remaining
roots with sharp angles

Following separation, both roots are
maintained.The distal surface of the
distal root and the mesial surface of
the mesial root must be prepared
parallel with each other to increase
the retention for a subsequent
restoration.
The mesial surface of the distal root
and the distal surface of the mesial
root should be prepared with
diverging angles to increase the
space available between the
separated roots

Following flap elevation, osseous resective
techniques are used to eliminate angular bone
defects that may exist around the maintained
roots.
Bone resection may also be performed to reduce
the buccolingual dimension of the alveolar process
of the extraction site.The remaining root(s) may be
prepared with a bevel cut to the level of the
supporting bone.This additional preparation may
serve the purpose of
 eliminating residual soft and hard deposits and
 eliminating existing undercuts to facilitate the final
impression

The provisional restoration is re-lined.The
margins of the provisional restoration must
end >_ 3 mm coronal of the bone crest.The
soft tissue flaps are secured with sutures at
the level of the bone crest.The relined
provisional restoration is cemented and a
periodontal dressing is applied to cover the
surgical area.

Since the prosthetic preparation of the roots was
completed during surgery, the clinician concerns
him/herself with only minor adjustments.The
preparation margins are located supragingivally,
which improves the precision of the definitive
crown restoration.
The framework of the restoration must be rigid to
compensate for the compromised abutments
(roots) with a compromised periodontal tissue
support.
The occlusion should be designed to minimize the
infliction of lateral deflective forcesJan Lindhe,Thorkild Karring, Niklaus P. Lang. Clinical Periodontology and Implant Dentistry, fourth editionwww.indiandentalacademy.com

There may be several factors contributing to the
loss of papilla height and the establishment of
"black triangles“ between teeth.The most
common reason in the adult individual is loss of
periodontal support due to plaque-associated
lesions. However, abnormal tooth shape,
improper contours of prosthetic restorations and
traumatic oral hygiene procedures may also
negatively influence the outline of the
interdental soft tissues.
Jan Lindhe,Thorkild Karring, Niklaus P. Lang.Clinical Periodontology and Implant Dentistry, fourth edition

Nordland &Tarnow (1998) proposed a
classification system regarding the papillary
height adjacent to natural teeth, based on
three anatomical landmarks:
 the interdental contact point, the apical extent of
the
 facial cemento-enamel junction (CEJ), and the
coronal
 extent of the proximal CEJ.

The interdental papilla occupies the entire
embrasure space apical to the interdental
contact point/area.
 Class I: the tip of the interdental papilla is located
between the interdental contact point and the level of
the CEJ on the proximal surface of the tooth.
 Class II: the tip of the interdental papilla is located at
or apical to the level of the CEJ on the proximal
surface of the tooth but coronal to the level of the CEJ
mid-buccally.
 Class III: the tip of the interdental papilla is located at
or apical to the level of the CEJ mid-buccally.

Facial CEJ
Interproximal CEJ
Interdental
contact point
Facial CEJ
Interproximal CEJ
Interdental
contact point

Several techniques have been described for
the reconstruction of the deficient papillae.
However, the predictability of he various
procedures has not been documented and no
data is available on the long-term stability of
the surgically regained papilla.

Beagle described a pedicle graft procedure
utilising the soft tissues palatal of the
interdental area.

Han andTakei proposed an approach for
papilla reconstruction ("semi-lunar coronally
repositioned papilla") based on the use of a
free connective tissue graft.

Azzi et al. (1998) described a technique in
which an envelope-type flap was prepared for
coverage of a connective tissue graft.

Allows for easy, quick, safe alteration or
removal of living tissue of the oral cavity with
little or no bleeding.
Its indications include, gingivoplasty, removal
of hyperplastic tissue, mucoperiosteal
surgery, excision of overhanging tissue,
frenuli removal, sulcus expansion,
hemorrhage control, endodontic procedures,
bleaching, biopsy excisions, etc.

Electrosurgery can be used to contour any
gingival architecture that is not conducive to
good esthetics or periodontal health, if attention
is paid to proper probing and respect for the
biological width.
Electrosurgical units are convert household
current into an electromagnetic radio
freequency (RF) wave, which oscillates at a rate
of 2-4 Mhz. Because it is impossible for a cell to
depolarise at this rate, the resistance of the
tissue produces localised intracellular heating
without the accompanying muscle contraction.

It is indicated when improper contours results from
any of these causes and when the biological width
will not be violated.
 Excess tissue caused by ectopic eruption or incomplete
passive eruption of one or more teeth
 Hypertrophied or malpositioned papialla
 Inflamed, hypertrophied gingiva during or after
orthodontic treatment
 Any hypertrophied tissue from drug therapy such as
Dilantin
 Any hypertrophied tissue of pathologic origin, including
poor oral hygiene
Jan Lindhe,Thorkild Karring, Niklaus P. Lang.Clinical Periodontology and Implant Dentistry, fourth editionwww.indiandentalacademy.com

Contraindications:
 Within 16 feet of unknown frequency pacemakers
(Coaxially shielded pacemakers allow for safe use)
 Patients who have undergone radiation therapy,
due to their decreased vascularisation
 Presence of certain chemicals like ethanol,
chloroform
It must be used with caution when used in
conjunction with Nitrous OxideAnalgesia.

Sparking current  localised but superficial
destruction
Partially rectified current  coagulates tissue
Fully rectified current incises and
coagulates
Fully rectified filtered current  clean
incision

No pressure is needed for tissue separation
Incision is smooth
Access to remote regions of the oral cavity is easier
than with other surgical modalities
Tissue separation occurs with less coagulation. And
better visibility
Little or no scar tissue formed
Sterility is more easily controlled, all bacteria in the
line of incision are volatilized at the electrode
Electroplaning is possible
Allows for planned restorative procedures to be
completed in the same appointment, if necessary.

An abnormal maxillary frenum may cause a pulling
force on the gingival margin in some cases leading to
gingival inflammation and progressive recession of the
gingiva.
It may also lead to esthetic problems especially in case
of gingival smiles.
Correction may be required prior to restorative
procedures.
A resection or a repositioning of the frenum may be
necessary.
Whenever there is excessive pressure caused by the
frenum then a frenectomy may be the treatment of
choice; however when esthetics is the only factor, then
frenotomy may be chosen to give the desired results.

Saturation of melanin pigments causes an
unesthetic dark gingival display.This looks
even more unesthetic in people with fair skin
and high lip lines.
It usually occurs in patches, but may also be
seen as a continuous area.
Techniques:
 Gingivo-abrasion technique
 Split thickness epithelial excision
 Combination technique

It is a troughing method, the purpose of which is to
produce limited removal of epithelial tissue in sulcus
while a chamfer finish line is being created on the
tooth structure. It is used with subgingival palcement
of margins.
The removal of epithelium from the sulcus by rotary
curettage is accomplished with little detectable
trauma to soft tissues.Although the tactile sensation
is significantly reduced for the operator.
It must be done only on healthy, inflammation free
tissue to avoid the tissue shrinkage that occurs when
diseased tissue heals.
HerbertT. Shillingburg, Jr., Sumiya Hobo, Lowell D.Whitsett, Richard Jacobi, Susan E. Brackett. Fundamentals
of Fixed Prosthodontics,Third Edition.www.indiandentalacademy.com

In conjunction with axial reduction, a shoulder
finish line is prepared at the level of the gingival
crest with a flat-end tapered diamond.Then a
torpedo diamond of 15-180 grit is used to extend
the finish line apically, 1/2 to 2/3 the depth of the
sulcus, converting the finish line to a chamfer.
Tupac and Neacy found no significant
histological differences between retraction cord
and gingival curettage.
Tupac RG, Neacy K: A comparison of cord gingical displacement with gingitage technique.J Prosthet Dent 1981;
46:509-515 www.indiandentalacademy.com

Surgical procedures enhance the success of
an Fixed Partial Denture Prosthesis.The
treatment planning phase is critical for the
success of the prosthesis.
Correct treatment planning and execution of
surgical procedures will result in restorations
that are esthetic, functionally sound and easy
to maintain.

1. Stephen F. Rosensteil, Martin F. Land, Junheo Fujimoto.
Contemporary Fixed Prosthodontics, fourth edition.
2. HerbertT. Shillingburg, Jr., Sumiya Hobo, Lowell D.
Whitsett, Richard Jacobi, Susan E. Brackett.
Fundamentals of Fixed Prosthodontics,Third Edition.
3. Jan Lindhe,Thorkild Karring, Niklaus P. Lang. Clinical
Periodontology and Implant Dentistry, fourth edition
4. Newman,Takei, Carranza. Clinical Periodontology, ninth
edition.
5. KennethW. Aschheim, Barry G. Dale. Esthetic Dentistry ,
Second Edition

5. Arun K Garg. Bone Biology.
6. Glossary of Prosthodontics terms – 8, ACP
7. Tupac RG, Neacy K: A comparison of cord gingival
displacement with gingittage technique. J Prosthet Dent
1981; 46:509-515

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