Periodontal Considerations in Fixed Partial Denture

Periodontal Considerations in Fixed Partial Denture

1. Periodontal Considerations
in Fixed Partial Dentures
Presented by :
Himani Priya Java

2. •Anatomy
•Diseases of the periodontium
•Etiology and terminologies
•Pathogenesis
•Examination, diagnosis and treatment planning
•General Periodontal Considerations in the
construction of fixed partial dentures

3. •Prosthetic considerations in Various periodontal
signs
•Review of literature
•Summary
•References

4. Anatomy
The lining of the oral cavity consists of three types
of mucosa, each with a different function':
1. Masticatory (keratinized) mucosa-
covering the gingiva and hard palate
2. Lining or reflecting mucosa-covering the
lips, cheeks, vestibule, alveoli, floor of the mouth,
and soft palate
3. Specialized (sensory) mucosa-covering
the dorsum of the tongue and taste buds

5. Gingiva
The gingiva is the part of the oral mucosa that
covers the alveolar processes of the jaws and
surrounding the necks of the teeth.

6. Keratinized gingiva
includes both the
attached gingiva as well
as the marginal gingiva
Gingival Sulcus:
The depth of this sulcus,
as determined in
histological sections, has
been reported as 1.8 mm,
with variations of from 0
to 6 mm.

7. Attached Gingiva
It is firm, resilient, and tightly bound to the
underlying periosteum of alveolar bone. The width
of the attached gingiva is the distance between the
mucogingival junction and the projection on the
external surface of the bottom of the gingival
sulcus or the periodontal pocket.
•Mucogingival junction remains stationary
throughout the adult life.
•Width of the attached gingiva increases in
supraerupted teeth.

8. Interdental Gingiva
The interdental gingiva can be pyramidal or have a
col shape.

Normal gingiva exhibiting no fluid exudates or
inflammation due to bacterial plaque is pink and
stippled. In a normal healthy patient there is no
visible flow of sulcular fluid, but as disease
progresses the crevicular flow increases.

9. Periodontal Ligament
•It is composed of collagen fibres arranged in
bundles that are attached from the cementum of
the tooth to the alveolar bone.
•In humans the width of the periodontal ligament
ranges from 0.15 to 0.38mm.
•It is widest at the margin and apex while
narrowest in the middle one third.

10. •Occlusal loading in function affects the width
of the periodontal ligament. If occlusal forces are
within physiologic limits, increased function
leads to increase in the width of the ligament.
•Due to physiologic mesial migration, the
periodontal ligament is thinner on the mesial
surface than on the distal surface.

11. It provides
•attachment and support
•nutrition
•synthesis
•resorption
•aids in shock absorption
•has formative and remodeling properties
•supplies nutrition to cementum, bone and gingiva ( by
way of blood vesels and lymphatic drainage)
•transmits tactile, pressure and pain sensations
through its abundant sensory nerve fibers ( by the
trigeminal pathway).

12. Biologic Width
It is the combined dimension of gingival
connective tissue and junctional epithelium
attachment formed adjacent to a tooth and
superior to the alveolar crest. (GPT-8)

13. Garguilo et al (1961) have
demonstrated from gingival
autopsy recordings that :-
•A sulcus depth of 0.69 mm
•Mean length of junctional
epithelium is 0.97 mm and
•Connective tissue attachment
is 1.07mm.

14. •Based on this works the Biologic Width is
commonly stated to 2.04 mm, which represents
the sum of the epithelial and connective tissue
measurements.
•However that significant variation of
dimensions was observed, particularly the
epithelial attachment.
•The connective tissue attachment, on the other
hand, was relatively constant.

15. If the restorative margins are placed into this area, then:-
•Gingival inflammation
•Pocket formation.
•The crestal bone will be lost to establish the biologic
width with recession.

16. The biologic width is always present and remains
constant.
The amount of pathologic response is related to the
individual patient’s susceptibility to periodontal disease.
 The chronic inflammation resulting from violation of
the biologic width compromises both esthetics and
periodontal health.

17. Diseases of the Periodontium

18. The two basic forms of periodontal diseases are

•Gingivitis
• Periodontitis.

19. Gingivitis
Gingivitis is the most common form of gingival
disease, it is defined as inflammation of the
gingiva. The two earliest symptoms of gingival
inflammation, which precede established gingivitis
are
(1)increased gingival fluid production rate
(2) bleeding from the gingival sulcus on gentle
probing.

21. Periodontitis
Periodontitis is an inflammatory disease of the
gingiva or the deeper tissues of the periodontium
and is characterized by pocket formation and
bone destruction.
Periodontitis is considered a direct extension of
neglected gingivitis.

22. Periodontitis is caused by extrinsic irritating
factors and is complicated by intrinsic disease,
endocrine disturbances, nutritional deficiencies,
periodontal traumatism and other factors.

24. Etiology

25. Most gingival and periodontal diseases result from
microbial plaque, which cause inflammation and its
subsequent pathologic processes. Other contributors to
inflammation however are calculus, acquired pellicle,
material alba and food debris.

26. Microbial Plaque
It is a sticky substance composed of bacteria and their by-
products in an extra cellular matrix and also containing
substances from the saliva, diet and serum. It is basically a
product of the growth of bacterial colonies and is the
initiating factor in gingival and periodontal disease. Left
undisturbed it will gradually cover the entire tooth surface
and can be removed only by mechanical means.

27. Calculus
Dental calculus is a chalky or dark deposit
attached to the tooth structure. It is essentially
microbial plaque that has undergone
mineralization with the passage of time

28. Acquired Pellicle
Pellicle is a thin brown or grey film of salivary
proteins that develops on teeth after they have
been cleaned.

29. Material Alba
This is a white coating composed of micro-
organisms, dead epithelial cells and leukocyte
that is loosely adherent to the tooth. It can be
removed by water spray or rinsing.

30. Periodontitis is caused by extrinsic irritating
factors and is complicated by intrinsic disease,
endocrine disturbances, nutritional deficiencies,
periodontal traumatism and other factors.

31. Pathogenesis

32. Initial lesion
• Is localized in the region of the gingival sulcus
• Is evident at approximately 2-4 days of
undisturbed plaque accumulation from a baseline
of gingival health.
•Collagen is lost perivascularly, and the resultant
space is filled with proteins and inflammatory
cells. The most coronal portion of the junctional
epithelium becomes altered.

33. •The vessels of the gingiva become enlarged and
vasculitis occurs, allowing a fluid exudate of the
polymorphonuclear leukocytes to form in the
sulcus.
Clinically this stage is not apparent.

34. Early lesion
•Appears within 4-7 days of plaque accumulation.

•Further loss of collagen from the marginal gingiva.

•The basal cells of the junctional epithelium begin to
proliferate and significant alterations are seen in
the connective tissue fibroblasts.

35. •Increase in gingival sulcular fluid flow occurs
with the increase in inflammatory cells and
accumulation of lymphoid cells adjacent to the
junctional epithelium.

36. Established lesion
• Within 7-21 days the lesion enters the
established stage.
•Still located in the apical portion of the gingival
sulcus and the inflammation is centered in a
relatively small area.
•Continuing loss of connective tissue, with
persistence of the features of the early lesion.

37. •Predominance of plasma cells,
immunoglobulins in the connective tissue, and
a proliferation of the junctional epithelium.
Pocket formation, however, does not necessarily
occur.

38. Advanced lesion
The deeper layers of the connective tissues become
involved with the ingress of inflammatory cells
that enhance osteoclastic activity, resulting in a
breakdown of the alveolar process if at the same
time the tooth is under occlusal trauma this area
will change.

39. There can be a concomitant lesion of the
periodontal disease with the occlusal traumatic
lesion enhancing the loss of bone around the
tooth.
Periodontal pockets are formed with increased
probing depths.

40. Examination
and
Diagnosis

41. Clinical features of
periodontitis
Periodontal Pocket- pathological deepening of
gingival sulcus
Recession- Exposure of the root surface by an apical shift
in the position of the gingiva.
Furcation Involvement
Mobility -pathological migration

42. Periodontal Pocket

43. Classification of Pockets based on
morphology and relationship to adjacent
structure
Gingival
pocket
Suprabony
pocket
Infrabony
pocket

44. ACCORDING TO NUMBER OF
SURFACES INVOLVED
Simple Compound Complex

45. SYMPTOMS
•Localized pain or sensation of pressure on eating
•Foul taste
•Sensitivity to heat and cold

46. Clinical Signs with Histopathological
Changes
Clinical signs
•Bluish red m. Gingiva.
•Flaccidity
•Smooth shinny surface
•Pitting on pressure
•Pink & firm (in some cases)
•Bleeding on probing
•Pain on probing
•Pus may be expressed
Histopathology
•By circulatory stagnation
•Destruction of g. Fibers
•Atrophy of the epithelium
•Edema ( leakage of plasma)
•Fibrotic changes predominant
 Vascularity & degeneration
of epithelium
•Ulceration of the inner pocket
wall
•Suppuration in the inner wall

47. Gingival Recession

54. Furcation Involvement

55. Based on the degree of
involvement

58. Mobility

59. •A classification of 1-3 is used. With 1 representing
the early stage of mobility and 3 representing a tooth
mobile in all direction and depressible in the socket.
Mobility is an indication of the loss of tooth
attachment to the jaw. This can be seen radio
graphically as a widened periodontal ligament space
caused by occlusal trauma or orthodontic tooth
movement.

60. Visual Examination
It is important during the examination to evaluate
the color, consistency, texture and shape of the
gingival unit. It is also critical to recognize the
initial stages of a marginal lesion. An adequate
light source is essential to differentiate between
normal and diseased tissues.

61. Normal gingiva: Colour – coral pink, physiologic
melanin pigmentation, scalloped contour on
facial or lingual surface, firm and resilient
consistency, stippled attached gingiva.

62. Probing

63. •The thinnest probe is desired.
•The probes are calibrated in mm.
•Probe six areas around the tooth.
•Evaluation should include bifurcation and
trifurcation areas on the molars and maxillary
first premolars.

64. •Check for bleeding or exudation, these are also signs
of periodontal disease. Clinically the bleeding of the
gingiva during probing is the sign of ulceration of
sulcular epithelium.
•Specially treated paper to monitor the
intracrevicular fluid is used

65. Radiographs
The areas to be reviewed on the radiographs are:
a) Alveolar crest resorption.
b) Integrity of thickness of the lamina dura.
c) Evidence of generalized horizontal bone loss.
d) Evidence of vertical bone loss.
e) Widened periodontal ligament space.
f) Density of trabeculae of both arches.
g) Size and shape of the roots compared to the crown
to determine crown to root ratio.

66. The radiographs can determine the area of root
embedded in bone, this is crucial in determining the
patient’s prognosis. Often patients with short conical
root will display minimal bone loss but maximal
mobility, and the prognosis is thus poor. Other
patients can loose 50 per cent of the bone but not
exhibit mobility, and yet have an encouraging
prognosis because they have normal shaped roots.

70. Treatment planning
•INITIAL THERAPY
–Control of microbial plaque
–Tooth brushing
–Flossing
–Other aids
–Scaling and polishing
–Correction of defective / overhanging restorations
–Root planing
–Strategic tooth removal
–Stabilization of mobile teeth
–Minor tooth movement

71. •EVALUATION OF INITIAL THERAPY
•SURGICAL THERAPY
–Soft tissue procedures
–Gingivectomy
–Open debridement
–Hard tissue procedures
–Bone induction

72. •Osseous resection
•Treatment of furcation involvements
–Odontoplasty-osteoplasty
–Root amputation
–Hemisection
–Provisionalization
–Restoration

73. •EVALUATION OF SURGICAL THERAPY
•GUIDED TISSUE REGENERATION
•(HARD AND SOFT TISSUE PROCEDURES)
»Technique
»Restoration
•MAINTENANCE
•PROGNOSIS

74. General Periodontal
Considerations in the
construction of fixed partial
dentures

75. Abutment evaluation
Crown to root ratio
optimum - 2:3.
minimum acceptable ratio - 1:1

76. Root configuration
•Roots that are broader
labiolingually than they are
mesiodistally are preferable to
roots that are round in cross-
section.
•Multirooted posterior teeth with
widely separated roots will offer
better periodontal support than
roots that converge, fuse, or
generally present a conical
configuration.

77. Periodontal ligament area / Ante’s law
Ante’s law, which states, “The total root surface area
of the abutment teeth should equal or exceed that
of the teeth to be replaced’’.

78. Factors Modifying Ante’s Law

79. S.
No.
Condition Existing Problem Modification in Ante’s Law
1. Bone loss from periodontal
disease
Increase the number of abutments
used to support.
2. Mesial or distal tipping or
changes in axial inclination.
Increase the number of abutments
used for support.
3. Migration of abutment teeth
decreasing mesiodistal length of
edentulous area.
Decrease the number of abutmens
used (less pericemental support
required).
4. Less than favorable opposing
arch relationship producing
increased load.
Increase the number of abutment
used for support.
5. Endodontically restored
abutments teeth with root
resections.
Increase the number of abutments
used for support.
6. Arch situations creating greater
levarage factor
Increase abutment support.

80. The combined root surface area of the second
premolar and the second molar (A
2p+A
2m) =
412mm² is greater than that of the first molar
being replaced (A
1m
) = 335 mm² .

81. •The combined root surface area of the first
premolar and the second molar abutment
(A1p+A2m) is approximately equal to that of
the teeth being replaced (A2p+A1m)

82. The combined root surface area of the canine
and the second molar (A
c
+A
2m
) is
exceeded by that of the teeth being
replaced (A
1p+A
2p+A
1m)

83. Double abutment
Many clinical situations require the use of double
abutments in the fixed bridges. The term as used
here refers to the use of two adjacent teeth at one or
both ends of a fixed prosthesis joined by a solid
connector. The usual reasons for use of double
abutment are:
•Increase retention of the restorations as a whole
• Splint and stabilize periodontally compromised
teeth and
•Increase the area of the supporting PDL and bone.

84. A fundamental decision
Mobility
continuing
process of
periodontitis
occlusal trauma
stabilization perfectly
justified, providing that
the trauma can be
eliminated in the occlusal
scheme of the restorations.
occlusal forces
cannot be controlled
double abutment to provide
the needed resistance to
lateral forces.

86. using this tooth as part of double abutment is
contraindicated
continuing process of periodontitis (disease is
not totally controlled)
this tooth becomes simply another pontic
pockets become less cleanable, compounding
the problem.
•periodontal therapy must precede fixed prosthodontic
therapy and further bone loss must be stopped.

87. Tilted abutment
It is impossible to prepare
the abutment teeth for a
fixed partial denture
along the long axis of the
respective teeth and
achieve a common path of
insertion

88. Preparation modifications
A proximal half crown
•The distal surface itself is untouched by caries
or decalcification
•There is very low incidence of proximal caries
throughout the mouth.
•If there is a severe marginal ridge height
discrepancy between the distal of the second
molar and the mesial of the third molar as a
result of tipping, the proximal half crown is
contraindicated.

89. •Telescopic crown and coping

90. Prosthetic considerations in
Various periodontal signs

91. Restoration of teeth with
1.Recession
2.Furcation
3.Mobility
4.Trauma from occlusion

92. Restoration of teeth with
recession

93. Restoration of a tooth around which there
has been a loss of gingival height or other
change in gingival architecture
frequently requires modification of the
tooth preparation.

94. The type and location of the finish line may have a
significant impact on the success of the
restoration. An improperly designed preparation
can unnecessarily damage the tooth and
potentially compromise the longevity of the
restoration and of the tooth itself.

95. The three factors . . .
•Margin placement – supra gingival / subgingival
•Margin contour / geometry – shoulder / champher
/ knife edge.
•Margin adaptation

96. Margin
Placement

97. Supragingival Margins
ADVANTAGES:
• They can be easily finished
• They are more easily cleaned
• Impressions are more easily made, with less potential for soft
tissue damage
• Restorations can be easily evaluated at recall appointments
DISADVANTAGE:
• Aesthetically not indicated for anterior region
• Metal can be seen
• Not indicated in short clinical crowns
• The proximal contacts extend to the gingival crest
• In case of root sensitivity

98. Subgingival Margins
SPECIFIC DEMANDS FOR SUBGINGIVAL MARGINS:
• Aesthetic demands
• Caries removal
•To cover existing subgingival restorations
• To gain needed crown length
• To provide more favourable crown contour
DISADVANTAGES:
• Difficult for preparation
• Gingival management should be perfect
• Prone for soft tissue trauma
• More prone for gingival and periodontal pathosis
• Difficult to maintain oral hygiene
• Metal margins can be seen thru the gingiva

99. Margin Geometry
Different shapes have been described and advocated. For evaluation
the following guidelines should be considered:
a). It should be easy to prepare without over extension.
b). It should be readily identified in the impression and on the die.
c). It should give a distinct margin to which the wax pattern can be
finished.
d). It should provide for sufficient bulk of material. This will
enable the wax pattern to be handled without distortion as well as
give the restoration strength and, where porcelain is used esthetics.
e). It should be as conservative as possible provided the other criteria
are met.

100. SHOULDER:
A shoulder is a poor choice when the
margin must be placed on the root
surface.
1.Smaller diameter of the root will
require that the axial reduction be
extended into the tooth to a pulp-
threatening depth to achieve the same
1.0 mm wide shoulder
2.Weakens the natural structural
durability of the tooth.
3.The shoulder has a greater potential for
concentrating stresses that could
ultimately lead to fracture of the tooth.

101. Preparation
for a metal-
ceramic
crown on a
maxillary
premolar
with a 1.0-
mm
shoulder in
the usual
position.
Preparation
for a metal-
ceramic
crown on a
maxillary
premolar with
a 1.0-mm
shoulder
apical to the
CEJ. Notice
the additional
destruction of
axial tooth
structure
required to
produce the
shoulder at
this level .
Wide gingival collar is used to
blend the root contour with that
required for a ceramic veneer of
adequate thickness
Preparation for a
metal-ceramic crown on
a maxillary premolar
with a chamfer apical to
the CEJ. The amount of
axial reduction similar to
that required for a
shoulder at the usual
position.

102. CHAMFER:
According to El Ebrashi et al 1967 margins with
chamfers provide a gingival area with an
acceptable stress distribution and an adequate
seal and require minimal uniform tooth
reduction
KNIFE EDGE FINISH LINE:
•Advantage – conservation of the tooth structure
•Disadvantage – location of margin difficult to
control

103. Furcation Flutes
Sometimes the crown margins on a molar must
extend far enough apical that the preparation finish
line approaches the furcation, where the common
root trunk divides into two or three roots The
designs of both the tooth preparations and the
crowns for these teeth must be different from those
customarily used.

104. This is caused by the intersection of the preparation
finish line with the vertical flutes or concavities in the
common root trunk, extending from the actual
furcation in the direction of the cementoenamel
junction.
When that occurs, the axial surface of the tooth
preparation occlusal to the inversion of the gingival
finish line must also have vertical concavities or
flutes.

105. Facial furcations for a maxillary
(A) and a mandibular (B)
first molar. The portion of the
furcation facing apicaily or
toward the bone is the vault
(vt), or roof. The vertical
concavity on the common root
trunk is the flute (fl).
Vertical concavities in the axial
walls of the tooth preparations
(arrows) extend occlusally
from the invaginations where
the finish lines cross the
furcation flutes on a
mandibular (A) and a
maxillary (B) molar.

106. Anatomic facial groove of
this mandibular first
molar merges (arrow)
with the vertical
concavity extending
from the furcation flute.
A horizontal ridge in the
gingival third of the
axial surface above the
furcation flute will
create a plaque-retaining
area that is difficult to
keep clean (arrow).

107. •RESTORATION OF TEETH WITH
FURCATION INVOLVEMENT

108. Treatment of degree I
furcation involvement
Odontoplasty
Osteoplasty

109. Treatment of degree II and
III furcation involvement
In case of mandibular molars –
•Hemisection – with the removal of more severely
involved half.
•Hemisection with orthodontic distancing of the roots -
to allow the passage of the proxa brush ( cases where the
bone loss is uniform)
•Premolarisation – elimination of distal half of the
molar.

110. In maxillary molars –
•One of the 3 roots may be amputed.
•if all 3 are through and through , then 1
st
the
roots are separated and then one or more roots are
resected.

118. Trauma from occlusion

119. WHO in 1978 as “ damage in the periodontium
caused by stress on the teeth produced directly or
indirectly by teeth of the opposing jaw.”

120. •Glossary of Periodontic terms (AAP 1986) “An
injury to the attachment apparatus as a result of
excessive occlusal force.”
•Carranza , when occlusal forces exceed the adaptive
capacity of the tissues, tissue injury results. The
resultant injury is termed as TFO.

121. Effects depend on –
• Magnitude
• Direction
• Duration & frequency

122. TYPES OF TFO
• Acute or Chronic
• Primary or Secondary

123. Primary TFO Secondary TFO

124. Tissue response to Increased occlusal forces
i Effect on periodontal ligament
ii Pathologic tooth wear
iii Effect on soft tissue

125. EFFECT ON PERIODONTAL LIGAMENT
Stage I : Injury
Stage II : Repair
Butressing bone formation Central
Peripheral
Stage III : Adaptive remodeling of the periodontium

126. Injury
•Due to excessive forces
•Furcation area more susceptible
•Widening of the pdl ligament
•Increased bone resorption
•Severe pressure – undermining resorption

127. Repair
•TFO stimulates reparative activity
•Forces remain traumatic when damage exceeds the
reparative capacity of the tissue
•Decrease resorption
•Buttressing bone formation

128. Adaptive Remodelling
•Thickened periodontal ligament
• funnel shaped
•Normal resorption and formation

129. Clinical Signs of TFO
•Mobility
•Changes in percussion sounds (dull)
•Migration of teeth (loss of interproximal contacts)
•Atypical pattern of occlusal wear( wear facets)
•Hyper tonicity of masticatory muscles (bruxism)
•Periodontal abscesses

130. Radiographic Signs of TFO
• Increased width of PDL space & thickening of the
lamina dura
• Vertical destruction of interdental septum
• Radioluscence & condensation of the alveolar bone
• Root resorption

132. Clinical Techniques (diagnosis)
Indicators of TFO –
• Fremitus
• Mobility
• Occlusal discrepancies
• Wear facets in presence of other indicators
• Tooth migration
• Fractured tooth/ teeth
• Thermal sensitivity

133. RESTORATION OF TEETH
WITH MOBILITY

134. The mobility is considered physiologic if it is
increased but not increasing, and does not
impair function or cause patient discomfort. As
such, it is reversible once the source of the
traumatic forces has been removed.

135. When advanced bone loss has
occurred on one or two surfaces of a tooth but not
on the others mobility is minimal. Residual
mobility of teeth or FPD may be present with
advanced bone loss but not increasing

136. Lindhe described these conditions as follows:
Situation I — increased mobility of a tooth with
increased width of the periodontal ligament, but
normal height of the alveolar bone.
Situation II —increased mobility of a tooth with
increased width of the periodontal ligament and
reduced height of the alveolar bone.

137. Situation III —increased mobility of a tooth with
reduced height of the alveolar bone and normal
width of the periodontal ligament.

Situation IV —progressive (increasing) mobility of
a tooth (teeth) as a result of gradually
increasing width of the periodontal ligament in
teeth with a reduced height of the alveolar bone.
Situation V —increased bridge mobility despite
splinting.

138. Splints
A splint has been defined as “any apparatus, appliance or device employed
to prevent motion or displacement of fractured or movable parts”. Myron
Nevins (1993)
1. Rest:
As for many injured or diseased part of the body, immobilization
permits undisturbed healing
2.Redistribution of forces
prevents the tilting effect of the unfavorably directed occlusal force.
3. Preservation of arch integrity:
Splinting restores proximal contacts that have been disrupted by
missing and migrated teeth
4.Restoration of Functional stability
5. Psychological well being
.

139. Splinting is contraindicated in patients with
gingivitis and early or moderate periodontitis.
Resolution of inflammation by root planing
and reduction of occlusal prematuritiesis
advised.

140. Even if mobility persists after completion of periodontal
therapy, fixed splints are usually not indicated.. If the
patient underwent periodontal surgery, residual
mobility persists for approximately 6 months before
returning to pre-surgical levels

141. The most important aspect of splint design is to secure the
teeth in all planes. Many times this principle
necessitates cross arch stabilization. This ensures tooth
stability without increasing mobility and allows the
periodontal ligament of each tooth to increase in surface
area, thus providing long-term retention.

142. Periodontal Splints
Removable splints Fixed splints
Unilateral Bilateral
Provisional or temporary
1.Acrylic splints
2.Metal band and acrylic splints.
3.Etched metal resin – bonded splints
Definitive fixed splinting
1.resin – bonded fixed partial
dentures (Maryland splints
2.Traditional fixed partial Denture
3.Telescopic coping fixed splints
4.Combined removable and fixed
splints
5.New generation bonded
reinforcing materials.

143. Definitive splinting with fixed
partial denture
Definitive splinting with a permanent fixed cast
restoration is accomplished after definitive
periodontal therapy is completed. Fixed prosthesis
provide excellent and better rigidity as well as a
more favorable force distribution as compared to
removable splints.

144. Resin bonded fixed splint -
Extremely mobile teeth may be contra indications for
this type of appliance in that the prosthesis frequently
debonds in these situations. It is frequently used for
splinting slightly mobile, periodontally compromised
mandibular anterior teeth and replacing one or more
mandibular incisors.

145. Traditional fixed partial Denture -
Rigid connectors
Fixed partial dentures or crowns connected with rigid
connectors, are typically used whenever possible in the
permanent or definitive splints for patients with the
compromised periodontium. Research shown that
combined periodontal and prosthodontic treatment with
fixed splinting eliminates or significantly reduces
mobility and aids in arresting periodontal breakdown.

146. Non-rigid connectors
This type of connection is used to avoid an
extensive bridge if a bilateral splint is treatment
planned for cross-arch stabilization or in situations
in which tooth mal alignment prevents a common
path of draw.

147. The non-rigid connector is a connection that is
comprised of a precision or semi-precision dovetail
lock-and-key design, a split pontic (connector inside
the pontic), or tapered pins. The clinical presentation
of the patient must allow for their incorporation in the
prosthesis with normal physiologic contours as well as
sufficient embrasure space for good oral hygiene if
they are to be advantageous to use both periodontally
and prosthetically.

148. Review of Literature

149. Valderhaug -1971
•Reported that gingiva adjacent to subgingival margins
(finish lines) of crowns showed more inflammation and
greater recession over a two year period than gingiva
adjacent to the supragingival margins.

150. Richter and Ueno- 1973
•Prepared and placed crowns on teeth with one half of the
facial margin positioned subgingivally and the other
half supragingivally.
•They found no significant difference in any of the above
criteria between supragingival and subgingival
placement of margins. And suggested that the fit ,finish
contact and contour of full crown restorations are more
significant to gingival health than the location of the
finish line.

151. M.D WISE – 1985
Conducted a study to assess the stability of gingival crest after
surgery and before the placement of the final crowns on 15
patients aged between 31 to 45 years
And concluded that the definitive crown preparation
should not be made for at least 20 weeks after surgery, as
there was a coronal re-growth of the gingival tissue before this
time period.

152. Kozlovsky, Tal H and Liberman -1987
Studied the effect on the periodontal condition in a group of
periodontally supervised patients treated with fixed bridges
Clinical data indicated little inflammation of the gingival
tissues of crowned teeth with margins at the gingiva while at
teeth with a supragingival location of the crown margin,
gingival tissues showed minor or even no clinical signs of
inflammation.

153. Wagenberg and Robert -1989
Said that restoring the tooth without adequate supragingival
tooth length is a common cause in the failure of full coverage
restorations. Using an insufficient amount of sound tooth
structure or invasion of the biological width for retention
causes iatrogenic periodontal disease and the premature
obsolescence of restorations

154. Wehr C, Roth A, Gustav M, Diedrich 2004
In a case report for the treatment of irreparably damaged
mandibular molar tooth with furcation involvement,
demonstrated that the tooth could be saved by hemi-secting
the tooth and fabricating 2 separate posts on them and later
orthodontically extruding the remaining tooth structure . A
final restoration was constructed on them after a period of 8
weeks.

155. Summary
Every restoration must be able to withstand the
constant occlusal forces to which it is subjected.
This of a particular significance when designing
and fabricating a FPD.
The forces that would normally be absorbed by the
missing teeth are transmitted through pontic,
connectors and retainers to the abutment tooth.

156. So supporting tissues surrounding the abutment
teeth must be healthy and free from inflammation
before and after prosthesis is completed. So
selection of abutment plays vital role in FPD
treatment.

157. References
REFERENCES

158. Theory and Practice of Fixed Prothodontics:
Tylman’s(eighth edition).
Contemporary Fixed Prosthodontics: Rosenstiel
( third edition).
Periodontal surgery. A Clinical Atlas- Naoshi Sato
Periodontal therapy- Clinical approaches and evidence
of success- Myron Navins and James-vol 1-

159. •Clinical Periodontology – Carranza 8th Ed
• Clinical Periodontology – Carranza 9th Ed
• Clinical Periodontology & Implant Dentistry - Jan
Lindhe 4th Ed
• Periodontal therapy – Nevins/ Mellonig
• Fundamentals of Periodontics – Wilson &
Kornman
•Perio 2000. 2003 vol 32 -
•Periodontal risk factors and indicators
•Perio 2000. 2004 vol 34 - Diagnostics

160. Forced eruption: Principles in periodontics and
retorative dentistry. Journal Of Prostho Dentistry:
1982; Vol 48: 141
Surgical crown lengthening for function and
esthetics. Dental Clinics Of North America 1993; Vol
37: 2
Restorative and periodontal considerations of short
clinical crowns.International Journal of Periodontal
1998;vol 18: 5.

161. •Stability of gingival crest after surgery and before
anterior crown placement. Journal of Prosthodontic
dentistry 1985;vol 53 : 20
•Forced eruption in crown-lengthening procedures. Journal
of Prosthodontic Dentistry 1986 vol 56 : 424
•Clinical periodontology of implant dentistry- Jan lindhe
( IV edt )pg 619
•Extension of clinical crown length. Journal of
Prosthodontic Dentistry. 1986 vol 55: 547.

162. Thank you