A comprehensive treatment rationale combining prosthodontics and periodontics

A comprehensive

treatment

prosthodontics Lawrence

and

J. Calagna,

College of Dentistry, New York, N. Y.

rationale

combining

periodontics

D.D.S.,

M.S.*

Brookdale

Dental

Center

of

New

York

(Jniuersity,

P

eriodontally involved dentitions that require restorative treatment should be approached wit h the most comprehensive and precise therapeutic modalities available today. This type of pathologic dentition must be treated with periodontal and restorative measures. In this article, an attempt will be made to present a concept and the rationale for treatment. A combined approach by the prosthodontist and the periodontist toward establishing a treatment plan is necessar)-. A mutual understanding of the etiologic factors present, anticipated therapeutic procedures required, and the final design of the periodontal prosthesis will provide the total control necessary for successful treatment. Results from investigations demonstrate that dental plaque is one of the primary etiologic factors in inflammatory lesions of the periodontium.‘, ’ Soft and hard tissue breakdown is the clinical sign which indicates the extent of the disease j Fig. 1’1. and trauma from occlusion have been Gingival inflammation, pocket formation, citrd as causes of marked changes in the attachment apparatus.” The topography of the infrabony pocket represents the resultant lesion, where local irritants initiate the marginal inflammation and excessive occlusal forces act on the spread of this inflammation.’ Once the etiologic agents responsible for producing disease arc evaluated, a treatment plan can be decided upon. Hopeless teeth are extracted. endodontir therapy is completed where indicated, and any anticipated tooth movement is incorporated into the initial preparation phase of the treatment (Fig. 2). PROCEDURE

Initial preparation. desire and motivation Presented

before

*Assistant

Clinical

During initial preparation, the patient will demonstrate his to perform the necessary hygienic duties. The entire dentition the

Northeastern

Professor,

Gnathological Department

Society,

of Removable

New

York,

N. Y.

Prosthodontics. 781

702

C&gnu

the remaining

abutments

are

prepared,

and

heat-cured

xrylic

resin

r-erainers

:jn.:

Prosthodontic-periodontic

treatment

783

relined to provisionally splint the remaining dentition. The provisional splint is a template for the final prosthesis (Figs. 3 and 4). Teeth with a questionable prognosis are carefully evaluated during this phase of treatment. Surgical phase. Dentitions classified as “terminal,” as well as the more moderate periodontally involved dentitions, require definitive operative therapy. There is no available diagnostic measure which can accurately predict whether or not a dentition will break down. The grey area of “physiologic tolerance” has no known measurable limits. As a result, complete pocket elimination should be attained. Following completion of periodontal therapy, the patient’s remaining teeth are provided with the best possible means of maintaining their stability, and this provides for a healthy environment in which the prosthodontist can complete therapy. In order to properly evaluate a completed clinical procedure, a complete list of objectives is reo,uired. In this fashion, meaningful evaluations can bc made regarding thf techniques used. Only those procedures which yualitatively fulfill the objectives have merit. OBJECTIVES

OF RESTORATIVE

THERAPY

The objectives of restorative therapy in periodontally involved dentitions include the following: ( 1) maintain the integrity of the periodontal supportive apparatus, ( 2) biologically contoured restorations, (3) bilateral simultaneous occlusal contacts at the correct \.ertical dimension of occlusion. (4) maximum distribution of contacts, (5) direct vertical forces, (6) limit horizontal forces, (7) maximum efficiency with minimum expenditure of energy, (8) maintain stability of centric position, and (9) physiologic acceptability. Maintain integrity of periodontal supportive apparatus. Abutment preparations should conform to the repositioned free gingival margin. The prepared margin should not extend into the attachment apparatus nor should retraction procedures impinge upon the epithelial attachment, Epithelization of tissue is complete six to eight weeks after surgery.” At this time, final chamfer margins are prepared to the exact height of the free marginal gingiva (Fig. 5). A bud or flame-shaped carbide bur* creates the necessary trough and also bevels the chamfer margin (Fig. 6‘1. During this period. the gingival salcus depth is 0.5 to 2 mm. The beveled margin need only be 0.5 to 1.0 mm. in length, depending upon the depth of the gingival sulcus. Minimum bleeding takes place since the operative site is in a state of good health. Gingival retraction cord? saturated in a hemostatic solution$ is lightly inserted into the trough to insure adequate access to the margins. Any type of elastic impression material may be used to satisfactorily capture the finished margin of the preparation (Fig. 7). Upon evaluation, these procedures insure that the integrity of the periodontal supportive apparatus will be maintained, and therefore they are justified. Biologically contoured restorations. The increase in clinical crown length following periodontal surgery locates the free gingival margin on root surfaces and farther “Pfingst, tVan

iTew R Dental

$Hemodent,

York,

N. Y.

Products, Premier

Dental

Inc.,

Los Angeles, Products

Calif.

Company,

Philadelphia,

Pa.

784

Calagna

Fig. 5. Chamfer margins are prepared gival tissue.

exactly tc> the coronal height of the frrkt* margina! ,?I

away from the protective axial convexities of tht~ tooth. If the reatorcad i;li,i,ii heq!l~ of contour is relocated on root surfaces, the s;tmc distanc.c from the. marginai tiystic,, as c-&ted before surgery. the, result Lvould be to creattt ;I triangular ;WW ir~ar~c~~srl~i~ for cleansing measures. Little. if any. physiologic~ rfTrc.1. functional rrlntiori5liiJ) 8 protective capacity upon the gingival tissue.:, would resmelt lronl this t\,l,!’ oi ( o:lto:!~ As the distance from the occlusal surface to the fre(l gingival margin iuc W;SIT tiltnecessity for protective axial convexities dccrfAas?s, and thy ;Ic,centuatiorr tj!’ ii:ltul,i lrit;ci,r :ir(’ must be lengthened occlusogin,givally and still l)rn\.id(> ;I ,glJlglvui 13tnhI’a411!i’ i\ ill( /I C:III be readily cleansed by c~onvcntional me;lsIirt~s Fig:. 9). I%ecaustl of t!!i:\ ~;I(‘[c>I in most instances, full-coverage restoration< arc indicated, and l~;lrti:~i-! !MTI’.IQ’ restorations arc contraindicated. Bilateral .rimultaneour occ~lusal rnntartr ut tlrc co/rc’( t i ~j-tzrcl/ !iltf!c.t/m:ri ,’ orclusion. Once the vertical dimension of oc,clusiorr lens been established, I!.l~c.ti~r~r .! is acceptrd as presented by the patient or restored u ith tllr l)rosthesis. “1 pY’~‘i\f :lll(T harmonious contact position must be attained. III order to prwisel~~ loratc~ hi\ :xY~I~I ~211 contact position, the position must be replicabl~~. For tlli5 rcasoI1. tll<, ir~l!~11:1::hin,qe position is chosc>n as the correct position for c.erltric. relation to i-oirlc~icic* 11iti: centric occlusion or mnximmn intercuspation. Consequently, thr potential 11;rlllll;i from retrusive occlusal discrepancies can be elinlinatt~d. Proprioccpti\,r nerl(’ t:~ldi~~g, in the periodontal membranes will reflexly condition the nPurnmusculaturc> w th:l: mandibular closure is harmonious and bilaterallv simrtltaneo~~s at the c‘or‘rec’t 1 !sr.tic.:i! dimension of occlusion. Maximum distribution o/ f orztac‘ts. f2e1lt1 ik holtli~itr c’usJls are th Ill.itltiii,lii.tr~ buccal cusps and thr maxillary lingual cusps. The occlusal schemes fahricatcd 1:. periodontally treated dentitions must providra for both mandibular bucral c.~sp :111c! maxillary lingual cusp contacts. In addition, a removable partial denturf, 1”1ostheG\

Prosthodontic-periodontic

treatment

785

Fig. 7. Reversible hydrocolloid impression material is used to record the shape of all prepared margins. The patient is premeditated with 15 mg. pro-Banthine to maintain a relatively dry field. Fig. 8. Restored contours hygiene techniques. Fig. 9. The impaction.

occlusogingival

recreate

natural

contact

area

convexities is lengthened

to promote in

better order

accessibility

to prevent

for sufcular horizontal

food

should be incorporated into the treatment plan where indicated to further distribute the forces of occlusion to supportive denture-bearing areas, as well as to the abutment teeth (Fig. 10). The use of cusp teeth necessitates the correlation of ridges and groo\.es with mandibular motion. Direct vertical forces. The design and arrangement of the principal periodontal fibers are such that vertical forces directed along the long axis of teeth are best tolerated by the supportive periodontium.’ Because of this, cusp-fossa occlusion should be used whenever possible (Fig. 11) . Cusp teeth located in fossae must be provided with ridges and grooves in order to harmoniously pass through opposing occlusal surfaces as determined by condyle pathways and the incisal guidance. The most precise way to determine the border paths of the mandible is with a pantographic recording. The lower lip, esthetics, and phonetics determine the length of the masillary

anterior

teeth.

The

lingual

concavity

of the

maxillary

anterior

teeth

is influenced

by the sagittal displacements of the working condyle, the lateral translation of the mandible or Bennett shift, the protrusive inclination of the condyle path, and the intercenter distance or the distance between the vertical axes. This information can only be obtained from the patient by means of locating the horizontal mandibular

asis

and

by

available

pantography.

total

In

order

discriminatory

to properi).

capabilities.

interpret a fulls

the

recording>

;IdjllDtable

xnti

Arcon-typr

IF IILIA~ ;hr.tic iilaio:

is rquircd.

Limit renctx method

cuspid teeth

cuspid tication

by

of

working

side

posterior-

teeth and

forces

in lateral

basis

away

posterior

from

parafunctional

the

from

teeth.

physical the

force

should take

IP;LSI

trauzll;~ti’

rrlovements is to diqc iudr Stir typ. of ocrfusal sc~hrmlt~. .I-10

sourw

0C polver

in

c.otltact. teeth oc~clusal

lateral protrusive

(thr.

elimination

is ilzlpossible,

posterior ‘Tllis side.’ the

th r):~(.ii‘

;~rrti

;nld

escursi\f~

all

In

of level-h

cfhcicnt

complete hv

destructiw

mo\,enwnts.

laws

mosl

excursions

nonworking

l>otentinlly

the Since

nlandibular

immediately and

of the

a cuspid-disrlusiot,

a lateral

should side

teeth,

farther

lateral

tolerating

\vorking

the natural

incorporating

during

capable

On in

horizontal

tooth is located ! than are the

encountered

tional

disclusion

of limiting

posterior

tllr

forcer.

hokontal

of

l’orws

musc~it5 of

onI)-

The

thrw

cuspid

iatrrd

01 rt:,~‘-tom-~

ttvtll

Perth

tllo\i

OII

out of oct,iuaioJi. l)o~h arranpement protcx’ts encountered

movement,

during the

anterior

till, oil ti,l~

111r-lc. trrtii

Prosthodontic-periodontic

treatment

707

immediately disclude all the posterior teeth. Minimum clearance on the Marking side is provided so that the inclination of the lingual cuspid concavity is maintained within its physiologic limitation. Also, if the cuspid becomes bveakened structurally, a posterior group-functional contact arrangement on the working side can be easily attained (Fig. 12). Maximum efficiency with minimum expenditure of energy. The occlusion is fabricated so that centric relation and centric occlusion coincide. Use of the terminal hinge position is mandatory in order to take advantage of a replicable reference position during reconstruction of the dentition.!’ Only in this way can precision occlusion be established. The muscles are programmed to effect closure without deviation into the maximum intercuspal terminal hinge position. The propriocepti\,e nerve endings continuously reinforce closure into this contact position. If a “long-centric” or occlusion-possessing minimum cuspal morphology were formed, the proprioceptivc n(xr\-c endings in the periodontal membrane would be continuously stimulated b) a \.ariety of positions of occlusal contacts. The effect of these occlusal schemes ~vould be to confuse the neuromuscular system and diminish the efficiency of the mechanism at the expense of increased muscle energy output. Maintain stability of the system. Restoration of an occlusion lvith a cusp-fossa occlusal scheme is a most efficient method of maintaining stability. The precision of the occlusion becomes extremely important in conditioning the neuromuscular mrchanism. Once this has b een established, via the proprioceptivr system, the prerision of the occlusion becomes more important than the position itself.‘” A precision orclusion fabricated in the terminal hinge position may, in a period of time, develop a “slide.” If the precision of the occlusion is responsible for programming thr neuromusculature and if the system is capable of adaptation, then the recurrence of a “slide” can be considered “normal” and within physiologic limits. Physiologic acceptability. Since there are no known methods available to determine an indixidual’s physiologic limitations, every possible measure must be taken to provide the crippled dentition with the best chances of survival. Whatever the etiologic factors present in a patient, the fact that periodontal disease has resulted means that, for that individual, the physiologic limitations have been exceeded. On this premise, definitive, comprehensive treatment modalities are considered mandatory when treating the periodontally involved dentition. The mere fact that ;1 nondrfinitive approach may be successful for a given patient does not rule out the fact that, in another individual. such therapy may contribute to the continuation of periodontal breakdown. The periodontal tissues arc the ultimate testing ground for the validity of all concepts of occlusal function. In the final analysis, the response of the periodontal tissues is the yardstick by lvhich longevity of prosthodontic treatment is measured (Fig. 13). SUMMARY 1. Periodontally involved dentitions requiring restorative therapy can be diagnosed and treated on a predictable basis. A team effort is required so that maximum control of total therapy can be maintained. 2. Definitive periodontal and prosthodontic measures can be evaluated, and based

788

Calagna

upon biologically and mechanically sound objectives, ;L rationale for treatmrnr ~-xi be made. 3. Complete elimination of local irritants and pockrt formation is a prriodorrtxr ob,jecti\,e. -1. Riologic contours and a precision occlusion, in lumony k\.ith dt~terrniri3xit~ t )’ mandibular motion and within the physiologic limitations of the patient, ;IIT pro\tho dontic objcctkw. .3. Maintenance of the integrity of the periodontal .supportivc apparatl:s I\ rhc. ultirna te goal of combined periodontal prosthodontic thr~rapy. References

1. Box, H. K.: Recent Developments Dental Foundation. 2.

3. 4. 5

6.

9. 10.

15%. VVt-terr.

j bf Clinical Manifestation> r)f PeriLovdal, A., Arm), A., and Waerhaug, J.: Incidence odontal Disease in Light of Oral Hygiene and Calculus Formation, J. i\m. Dvtl:. .*iw;i 56: 21-33, 1958. Itoiz: M. E., Carranza, F. .4., Jr,, and Cabrini, R. I..: Exprrimental ‘I‘raunutic l,wion~, Rcxv. Asoc. Odontol. Argcnt. .‘,I: 383-391, 1963. <;lickman, 1.: and Smulow, J. B.: Effect of Excessive Wclusal Forces L-JXBII ttw Patt!wa\ of Gingival Inflammation in Humans, J. Periodontol. 36: l-11 -147, 196,5. Rosen, H., and Gitnick, P. J.: Integrating Restorative Prowdurw Into the ~I’rratmcnr 11: Periodontal Disease, J. PROSTHET. DEKT. 14: 343-354, 1964. Eissmann, H. F., Radke, R. A.; and Noble, W. H.: Physiologic Design Criteria i<~r F&d Dental Restorations, Dent. Clin. North Am. 1.5: 543-568. 197 i,

7. Ramfjord. Company. 8.

in the Cunc,ept of Oral Sepsis, Ontario,

S. P., and Ash. M. M., Jr.: Occlusil>n, Philadelphia,

1966, M’. K. Saunders

D’:lmico, A.: The Canine Teeth--Normal Functional Relation of the Natural Man, J. South. Calif. Dent, Assoc. 26: 49-60, 127-142, 1 Z-182, 1958. Atwood, D. A.: A Critique of Research of the Posterior Limit of the Mandibular J. PKOSTHET. DENT. 20: 21-36, 1968. Celenza, F. V.: Personal Communication, Oct., 1972. :30 CENTRAL NEW

YORK,

PARK SOUTH hT.

Y.

10019

‘I’wth Positiux:.

C-I!