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DEVELOPMENTAL OR ACQUIRED DEFORMITIES AND CONDITIONS Localized Tooth-Related Factors That Modify or Predispose to Plaque-Induced Gingival Diseases or Periodontitis

In general, these localized tooth-related factors contribute to the initiation and progression of periodontal disease through an enhancement of plaque accumulation or the prevention of effective plaque removal by normal oral hygiene measures.5 These factors fall into four subgroups as outlined in Box 4-4. Tooth Anatomic Factors. Tooth anatomic factors are associated with malformations of tooth development or tooth location. Anatomic factors, such as cervical enamel projections and enamel pearls, have been associated with clinical attachment loss, especially in furcation areas. Cervical enamel projections are found on 15% to 24% of mandibular molars and 9% to 25% of maxillary molars, and strong associations have been observed with furcation involvement. 15 Palatogingival grooves, found primarily on maxillary incisors, are observed in 8.5% of individuals and are associated with increased plaque accumulation, clinical attachment, and bone loss. Proximal root grooves on incisors and maxillary premolars also

Figure 4-28 A and B, Clinical image of fistula tract. C, Root fracture. D, Resul tant alveolar ridge defect. B C D A predispose to plaque accumulation, inflammation, and loss of clinical attachment and bone. Tooth location is considered important in the initiation and development of disease. Malaligned teeth predispose individuals to plaque accumulation with resultant inflammation in children and may predispose to clinical attachment loss in adults, especially when associated with poor oral hygiene habits. In addition, open contacts have been associated with increased loss of alveolar bone, most probably through food impaction.11 Dental Restorations or Appliances. Dental restorations or appliances are frequently associated with the development of gingival inflammation, especially when they are located subgingivally. This may apply to subgingivally placed onlays, crowns, fillings, and orthodontic bands. Restorations may impinge on the biologic width by being placed deep in the sulcus or within the junctional epithelium. This may promote inflammation and loss of clinical attachment and bone, with apical migration of the junctional epithelium and reestablishment of the attachment apparatus at a more apical level.

Root Fractures. Root fractures caused by traumatic forces, restorative or endodontic procedures (Figure 4-28, A to C) may lead to periodontal involvement through an apical migration of plaque along the fracture when the fracture originates coronal to the clinical attachment and is exposed to the oral environment with resultant alveolar ridge defect (Figure 4-28, D). Cervical Root Resorption and Cemental Tears. Cervical root resorption, as noted on the computed tomography (CT) scans in Figure 4-29, A and B, and cemental tears may lead to periodontal destruction when the lesion communicates with the oral cavity and allows bacteria to migrate subgingivally. Avulsed teeth that are re-implants frequently develop ankylosis and cervical resorption many years after re-implantation. Atraumatic removal of such ankylosed teeth and reconstruction of resultant ridge defects with bone grafts, dental implants, and prostheses are viable solutions for such defects (Figure 4-30). Mucogingival Deformities and Conditions around Teeth Mucogingival deformity is a generic term used to describe the mucogingival junction and its relationship to the gingiva (Figure 4-31), alveolar mucosa, and frenula muscle attachments. A mucogingival deformity is a significant departure from the normal shape of gingiva and alveolar mucosa and may involve the underlying alveolar bone. Mucogingival surgery corrects defects in the morphology, position, and/or amount of gingiva and is described in detail in Chapter 63. The surgical correction of mucogingival deformities may be performed for esthetic reasons, to enhance function, or to facilitate oral hygiene.22 Mucogingival Deformities and Conditions of Edentulous Ridges Mucogingival deformities such as lack of stable keratinized gingiva between the vestibular fornices and the floor of the mouth (Figure 4-32, A) may require soft tissue grafting and vestibular deepening before prosthodontic reconstruction (Figure 4-32, B to D). Alveolar bone defects in edentulous ridges (Figure 4-33, A and B) usually require corrective surgery (Figure 4-33, C and D) to restore form and function before placement of implants and prosthesis to replace missing teeth (Figure 4-34).22 Occlusal Trauma The etiology of trauma from occlusion and its effects on the periodontium8 is discussed in detail in Chapters 20 and 49. 52 Figure 4-30 A, Posttreatment clinical image of same patient depicted in Figur e 4-29 with implant-supported crowns and veneers on laterals. B and C, CT scan of bone grafts and implants replacing central incisors lost as the result o f severe cervical root resorption. A B C A B C D Figure 4-29 A and B, CT scan reveals severe cervical root resorption of maxillar y central incisors and periapical abscess. C, Crowns fractured because of resorption. D, Biopsy of soft tissue from resorption. Figure 4-31 A, Mucogingival defect depicted by recession. B, Defects extend into alveolar mucosa and lacks keratinized gingiva. B A Figure 4-32 A, Mucogingival ridge defect from floor of mouth to vestibular forni x. B, Partial thickness flap with vestibular deepening. C, Placement of

free gingival graft. D, Reestablishment of vestibular depth and keratinized atta ched gingiva. C B D A Figure 4-34 A, Clinical image of ridge 6 months after grafting. B, Placement of implants in area of teeth #23 and 25. C, Porcelain fused to metal (PFM) crowns for maxillary incisors and implant-supported bridge from teeth #23 to #25 .