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Carranza, Newman, Takei. 2012.

Clinical
Periodontology. 9th ed. W. B. Saunders.
London

Lindhe, Karring, Lang. 2008. Clinical


Periodontology and Implant Dentistry.
5th ed. Blackwell Munksgaard. Oxford
Periodontal Therapy Sequences
Emergency Phase

Phase I:
Non Surgical Peridontal Therapy

Phase IV:
Maintenance

Phase II: Phase III:


Surgical Peridontal Therapy Restorative Phase
Alasan untuk menegakkan kesehatan periodontal
sebelum tindakan restorasi gigi :
1. Perawatan periodontal dilakukan untuk
mendapatkan gingival margin yang stabil sebelum
preparasi gigi

2. Prosedur periodontal didisain untuk menyediakan :


Panjang gigi yang adekuat untuk retensi
Akses untuk preparasi gigi
Pembuatan cetakan gigi
Finishing restorative margin
3. Terapi periodontal seharusnya dilakukan terlebih dahulu
sebelum perawatan restorasi karena inflamasi mungkin
menghasilkan reposisi gigi / jaringan lunak dan
perubahan mukosa.

4. Trauma yang mengenai gigi dengan periodontitis akan


meningkatkan kegoyangan gigi, ketidaknyamanan,
attachment loss.
Restorasi ditempatkan pada gigi :
Bebas inflamasi periodontal
Sinkron dengan oklusi fungsional
Long term
periodontal stability
& comfort
5. Kualitas dan kuantitas dari periodontium berperan
penting sebagai faktor pertahanan struktur dalam
mempertahankan kesehatan periodontal.

6. Keberhasilan estetik dan prosedur implant mungkin


sulit atau imposible tanpa prosedur periondontal
khusus untuk tujuan ini
Persiapan periodontium untuk prosedur
restoratif adalah :
1. Kontrol inflamasi periodontal dengan
pendekatan non surgical dan surgical

2. Preprosthetic periodontal surgery


Sequence of Treatment in Preparing
Periodontium for Restorative Dentistry
Emergency Treatment
Emergency treatment dilakukan untuk
meredakan gejala dan menstabilkan infeksi
akut. This includes endodontic as well as
periodontal condition
Extraction of hopeless teeth
Extraction of hopeless teeth is followed by
provisionalization with fixed or removable
prosthetics. Retention of hopeless teeth
without periodontal treatment may result
in bone loss on adjacent teeth.
Restorative margins are refined and
provisional restorations refitted after the
completion of active periodontal therapy
Oral Hygiene Measures
Oral hygiene measures, when properly
applied, have been shown to reduce plaque
score and gingival inflamation.
However, in patients with deep periodontal
pockets (>5 mm), plaque control measures
alone are insufficient in resolving subgingival
infection and inflammation
Scaling and Root Planing
Scaling and root planing combined with
oral hygiene measures have been
demonstrated to significantly reduce
gingival inflammation and the rate of
progression of periodontitis.
This applies even to patients with deep
periodontal pockets
Reevaluation
The gingival tissues are evaluated to determine oral
hygiene adequacy, soft tissue response and pocket
depth after 4 weeks. This permits sufficient time for
healing, reduction in inflammation and pocket depths,
and gain in clinical attachment level.
In deeper pockets (>5 mm), however plaque and
calculus removal is often incomplete, with risk of
future breakdown.
As a result, periodontal surgery to access to the root
surfaces for instrumentation and reduce periodontal
pocket depths must be considered before restorative
care may proceed.
Periodontal surgery
Periodontal surgery should be undertaken
with future restorative and implant
dentistry in mind.
Some procedures are intended to treat
active disease successfully and some are
aimed at the preparation of the mouth for
restorative or prosthetic care
Adjunctive Orthodontic Therapy
Adjunctive orthodontic treatment should be undertaken only
after active periodontal disease has been controlled
If non surgical treatment is sufficient, definitive periodontal
pocket therapy may be postponed until after the completion of
orthodontic tooth movement. This allow for the advantage of
the positive bone changes that orthodontic therapy can
provide
Deep pocket and furcation invasion may require surgical access
for root instrumentation in advance of orthodontic tooth
movement.
Failure to control active periodontitis can result in acute
exacerbations and bone loss during tooth movement
Soft tissue grafting procedures are often indicated in
anticipation of orthodontic therapy to increase the dimension
of attached tissue.
A. Management of mucogingival problems
The most common technique include those that :
Increase gingival dimension
Achieve root coverage
These Procedures are often indicated :
Before restoration
For prosthetic reason
Conjuction with orthodontic tooth movement
Root coverage procedures may also be undertaken for purpose
of comfort and esthetics
At least 2 month of healing is recommended after soft tissue
grafting procedures, before initiating restorative dentistry
A. Management of mucogingival problems
A. Management of mucogingival problems
B. Preservation of Ridge Morphology after Tooth Extraction
Alveolar ridge resorption is a common consequence of
tooth loss
Ridge preservation procedure have been shown to be
useful in anticipation of the future placement of a
dental implant or pontic, as well as in cases where
unaided healing would result in an unesthetic
deformity
B. Preservation of Ridge Morphology after Tooth Extraction
C. Crown-Lengthening Procedures
Surgical crown-lengthening procedure are performed to :
Provide retention form
Allow for proper tooth preparation, impression
procedures
Placement of restorative margin
Adjust gingival levels for esthetics

It is important that crown lengthening surgery is done in


such a manner that the biologic width is preserved
C. Crown-Lengthening Procedures
Biologic width is the physiologic dimension
of the junctional epithelium and connective
tissue attachment
Relative constant at approximately 2 mm
(30%)
The healthy gingival sulcus has shown an
average depth of 0,69 mm
Its recommended that there be at least 3,0
mm between the gingival margin and bone
crest
Infringement on the biologic width by
placement of restoration within its zone
may result in gingival inflammation, pocket
formation, and alveolar bone loss
This allows for adequate biologic width
when restoration is placed 0,5 mm within
the gingival sulcus
C. Crown-Lengthening Procedures
Surgical crown lengthening may include the removal of soft tissue or both
soft tissue and alveolar bone
Reduction of soft tissue alone is indicated if there is adequate attached
gingiva and more than 3 mm of tissue coronal to the bone crest This may
be accomplished by either gingivectomy or flap technique
C. Crown-Lengthening Procedures
Inadequate attached gingiva and less than 3 mm of soft tissue
require a flap procedure and bone recontouring
C. Crown-Lengthening Procedures
In the case of caries, tooth fracture, to ensure margin placement
on sound tooth structure and retention form, the surgery
should provide at least 4 mm from the apical extent of the
caries or fracture to bone crest
C. Surgical Crown-Lengthening
D. Alveolar Ridge Reconstruction
Patient are frequently seen after tooth loss and alveolar
ridge resorption have been occurred.
To provide for adequate anatomic dimensions for the
construction of an esthetic pontic or the placement of
dental implant Alveolar ridge reconstruction is
undertaken
In the case of esthetic pontic construction, small defect
may be treated with soft tissue ridge augmentation
For larger defects and in those site receiving dental
implants, hard tissue modalities are used
D. Alveolar Ridge Reconstruction
D. Alveolar Ridge Reconstruction
Tissue management is the key to
quality direct and indirect restorations.
Pertimbangan penempatan margin restorasi
di bawah the gingival tissue crest :
1. Untuk mendapatkan resistance dan
retentive yang adekuat dari preparasi
2. Untuk membuat perubahan kontur yang
significant karena karies atau defisiensi
gigi yang lain
3. Untuk menutupi margin gigi / restorasi
dengan menempatkan secara sub gingival

This allows for adequate biologic width when


restoration is placed 0,5 mm within the
gingival sulcus
Ketika margin restorasi ditempatkan
terlalu jauh di bawah the gingival
tissue crest mengenai apparatus
attachment gingival membuat
perubahan biologic width

Makigusa K. Histologic Comparison


of Biological Width around Teeth and
Implants: The Effect of Bone
Preservation. Jurnal of Implants and
Restorative Dentistry. 2009; 1(1): 20-
4.
Two different response can be observed from
the involved gingival tissue :
1. Bone loss of an unpredictabe nature along
with gingival tissue recession
2. Gingival inflammation develops and
persist

To restore gingival tissue health Its


necessary to establish space clinically
between the alveolar bone and the margin
This can be accomplished either by :
1. Surgery to alter the bone level
2. Orthodontic extrusion to move the
restoration margin father away from the
bone level
The left central incisor was fractured in an
accident 12 months ago and restored at
that time. The patient is unhappy with the
appearance of the tissue surrounding the
restoration

Radiograph reveals a biologic width violation


on the mesial surface interproximally. Removal
of interproximal bone would create an esthetic
deformity. This patient is better treated with
orthodontic extrusion
After orthodontic eruption. The tooth has
been erupted 3 mm to move the bone and
gingiva coronally 3 mm on the left central
incisor. It is now possible to reposition the
bone surgically to the correct level and
position the gingiva to the correct level,
reestablishing normal biologic width.

One-year recall photograph after


orthodontic extrusion, osseous surgery,
and placement of a new restoration for
patient in . Note the excellent tissue
health after the reestablishment of
biologic width.
Pada jaringan sehat, ada 3 aturan untuk menempatkan margin intracreviular, yaitu :
1. Jika kedalaman sulkus 1.5mm atau kurang, tempatkan margin restorasi 0.5mm di
bawah puncak gingival. Khususnya untuk sisi fasial dan untuk mencegah
gangguan biologic width pada pasien yang berisiko tinggi.
2. Jika kedalaman sulkus lebih dari 1.5mm, letakkan margin setengah dari
kedalaman sulkus di bawah puncak jaringan.
3. Jika sulkus lebih dalam dari 2mm, khususnya pada aspek fasialnya, evaluasi
apakah gingivektomi dapat membuat gigi tampak lebih panjang dan menciptakan
sulkus dengan kedalaman 1.5mm. setelah itu, perawatan dilanjutkan dengan
aturan no.1.

Alasan aturan no.3 adalah karena penempatan margin yang dalam lebih sulit dan
stabilitas margin free gingival lebih tidak dapat diprediksi pada sulkus yang dalam.
Mengurangi kedalaman sulkus menciptakan situasi yang lebih mudah diprediksi
dalam penempatan margin intracervicular. Tapi tidak jaminan jika jaringan akan
berada pada level yang benar karena beberapa gingival dapat menggelembung
setelah gingivektomi. Tapi setidaknya lebih meyakinkan bahwa margin restorasi tidak
terekspos dan terlihat dalam mulut pasien.
Tissue Retraction
Pada saat penempatan margin
restorasi pada sulkus, jaringan harus
dilindungi dari abrasi, yang dapat
menimbulkan perdarahan dan
mempengaruhi stabilitas level jaringan
di sekitar gigi.
Maka dari itu, akses ke margin,
kebersihan, dan control cairan dari
lingkungan mulut harus diatur dengan
baik.
Pengaturan jaringan dilakukan dengan
gingival retraction cord (benang
penarik gingiva). Cord dengan diameter
kecil menjadi pilihan untuk gingival
yang tipis, rapuh, dan sulkus yang
dangkal.
Tissue
management for
Impression making
Tissue
management for
Impression making
Managing Interproximal Embrasures
Tinggi papila berasal dari ketinggian tulang, biologic width, dan bentuk
embrasur. Jadi perubahan bentuk embrasur dapat mempengaruhi tinggi dan
bentuk papila
Idealnya, jarak titik kontak dengan tulang alveolar adalah 5 mm. Pada jarak
ini papila dapat mengisi seluruh space. Bila jaraknya >5 mm, papila tidak
dapat mengisi seluruh space
Comparison of the behavior of the interproximal
papilla relative to bone and the free gingival
margin relative to bone in the average human.
There is a 3-mm scallop from the facial bone to
the interproximal bone. However, on average, a
4.5- to 5.0-mm gingival scallop exists between
the facial tissue height and the interproximal
papilla height. This extra scallop of 1.5 to 2.0
mm of gingiva compared with bone is the result
of the extra soft tissue height above the
attachment interproximally.
Managing Interproximal
Embrasures
Cara mengevaluasi
embrasure dan jaringan
papila :
Correcting Open Gingival Embrasures Restoratively
Dua penyebab open embrasure
Tinggi papilla tidak ideal karena bone loss
Lokasi kontak interproksimal terlalu coronal, karena :
Akar yang menyebar
Bentuk gigi tapered

Restorasi dapat memperbaiki open embrassure dengan cara


memindahkan titik kontak ke ujung kuncup papila + margin
restorasi dibuat subgingivally 1-1,5 mm menggunakan
restorasi direct bonded
This patient has parallel roots, has
recently completed orthodontic therapy,
and is unhappy with the open gingival
embrasure between her central incisors.
An evaluation of papillary height reveals
that all are at an equal level. This can only
mean that the open embrasure is the
result of an overly tapered tooth form

One method of correctly altering tooth form of


patient in . A metal matrix band has been
shaped to the desired tooth form and placed
1.0 to 1.5 mm below the tip of the papilla.
Restorative material then was added to the
tooth against the matrix band, forming the
new mesial surface of the left central incisor.

One-year recall photograph after restoring


the mesial surfaces of the right and left
central incisors, moving the proximal
contact to the tip of the papilla and
extending the restorations 1.0 to 1.5 mm
below the papilla, blending them into the
tooth and making an easily cleaned area
Pontic Design
ada 4 macam pontic design :
1. Sanitary : jarak permukaan jaringan pontic dengan ridge sekitar 3mm,
bentuk konveks, paling mudah untuk pembersihan. Tapi jarang digunakan
karena bentuknya yang kurang estetis
2. Ridge lap : permukaan jaringan pontic membentuk pelana mengelilingi
ridge, bentuk konveks, sulit untuk pembersihan, tidak direkomendasikan
3. Modified ridge lap :
Facial konkaf, mengikuti bentuk ridge
Lingual sedikit dikurangi, untuk memudahkan pembersihan
indikasi bila ridge tidak mencukupi untuk membuat ovate pontic
4. Ovate : permukaan pontic konveks, sehingga baik secara estetis,
memudahkan pembersihan, dan menciptakan receptor site (gbr. 75-31).
Merupakan bentuk yang paling ideal
Four options to designing the shape of a pontic. A, Sanitary pontic. tissue
surface of the pontic is 3 mm from the underlying ridge. B, Ridge-lap pontic.
Tissue surface of the pontic straddles the ridge in saddlelike fashion. The entire
tissue surface of the ridge-lap pontic is convex and very difficult to clean. C,
Modified ridge-lap pontic. Tissue surface on the facial is concave, following the
ridge. However, the lingual saddle has been removed to allow access for oral
hygiene. D, Ovate pontic. The pontic form fits into a receptor site within the
ridge. This allows the tissue surface of the pontic to be convex and also
optimizes esthetics.
Pontic Design
Kedalaman receptor site bergantung pada kebutuhan estetik dr
pontic :
Gigi anterior :
Facial : reseptor area dibuat sedalam 1-1,5 mm
menciptakan free gingival margin & estetik yang baik
(gambar 66-38)
Palatal : dibuat agak taper dibandingkan pada facial
memudahkan pembersihan
Gigi posterior : receptor site yang dalam akan mempersulit
pembersihan. Sebaiknya receptor site dibuat sama tinggi
dengan ridge (gambar. 66-39)
Figure 66-38 Ideal shape and form of an ovate
pontic in the esthetic area. The receptor site
has been created 1.0 to 1.5 mm apical to the
free gingival margin on the facial aspect. This
creates the illusion of the pontic erupting from
the tissue. On the palatal side, the pontic is
tapered so that the receptor site is not
extended below tissue; this allows easier
access for oral hygiene. Note that when the
receptor site is created, the bone must be a
minimum of 2 mm from the most apical portion
of the pontic.

Figure 66-39 Option for creating an ovate pontic


receptor site in less esthetic areas of the mouth.
Rather than creating the receptor site so that the
pontic extends into the ridge, it is possible to create
a flattened receptor site in which the pontic sits flush
with the ridge. This facilitates oral hygiene.