CROWNS & BRIDGES

LECTURE # 7
Dr. MOUSA MARASHDEH

This lecture will deal with the last principle of tooth

preparation which is " preservation of periodontium " . It's

about very important issue , periodontal information very

relative to prosthodontics .

As Dr said the reference of this lecture is not the book, it's

the handout he gave us .

2a5er eshe gbl manballesh : next lecture will be given by Dr.

Khaled Al Hamad who will be very strict in the " presence &

absence " of students , & there will be a quiz in this lecture.

NOW LETS BEGIN :

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BACKGROUND :

- Maintenance of periodontal health is a key factor in

successful prosthodontics : you cannot succeed in your

prosthodontics unless your perio is stable .

- The gingival tissues provide the background against which a

prosthesis is viewed : when you look to teeth you can't see

them without gum .

MUCOGINGIVAL CONSIDERATION :

- The importance of attached gingivae cannot be stressed

more.

Attached gingivae is significant because you will ruin the whole

esthetic of your patient if the gingivae recede back .

- The gingivae is the key factor in preventing gingival recession.

- 3mm is an adequate width of keratinized & attached gingivae :

if you have 3mm of keratinized gum that's fair enough to be

dealt with,if you deal with it gently , it won't be recede back .

Finally you will look to the gingival margin it should be stable in

its place , if attached gingivae is weak , the gingival margin will

recede back & the margin of your preparation will show .

PERODONTAL THERAPY AS AN AID TO RESTORATIVE

DENTISTRY :

- It's important to inform prognosis : we cannot restore tooth

if we are suspicious of its mobility . we should consult a

periodontist to tell you if this tooth will survive for a while or

not .

- Improves soft tissue management .

- Establishes stable gingival margin position : this is very

significant especially if we are talking about poor margins or

unesthetic restoration , if you fabricate a metal ceramic

crown, the margin more or less will be grayish whatever the

skill of your technician , so if your gingival margin recedes back

& finish line within the gum , after a while your patient will

complain from unesthetic restoration .

- Reduces tooth mobility : by improving the attachment .

- Contributes to esthetic ( explained before )

The inflamed gingival margin :

- If you are doing class3 composite & you have bleeding gum, is

there any problem ? yes, it's the isolation so during the

operative procedure you cannot restore the tooth unless the

gum is stable .

- is unstable in its apico-coronal location : gum is inflamed

means that if it heals it will shrink back so the apico-coronal

position is unstable if your gum is inflamed .

Slide 6 page 1: in the pictures we see very inflamed gum ,

perio probe , pus , if this tooth needs crown you cannot restore

right now , you need to send to a periodontist to do scaling &

root planning to stabilize the gum before fabricating the

restoration .

PERIODONTAL INVOLVEMENT :

When do you involve perio in your treatment ?

Actually all the way through from :

Treatment planning , tooth preparation , impression ,

temporization , marginal placement & accuracy ,to contour &

emergency profile .

BIOLOGIC WIDTH :

It's 2-3mm of healthy gingival tissues attached to a clean

healthy tooth surface coronal to the alveolar bone crest .

(Refere to slide 3 page 2)

you have this alveolar crest there's periodontal ligament

attachment then the junctional epithelium , the distance

between alveolar crest to the bottom of your gingival sulcus is

called BIOLOGIC WIDTH .

I want to fabricate a crown to this tooth , you see the arrow

on the figure < it refers to the maximum depth you can get

yourself inside the sulcus , you cannot get anymore <

- Biologic width should not be encroached by any restorative

margins and\or defects ; if you have class 5 caries , the margin

of the defect should not be close to the alveolar crest within

2-3mm which is the biologic width . or if you fabricate a crown

,the margin of your crown should not encroach that space , if it

does it will lead to inflammation , pocketing , recession or

combination . then if you fabricate a very esthetic crown for a

lady ( eg)upper central ) and you encroach the biologic width ,

she left the clinic very happy because the esthetic is very nice
, after few weeks there will be inflammation , pocketing ,

recession , whatever , then the margin will show which is bad

esthetic .

Slide 5 page 2 :

Diagram showing the biologic width at the left top , we prepare

crown there & there is a margin , we encroach the junctional

epithelium ( means you encroach the biologic width ) , the

ordinary reaction is inflammation , pocketing & recession so the

margin of your crown will show so the esthetic will be bad & by

that you sacrifice the periodontium .

Slide 6 page 2 :

These crowns cemented encroaching the biologic width, after

while gingival inflammation around the margin , very stagnated

gum ( bluish gum ) .

How to improve the periodontal status of your patient ?

You have to do the following : remove old crowns then

fabricate proper temporary crowns ( properly

placed,contoured, & easy to clean ) then you will see the

difference in the gum ( refer to slides 1+2 page 3 )

Slide 3 : after a while we will end up with these nice

preparations .

- Back to the previous lecture talking about cores :

You have to prepare your tooth 1-2mm apical to core , also we

talked about ferrule effect 1-2mm band of sound tooth

structure .

Remember if you don't have enough tooth structure to make

ferrule you can do (sth) else like extrusion , crown lengthening

or whatever , actually what you do is recreating or

repositioning the biologic width .

There are 2 factors which will tell you :"I need to recreate the

biologic width" :

Either : 1- you need deep marginal placement : for example :

you have deep class 2 when you clean the caries you find

yourself that you are encroaching the junctional epithelium ,

but you need to fabricate a crown for this tooth & lets say

that you need to prepare further 1mm then you will encroach

the biologic width further & further , and if you don't protect

it , the long term prognosis of the gum will be poor so what to

do ? a periodontist have to cut the gum & recede the bone

alittle bit downward so to keep the margin 2-3mm away from

alveolar crest .

Or

2- Mechanical consideration : if you have short crown ( what's

the minimum length of anterior crown after preparation ?3mm),

if you have 2mm it won't be stable crown so you need to do

crown lengthening .
The above procedures are usually achieved by crown

lengthening .

Slide 5 page 3 :

A lady came to the clinic to enhance the look of her centrals,

they are quite short so we decided we need crown lengthening ,

we fabricate a temporaries with proper lengths that the lady

liked , a periodontist raised a flap , we place the temporaries &

you can see the relationship between the crowns & the bone

beneath them ( slide 6 ) , return the flap back , put the

temporary with its margin away from alveolar crest 2-3mm so

once you restore the teeth the gum won't recede back . usually

we wait for 3 months after crown lengthening to make sure

gum won't recede after healing .

RESTORATION MARGINS :

Now we agree where to place our finish line , usually it should

be supra gingival .

HOW WELL DO RESTORATION MARGINS FIT ?

& HOW SHOULD RESTORATIONS BE SHAPED TO

MINIMIZE PLAQUE RETENTION & FACILITATE

CLEANING?

(we will answer these questions later on enshalla)

There is no such thing as the perfect margin means :

All the time whatever the skill of clinician or technician there

will be a gap between the crown & the margin or finish line .

this gap is recommended to be 39 microns ( the best is 39

microns,the very best is zero but no way to achieve ) , clinically

39 is unachievable so many authors accept up to 100 microns

(0.1mm) as a marginal opening .

If you cement your crown what will come in this gap all around?

Cement,in cementing a crown we usually use a conventional

cements like glass ionomer , these cements are washable means

after period of time they will wash out , leaving the gap open ,

leads to food accumulation & affect the esthetic . for this

reason we need cements that won't be washed out , one of

those is RMGI which make sure that the gap will be filled all

the time with cement .

MARGINAL PLACEMENT :

- should be supra gingival when possible y3ne your default

margin is supra gingival .

- sub gingival placement is justified in :

A) aesthetic : (refer to slide 4 page 4): the figure shows the

appearance of grey margins of the upper left central incisor &

upper right lateral incisor .

We need to put our margin a little bit sub gingival for esthetic

point of view . sometimes the technician could have a band of

metal beneath the finish line ( in beveled shoulder ) so if you

want to use beveled shoulder , you have a ring of metal , then

you need to go sub gingival , if you don't have enough length of

crown then you need to do crown lengthening .

B) mechanical considerations : y3ne if you need longer crowns ,

we need to place the margins sub gingival .

FROM THE HANDOUT : The height of the crown preparation is one of
the important factors in determining the retention & resistance of the final
restoration . if insufficient coronal tooth structure is available then the
clinical crown height can be increased by involving the sub gingival
tissues .

C) dental caries or defects : you don't put the margin on

caries, you need to clean the defect , so your margin should be

on sound tooth structure . and if you have a filling (core

material for example) you don't put the finish line on it,why?

Because of microleakage & possible fracture of amalgam

restoration .

Note : If there is root caries & it's part of your preparation

you need to clean the decay , but if it's not so you fill it & put

the margin on top of that .

D) existing restorations : Do you need to remove all

restorations from teeth need crowning ? yes , to see if we

have pulp exposure & caries .

THE INFLUENCE OF MARGINS OF RESTORATIONS ON

THE PERIODONTAL TISSUES (over 26 years) :

Sub gingival margins means persistent increased inflammation

means loss of attachment means pocketing & recession .

Then your default is ----------- unless ------------- (2 marks)!!!!

(kolko elko 3alamten bs ma ba3raf meen ra7 y36eeko yahom!!)

If you want to encroach the gingival sulcus your maximum

extention is 0.5mm , this is more achievable in upper posteriors

than upper anteriors (esthetic teeth) because gingival sulcus is

deeper in esthetic teeth .

CONTOUR :

What shape should restoration be ? when you prepare a crown

for a tooth you need to prepare a mini-tooth ; the same shape

of the tooth which will be crowned most likely , ( same

cusps,pits,fissures….) .

EMERGENCE PROFILE :

This term was defined as the contour of the restoration at

the point of emergence from the gingival sulcus , they

suggested that if the emergence profile was not correctly

established , all other contours of the crown would be

incorrect .
:‫ﺑﺎﻹﻧﺠﻠﻴﺰي اﻷردﻧﻲ‬
Ideally your crown should not emerge underneath the gum , it

should emerge from supra gingival ,however, if you want to

emerge it from underneath the gum (sub-gingival level) that

means the way it will emerge will exit from the gingival sulcus ,

it should be the same like the original tooth , this is called

EMERGENCE PROFILE .

Imagine your restoration emerge wrongly at the point of

gingival margin , then the rest of the contour (at the contact

area,occlusally ….) would be wrong .

In natural dentition what's the shape of emergence profile?

When it emerges from CEJ upward it's straight , then start to

increase in width to make proper contour .

FROM THE HANDOUT : it has been suggested that the ideal

emergence profile would be flat or even a slightly concave profile as this
best replicated that contour seen in emergence of natural teeth from the
gingival sulcus .

TOOTH PROTECTION THEORY :

Before 40 or 50 years they told people that you need to create

the restoration bulky as it emerge from the gum area to

protect the gum from food .

Refer to slide 2 page 5 : when patient eats food will be

directed as the direction of arrows in the figure , so if you

have bulge , they believed that food won't fall on gingival

margin by this it will be protected from trauma comes from

food .

SO WE NEED TO RECREATE THE CONTOUR OF THE TOOTH

LIKE THE ORIGINALL ONE TO AVOID FOOD STAGNATION

AREA .

Slide 3 page 5 : see how central incisors appear, the same

from the top to the bottom , this will lead to food stagnation.

If you remove this bridge you will see this very nice healthy

gum !!!!!!!!!

(all of this we think about it only when we talk about sub-

gingival margin)

WHEN DO YOU CREATE OVERCONTOURED

RESTORATIONS ? WHEN YOU PREPARE LESS THAN

NEEDED . for example you should cut 1.2mm from tooth for

MCC , if you cut only 0.5mm then when the technician fabricate

the restoration , he will make it overcontoured .

‫اﻋﺬروﻧﻲ هﻮن ﻓﻲ أﺷﻴﺎء ﺣﻜﺎهﺎ اﻟﺪآﺘﻮرﻋﺸﺎن ﻳﻮﺿﺢ اآﺜﺮ ﺑﺲ ﻣﺎ ﻗﺪرت أﺳﻤﻌﻬﺎ وأآﺘﺒﻬﺎ‬
KEYS TO PERIODONTALLY SUCCESSFUL INDIRECT

RESTORATIONS :

1- start with healthy tissue :you should not start fabricating

a restoration for patient has gingivitis, periodontitis or

whatever , you need first to send him to the perio. Clinic .

2- adequate tooth preparation , why ? to avoid overcontour

3- precise margin location : proper & clear margin or finish line

4- excellent provisional (temporary) restorations : one aim is to

let the gingival heal before placing the permanent restoration .

5- careful tissue handling & impression technique :

Refer to slide 6 page 5 : tissue management in impression

making :

Usually we pick our impression with additional silicone

materials( hydrophobic materials ) , if your finish line is very

close to the gum ( which is a source of fluids ;gingival

crevicular fluid GCF ) so the fluid will prevent the impression

material to come close to the finish line & pick it up , if it's

difficult for the impression material I need to make it easier

HOW ? If I push the gum away to prevent GCF to come out to

the finish line so I can pick up my impression properly . but

HOW TO PUSH THE GUM AWAY ?

We have many procedures , the most common is to insert a

piece of cord in the gingival sulcus , this will mechanically push

the gum away so it will retract the gum from the finish line, for

this reason they are called : retraction cords (comes in

different sizes the minimum is 00 then 0 , 1, 2 , 3) .

Sometimes we could impregnate the cord in fluid , the

impregnating material we use is HEMOSTAT ( the brand name

of : ferric sulfate , aluminium sulfate , aluminium fluoride ), it's

a vasoconstrictor .

DAMAGE FROM FIXED PROSTHODONTICS :

1- plaque retention :

a) contour of retainers & pontics is a problem .

b) location & fit of restoration margins

if restoration margins are very deep …………

☺ ! ‫اﻟﺪآﺘﻮر ﺑﻌّﺪ ﻋﻦ اﻟﻤﺎﻳﻚ ودﻳﻤﺎ ﻗﺤّﺖ ! ﺻﺤﺔ دﻣﺪم‬،‫ﺑﻌﺪﻳﻦ ﻣﺎ ﺳﻤﻌﺖ اﺷﻲ‬
2- unfavourable transmission of occlusal forces

3- pulp damage how ? during the preparation .

DAMAGE FROM RPD's :

1- plaque retention : it's very recommended to make the RPD or

the major connector away from gingival margins .

2- unfavourable transmission of forces : it's more with RPD

than FP .

3- direct trauma from components : it's more in RPD

FROM A PERIODONTAL PERSPECTIVE , FIXED

PROSTHESES ARE USUALLY PREFERABLE .

Wa 2a5eeran kammalna , ya36eena l3afye

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