Romanian Journal of Medical and Dental Education

Vol. 8, No. 8, August 2019 EVALUATION OF THE RELATIONSHIP BETWEEN PROSTHODONTICS AND PERIODONTICS. A REVIEW

Odette-Elena Luca1, Ioana Martu1*, Ionut Luchian2*, Elena Luca1, Dragos Virvescu1, Vladina Andronache2,3, Monica Tatarciuc1, Silvia Martu2 1”Grigore T. Popa” University Medicine and Pharmacy, Faculty of Dental Medicine, Department of Prosthodontics, Iasi, Romania. 2”Grigore T. Popa” University Medicine and Pharmacy, Faculty of Dental Medicine, Department of , Iasi, Romania. 3 PhD. Private Practice, Iasi, Romania.

*Corresponding author: Martu Ioana [email protected] Luchian Ionut: [email protected]

Abstract

This article was aimed at addressing the key relationship between prosthodontics and periodontics. The impacts of healthy periodontium on longevity of prostheses were addressed. The interdisciplinary approach has been a trend for a comprehensive dental treatment. Within modern , periodontics and prosthodontics share an intimate and inseparable relationship in multiple aspects, including treatment plan, procedures execution, outcome achievement and maintenance. By controlling inflammation and preparing sites for proper prosthetic prostheses, periodontists no doubt can provide a solid foundation for successful prosthetic outcomes. On the other hand, prosthodontists could construct proper restorative margin, shapes and contacts that benefit the harmony of periodontium and prosthesis. Keywords: Periodontics, restorative, prosthodontics, biologic width.

Introduction involvement, tooth mobility, the severity of bony destruction, etc. This review attempted to address Through identifying the etiology the key relationship between periodontics and contributing factors of periodontal and prosthodontics. Of all disciplines diseases, these prognositication systems within modern dentistry, periodontics and indicate the possibility of tooth prosthodontics have the strongest and the sustainability in short term and long term. most intimate connections. For As an integral portion of dental practice, prosthodontics, periodontal health plays an determination of individual teeth prognosis important role on the longevity of allows a virtual approach on restorations. interdisciplinary conversation for Prior to treatment plan, tooth treatment strategies. prognosis should be addressed both on The signs of active periodontal individual tooth and the overall dentition. inflammation include pocket formation, Several periodontal prognositication the presence of bleeding on probing or systems have been introduced based on suppuration, and tissue changes of gingiva. either periodontal stability1 or certain In addition, periodontal inflammation parameters [1-4], such as furcation results in soft tissue changes in terms of 51

Romanian Journal of Medical and Dental Education

Vol. 8, No. 8, August 2019 texture, color, size and gingival and retention of food debris and consistency. It then leads to impaired determination invasion of “biologic esthetic outcomes by deteriorating the width”may also result in periodontal harmony between periodontium and inflammation. prosthesis. In addition to inflammation Biologic width. control, periodontists could offer a hand The dimension of dentogingival for soft and hard tissue management to complex, called "biologic width ", is a prepare sites for successful prosthetic cuff-like barrier that acts as a protective treatments. physiological seal around natural teeth. It Regular periodontal maintenance is possesses a selfrestoration capacity and a key to reduce the incidence of tooth or dynamic adaptability. The mean distance implant loss following prosthetic therapy. of epithelial and connective tissue Due to limitation of routine home cares, components are 0.97mm and 1.07mm, regular professional maintenance therapy respectively. However, the dimension is plays a key role on reduction of dynamic in particular the epithelial periodontal inflammation induced by attachment, varying from individuals [5]. plaque accumulation, especially in the Similar to natural teeth, a subgingival space. consistent width of peri-implant mucosa For those patients who had history was found adhering to the surface of the of periodontitis, regular supportive implant abutment. Histologically, it periodontal therapy is even more prevents further supragingival plaque beneficial to prevent further disease formation via a zone of healthy connective progression. Previous studies showed that tissue separating the inflammatory cell sites with treatment but without infiltration and alveolar bone crest [6,1]. maintenance had a 2 times higher tooth The violation of biologic width has been loss than the sites with regular widely discussed as a contributing factor maintenance after periodontal treatment which jeopardizes periodontal health [7,8]. [2,3]. A recent study even showed a 3 time Biologic width invading could result from higher tooth loss in the irregular compliers several reasons, such as extensive caries, comparing with patients with regular subgingival restorations, short clinical maintenance over a 5-year observation , and teeth fracture. period. In other words, regular compliance Clinically, the signs of biologic of periodontal maintenance is the key to width violation consist of pain, gingival prevent the recurrence of periodontal inflammation, localized gingival diseases and to maintain the integrity of hyperplasia, pocket formation, and loss of treatment outcomes8. periodontal apparatus. From periodontal

point of views, several parameters should The impacts of prosthetic factors be taken into account for the feasibility of on periodontal health this surgery: esthetics, possible exposure Prostheses should be carefully of furcation involvement, remaining bony designed and performed, in harmony with support and crown/ root ratio for the future the surrounding periodontium, to maintain results. periodontal. Defective restorations Postoperatively, final prostheses contribute to disease progression by should only be delivered once the tissue increasing accumulation of dental plaque maturation was completed. A minimum of 52

Romanian Journal of Medical and Dental Education

Vol. 8, No. 8, August 2019 6-8 weeks of healing period is highly (2.4%) in the patients with initiate recommended following surgical crown periodontitis [11]. lengthening that without bone resection. In spite of an indirect relationship between Hence, communication prior to treatments open contact and periodontal between periodontists and prosthodontists inflammation, it could be speculated from is essential to determine the treatment these studies that food impaction timeframe, feasibility of surgery and the contributes to increasing pocket depth and locations of restorative margins. clinical attachment level. Thus, clinicians The clinical significances of effects should avoid to place open contacts on marginal bone preservation may be between fixed prostheses. Meanwhile, questioned. In conclusion, the available through proximal cleaning should be data remained controversial and further addressed to patients. longitudinal studies are still needed. Restoration contours

Adequate crown contours could Proximal relationship provide protection of gingival margins, Embrasure types, referring both allow cleansing action of the musculature horizontal and vertical dimensions of the and facilitate the access for interproximal spaces, show impacts on the [12]. Indeed, overcontour may have presence of interproximal papilla. Loss of negative influence on periodontium since interproximal papilla results in impaired it increases plaque retention [13,14]. esthetics and promotion of food impaction, Utilizing acrylic facings as standard aggravating periodontal destruction. As for overcontour, Sackett and Gildenhuys the distance from contact point to the compared tissue changes at 42 pairs of alveolar crest, the maximum of the experimental and control sites (adjacent distance should not exceed more than 5mm teeth) over a period of 42-49 days. 59% of to preserve the interdental papillae in mandibular test sites and 70% of maxillary natural dentition [9]. test sites showed significant gingival Contact types between prostheses inflammation in relation to overcontour. may also play a role on periodontal health. Besides, more than 50% of these The relationship between open contacts sites had increasing amount of gingival and periodontal destruction has been a sulcular fluid compared with their controls controversial issue since last century. To [15]. Restorative overhang is also verify the impacts of open contacts on considered as a contributing factor of periodontium, Jenberg and colleagues periodontal diseases. As a prevalent type conducted a cross-sectional study enrolling of restorative defects [16], filling excess 104 patients with unilateral open contacts. may aggregate the plaque accumulation In addition to greater prevalence of food which potentiates gingival inflammation impaction, the sites with open contacts and worsen the periodontal status [17,18]. presented greater pocket depth and clinical Meanwhile, inadequate crown reduction attachment loss although there was no for the restorative material should be significant difference for gingival index, avoided to prohibit the overcontoured bleeding and calculus index between crown. contact types [10].

Moreover, another cross-sectional The location of restorative study reported an increase of bone loss margins 53

Romanian Journal of Medical and Dental Education

Vol. 8, No. 8, August 2019 Restorative margin locations (AAP) positioned paper suggested a 3mm should be established based on several of subgingival penetration or 50% of the factors, including extension of caries, probing depth [26]. To prevent periodontal retention/resistance forms, and esthetics. destruction, in conclusion, supragingival Using free gingival margin as the restorative margins are highly references, the supra- and subgingival recommended at the sites with less esthetic restorations have their own pros and cons. concerns. Adequate daily home care needs With respect to periodontal health, the to be addressed to patients and regular supragingival restoration is the most professional maintenance is necessary. favorable design since it is easy to be cleaned [19]. In addition to tissue biotype, Trauma from subgingival restorative margins may be As a functional unit, the tooth and harmful to periodontium tissues because of its supporting structures bear the brunt of the following reasons. occlusal forces on the crown. In response First, the margin has higher risk of to occlusal forces, the attachment BW invasion, enhancing further apparatus may experience tissue changes, periodontal destruction. A strong positive including injury, repair and adaptive correlation was found between gingival remodeling of the periodontium. inflammation and the subgingival The role of TFO plays in extension of restorative margins [20]. The periodontal/ peri-implant diseases remains limited access is another possible cause controversial, clinicians should perform when restorative margins are placed prosthetic treatments with caution to avoid subgingivally. In particular amalgam or failure following TFO. As a result of composite resin fillings, it is difficult for excessive force or reduced periodontal operative to polish restorations supports, teeth under TFO or occlusal and thereby produce rough surfaces trauma showed following clinical underneath gingiva. characteristics: tooth pain, increasing tooth Investigating the amounts of mobility, sensitivity to percussion, undetected cement following cleaning, fremitus, occlusal wear and even tooth Linkevicius and coworkers found fracture. significantly greater cement remnants were The radiographic changes consist linked to deeper subgingival margin of PDL space widening, disruption of the positions. lamina dura, root resorption and peri- The lack of perpendicular fiber apical or furcation radiolucency [27]. attachment around dental implants may Ultimately, the patient is highly even facilitate the apical migration of recommended to wear the occlusal splint cement excess and worsen the tissue to prevent the recurrence of biomechanical inflammation [21] complications. The penetration depths of plaque control methods for homecare is within 1-3mm Gingiva retraction technique: the subgingivally, such as mouth rinsing [22], effects on soft tissue toothbrush [23,24] and interproximal An acceptable impression was cleaning [25]. needed to avoid improper marginal In regards to subgingival irrigation, adaptation that may cause periodontal American Academy of Periodonotology tissue inflammation or the risk of recurrent

54

Romanian Journal of Medical and Dental Education

Vol. 8, No. 8, August 2019 caries. Management of the gingival tissue conventional and cordless techniques. The is essential for obtaining acceptable results demonstrated the cordless method impression especially for subgingivally was less stress for patients and resulted in located restorations [28]. Various gingival lower post-treatment levels of displace ment methods, such as inflammatory cytokines [32]. mechanical, chemomechanical and surgical are available. Conclusion Chemical agents as well as the The relationship between mechanical force of retraction cords could prosthodontics and periodontics is intimate trigger temporary gingival recession and and inseparable. Robust supporting gingival inflammation [29,30]. periodontal tissues provide solid It has been shown that the different time foundations for predictable prosthetic intervals of the chemical retraction agent therapy. In addition, regaining stable placement could cause different degree of periodontal conditions should rely on tissue inflammation changes in the establishment of proper contact types, beginning [31]. occlusal scheme and quality prosthesis. Hence, the proper manipulation Frequent and efficient communications are different gingival retraction techniques essential between periodontists and such as materials and time-control are the prosthodontists through the entire key factors to avoid permanent tissue treatment procedures, including plan, damage while impression-taking process is treatment procedures and maintenance, made. Furthermore, a randomized clinical since both share a common goal: trial was conducted to assess the clinical to create pleasing esthetic with a and immunological factors related to harmonious stomatognathic system.

References 1. Kwok V, Caton JG. Commentary: prognosis revisited: a system for assigning periodontal prognosis. J Periodontol 2007; 78: 2063-71. 2. Becker W, Becker BE, et al. Periodontal treatment without maintenance. A retrospective study in 44 patients. J Periodontol 1984; 55: 505-9. 3. Becker W, Berg L, et al. The long term evaluation of periodontal treatment and maintenance in 95 patients. Int J Periodontics Restorative Dent 1984; 4: 54-71. 4. McGuire MK, Nunn ME. Prognosis versus actual outcome. II. The effectiveness of clinical parameters in developing an accurate prognosis. J Periodontol 1996; 67: 658-65. 5. Gargiulo AW, Wentz FM, et al. Dimensions and Relations of the Dentogingival Junction in Humans. J Periodontol 1961; 32: 2617 6. Berglundh T, Lindhe J, et al. The soft tissue barrier at implants and teeth. Clin Oral Implants Res 1991; 2: 81-90. 7. Tal H, Soldinger M, et al. Periodontal response to long-term abuse of the gingival attachment by supracrestal amalgam restorations. J Clin Periodontol 1989; 16: 654-9. 8. Padbury A, Eber RJr, et al. Interactions between the gingiva and the margin of restorations. J Clin Periodontol 2003; 30: 379-85. 9. Tarnow DP, Magner AW, et al. The effect of the distance from the contact point to the crest of bone on the presence or absence of the interproximal dental papilla. J Periodontol 1992; 63: 995-6. 10. Jernberg GR, Bakdash MB, et al. Relationship between proximal tooth open contacts and periodontal disease. J Periodontol 1983; 54: 529-33. 11. Koral SM, Howell TH, et al. Alveolar bone loss due to open interproximal contacts in periodontal disease. J Periodontol 1981; 52: 447-50. 55

Romanian Journal of Medical and Dental Education

Vol. 8, No. 8, August 2019

12. Becker CM, Kaldahl WB. Current theories of crown contour, margin placement, and pontic design. J Prosthet Dent 1981; 45: 268-77. 13. Yuodelis RA, Weaver JD, et al. Facial and lingual contours of artificial complete crown restorations and their effects on the periodontium. J Prosthet Dent 1973; 29: 61-6. 14. Parkinson CF. Excessive crown contours facilitate endemic plaque niches. J Prosthet Dent 1976; 35: 424-9. 15. Sackett BP, Gildenhuys RR. The effect of axial crown overcontour on adolescents. J Periodontol 1976; 47: 320-3. 16. Arneberg, P, Silness J, et al. Marginal fit and cervical extent of class II amalgam restorations related to periodontal condition. A clinical and roentgenological study of overhang elimination. J Periodontal Res 1980; 15: 669-77. 17. Highfield JE, Powell, RN. Effects of removal of posterior overhanging metallic margins of restorations upon the periodontal tissues. J Clin Periodontol 1978; 5: 169-81. 18. Jansson L, Ehnevid H, et al. Proximal restorations and periodontal status. J Clin Periodontol 1994; 21: 577- 82. 19. Silness J. and periodontal health. Dent Clin North Am1980; 24: 317-29. 20. Newcomb GM. The relationship between the location of subgingival crown margins and gingival inflammation. J Periodontol 1974; 45: 151-4. 21. Linkevicius T, Vindasiute E, et al. The influence of the cementation margin position on the amount of undetected cement. A prospective clinical study. Clin Oral Implants Res 2013; 24: 71-6. 22. Pitcher GR, Newman HN, et al. Access to subgingival plaque by disclosing agents using mouthrinsing and direct irrigation. J Clin Periodontol 1980; 7: 300-8. 23. Waerhaug J. Effect of toothbrushing on subgingival plaque formation. J Periodontol 1981; 52: 30-4. 24. Youngblood JJ, Killoy WJ, et al. Effectiveness of a new home plaque-removal instrument in removing subgingival and inter proximal plaque: a preliminary in vivo report. Compend Contin Educ Dent 1985; 6: S128-32, S141. 25. Waerhaug J. The interdental brush and its place in operative and crown and dentistry. J Oral Rehabil 1976; 3: 107-13. 26. Greenstein G. Position paper: The role of supra- and subgingival irrigation in the treatment of periodontal diseases. J Periodontol 2005; 76: 2015-27. 27. Parameter on Occlusal Traumatism in Patients With . J Periodontol 2000; 71: 873-5. 28. Bennani V, Schwass D, et al. Gingival retraction techniques for implants versus teeth: current status." J Am Dent Assoc 2008; 139: 1354-63. 29. Donovan TE, Gandara BK, et al. Review and survey of medicaments used with gingival retraction cords. J Prosthet Dent 1985; 53: 525-31. 30. Feng J, Aboyoussef H, et al. The effect of gingival retraction procedures on periodontal indices and crevicular fluid cytokine levels: a pilot study. J Prosthodont 2006; 15: 108-12. 31. Ahmadzadeh A, Majd NE, et al. Inflammatory response of canine gingiva to a chemical retraction agent placed at different time intervals. Dent Res J (Isfahan) 2014; 11: 81-6. 32. Sarmento HR, Leite FR, et al. A double-blind randomised clinical trial of two techniques for gingival displacement. J Oral Rehabil 2014; 41: 306-13.

56