PERIO-PROSTHO LITERATURE REVIEW SUMMARY

Prepared by: Mashael Abuabat - 2017

CLASSIFICATION & DIAGNOSIS OF PERIO DISEASES/CONDITIONS

New Classification for Periodontal Diseases and Conditions:

Differs from the classification system developed at the 1989 World Workshop in Clinical Periodontics:
Development of a Classification § Addition of a Section on "Gingival Diseases"
System for Periodontal Diseases and § Replacement of "Adult Periodontitis" With "Chronic Periodontitis"
Conditions § Replacement of "Early-Onset Periodontitis" With "Aggressive Periodontitis"
§ Elimination of a Separate Disease Category for "Refractory Periodontitis"
Armitage - 1999 - Periodontology
§ Clarification of the Designation "Periodontitis as a Manifestation of Systemic Diseases"
§ Replacement of "Necrotizing Ulcerative Periodontitis" With "Necrotizing Periodontal Diseases"
§ Addition of a Category on "Periodontic-Endodontic Lesions"
§ Addition of a Category on "Developmental or Acquired Deformities and Conditions"

Reasons to consider periodontal diseases as infections:

- Bacterial etiology - Immune response - Bacterial products in tissues - Bacterial invasion of tissues
- Tissue destruction - Rubor (redness), calor (heat), dolor (pain) - Sometimes loss of function

Periodontal Diseases:
Advances in Periodontal Disease Ø Adult periodontitis (Affects patients 35 years or older; microbial deposits; no systemic illness)
Diagnosis Ø Juvenile periodontitis (Circumpubertal; neutrophil dysfunction; affects first molars & incisors)
Ø Pre-pubertal periodontitis (Generalized; neutrophil dysfunction; affects deciduous dentition)
Greenstein - 1990 - IJRD Ø Rapid progressive periodontitis (Young adults; rapid, progressive; neutrophil dysfunction)
Ø Refractory periodontitis (Does not respond to conventional therapy)
Ø Gingivitis (Isolated or generalized; endemic; redness, bleeding upon probing)
Ø ANUG (Necrosed papilla; gingival pain)

Diagnostic Signs of Periodontal Disease:

1. Probing 2. Bleeding upon probing 3. Mobility 4. Keratinized tissue 5. Bone assessments
6. Culturing 7. Crestal lamina dura 8. DNA probe 9. Microbiological eval 10. Microscopic
11. Biochemical assays 12. Immunological testing 13. Nuclear medicine 14. Subtraction radiography
 Diagnosis using standard clinical parameters & application of conventional methods will result in health
Most patients manifesting periodontal pathosis will not require laboratory assays
The need for testing becomes critical when therapy fails to improve periodontal status

Criteria of Accuracy of Radiographs:

1. Tips of molar cusps recorded with little or none of the occlusal surface showing
2. Open interproximal spaces (contacts do not overlap Unless teeth are out of line anatomically)
3. Distinct enamel caps & pulp chambers
Interpretation of Radiographs in
Periodontics Information that Can be Obtained Only from Radiographs:
1. Root length & morphology 2. Approximate gross amount of bone destruction
3. Clinical-crown-to-clinical-root ratio 4. Most coronal position of bone in the septal regions
Prichard - 1983 - IJRD 5. Position of the maxillary sinus in relation to the periodontal deformity
6. Condition of alveolar bone & periodontal space on the mesial, distal & apical aspects of the root

Information that Cannot be Obtained Only from Radiographs:

1. Existence or absence of periodontal pockets 2. Morphology of bone deformities
3. Soft-to-hard tissue relationship 4. Tooth mobility
5. Position or condition of structures on the buccal, labial & lingual aspects of the tooth

A) Normal Physiologic Tooth Mobility:

Allowed by the resilience of the periodontium
The resistance of the periodontal tissue to tooth displacement increases progressively
Tooth Mobility and Periodontal The mechanism involves simultaneously interaction of:
Disease 1. Fibers 2. Blood vessels 3. Interstitial fluid displacement 4. Bone deformation
Giargia & Lindhe - 1997 - J Clin B) Altered Tooth Mobility:
Periodontol
I- Trauma from Occlusion:
Characteristic:
1. Widened PDL space 3. Vascular alterations & degenerative changes in PDL
2. Osteoclastic alveolar bone resorption 4. Increased vascularity & reduced collagen content
5. Reduced number of inserting collagen fibers
 Removal of Causative Agents Results in Recover of:
1. Normal tooth mobility values 2. Radiographic width of the PDL space
3. Complete reorganization of the soft and hard periodontal tissues

II- Periodontal Disease:

Associated with:
quantitative (bone & CT loss) & qualitative changes (inflammatory alterations in soft tissue)
Periodontally diseased teeth showed higher TM values also when small loads were used
Increased mobility is not always found at teeth showing severe periodontal breakdown

“Clinically Healthy Periodontium”

Denotes lack of clinically detectable inflammation, stable clinical attachment levels & is often associated
with shallow probing depths

Probing depth assessment used to determine the need for therapy can be misleading (because it is
possible to have healthy deep sulci). Increasing probing depth reflect progressive periodontitis unless
they can be attributed to coronal migration of the gingiva or measurement error
Clinical attachment levels are the most accurate way to monitor patients
Contemporary Interpretation of
Probing Depth Assessments:
Reproducibility of Probing Depth Assessments:
Diagnostic and Therapeutic
Prior to therapy, assessment of deep probing depths was associated with increased measurement error
Implications. A Literature Review
After therapy, probing depths were more reproducible (resolution of inflammation & reduced probing
depths after treatment)
Greenstein - 1997 - J Periodotol
Relationship Between Bleeding Upon Probing and Probing Depth:
Direct relationship between the prevalence of bleeding upon probing & increased probing depth
Deep probing depth bleed more frequently upon probing than shallow site

The two most commonly used parameters to characterize a patient as having Periodontitis:
Measurements of probing depth & clinical attachment loss

Meticulous oral hygiene can influence subgingival microflora in shallow & moderately deep pocket but
were not altered in deep pockets >5mm

Scaling & root planning of periodontitis lesion usually result in probing depth reduction due to either
gain of clinical attachment or recession
 Probing Reproducibility:
Varies between patients & for different sites within patients
Differing probing forces lead to different amounts of penetration of the probe tip into the tissues
Gold standard - clinical and Tendency for examiners to round off readings to nearest millimeter is a source for magnification & errors
radiographical assessment of disease Angulation of probing is a source of eproducibility error
activity
Radiographic Method:
Claffey - 1997 - J Periodotol Cannot reflect bony morphology buccally & Iingually
Can provide information on interproximal bone levels

The Golden Rule (Bernard Shaw): “There are no golden rules”

Lang et al - 1997 Any force greater than 0.25 N may evoke bleeding in healthy sites with an intact periodontium

RATIONAL & GOALS OF PERIODONTAL THERAPY

The Present Approach to Periodontal Therapy:

Control of the infection & regeneration of the lost periodontal support whenever feasible

Parameters to be considered during re-evaluation:

1. Tissue characteristics (color & form) 2. Tissue tone (how easy it is to probe)
3. Presence of subgingival plaque & calculus 4. Clinical probing depth & attachment levels
The rationale for periodontal therapy 5. Bleeding & exudates (their absence is most significant as a sign of periodontal health)
Caffesse et al - 1995 - Periodotology Periodontal Therapy:
I. Systemic phase
II. Hygienic phase
(Scaling & root planning, antimicrobial agents, extraction of hopeless teeth & caries control)
III. Corrective phase
(Occlusal, surgical & restorative)
IV. Supportive phase
All patients receiving periodontal therapy require constant follow-up generally between 3-4 months
 MULTILEVEL RISK ASSESSMENT:

A) Subject risk assessment

Periodontal Diagnosis in Treated 1. Systemic disease 2. Environmental exposures 3. Patient’s age
Periodontitis. Why, when, and how to 4. Oral hygiene 5. Compliance with recall
use clinical parameters
B) Tooth risk assessment
Lang & Tonetti - 1996 - Clin 1. Tooth position within the arch 2. Mouth breathing & extreme overjet 3. Iatrogenic factors
Periodotol 3. Residual periodontal support & mobility 4. Variations of tooth morphology & furcation involvement

C) Site risk assessment

(Clinical utility of the risk assessment allows determination of recall frequency)

Attstrom & Van der Velden - 1994 Classified Periodontal Conditions to:
I. Gingivitis II. Adult periodontitis III. Early onset periodontitis IV. Necrotizing periodontitis

DEFINITIONS:
Determinants “Risk factors that cannot be modified”
Risk factor “Risk factors that can be modified”
Risk indicator “A possible factor associated with a disease”
Risk marker “Predictive risk factor associated with an increased probability of disease in the future”

DETERMINANTS:
Current View of Risk Factors for
1. Age (More periodontal disease in older age groups)
Periodontal Diseases
2. Race (No differences between African-American & whites)
3. Gender (Male gender is associated with more severe periodontal disease)
Genco - 1996 - J Periodontol 4. Socioeconomic status (No relation between Socioeconomic status & periodontal disease)

RISK FACTORS OR INDICATORS:

1. Periodontal microflora (P. intermedia, B. Forsythus, P. intermedia)
2. Diabetes Mellitus (Subjects with diabetes had higher prevalence of periodontal disease)
3. Smoking (increase the risk by 2-7 times)
4. Stress (not associated with periodontal disease)
 PROGNOSIS VERSUS ACTUAL OUTCOME

ASSIGNING PROGNOSES BASED ON CLINICAL & RADIOGRAPHIC FINDINGS:

I. Good Prognosis: (one or more of the following)
Adequate periodontal support & control of the etiologic factors
II. Fair Prognosis:
Attachment loss to point that the tooth could not have a good prognosis or Class I furcation involvement
III. Poor prognosis:
Moderate attachment loss with Class I or Class II furcations
III. Questionable Prognosis:
Severe attachment loss resulting in a poor crown-to-root ratio, Poor root form,
Prognosis versus actual outcome: A Class II furcations not easily accessible to maintenance care or Class III furcations,
long-term survey of 100 treated 2+ mobility or greater & Significant root proximity
periodontal patients under IV. Hopeless prognosis:
maintenance care Inadequate attachment to maintain the tooth in health, comfort & function

McGuire - 1991 - J Periodontol Only the good prognosis category stayed relatively stable over time
Fair & poor categories improved
Questionable category generally got better, but a significant number of teeth were lost
Hopeless teeth either improved or were lost (never retained a questionable prognosis)

Mandibular molars & mandibular 2nd premolar tended to maintain worse than expected
Maxillary cuspid & mandibular teeth from 1st bicuspid to 1st bicusbid maintained better than expected
Maxillary lateral incisor performing worse while maxillary central incisor performing better
Results of maxillary arch were almost a mirror image of the results of the mandibular arch

Accurate prognosis was more difficult to make for teeth with an initial less than good prognosis

Prognosis Versus Actual Outcome The overall accuracy for teeth with less than "good" initial prognoses:
II. The Effectiveness of Clinical was 43% at 5 years & 35% at 8 years
Parameters in Developing an
Accurate Prognosis care Clinical Factors Related to Worse Prognoses:
1. Smoking 2. Probing depth 3. Furcation involvement 4. Root form 5. Malposition
McGuire - 1996 - J Periodontol 6. Diabetes 7. Parafunctional habit 8. Percent bone loss 9. Endodontic involvement
 Teeth with poor prognoses initially were 7 ½ times as likely to improve compared with fair prognoses
Teeth with questionable prognoses initially were 12 times as likely to improve when compared to fair

Smoking decreased the likelihood of improvement by 60%

Good hygiene increase likelihood of improvement by 2 ½ times that of teeth that had fair or poor hygiene

Prognosis Versus Actual Outcome III

The Effectiveness of Clinical In smokers 62% of the teeth were lost while 36% survived
Parameters in Accurately Predicting Age had little effect on tooth survival
Tooth Survival Type of bone loss had little effect on tooth survival
McGuire - 1997 - J Periodontol

LONG-TERM SURVIVAL STUDIES

Sample was divided on the basis of response to therapy into 3 groups:

1. Well-maintained (WM) group: lost 0 to 3 teeth
2. Downhill (D) group: lost 4 to 9 teeth
3. Extreme Downhill (ED) group: lost 10 to 23 teeth
A Long-Term Survey of Tooth Loss in
600 Treated Periodontal Patients Over the 22-year average period of maintenance, 7.1% of teeth were lost from periodontal causes

Hirschfeld & Wasserman - 1978 - J The total number of teeth were lost was 2.6% in the WM group, 22.7% in the D group & 55.4% in the
Periodontol ED group with higher percentages of non-questionable teeth lost

There was variation in pattern of tooth loss in different positions in the arch & bilateral symmetry

In all groups, 4 times as many repeated surgical procedures were done in mandibular arch as in maxilla

Questionable maxillary incisors were more resistant to loss (8.2% lost) than mandibular incisors (17.2%)
The greatest inflammation was found about Mandibular central incisors, lateral incisors & cuspids
The most resistant to loss that had greater survival after surgery were mand cuspids & 1st bicuspids
 Maxillary 2nd molars had the highest frequency of tooth loss between examinations
Mandibular 2nd molars were lost slightly less frequently
Maxillary & mandibular canines & mandibular central incisors had the lowest loss rate

The Long-Term Evaluation of Molars had the highest mean probing scores at the first examination
Periodontal Treatment and Anterior teeth had the lowest first examination scores
Maintenance in 95 Patients
FACTORS IN DETERMINING A PROGNOSIS:
Becker et al - 1984 - J Perio Rest Dent 1. Remaining supporting bone 2. Crown-root ratio 3. Root proximity
4. Health of adjacent teeth 5. Mobility 6. Restorative treatment plans

Periodontal therapy & maintenance are successful in reducing moderate to deep pockets with minimal
long-term bone loss

The average periodontal tooth loss rate was 0.29 teeth per patient over an average 12.9 year period

Tooth Loss in 1535 Treated Causes of Teeth Loss:

Periodontal Patients
1. Diabetes 2. Poor Oral Hygiene 3. Patients with Partials or Fixed Splinting
Nabers et al - 1987 - J Periodontol
Factors contributing in the Low Tooth Loss Rate:
1. Elimination of pockets (enable patients to control plaque) 2. Maintenance recall program 3-6 months

Factors that Play a Part in Determining Prognosis:

1) Pocket depth 2) Mobility 3) Furcation involvement 4) Anatomic aberration (tooth form or position)

Facial Pocket on Lower Molars:

Survival characteristic of periodontal 1st molar easily handled (if there is adequate vestibule & plenty attached gingiva). Same pocket on 2nd
involved teeth molar place this tooth in questionable category (shallow vestibule & prominent external oblique ridge)
Chace et al - 1993 - J Perio Furcal involvement of the Upper 1st Premolar:
A negative factor (progress beyond the beginning stage & perio therapy has no satisfactory solution on it)

Tooth Type:
Majority of periodontally involved teeth lost were maxillary molars (63.7%). Followed by mandibular
molars (20.0%) & maxillary premolars (7.3%)
 COMPARED PERIODONTAL THERAPIES

Surgical therapy produced greater & retained probing depth reduction than non-surgical therapy
A Review of Longitudinal Studies
That Compared Periodontal Plaque control alone either produced no change or a minimal reduction in clinical inflammation
Therapies Root planning with plaque control produced a much greater reduction

Kaldahl et al - 1993 - J periodontal Molars had a less favorable response

Furcation regions of molars responded less favorably to therapy than nonfurcation regions

SCALING:
“Removal of plaque, calculus & stain from crown & root surfaces”

ROOT PLANNING:
Removal of cementum or surface dentin that is rough or impregnated with calculus, toxins,
or microorganisms”

Scaling & root planning affected by:

Periodontal Response to Mechanical 1. Skill of the clinician 2. Time allocated for procedures
3. Inflammatory status of tissues 4. Anatomy of roots
Non-Surgical Therapy: A Review

Greenstein Assessment of changes in probing depths & clinical attachment levels should be made 3 to 4 weeks after
scaling & root planning

Reformation of a new dento-epithelial junction appeared to be completed within 2 weeks

Ultrasonic debridement was more effective than hand scaling in Class II & III furcation at reducing
spirochetes & motile rods

if signs of inflammation persist after non-surgical care then surgical access may be necessary
Non-surgical therapy frequently was sufficient to resolve inflammation & arrest Periodontitis

it is often difficult to remove plaque & calculus when probing depths exceed 5 mm
 Dimensional Alteration of the Compared baseline & six-month examinations of probing attachment levels:
Periodontal Tissues Following Sites with initially shallow < 4 mm pockets tended to lose on between 1 & 2 mm of attachment
Therapy Sites with 4 to 6 mm pocket depth, gained probing attachment between 0.5 & 1.2 mm
Sites with initially deep pocket > 6 mm, gained probing attachment between 1.8 & 2.8 mm
Lindhe - 1987 - Int J Perio Rest Dent

PERIODONTAL OSSEOUS SURGERY

Treatment of deep and shallow With GTR, most of the sites gained 2 mm or more of attachment with no attachment loss observed in any
intarbony defects. A multicenter of the treated cases
randomized controlled clinical trial
Clinical attachment level gains & probing pocket depth reductions in GTR with bioresorbable barrier
Cortellini - 1998 - J Clin Periodontal membranes treated sites were greater than those observed in sites treated with the access flap alone

CRATERS TYPES:
I. Shallow 1mm to 2mm deep II. Medium 3mm to 4mm deep III. Deep 5mm or more

ROOT TRUNK TYPES:

I. Short root trunk II. Average root trunk III. Long root trunk
(Determined by amount of bone coronal to the furcation)

MANAGEMENT OF CRATERS IN THE MAXILLARY MOLAR AREA:

Primer for Osseous Surgery

Ochesenbein - 1986 - Int J Perio Rest Shallow Craters:

Managed from the palatal aspect only (Marginal bone on the buccal aspect will remain intact)
Management is the same for short, average & long root trunk

Medium Craters:
Cannot be managed by palatal approach alone and will require buccal osseous procedures

MAXILLARY PREMOLARS:
Maxillary 1st premolar is a challenging tooth to manage than 2nd premolar
(Proximity of mesial furcation to the CEJ & frequently bifurcated)
 Positive Architecture:
“Scalloped architecture of interdental bone height coronal to the radicular bone”
Reversed Architecture:
“Existed when interdental papilla is apical to the buccal & lingual marginal gingiva”

Vertical Grooving:
Gradual diminishing of interdental bone height as the transition is made from anterior to posterior

Anatomy & Classification of Furcation Involvement

Root Trunk Concavity:

“Broad, gently curved depression located between the root prominences”
Root Trunk Groove:
“Narrow elongated & well defined developmental depression that lead toward the area of root separation”
Root Trunk Dimension Of 5 Different Root Trunk Characteristics of Maxillary Teeth:
Tooth Type Maxillary mesial & distal root trunks were longer than buccal root trunks
Maxillary 2nd molar buccal root trunks were longer than maxillary 1st molar buccal trunks
Kerns - 1999 - Int J Perio Rest Dent 1st molar Buccal root trunk 4.11, Mesial root trunk 4.73, Distal root trunk 4.66

Root Trunk Characteristics of Maxillary teeth:

Mandibular lingual root trunks were longer than buccal root trunks
CEJ to buccal groove 1.16, CEJ to lingual groove 1.22

Grant et al Divided Furcation Into 3 Parts: 1. Root trunk 2. Furcation roof or dome 3. Root separation

Maxillary 1st Molar Teeth:

The deepest concavity was in the furcal aspect of the mesio buccal root (mean concavity 0.3 mm)
Furcation Morphology Relative to Furcal aspect of the root was concave in 94% of mesiobuccal roots, 31% of distobuccal & 17% of palatal
Periodontal Treatment
Furcation Root Surface Anatomy Mandibular 1st Molar Teeth:
Deeper concavity in mesial root (mean concavity 0.7 mm) than the distal (mean concavity 0.5 mm)
Bower - 1979 - J Periodontol Concavity of the furcal aspect was found in 100% of mesial roots & 99% of distal roots
Wider root separation is associated with larger furcation entrance diameter
 Distribution of Cementum over the Furcal Aspects of the Roots:
Cementum distribution was not uniform

ROOT TRUNK:
“Part of the root that extends from CEJ to the area of root separation”

Long root trunk & short root anatomy has a more favorable prognosis during early furcation
involvement (if the furcation becomes diseased, the prognosis is often poor)

Multi-rooted teeth with short root trunks have the highest furcation involvement 75%, but are the best
Anatomic Considerations in the candidates for respective procedures (longer root)
Etiology and 01 Maxillary and
Mandibular Molars with Furcation Distal furcation have a higher incidence of furcation involvements than mesial furcation in maxillary
Involvement molars (although more apically located, is more prone to earlier invasions than the mesial because of its
position directly beneath the interproximal contacting area)
Mardom-Bey et al - 1991 - Int J Perio
Rest Dent THREE CATEGORIES OF CERVICAL ENAMEL PROJECTION (CEP):
Grade I: Showing a change in the CEJ with enamel projecting toward the bifurcation
Grade II: Approaching the furcation, but not actually making contact with it
Grade III: Extending into the furcation

Grade I & Grade III projections were the most often observed
There are more CEPs in mandibular molars than in maxillary molars
Cervical enamel projections seem to be more prevalent in maxillary & mandibular 2nd molars

Bifurcation Ridge:
The incidence of bifurcation ridges has been found to vary from 70% to 73% in mandibular molars

Clinical Significance of Furcation Maxillary First Premolars:

Anatomy of the Maxillary First Frequency of bifurcation 37%
Premolar: A Biometric Study on
The mean length of the root trunk was calculated as 7.9 mm
Extracted Teeth
The minimum root length recorded was 10 mm & the maximum 17.1 mm
Joseph et al - 1996 - J Periodontol The mean furcation width was 0.71 mm & the mean root divergence 3.0 mm
 MANAGEMENT OF FURCATION INVOLVED TEETH

A retrospective analysis of the Evaluated a group of patients with teeth treated by hemisection and/or root amputation:
periodontal-prosthetic treatment of The main reasons for failure was other than periodontal disease (Endodontic reasons & caries)
molars with interradicular lesions It was possible to maintain good oral hygiene in patients with root amputations & hemisections
Carnevale - 1991 - IJPRD The inflammation resolved

Observed Patients who had been Treated with Root Resection:

Long-term evaluation of root-resected 8% had to be extracted due to recurrent caries & endodontic therapy (Low failure rate)
molars: A retrospective study The root resection should be performed after standard patient preparation (OHI, scaling & root planning)
Basten - 1996 - IJPRD Extraction & replacement by implant provide a more predictable long-term prognosis than retention of
natural tooth and root resection

Prognosis and mortality of root- Compared Tooth Mortality of Root-Resected Molars with that of Root-Filled Single Rooted Teeth:
resected molars Survival rates were 68% for root-resected molars & 77% for root-filled single rooted teeth over 10-year
(Not statistically significant) Prognosis of root-resection is not poorer than prognosis of single rooted
Biofilm et al - 1997 - IJPRD teeth if endodontic conditions & maintenance care are optimal

A Lesion in the Inter-Radicular Area can be of:

a) Endodontic origin b) Occlusal origin c) Plaque-associated origin d) Combined origin

Anatomical Features Affecting Onset of Furcation Involvement & Outcome of Therapy:

Management of Furcation 1. Root concavities 2. Enamel projections 3. Root trunk length 4. Location of furcation entrance
Involvement
CLASSIFICATION OF FURCATION INVOLVEMENT:
Carnevale et al - 2000 - J Periodontol Degree I: Horizontal loss of periodontal support within the furcation area less than one third of the tooth's
buccolingual dimension
Degree II: Horizontal loss of support exceeding one third of the tooth's dimension but not exceeding the
total width of the furcation area
Degree III: Horizontal "through & through" destruction of the periodontal tissue in the furcation
 Tunnel Preparation:
Used to treat deep degree II or degree III furcation defects, especially in mandibular molars

CLASSIFICATION OF THE FURCATIONAL INVOLVEMENT:

Class I:
Incipient horizontal involvement just into the intraradicular area
No intraradicular horizontal bone loss

Class IA:
The Restoration of the Approximately the first one half of the initial one third of the buccolingual tooth dimension
Sectioned Molar Early intraradicular horizontal bone loss

Kastenbaum - 1986 - IPRD Class II:

Horizontal involvement beyond the intraradicular area but not into the middle one third of the tooth
Intraradicular vertical & horizontal bone loss; usually a crater

Class IIA:
Horizontal involvement into middle one third of the tooth but not beyond one half of the tooth dimension
Intraradicular vertical & horizontal bone loss; almost always a crater

Class III:
Horizontal involvement beyond one half of the buccolingual tooth dimension
Intraradicular vertical & horizontal bone loss; a more severe combination type of defect

Combined Therapy for Teeth With Therapeutic Possibilities According to the Degree of Furcation Involvement:
Furcation Involvement Used as Degree 1: Scaling, root planning, odontoplasty
Abutments for Fixed Restorations Degree 2: Periodontal surgery
Degree 3: Endodontocs, periodontics & fixed prosthodontics (integrated tx have shown a higher long-
Hurzeler - 1990 - Int J Pros term success rate than that obtained using other modalities)

Problems that may be Encountered During Root Resections:

Backman 1. Fracture of abutment teeth 2. Continued periodontal disease
3. Endodontic failure 4. Loss of luting agent
 DIFFERENTIATED BETWEEN 3 DEGREES OF FURCATION INVOLVEMENT:
1) Horizontal loss of supporting tissues not exceeding one third of the tooth width .
Lindhe 2) Horizontal loss of supporting tissues exceeding one third of the tooth width but not encompassing the
total width of the furcation area
3) Horizontal “through & through” destruction of the supporting tissues in the furcation area

ROLE OF GUIDED TISSUE REGENERATION

INDICATIONS OF GTR:
1. Class II furcation defects
Current status of guided periodontal 2. Two or three wall vertical interproximal
tissue regeneration 3. Circumferential intrabony osseous defects

Quistones - 1995 - JOP GTR is based on the type of healing resulting after periodontal surgery is determined by the tissues that
first repopulate the root surface by placing a physical barrier between the gingival flap & the root surface
during surgery (to exclude gingival epithelium & CT from the root surface & creates an area into which
progenitor cells from the periodontal ligament & the alveolar bone can migrate)

Clinical Objectives of Regenerative Therapy:

1. Increased bone height
2. Reduction in probing pocket depth (PPD)
3. Limiting recession of gingival margin
Periodontal Regeneration of Outcomes Desired by the Patient:
intrabony Defects: An Evidence 1. Decreased tooth mobility 2. Ease of Care 3. Esthetic 4. Comfort 5. Minimal morbidity
Based Treatment Approach 6. Stability of periodontal status
Cortellini & Bower - 1995 - IJPRD Systemic antibiotics should be prescribed for at least 1 week
Use of chlorhexidine 0.2% is recommended twice a day
Regenerated sites should not be debrided subgingivally or probed for l year
Restorative that requires placement of subgingival retraction cord not performed for 1 year
Supragingival restorations can be performed after 6 months
Recalls every 1 to 2 weeks for 2 months, then monthly recalls up to 1-year follow-up are recommended
 Surgical Modalities to Achieve Regeneration of Class II Furcation Defects:
A) Placement of iliac autografts, demineralized freeze-dried bone allografts (DFDBA) & composite grafts
B) Coronally positioned flap with root surface conditioning
C) Guided tissue regeneration (GTR) alone or in combination with bone replacement grafts (BRG)
Successful Regeneration of
mandibular Class II Furcation A combination of guided tissue regeneration & bone replacement grafts yielded better results than did
Defects: An Evidence-Based guided tissue regeneration alone in reducing probing depths and increasing vertical attachment levels
Treatment Approach
GTR resulted in greater reduction in probing depths & greater gains in vertical & horizontal attachment
Machtei & Schallhorn - 1995 - IJPRD levels compared to flap debridement

Root surface conditioning with citric acid had minimal or no effect in furcation defects

GTR used alone or in combination with bone replacement grafts, had the highest overall ranking
The treatment of choice for Class II furcation defects is GTR with bone replacement grafting or alone

Low-level radiation (less than or equal to 2.5 Gy) does not affect bone regeneration
Jacobsson et al - 1985 Higher doses of irradiation (5 Gy or more), resulted in significant reduction in bone regeneration

Metzler et al - 1991 Reported better results in buccal defects than in interproximal furcation defects due to better accessibility

2 & 3 wall intrabony defects have a significantly better response to GTR procedures (82% to 91% defect
Cortellini et al - 1993 fill) than do 1 wall defects (39% defect fill)

Caton et al - 1992 Most of the healing following GTR is completed within 3 months

CONCEPT OF BIOLOGIC WIDTH

CT Attachment:
Dimensions and Relations of the “The distance from the base of the epithelial attachment to the crest of the alveolar bone”
Dentogingival Junction in Humans The most constant (1.07 mm mean average length)

Gargiulo - 1961 - J Periodontol Epithelial Attachment:

The most variable part of the dento-gingival junction
 PHYSIOLOGIC DIMENSIONS OF PERIODONTIUM CLASSIFIED AS:
I. Superficial PD
Physiologic Dimensions of the II. Crevicular PD “Distance from free gingival margin to junctional epithelium”
Periodontium significant to the III. Subcrevicular PD “Distance from base of the gingival crevice to alveolar crest”
Restorative Dentist
How Much Gingiva is Adequate for Restorative Procedures?
Maynard - 1979 - J Periodontol 5 mm of keratinized tissue (2 mm of free gingiva & 3 mm of attached gingiva)
The minimum suggested depth for an intracrevicular margin is 1.5 to 2 mm

The Intracrevicular Restorative Indications of Intracrevicular Margin Placement:

Margin, the Biologic Width, and the 1. Cosmetics 2. Refinement of a preexisting tooth preparation when replacing existing restoration
Maintenance of the Gingival Margin 3. Root caries 4. Mechanical & technical retention
5. Root sensitivity 6. Teeth with severe cervical abrasion
Nevins & Skurow - 1984 - IJPRD
There is no apparent reason for more than minimal extension of 0.5 to 1 mm below the gingival crest

Probing Depth of Healthy Crevice:

Within the range of 0 to 3 mm but is frequently less than 1 mm

Biologic Width:
Considered to have a constant dimension of 2 mm
Used as a unit of measure for locating restorative margins with respect to the alveolar crest
Restorative margins and periodontal
health: A new look at an old Junctional Epithelium:
perspective The normal length of a junctional epithelium is 1 mm or less
Block - 1987 - JPD Oral epithelium proliferates & forms a new junctional epithelium in approximately 5 days

Restorative Margin Placement:

Not deeper than 0.5 mm into the sulcus (to be reached by the patient's hygiene efforts)
When restorative margins would terminate at or below alveolar crest, surgical CL is necessary
The distance from bone crest to tooth margin should be between 3 & 4 mm
Allow healing of the gingival margin before any final restorations are placed for at least 6 to 8 weeks

Gargiulo et al The average length of the junctional epithelium was 0.97 mm & average sulcus depth was 0.69 mm
 Youngblood et al Manual brush was effective to a depth of only 0.7 mm
Electric brush could reach plaque 1.4 mm below the gingival margin

Eissman et al Restorations should not be placed at or near the alveolar crest

There must be 2 mm of root surface between alveolar crest & restoration to provide for the biologic width

BIOLOGIC WIDTH:
“The combined dimension of CT attachment & junctional epithelium averages 2.04 mm”

The Importance of Restorative A. The average sulcus depth is 0.69 mm

Margin Placement to the Biologic B. The average junctional epithelium is 0.97 mm
Width and Periodontal Health. Part I C. The CT attachment is 1.07mm

De Wall - 1993 - Int J Periodontol When restorative margins extend into BW, one of four pathologic alterations will develop:
1) Crestal bone loss resulting in a localized infrabony pocket
2) Gingival recession and localized bone loss
3) Localized gingival hyperplasia with minimal bone loss
4) Combinations of all

Sulcus Depth (SUL):

“Distance from the crest of the free gingiva to the most coronal extent of the epithelial attachment”

Epithelial Attachment (EA):

“Distance from most coronal extent of epithelial attachment to the most coronal extent of CT attachment”
The Dimensions of the Human
Dentogingival Junction Connective Tissue Attachment (CTA):
“Distance from most coronal extent of CT attachment to most coronal extent of the periodontal ligament”
Vacek - 1994 - IJPRD
Loss of Attachment (LOA):
“Distance from the cementoenamel junction (CEJ) to the most coronal extent of the CT attachment”

Biologic width of the molars was significantly greater than that of the anterior teeth & premolars
The concept of BW requires a minimum of 2.04 mm of sound tooth structure above the osseous crest
 Base of the Sulcus:
The single most important factor determining the gingival response to restorative dentistry
Define the cervical limitation of tooth preparation & the intracrevicular margin location
Altering Gingival Levels: The
Restorative Connection. Part I: Osseous Crest:
Biologic Variables For determining gingival levels
Kios - 1994 - J Esthet Dent COMPONENTS OF DENTO-GINGIVAL COMPLEX (DGC):
1. Connective tissue fibrous attachment
2. Junctional epithelium or epithelial attachment
3. Sulcus

The desired distance from margin to bone on facial & interproximal is 2.5 mm

CROWN LENGTHENING

The minimal distance from alveolar crest to coronal extent of sound tooth structure should be 4 mm
(2 mm bracing on sound tooth structure & 2 mm biologic width)

Disadvantages of Surgical Crown Lengthening:

1. Difficult on a single anterior tooth without creating an esthetic deformity
2. Unfavorable root-to-crown ratio expected
Restoring teeth following crown 3. Compromise the osseous support of the tooth
lengthening procedures 4. Compromise supporting bone of adjacent teeth
5. May expose furcations (exceptional oral hygiene measures are needed)
Assif et al - 1991 - JPD 6. May cause excessive mobility of teeth that have short or concial roots

Advantages of Forced Eruption of Teeth:

1. Conservation of bone 2. Preservation of biologic width
3. Maintenance of esthetics 4. Exposure of sound tooth structure for placement of restorative margins

Indication of Forced Eruption:

Preferable in the anterior region of the dentition where esthetics is of major concern
 Indication of Crown Lengthening:
More appropriate in the posterior region of the dentition (because flared molar roots may present
proximity problems if extruded & esthetics is of less importance & extrusion may be precluded by tipping
& unfavorable axial tooth position)

DETERMINING RESTORABLE TEETH:

Calculate the amount of eruption necessary to restore the tooth (4mm sound tooth structure coronal to
the alveolar crest). Calculate the effective root length remaining after root extrusion & divide it by the
clinical crown height (If the result is 1 or more, then favorable conditions exist for completion of the
restorative procedures. If the result is less than 1, then root extrusion will not provide the necessary basis
for a properly constructed cast restoration)

The maxillary canine is the tooth with the most favorable prognosis for successful treatment
The poorest candidate is the maxillary central incisor

Surgical lengthening of clinical crown Creating a distance of 3 mm from the alveolar crest to the future reconstruction margin during surgical
Bragger - 1992 - JCP CL leads to stable periodontal tissue levels over a period of 6 months

The greatest amount of both mean bone removal & biologic width was found on the mid-facial surface
Clinical comparison of desired versus & the least amount at distal-lingual surface
actual amount of surgical crown
lengthening The proposed minimum desired 3 mm biologic width was not routinely achieved in this study
(Clinicians may need to be more aggressive during surgical CL procedures to achieve the proposed goal
Herrero et al - 1995 - J Periodontol of 3 mm biologic width)

Periodontal and dental When restoration margins are placed intra-crevicularly, they should be no deeper than 0.5 mm & parallel
considerations in clinical crown to the gingival margin
extension- a rational basis for
treatment Whenever possible, the finish line should be determined prior to surgery (or should be anticipated if it is
not possible)
Smukier & Chaibi - 1997 – IJPRD
 Cohen - 1902 Defined Biologic Width as “junctional epithelial & connective tissue elements of the dento-gingival
continuum that occupy the space between the base of the gingival crevice & the alveolar crest”

Dimension of biologic width vicinity 2.04 mm (made up of junctional epithelial dimension of 0.97 mm
Gargiulo et al plus 1.07 mm of connective tissue attachment in a coronal-apical direction)
The sulcular depth was estimated to be in the vicinity of 0.69 mm

Ingber et al Advised 3 mm of tooth exposure

Rosenberg Advised 4 mm of tooth exposure

SHORT CLINICAL CROWN:

“Any tooth with less than 2 mm of sound, opposing parallel walls remaining after adequate occlusal &
axial reduction”

Common Causes of Short Clinical Crowns (SCC):

1. Disease 2. Trauma
3. Eruption disharmony 4. Exostosis
Restorative and Periodontal 5. Genetic variation in tooth form 6. Iatrogenic dentistry (excess tooth reduction, large endo access)
Considerations of Short Clinical
Crowns Anterior Crown Lengthening:
For placement of an intracrevicular restoration, there must be 5 mm of tooth structure incisal to the
Davarpanah - 1998 - IJPRD alveolar crest, including 2 mm to maintain the biologic width, 2 mm of sulcular depth for intracrevicular
margin placement, and 2 mm for retention, with the finish line 1 mm into the sulcus

TOOTH PREPARATION:
Should be performed 4 to 6 weeks after surgical CL for a supragingival finish line and 8 weeks after
crown lengthening if the margins are to be placed in the sulcus

Orthodontic Forced Eruption (Extrusion):

“intentional coronal displacement of a tooth, attachment apparatus & gingiva to position the root segment
coronally, resulting in a more favorable crown-to-root ratio”
Can progress 1 mm in 1 to 2 weeks in absence of inflammation
 Indications for Crown Lengthening:
Crown Lengthening: The 1. Teeth with decay at or below the gingival margin
Periodontal-Restorative Connection 2. The gingival margin is coronal to the CEJ (delayed passive eruption)
3. Fractured teeth with adequate remaning periodontal attachment & excessive occlusal or incisal wear
Becker - 1998 - Contin Edu Dent 4. Teeth with inadequate interocclusal space for proper restorative procedures

Normal Probing Depth 2-3 mm

Interproximal Contact & Root Proximity Consideration

Role of Marginal Ridge Relationships

as an Etiologic Factor in Periodontal UNEVEN MARGINAL RIDGES of posterior teeth are of far less importance than the presence &
Disease extent of plaque & calculus deposits in determining periodontal health status
Kepic - 1978 - J Periodonol

Interproximal Periodontal Disease - The most frequent lesion noted occurs where there is damage to the bone under the contact point
The Embrasure as an Etiologic Factor The most complicated area to take an impression with retraction cord is interproximal of upper centrals
Nevins - 1982 - IJRD The alveolar housing for the roots of anterior teeth is narrower than that for posterior teeth

Relationship Between Proximal Tooth OPEN CONTACT SITE:

Open Contacts and Periodontal Significantly greater probing depth, attachment loss, food impaction & occlusal interference
Disease Gingival index, crevicular bleeding & calculus index show no significant differences
Jernberg et al - 1982 - J Perio

Three Structural Entities Influenced by Root Proximity:

1. Number, compactness & direction of the interdental CT fibers coronal to the osseous crest
A Consideration of Root Proximity 2. Density or trabecular nature of the proximal bone
3. Location of proximal blood vessels
Kramer - 1987 - Int J Perio
Increasing Inter-Root Dimension can be accomplished in Three Ways:
1) Selective extraction of teeth (or roots) 2) Tooth (crown/root) preparation 3) Orthodontic treatment
 Loss of the papilla can lead to:
1. Cosmetic deformities 2. Phonetic problems 3. Lateral food impaction

The Effect of the Distance from the Variables that may contribute to presence or absence of the papilla:
Contact Point to the Crest of Bone on 1. Degree of inflammation 2. Pocket depth of adjacent teeth
the Presence or Absence of the 3. Fibrous or edematous nature of tissue 4. Anterior versus posterior teeth
Interproximal Dental Papilla 5. Presence of proximal restorations 6. History of previous non-surgical & surgical therapy
7. Mesio-distal distance between the 2 teeth 8. Total volume of the embrasure space
Tarnow et al - 1992 - J Periodontol DISTANCE FROM BASE OF THE CONTACT POINT TO THE CREST OF BONE:
5 mm or less --- inter-proximal papilla Almost always present (100% of the time)
6 mm --- Present more than half of the time (56% of the time)
7 mm or more --- Missing most of the time(27% of the time or less was present)

TREATMENT OF MUCOGINGIVAL PROBLEMS

Periodontal Plastic and Mucogingival Predisposing Factors to Gingival Recession:

surgery 1. Thin gingiva 2. Prominent root surface 3. Buccally positioned teeth
4. Frenum pull 5. Bone dehiscence
Prato et al - 1995 - Perio 2000

Mucogingival Surgery:
Mucogingival surgery “Plastic surgical procedures designed to correct defects in the morphology, position and/or amount of
gingivae surrounding the teeth”
Wennstrom - 1994 - Quint Publ
The possibility of achieving a new CT attachment in the apical portion of the defect seems to be
considerably better in narrow gingival recessions than in wider one

CLASSIFIED RECESSION DEFECTS INTO 4 GROUPS:

Miller - 1985 Class I:
Marginal tissue recession not extending to the mucogingival junction
No loss of interdental bone or soft tissue
 Class II:
Marginal tissue recession extends to or beyond the mucogingival junction
No loss of interdental bone or soft tissue

Class III:
Marginal tissue recession extends to or beyond the mucogingival junction
Loss of interdental bone
Interdental soft tissue is apical to CEJ, but coronal to the apical extent of the marginal tissue recession

Class IV:
Marginal tissue recession extends beyond the mucogingival junction
Loss of interdental bone & soft tissue to a level corresponding to apical extent of marginal tissue

PERIODONTAL CONSIDERATION DURING FIXED PROSTHODONTICS PROCEDURES

THREE THEORIES OF CROWN CONTOUR:

1) Gingival protection (3 elements):
1. Protection of gingival margins 2. Gingival stimulation 3. Self-cleansing contours
2) Muscle action
3) Access for oral hygiene

Undercontouring of the clinical crown will cause deflection of masticated food onto the gingival margin,
forcing it into the sulcus, thus initiating gingivitis
Current theories of crown contour,
margin placement, and pontic design A normal tooth at the bucco-cervical bulge is usually equal or less than 0.5 mm wider than the CEJ

Becker & Kaldahl - 1981 - JPD Interproximal space that is slightly larger than normal (Open embrasure) may be desirable since it
provides adequate room for the gingival papilla and is a more accessible area to clean

Location of Contact Areas:

The contact area of all teeth, except between the maxillary 1st & 2nd molars, should be buccal to the
central fossa (Contacts should be high - incisal one third)

Few incidences of new caries associated with supragingival margins have been reported because of
improved access for plaque control
 Subgingival margins should be avoided except for the following specific situations:
1. Esthetic demands 2. Caries removal 3. Subgingival tooth fracture
4. To gain crown length 5. Existing subgingival restorations 6. Provide favorable crown contour

PONTIC DESIGN:
The modified ridge-lap design in posterior region & ridge-lap facing design in the anterior region offer
minimal tissue contact, acceptable cosmetic value, proper cheek support & accessibility for adequate OH
(design of the pontic may be the most important factor in preventing inflammatory reactions, not the
material used in the pontic)

Overcontouring prevents the normal cleansing action of the musculature and allows food to stagnate in
Morris
the overprotected sulcus

Townsend Even with grossly undercontoured, open embrasure spaces, lateral food impaction rarely occurs as long
as interproximal tooth contacts are properly maintained

Supragingival margins increase the potential for achieving optimal gingival health around restored teeth

33% of the people, gingival aspect of their most visible anterior teeth did not show during a normal smile
& 16% during an exaggerated smile

Shoulder finish line can be established subgingivally while keeping the entire rotary instrument diameter
Gingival Esthetics within peripheral tooth contours where there is less chance of gingival contact
Chamfers & beveled shoulders requires that part of the rotary instrument diameter be located outside
Goodacre - 1990 - JPD peripheral tooth contours, with greater potential for gingival trauma

Provisional restorations are in position for as little time as possible preferably no more than 2 to 3 weeks

Factors deserve consideration in using retraction cord & attempting to minimize soft tissue trauma:
1) Time (Should not exceed 15 to 20 minutes)
2) Size & number (Too large a retraction cord or too many cords can cause excessive trauma)
3) Pressure of Placing retraction cord (excessive pressure can produce tissue blanching & recession)
 Subgingival crown margins result in less favorable periodontal condition than margins at gingival crest or
above

A new epithelium will proliferate to cover the exposed connective tissue wound and complete healing
Maintaining and enhancing gingival will normally take place within 8 to 14 days
architecture in fixed prosthodontics
Typical extension into the gingival sulcus should not exceed 0.5 to 1 mm, (depending upon the depth of
Ferencz - 1991 - JPD the sulcus)

The damage inflicted to the soft tissue depends upon:

1. Chemical agent with which the cord has been impregnated
2. Force used in packing the cord
3. Length of time the cord is left in place within the sulcus

Observed 546 crowns in 288 patients:

Larato 21% of the crowns with margins at or above the gingival crest showed gingival inflammation compared
with 83% of the crowns with subgingival margins

Predictable Esthetic Gingival Management in Fixed Prosthodontics is based on 2 objectives:

1) Precise intracrevicular placement of the restorative margin
2) Final margin placement in a stable gingival environment

The average depths of the healthy cervice vary between 1 to 1.5 mm on the facial aspect of the maxillary
anterior region (The recommended subgingival margin level for a crown is half of this value and should
Impression Considerations in the be no deeper than 0.5 mm to 0.7 mm)
Maxillary Anterior Region
Two methods to minimize the potential for penetration beyond the base of the crevice by the bur:
Chiche - Compend Contin Edu Dent 1) Prepacking gingival tissue with a thin, non-impregnated cord
2) Probing the crevice depth during tooth preparation (when the crevice tissues is less than l-mm deep)

Timing of Final Margin Placement Varies According to Three Situations:

1) Healthy gingival tissues preoperatively
2) Chronically inflamed gingival tissues
3) After periodontal surgery
 Before Removing Deficient Crowns:
Control gingival inflammation, scaling & root planning should be started 3 to 4 weeks

A minimum waiting period of 3 months after surgery is recommend before initiating the final restoration

Facial aspect of Maxillary Anterior Teeth:

Shallow crevice depth typically encountered, which creates a potential for violation of BW

Summarized Iatrogenic Causes of Gingival Recession Associated with Restorative Treatment:

Donovan 1. Failure to attain gingival health 2. Aggressive gingival displacement
3. Violation of the biologic width 4. premature restorative treatment after periodontal surgery

Tarnow et al Marginal tissue recession resulting from violation of BW rapidly stabilize within 2 weeks
post-surgery with no further apical migration

Mastering the Art of Tissue

Management During
Provisionalization and Biologic Final 2 to 3 weeks post-provisionalization, signs of gingival health become manifest, interproximal tissues
Impressions appear normal & final impressions can be scheduled (never performed on the day of preparation)

Shavell - 1988 - IJPRD

Guidelines for the Use Of 0.12% Chlorhexidine Gluconate Mouthrinse in Fixed Prosthodontics:
1) Assess gingival health
Gingival enhancement in fixed (patient's oral hygiene abilities, pocket depths, plaque levels & presence of bleeding upon probing)
prosthodontics. Part I: Clinical Patient with pocket depths greater than 4 mm should first be treated or referred to a periodontist
findings
2) Prophylaxis on initial appointment & regimen of CHX 15 ml h.i.d. at least 2 weeks before fixed
Sorensen et al - 1991 - JPD prosthodontic procedures

3) If the patient has no bleeding sites, minimal plaque levels, or gingivitis, the use of chlorhexidine is
probably not indicated (with a gingival index much less than 1, limited benefit would be observed)
 Gingival enhancement in fixed Chlorhexidine has been shown to be the most efficacious agent in reducing supra-gingival plaque &
prosthodontics. Part II: Microbiologic gingivitis when compared with other antimicrobial agents (Rinsing twice daily with 0.12%
findings
chlorhexidine resulted in significantly greater reduction of perio pathogens)
Flemmig et al - 1991 - JPD

Chlorhexidine’s Action:
The positively charged chlorhexidine molecule binds to negatively charged regions on the bacterial cell
wall leading to rupture & cell death
Gingival enhancement in fixed
prosthodontics. Part III: Anamnestic Chlorhexidine’s Side Effects:
findings 1. Development of brown pellicle discolorations (most in interproximal aspect of mandibular anterior teeth)
2. Altered taste sensation
Sorensen et al - 1991 - JPD 3. Discoloration of the tongue & mucosa
4. Gingival irritation

Of the reported side effect, taste alteration was more objectionable side effect than staining
Patient perceived gingival health benefits were more important than patient perception of the side effects

THE EFFECT OF RPDS OR CANTILEVER ON THE PERIODONTIUM

Clinical evaluation of patients eight to There was no significant difference in caries incidence, change in sulcus depth, tooth mobility or alveolar
nine years after placement of bone loss between those who wore the dentures & those who didn’t
removable partial dentures
There were increased levels of inflammation in areas covered by RPDs & areas bellow clasp arms
Chantler - 1984 - JPD

Plaque and Oral Hygiene:

Periodontal Reactions Related To RPD insertion caused quantitative & qualitative changes of plaque formation & increased risk of
Removable Partial Dentures: A gingivitis & periodontitis
Literature Review
Coverage of Marginal Gingivae by Parts of an RPD:
Bergman - 1987 - JPD The severest pathological changes were found when marginal gingivae were covered without relief
Less changes when covered with relief & the least changes when left uncovered
 Periodontal Conditions Following
Treatment with Distally Extending Patients treated with RPD showed higher mean plaque & gingival Indexes than the patients treated with
Cantilever Bridges or Removable
cantilever bridges (No change in probing pocket depths was observed in either group)
Partial Dentures in Elderly Patients

Isidor & Jorgensen - 1990 - J Periodon

The Influence Of End Abutment and

Cantilever Fixed Partial Dentures On both FPD types (end abutment & cantilever) do not lead to deterioration of the periodontal situation if
Periodontal health oral hygiene is Closely monitored

Stelzel - 1997 - IJPRD