A Longitudinal Study of
tion. Following treatment, which in several cases in-
Combined Periodontal and
Prosthetic Treatment of
Patients With Advanced
Periodontal Disease
by
Sture Nyman*
Jan Lindhe*
Clinical and laboratory research endeavors have
revealed unanimously that most, if not all, forms of
periodontal disease are plaque associated disorders. Con-
sequently, treatment of gingivitis and Periodontitis must
always involve debridement, elimination of deepened
periodontal pockets and other retention factors for
plaque and the institution of a careful plaque control
program including regularly repeated oral prophylaxis
and tooth cleaning instruction. Studies by Lòvdal et al.,1
Suomi et al.,2 Ramfjord et al.,3,4 Lindhe and Nyman,0
Rosling et al.,6 Axelsson and Lindhe' have documented
that such treatment will eliminate clinical signs of gin-
givitis and prevent further deterioration of the supporting
tissues.
Frequently in cases of advanced Periodontitis, the
destruction of the attachment apparatus has reached a
level which calls for extraction of several teeth. This
implies that towards the end of the initial treatment
phase0 of such patients only a few teeth may remain,
teeth which in addition to having reduced periodontal
tissue support often also exhibit pronounced hypermo-
bility or even signs of progressive, i.e. gradually increas-
ing, mobility. In such cases there is an obvious need for
splinting and additional prosthetic treatment,8 even if
prevalent concepts prescribe that in this particular situ-
ation prosthetic treatment involving fixed bridgework is
hazardous.9"11 It has been demonstrated,12'13 however,
that teeth with severely reduced periodontal support and
with progressive mobility can serve as reliable abutment
teeth for extensive fixed splints/bridges provided perio-
dontal health has been established and can be maintained
in the remaining dentition, and provided the bridgework
is designed as to preclude undue stress concentrations in
the supporting apparatus.
The present investigation describes the result of treat-
ment of a group of patients who initially suffered from
advanced Periodontitis, in many instances complicated
*
Department of Periodontology, University of Gothenburg, Fack,
S-400 33 Gothenburg 33, Sweden.
163
by tooth hypermobility in several sections of the denti-
volved multiple extractions and splinting combined with
prosthetic rehabilitation, all patients were enrolled in a
carefully designed plaque control program. The study
also reports on the frequency of failures of the combined
periodontal and prosthetic treatment.
Materials Methods
and
The material consisted of 299 individuals (aged 23-72
years, mean age 48.7 years) who during the period 1969
to 1973 were referred to the Department of Periodontol-
ogy, University of Gothenburg, for periodontal treat-
ment. The limiting criterion for acceptance of patients
for this study was that their dentition had lost 50% or
more of the periodontal tissue
support. In addition, they
should be (i) willing to accept periodontal treatment
including tooth extractions, periodontal surgery and, if
indicated, prosthetic treatment, (ii) capable of maintain-
ing optimal plaque control and, (iii) willing to appear for
regular appointments for additional maintenance care.
In some patients, a well-functioning dentition could
be established without prosthetic treatment (Group I).
The periodontal status of these patients 5 years after
treatment as well as a detailed description of the various
therapeutic procedures utilized have been presented ear-
lier.5 Forty-eight of these patients (22 males and 26
females), namely those who still 8 years following initial
treatment participated in the controlled oral hygiene
program and appeared at the 8-year follow-up reexami-
nation constituted the "non-bridge treatment group"
(Group I) described in the present paper.
The remaining 251 patients described here displayed
at the initial examination a similar degree of periodontal
disease as the patients of Group I but, in addition, the
breakdown of the periodontal tissues around certain
teeth had reached a level where tooth extractions and
subsequent prosthetic replacement were required. Out of
these 251 individuals, every fifth (in consecutive order
according to date of commencement of treatment), i.e.
in all 50 patients, were selected to form the "bridge-
treatment group" (Group II). In these 50 patients, 74
fixed bridges were placed. According to the design of the
bridgework "the bridge treatment group" was divided
into three subgroups:
Ha: 21 bridges of cross-arch extension with
Group
abutment teeth present at the distal termination of
the bridges. In this bridgework, the number of pon-
tics between two neighboring abutments ranged
from one to eight.
Group lib: 39 bridges of cross-arch extension with
distal cantilever segments in one or both sides of the
jaw. In this bridgework, the mean number of free-
end pontics per cantilever segment was 2.3 (range
1-7).
Group lie: 14 bridges of unilateral extension.
 J. Periodontol.
164 Nymán, Lindhe April, 1979
The patients of Group II have been followed for 5 to 8 in the various groups with respect to alterations of
years (mean 6.2 years). Plaque- and Gingival Index scores, pocket depth, attach-
The outline of treatment of Periodontitis in the patients ment level and alveolar bone height.
of the "bridge treatment group" was identical to that
Results
described for the patients of Group I.
Following the active phase of treatment (initial treat- Oral Hygiene and Gingival Condition
ment), all patients of Group I as well as of Group II were The individual mean P1I scores (Table 1) for the
placed in a maintenance care program including recall abutment teeth assessed immediately after the initial
appointments every 3 to 6 months. At these periodic treatment in the three "bridge treatment groups" were
recalls, each patient was scaled and also was given careful 0.32 (Group Ha), 0.39 (Group lib) and 0.42 (Group lie).
professional tooth cleaning14 and oral hygiene instruc- The corresponding value in the "non-bridge treatment
tion. group" (Group I) was 0.40. The results from the final
Immediately after completion of the initial treatment examination (5-8 years in the "bridge treatment groups"
and then once a year, all patients were reexamined and 8 years in the "non-bridge treatment group") re-
regarding: vealed that the patients had maintained low P1I scores.
1. Oral hygiene status (Plaque Index15). The GI scores (Table 1) which at the termination of
2. Gingival condition (Gingival Index).16 the initial treatment phase varied in the different groups
3. Pocket depth (measured with a calibrated perio- between 0.30 and 0.42, showed during the maintenance
dontal probe to the nearest one millimeter). period consistently low values with only insignificant
4. Attachment level (from well-defined landmarks on variations from the initial mean scores. The GI scores
the tooth surfaces.3,17 The assessments were made to the calculated from measurements made at the final exami-
nearest one millimeter. Assessments regarding oral hy- nation in the four groups of patients varied between 0.28
giene, gingivitis, pocket depths and attachment levels (1, and 0.35.
2, 3 and 4) were made by the same dentist and included
all parts of the dentition and all four surfaces (mesial,
Pocket Depth and Attachment Level
distal, buccal, lingual) around each tooth. The individual The mean pocket depths for all tooth units at the end
mean values were calculated. of the initial treatment phase were in Group I 2.1 mm
5. Alveolar bone height (Bone Score18). and in Group Ha 2.3 mm, Group lib 2.1 mm, Group lie
2.3 mm (Table 2). In none of the treatment groups did
The bone level at the mesial and distal surface of each
these values vary in a significant way during the course
tooth was measured in radiographs obtained according
of the study. The mean pocket depths calculated for the
to a method described by Eggen.19 Individual mean Bone
4 different groups at the final examination were 2.4 mm,
Scores were calculated. The radiographie readings were
2.4 mm, 2.3 mm and 2.3 mm respectively.
made by two dentists.
In addition, information was collected regarding tech- The attachment level measurements (Table 2) revealed
that no additional loss of clinical attachment occurred
nical failures which were detected in the bridgework*
during the maintenance period. An analysis was carried during the 5 to 8 years of observation around the teeth
out to assess the frequency of and reasons for failures in which remained following the initial treatment.
all 251 patients who received prosthetic treatment during Alveolar Bone Height
the period 1969 to 1973. In all, 332 fixed bridges had
The results of the measurements of the interproximal
been placed, and the various bridgework had the follow-
alveolar bone height are presented in Tables 3 to 6. Table
ing general design: 3 shows that the bone level was maintained unchanged
139 bridges of cross-arch extension with abutment in all four groups over the entire observation period. A
teeth present at the distal termination of the bridges. further analysis revealed that the bone height was main-
In this bridgework, the number of pontic units
between two neighboring abutments ranged from 1 Table 1. Plaque Index ( PU) and Gingival Index ( GI) Scores Assessed
to 8. Immediately After the End of the Active Treatment Phase (X¡) and at the
Final Examination (X2)
159 bridges of cross-arch extension with distal canti- It should be observed that for the patients in Group I the X2 values
lever segments in one or both sides of the jaw. In always represent data collected at the 8-year follow-up examination.
this bridgework, the mean number of free-end pon- For Groups IIa, IIb and He, the X2 values represent data from
tics per cantilever segment was 2.2 (range 1-7). reexaminations made between 5 and 8 years after the end of active
34 bridges of unilateral extension. treatment. NS =
nonsignificant.
P1I GI
Statistical Analysis
X] X2 Xl X2
Analysis of variance was used for testing differences
0.40 0.32 NS 0.34 0.28 NS
Group I
Group Ha 0.32 0.34 NS 0.30 0.34 NS
*
The periodontal and prosthetic treatment described in the present
Group lib 0.39 0.33 NS 0.42 0.31 NS
study has been carried out by staff members and graduate students of 0.38 0.35 NS
the Department of Periodontology, University of Gothenburg. Group He 0.42 0.36 NS
Volume 50
Number 4 Prosthetic Treatment of Periodontal Patients 165

tained equally well around vital and nonvital, root-filled
teeth (Table 4) as around one-rooted (hemisected), and
multirooted molar abutments (Table 5). The assessments
furthermore disclosed that the bone height remained
unchanged around all terminal abutment teeth which
were adjoined with distal cantilever pontics irrespective
of the length of the cantilever segment (Table 6).
Technical Failures
The analysis of the total material (332 bridges in 251
patients) regarding frequency of and reasons for techni-
cal failures which were encountered in the various
bridgework after placement, gave the following result:
abutment teeth, and in three bridges of cross-arch exten-
sion involving cantilever units.
3. Fracture of abutment teeth (one tooth in each of
eight bridges, 2.4%) occurred in three bridges of cross-
arch extension with distal abutment teeth present and in
five cross-arch bridges with cantilever segments. Four of
these fractures occurred in the abutment tooth adjoining
free-end units. Of a total of eight fractured teeth, six
were nonvital but root-filled, and two were vital.
Discussion
The present investigation showed that it is possible to
prevent of gingivitis of clinical importance
recurrence

1. Loss of retention of retainer crowns from abutment
teeth (11 bridges, 3.3%). This failure occurred in six
bridges of cross-arch extension with distal abutment
teeth present, and in five bridges of cross-arch extention
with distal cantilever segments.
2. Fracture of bridgework (seven bridges, 2.1%). Such
fractures were noted in one bridge of unilateral exten-
sion, in three bridges of cross-arch extension with distal
Table 2. Pocket Depth and Alterations in Attachment Level Assessed
Immediately After the End of the Active Treatment Phase (X¡) and at the
Final Examination (Xi)
It should be observed that for the patients in Group I the X2 values
always represent data collected at the 8-year follow-up examination.
For Groups IIa, IIb and He, the X> values represent data from
reexaminations made between 5 and 8 years after the end of active
treatment. NS nonsignificant. SE standard error.
= =
and to terminate progression of periodontal tissue break-
down in patients who, following proper periodontal
treatment, were enrolled in a well controlled oral hygiene
program. The treatment procedures which in the present
trial resulted in healing of the periodontal tissues, in-
cluded the removal of the soft and hard bacterial deposits
and the elimination of retention factors for plaque in-
cluding ill-fitting restorations and deepened periodontal
pockets. The periodontal conditions of the patients of
Group I 5 years after initial treatment have been de-
scribed previously.5 In the paper referred to, it was
concluded: "It is possible by a detailed plaque control
program not only temporarily to cure the disease, but
also to prevent further progression of periodontal break-
down, even in patients with severely reduced periodontal

support". In the present study, the same patients were

Alterations in reexamined 8 years after initial treatment. The final
Pocket depth (mm) attachment reexamination revealed that still after 8 years of careful
level (mm)
maintenance care, they displayed an unaltered attach-
SE X2 SE SE
0.1 2.4 0.3 NS 0.1 NS
Table 5. Bone Height Measurements of Hemisected and Nonhemi-
Group I 2.1 +0.1 sected Molar Abutment Teeth*
Group Ha 2.3 0.2 2.4 0.1 NS +0.3 0.2 NS = number of teeth.
Group IIb 2.1 0.1 2.3 0.2 NS +0.1 0.3 NS
0.3 2.3 0.2 0.3 NS Molar abut-
Group Ile 2.3 NS -0.2 SD SD Diff
ment teeth

Hemisected 30 6.15 0.85 6.18 0.89 -0.03 NS

Table 3. Bone Height Measurements Nonhemisected 28 5.64 0.57 5.61 0.61 +0.03 NS
] Individual mean (patient) Bone Score (± standard deviation)
—

assessed from radiographs obtained immediately after the end of the

*
Only those patients have been included in whom both types of
active treatment phase. X2 Bone Score assessed from radiographs
=
teeth were utilized as abutments.
obtained at the final examination. It should be observed that for the
patients in Group I the X2 values always represent data collected at the Table 6. Bone Height Measurements ( Group lib) Around the Terminal
8-year follow-up examination. For Group IIa, IIb and Oc, the X2 Abutment Tooth Adjoined With Free-end Pontics
values represent data from reexaminations made between 5 and 8 years number of teeth.
=

after the end of active treatment. NS nonsignificant.

=
No of
X, SD SD Diff free-end X, ± SD X2 ± SD Diff
Group I 6.41 0.65 6.37 0.61 +0.04 NS pontics
Group Ha 5.98 0.64 5.83 0.71 +0.15 NS 1 15 5.94 0.84 5.97 0.88 -0.03 NS
Group lib 5.66 0.77 5.68 0.71 -0.02 NS 2 18 5.37 0.89 5.45 0.86 -0.08 NS
Group lie 5.34 0.61 5.26 0.58 +0.08 NS 3 or more 10 5.24 0.71 5.24 0.51 ±0 NS

Table 4. Bone Height Measurements of Nonvital, Endodontically Treated and Vital Abutment Teeth*
number of teeth.
=

Abutment teeth X, ± SD X2 ± SD Diff

Endodontically treated 47 5.57 0.68 5.54 0.66 +0.03 NS

Vital 52 5.70 0.74 5.72 0.77 -0.02 NS
*
Only those patients have been included in whom both types of teeth were utilized as abutments.

166 Nymán, Lindhe
ment level and an unaltered height of alveolar bone.
These findings, which are consistent with observations
reported by Lovdahl et al.,1 Suomi et al.,2 Ramfjord et
al.,3 Axelsson and Lindhe7 show that periodontal health
can be maintained in patients for whom, following initial
treatment, the recurrence of plaque infection is pre-
vented.
The present findings furthermore revealed that de-
bridement, elimination of deepened pockets and the
establishment of a carefully designed maintenance pro-
gram is effective also in patients for whom splints or
bridge restorations were part of the initial treatment.
This simply means that the periodontal tissues around
teeth which are serving as abutments for fixed bridge-
work do not react to treatment in a different way than
the supporting tissues around "non-abutment" teeth.
The observations made here also disclosed that differ-
ences in the design of the bridgework (i.e. unilateral or
cross-arch design, length of pontic- or cantilever seg-
ments, the utilization of hemisected- or nonhemisected
molars as abutment teeth etc.) will not jeopardize the
treatment which in all patients was aimed at eliminating
the plaque infection and the retention factors for plaque.
In the present study, the initial treatment of periodon-
tal disease around abutment teeth and "non-abutment"
teeth was similar. In all bridgework made, the marginal
fit of the retainer crowns of the abutment teeth were
placed in a supragingival position. This means that the
design of the maintenance care program for abutment-
and "non-abutment" teeth was similar. The supragingi-
val location of the crown margins facilitates the inspec-
tion of the marginal fit of the retainers and the early
discovery of incipient caries lesions. Furthermore, studies
by Waerhaug,20'21 Karlsen,22 Silness,23 Valderhaug and
Birkeland24 have shown that a subgingival location of
the crown margins favors plaque accumulation, thereby
enhancing the risk of recurrence of periodontal disease.
In addition, Valderhaug and Heloe23 in a 5-year longi-
tudinal study reported that the incidence of caries could
be kept as low around crown margins in supragingival
position as around those located below the gingiva in
patients who participated in a regularly repeated oral
hygiene program.
Even if the establishment and maintenance of perio-
dontal health around the abutment teeth are prerequi-
sites for a proper prognosis of a fixed bridge, certain
elementary principles regarding the design of the artifi-
cial constructions cannot be neglected. The most impor-
tant factor in our view is that a status quo of bridge
stability can be obtained. This means that increasing
(progressive) mobility or drifting of the bridgework with
time has to be avoided. The problems involved in ob-
taining stability of fixed bridgework in patients with
severely reduced periodontal support, however, will not
be further discussed in this paper, since this aspect of the
treatment has been extensively analyzed in previous
publications.8'13'28"28
J. Periodontol.
April, 1979
Although in the present trial exceptional efforts were
made to prevent the occurrence of technical failures in
the bridgework, during the observation period around
8% (26 bridgework) of the fixed restorations had to be
replaced due to (1) loss of retention, (2) fracture of the
bridgework, (3) fracture of abutment teeth. A further
analysis revealed that in all cases of failure in the pros-
thetic treatment, certain fundamental principles regard-
ing the design and construction of the bridgework had
been overlooked. A few examples will illustrate some of
the frequent reasons for failures.
In the present material, loss of retention occurred in
abutment teeth fitted with partial crowns. It is well
known that the rigidity of an intact tube, such as a full
crown, is much higher than that of a tube which has
been cut open.29 This means that a partial crown in
comparison to a full crown has a reduced resistance to
deformation. The ultimate consequence of plastic defor-
mation of a crown in a bridgework is fracture of the
luting cement and subsequent loss of retention. Loss of
retention also was noted in some patients whose bridge-
work included long pontic spans and long free-end seg-
ments. In order to secure proper retention for bridgework
of this kind it is necessary to give the prepared portion
of an abutment tooth maximum length and minimal
taper, i.e. the length of the diagonals of the prepared
portion of the abutment tooth must exceed the diameter
of its base (For discussion see Hegdahl and Silness30).
Figure 1 illustrates a maxilla in which bridgework of
cross-arch extension is to be inserted. If we assume that
a "normal" intermaxillary relationship (normal overbite
and o verj et) is prevailing, protrusive movements of the
mandible will produce a force in occluso-frontal direc-
tion (arrow, Fig. 1) operating on the distal abutment
crown. A dislodging effect of such a force can be pre-
vented provided the distal aspect of the molar is made
parallel to the mesial (and distal) surface of the canine
and the buccal (and lingual) surface of the incisor. In
two of the bridgework (Group Ha) described in this
paper, the distal surfaces of the molars were prepared
with a large convergence angle in relation to the canines.
Figure 1. The distal surface of the molar is prepared parallel
to the mesial surface of the canine and the buccal surface of the
incisor in order to counteract the occluso-frontally directed dis-
lodging force (arrow) acting on the molar abutment tooth on
protrusive mandibular glide. The retentive capacity is further
increased by box preparation on the buccal surface of the molar.
Volume 50
Number 4 Prosthetic Treatment of Periodontal Patients 167

As a consequence, the bridgework had no "self-reten-
tion" in the molar area, the cement film became the sole
retention factor, and after a few months the restorations
lost the retention of the distal abutment tooth. In the
bridgework discussed, retention was improved following
placement of new restorations by utilizing box prepara-
tions in the molar abutments. Thus, in order to avoid
loss of retention of bridgework with long pontic spans,
it is imperative to obtain parallelism between the pre-
pared surfaces of the various abutment teeth.
Fracture of the bridgework occurred in the present
material in seven bridges. An analysis of the reason for
this type of failure disclosed that the metal constructions
of these bridges were under-dimensioned. In cases in
which long pontic spans or cantilever segments are used,
the stress-increasing effect produced by the pontic seg-
ment elongation must be compensated for by increasing
the height of the various components of the bridge (i.e.
crowns, pontics, solder joints, etc.) in the loading direc-
tions.29
Fracture of abutment teeth in the present material was
found to occur more frequently in root-filled than in
vital teeth and appeared primarily in root-filled teeth
fitted with posts and serving as terminal abutments for
free-end segments (Fig. 2). In order to minimize the risk
for such root fractures (1) the root canal should not be
prepared too wide, (2) a gold collar should circumscribe
the neck of the tooth. Using standard models, Sass et
al.31 showed that the strength of a rootfilled tooth with
metal post and a gold collar is more than 10 times that
of a corresponding tooth without collar. It should also
be understood that the wider the gold collar is, the higher
becomes its retentive capacity.
Summary
The purpose of the present investigation was to present
the results of periodontal and prosthetic treatment of
patients with advanced breakdown of the periodontal
tissues. The material consisted of 299 individuals. In 48
of the patients (Group I), a well-functioning dentition
could be established with periodontal treatment only,
whereas in the remaining 251 patients prosthetic therapy
was required subsequent to the treatment of the
perio-
dontal tissues. Out of these 251 individuals, every fifth
patient (50 patients in all) was selected to form Group II
in the present study. Following the active phase of
treatment, all patients were placed in a maintenance care
program which included recall appointments every 3 to
6 months. At these periodic recalls, scaling, professional
tooth cleaning and repeated oral hygiene instructions
were given to each individual. The patients of Group I
have been followed up for 8 years and those of Group II
for 5 to 8 years (mean 6.2 years).
Following the termination of the initial treatment and
then once a year, the following parameters were assessed:
Plaque Index, Gingival Index, pocket depth, attachment
level and marginal alveolar bone height. In addition, an
analysis was carried out to assess the frequency of and

Figure 2a. Radiographic presentation of a patient of Group lib before treatment. The upper right first and second premolars and the
upper left second incisor and first premolar were extracted. The remaining maxillary teeth were periodontally treated and the patient
restored with a new maxillaryfixed bridge with three cantilever units on the left side. The original mandibular bridge was preserved after
extraction of the two left molars and periodontal treatment of the remaining abutment teeth, b. Radiographs obtained at the 5-year
control of the patient seen in Figure 2a. Two weeks after this follow-up appointment, the patient reappeared with the upper left canine
fractured. The root of the tooth was extracted, c. Control radiographs of the patient presented in Figures 2a and b 8 years after treatment,
i.e. 3 years after the extraction of the root of the maxillary left canine. Note that no further loss of alveolar bone has occurred around
any of the maintained abutment teeth following the initial treatment (compare with Figure 2a).

168 Nymán, Lindhe
Figures 2b and 2c
the reasonsfor technical failures which were detected in
bridgework during the maintenance period. This analysis
comprised the total patient material (251 individuals)
given the combined periodontal and prosthetic treat-
ment. In all, 332 fixed bridges of various extension were
analyzed.
The results showed that following periodontal treat-
ment, periodontal health can be maintained in patients
enrolled in a controlled oral hygiene program. The type
of maintenance care exercised in the present study was
equally effective in patients for whom fixed bridgework
was part of the initial treatment. Severe reduction of
periodontal support around the abutment teeth and dif-
ferences in design of the bridgework did not influence
the periodontal status during the observation period.
However, failures of technical nature occurred in 26 out
j. Periodontol.
April, 1979
of the 332 bridges. These failures appeared as (1) loss of
retention of retainer crowns from abutment teeth in 11
bridges, (2) fracture of bridgework in seven bridges, and
(3) fracture of abutment teeth in 8 bridges. The reasons
for these failures are discussed.
Acknowledgments
The authors express sincere gratitude to Dr. Per-Olof Glantz,
Chairman of the Department of Dental
Technology, Faculty
of Odontology, University of Gothenburg, for advice with the
biomechanical aspects on the present bridge material and to
Dr. Ricardo Parodi for his assistance in
radiographie bone
height determinations.
References
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Volume 50
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