53 Treatment of a Case of Advanced Periodontit Clinical Procedures Uti “Combined Preparation’ Technique Glankanco Diebo, ME, DDS* Grantence Comevol, HD. DDS, Son at Strano, MD. D 1M ScD" Pe) The clinical procedures described in this article refer to 6 case previously reported in earrer issues ofthis jour: rial (Figs. | to 3), in which both the treatment plan’ and laboratory pro- cedures? were delineated. The ou- thors will herein focus attention on the periodontal ond prosthetic dini- cal procedures which differ, some- whai, from those olready described by Yuodelis* and others.* In fact, clinical observations made in many previously treated cases and, more recently, in this case being pre- sented, caused the authors to make some modifications in the finishing line that may contribute to the soli tion of certain frequently encoun- tered problems. In this case, teeth ‘were prepared during periodontal surgery (Figs. 40 and 4b), in order to ‘obtain the following results * Plazes di Porta Mascorella No. 7, Bologna, aly + Via di Ville Ricott No, 28, Rome, aly 1. Elimination of residual calculus ‘and contaminated cementum in order to create « healthy root sur- face (fig. 5) 2. Elimination of undercuts (Fig. 6) in order to: a) Permit the accurate ‘elining of the provisional splint shortly after surgery. Normoly, itis necessary to remove and replace the provisional splint while the ccrylic is setting to ‘avoid “locking” into undercuts. Such manipulation generally deforms the margins ond preempts accurate clo- sure, It is also possible to inadver- tently extract o key abutment (Fig. 7) if meticulous care is not exercised, or ifthe acrylic polymerizes too rapidly bj Replace the old provisional splint with 0 new one shorly after surgery (Fig. 8). Ihis possible, in fact, to take aceurcte impressions without having t0 reprepare abuiments near the gin- Gival margin and, thereby, avoid in- terfering with wound healing during its delicate initial phase. ¢) Facilitate final preparations and impression. Most often this method allows the final impression to be taken without the necessity of ging val retraction, * achieving an accu- rate finishing line without the neces- sity of applying a bur subgingivally for further refinements (Figs. 9a to 9). The operator, therefore, need ‘only concem himself with adjust- ments of the occlusion, modifications in parallelism and, eventual, refine- menis of the preparation. In case it should become necessary to modify the preparation, having prepared the tooth during the surgicol proce- dure does nol interfere with the achievement of the new form 3. Deepening the form (Fig. 10} ‘barelling in” “Th lrtoratonal Jounal of Pods and Restorative Deny” 1/19859.8 A sree! fnew proviral shorty ber onadonal surge Cran fe snes of Gndteus and he presence ood ath apenas tc prea toch ‘aot hs thereby posto fasreae cn pro ‘sonal san whch oles several adetages ‘rina cl coc sensiy ral Eten soley, and tayo veeloahon of beter exten pearance The tow pra tmoy teore sere dvi “gener mais Gelodch wl ra ries oman for ‘re cansrvchon of he hn postess Aaion (by, he poten wil ein bath poychagcaty om the ethene cd encaoncf proven end Bolomealy because of bare antes se de brome Figure Fo Figure Figs 900 8 Fin! proporatons demonsrot "Sinoo sla, Gnguor rockon cords mere M3} "aod anc ghtorconcel ponorcters fee p ‘pdrcis fmhch contre os sich opal, bayand te unclonaeptha) he ina! pres 9) wal spp te lechncion wi rece, ‘Soch dacomed fahig ines The rnuton plasoe rods pase sich ay ela inching ne hal 9 becomes unnscosery to seach aulsangualy forthe end Of enor Jooihartre hfe ile pout one ‘ote he occeplabl esthete nl even hug femora move! be svegrahaly coved Te "The Intemational Jounal Pesodentes and Restorative Deny" 85 1985Fg_}0. During “open flop’ procedures spas. ig. 1) Toslmhae second and hid grace n- ig 12, never ta eliminate second an hind sto oc ra dy doen ates Bel sone ondm: Gade hon decir ng prose lireviemenancecrerareet acerca tuemercea ofthe root auch annonce repreparwicn of The emegring oot or ook Smee ok CF beret, figs a.nd 196, Josorre cases, 1th craparation dung period! rgey may perm the cvecion Pp. Most en ate soot preporton ding fecal whi are tao clase to each other Alor wound Resing in hese oe aces for prope ial sity, tnven Foot conte oh pronounce Srgine nl be posstle that would starwze be onatainabe wibaut the sxtcton of ane of toa Soneatie preva, fie, 18.“Semslonor” prooratons afer dito. Figs, a and Id Cronica toad, hyperplastic esve found nthe concoies pial of root ‘tical aor sacon nanny ola ‘Stotomy aller “Boreling mr propormions O00 esos “The lrtemotono Journal of Paredes ond Resoratva Dans” 1/1985,87 4, Root separation (Fig. 11). 5. Root amputation (Fig. 12) 6. Cortecting root proximity (Figs 13a and 136) Cleatly, tooth preparation does not ‘always extend to the alveolar crest The technique of fiber retention re. stricts footh remodeling to the level of connective tissue attachment, and, moreover, demonds that the ‘operator be very attentive and exer cise great restrain! and delicacy in ‘order to avoid injuring intact fibers cond removing healthy cementum. The outhors have used this method for si years and have noted the val- idity of the technique, which they maintain fo be of great value when opplied where indicated, The technique which will be described is, presented in on atlemp! to resolve, or at least diminish, soft fssue prob- lems which are frequently found in conjunction with accentuated con cavities on tooth surfaces. In order to eliminate the horizontal components of Class | and Class I furcation detachments, without +e. sorting fo root separation or root ee moval, it is necessary to markedly deepen the natural enatomic con- cavities found in maxillary and man- dibular molars’ and maxilary first premolars, The crown forms which inevitably result from these prepora- tions either are an exaggerated “tig ure 8” fin the case of maxillory fist premolers} or have extremely fort ‘ous contours (maxillary and man: dibular molars) (Fig. 14). In maxillary molars, where either of the vestibular roots hos been removed, the prep- ration is “semi-lunar” in form? (Fig. 15}. Likewise, concovities of varying depths are found after root separa- tion of removal, on the distal sur- faces of mesial roots and the mesicl surfaces of distal roots of lower mo- lors. This is also true ofthe distal sur- faces of mesiobuccel roots of maxi- lary molars? Along with these con- coviles, ond mos! notobly if they ore deep, there is @ nearly constant oc currence of chroniccily inflamed hyperplastic tissue, either during the healing period or during the final prosthetic phase (Figs. 160 and 16b}. Even if these sites are dificult to maintain hygienically, given their porticuler anatomy? it does not completely explain the phenomenon, since this tissue is also observed in potients with evidently good plaque control; on the other hand, itis not likely related to a restoration with margins at or below the gingiva since it has olso been noted when a provisional restoration is maintained for long periods of jime with margins 2 or 3 mm distant from the gingival suleus. It has been reported in the li- erature thot this sof lisue response may be attributable loa discrepancy between broad osseous architecture tnd a slender profile."°"" Combined Preparation’? In order to diminish such concavites, ‘and consequently to avoid the der- ivative soft tissue problem, tooth prep- ‘aration to the bony crest [or to the connective issue attachment level) during periodontal flap surgery seems an atiraciive solution. Aer having eliminated all of the under cuts ond interradiculor involvements, rather than leave a preporation which uniformly reflects the root or- chitecture ("igure 8” or ‘semi- lunar’), itis helpful to apply the fol lowing method. A chomfer is pre- pared ot the crestal level on only those portions of the root that are convex, without touching the con- ‘cave portions which thereby have a feathor-edge finishing line. In place cof a deep chamfer, o shoulder prep: ‘tation may be preferred depending upon the degree of protuberance of the convexities and the inclination of the r00! (Figs. 17a to 17c, 180 and 180), The various modifications of finishing lines at the crestal level re- main subgingival after healing and it is the profile of the abuiment which ‘emerges from the gingival suicus tha is considerably flattened as o result (Figs. 190 and 19b). Because the completed preparation may hove finishing line of varying form the name “combined preparation seems most appropriate.” ‘Wound heoling results in an epithe- lial attachment”? and, as previously described, the “combined prepora- tion’ finishing line remains subgingi- vol while the emergent profiles, which ore the contours of interest, will be rounded, ovoid, or, in any event, free of exaggerated con caviies. The odvantages of this technique are summarized below. “The hveatonalloumel of Parodontcs ord Restorative Defy” 1/176558 £3, hese pre tp 8 eh, mado apremstatpea te Hoteten fe ten et irae rar ered eens Sie SS len Se Se coe etl hon do weg own {1% “Combe repoaton* Ie one Wien comes Chonng échenlrorsahau Sheol a by ceo te pat of race ob whooche dlng ba pose a 17e Aer healng he prepared oot nore ‘none opal ho ter ono Senta neha the ucla Cotour ofthe Fins ine cman shoul remains a te Croan) suognghaly “The ntrtona Joumal of Pedant and Restorative Denisty” 1/1985Fig. 180 Alter removal of on a he buccal sito he manalan malar and preparation ot theremin roa there rome 9 orge ‘ve raion ether masoly ea 1. foe ron sca eee saeeees aes son Arh erent ea “he Intemtone! Jounal ot Pesedantics ard estorohve Dena” 1/198560 Pure a Fowe 200 Powe 206 Powe 1% Fg. 182 In tho cose ofthe patent nF. 1,0 opined prone one, (etulant concoioe os tsad on EF man \eryiefovemolar Fey to} Pre wor dane Sve the cernce sf true teens be ince the ho ans inthe sare subject oosom grease, conten logue coral ‘le foc te concise fon ist Premoir since wor fat hor fc be moro oe Seer pine coal pocedes on mow Fg 19 Thrae months eer sugary, veo pars normal arcund molars, wishes Ecxcnd mos cht vg fe “conned [pcporoton "Atarhe some teen te Theprosencec nilmeshypermloe eset on he Sethe et monly Retoremoir here he Stondordpreporahan was sed ig te ge Mo ond 208. Ata prepratons in enon suger Astin ins ro cal CS ‘os0 0 ene sdaguate gig embrasure Srottny Uilarg fhe prince the “combined Broparation "a ieus ict becrec pel {he prnma sifacee of accor eet sing © ‘red rnd domed stone, Car ko Hot [Gieeerd undone eo deco nen Belo 2S A coarse-grained tapered demond Sone s sds ears undrs, ‘Goring a srparot seth char erro ‘pall andloaher gor on acl ond ings facesge, 20e tp 208 Thre monte postopera ‘tle embronue spacer wit doulas. ‘ose if ensure hal posed haw be ‘Echncallysraiitiorward fo corstvct d easy fomanan by the poten ond heat pokes Pig. 20g, Droaram representing he ade space choot wag te “combed pegoron The om ‘nsnates ha fom the pred foots wovidhove hold he onda eresoron Fed boon usd 1. Improved access, factitating the polient’s oral hygiene, 2. A more uniform root/soft tissue relationship with disappearance of chronically inflamed, hyper- plastic tissue which suggests that the affirmations of Ochsen- bein'? and of Weisgold” may not bbe the only explanations of such @ phenomenon 3. Improved crown contours with optimal emergent profiles Factors which may limit the applica: tion of this method ore. 1. Size of the pulpal canal which may restrict the depth of root preparation. 2. Possible weakening of the abut- ment. There are several applications ofthis method, of which two will serve as i lustrations. In the case of close root proximity, where a standard prep- ration is inadequote, the use of round bur of appropriate size of the crestal level will create the space re- Quired, Subsequent use of a tapered stone will eliminate the resulting un- dercuts. After healing occurs, the chamiers will be beneath the gingiva cond the interproximal distance be- tween the prepared teeth will be ‘ample to provide space fora healthy popilla and proper hygienic mainte: nance (Figs. 20a to 20g) Another, and much less common, application of this method occurs when dealing with molars, especially mandibular molars which hove grade Il or Ill furcotion detachments combined with apically fused roots. The above desenbed technique is sed to create a separation of the roots since most often the inter radicular bony system is very thin with restricted access to the bifurco tion area. After healing there will be two emergent preparations with sut- ficient interradicular space. In cases ofthis type, where itis clearly mpos- sible to uilize either orthodontic pro- cedures or @ oct amputation without the aid of combined preparation, tooth extraction would probably be indicated (Figs. 21a and 216} The rtemotoral Journal of Psidontis and Restorative Danisy™ 1/19852 Figs 21a ond 206, Clinica ane radiological appearance, thee months ater suger, of o lower molar ‘nth apical fesed rats in whch there wos 2 second grade hucohon swonenont The yadopreak ‘hry chmcnstoes he adauate merproumal ombrasurs page sblsinod can tg “somboced oe sgraton”fachngue. The fal esterghons hae ol fen competed The rcgiaph Shows 9 mee iromewerk ma on acre overoy cong the hosing phase. Summary As a result of clinical observations, the authors have developed a method of tooth preparation during periodontal surgical procedures called “combined preparation” which permits the reduction or elimi nation af concavities created on root surfaces as the result of “barrelling in” preparations, or after root ampu: tations, This technique reduces or eliminates the consequent formation of chronically inflomed, hyperplastic fissues commonly observed in such ‘teas. Applications of this technique ‘ote proposed when confronted with ro0Is in close proximity to each other ‘ond in periodontolly compromised mandibular molars with furcation de tachments in combination with roots fused at their apices: “The Internationa Jounal l Pelco nd ResloaiveDenisy” V/1965 References | Camere, 6 feb, Gnd Tab LA poten! presentation: Banting « difcul case Int Periodont, Rest Dem. 651 1981 2, Tebbi,L, DiFebo, F, and Camevele,G. AA technique to obtain 0 precise funcional Geko Ving poral ied fo gl. n S'Peviodont Rest Den 449,198 3. Yuodelis, 8 A, and Faucher, R Prov Sioncl restorations: An integrated approach 1g peredontics and’ restorative dents. Dem Clin. Noth Am, 24.258, 1980, 4, Ross, 5. E, ond Gorgulo, A. The surgical management ofthe restoraive avec in- tetoce. In. J. Penodont Rest. Dent 39, i) 6. Comevale, G, ond DiFebo, G. Personal cammsunicalen, ” Grecter New York ‘Academy of Prosthodomies, Annual Con gress, New York, December 198) 2. Hamp, 5... Nyman, S., and Lindhe, Periodontal ‘rectment of mulfroated teeth 3°Clin Penodontal. 2-126, 1975, 8. Amsterdam, M, ond Rossman, S. R Technique ond homiseeton of multrocied teeth Alpha Omegon $3: 1960 9. Bower, C,.Furcaion morphology ol tive fo periodontal heatment 1 Petodonol 50.366, 1979. 10, Osteen, Card Ross, S.A evaluation ol osseous. surgery. Dent, Glin: Noh Am. 13:87, 1969 11. Weisgold, AS. Contours of the full crown testoration. Alpha Omegon Dee iar 12. Difebo, G. Personal Communication {sneer Congres oho aon Academy of Prosthetic Denisry. Bologna, Setober 1982. 13, Comevole, G,, Freni Stertntino, $ ‘ond Bifebo, G. Sot and hard tssvo wound feaing Iolowing toot preparation to te alveolar crest) Peviodon. Rest Dent 6:37 1988,