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CONTENTS

SL.N PAGE
TITLE
O. NO.
1 Introduction 2-5
2 Review of literature 6-12
3 Soft tissue consideration in rehabilitating patient with
completely edentulous ridges. 13-28

4 Soft tissue consideration in rehabilitating patient with

partially edentulous ridges. 29-33
5 Soft tissue consideration in rehabilitating patient with 34-61
fixed prosthesis.
6 Soft tissue consideration in patient undergoing 62-67
implant therapy
7 Managing soft tissue in patient rehabilitating with 68-69
maxillofacial defects
8 Conclusion 70-71
9 Bibliography 72-74


ͳ

 Introduction
The oral cavity is a difficult area to treat in prosthetic dentistry because of the
constraints of the lips, tongue and cheeks, challenges for access to visualize and
manipulate instruments, as well as the position of the teeth that are being treated
relative to the gingival tissues — which bleed if improperly managed. While for
operative dentistry and single-tooth restorations, the use of the dental dam provides
control of the field and access to tooth preparation and restoration, there are many
times in restorative dentistry that use of the dental dam is precluded. There are times
that caries or non-carious cervical lesions are at or below the free margin of the
gingiva — as well as, for fixed prosthodontics, crown or inlay/onlay margins are at
or below the free margin of the gingiva and access to them for preparation,
impressioning and cementation is impossible without additional techniques to
displace the gingival tissues and control gingival hemorrhage and sulcular fluids.
One of the most challenging aspects of crown and bridge is management of the
gingival tissues when making an impression. Tissue management includes placing
the gingival tissues away from the preparation margins so they can be impressed,
combined with providing for hemostasis when the gingival tissues are susceptible to
bleeding. The rationale for tissue management is a critical aspect of impression
making, whether the impression is made with a conventional impression material or
by a digital impression technique so that all tooth preparation margins are captured in
the impression to assure an excellent marginal fit of a laboratory fabricated
restoration. From this, the final restoration will be well adapted to the tooth
preparation so that when cemented, the restoration will prevent recurrent caries, tooth
sensitivity and gingival irritation. No matter what the circumstance for soft tissue
management for restorative dentistry, the goal for management of gingival tissues
requires that the periodontium be in a state of health. As part of any comprehensive
treatment plan, especially if a restorative intervention is required and there is need for
control of the gingival tissues, that the teeth are cleaned and the periodontium
brought to a state of health. With this accomplished, restoration will be more easily
accomplished. Management of the gingival tissues for access, visualization,
maintaining a controlled field for restoration placement and cementation can be
accomplished with a variety of techniques.
While rehabilitating the patient with fixed prosthesis, there are a variety of
techniques and materials that allow the clinician to manage the gingival tissues
during restoration and when making impressions. These include gingival retraction
cords, chemical reagents, electrosurgery, laser tissue sculpting, copper tube


ʹ

impressions, hydraulic impressions and non-invasive, atraumatic
displacement/hemostatic materials. In most cases, gingival retraction cord is the most
effective method for retracting tissue to the depth of the sulcus. The other methods
have their advantages and indications. In any case, the control of the soft tissue for
exposing the margins of the tooth preparation for restoration and impressioning is
critical. It would be worthwhile for the clinician to understand all the choices
available.
The complete denture more than any other dental treatment depends for its
success not only on meticulous replacement of lost teeth and adjoining structure but
also health of oral soft tissue at the start of the treatment. If we ignore the oral health
of soft tissue around the denture even the scientifically constructed and meticulously
planned denture will fail at some point of time. So thorough examination of soft and
hard tissue, if pathological, then proper treatment before constructing denture should
be done. Some soft tissue undercuts which were unfavorable at the start of the
treatment may be turned to favorable and may help in retention of denture after
proper preprosthetic surgery whenever indicated or by using nonsurgical means when
surgery is not indicated. Today’s completely edentulous patients are more health
conscious and discriminating. Proper intraoral and extra oral examination before start
of the treatment holds the key to success of denture.
When occlusal pressure is applied to a complete denture, there is a
displacement or distortion of the mucous membrane and a consequent movement of
the denture. This displacement is related to changes in blood circulation and tissue
elements of connective tissues, and depends on the histological and morphological
characteristics of the mucous membrane that is in close contact with the prosthesis.
The distortion of the masticatory mucosa and the related movement of the denture
can result in acceleration of residual ridge resorption and loss of retention and
stability of the denture. The thickness and displace ability of the mucosal support for
dentures should be considered when recording impressions. Mobile tissue presents
problems of support and stability which are dealt with either by surgical reduction in
the thickness of these tissues or by using special impression techniques which
distribute the load in a particular manner. Clinical assessment of the supporting tissue
in complete denture patients is important for preoperative diagnosis and treatment
planning.Clinicians and patients were initially satisfied with the return to normal
masticatory function and fixed implant restorations. However, clinicians and patients
soon expressed interest in the aesthetic replacement of individual missing teeth with
implant restorations. Standard abutments with cylindrical, non-anatomic emergence


͵

profiles were never aesthetically acceptable; they were indeed quite functional.
Anatomic, emergence profiles were considered essential for optimal, peri-implant
soft tissue contours (fig.1).

Fig.1 Emergence profile around implant

Lazzara, designed three sizes of anatomic-like healing abutments that guided

peri-implant soft tissue healing after implants were placed or uncovered. These
healing abutments were available in three diameters and multiple heights. The
healing abutments replicated the approximate sizes of the teeth being replaced and
generated reasonable peri-implant soft tissue contours for restorations in the aesthetic
zone. During the transition from treating edentulous patients to treating partially
edentulous patients, custom abutments were the only realistic alternative to develop
aesthetic, anatomic-like implant restorations. Custom abutments were expensive for
both clinicians and dental laboratory technicians to use in terms of technique
sensitivity, expense and labor. Custom abutments were ideal in following soft tissue
contours and also for correcting angulations associated with mal-posed implants. A
major challenge in implant dentistry is to provide a ‘‘perfect’’ aesthetic finish of the
final restoration on implant support. The need for ‘‘perfect’’ aesthetics is usually
more demanding in the anterior region (aesthetic zone).This requires the restored
tooth to resemble the size, form, colour and hue of its neighbours and to be framed
by soft tissues that mimic those in a healthy/normal state. To achieve this, it is
necessary to pay attention to the position of the gingival margin, the shape, color and
contour of the labial gingival tissue and the adequacy of the interdental papillae.
Not all situations can be treated partially or totally with surgery, so that
suitable rehabilitation may call for the provision of facial prosthesis. This may be
free standing or linked to oral prosthesis depending upon the site, size of defect &
need for mutual stability created by the interlocking of two or more parts. The
prosthetic restoration of dentoalveolar and maxillofacial defects has significantly
improved with development of new materials and advances in clinical, surgical and
lab techniques. Soft tissue in and around the prosthesis should be given importance to


Ͷ

provide the best treatment option for patient. Thus in replacing any missing part in
prosthodontics by removable or fixed therapy or with the help of implants soft tissue
management before during and after the treatment play a major role in success of the
prosthesis.


ͷ

 Review of literature
A study was done to compare the gingival health surrounding full crown
restoration on a controlled population .A total of 26 patients aged between 39-68
which had previously received periodontal therapy and extensive oral hygiene
instructions and in rigid monitoring and maintenance programme and whose
restorations were placed 1-9 years were selected for the study. The volume of
crevicular fluid around full crown restoration was measured with Periotron
instrument to compare gingival inflammation between restored and non restored
tooth in same patient .And the results shown that the degree of inflammation was
same in tissue surrounding restored and non restored teeth because the patients were
highly motivated and was undergoing rigid dental recall program and even this study
does not show any difference in gingival inflammation between the crowns with
supragingival and subgingival margins.5
In another study author compared gingival retraction methods with respect to
crevicular fluid measurement, recession and loss of attachment. Rotary gingival
cuerettage produced a stastically significant recession greater than that of the
retraction and/or electrosurgery methods. Retraction cord induced the least amount of
damage both in terms of attachment loss and recession.Clinical implications: All
methods induce some degree of transient damage which heals without any permanent
loss of attachment. Recession was greater with gingittage, minimal with
electrosurgery and nonexistent with cord. If extreme care and respect for tissue are
not exercised, all three methods can induce irreparable damage.6
A study was done to determine the effect of gingival inflammation of gingival
retraction cords impregnated with different chemical agents. 18 adolescents needing
premolar extraction prior to orthodontic treatment were selected. At random different
retraction cord was placed into 4 sulci-right buccal, right lingual, left buccal, and left
lingual .These retraction cords were either untreated or contain potassium aluminum
sulfate, aluminum chloride or 8% racemic epinephrine. Cords were kept for 15 min.
Half of the subjects were recalled after 24 hours and the other half in 7 days. Free
gingival tissues were excised surgically from four sites and histologically studied for
inflammation. It was found that potassium aluminum sulfate, aluminum chloride or
8% racemic epinephrine did not demonstrate practical difference although potassium
aluminum sulfate produced fewer inflammatory changes than other agent .study also
showed that factor other than chemical agents like physiologic difference in
individuals may play a role in amount of gingival inflammation.7


͸

 Another study was done to compare three impression techniques: minimal
pressure, biting (maximum) pressure, and functional pressure. A study of the
technique used in impression making, as it has an important role in the reaction of
supporting tissues to complete dentures. Thirty edentulous patients were divided into
three groups of ten. Impressions were made by one of the three techniques listed
above, and dentures fabricated and delivered. Biopsies were taken from the
mandibular ridges in the premolar area before, and six months after denture delivery.
The biopsies were evaluated histologically and histochemically. Results shown that
after dentures were worn for six months there was a relative increase in the thickness
of the keratinized layer. The biting (maximum) pressure technique produced
disturbed dekeratinization and an increased number of mononuclear inflammatory
cells. They concluded that the biting (maximum) pressure technique may alter tissues
unfavorably. The minimal pressure technique proved to be satisfactory, but not to the
same extent as the functional technique. Therefore the functional technique is the
recommended method of impression making.8
A clinician is presented with three options for margin placement:
supragingival, equigingival (even with the tissue), and subgingival locations. The
supragingival margin has the least impact on the periodontium. This margin location
has been applied in non-esthetic areas due to the marked contrast in color and opacity
of traditional restorative materials against the tooth. With the advent of more
translucent restorative materials, adhesive dentistry, and resin cements, the ability to
place supragingival margins in esthetic areas is now a reality. Therefore whenever
possible, these restorations should be chosen not just for their esthetic advantage but
for their favorable periodontal impact as well. The use of equigingival margins
traditionally was not desirable because they were thought to train more plaque than
supragingival or subgingival margins and therefore result in greater gingival
inflammation. There was also the concern that any minor gingival recession would
create an unsightly margin display. These concerns are not valid today, not only
because the restoration margins can be esthetically blended with the tooth but also
because restorations can be finished easily to provide a smooth, polished interface at
the gingival margin. From a periodontal viewpoint, both supragingival and
equigingival margins are well tolerated. The greatest biologic risk occurs when
placing subgingival or equigingival margins for finishing procedures, and in addition,
if the margin is placed too far below the gingival tissue crest, it violates the gingival
attachment apparatus. When the restoration margin is placed apical to the gingival
tissue crest, it impinges on the gingival attachment apparatus and creates a violation


͹

of biologic width. Two different responses can be observed from the involved
gingival tissues. One possibility is that bone loss of an unpredictable nature and
gingival tissue recession occur as the body attempts to recreate room between the
alveolar bone and the margin to allow space for tissue reattachment. This is more
likely to occur in areas where the alveolar bone surrounding the tooth is very thin.
Trauma from restorative procedures can play a major role in causing this fragile
tissue to recede.9
Using a representative sample of 5028 dentulous adults the occurrence of
periodontal pockets was studied separately for the maxillae and the mandibles among
removable partial denture (RPD) wearers and non-wearers, RPD(s) were worn in
11.2% of the 3444 maxillae with at least four natural teeth remaining, and in 7.7% of
the 4706 corresponding mandibles (P'<0-001). Periodontal pockets were more
frequently observed in the maxillae than mandibles. Wearing of RPDs highly
significantly (P<0-0001) increased the odds of having periodontal pockets in general
(4 mm or more) as well as the odds of having deeper periodontal pockets (exceeding
6 mm). This was observed both in the maxillae and in the mandibles. These results
suggest that wearing of RPD is a threat to periodontal tissues and that dentist should
take care to frequently recall their patients fitted with RPD(s).During the recall visits
more attention should be paid to the periodontal conditions of patients wearing
RPD(s).10
A study was done to describe a simple alternative approach that does not
record the position of the neutral zone, but rapidly assesses how well a functioning
denture conforms to the potential space, and to evaluate the contour of polished
surface.The technique used here involved applying about 5ml of low viscosity
silicone impression material (Provil), to all of the polished labial/buccal surfaces
including 3mm onto the fitting surfaces of the maxillary denture. The process was
repeated (except all polished surfaces were coated with Provil) for the mandibular
denture. The patient was given a moistened piece of paper to chew (3 x 3 cm)
vigorously but not swallowing it. Once the impression material has set, the denture
was removed and evaluated. Results shown that areas where the impression material
has been displaced indicate areas of denture impingement on normal muscular
activity. From this technique, it can be determined if the flange length or thickness of
the denture is overextended (ie. mylohyoid area), a tooth is not in the correct
position. Assessment of the anterior tooth position can also be done using the
labiodental and linguodental speech sounds (i.e. "F", "V" and "Th").12


ͺ

 A study was done to find out the effect of crown margins on periodontal
conditions in patients who regularly receive professional care. For this study 831
regularly attending patients were examined for plaque, gingival inflammation,
calculus and probing depth were assessed on facial and mesiofacial surface of the 6
teeth as per Ramjford index. And the final results showed significantly greater
gingival inflammation and deeper probing depths with subgingival cast restoration
margins. But plaque score and calculus index score were significantly less frequent in
crowned teeth than in uncrowned teeth.13
Investigated the length of the time medicated displacement cord should remain
in the sulcus prior to impression making. A silk cord was placed and not removed
from the sulcus. Medicated cords (Hemodent/Ultrapack) were placed for 2, 4, 6, and
8 minutes. Crevicular widths were measured at the midbuccal and transitional line
angle areas. At both regions, crevices displaced for 2 mins were significantly smaller
at 20 secs than crevices displaced for 4, 6, and 8 mins. In the transitional line angle,
crevicular widths were significantly smaller than at the midbuccal at 20 secs for all
times, and remained so upto 180 secs. The authors concluded that cord should remain
in the sulcus for an optimum time of 4 mins prior to impression making. Longer
periods failed to provide greater sulcular width.1
A follow-up study was done to quantify the change in the periimplant mucosal
level after treatment of edentulous patients with fixed prostheses on osseointegrated
endosseous implants. Twenty patients were included in the study: 10 were treated in
the maxilla, and 10 were treated in the mandible. Both groups had fixed prostheses
on osseointegrated Brånemark implants. Periimplant mucosal level was measured
with a calibrated probe after removal of the prostheses at the 1-year follow-up. These
measurements were compared to those made on the original master casts. Results: A
larger mean retraction (–) was observed in the mandible (–1.6 mm) compared to the
maxilla (–0.8 mm), but there was great variation. The individual values varied from –
4.5 to +1.0 mm in the mandible and from –6.0 to +6.0 mm in the maxilla. And it was
concluded that peri-implant soft tissue recession occurs during the first year in
edentulous jaws after treatment with implant-supported fixed prostheses and more so
in the maxilla than the mandible.20
A study was done to determine the optimal soaking time for 3 retraction cords
of different thickness to ensure adequate uptake of the haemostatic solution. Braided
ULTRAPAC retraction cords of 3 different thicknesses (No. 00, No. 0, and No. 1)
with identical lengths (35 mm) were used. The capability of the cords to absorb
liquids was measured by a gravimetric method. Different sulcus retraction solutions


ͻ

(epinephrine, aluminum chloride, and ferric sulfate) were tested, with physiological
saline solution used as the control. The cords were soaked for various time intervals
(2 seconds; 1, 5, and 60 minutes; and 24 hours) in the medicament solutions at room
temperature. In each of the 4 treatment groups, 75 pieces of cord were tested by
determining the grams of fluid absorbed by grams of dry cord (gram/gram). Before
the cord was weighed, excess fluid accumulating on the outer surface of the cord was
removed by filter paper saturated in the corresponding test solution. The data were
analyzed by F test analysis and P<.05 was regarded as significant. Results showed
that in each group, regardless of the cord type (No. 00, No. 0, or No. 1) or
medicament solutions tested, the amount of fluid absorbed increased with the soaking
time, but to different extents. A logarithmic relationship in a linear plot between the
amount of fluid absorbed and the soaking time was demonstrated. The relationship
established offered an exact determination of both the rate and the saturation level of
liquid uptake. The rate of liquid uptake calculated from the saturation equations
exhibited significant correlation with the cord thickness (P<.05). The saturation
levels of the solutions did not show correlation with the cord thickness (P>.30).it is
found that 20 minutes of soaking time was necessary for saturation of the cords
before use, provided that air trapped within the cords was removed. In addition to the
soaking time, the saturation of the cords with the solutions largely depended on the
wetting of the cords 22
A study was done to find the effect of three different periodontal pre-treatment
procedures on the success of telescopic removable partial dentures. For this
prospective study, 120 teeth consisting of maxillary and mandibular canines and
premolars were divided into three groups each containing 40 teeth. The first group
was treated with professional prophylaxis only. The second group received additional
deep scaling. With the third group, additional surgical periodontal flap surgery and
scaling was performed. Both papillary bleeding index (PBI) and probing depth (PD)
were evaluated before, during and after treatment. During the subsequent prosthetic
treatment phase all teeth were then used as telescope abutments supporting a
removable prosthesis. The documentation of the attachment level (AL) was then used
as a clinical parameter. One year after the incorporation of telescopic removable
partial dentures (RPDs), PD, PBI and AL were again evaluated. A significant
decrease in inflammatory indices (PBI) was found for all types of periodontal
treatment. And the reduction in PD was significant for all of the three groups. The
greatest reduction in PD was observed in the group in which a surgical approach was
used. Evaluation of the attachment level after the incorporation of the telescopic


ͳͲ

RPDs showed that tooth position did not influence the periodontal prognosis and that
the use of telescopic RPDs exerted no ascertainable negative influence on the
periodontium of the abutment teeth.23
Another study was done to examine the effects of placement of retraction cord
subgingivally upon periodontal indices including plaque index (PI), gingival index
(GI), pocket depth (PD), bleeding on probing (BOP), and attachment level (AL), as
well as gingival crevicular fluid (GCF) and TNF-alpha levels. Ten teeth in 6 patients
who were periodontally healthy were selected. These teeth had pocket depths of 3
mm or less, no evidence of significant loss of attachment, BOP, or plaque
accumulation. The patients each received an oral prophylaxis. The following week,
baseline measurements of periodontal indices and TNF-alpha were taken and
the retraction cord was placed for 15 minutes. Following removal, the patients were
dismissed. The periodontal indices measured included PI, GI, PD, BOP, and AL. In
addition, the levels of TNF-alpha in GCF were investigated. These measurements
were made before gingival retraction as a baseline and on the 1st, 3rd, 7th, 14th, and
28th days post retraction. A repeated measure ANOVA showed that TNF-alpha
levels in GCF were significantly increased at all five intervals
after gingival retraction compared to the baseline. The mean TNF-alpha level peaked
at Day 1 (0.90 +/- 0.62), then declined at Days 3 (0.53 +/- 0.16), 7 (0.43 +/- 0.08), 14
(0.47 +/- 0.10), and 28 (0.43 +/- 0.08) but was still elevated 54% above baseline at
Day 28, p < 0.01. The GI was significantly elevated at Day 1 (0.9 +/- 0.49), p < 0.01;
Day 3 (0.53 +/- 0.32); and Day 7 (0.33 +/- 0.33), p < 0.05. Unlike TNF-alpha, GI
recovered to the baseline by day 14. Other periodontal parameters, PI, PD, BOP, and
AL were not significantly altered by the gingival retraction procedure.And it was
concluded that that gingival retraction causes an acute injury that heals clinically in 2
weeks as is indicated by the GI. It also provides the first evidence
that gingival retraction results in an elevation of the pro inflammatory cytokine,
TNF-alpha, in GCF.25
Another study was done to evaluate the effect of a cordless retraction paste
material, Expasyl(Acteon), on TiUnite (Nobel Biocare) implant surfaces. Three areas
of the fixtures were evaluated before and after contact with the retraction paste using
scanning electron microscopy (SEM) to evaluate changes in surface topography and
energy-dispersive spectroscopy (EDS) to identify any surface chemistry
modifications. Analysis of the TiUnite surface on a nanometer scale revealed a
porous structure with numerous craters created during the breakdown phenomenon of
anodic oxidation produced by the manufacturer. Under SEM low magnification


ͳͳ

(×500), no difference was seen on the surface before and after contact with the
retraction paste. In backscattered electron (BSE) mode, composition contrast was
evident with “white particles” observed on the implant surfaces. Local analysis via
EDS showed these “residual deposits” to be composed of Al and Si. SEM images at
higher magnification (×5000) showed more surface alterations in the form of similar
deposits on the implant surfaces The data obtained from the surface chemical
analysis of each implant was analyzed by three-way analysis of variance (ANOVA)
using the StataV11 statistical program. The number of rinses, the exposure times and
the three areas (C, JC and MT) were the selected factors. Separate analysis was
performed for each sample for the different periods. P < 0.05 was considered
statistically significant.27
A study was done to analyze the pattern of upper complete denture movement
related to underlying ucosa displacement. A sample of 10 complete denture wearers
was randomly selected, which had acceptable upper and lower dentures and normal
volume and resilience of residual ridges. The kinesiographic instrument K6-I
Diagnostic System® was used to measure denture movements, according to the
method proposed by Maeda et al.7, 1984. Denture movements were measured under
the following experimental conditions: (A) 3 maximum voluntary clenching cycles
and (B) unilateral chewing for 20 seconds. The results showed that under
physiological load, oral mucosa distortion has two distinct phases: a fast initial
displacement as load is applied and a slower and incomplete recovery when load is
removed. Intermittent loading such as chewing progressively reduces the magnitude
of the denture displacement and the recovery of the mucosa is gradually more
incomplete. 31


ͳʹ

Soft tissue management in complete denture

With the eventual bony remodeling that follows tooth loss, muscle and frenum
attachments that initially were not in a problematic position begin to create
complications in prosthetic reconstruction and to pose an increasing problem with
regard to prosthetic comfort, stability, and fit. Often these attachments must be
altered before conventional restoration can be attempted.1 As dental implants become
commonplace in the restoration of partially and totally edentulous patients, surgical
alteration of these attachments is indicated less often. Nevertheless, inflammatory
conditions such as inflammatory fibrous hyperplasia of the vestibule or epulis, and
inflammatory hyperplasia of the palate must be addressed before any type of
prosthetic reconstruction can proceed. 2 Obviously, any lesion presenting pathologic
consequences should undergo biopsy and be treated accordingly before
reconstruction commences. In keeping with reconstructive surgery protocol, soft
tissue excesses should be respected and should not be discarded until the final bony
augmentation is complete. Excess tissue thought to be unnecessary may be valuable
after grafting or augmentation procedures are performed to increase the overall bony
volume.
The evolutionary cycle has selected a masticatory system which is functionally
efficient using natural teeth and an omnivorous diet. This system would be designed
in a totally different fashion if it were selected based on the model of the complete
denture wearer. Dentures are rigid pieces of acrylic resin which are shaped to fit the
soft tissue covering of the jaws and be compatible with the functioning and ever
changing oral environment. Dentures are subject to the physical laws which form the
realities of this oral environment. No denture, regardless of how well it is
constructed, can overcome the limitations of the foundation on which it is placed.The
goal of preprosthetic surgery is to modify the oral environment to render it free of
disease and to make its form and possibly its function more compatible with the
requirements of complete denture wearing.

Here we will discuss about the soft tissue abnormalities which can create
interferences in proper functioning of denture and their management under two
headings:

A) SURGICAL
B) NON SURGICAL


ͳ͵

 Preprosthetic surgery in the
t 1970s and early 1980s involved meethods to prepare or
improve a patient’s ability to wear complete or partial denturess. Most procedures
were centered on soft tissuee corrections that allowed prosthetic devices
d to fit more
securely and function more comfortably.
c

Definition of preprostheticc surgery

“Surgery performed to prrepare the remaining oral tissues to t best support a

prosthesis”
GPT8 : - “Surgical proceduures designed to facilitate fabrication of
o a prosthesis or to
improve the prognosis of proosthodontic care.”

Soft Tissue Procedures und

der preprosthetic surgery are:
1. Maxillary tuberosity reduction
r (soft tissue)
2. Mandibular retromolaar pad reduction
3. Lateral palatal soft tissue excess
4. Unsupported hypermoobile tissue
5. Inflammatory fibrous hyperplasia
6. Inflammatory papillarry hyperplasia of the palate.
7. Labial frenectomy
8. Lingual frenectomy

Soft tissue surgery for ridgge extension of the mandible

1. Transpositional flap vestibuloplasty

v (Lip Switch)
2. Vetibule and floor of the
t mouth extension procedure
3. Relocation of the menntal nerve
Soft tissue surgery for maxxillary ridge augmentation

1. Submucous vestibulopplasty
2. Maxillary skin graftinng vestibuloplasty

1. Maxillary tuberosity reduction (Soft Tissue)

Fig.2 Enlaarged maxillary soft tissue on both sidee.


ͳͶ

 The amount of soft tisssue available for reduction can oftenn be determine by
evaluating a presurgical pannoramic radiograph – If a radiograph is not of the quality
necessary to determine soft tissue thickness, this depth can be meaasured with a sharp
probe after local anaesthesiaa is obtained at the time of surgery.If sooft tissue undercuts
are there on both tuberositiees ( Fig.2), most often reduction of soft
ft tissue undercut of
only one side is removed andd other side undercut is used as a favorrable undercut

Technique
1. Administer local anesthettic infiltration in the posterior maxillarry area.

2. An initial elliptical incision is made over the tuberosity in the area requiring
reduction and this sectionn of tissue is removed (Fig.3).

Fig.3
Technique for soft tissue tubberosity reduction.

3. The medial and lateral margins

m of the excision must be thinnned out to remove
excess soft tissue, allowiing further soft tissue reduction and providing
p a tension
free closure.

4. Interrupted or continuouus sutures are placed, removed afterr 5 to 7 days and

impressions can generallyy be taken 3 to 4 weeks postoperativelyy.

2. Retromolar pad reductiion

Rarely is it required to perform this procedure. LA infiltration in the area
requiring excision is sufficiient. An elliptical incision is made, exxcising the greatest
area of tissue in the posterrior mandibular area.Slight trimming of the margins is
carried out with the majorityy of tissue reduction on the facial aspeect.Excess removal
of tissue in the submucosaal area of the lingual flap may resultt in damage to the


ͳͷ

lingual nerve and artery.Thhe tissue is approximated with interruppted or continuous
sutures.

3. Lateral palatal soft tissuue excess

The preferred technnique requires superficial excision of o the soft tissue
excess.LA infiltrated in the greater
g palatine area and anterior to thee soft tissue mass is
sufficient. With a sharp scallpel blade in a tangential manner, the superficial
s layers of
mucosa and underlying fibbrous tissue can be removed to the extent e necessary to
eliminate undercuts in soft tissue bulk. Following removal of thiis tissue, a surgical
splint lined with a tissue conditioner (5-7 days) can be insertted to aid healing.
Submucosal resection as described for soft tissue tuberosity redduction is avoided
because the amount and exteension of soft tissue removal under muucosa is much more
extensive and creates the rissk of damage to the greater palatine vessels, with possible
sloughing off of the lateral palatal
p soft tissue area.

4. Unsupported hyper mob bile tissue (Fig.4).

Excessive hypermobiile tissue without inflammation on thhe alveolar ridge is
generally the result of resorpption of the underlying bone, ill-fitting dentures or both.

Fig. 4 Unsupported hyper mobile

m tissue

Technique
1. A local anesthetic is injeccted adjacent to the area requiring tissuue excision.

2. Two parallel full thickness incisions are made on the buccal andd lingual aspects of
Fig 5-A).
the tissue to be excised (F

3. A periosteal elevator iss used to remove the excessive sofft tissue from the
underlying bone. A tangeential excision of small amounts of tisssue in the adjacent
areas may be necessary to allow for adequate soft tissue adaptaation during closure
(Fig 5- B,C).


ͳ͸

 These additional excisionns should be kept to a minimum to avoid
a removing too
much soft tissue and to prevent detachment of periosteum from underlying bone.

4. Continuous or interruptinng sutures are used to approximate thhe remaining tissue

and are removed 7 days after
a surgery (Fig 5-D).

 

 

Fig. 5 A- Full thickness inncision on buccal and lingual aspectts. B,C- Periosteal
elevator is used to remove the excessive soft tissue, D- Continuous or interrupting
sutures are used to approxim
mate the remaining tissue.

A possible complicattion of this procedure is the obliteraation of the buccal

vestibule as a result of tissuee undermining necessary to obtain tissuue closure.
5. Inflammatory fibrous hyperplasia
h

In the early stages, whenw fibrosis is minimal nonsurgicaal treatment with a

denture in combination witth a soft liner is frequently sufficientlly for reduction or
elimination of this tissue.
When this condition has h existed for some time, significant fibrosis occurs and
then this will not respond too non surgical treatment and excision is the treatment of
choice.
Three techniques can be used for successful treatment of infflammatory fibrous
hyperplasia.
a. When the area to be exccised is minimal, electrosurgical techniiques provide good
results for tissue excisionn.

ͳ͹

 (If tissue mass is extensive, excessive vestibular scarring will occur).
b. If the tissue mass is extensive, simple excision and reapproximation of remaining
tissue is preferred.
c. Areas of gross tissue redundancies, excision frequently results in total elimination
of the vestibule – in such cases, excision of the epulae with mucosal repositioning
peripherally and secondary epithelialization is preferred.
In this procedure, the hyperplasic soft tissue is excised superficial to the
periosteum from the alveolar ridge area.
A clean subperiosteal bed is created over the alveolar ridge area and the
unaffected margin of tissue excision is sutured to the most superior aspect of the
vestibular periosteum with an interrupted suture technique.
A surgical splint or denture lined with soft tissue conditioner is inserted and
worn continuously for the first 5 to 7 days with removal only for oral saline rinses.
Secondary epithelialization usually takes place allowing for denture impressions
within 4 weeks.

Note: The hyperplastic tissue usually represents only the result of an inflammatory
process; however other pathologic conditions may exist. It is therefore imperative
that representative tissue samples always be submitted for pathologic examination
after removal.

6. Inflammatory papillary hyperplasia of the palate

In very early stages, non surgical treatment, such as proper denture adjustment,
combined with a tissue conditioner may eliminate or reduce the problem.3 If removal
is required, a mucosal excision superficial to the periosteum is recommended and can
generally be performed with local anesthetic infiltration in the palatal area.
Another technique is to use electrosurgical loops for excision of the palatal
mucosa maintaining a split thickness excision so the palatal bone is not cauterised. A
corsely fluted acrylic or bone bur or dermabrasion brush in a rotating handpiece can
be used to abrade the superfacial layer of palatal mucosa. Following tissue incision,
insertion of a splint or denture containing a soft tissue liner provides improved
patient comfort during the healing period.
Secondary epithelialization usually takes place in approximately 4 weeks.

7. Labial frenectomy
Three surgical techniques are effective in the removal of frenal attachments:

ͳͺ

1. Simple excision (effective when mucosal and fibrous tissue band is relatively
narrow),
2. Z- plasty (Fig. 6),
3. Localized vestibuloplastty with secondary epithelialization (ppreferred when the
frenal attachment has widde base).

Fig. 6 Z-plasty

Techniques
Local anesthetic infilltration in area of frenem is administeered taking care to
avoid excess infiltration diirectly into the frenum area since itt may obscure the
anatomy that must be visualiized at the time of excision.

A.

1. For simple excision, a narrow

n elliptical incision around the frenal
fr area down to
the periosteum is complleted. The fibrous frenum is then sharrply dissected from
the underlying periosteuum and soft tissue, and the margins of the wound are
gently undermined and reapproximated.
r
2. Placement of the first sutture should be at the maximal depth oof the vestibule and
should include both edgees of mucosa and underlying periosteuum at the height of
the vestibule beneath thet anterior nasal spine. This will reduce hematoma
formation and allow forr adaptation of the tissue to the maxximal height of the
vestibule.

3. The remainder of the inciision should then be closed with interruupted sutures.

B.
1. In the Z-Plasty techiquee an excision of the fibrous connecttive tissue is done
similar to above. After excision
e of the fibrous tissue, two obblique incisions are
made in a Z fashion – one at each end of the previous area of exxcision.


ͳͻ

2. The two pointed flaps are then gently undermined and rotated to close the initial
vertical incision horizontally.

This technique may decrease the amount of vestibular ablation sometimes seen
after linear excision of a frenum.

C. Localized Vestibuloplasty with secondary epithelialization – indicated when the

base of the frenal attachment is very wide as in many mandibular anterior frenal
attachments.

1. Local anesthetic is infiltrated primarily in the supraperiosteal areas along the

margins of the frenal attachments.

2. An incision is made through mucosal and underlying submucosal tissue without

perforating the periosteum. A supraperiosteal dissection is completed
undermining the mucosal and submucosal tissue with scissors or by digital
pressure on a sponge placed against the periosteum.

3. After a clean periosteal layer is identified the edge of the mucosal flap is sutured
to the periosteum at the maximal depth of the vestibule, and the exposed
periosteum is allowed to heal by secondary epithelialization. A surgical splint or
denture containing soft tissue reliner is often useful in the healing period.

8. Lingual frenectomy (Fig. 7)

 

Fig. 7 Lingual frenectomy (surgical procedure).

Technique
1. Bilateral lingual blocks and local infiltration in the anterior area provide adequate
anesthesia.

2. The tip of the tongue is controlled by placing a traction suture.

3. The lingual frenum is released by incising the attachment of the fibrous

connective tissue at the base of the tongue in a transverse fashion followed by

ʹͲ

 closure in a linear directiion, allowing for complete release of the
t anterior portion
of the tongue. (Fig. 7-A)

A hemostat can be placeed across the frenal attachment at the base of the tongue
for approximately 3 minnutes providing vasoconstiction and a nearlly bloodless
field during the surgical procedure.
p

4. Margins of the wound arre carefully undermined and closed parrallel to the midline
of the tongue.

Care must be excised to avooid blood vessals at the inferior aspectt of the tongue and
floor of the mouth region annd to the submandibular ducts openinggs – during incising
and suturing

Transpositional flap vestib

buloplasty (Lip switch) (Fig. 8)

Fig. 8 Transpositional flap vestibuloplasty

v (Lip switch)

‡ Lingually based flap vestiibuloplasty was first described by kazannjian

‡ Mucosal flap pedicled frrom the alveolar ridge is elevated froom the underlying
tissue and sutured to the depth
d of the vestibule
‡ The inner portion of the liip is allowed to heal by secondary epithhilization
‡ Modified technique of transposing
t a lingually based mucosaal flap and labially
periosteal flap has becomee popular
‡ When adequate mandibuular height exists this procedure incrreases the anterior
vestibular area which impproves the denture retention and stabilitty

Indications:
‡ Adequate anterior mandibbular height,
‡ Inadequate facial vestibular depth from mucosal and muscularr attachment in the
anterior mandible

ʹͳ

‡ Presence of adequate lingual vestibular depth
Advantages:
‡ Do not require hospitalization
‡ No Donor site surgery
‡ No prolonged periods without a denture
Disadvantages
‡ Unpredictable relapse of vestibular depth
‡ Scarring in the depth of vestibule
‡ Problems with adaptation of the peripheral flange area of the denture

Vestibule and floor of the mouth extension procedure

‡ Similar to attachment of labial muscles and soft tissues to denture bearing area
mylohyoid and genioglossus muscles in the floor of the mouth reduce the
vestibular depth in lingual aspect
‡ Trauner described detaching the mylohyoid muscles from the mylohyiod ridge
area and repositioning them inferiorly
‡ This effectively deepens the floor of the mouth thus relieving the influence of the
muscle on the denture
‡ Macintosh and obwegesser described effective use labial extension procedure
combined with Trauners procedure to provide maximum vestibular extension to
both buccal and lingual aspects of mandible
‡ After the two vestibular extensions a skin graft can be used to cover the area of
denuded periostium

This combination procedure

‡ Effectively eliminates the dislodging forces of mucosa and muscle attachments
‡ Provides a broad base of fixed keratinized tissue on the primary denture bearing
area


ʹʹ

Skin grafting with buccal vestibuloplasty and floor of mouth procedure
‡ Indication:
‡ Adequate amount of bone loss is there, but at least 15 mm of mandibular bone
height remains
‡ Remaining bone should have adequate contour
Advantage:
‡ Early coverage of the exposed periosteal bed, which improves patient comfort and
allows early denture construction
‡ Long term results of vestibular extension are predictable
Disadvantages:
‡ Need of hospitalization
‡ Donor site surgery combined with the moderate swelling and discomfort
experienced by the patient postoperatively
‡ If the skin graft is too thick at the time of harvesting, hair growth may be seen at
isolated areas

Palatal tissue grafting:

‡ Provides a firm, resilient tissue
‡ Minimal contracture of the grafted area
‡ Easy to obtain
‡ Disadvantages:
‡ Limited amount of tissue
‡ Discomfort with donor-site surgery

Soft tissue surgery for maxillary ridge extension:

Submucosal vestibuloplasty:
‡ Technique described by obwegesser
‡ Procedure used for correction of soft tissue attachment on or near the crest of
alveolar ridge of the maxilla


ʹ͵

Indications:
‡ When maxillary alveolar ridge resorption has occurred but residual bony maxilla
is adequate for proper denture support
‡ Underlying sub mucosal tissue is excised or repositioned to allow direct apposition
of the labiovestibular mucosa to the periostium of remaining maxilla
‡ To provide adequate vestibular depth with this technique adequate labiovestibular
mucosal length is required
‡ A midline incision is made in the anterior maxilla
‡ Mucosa is undermined and separated from the underlying sub mucosal tissue
‡ A supraperiosteal tunnel is developed through the muscular and submucosal
attachments
‡ Underlying submucosal tissue is either excised or repositioned to allow direct
apposition of labiovestibular mucosa to the periostium of remaining maxilla
‡ After closure of the midline incision a preexisting denture or prefabricated splint is
used to hold the mucosa over the ridge in close apposition

Advantages:
‡ Provides a predictable increase in vestibular depth and attachment of mucosa over
the denture bearing area
‡ Relined denture can be worn immediately after surgery or after removal of splint

Maxillary vestibuloplasty with tissue grafting

Indications;
‡ If insufficient labiovestibular mucosa exists
‡ Lip shortening results from submucosal vestibuloplasty
‡ Mucosa pedicled from upper lip and sutured at the depth of the vestibule
‡ Denuded periostium heals by secondary epithelization

Disadvantages:
‡ Postoperative discomfort
‡ Longer healing time


ʹͶ

‡ Maintenance of vestibular depth unpredictable
Soft tissue surgery for ridge extension of the mandible:
‡ As the alveolar ridge resorption takes place the attachment of mucosa and the
muscles near the denture bearing area exerts greater influence on the retention and
stability of the denture
Soft tissue preprosthetic surgery are performed to provide an enlarged area of fixed
tissue in the primary denture bearing area and to improve the extension in the area of
denture flanges.

C) Non surgical management of soft tissue

• Rest for the denture supporting tissues.
• Use of temporary soft liners inside the old dentures.
• Occlusal correction of the old prosthesis.
• Good nutrition- whose metabolic and masticatory efficiency may be
comprised.
• Conditioning of patients musculature.
• Regular finger massage of denture bearing mucosa especially areas that
appear edematous and enlarged.

'Fibrous' or 'flabby' ridge is a superficial area of mobile soft tissue affecting the
maxillary or mandibular alveolar ridges. It can be developed when hyperplastic soft
tissue replaces the alveolar bone and is a common finding, particularly in long term
denture wearers. (Fig. 9)

Fig. 9 Fibrous or flabby ridge with hyperplastic soft tissue.

Histologically, flabby ridges are composed of hyperplastic mucosal tissue and

loosely arranged fibrous connective tissue and dense collagenised connective tissue.
In the soft tissue, a great amount of metaplastic cartilage and/or bone are observable.
Prosthetic rehabilitation in these patients can be challenging. Major problems
encountered in these patients are loss of stability and inadequate retention of the
dentures. These problems occur because of the easily distorted flabby tissue during
impression taking. Treatment options for these patient's include surgery, implant

ʹͷ

retained prosthesis or conventional prosthodontics without surgical intervention.
Modality has to be chosen depending on patient's state of health and need, extent of
flabby tissue, financial capacity and skill of the dentist. In most situations, surgical
intervention or use of implants is not possible and conservative management is the
treatment of choice. Descuttz introduced the use of elastic impression material to
relieve traumatised tissue. But this can be only a temporary provision. Moreover, it
might easily derive candidal growth. In a flabby ridge condition, an ideal denture
should be able to withstand masticatory forces and have flexible tissue surface to
reduce stress concentration and trauma on the underlying tissues

Major problems associated with most of case were the presence of flabby
tissue in maxillary arch (anterior portion) and the presence of natural dentitions in the
opposing arch causes unfavourable distribution of forces that can cause unfavourable
tissue changes. These problems were solved by modifying the impression procedures
and by fabricating upper liquid supported denture. Liquid supported denture is based
on the theory that when the force applied on the denture is absent, the base assumes
its preshaped form that is the one during processing. But under masticatory load, the
base adapts to the modified form of mucosa due to hydrodynamics of the liquid
improving support, retention and stability.

Prosthodontic management of flabby tissue

With the advancing age the and long term wearing of ill dentures results in
bone resorption especially in anterior maxillary edentulous foundation. This results
in poor quality denture bearing area like excessively resorbed ridges and flabby
tissues…Displaceable, or 'flabby ridges', present a particular difficulty and may give
rise to complaints of pain or looseness relating to a complete denture that rests on
them. Many times the surgical intervention was not the choice because either patient
was not affirmative or his age and health was not reminiscent of surgery. Thus first
two options mostly accomplish less preference and above all, the cost factor involved
in implant, makes it a less viable option to patients.
Making a definitive impression of an edentulous foundation can be challenging
when the residual ridges present with less-than-ideal conditions, especially when
there is minimal bone height, unfavorable residual ridge morphology, and/or highly
displaceable as in the presented case (Fig. 10).


ʹ͸

Fig. 10 Making impression for
f highly displaceable residual ridge

Several techniques for manaagement of flabby ridge are

a) One part impression technnique (Selective perforation tray)
b) Controlled lateral pressurre technique
c) Palatal splinting using a tw
wo-part tray system
d) Selective composition flaming
e) Two part impression technnique: Mucostatic and Mucodisplacivee combination.

Prosthodontic managemen
nt of bulbous maxillary tuberosity

Unilateral or bilaterral undercuts on the buccal aspect of the maxillary

tuberosity are frequently encountered
e and these may compliccate the successful
fabrication of a complete maxillary
m denture. The management in these situations
includes an alteration of thhe denture-bearing area, adaptation off the denture base,
careful planning of the path of insertion, and the use of resilient linning materials. The
alteration of the denture-beearing area refers to the elimination of o the undercut by
surgical reduction of the tuberosity.
Following surgery, a good border seal can generally be attaained. If surgery is
not an option, prosthodonticc management of the bilateral undercuuts can be done by
blocking out the undercut ono the cast and finishing the denture too the full available
height of the vestibule. Alteernatively, the height of the flange of the denture can be
reduced to the crest of thee undercut (to the survey line when the cast has been
surveyed). A reduced border seal may accompany such a denture base adaptation. A
pre-planned rotational path of placement may be used when a uniilateral undercut of
the tuberosity occurs, thus allowing
a the buccal undercut to aid in thet retention of the
denture. A good border seall in this situation is generally achievabble. Sectional lining
of the denture base with a resilient lining material in the area of o the undercut can
allow the engagement of thee undercut with resultant increased dennture retention. This


ʹ͹

procedure is usually limitedd to shallow undercuts which does noot affect the border
seal. A novel means of mannaging the bilateral undercut areas in the posterior region
without compromising on thhe border seal has been reported in thhe literature for the
past 20 years. Abrams repoorted on the use of resilient lining material
m which was
supported by a harder but flexible
f base which was extended into the undercut area.
Such a bilaminate peripheryy may be too thick in situations wherre the width of the
vestibule is limited.

Fig. 11 The width of the poosterior buccal vestibule is reduced byy the movement of
the coronoid process in the final
f denture.

Other methods of inncorporating an undercut into the deesign of a denture

include sectional dentures orr hinge mechanisms. These options aree complex and may
require specialized technicaal skills. When the mouth is openedd, the width of the
posterior buccal vestibule iss reduced by the movement of the corronoid process (fig.
11)


ʹͺ

Soft tissue management in partially edentulous ridges

From the periodontal viewpoint, fixed prosthesis are the restorations of choice
for replacement of missing teeth, but there are some clinical situations in which
removable partial prosthesis are the only possible way to restore the lost function of
the dentition.
It is unwise consider a removable partial denture in patients whose oral
hygiene is inadequate. RPD insertion results in quantitative as well as qualitative
changes in plaque accumulation. However, careful examination of any existing
periodontal condition and its elimination prior to prosthetic treatment can contribute
to success of prosthesis. Oral hygiene instructions and periodic reinforcement is
mandatory. Also, RPD must be designed according to “hygienic principles” and
every effort should be made to reduce forces directed to supporting tissues.19 Interim
partial dentures have more detrimental effects on the surrounding soft tissue as
compared to cast partial dentures.
Effect on plaque and Forces Exerted on Teeth and Tooth Mobility
Several studies show an effect of RPDs on the quantity and quality of plaque.
Bissada NF et al in their study, comparing three different designs of RPD, concluded
that gingival areas that are covered by parts of the RP without relief show the most
adverse periodontal reactions, both clinically and histologically, whereas the
uncovered areas are the least affected.
It has been reported that RPD design affects the distribution of force on
abutment teeth and residual alveolar ridges. Two similar photoelastic studies,
compared the stresses induced on the abutment teeth by different RPD designs of
direct retainers and concluded that the typical “RPI” retainer design (mesial rest seat
and buccal I bar) produces the lowest torque on abutment teeth. 24
Various studies concluded that there is an initial increase in tooth mobility,
which comes to baseline after “settling” period of about 1 to 1.5 months following
insertion of new RPDs.
Managimg soft tissue in contact with RPD by giving special importance to
individual component of RPD
In addition to biomechanical considerations such as stability and retention, it is
of fundamental importance that RPDs be designed so that they interfere as little
possible with plaque control and must not damage the oral tissues. Such design
parameters are termed as secondary prophylactic measures or hygienic principles.
The basic principle of open hygienic design is that “ if the base elements of the RPD


ʹͻ

do not contact either teeth or periodontium, it can not cause any injuries to these
structures” Also, it is emphasized to use contemporary design with reduced number
of components and elimination of components whenever possible without
compromising biomechanical requirements
Major connectors
• Should be free of movable tissues.
• Impingement of gingival tissue should be avoided.
• Relief should be provided in case of distal extensions, as they tend to rotate in
function.
• It should not contribute to the retention or trapping of food particles.
• Margins should be located far enough from gingival margin to avoid tissue
irritation.
• Borders of maxillary major connector should be minimum of 6mm away from
gingival margin.
• In mandibular lingual bar major connector the superior border should be 3-4
mm away from gingival margin.
• Borders should be rounded without any sharp margins.
• All the borders must be parallel to gingival margin.
• Also for stabilizing periodontally weakened teeth a manibular linguoplate
major connector is recommended.
Minor connectors
• Minor connectors connecting clasp assemblies to major connector must be
located on proximal surfaces of abutment teeth or in the embrasure between
two abutment teeth
• Should not be bulky to avoid any interference in function.
• Minor connectors connecting rests to major connector should arise at right
angles from major connector with rounded junction.
• Should cover as little gingiva as possible.
• Relief should be provided under minor connectors connecting denture base to
major connector.
• Also minor connector acting as approach arm for I-bar retainer, should not
interfere with the contour of soft tissue around abutment.
Rests and rest seats
• Rests control forces acting upon remaining teeth.


͵Ͳ

 • In distal extension situation, the occlusal rests are positioned on mesial surface
rather than on distal surface of abutment tooth to distribute the occlusal forces
along the long axis.
• In tooth borne situations, rest should extend to the center of tooth to prevent
tipping action and to provide vertically directed forces to the tooth.
• Rests on anterior teeth are placed as close to cervical aspect of tooth as
possible to gain support advantage, to reduce torque and to establish a positive
relationship between tooth and prosthesis
• To avoid unnecessary contact with marginal gingiva, the cingulum rest can be
designed in a “C” form, with one extension to minor connector.
• This will reduce contact with soft tissues by half and enhances periodontal
health.
Direct retainers
Can be classified as:
¾ Intracoronal retainers
• Manufactured retainers such as dolbo
• Custom made retainers
1. Occlusally approching
2. Gingivally approching
¾ Extracoronal retainers
Occlusally approching clasps (Fig. 12)
• Approch the retentive undercut from occlusal suface.
• As it increases the buccolingual width of the crown, it effects the normal food
flow leading to food accumulation
• Also as width of occlusal table is increased, greater forces are generated.

Fig. 12 Occlusally approaching clasps


͵ͳ

Gingivally appoching clasp (Fig. 13)
• Better esthetics than occlusally approching clasp
• Also less tooth contact
• Less interference with natural tooth contours.

Fig. 13 Gingivally approaching clasps.

RPI system
y Advocated by Kratochvil and Kroll
y Designed to accommodate functional prosthesis movement.
y Thus decreasing the harmful tipping or torquing forces on teeth.
Consists of
y Mesioocclusal rest with minor connector placed in mesiolingual embrasure
without contacting the adjacent tooth
y Proximal guide plate contact the guide plane on distal surface of abutment
teeth
y I- bar retainer
There are three basic approaches to RPI system:
y First approach recommends that the guiding plane and proximal plate extend
the entire length of proximal surface. (Fig. 14-A.)
y However, because of greater contact area of guide plane more horizontal
forces are directed to abutment tooth.
y Second approach recommends guide plane and proximal plate to extend from
marginal ridge to junction of middle and gingival third. (Fig. 14-B.)
y This decrease in surface area evenly distributes functional forces between teeth
and residual ridge.
y Third approach recommends proximal plate that contacts only 1mm of
gingival portion of guide plane (Fig. 14-C.)
y This also redistribute forces between teeth and residual ridge


͵ʹ

   

Fig. 14 A- Guiding plane and proximal plate extend the entire length of proximal
surface. B- Guide plane and proximal plate to extend from marginal ridge to junction
of middle and gingival third. C- proximal plate that contacts only 1mm of gingival
portion of guide plane.

Fit of framework
y Framework for RPD must be fitted to teeth and adjusted for functional
movement.
y This will assures that the casting does not produce undue torque against
abutment teeth and also controls stress transfer to the soft tissue.
y The physiologic adjustment of the casting can be accomplished with marking
materials such disclosing wax, to show abnormal contact areas , which are then
removed by grinding

Hygiene Maintenance for RPD

y Mouth and RPD should be cleaned after eating and before retiring
y Use small, soft-bristle brush with non abrasive dentifrice to clean the RPD.
Denture cleaning solutions can also be used.
y Calculus deposits on the RPD should be removed by ultrasonic scaler in the
dental office.
y Substitute toothbrush massage for the normal stimulation of tongue and food
contact with areas that will be covered by the denture framework.


͵͵

 Soft tissue management in designing fixed dental prosthesis

Factors affecting soft tissue response while designing of fixed partial denture
A) Placement of margins of restoration
B) Intracrevicular depth
C) Biological width
D) Adequate attached keratinized tissue
E) Finish line exposure during impression
F) Crown lengthening
G) Temporary or provisional crowns
H) Embrasures
I) Crown contour
J) Pontic design
K) Cementation procedure
L) Occlusal consideration

A) Placement of margins of restoration

Whenever possible margins are prepared extracervically on the enamel of the
anatomic crown. Any restorative material is a foreign body in the gingival sulcus
and unfortunately they provide an area favourable for plaque formation.
Advantages of supragingivaly placed margins are:
• Favorable reaction of the gingiva.
• Wider shoulder tooth preparations can accommodate an adequate bulk of
porcelain without-pulpal injury.
• Metal margin finishing techniques are easier.
• Accessibility for removing excess cement
Subgingival Margin Placement
Despite the advantages of supragingival margins there are clinical situations
requiring intracrevicular margin placement. They are:
1. Better Esthetics.
2. Severe cervical erosion, restorations or caries extending beyond gingival crest.
3. Adequate crown retention in short or broken down clinical crowns.
4. Elimination of persistent root sensitivity.


͵Ͷ

B) Intracrevicular Depth
Accurate estimate of true gingival crevice is important to ensure that margins
do not disturb junctional epithelium or connective tissue attachment (biologic width).
This requires the use of an accepted periodontal probe. Position of the probe and
probing force are critical for accuracy. In health, the probe is stopped by the
junctional epithelium, whereas gingivitis allows penetration of junctional epithelium
and connective tissue fibers. Studies have estimated that the ideal intracrevicular
depth for margins is 0.5-1mm beneath gingival crest and not more than 0.5mm when
the crevice is adjacent to root surfaces.
Studies have also demonstrated that a space of 2mm is needed for supracrestal
connective tissue attachment and junctional epithelium to attach the tooth. This 2mm
band is a physiologic dimension that is required around every tooth in the mouth. It
has been called as biologic width. If the restoration infringes on this width, there is
no place for attachment apparatus to insert. An inflammatory response results,
attachment loss with apical migration occurs and pocket formation ensues.4

C) Biological width (Fig. 15)

Fig. 15 Biologic width.

A great part of periodontal literature deals with the checking, reconstruction

and maintenance of biologic width. This, in Croatian literature, relatively unknown
term, deserves to be closely explained. Gargiulo et al reported in 1961 a certain
uniformity of the dimension of some components of biologic width:
-mean depth of the histologic sulcus is 0.69 mm,
-mean junctional epithelium easures 0.97 mm (0.71 to 1.35 mm),
-mean supraalveolar connective tissue attachment is 1.07 mm (1.06 to 1.08
mm).
The total of the attachment is therefore 2.04 millimeters (1.77 to 2.43 mm) and
is called the biologic width (2,3), essential for preservation of periodontal health and
removal of irritation that might damage the periodontium (prosthetic restorations, for


͵ͷ

example). The millimeter that is needed from the bottom of the junctional epithelium
to the tip of the alveolar bone is held responsible for the lack of inflammation and
bone resorption, and as such the development of periodontitis. The dimension of
biologic width is not constant, it depends on the location of the tooth in the alveola,
varies from tooth to tooth, and also from the aspect of the tooth. Its constancy (is
only one - it) can only be found in healthy dentition.18
There are literature reports of unfavorable effects of restorative therapy on
periodontal tissue. Prosthetics can lead to greater plaque accumulation; they can
incite inflammation as well as add to the progression of periodontal disease. It has
been proved that even marginally adapted prosthetic structure can have negative
effects on the periodontium, had it been placed subgingivally.13 Subgingival
placement of the crown and preparation margins potentially endangers biologic width
and lead to periodontal reaction. If the biologic width is violated during the
preparation of the tooth, some authors claim that there will be no place left for the
attachment and the result in the development of attachment loss and pocketing can be
observed. Violated biologic width can result in uncontrolled bone resorption and
might grow over the quantity of the bone necessary for the supralimbal insertions of
the connective tissue attachment on the tooth root. The result is advanced
periodontitis.
Sub gingival placement of a restoration margin usually results in iatrogenic
marginal inflammation. There is data that show that restoration margins, placed even
at the gingival margin, may worsen clinical and microbiological parameters of
periodontal health. In these studies, some parameters were worse in the group that
had restoration margins placed in the gingival part than in the group that had the
restoration margin subgingivally. Incorrectly placed restoration margin and
unadapted restoration are not welcome, but a perfectly adapted restoration, whose
margin lies more than 0.5 millimeters subgingivally, violates the biologic width This
results in marginal iatrogenic irritation, especially in narrow zones of attached
gingival.
Reconstruction of biologic width:
Reestablishment of healthy anatomic relations in the area of the tooth neck is a
prerequisite for any reconstructive therapy and prevention of further development of
periodontal disease. Violated biologic width can be reconstructed by means of a
number of techniques. According to the need of Rebuilding damaged teeth and
possibilities offered by dentistry today, there are two possible way of reconstructing
the anatomy in this susceptible area of the tooth supporting structures.26


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 a) Surgical techniques
o Gingivectomy (gingival
( reduction)
o Periodontal flapp
o Apically reposiitioned flap with resective osseous surggery
b) Orthodontic eruption of tooth

D) Adequate attached keraatinized tissue

To know the width of o attached gingiva, one must first diffferentiate between
attached and unattached ginngiva. In the best of situations, the gingival
g sulcus will
probe at least 1mm so that this
t amount of keratinized tissue will be b unattached. Next
we encounter a millimeterr of junctional epithelial cells, accouunting for another
millimeter of unattached ginngiva. Thus in order to provide at leasst 1mm of attached
gingiva in an ideal situatioon of a very shallow probing depth, at least 3mm of
keratinized tissue must be present.
p If more than 1mm of gingiva coincides with the
sulcus depth, then an even greater
g amount of keratinized tissue is necessary.
n
Several studies have proved that the greatest increase inn gingivitis, pocket
depth, and loss of attachmennt occurs with subgingival margins, whhile margins placed
at the level of the free gingivval margin result in an insignificant inccrease in gingivitis.
Thus, short-term irritation att the free gingival margin is not as signnificant as irritation
at the bottom of the gingivaal crevice since the latter can lead to loss of connective
tissue attachment to the cem mentum. The closer a subgingival crow wn margin is placed
to the base of the gingivaal sulcus, the more severe the gingival inflammation.
Consequently, the farther (coronally)
( the gingival margin is froom the base of the
clinically determined sulcus bottom while still achieving esthetic and a retentive goals,
the more predictable will be b the location of the gingiva in relaation to the crown
margin (Fig.16). Careful evaluation of the mucogingival areea prior to fixed
prosthodontic treatment willl also increase the reliability of predictting gingival tissue
levels.

Fig. 16 Gingival margin loccated coronally from the base of the cliinically determined
sulcus bottom.


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 There must be sufficient width and breadth to the attached gingiva. Narrow
and thin attached gingiva not only creates an esthetic problem due to their
translucency but also is more prone to an altered microcirculation from
overcontoured subgingival crowns. This microcirculation alteration will often
manifest itself as bluish gingival tissue around the restoration. Periodontal grafts
prior to restorative work offer a viable solution to these mucogingival conditions.
Keeping a mental picture of the clinically determined sulcus depth during gingival
margin preparation is necessary to avoid trauma to the connective tissue attachment
fibers. If the high-speed rotary instrument severs fibers attached to cementum,
regeneration of fiber attachment is unlikely.
Retraction of the gingival tissue to facilitate marginal exposure for impressions
must avoid attachment displacement and prolonged exposure to vasoconstrictors
since ischemic necrosis and/or recession is likely.

E) Soft tissue management (Finish line exposure)

Indirect restorations including cast gold inlays, onlays, partial veneer restorations
and complete crowns, metal-ceramic and all-ceramic crowns, and bonded ceramic
inlays and on lays are routinely used to restore defective teeth. These restorations
frequently have cervical margins that are intentionally placed in the gingival sulcus
for esthetic or functional reasons. In these situations, the clinician must make
impressions that accurately capture the prepared cervical finish lines and permit the
fabrication of accurate dies on which the restorations are fabricated. There is
evidence that inadequate impressions are frequently forwarded to commercial
laboratories, and the chief deficiency seen in such impressions is inadequate
recording of the cervical finish lines. The primary reason for not adequately
capturing marginal detail is deficient gingival displacement technique.14 The
procedure used to facilitate effective impression making with intracrevicular margins
is gingival "displacement" as opposed to gingival "retraction". The goal of the
procedure is to reversibly displace the gingival tissues in a lateral direction so that a
bulk of low-viscosity impression material can be introduced into the widened sulcus
and capture the marginal detail. A bulk of impression material is required to obtain
maximum accuracy and to improve the tear strength of the material so that it can be
removed from the mouth intact with no tearing. The critical sulcular width in this
regard seems to be approximately 0.2 mm. A width of less than 0.2 mm results in


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impressions that have a higher incidence of voids in the marginal area, an increase in
tearing of the impression material, and a reduction in marginal accuracy. It is
imperative that a small amount of impression material flows beyond the prepared
margin. This permits accurate trimming of the recovered die. If the gingival tissues
are healthy and the cervical margin is placed in the appropriate position, gingival
displacement is a relatively simple, atraumatic procedure. Most of the difficulties
with gingival displacement result from attempting to make impressions when the
tissues are clinically inflamed, when clinically there is inadequate attached gingiva,
or when prepared margins are placed too deep in the sulcus. Gingival displacement is
an important procedure with fabricating indirect restorations. Gingival displacement
is relatively simple and effective when dealing with healthy gingival tissues and
when margins are properly placed a short distance into the sulcus. The most common
technique used with gingival displacement is use of gingival retraction cords with a
hemostatic medicament. Retraction cords of sufficient diameter should be used to
provide adequate lateral displacement to create a mean sulcular width of 0.2 mm.
Epinephrine containing retraction cords should be avoided.6 Several techniques have
proven to be relatively predictable, safe, and efficacious. No scientific evidence has
established the superiority of one technique over the others, so the choice of
technique depends on the presenting clinical situation and operator preference.

There are three main variations of the mechanical-chemical technique for gingival
displacement. They include the single cord technique, the double cord technique, and
the infusion method of gingival displacement.
These measures are accomplished by one or more of three techniques

• Mechanical
• Chemicomechanical and
• Surgical.
The surgical techniques can be further broken down into rotary curettage and
electrosurgery.

a) Mechanical
Physically displacing the gingiva was one of the first methods used for insuring
adequate reproduction of the preparation finish line.


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Fig. 17 Mechanical methhods of ginigival displacement using coopper band.

A copper band or tube (Figg. 17)

• It can serve as a means
m of carrying the impression matterial as well as a
mechanism for displaacing the gingiva to insure that the ginngival finish line is
captured in the impresssion.
One end of the tube is festooned, or trimmed, to follow the profile of the
gingival finish line, which, in turn, often follows the coontours of the free
gingival margin. Thee tube is filled with modeling compouund, and then it is
seated carefully in plaace along the path of insertion of the tooth preparation.
The technique has been utilized in restorative dentistry for many years. It has
been used with impression compound and elastomeric materials. Several types
of die material can bee used, depending on the material used for the impression.
If the impression is made
m with an elastomeric material the diie can be formed of
stone or electroplatedd metal. If the impression is compouund, the die can be
made of amalgam or electroplated metal.

• The use of copper baands can cause incisional injuries of giingival tissues, but
recession following their
t use is minimal, ranging from 0.10 mm in healthy
adolescents and 0.3 mm
m in a general clinic population.
• Copper bands are esppecially useful for situations in which several teeth have
been prepared. The likelihood of capturing all of the finish
fi lines in one
impression decreases as the number of prepared teeth increeases. The use of a
copper band could negate
n the necessity of remaking ann entire full arch
impression just to cappture one or two preparations.
• A rubber dam also canc accomplish the exposure of the finishf line needed.
Generally it is used when
w a limited number of teeth in one quadrant are being
restored and in situattions in which preparations do not haave to be extended
very far subgingivallyy. It can be used with modified trays if the bow and the
wings of the clamp are blocked out.


ͶͲ

 • A rubber dam should not be used with polyvinyl siloxane impression because
the rubber inhibits its polymerization.
Plain cotton cord
• With the introductionn of new elastic impression materialss plain cotton cord
was used for sulcus enlargement
e physically pushing awayy the gingival from
the finish line. Unforttunately, the effect is limited because the
t use of pressure
alone often will not coontrolm sulcular hemorrhage.

b) Chemicomechanical

Fig. 18 color coded reetraction cords

Retraction cords (Fig. 18).

• Are supplied in three basic designs, including twisted cords,, knitted cords, and
braided cords. There is little scientific evidence to differeentiate one type of
cord from another; thus,
t the selection of which design of cord to use is
determined by operaator preference. The authors prefer to t use braided or
knitted cords.
• One key to effective displacement is to use a cord of suffficient diameter to
provide adequate dispplacement so that adequate bulk of immpression ma terial
can be introduced into the sulcus. The largest cord that cann be atraumatically
placed in the sulcus shhould be used. The primary error made by inexperienced
dentists is to use a cord that is too small in diameter. Theese small-diameter
cords are placed with minimal trauma; however, they do noot provide adequate
lateral displacement of
o the gingival tissues.

By combining chemical actiion with pressure packing enlargementt of gingival sulcus

as well as the control of fluiids seeping from the walls of the ginggival sulcus is more
easily accomplished. Caustic chemicals such as sulfuric acid, trrichloroacetic acid,

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negatol (a 45% condensation product of meta cresol sulfonic acid and formaldehyde )
and zinc chloride can be effective for gingival retraction but their undesirable effects
on the gingival led to their abandonment.
Over the years, racemic epinephrine has emerged as the most popular chemical for
gingival retraction. Surveys published in the 1980’s document that cord impregnated
with 8% racemic epinephrine is the most commonly used means of producing
gingival retraction.

The three criteria for gingival retraction material are

1. effectiveness in gingival displacement

2. absence of irreversible damage to the gingival
3. paucity of untoward systemic effects
• For those patients with cardiovascular disease, hypertension, diabetes,
hyperthyroidism, or a known sensitivity to epinephrine a cord impregnated
with some other agent must be substituted.
• Because epinephrine has been used successfully for nearly half a century,
there is reluctance to abandon its use. Even then it must be used only on
healthy patients with no history of cardiovascular problems.
• Aluminum chloride [AICl3], alum (aluminum potassium sullfate)
[AIK(S04)2], aluminum sulfate [AI2(S04)3], and ferric sulfate [Fe2(S04)3]
are also used for gingival retraction.

Techniques
1. Single cord technique

The single cord technique is indicated when making impressions of one to three
prepared teeth with healthy gingival tissues. It is relatively simple and efficient
and is probably the most commonly used method of achieving gingival
displacement.
• The operating area must be dry. An evacuating device is placed in the
mouth and the quadrant containing the prepared tooth is isolated with
cotton rolls.
• The retraction cord is drawn from the dispenser bottle with sterile cotton
pliers and a piece approximately 5.0cm. (2.0 inches) long is cut off. If a
twisted or wound cord is used, grasp the ends between the thumb and the
forefinger of each hand. Hold the card taut and twist the ends to produce a


Ͷʹ

 tightly wound cordd of small diameter. If a braided or woven
w cord is used
twisting is not neceessary.
• Be careful not to touch
t any of the cord other than the ends
e which will be
cut off later with yyour gloved fingers. It has been postuulated that handling
the cord with latex gloves may indirectly inhibit the polymerization
p of a
polyvinyl siloxanee material. If that happens, it will occurr in that segment of
the impression repplicating the gingival crevice and the gingival
g finish line
of the preparation.
• The retraction corrd should be moistened by dipping it i in buffered 25%
aluminium chloridde solution in a dappen dish. Cords impregnated with
either epinephrinee or aluminium sulphate are twice as effective when
saturated with aluuminium chloride solution prior to insertion into the
gingival crevice. If there is a slight hemorrhage in the gingival crevice it
can be controlledd by the use of hemostatic agent such s as hemodent
liquid(aluminium chloride). Removing the dry cord from the gingival
crevice can cause injury to delicate epithelial lining thaat is not unlike the
“cotton roll burn”” produced by prying an adhered cotton roll of the
desiccated mucouss membrane of the mouth.
• Form the cord intoo a "U" and loop it around the prepareed tooth . Hold the
cord between the thumb
t and forefinger, and apply slightt tension in an api-
cal direction. (Fig. 19-A). Gently slip the cord betweenn the tooth and the
gingiva in the messial interproximal area with a Fischer packing
p instrument
or a DE plastic insstrument IPPA (Fig. 19-B). Cord placcement is a finesse
move, not a power play. Once the cord has been tuckedd in on the mesial,
use the instrument to lightly secure it in the distal interprooximal area.

Fig 19 A- Cord formed into a "U" and looped around the prepared tooth.
B- Cord slipped between thee tooth and the gingiva in the mesial intterproximal area

• Proceed to the linngual surface and begin working from m the mesiolingual
corner around to thhe distolingual corner (Fig. 20). The tipp of the instrument

Ͷ͵

 should be inclined slightly toward the area where the corrd has already been
placed; ie, the messial . If the tip of the instrument is incliined away from the
area in which the cord has been placed, the cord mayy be displaced and
pulled out.

Fig. 20 Cord on thhe lingual surface working from the mesiolingual

m corner
around to the distoolingual corner.

• In some instancess where there is a shallow sulcus or a finish line with

drastically changinng contours, it may be necessary to hoold the cord already
placed in position with instrument held held in the left hand.
h Placement of
the card can then proceed with the packing instrumennt held in the right
hand.
• Gently press apically on the cord with the instrumentt, directing the tip
slightly towards thhe tooth (Fig. 21). Slide the cord giingivally along the
preparation until thhe finish line is felt. Then push the cordd into the crevice.

Fig. 21 Tip directed sllightly towards the tooth while pressingg apically

• If the instrument is directed totally in an apical directionn, the cord will the
rebound off the ginngival and roll out of sulcus.
• If cord persists inn rebounding form from a particularlyy tight area of the
sulcus, do not appply a greater force. Instead apply a gentle force for a
longer time. If it still rebounds for a longer time, channge to a smaller or
more pliable cord. (i.e, twisted rather than a braided).


ͶͶ

 • Continue on around to the mesial, firmly securing the cod where it was
lightly packed before. Cut off the length of the cord protruding from the
mesial sulcus as closely as possible to the interdental papilla.
• Continue packing the cord around the facial surface overlapping the cord in
the mesial interproximal area. The overlap must always occur in the
proximal area where the bulk of tissue will tolerate the extra bulk of the
cord. If the overlap occurs in the facial or lingual surface where the gingival
is tight, there will be a gap apical to the crossover and the finish line in that
area may not be replicated in the impression.
• Place all but the last 2.0 or 3.0 mm of cord. This tag is left protruding so
that it can be grasped for easy removal. Tissue retraction should be done
firmly but gently, so that the cord will rest on the finish line.
• Heavy handed operators can traumatize the tissue, create gingival
problems and jeopardize the longevity of the restorations that they place.
Do not over pack.
• Place a large bulk of gauze in the patient’s mouth. This will make the
patient more comfortable by having something to close on and at the same
time it will keep the area dry.
• After 10 minutes remove the cord slowly to avoid bleeding. Inject
impression material only if the sulcus remains clean and dry. It may be
necessary to gently rinse away any coagulum, and then lightly blow air on
it. If active bleeding persists, abort the impression attempt. Electro
coagulation and ferric sulphate are sometimes effective in stopping the
effective bleeding.
• If ferric sulphate (Astringent) is used as chemical, soak a plain knitted cord
in it and place the cord in the gingival sulcus as described above. After 3
minutes, remove the cord. Load the 1cc special syringe (Dento-Infusor)
with the astringent chemical and place a tip on the syringe. Use the fibrous
syringe tip or burnish cut sulcular tissue until all bleeding stops. Using the
tip in this manner will wipe off excess coagulum.
• Keep the sulcus moist so that the coagulum is easy to remove. Keep
circling the preparation until the bleeding has stopped completely. The
solution usually will puddle in the sulcus when hemostasis is complete.
Verify this by thoroughly rinsing the preparation with a water or air spray.
The coagulum is black and traces may linger in the sulcus for few days.


Ͷͷ

Evaluation: when looking the preparation from the occlusal aspect, the entire
preparation margin should be clearly visible circumferentially and the uninterrupted
cord with no soft tissues folded over it, in contact with the tooth surface. If in doubt,
remove the cord and assess displacement. The entire preparation margin should be
clearly visible and remain directly accessible for at least a minute. If excess soft
tissue is preventing easy access is present, displace using an additional small section
of cord, or excise using an electrosurgical tip or soft tissue laser.
• Gently air dry the preparation and proceed to impression making.

2. The double cord technique (Fig. 22)

The double cord technique is routinely used when making impressions of multiple
prepared teeth and when making impressions when tissue health is compromised and
it is impossible to delay the procedure. Some clinicians use this technique routinely
for all impressions.

1. A small diameter cord (deknatal 2/0 surgical silk suture material) is placed in
the sulcus. The ends of this cord should be cut so that they exactly abut against
one another in the sulcus. This cord is left in the sulcus during impression
making and if the cord is too short (creating the space between the ends) or too
long (creating overlapping ends), it may become impregnated into the
impression. This can create difficulties and trimming the dies.

A. A small diameter cord with no medication is first placed in the depth of the sulcus

B. A large diameter cord with the medicament is placed above the small diameter
cord. After waiting to 8 to 10 minutes, the large diameter cord is soaked in water and
removed. The small diameter cord is left in the sulcus during impression making

Fig. 22 The double cord technique

A second cord, soaked in the hemostatic agent of choice, is placed in the


Ͷ͸

 2. sulcus above the smalll-diameter cord. The diameter of the second
s cord should
be the largest diameteer that can readily be placed in the sulcuus.
3. After waiting 8 to 100 minutes after placement of the large cord, the second
cord is soaked in waater and removed. The preparation(s) are dried. and the
impression is made with
w the primary cord 'in place.
4. After successfully maaking the impression, the small-diametter cord is Honked
in water and removedd from the sulcus.
This technique can be used with single or multiple preparatioons. It is especially
useful with multiple preparrations where gingival fluid exudates can seep over the
prepared cervical margins off the last teeth to be impressed after thee cord removal.
Tissue reaction to chemically impregnated cords:
• Stripping
• Desquamation of epitheliium
• Intracellular Hydropic deegeneration
• Hyperemia
• Inflammation
• Necrosis
GIngival tissue healinng process:
• Epithelization process that takes place from the gingiival margin and is
completed within 6 – 9 days.
• Healing is complette provided process is not disturbed, acccurate provisional
restoration and oraal hygiene to be maintained.
• The new epithelium
m is of inferior quality, with numerous leucocytes.

o gingival displacement (Fig. 23)

3. The infusion technique of

Fig. 23 The infusion techniqque for gingival displacement

The infusion technique for

f gingival displacement uses a signiificantly different
approach from the single or double cord techniques.


Ͷ͹

 1. After careful preparation of the cervical margins in an intra-crevicular
position, hemorrhage is controlled using a specifically designed infusor with a
ferric sulfate medicament. Two concentrations of ferric sulfate, 15%
(Astringedent; Ultradent Dental Products, Salt Lake City, Utah) and 20%
(Viscostat; Ultradent Dental Products, Salt Lake City, Utah), are available.
The 20% material is preferred because it is less acidic than the 15% solution
and does not remove the smeared layer of dentin from the prepared tooth.
2. The infusor is used with a burnishing motion in the sulcus and is carried
circumferentially 360° around the sulcus. The medicament is extruded from
the syringe/infusor as the instrument is manipulated around the gingival
sulcus.
3. When hemostasis is verified, a knitted retraction cord (Ultra pack Retraction
Cords; Ultradent Dental Products) is soaked in the ferric sulfate solution and
packed into the sulcus.
4. Advocates of this technique recommend leaving the cord in place I to 3
minutes.
5. The cord is removed, the sulcus is rinsed with water, and the impression is
made.
In the opinion of the authors, this technique is effective in achieving hemostasis,
but, because the cord is left in place for only I to 3 minutes, it may not provide
adequate lateral displacement to permit an adequate bulk of impression material into
the sulcus. It is not recommended that the cord be left in the sulcus for longer times
because histologic data are not available to demonstrate that it is safe to do so. The
dento-infusor and the 20% ferric sulfate have proven to be an effective ancillary
technique for control of hemorrhage when using the single cord technique.
Occasionally, even with careful technique, isolated areas of bleeding may occur
when the cord is removed from the sulcus. In such situations, the infusor and
medicament can be used in the sulcus with firm burnishing pressure for
approximately 15 seconds. This predictably controls hemorrhage. When using ferric
sulfate materials, patients should be forewarned that the tissues may be temporarily
darkened. The tissues take on a blue-black appearance that usually disappears in a
few days.

4. The “every other tooth” technique

When making impressions of anterior tooth preparations, it is critical that no
damage is done to the gingival tissues that may result in recession. With teeth with

Ͷͺ

 root proximity, placing retraction cord simultaneously around all prepared teeth may
result in strangulation of the gingival papillae and eventual loss of the papilla. This
creates unesthetic black triangles in the gingival embrasures.
This undesirable outcome can be prevented with the "every other tooth" technique.
This can be used with the single or double cord technique. Retraction cord is placed
around the most distal prepared tooth. No cord is placed around the prepared tooth
mesial to this tooth. Retraction procedures are completed on alternate teeth. If, for
example, teeth #5 through #12 are prepared, cords would be placed around teeth #5,
#7, #9, and #11. The impression is made; gingival displacement is accomplished on
teeth #6, #8, #10, and #12; and a second impression made. A subsequent pick-up
impression allows fabrication of a master cast with dies for all eight prepared teeth.

Rotary curettage (Fig. 24)

Rotary curettage is a "troughing" technique, the purpose of which is to produce
limited removal of epithelial tissue in the sulcus while a chamfer finish line is being
created in tooth structure. The technique, which also has been called "gingettage," is
used with the subgingival placement of restoration margins. It has been compared
with periodontal curettage, but the rationale for its use is decidedly different.
Periodontal curettage is used to debride diseased tissue from the sulcus to allow re-
epithelialization and healing.

Fig. 24 Rotary curettage

•
The removal of epithelium from the sulcus by rotary curettage is accomplished
with little detectable trauma to soft tissue, although there is a lessened tactile
sense for the dentist.
•
Rotary curettage, however, must be done only on healthy, inflammation-free
tissue to avoid the tissue shrinkage that occurs when diseased tissue heals.
•
The concept of using rotary curettage was described by Amsterdam in 1954.


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 The technique described here was developed by Hansing and subsequently
enlarged upon by Ingraham.
•
Suitability of gingiva for the use of this method is determined by three factors:
absence of bleeding upon probing, sulcus depth less than 3.0 mm, and
presence of adequate keratinized gingiva. The latter is determined by inserting
a periodontal probe into the sulcus. If the segment of the probe in the sulcus
cannot be seen, there is sufficient keratinized tissue to employ rotary
curettage. Kamansky et al found that thick palatal tissues responded better to
the technique than did the thinner tissues on the facial aspect of maxillary
anterior teeth.
•
In conjunction with axial reduction, a shoulder finish line is prepared at the
level of the gingival crest with a flat-end tapered diamond. Then a torpedo
nosed diamond of 150 to 180 grit is used to extend the finish line apically,
one-half to two-thirds the depth of the sulcus, converting the finish line to a
chamfer.
•
A generous water spray is used while preparing the finish line and curettage
the adjacent gingiva. Cord impregnated with aluminium chloride or alum is
gently placed to control hemorrhage.
•
The cord is removed after 4 to 8 minutes and the sulcus in thoroughly irrigated
with water. The technique is well suited for use with reversible hydrocolloid.
•
Several studies have been done to compare the efficacy and the wound healing
of rotary cuerettage with those of conventional tecgniques. Kamansky and his
associates reported less change in gingival height with rotary cuerettage than
with lateral gingival displacement using retraction cord. With cuerettage there
was an apparent disruption of the apical sulcular and attachment epithelium,
resulting in apical repositioning and an increase in sulcus depth. The changes
were quite small and however, they were not regarded as clinically significant.
•
Tupac and Neacy found no significant histologic differences between
retraction cord and rotary cuerettage. Ingraham et al reported slight differences
in healing around rotary cuerettage, pressure packing and electrosurgery at
different time intervals after the tooth preparation and impression. However,
complete healing had occurred by 3 weeks with all techniques.
•
There is poor tactile sensation when using diamonds on sulcular walls which
can produce deepening of the sulcus. The technique also had the potential for
destruction of periodontium if used incorrectly making this a method that is


ͷͲ

 probably best used onnly by experimental dentists.

d) Electrosurgery (Fig. 25)2

There are situations inn which it may not be feasible or desirrable to manage the
gingiva with retraction coord alone. Even if the general conditioon of the gingiva in
a mouth is healthy, arreas of inflammation and granulatioon tissue may be
encountered around a givven tooth. This can be caused by overrhangs on previous
restorations or by the carries itself. It may have been necessaryy to place the finish
line of the preparation sos near the epithelial attachment that it is impossible to
retract the gingiva sufficciently to get an adequate impressionn. In these cases, it
may be necessary to use some means other than cord impregnaated with chemicals
to gain access and stop minor
m bleeding.

Fig. 25 Electrosurgery unit

• The use of electrosuurgery has been recommended for enlargement

e of the
gingival sulcus and control
c of hemorrhage to facilitate im mpression making.
Strictly speaking, ellectrosurgery cannot stop bleeding once it starts. If
hemorrhage occurs, itt first must be controlled with pressuree and/or chemicals,
and then the vessels can be sealed with a coagulating ball eleectrode.
• Electrosurgery hass been described for the removal of irritated
i tissue that
has proliferated ovver preparation finish lines, and it is commonly
c used for
that purpose (Fig. 26).There has been concern expresseed about the use of
electrosurgery on inflamed tissue, based on an exaggeraated response to an
electrosurgical proocedure. Proximity to bone and laterral heat production
may have responsiible for the response. Bone is very senssitive to heat.


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 Fig. 26 Removal of irritated tissue that has proliferated over preparation
finish lines by electrosurgery

• EIectrosurgery is unquestionably capable of tissue damage. Most surgical

instruments are dangerous if used improperly. Tremendous iatrogenic
damage has been done over the years by the rotary handpiece, but no one
has suggested that it not be used. Kalkwarf et al reported that wounds
created by a fully rectified, filtered current in the healthy gingiva of adult
males demonstrated epithelial bridging at 48 hours and complete clinical
healing at 72 hours. In a double-blind study on 27 patients, Aremband and
Wade detected no difference in healing in gingivectomies done by scalpel
or electrosurgery. When variables are properly controlled in electrosurgery,
untoward events in wound healing are rare.
• Electrosurgery produces controlled tissue destruction to achieve a surgical
result. Current flows from a small cutting electrode that produces a high
current density and a rapid temperature rise at its point of contact with the
tissue. The cells directly adjacent to the electrode are destroyed by this
temperature increase. The current concentrates at points and sharp bends.
Cutting electrodes are designed to take advantage of this property so they
will have maximum effectiveness.
• The circuit is completed by contact between the patient and a ground
electrode that will not generate heat in the tissue because its large surface
area produces a low current density, even though the same amount of
current passes through it. The cutting electrode remains cold, this differs
from electrocautery, in which a hot electrode is applied to the tissue.

Gingival sulcus enlargement

• Before any tissue is removed, it is important to assess the width of the
band of attached gingiva. The electrosurgery tip is a surgical
instrument; it cannot restore If there is unattached alveolar mucosa too
near the gingival crest, periodontal surgery, probably in the form of a
gingival graft, must be employed to reinstate adequate band of
healthy, attached tissue.
• To enlarge the gingival sulcus for impression making, a small, straight


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 or J-shaped electrode is selected. It is used with the wire parallel with
the long axis of the tooth, so that tissue is removed from the inner wall
of the sulcus. If the electrode is maintained in this direction, the loss of
gingival height will be about 0.1 mm. Holding the electrode at an
angle to the tooth, however is likely to result in a loss of gingival
height.
• Around those teeth where the attached gingival tissue is thin and
stretched tightly over the bone on the labial surface, there is greater
chance for a loss of gingival height. This is frequently true for
maxillary anterior teeth and particularly the canines it is important that
if the esthetic requirements are great and any gingival recession will
be unacceptable.
• With the electrosurgery unit off, the electrode is held over the tooth to
be operated and the cutting strokes are traced over the tissue.
• Depress the foot switch before contacting the tissue, and then move
the electrode through the first pass. A whole tooth should be encom-
passed in four separate motions: facial, mesial, lingual and distal at a
speed of no less than 7 mm per second.
• If a second pass is necessary in any one area, wait 8 to 10 seconds
before repeating that stroke. This will minimize the production of
lateral heat. Clean tissue debris off the electrode tip after each stroke. -
Use a cotton pellet dipped in hydrogen peroxide to clean debris from
the sulcus.
Better results are obtained if retraction cord is loosely packed in the enlarged
sulcus before the impression is made.

Removal of edentulous cuff

Frequently, the remnants of the interdental papilla adjacent to an edentulous
space will form a roll or cuff that will make it difficult to fabricate a pontic
with cleanable embrasures and strong connectors. Before a pontic is
fabricated, an edentulous ridge should be examined carefully. If there are
cuffs, they should be removed.
Malone and Manning found in a bilateral comparative study of
gingivoplasties on 10 patients there was no difference in healing between
conventional surgery and electrosurgery. A large loop electrode is used for
planing away the large roll of tissue. When this larger electrode is used, it


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requires a higher power setting of the unit.

F) Crown lengthening (Fig. 27)

Fig. 27 Crown lengthening

There are circumstances in which it may be desirable to have a longer

clinical crown on a tooth that is present.
If there is a sufficiently wide band of attached gingiva surrounding the tooth,
this can be accomplished with a gingivectomy using a diamond
electroctrode. It is frequently necessary to do a second series of cuts to
produce a bevel around the first. This will produce a better tissue contour
without hard to clean edges near the tooth. The “bevel” also must be done
only on the attached gingiva. When surgery leaves an extensive
postoperative wound, it is necessary to place a periodontal dressing which
should be changed in about 7 days. The lengthened tooth that results from
this surgery should afford better retention for any crown placed on it, with
margin placement in area of the tooth more accessible for cleaning. If the
band of the attached gingiva is too narrow, it must be made wider with a
graft or an alternative restoration must be made for the tooth.

G) Temporary or provisional crowns

Provisional restorations play a critical role in the successful treatment of the
prosthodontic patient. An interim restoration that meets the functional and aesthetic
requirements of the patient can mean the difference between success and failure of a
treatment plan.
Ideal requirements include
• Provide pulpal protection.
• Provide positional stability.
• Provide the patient with the proper occlusal function.
• Be easily cleanable.

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 • Be strong and retentive.
• Be aesthetically pleasing.
• Margins should not impinge upon the gingival tissues.
Improperly constructed “interim” restorations may cause periodontal
inflammation and gingival recession. The requirements for fit, polish and contour in
the interim restoration should be the same as for the final restoration.
Long-term restorations should not be called as temporary but should be
regarded as provisional or treatment restorations. These allow the dentist to assess the
effect of final restoration.

H) Embrasures
When teeth are in proximal contact, the spaces that widen out from the contact
are known as embrasures. Each interdental space has 4 embrasures.
1. An occlusal or incisal embrasure that is coronal to the contact area.
2. A facial embrasure.
3. A lingual embrasure.
4. A gingival embrasure which is the space between the contact area and the
alveolar bone.
In health, the gingival embrasure is filled with soft tissue, but periodontal
diseases may result in attachment loss creating open gingival embrasures.The
gingival embrasure: From a periodontal view point, the gingival embrasure is the
most significant. Periodontal diseases cause tissue destruction, which reduces the
level of alveolar bone, increases the size of the gingival embrasure and creates an
open interdental space. Restorations may be constructed to preserve the morphologic
features of the crown and root and retain the enlarged embrasure space or when
esthetic situations dictate, the teeth may be reshaped by the restorations so that the
gingival embrasures are relocated close to the new level of the gingiva. To relocate
the gingival embrasure, the dentist changes the contour of the proximal surfaces and
broadens the contact areas more apically. Dimensions of gingival embrasure: Height,
width, depth. The proximal surfaces of crowns should taper away from the contact
area facially, lingually and apically. Excessively broad proximal contacts and bulky
contour in the cervical region crowd out the gingival papillae. This can make oral
hygiene difficult resulting in gingival inflammation and attachment loss.
Restorative dental procedures too often result in the restorative materials
taking up space that is normally occupied by the interdental papilla. The problem
begins with under preparation of tooth, so that the technician is left with no choice


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except to place an excessive amount of restorative material into the interproximal
space. During the preparation of dies for cast restorations, the technician first
removes all of the replicated tissue to gain access to the finish lines. Thus it is
impossible for him to visualize the space available for dental restoration in the
interproximal embrasure area. If two models are poured from the same impression
and the second one is used as an indicator of how much space is currently occupied
by gingival tissues, the technician can have a much better understanding of what the
contour of the final restorations should be.
In fixed prosthesis and / or multiunit fixed splints, the interproximal contact
and / or soldered joint is frequently carried for too apically so that it invades the
embrasure space from its coronal aspect. This leads to inflammation and destruction
of periodontal tissues. The responsibility of determining the size of the interproximal
contact should rest with the dentist, not the technician.

I) Crown contour
The contours of full and partial coverage restorations play a supportive role in
establishing a favorable periodontal climate. The theories of crown contouring that
have evolved are:
1. Gingival protection.
2. Gingival stimulation.
3. Muscle action.
4. Access for oral hygiene.
1.Gingival Protection Theory
It advocates that contours of cast restorations be designed to protect the
marginal gingiva from mechanical injury. In 1962 this concept was challenged by
Morris who reported that the response of gingival tissue around teeth prepared for
complete artificial crowns but which had lost their temporary crowns were similar to
the adjacent unprepared teeth. Schluger stated that the so called protective cervical
bulge protects nothing but the microbial plaque.

2.Gingival stimulation theory

This concept reasons that as food is masticated, it will pass over the gingiva
stimulating it and causing increased keratinization of the epithelium. Keratinized
epithelium would be more resistant to periodontal breakdown. Several authors have
shown that the gingival margin is not in the path of masticated food. Even if the food


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passing over the teeth were to increase keratinization, this stimulating would occur at
the buccal and lingual surfaces.
3.Muscle action theory
This theory advocates that the perioral musculature (tongue, cheeks) are
responsible for maintaining a healthy periodontal environment. They suggest that
overcontouring prevents normal cleansing action by the musculature and allows food
to stagnate in the overprotected sulcus.
4. Theory of access for oral hygiene
This theory is based on the concept that the prime etiologic factor in caries and
gingivitis is plaque. Thus, crown contour should facilitate plaque removal, not hinder
it.
Four guidelines to contouring crowns are:

1) Buccal and lingual contours – flat, not fat

Plaque retention on the buccal and lingual surfaces occurs primarily at the
infra bulge of the tooth. Reduction or elimination of infra bulge would reduce plaque
retention.
2) Open embrasures
Every effort must be made to allow easy access to interproximal area for
plaque control. An overcontoured embrasure will reduce the space intended for the
gingival papilla.

3) Location of contacts
Contacts should be directed incisally or occlusally and buccally in relation to
the central fossa, except between maxillary first and second molars. This creates a
large lingual embrasure space for optimum health of lingual papilla.
4) Furcation involvement
Furcations that have been exposed owing to loss of periodontal attachment
should be ‘fluted’ or ‘barreled out’. It is based on the concept of eliminating plaque
traps.
Facial and Lingual sulcular contours. In the patient whose gingival margins are apical
to the CEJ the sulcular morphology differs from that of healthy patients whose
gingival margins are on enamel. The intracrevicular contours of an artificial crown
should be as close to the original enamel contour as possible. Wagman has estimated
the angle of enamel flare from CEJ to be approximately 22.5 degrees from the


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vertical axis of gingival housing. As the gingival margin progresses more apically,
the sulcus narrows and the intracrevicular contours of the tooth become the flat
contours of the root rather than the convex surface of the anatomic crown.
Intracrevicular contours in such cases depend on the adjacent gingival morphology.
When the intracrevicular margins are adjacent to thin gingiva on the root, the
sulcular contours of the artificial crown should be flat, mimicking the shape of the
root. Often the gingiva adjacent to a flat root surface develops a thick free gingival
margin when the underlying bone is thick. In these situations it may be advisable to
create a thicker intracrevicular crown contour similar to that of a natural crown.

J) Pontic design (Fig. 28)

A pontic should meet the following requirements.
• Be esthetically acceptable.
• Provide occlusal relationships that are favourable to abutment teeth.
• Restore the masticatory effectiveness.
• Be designed to minimize accumulation of irritating dental plaque and food
debris.
• Provide embrasures for passage of food.
The health of the tissues around the fixed prosthesis depends primarily on the
patient’s oral hygiene. The materials with which pontics are constructed make little
difference and pontic design is important only to the extent that it enables the patient
to keep the area clean.
Plaque accumulates to an equal degree under pontics made of glazed and
unglazed porcelain, polished gold and polished acrylic resin. The principles of
contours of crowns apply equally well to pontics but with pontics there is an
additional concern associated with the contour of the tissue facing surfaces. In the
mandibular posterior region, esthetics is not a major consideration, so the spheroidal
pontic is the design of choice because of its contour. In the maxillary posterior area,
the modified ridge lap satisfies both esthetics and hygiene. Mandibular anterior area
also requires a ridge lap design. When using a spheroidal design, the pontic contacts
without pressure the tip of the ridge or the buccal surface.
When there is excessive bone loss and the rigidity of the connector is suitable (non-
esthetic posterior areas), the pontic is not required to touch the ridge. There should be
atleast 3mm of space so that the patient can maintain hygiene.


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Fig. 28 Pontic designs A: S Sanitary pontic B: Ridge Lap Pontic C: C Modified Ridge
Lap Pontic D: Ovate Pontic
K) Cementation proceduree
During cementation itt is important that the restoration be seated as close to the
tooth preparation as possiblle. A minimal cement line at the marggin reduces plaque
formation. It is extremely important that all excess cement be removed from the
sulcus after cementation. R Removal of cement from the interproxximal joints can be
facilitated by lightly coatingg the exterior surfaces of the prosthesis with petroleum
jelly prior to cementation.
.Subgingival debris
• Leaving debris bellow the tissue can create adverse perioddontal response.
• The cause can be retraction
r cord, impression material, prrovisional material,
or either temporaryy or permanent cement.
Hypersensitivity to Dental Materials
M
• Inflammatory gingivaal responses have occurred on use of nonprecious alloys
in dental materials esppecially those containing nickel.
• In such cases preciouss alloys can be used.
Plaque retention on Dental Materials
• Rough surfaces enhaance the development of gingivitis beecause they induce
accumulation of plaquue.
• Threshold surface rouughness for retention of bacteria is 0.2 micrometer, below
which no further bacteerial accumulation occurs.
• Glantz demonstratedd that dental materials possess a greater
g capacity to
accumulate dental plaaque than either enamel or dentin.
• Highly polished dentaal gold, porcelain and heat cure acryllic resin irritate the
tissues little, if at all.
• Porosity on the surfacce increases plaque accumulation and reetention.
• PMMA accumulates plaque faster than gold or porcelaain because of the
absorption of fluids.
L) Occlusal Considerations


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 • Improper occlusion of the restoration causes trauma to the periodontium which
manifests as periodontal disease.
• To manage occlusion the dentist must be able to make accurate casts, use a
face bow, and create centric relation records so that the information can be
transferred to a suitable articulator.

Guidelines to achieve proper occlusion

1. Even, simultaneous contact on all teeth during centric closure.
2. When the mandible moves from centric closure, some form of canine or
anterior guidance is desirable, with no posterior tooth contacts. This reduces
the ability of the elevator muscles to contract and distributes the force of the
movement onto the anterior teeth, which receives less force because of the
class III lever system being applied in this situation
3. The anterior guidance needs to be in harmony with the patient’s neurovascular
envelope of function. Harmony of this relationship is demonstrated by a lack
of fremitus and mobility on the anterior teeth, by the ability of the patient to
speak clearly and comfortably, and by the patient’s general sense of comfort
with the overbite, overjet, and guidance created during chewing and when
holding the head upright.
4. The occlusion should be created at a vertical dimension that is stable for the
patient. It is generally accepted that the patient’s existing vertical dimension is
at equilibrium between the eruptive forces of the teeth and the repeated
contracted length of the elevator muscles.
5. When managing a pathologic occlusion or when restoring a complete
occlusion, the clinician needs to set the occlusion on the centric relation
because it is the only position from which an interference free occlusion can be
created.

Restoration of molar teeth with furcation invasions

In long-term studies of tooth longevity, molars are the teeth that are most often
lost. This is due to the complex root anatomy and furcations that make periodontal
therapy and plaque control difficult for the patients.
In the maxillary molars, the distal furcation is usually more apical on the tooth
than the mesial furcation. It is less frequently involved with periodontal attachment


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loss than the mesial and buccal furcations. The concavities and root alignments result
in a furcation chamber that is wider than the entrances.
In the mandibular molars, the root surfaces facing the furcation, both have a
high prevalence of concavities.

Tooth preparation for furcation involved teeth

If a full coverage restoration is indicated on a Grade I or early Grade II
furcally involved teeth, the principles are same as that for a normal tooth except that
the preparation has to be fluted or barreled into anatomic depressions.

Tooth Preparation in case of Root resection or Hemisection

It is critical when intracrevicular margins have to be placed on resected or
hemisectioned teeth. A minimum of 4 to 6 weeks of healing after surgery is required
before the soft tissues can resist the trauma of tooth preparation
Intracrevicular margins are usually required to cover portions of root-resected area.
The crown margin should be apical to the pulp chamber or root canal that was
exposed by resection. To preserve remaining tooth structure and encourage a better
fitting restoration a chamfer finish line is recommended. The gingival third of the
restoration is fabricated with a flat emergence profile from the gingiva to facilitate
oral hygiene.


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Soft tissue management in implant therapy

Dental implant:(GPT-8)- a prosthetic device made of alloplastic material(s)

implanted into the oral tissues beneath the mucosal or/and periosteal layer, and on/or
within the bone to provide retention and support for a fixed or removable dental
prosthesis; a substance that is placed into or/and upon the jaw bone to support a fixed
or removable dental prosthesis. The health or quality of the soft tissue surrounding an
implant may be influenced by many factors. The presence of keratinizing mucosa
surrounding an implant is thought to be a positive factor in maintaining soft-tissue
health. In many implant systems, the connection between the implant and the
prosthesis creates a small microgap that has been implicated in the ongoing health of
soft tissue surrounding implants. 20 The material selected for the transmucosal
connector to the implant has likewise been shown to affect bone and soft-tissue
reactions. In some instances, softtissue inflammation is observed without changes in
bone level, a condition termed ‘‘peri-implant mucositis.’ This condition is distinct
from bacterially mediated peri-implant bone loss in a condition known as ‘‘peri-
implantitis”. In addition, the connective tissue and epithelium may actually integrate
with the titanium surfaces of dental implants, suggesting that the health and
resistance to peri-implant disease states may be a reflection of the overall integration
process. These observations may be of clinical significance and contribute to the
functional and esthetic success of the prosthesis.
Gould et al used a technique to grow oral epithelial cells on epoxy resin coated
with thin films of titanium. In this in vivo study, multiple layers of epithelial cells
were formed against the surface of the titanium. There was clear evidence of
hemidesmosomes, as well as the appearance of a basal lamina. It is currently
accepted that the implant–soft-tissue interface has certain similarities with that of
natural teeth, including an oral epithelium, a sulcular epithelium, and a junctional
epithelium with underlying connective tissue. Berglundh et al compared the soft-
tissue barrier at dental implants and natural teeth. The authors showed a cuff-like
barrier of well-keratinized oral epithelium adhering to both teeth and implants. One
difference was that collagen fibers of the peri-implant mucosa appeared to run
parallel with the surface of the transmucosal abutment. Moon et al postulated that the
fibroblast-rich layer adjacent to the titanium surface has a role in the maintenance of
a proper seal between the oral environment and the peri-implant tissue. Buser et al
examined surface variations in the implants and the relationship to soft-tissue
inflammation, the authors concluded that the different surface textures of the dental


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implants did not influence the healing pattern of the soft tissues and found non
keratinized sulcular epithelium with a zone of dense circular fibers close to the
implant surface. In another study, Abrahamsson et al investigated the influence of the
type of abutment on the quality of the mucosal barrier that formed following
placement. Abutments made of titanium, gold, and ceramic were tested. An
important observation was that the gold alloy abutments were apparently unable to
promote mucosal healing and a zone of connective tissue attachment. It was
postulated that the surface layers of gold alloys are not as chemically stable as those
of titanium and ceramics. Thomsen et al in which increased areas of soft connective
tissue were observed more frequently at gold implant sites than at those sites with
titanium and zirconium. It has been proposed that the depth of the implant in the
bone affects the peri-implant soft tissues. Todescan et al investigated this with a
study of 24 implants. Three implants were placed on each side of the mandible at
varying heights in the bone: 1 mm above the crest, even with the crest, and 1 mm
below the crest of alveolar bone. In the short 3-month span of this study, there was a
tendency for the epithelium and connective tissue to be longer when the implants
were placed deeper. These results confirm the findings of Abrahamsson et al and
Berglundh et al that the epithelium establishes an attachment of approximately 2 mm,
and the connective tissue, an attachment of approximately 1 mm around dental
implants. Bone loss was found to be smaller for the countersink group, in contrast to
articles by Hermann et al which stated that bone would maintain its biologic width.
Todescan et al postulated that this could be because the microgap was much smaller
and the surface texture of the implants used in the study was different.

HEALING ATROUND IMPLANTS

All wounds heal using a combination of 3 mechanisms:
• Contraction,
• Epithelialization, and
• Connective tissue deposition.
The 4 stages of healing are
• Hemostasis,
• Inflammation,
• Proliferation, and
• Remodelling.


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 In each of these phases, specific cellular components act through several
mediators.
In hemostasis, platelets, endothelial cells, fibrin, and fibronectin function through
growth factors and cytokines. Inflammation appears in 2 to 5 days through the action
of neutrophils, macrophages, and lymphocytes mediated by growth factors and
proteases. Proliferation occurs in 2 days to 3 weeks through the actions of fibroblasts,
epithelial, and endothelial cells, and is largely dependent on growth factors and
collagen deposition During remodeling and wound maturation, collagen cross-
linking and collagen degradation increase scar strength. Traditional periodontal
parameters have commonly been used for clinical monitoring of the soft tissues
around dental implants. Periodontal probing is commonly used to monitor tissue
heights. Quirynen et al assessed various types of periodontal probes to determine
which was the most reliable method to measure clinical attachment level and whether
a relationship between bone and attachment levels around dental implants exists. The
authors concluded that for implants with healthy gingiva, the clinical attachment
level is a reliable indicator of bone level. Etter et al determined that healing of the
epithelial attachment after probing around dental implants is complete after 5 days
and does not appear to have any detrimental effects on the soft-tissue seal and the
longevity of oral implants. Tarnow et al investigated the height of the soft tissue
between 2 adjacent implants in 136 sites in 33patients. Under local anesthesia,
periodontal probing was used to measure the vertical distance of the crest of the bone
to the papilla height. The authors concluded that an average of only 3.4mmof soft
tissue could be expected to form over the interimplant crest of bone. The authors
recommended modification of treatment plans in highly esthetic areas. Modified
surgical techniques have been recommended for uncovering of 2-stage dental
implants for preservation of the soft tissues. In a pilot study, Becker and Becker
tested a conservative flap design to minimize gingival recession. Results suggested
that the type of flap design could minimize the recession at teeth adjacent to implant
sites in the maxillary anterior region. In addition, a soft-tissue punch has become a
popular alternative for clinicians using the 2-stage surgical approach. Standard
protocols for clinical use of dental implants include an abutment connection
following the healing of the tissues to a healing abutment. Abrahamsson et al
evaluated tissue reactions following removal of the healing abutment and the
placement of a definitive abutment. The authors found that the length of the barrier
epithelium, the height of the connective tissue attachment, and the level of the
marginal bone did not differ in the 3 groups tested.


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 Soft-tissue health is critical to the patient’s perception of a successful
restoration. For the clinician, patient dissatisfaction with esthetic results can be costly
in both time and laboratory costs if an early remake of the prosthesis is necessary.
Several patient factors that influence healing around dental implants include the
patient’s health, soft- and hard-tissue contours, and the use and care of the prosthesis.
Other factors influencing healing include the manufacturer’s implant-abutment
designs, surgical augmentation and placement, and the design of the definitive
prosthesis.
Internal and external factors that affect the health of peri implant soft tissues:
Internal factors:
• Age of Patient
• General health of patient
• Periodontal status of remaining dentition
• Host resistance
• Systemic disease
• Periodontal Phenotype
• Pre existing bony dehiscence
• Vestibular depth
• Aberrent frenum
• Thickness of attached tissue
• Apicoronal dimension of attached gingival if present

External Factors
¾ Tobacco use
¾ Use of medications
¾ Oral Hygiene
¾ Implant dsign and surface characteristics
¾ Submerged vs non submerged technique
¾ Surgical approach
¾ Location of implant
¾ Depth of implant placement
¾ Prominence of implant position in alveolus
¾ Restorative technique
¾ Restorative materials


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 ¾ Restoratiove margin via biologic width

Recordings of teeth and soft-tissue contours are critical steps toward achieving
proper esthetics, function, and a compatible synergy between biological tissues and
prostheses that are placed. It is understood that the health of the soft tissues is a
requirement prior to making any impression.
Along with tissue maturation, this contingency often requires other preemptive
procedures such as proper oral hygiene, periodontal treatment, or soft-tissue rest by
leaving the prostheses out of the mouth for extended periods, and/or the placement of
tissue conditioning materials. These corrective procedures are often challenged by
patients expecting immediate gratification. Intervention prior to the maturation or
completion of the healing process in response to patient demands may result in
unpredictable soft tissue manifestations.16
In addition, patients must cooperate by removing provisional prostheses at
specified intervals to allow proper soft-tissue rebound and proper residual ridge form
prior to the initiation of definitive treatment. These influencing factors may be further
confounded by the material surface (enhanced titanium, gold alloy, ceramic, or
polymer)and form (round or custom esthetic profile) of the transmucosal abutment.
The outcome of such treatment may result in undesirable clinical manifestations,
such as the selection of an improper implant component, deficiencies in the
interproximal papillae form, or the presence of either too much or too little space
beneath prosthesis. Increased space can interfere with speech, function, and fluid
control. Conversely, inadequate space can occur if there is a rebound of compressed
soft tissue after placement of a completely implant-supported prosthesis. The latter
may ultimately be recognized as soft-tissue enlargement that encroaches on the
intaglio surface of the prosthesis or exaggeration of bone and soft-tissue formation
beneath the cantilevered extensions of a mandibular fixed implant-supported
prosthesis. Dental implant manufacturers have suggested protocols to clinicians for
earlier restoration and immediate, early, and delayed loading of dental implants.
Many dental implant manufacturers are recommending single- stage surgical
approaches, as well as immediate placement into extraction sockets. The method of
placing and uncovering the implant may likely affect how the soft tissues react over
time.
Healing around dental implants is affected by the patient’s health, soft- and
hard-tissue contours, and the use and care of the prosthesis, as well as the


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manufacturer’s implant-abutment designs, surgical augmentation and placement, and
the design of the definitive prosthesis.
1. There are no specific guidelines relative to the amount of space or clearance
necessary for a patient to clean beneath a fixed implant-supported prosthesis and
whether these tissues change predictably over time.
2. Individual variability contributes to the difficulties in assessing soft tissues around
dental implants in edentulous patients.
3. Data on trends in soft-tissue shrinkage or hyperplasia should not be pooled to
include partially dentulous and edentulous patients.


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Soft tissue management in maxillofacial prosthesis

Tumors in and around the mandible usually require surgical removal of the
lesion and extensive resection of the bone. Smaller lesions removed without
discontinuity of the bone are relatively simple to restore with prosthesis. Larger
lesions that extend into the floor of the mouth may be more difficult to restore with
prosthesis even though the continuity of the mandible is maintained. The prognosis
for edentulous segmental mandibulectomy patients becomes less favorable as the size
of the resection increases. Success of the edentulous mandibular resection prosthesis
is related directly to the amount of the remaining bone and soft tissue. If the tongue is
broadly resected or used for mandibular closure, valuable vestibule extension regions
may be obliterated after surgery. Prosthetic rehabilitation for such patients is a
challenge for clinicians. Frequently, the edentulous mandible requires reconstructive
plastic surgery to create a buccal or lingual sulcus to provide a suitable tissue
foundation for an acceptable mandibular denture. Without preprosthetic
reconstructive surgery, denture fabrication for mandibulectomy patients becomes
extremely difficult. After reconstructive surgery, implant-assisted overdentures may
improve denture retention and stability, but some patients cannot afford this
treatment.
With the loss of buccal and lingual sulcus and the presence of scar tissue,
denture stability was extremely difficult to achieve. Displacement of the scar by the
denture base needed to be avoided. Proper border extension of the denture and
correct denture polishing surface contours were important for denture stability. In
patients with unfavorable edentulous tissue support, the neutral zone impression
technique should be used to register the soft tissue contour and the denture polished
surface. The obliteration of the mandibular sulcus often requires a skin graft and
immediate stent prosthesis to stabilize and maintain the graft during the healing
period. The general principles of removable partial denture (RPD) design apply to
obturator prosthesis design as well. Relevant among these are
(1) The need for a rigid major connector;
(2) Guide planes and other components that facilitate stability and bracing;
(3) A design that maximizes support;
(4) Rests that place supporting forces along the long axis of the abutment tooth;
(5) Direct retainers that are passive at rest and provide adequate resistance to
dislodgment without overloading the abutment teeth; and


͸ͺ

 (6) Control of the occlusal plane that opposes the defect, especially when it involves
natural teeth.
In addition, many unique considerations involved in the design are provided by
the nature of the problem and the treatment required. Among these are (1) the
location and size of the defect, especially as it relates to the remaining teeth; (2) the
importance of the abutment tooth adjacent to the defect, which is critical to the
support and retention of the obturator prosthesis; (3) the usefulness of the lateral scar
band, which flexes to allow insertion of the prosthesis but tends to resist its
displacement; and (4) the use of the surveyor to examine the defect for the purpose of
locating and preserving useful undercuts or eliminating undesirable undercuts.
The prognosis of the obturator will improve with
(1) The size (amount remaining after surgery) and curvature of the arch;
(2) The quality of the tissue covering the ridge and lining the defect;
(3) An abutment alignment that is curved instead of linear; and
(4) The availability of teeth on the defect side for support and retention.
Many designs require full coverage of the remaining palate for maximum
support. In all instances, the gingival margins should be relieved when they are
crossed by the major connector to avoid impingement during function. The
uncovering of the gingival margins in such a design should be discouraged because it
is not a replacement for good oral hygiene and is probably not necessary for tissue
stimulation if good hygiene is practiced.


͸ͻ

Conclusion

The soft tissue evaluation should involve careful visualization, palpation, and
functional examination of the overlying soft tissue and associated muscle
attachments before taking any decision regarding treatment plan for the patient. In
examining completely edentulous patient retraction of the upper and lower lips help
one identify muscle and frenum attachments buccally. A mouth mirror can be used
lingually to tent the floor of mouth to evaluate the mylohyoid–alveolar ridge
relationship. Careful palpation with manipulation of both upper and lower alveolar
ridges is the best diagnostic determinant of loose and excessive soft tissue. One must
be aware of occult bony abnormalities obscured by soft tissue excess, especially in
cases where adequate alveolar ridge height and width is imperative for implant
placement. Such abnormalities can lead to embarrassing and unexpected changes in
the restorative plan at the time of mucoperiosteal reflection of the overlying soft
tissue. If conventional prosthetic restorations are planned, attention to bony and soft
tissue undercuts that oppose the prosthetic path of insertion must be addressed.
The aim of preprosthetic surgery is to increase the quality and quantity of
denture foundation. The procedures range from simple technique like frenectomy to
complex reconstructive procedures involving bone grafts and implants. Preoperative
evaluation, case selection and careful treatment planning are important to achieve
desirable results. Otherwise the results would be embarrassing. For example the
vestibuloplasty procedures are useful only if sufficient vertical available bone is
there.
Poor case selection will end up with scarring and relapse which together
worsens the situation. Such results would be embarrassing to the practicing dentist.
The preprosthetic surgery attempts to create and oral environment that is conductive
to a functional, aesthetic, stable and retentive prosthesis that enhance patient comfort
and acceptance.
Injudicious use of these techniques to all patients should be discouraged. In
fact the actual situation requiring surgery is very rare as much of such constraints can
be overcome by the skilled hands of a competent prosthodontist.
Preprosthetic surgery is a rapidly changing area of oral and maxillofacial
reconstructive surgery, and knowledge of the range, capabilities, and limitations of
the available surgical procedures is a must to achieve the best overall result. In these
instances, a team approach is needed with the prosthodontist and oral surgeon serving
as equal members of the team.


͹Ͳ

 Success of fixed prosthesis to much extent depends on the proper recording of
the margin of prepared abutments, which in turn depends on gimgival retraction
during impression making. Gingival displacement is an important procedure during
fabrication of restoration. Both mechanical-chemical and surgical methods can be
used to enlarge the sulcus. The most common technique used is that of retraction
cords with haemostatic medicament. Cord of sufficient diameter should be used to
provide lateral displacement to create a mean sulcular width of 0.2 mm.
Whatever may be the type of restoration, soft tissue around the prosthesis play
a key role in outcome of the prosthesis, consideration to the soft tissue should start
from the first visit of patient, during the various phases of the treatment and
continues till the follow up of the patient and sometimes even beyond that.


͹ͳ

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