Mouth preparation refers to procedures that must be accomplished before fixed prosthodontic treatment can be properly performed. Rarely are crowns or fixed prosthodontic treatment provided without initial therapy because what causes the need for the fixed prosthesis also promote other pathological processes (caries and periodontal disease are the most common). Failure of fixed prosthesis often results from inadequate or incomplete mouth preparation.

1. Mouth Preparation for Fixed
Prosthodontics' Treatment
By
Radwa Ibrahim El-Tahawi

2. • Mouth preparation refers to procedures that must be
accomplished before fixed prosthodontic treatment can
be properly performed.

3. • Rarely are crowns or fixed prosthodontic treatment
provided without initial therapy because what causes the
need for the fixed prosthesis also promote other
pathological processes (caries and periodontal disease are
the most common).
• Failure of fixed prosthesis often results from inadequate
or incomplete mouth preparation.

4. • These problems must be corrected in the early preparatory
phase of treatment to stabilize the residual dentition and
prevent further deterioration.
• Fixed prosthodontic treatment is successful only if
restorations are placed on caries-free, well-restored teeth in a
healthy environment.

5. • So some dentists do misguided attempts to help patients by
premature fixed prosthodontic treatment and unfortunately
such action leads to early failure.
• Ex, prepare a tooth for a crown without replacing a pre-
existing defective restoration so dislodgment occurs for the
restoration and may also have underlying caries even the
radiographic assessment not noticeable and need to replace
this restoration and alter the treatment plan and lead to
diminishing the patient confidence in his dentist.

6. • Comprehensive treatment planning ensure that mouth
preparation is undertaken in a logical and efficient
sequence to bring the teeth and supporting structures to
optimum health.
• As a general plan, treatment procedures should be
performed in the following sequence,
1. Relief of symptoms (chief complaint)
2. Removal of the causes ( caries or calculus )
3. Repair of damage
4. Maintenance of dental health

7. So mouth preparation involve
different phases:
1. Preliminary assessment
2. Emergency treatment of
presenting symptoms
3. Oral surgery
4. Restorative phase
5. Endodontic treatment
6. Periodontal treatment
7. Orthodontic treatment
8. Definitive occlusal treatment
9. Fixed prosthodontic treatment
10.Removable prosthodontics
11.Follow up care phase
• Sequence of preparatory
treatment should be flexible.
Two or more of the phases are
often performed concurrently.

8. Medical history
• Check all medical information related to the patient.
• Taking any medication (ex, anti coagulants or steroid treatment).
• Having any condition affects the treatment plan (ex, radiation therapy or
haemorrhagic disorder).

9. Medical history
• Has any systematic condition with oral manifestations (periodontitis
related to diabetes or pregnancy).
• Has any blood or saliva transmitted disease (HIV or hepatitis).
• If there is any allergy from medication or material like Nickle allergy
which is important in choosing the fixed prosthesis material.

10. Dental history
• If the patient has any previous dental treatment related to any
dental aspect and its effectiveness and complications and his
satisfaction about it.
• If there is any myofascial pain, clicking in the TMJ or
neuromuscular symptoms such as abnormal muscle tone or
tenderness to palpation should be treated and resolved before
fixed prosthodontic treatment.

11. Patient with implant placement should be
checked with the contraindications
• Acute illness.
• Pregnancy.
• Uncontrolled metabolic disease.
• Radiation therapy or osteoporosis.
• Poor oral hygiene especially smoking.

12. Radiographic Assessment (Tooth Supported
or Implant Supported FP)
• Use of radiographic assessment like panoramic x-ray or
periapical or bitewing for check out the remnant teeth and
restorations if there is any recurrent caries or any restoration
leakage and confirm the success of any previous endodontic
treatment and investigate any lesion presence like abscess or
granuloma.

13. Radiographic Assessment (Tooth Supported
or Implant Supported FP)

14. Radiographic Assessment (Tooth Supported
or Implant Supported FP)
• Also in implant supported treatment we may need 3-D radiographic assessment
called CBCT to:
1. Check the bone height and thickness in the implant site and the bone quality
which varies from D1 (compact bone) to D5 (v. soft bone).
2. Presence of any vital structure like approximation of the maxillary sinus (which
may need sinus lifting operation) or the inferior alveolar nerve (which may need
usage of short implants or bone augmentation to increase the height of the bone)
and
3. Need of bone splitting and augmentation in narrow bone or knife edge bone for
getting thicker bone.

15. Radiographic Assessment (Tooth Supported
or Implant Supported FP)

16. Clinical Examination

17. A- Extra oral Examination
If there is facial asymmetry
because of small deviation
related to underlying
conditions and lymph nodes
check and TMJ and muscles
of mastication check.

18. TMJ check by palpating bilateral anterior to auricular tragi while patient open
and close his mouth. This enable a comparison between the relative timing of
left and right condylar movements during the opening stroke. Asynchronous
movement indicates a disc displacement that prevent one of the condyles from
making a normal translatory movement.
Auricular palpation with light anterior pressure identify
disorder in the posterior attachment of the disc. If there
tenderness or pain on movement can be inflammatory change
in retrodiscal tissues. Clicking in TMJ is also noticed but
may be difficulty detected as the overlying tissues around the
lateral pole of condylar process can muffle the click so it’s
better to place the fingertip on the angles of the patient
mandible.

19. • Also check the maximum mandibular
opening which is averaged more than
50 mm.
• And if it’s less than 35 mm it’s
considered restricted opening and
complicate the accessibility of fixes
prosthodontic treatment especially in
posterior area.

20. Lips
• Observe tooth visibility during normal and exaggerated smile as it’s critical in
the planning of the fixed prosthodontic treatment in the aesthetic zone.
• Some patients show all their maxillary teeth during smiling.
• More than 25% don’t show the gingival third of the maxillary central incisors
during exaggerated smile.

21. Lips
• The extend of the smile is related to the length and mobility of the upper
lip and the length of the alveolar process.
• When patient laugh, the jaw open slightly and dark space is visible
between the maxillary and mandibular teeth which called the negative
space.
• Missing teeth, diastema, fractured or poorly restored teeth disrupt the
harmony of the negative space and often must be corrected.

22. Diagnostic casts
• Accurate diagnostic casts transferred to semi-
adjustable articulator is essential in planning the
fixed prosthodontic treatment.
• It enables examination of static and dynamic
relationship of the teeth without interference from
protective neuromuscular reflexes.

23. Diagnostic casts
• If the maxillary cast transferred with facebow, a centric
relation interocclusal record has been used for
articulation of the mandibular cast.
• Condylar elements have been appropriately set
(protrusive and excursive interocclussl records) to
reproduce the patient movements with reasonable
accuracy.

24. Diagnostic casts
• Also the diagnostic casts are essential in determining occlusocervical
dimension of edentulous space.
• Also the alignment and angulation of proposed abutment teeth are easier
to evaluate on the case than intraorally.
• Finally the diagnostic casts enable detailed analysis of the occlusal plane
and the occlusion.

25. Diagnostic Casts
Finally diagnostic casts are
important in planning implant
supported FP as it help the dentist
to study the maxillomandibular
relationship and decide the perfect
places of fixtures placement and
can make resin template to guide
the surgeon especially in full
rehabilitation cases.

26. Soft Tissue Procedures
• Check If there is any soft tissue abnormality
need surgical intervention to facilitate
treatment by clinical examination like
removal of excessive soft tissue
(hyperplastic tissues ) distal to the molars to
enable accessibility during tooth
preparation and enhance the oral hygiene
measurements or modification of the shape
of edentulous space to better accommodate
fixed prosthesis.

27. Diode Laser in Dentistry
• Diode lasers are the most frequently used in
dentistry. Several advantages of diode lasers are as
follows: extreme compactness, affordability, ease of
operation, simple setting-up, versatility and small
size.
• The active medium of the diode laser is a solid state
semiconductor made of aluminum, gallium and
arsenide, which produces laser wavelengths in the
near-infrared spectral region, between 808 and 980
nm.

28. Diode Laser in Dentistry
• The diode wavelengths are highly absorbed in hemoglobin and melanin
and have little absorption in dental hard tissue. This gives the diode laser
the ability to act selectively, and precisely cut, coagulate, ablate or
vaporize the areas around dental structure with less damage and better
post-operative healing.
• In addition, applying diode lasers decreases the need of anesthesia;
significantly controls hemostasis; provides a relatively bloodless surgical
and postsurgical course, and generally does not require sutures.

29. Diode Laser in Dentistry
• Diode lasers utilize an optical
flexible fiber ranging from 200 to
600 µm to deliver the treatment
beam to the target area, and the
radiation emission can be
continuous or pulsed. Thanks to
above-mentioned characteristics,
diode lasers have demonstrated
excellent clinical benefits.

30. Diode Laser in Dentistry
• The beneficial effect of using diode laser in
dentistry has been investigated in a variety
of oral soft tissue surgeries and observed
numerous intraoperative and postoperative
clinical advantages including sufficient
hemostasis, precise incision margin, lack of
swelling, bleeding, pain or, scar tissue
formation, and good wound healing.

31. Hard Tissue Procedures
• Starting from need of simple extraction of any hopeless
tooth or non-stratigic tooth.
• It’s better to be the earlier in the treatment procedures to
permit accomplishment of other therapeutic phases
during healing and osseous recontouring after extraction.

32. Hard Tissue Procedures
• Also tuberosity reduction is common if the space is
inadequate to accommodate a prosthesis.
• And also removal of any impacted tooth which may
influence or damage the adjacent structures.
• And finally if patient has severe skeletal discrepancies
which necessitate surgical correction by maxillofacial
surgeon to repair the facial skeleton and restore the
normal relationship between the maxillary and the
mandibular arch.

33. Orthognathic Surgery
• Severe skeletal discrepancies may necessitate surgical correction in
conjunction with tooth movement before comprehensive prosthodontic
treatment.
• Communication between all members of the treating team of specialists is
crucial to achieve success.

34. Orthognathic Surgery
• Otherwise, an expected improvement in the facial skeleton may be
accompanied by unexpected occlusal dysfunction.
• After surgery, plaque control, caries prevention and periodontal health
should be stressed to the patient.

35. Bone grafts
• Ridge defects develop as a result of surgery, trauma, infection, or congenital
malformations.
• The goals of osseous replacement are maintenance of contour, elimination of dead
space, and reduce postoperative infection; and thus enhance bony and soft tissue
healing.
• The insufficient quantity of bone is due to tooth loss which results in rapid
resorption of alveolar bone due to lack of intraosseous stimulation by periodontal
ligament (PDL) fibers, for example, pneumatization of maxillary sinus following
tooth loss.

36. Bone grafts
• Bone grafting is a surgical procedure that replaces missing bone
with material from patient′s own body, an artificial, synthetic, or
natural substitute.
• Bone grafting is possible because bone tissue has the ability to
regenerate completely if provided the space into which it has to
grow.
• As natural bone grows, it generally replaces the graft material
completely, resulting in a fully integrated region of new bone.

37. Bone augmentation in
bone-defect site
•

38. Bone Splitting in a Narrow Ridge
• presence of any vital structure during implant placement like approximation
of the maxillary sinus (which may need sinus lifting operation) or the
inferior alveolar nerve (which may need usage of short implants or bone
augmentation to increase the height of the bone) and also need of bone
splitting and augmentation in narrow bone or knife edge bone for getting
thicker bone.

41. Short implants
• The alveolar ridge undergoes reduction in height
and width after tooth loss.
• In the posterior maxilla and mandible, this
resorption results in proximity of the maxillary
sinus and inferior alveolar nerve to the alveolar
crest.

42. Short Implants
• Advanced bone grafting procedures such as sinus
augmentation or guided bone regeneration (GBR) with
simultaneous implant placement have shown more
intra- and postoperative complications.
• Therefore, placing short implants might provide higher
patient satisfaction in terms of surgical procedure and
treatment outcomes.

43. Factors Affecting Success of Short Dental
Implants
1- Bone type
- Studies demonstrate greater success of short implants in the mandible than in the maxilla.
2- Implant diameter
3- Surface texture of implants
- short implants is confounded by the studies involving machined surfaces and various surface
modifications. Roughened surface implants appear to increase implant survival.
4- Implant thread design
- Deeper threads have an important contribution to implant stabilization, particularly in the soft
bone. In addition, the inclusion of microthreads at the crest may increase bone-to-implant
contact and reduce crestal bone loss.

44. Restorative phase
• Many teeth that require crowns are severely damaged or have large exciting
restorations.
• Any pre-existing restorations must be carefully examined and if any doubt exists,
the restoration should be replaced as studies have shown that accurately detecting
caries beneath a restoration without its complete removal is difficult.
• Preparation design for a foundation restoration is different from a conventional
restoration particulary with regard to the placement of its retention.

45. Restorative phase
• Foundation restoration or core is used to build a damaged tooth to ideal
anatomical form before the tooth is prepared for crown.
• Foundations may have to serve for an extended time before fabrication of the
final prosthodontic treatment.
• They should be contoured and finished to facilitate the oral hygiene and to
simplify the preparation step by making the depth grooves to enable evaluation
of occlusal and axial reduction.

46. Material Advantage Disadvantage Recommended use Precausions
Amalgum Good strength
Intermediate
restoration
Corrosion
No bonding
Most foundations Well-supported
matrix
Glass ionomer Rapid setting
Adhesion
fluoride
Low strength
Moisture sensitive
Smaller lesions Moisture control
Composite resin Rapid setting
Ease of use
Bonding
Thermal expansion
Setting contraction
Delayed expansion
Smaller lesions
Anterior teeth
Moisture control
Cast gold Highest strength.
Indirect procedure.
Two-visit procedure.
Interim restoration
needed
Extensive lesions Alignment of
pinholes.

47. Endodontic treatment
• During the initial data collection, attention should be directed towards
potential endodontic needs of the patients.
• The clinical examination should include vitality test of all teeth in both
arches by aerosol cryogen spray, ice pencil, heated gutta-percha or an
electric pulp tester.
• Thermal testing is considered more useful because it may indicate the
degree of pulpal inflammation, whereas electric testing reveals only
whether the pulp is vital or non-vital.

48. Endodontic treatment
• Tenderness to percussion should also be noted. Any abnormal sensitivity,
soft tissue swelling, fistula tracts or discolored tooth should suspect pulpal
involvement.
• When pulpal health is in doubt, patient should be examined
radiographically and inspected for signs of periapical disease
(radiolucency or widening of the periodontal ligament space).

49. Endodontic treatment
• As a general rule, conventional (or orthograde) rather than surgical
(retrograde) endodontic treatment should be performed if possible because
the additional trauma results from the surgical approach and because it
affects the crown-to–root ratio and the periodontal support and recently
there are many trials for incorporation the tissue regeneration in pulp
revascularization instead of endodontic treatment.

50. Pulp Revascularization
Pulp revascularization is a regenerative treatment of necrotic
immature teeth that involves inducing the formation of a blood clot
within the previously disinfected canal, by involving the recruitment
of stem cells from the apical region.

51. Pulp Revascularization
• The objective of this therapeutic approach is to regenerate tissue
comparable to pulp tissue and to reactivate dentinogenesis which
has become non-existent following the necrosis of pulp tissue and
subsequently allows the development of the root.
• The indication for pulpal revascularization is currently limited to
immature teeth, but this treatment has been successful in some
cases, performed on mature teeth.

52. Pulp Revascularization
• From the tissue engineering perspective, pulp regeneration of
mature teeth have the advantage of restoring the neurovascular
system of the root canals, which provides the tooth with an
immune system to defend against the microbial attack.

53. Pulp Revascularization
• The problem of the revascularization of mature teeth is that they
have fewer progenitor cells than immature teeth, a difficulty in
inducing bleeding because of the closed apex, a difficulty in
disinfecting the root canals; the closed apex of mature teeth gives
less chance to stem cells to migrate to the canals.
• Pulp revascularization of mature teeth is related to the amount of
progenitor cells, it depend of the aging of the tooth.

54. Selection and Evaluation of Abutment
• It’s critical to investigate each abutment tooth before tooth
preparation and radiograph checked and assesses the pulpal health
by evaluating response to thermal or electrical stimulation.
• Any existing restoration, cavity linear or caries should be
removed.
• Teeth in which pulpal health is doubtful should be endodontically
treated before FDP.

55. Selection and Evaluation of Abutment
• And direct pulp capping under simple restoration but if crown is
planned to the tooth, conventionally endodontic treatment is
preferred.
• If the abutment tooth was endodontic treated, we should confirm
that it hasn’t any symptoms of inflammation or discomfort by
clinical examination and radiographic.

56. Selection and Evaluation of Abutment
• And finally we should decide if this tooth need post treatment
before crown if the remaining sound tooth structure after the tooth
preparation is less than 50% to provide adequate ferrule effect.
• FDP should be designed as simple as possible and the use of
multiple splinted abutment teeth, non-rigid connectors or
intermediate abutment make the procedure more difficult.

57. • For example in replacing missing maxillary or mandibular missing first
molar with good bone support of the both adjacent teeth by 3 unit FDP but
in other scenario to replace the maxillary or mandibular canine tooth, we
need to splint the small lateral incisor with the central tooth to prevent
lateral drift of FDP which called double abutting.
• Also in some cases we use cantilever design in replacing the lateral incisor
by extracoronal retainer on a canine tooth, however the long term
prognosis ofvthe cantilever abutment is poor as it exposed to lateral forces
on its supporting tissues which is harmful and lead to tipping, rotation or
drifting of the abutment.

58. • Loss of a permanent mandibular first molar may affect mesial
drifting to the second molar especially with eruption of the third
molar.
• So the positional relationship not allow parallel paths of placement
without interference of the adjacent tooth starting from use of non
rigid connector or uprighting the tilted abutment orthodontically
or over reduction of the tilted tooth from the tilted site (mesial
side) but it’s somehow destructive solution and may harm the
pulpal tissue or use telescopic crown to regain the parallel path of
the abutments then make the final FDP.

59. • Pier abutment is an intermediate abutment for a fixed dental
prosthesis. Moreover, an intermediate abutment is a natural tooth
located between terminal abutments that serve to support a
fixed/removable prosthesis.
• Pier abutment poses a challenge to prosthodontist. Restoration of
pier abutments with rigid FPDs is associated with higher
debonding rates than short-span prostheses.

60. • Thus, these restorations may result in
marginal leakage and caries. Conversely,
nonrigid connector functions as a stress
breaker between retainer and pontic and
have thus been recommended to diminish
the forces instead of usual rigid connector.
• The movement in a nonrigid connector is
enough to impede the transfer of stress
from segment being loaded to the rest of
the FPD.
• The most commonly used nonrigid
connector comprises a T-shaped key
(patrix/male) that is attached to the pontic
and a dovetail keyway (matrix/female)
placed within the retainer

61. • The four mandibular incisors can be replaced by FDP with
retainers on only each canine and if a lone incisor remains, it
should be extracted because it may complicate the FDP design
and consider non-strategic tooth.
• On the other hand, replacing the maxillary four incisors is more
challenging because of the curvature of dental arch and the more
tipping force to be exposed. So a lot of studied promote using the
both canines and first premolars as abutment.

62. Factors Affecting Abutment Evaluation
and FDP Design
Root surface area
• Ante suggested that the root surface area of the abutment should
be at least equal to root surface area of the replaced teeth.
• Nyman and Ericsson doubt on the validity of Ante's law as they
discussed that the abutment root surface area can be less than half
of the replaced teeth and no attachment loss occur after 11 years
and they attributed their result to proper plaque control and root
planning during active phase of treatment and proper occlusal
design of the prosthesis.

63. Factors Affecting Abutment Evaluation
and FDP Design
Root shape and angulation
• Molar with divergent roots provide better support than conical
roots with no interradicular bone.
• Single rooted tooth with an elliptic cross section offer better
support than circular cross section. A well aligned tooth provide
bettter support than a tilted one.

64. Factors Affecting Abutment Evaluation
and FDP Design
Span length
• Occlusal load leads to flexing and failure of long span FDP and fracture of
porcelain veneer and breakage of connector and loosening of the retainer and
unfavorable soft tissue response.
• All FDP flex slightly when subnected to load but the longer of span, the
greater of flexing.

65. Factors Affecting Abutment Evaluation
and FDP Design
Span length
• And the relationship between the span length and the deflection is not linear
but the deflection increase to the cube magnitude when the span length
doubled.
• So long span FDP is better fabricated with bulky connectors cross section
and pontic for assuring high strength and rigidity.

66. Periodontal Phase
• Periodontal therapy is critical in succession of the fixed prothodontic treatment.
The initial plaque-induced lesion in periodontal disease is termed gingivitis and
divided to 4 stages (initial, early, established and advanced).
• After loss of connective tissue attachment, the gingivitis transform to
periodontitis and then amount of bone and connective tissue attachment loss
affect the prognosis of the abutment teeth so the early detection of the
periodontal problems is crucial by probing depth, BOP, mobility test and
furcation involvement to evaluate the periodontal health of the abutment teeth.

67. • The effective periodontal care incorporates
1. Effective daily plaque removal by patient
2. Active therapy to remove calculus and pathological bacteria from the
root surfaces and pocket
3. Preventive periodontal maintenance therapy (supportive periodontal
therapy) every 2 to 6 months.
4. Need of surgical periodontal therapy if:
A. Continued bone loss in a patient who had SC/RP and is on 2-3 month
periodontal maintenance schedule.
B. The need of fixed prosthesis on posterior quadrant that result in
subgingival crown inaccessible for cleaning or short clinical crown
that will have inadequate retention.

68. Criteria for Consideration in Determining
Periodontal Prognosis
Overall clinical factors
• Age
• Disease severity
• Plaque control
• Finance available
Local factors
• Plaque and calculus
• Subgingival restoration
• Tooth crowding
• Root resorption

69. Criteria for Consideration in Determining
Periodontal Prognosis
Tooth mobility
Systemic factors
• Smoking
• Systemic disease
• Genetic factors
• Stress
• Dry mouth
Anatomic factors
• Short, conical tooth
• Root concavities
• Developmental grooves
• Root proximity
• Furcation involvement

70. Biologic Width
• The normal gingival attachment consist of
1mm of connective tissue attachment to the
root and 1mm of epithelial adhesion .
• The combination of the connective tissue
attachment and epithelial adhesion is termed
biologic width.
• So if our restoration is within the attachment
lead to what we called Biologic width
violation.

71. Biologic Width
• To correct BWV is either by surgical removal of the bone below the
restorative margin and movement the attachment apically and the new
margins are placed at east after 3 months after the surgery (crown
lengthening) or by orthodontic movement of the tooth coronally from the
attachment.

72. Margin Placement
• If preparation margins are supragingival (at the crest) are easier to
prepare, impress and finish to smooth polished surface. In some
circumstances we need allowing the margin to be placed on
sound tooth under deep restoration , promote aesthetics by hiding
the crown margins or masking the tooth restoration interface or
creating adequate retention.

73. Margin Placement
• So we use subgingival margin even in many times leads to
gingival inflammatory response range from mild inflammation to
swelling, redness, tenderness, bleeding and bone loss and the
degree of these factors is related by patient systemic health and
the patient gingival biotype.

74. Margin Placement
• So the best guidelines for placing the subgingival margins is half
the depth of gingival sulcus which is about 1 mm in the healthy
facial and lingual aspects and about 3 mm in healthy
interproximal sulcus.
• The farther the margin from the gingiva, the easier the access for
plaque control and the healthier the gingival tissue as the tooth
brush can clean only 0,5 mm subgingivally and floss can clean up
to 2.5 mm and water irrigation device can clean up to 4 mm below
the gingiva.

75. Gingival Biotype
• Variable responses to biologic width violation as if exist
thin bone with thin gingiva overlying the bone is termed
thin biotype which affected by gingival recession and
bone loss.
• Thin biotype is characterized as if the probe is placed
within the gingival sulcus and the tip of the probe can be
visualized through it. both types can be existed in the
same mouth.

76. Gingival Biotype
• In thick bone and thick overlying gingiva called thick biotype and it’s
affected by BWV in inflammatory response like swelling, edema ,
redness and bleeding.

77. Papilla
• The ideal interdental gingival papilla fills an interproximal
embrasure created by:
1. Lateral walls of adjacent teeth
2. Coronally by base of interproximal contact
3. Apically by coronal aspect of attachment.
• The clinician can change 1,2 by restorative or orthodontic
treatment.

78. Papilla
• Spear and cloony suggested that viewing the papilla as a balloon
of a certain volume sitting on the attachment.
• The balloon of tissue has a form and height dictated by the
gingival embrasure of the teeth.
• With an embrasure that is too wide, the balloon flatten out,
assuming blunted shape and has shallow sulcus.

79. Papilla
• If the embrasure is ideal width, the papilla assumes a pointed
form, has a sulcus of 2'5-3 mm and is healthy.
• If the embrasure is too narrow, the papilla may grow out to the
facial and lingual, and become inflamed.

81. • implant placement especially in the maxillary aesthetic zone accompanied
with maintenance of peri-implant soft tissue is a clinical challenge.
• The interimplant papilla and soft tissue depends on various factors like
interimplant distance, thickness of the alveolar housing, peri-implant
marginal bone, biologic width, gingival biotype, amount of keratinized
tissue, tooth form, implant neck geometry, and abutment connection.
• The interimplant papilla in the aesthetic zones can be managed either
surgically or non-surgically.
• Surgical methods include flapless technique, crestal-punch method or
papillary reconstruction intraoperatively.

82. • Non-surgical methods include restorative, prosthetic and orthodontic
techniques to maintain or achieve sufficient interimplant papilla for a
pleasing esthetic outcome.
• Raising a full-thickness periosteal flap, results in the possibility of marginal
bone loss and soft tissue recession, whereas the FL technique has the
potential to minimize crestal bone loss and soft tissue inflammation.
• Avoiding the creation of a mucoperiosteal flap results in less postoperative
patient discomfort and a reduced chance of scar tissue formation.
• Leaving the periosteum intact on the buccal and lingual aspects of the ridge
maintains a better blood supply to the site, reducing the likelihood of
resorption.

83. Novel Window Technique
Window incision (Crestal
incision placed about 1.5
mm palatal to the greatest
bony height with an
angulation of 45° with no.
15 bard parker blade).

84. Novel Window Technique
Flap reflection (A vertical
releasing incision placed
mesially and distally to the
crestal incision without
disturbing the adjacent teeth
papilla and extending about
3 mm labially).

85. Novel Window Technique
Soft tissue reflected to
expose the cover screw.

86. Novel Window Technique
Palatal extension of the
incision followed closer to
the adjacent teeth on both
sides, and a release incision
made around the palatal
portion of the exposed cover
screw.

87. Novel Window Technique
healing abutment is placed
after thoroughly cleaning the
soft tissue around internal
hex of the implant.

88. Novel Window Technique
Interdental papilla is seen in
the space between two
adjacent teeth. It acts as a
biological barrier in the
protection of periodontium.

89. Novel Window Technique
Final esthetic result after 2
years with papillary
reconstruction I both mesial
and distal aspects.

90. Papillary
Reconstruction
Periapical radiograph of patient showing the
distance from the implant shoulder to the most
coronal bone to implant contact (DIB) both at the
mesial and distal aspect of the implant (white
arrow). Chances of having complete papillae
around single tooth implant supported crown are
minimal when distance between contact points to
the crest of the alveolar bone is more than 5 mm.

91. Papillary
Reconstruction
Incision excluding papillae of
the adjacent teeth

92. Papillary
Reconstruction
Tunnelling beneath the
papilla creating a pouch.

93. Papillary
Reconstruction
Suture placed to guide the
graft beneath interdental
papilla.

94. Papillary
Reconstruction
Connective tissue graft
submerged beneath the flap.

95. Papillary
Reconstruction
Connective tissue grafts after
suturing.

96. Papillary
Reconstruction
Final restoration placed.

97. Keratinized Gingival Tissue
• The amount of keratinized gingiva necessary for long term
periodontal health is open to debate. In a healthy mouth subjected
to minimal stress, a total lack of keratinized tissue may be
acceptable but in a mouth requiring comprehensive fixed
prosthodontics treatment, the stress level are no longer minimal.

98. Keratinized Gingival Tissue
• For a tooth or implant to be treated with restoration extending into
the gingival sulcus, minimum of 5 mm of keratinized gingiva with
3 mm of attached gingiva is recommended to be found.
• In cases of deficient keratinized gingiva (gingival recession),
grafting or other gingival augmentation procedure should be
considered.

99. Mucosal Reparative Therapy
• Mucosal reparative therapy is indicated to increase the width of
the band of keratinized gingiva through surgical grafting.
• The laterally positioned pedicle graft is used for an area of
recession or lack of attached gingiva on a single tooth when
amounts of keratinized gingiva in adjacent teeth or edentulous
spaces are adequate. The pedicle graft is the most predictable
treatment because of maintenance of the blood supply to the
pedicle.

101. Mucosal Reparative Therapy
• A free autogenous gingival graft can be used to increase the width
of the attached gingiva and the donor site most commonly from
the hard palate or the retromolar pad and the healing time is
approximately about 6 weeks.
• A coronally positioned pedicle graft is used when a single tooth or
multiple teeth exhibit gingival recession and sensitivity. If the
width of the attached keratinized gingiva is inadequate, a free
gingival graft may be placed to increase it before the coronal
positioning.

102. Mucosal Reparative Therapy
• The most common gingival augmentation technique is the
connective tissue graft with use of subepithelial connective tissue
graft from the palate to minimize the patient discomfort at the
donor site and the color match is improved.
• Connective tissue grafts can be combined with pedicle grafts and
tunneling procedures to improve blood supply and survivability.
Connective tissue grafts can be utilized to cover exposed roots and
augment deficient ridge and rebuild the papilla.

104. Orthodontic Treatment
• Minor orthodontic tooth movement can enhance the prognosis of
restorative treatment. Uprighting malpositioned abutment teeth
can improve axial alignment, create more favorable pontic spaces
and improve embrasure form in the final prosthesis.
• Tooth movement can also help direct occlusal forces more
favorably, parallel to the long axis of the teeth.

105. Orthodontic Treatment
• Clinical examination should focus on tooth malposisioning and if
there any abnormal tooth relationship as anterior or posterior
reverse articulation.
• The need of orthodontic treatment is determined through a careful
analysis of articulated diagnostic casts, whose usefulness can be
enhanced with a dental surveyor.

106. Orthodontic Treatment
• One helpful procedure is to section a duplicate cast and resemble
it according to the proposed orthodontic modifications.
• It facilitate to imagine the treatment plan and to illustrate It to the
patients especially in minor tooth movement (closing diastema, up
righting molars or aligning tilted teeth).
• Many dentists now use computer imaging technology to optimize
esthetic treatment planning and improve patient communication
and also use it in the treatment procedures which called invisalign.

107. Orthodontic Treatment
• Invisalign comes as series of clear aligners fabricated from
patented thermoplastic material that are custom-made for the
patient.
• Each aligner is worn for 1-2 weeks before being replaced by the
next in the series - gradually moving your teeth towards their
projected final position within as little as six months.

108. Orthodontic Treatment
• Unlike fixed braces, there are no metal wires or brackets. This
means they are virtually invisible when you wear them.
• Also, Invisalign aligners can be removed briefly for eating,
brushing teeth and attending special occassions.

109. Definitive Occlusal Treatment
• Mouth preparation involves reorganization of the patient
occlusion, to make the maximum intercuspation co-occurrent with
centric relation and remove eccentric interference.
• This treatment may be therapeutic to relieve myofascial symptoms
or prerequisite to extensive restorative treatment ensuring stable
orthopedic position throughout the course of prosthodontic
treatment.

110. Definitive Occlusal Treatment
• When centric relation and maximum intercuspation co-occur, it’s
easier to transfer the patient casts to articulator accurately.
• Occlusal reshaping is a therapeutic measure to solve premature
contact problem but several studies stated that it’s limited by the
thickness of the enamel .
• So before any irreversible changes are made to dentition, carful
diagnostic process must establish whether restorations are needed
in conjunction with occlusal reshaping or not.

111. Diagnostic Reshaping
• Two sets of articulated diagnostic casts in centric relation are
required for diagnostic occlusal reshaping. One set serves as
reference and the second is used to perform a trial adjustment and
to evaluate how much tooth structure has been removed.
• The comparison between two sets facilitate the determination of
how much tooth structure may need to be removed to meet the
treatment objectives.

112. Diagnostic Reshaping
• The occlusal surfaces of the casts that are to be adjusted are
painted with poster paint (which not soak into the stone) to
demonstrate the extent of any planned corrective reshaping.
• The pin sitting on the articulator is recorded at the initial point of
occlusal contact in centric relation before reshaping so the
operator can judge the amount of enamel must be removed.

113. Diagnostic Reshaping
• Then record the pin sitting at maximum intercuspation position.
The casts then modified with hand instruments like discoid carver.
• Each step in adjustment is recorded on reshaping list and on
completion, the results of reshaping are reviewed carefully.
• Areas of enamel to be penetrated may be needed for additional
restoration to avoid sensitivity.

115. Importance Of Occlusal Reshaping
1. To redistribute forces parallel to the long axis of teeth by elimination
contacts on inclined planes and create cusp-fossa occlusion
2. To eliminate deflective occlusal contacts so centric relation meets the
maximum intercuspation
3. To improve worn occlusal anatomy and flat surfaces to proper
developmental tooth morphology.
4. Patient selection is critical in occlusal reshaping as it’s irreversible
subtractive treatment. If initial contacts occur relatively close to the
central fossa is more predictable than contacts occur on the cusp slopes
or close to the opposing cusps.

116. Contraindications To Definitive Occlusal
Reshaping
1. Patient with bruxism whose habit cannot be controlled.
2. Diagnostic adjustment shows too much tooth structure will be removed.
3. Complex spatial relationship (angle class 2 or skeletal class 3 occlusion)
4. Contact between maxillary palatal cusps and mandibular buccal cusps.
5. An open anterior occlusal relationship
6. Excessive wear
7. The period before orthodontic or orthognathic treatment.

117. Vertical Dimensions Loss And
Rehabilitation
• One of the most important strategies of the restorative treatment is the
evaluation and re-establishment of occlusal vertical dimension (OVD).
• This phase must not be neglected, because the decrease or increase of
OVD causes damage to teeth, muscles, joint and difficult the patient’s
swallowing and phonation.

118. Vertical Dimensions Loss And
Rehabilitation
• During the life of a person all teeth suffer a certain wear due to functional
activity.
• Occlusal wear has mostly been attributed to attrition, erosion, abrasion,
and parafunctional habits.
• Besides that, diet and diseases such as gastric reflux, congenital
abnormalities, and eating disorders are important contributors to excessive
occlusal wear or from sequent posterior teeth extractions and loss of
posterior stoppers which results in incisal wear to the anterior teeth.

119. Vertical Dimensions Loss And
Rehabilitation
• Excessive wear of anterior dental elements is a fact of high influence on
the smile’s esthetics and harmony. As cases become more complex,
aspects related to the patient’s occlusion re-establishment must be
observed, including the recovery of the occlusal vertical dimension
(OVD), which is defined as the vertical distance between two points, one
in maxilla and one in mandible, when the occlusal surfaces are in contact.

120. Vertical Dimensions Loss And
Rehabilitation
• One of the most important aspects in facial appearance involves the
Occlusal Vertical Dimension, as the esthetics of the face is affected by
facial form and facial height.
• When a patient presents decreased OVD, because of advanced tooth
abrasion, attrition, or tooth loss, its facial appearance is aged due to the
decrease of the lower third of the face, lips intrusion, drop of the nose and
can also bring phonetic and masticatory disorders and possible
involvement of the temporomandibular joint (TMJ) and mastication
muscles.

121. Vertical Dimensions Loss And
Rehabilitation
• In general, in a situation that there was loss of dental elements or
excessive wear of them, the OVD must be recovered before any definitive
restorative procedure is executed, it must be done gradually at the
beginning of treatment.

122. Vertical Dimensions Loss And
Rehabilitation
• Several methods could be applied to determine the occlusal vertical
dimension. The first method is Niswonger, as he claims that occlusal
vertical dimension could be achieved from vertical jaw dimension in rest
position subtracted free way space (2–4 mm).
• The second method is Willis, the distance between the pupil of the eye and
the rima oris is equal to the distance between nasal base to the point below
the chin when the teeth in maximum intercuspation.

124. Vertical Dimensions Loss And
Rehabilitation
• In general, in a situation that there was loss of dental elements or
excessive wear of them, the OVD must be recovered before any definitive
restorative procedure is executed, it must be done gradually at the
beginning of treatment.
• Temporary acrylic resin crowns, fixed prosthesis or even interim
removable prosthesis should be used for initial adaptation like using a
provisional device (occlusal overlay bilateral splints) made in acrylic
resin, particularly in determining a stable and functional occlusal vertical
dimension.

125. Vertical Dimensions Loss And
Rehabilitation
• After the creation of an optimum maxillomandibular relationship and the
restitution of a restorative space the treatment plan can evolve into a
definitive rehabilitation.
• The final restoration occurred after a 60-day follow-up and was made with
ceramic crowns in posterior teeth and direct restorations in anterior teeth.