Oral Hygiene Access Research Articles

Pontic design and its effects on the health of the gingiva

A pontic is an artificial tooth that substitutes a lost natural tooth, preserves its function, and typically fills the space left by the actual crown. Sanitary/hygienic and modified sanitary/hygienic designs do not contact the alveolar mucosa. On the other hand, ridge lap, modified ridge lap, ovate, modified ovate, and conical are designs that maintain contact with the mucosa. The ideal biological properties to be taken into consideration while designing pontics are periodontal health, access for oral hygiene, no food trapping and occlusal harmony. Accumulation of dental plaque has been implicated in the onset of gingival and periodontal disease as well as caries in the vicinity of the fixed restoration. The connection of the pontic to the supporting crowns must be constructed in such a way as to make a flushable area in the direction of the gingiva, in order to ensure that this area can be cleaned by toothbrushing and flossing but not the large triangular spaces that make it easy for food particles to cling. Modified ridge lap and ovate types, out of all the pontic shapes described below, exhibit convex cleansable faces. Ovate pontics are most effective for use in anterior regions, while the modified ridge lap design can be utilized predominantly in fixed partial denture designs posteriorly. The important etiological factor for gingivitis, periodontitis and peri-implantitis is bacterial colonization which is impacted by the individual's immunologic response and genetic predisposition in addition to dental care practices and pontic design. It is believed that no matter what the material of the pontic is, it must provide a highly polished intaglio surface to help floss slide through and make contact with the full base of the pontic in order to minimize plaque accumulation.

Editorial: Prosthetically Driven or Periodontally Maintainable? We Need Both.

Emil Capetta, DMD/Howard Drew, DMD/Joel Pascuzzi, DMD/Andrew Sullivan, DDS: We were educated in the age of periodontal prostheses, when periodontics and prosthetics were integrated and dependent upon each other. The authors of this editorial would often travel to hear the masters, including Abrams, Amsterdam, Cohen, Kramer, Nevins, Skurow, Weisgold, and others. We were taught restorations had to be hygienic. Rules about contour, emergence profile, embrasures, attached gingiva, tooth positioning, adequate support, and balanced occlusion, to name a few, were emphasized and mandated. In the era of periodontal prostheses, we were nervous about long teeth, small gingival overhangs on restorations, and inadequate embrasures. In the 1980s, we embraced implants, but Brånemark again emphasized “high water” cases that allowed access for oral hygiene, debridement, and maintenance. Years later, as a reaction to the concept of placing implants “where the bone is,” we embraced the concept of prosthetically driven implant placement. Adopting this concept has not solved all of our problems, and improvements in guided bone regeneration (GBR) and prosthetic abutments are not always the complete solution. Presently, many treatment plans are based on the prosthesis that is currently preferred or can be marketed profitably. It is not uncommon to see periodontally maintainable teeth extracted, or 5 to 8 mm of vertical bone removed, to make room for prosthetic materials. That removed bone could prove to be critical if, in time, peri-implantitis strikes the patient. We often see prostheses inserted with inadequate access for patients or clinicians to debride the area, or hybrid prostheses with significant buccal/facial cantilevers that are not maintainable. Due to patient esthetic demands, we often place a fixed appliance when it should be removeable. Staging cases with natural teeth and/or transitional implants may add additional time and cost to the case, but there are benefits: Very often, bone can be preserved, hygiene assessed, GBR sites kept from loading forces, soft tissue managed, vertical dimension maintained or adjusted, and better implant positioning achieved. Years ago, when an implant-supported hybrid prosthesis was placed, it was common to remove it during maintenance visits to access the implants for debridement, and we often saw significant amounts of plaque and calculus on the intaglio surfaces. The implants were debrided, the prosthesis was cleaned, and many times the screws were removed and changed. Why have peri-implantitis rates skyrocketed? The literature lists multiple possible explanations, including plaque-retentive surfaces, active periodontal disease on remaining teeth, occlusion, inadequate zones of attached keratinized gingiva, and poorly positioned implants, among others. At what point do we embrace restorations, which are both prosthetically driven and periodontally maintainable? Restorations should be esthetic but must be cleansable by both the patient and the clinician. We need to remember the masters, and an appliance placed in a sound periodontal environment needs to be our primary goal. Why have peri-implantitis rates skyrocketed? The literature lists multiple possible explanations, including plaque-retentive surfaces, active periodontal disease on remaining teeth, occlusion, inadequate zones of attached keratinized gingiva, and poorly positioned implants, among others. At what point do we embrace restorations, which are both prosthetically driven and periodontally maintainable? Restorations should be esthetic but must be cleansable by both the patient and the clinician. We need to remember the masters, and an appliance placed in a sound periodontal environment needs to be our primary goal. Emil Capetta, DMD Howard Drew, DMD Joel Pascuzzi, DMD Andrew Sullivan, DDS Newark, New Jersey, USA

The CAD/CAM Compound Prosthesis: Digital Workflow for Fabricating Cement-Retained Zirconia Prosthesis Over Screw-Retained Milled Titanium Bars

The computer-assisted design/computer-assisted manufactured compound prosthesis involves designing and milling a cement-retained prosthesis over milled titanium bars. In the presented clinical case report, a diagnostic wax pattern was made to assess esthetics, contours, and occlusion. A total of eight maxillary root-form implants were restored by following the combined prosthesis design concept. The mandibular arch was restored with a screw-retained implant-supported zirconia fixed prosthesis. A milled polymethyl methacrylate (PMMA) maxillary interim prosthesis was fabricated to intraorally confirm the diagnostic wax pattern. The interim PMMA prosthesis was then scanned, and three screw-retained titanium milled bars were designed that provided the substructure of the definitive restoration. A cement-retained milled zirconia prosthesis was then designed and fabricated. The zirconia prosthesis provided the superstructure of the definitive complete-arch restoration. After confirming esthetics, phonetics, occlusion, and accessibility for oral hygiene, the superstructure was cemented with temporary cement to enable retrievability.

A digital technique for fabricating an interim implant-supported fixed prosthesis immediately after implant placement in patients with complete edentulism

The conversion of a denture into an interim implant-supported, screw-retained restoration has become the standard method for immediate interim restoration in patients with complete edentulism. The most critical steps of the denture conversion process are the creation of appropriate denture access holes to prevent displacement of the denture by the interim cylinders and removal of the denture flanges to facilitate both good esthetics and accessibility for oral hygiene after the denture is connected to the interim cylinders. This article presents a digital technique for designing and fabricating an interim implant-supported, fixed prosthesis for edentulous patients. The interim prosthesis has cylinder access holes that are digitally prefabricated and a denture flange part that is designed to be easily sectioned. This technique facilitates more straightforward and efficient immediate restoration for edentulous patients after implant placement.

Use of a CAD-CAM poly(methyl methacrylate) interim prosthesis for direct intraoral splinting

This article describes a technique where an interim computer-aided design and computer-aided manufacturing (CAD-CAM) prosthesis is milled from a poly(methyl methacrylate) blank to confirm esthetics, occlusion, function, phonetics, and accessibility for oral hygiene. The interim prosthesis is then sectioned and reconnected intraorally with autopolymerizing acrylic resin. This interim prosthesis is used to fabricate the definitive stone cast. The interim prosthesis is then scanned with a laboratory scanner. By applying this technique, the implant positioning can be related to the occlusal plane, the contours of the teeth, and the flange. The clinician can more effectively design the definitive prosthesis because the location of the implants and the exact contours of the teeth are all captured in a single digital file.

Prosthodontic treatment of a retrognathic edentulous maxilla demonstrating limited interarch distance: 3.5-year results with fixed and removable implant prostheses

The prosthodontic treatment of patients with a retrognathic edentulous maxilla should consider the restoration of the lower facial profile and access for oral hygiene. This clinical report describes prosthodontic treatments of a patient with edentulism who presented with repeated fractures of the denture teeth of a maxillary implant-supported complete fixed dental prosthesis (ICFDP) and a mandibular implant-supported overdenture. Considerable plaque accumulation was noted on the ICFDP, which was replaced with an open palatal design implant-supported overdenture. However, the patient experienced difficulty managing the 2 removable prostheses. The patient’s mandible was eventually restored with a milled titanium alloy framework ICFDP with metal occlusal surfaces. This combined approach of fixed and removable prostheses was stable at 3.5-year follow-up appointment, without compromising the patient’s oral hygiene or comfort.

Outpatient dental treatment under general anesthesia in children with cleft lip palate: case report

This study aimed to report the case of an eight-year-old patient with cleft lip and palate associated with undiagnosed syndrome presenting high level of carious lesions, difficulty on oral hygiene, no collaborative behavior and cariogenic diet. Case report: The patient underwent outpatient treatment for dental extraction and Atraumatic Restorative Treatment. Later at the following-up appointment, the child presented new active white spots and fractured restorations. Then, dental treatment under general anesthesia for amalgam restorations was indicated. Conclusion: We conclude that dental care under general anesthesia was an alternative treatment for the reported child in this clinical case that had a high prevalence of caries, cariogenic diet, loss of lip elasticity due to corrective surgeries, difficult access for oral hygiene and caregiver’s fear to toothbrush near to the cleft.

Telescopic overdentures with cercon primary coping and gold galvano secondary coping

Overdenture treatment provides an esthetic and functional result that allows proper access for hygiene and maintenance. In addition, with their improved strength, zirconia ceramics may be used to restore removable partial denture abutments in areas previously limited to metal or metal-ceramic restorations. The electroforming process makes for a viable, convenient, and economic alternative to cast metal substructures. However, limited data are available on the use of telescopic crowns on implants. Compared with the use of fixed implant-supported dentures, this treatment modality may improve esthetics and oral hygiene access, reduce the need for implants, and provide sufficient denture support in cases where single abutments have failed. Furthermore, the high retention obtained with telescopic crowns leads to good mastication and phonetics.

Peri‐implantitis in partially edentulous patients: association with inadequate plaque control

The aim of the present study was to describe some clinical periodontal features of partially edentulous patients referred for the treatment of peri-implantitis. The 23 subjects involved in this study were selected from consecutive patients referred to the department of Periodontology Södra Alvsborgs Hospital, Borås, Sweden, for treatment of peri-implantitis during 2006. The patients had clinical signs of peri-implantitis around one or more dental implants (i.e.>or=6 mm pockets, bleeding on pockets and/or pus and radiographic images of bone loss to>or=3 threads of the implants) and remaining teeth in the same and/or opposite jaw. The following clinical variables were recorded: Plaque Index (PI), Gingival Bleeding Index (GBI) Probing Pocket Depth (PPD), Access/capability to oral hygiene at implant site (yes/no), Function Time. The patients were categorized in the following sub-groups: Periodontitis/No periodontitis, Bone loss/No bone loss at teeth, Smoker/Non-smokers. Out of the 23 patients, the majority (13) had minimal bone loss at teeth and no current periodontitis; 5 had bone loss at teeth exceeding 1/3 of the length of the root but not current periodontitis and only 5 had current periodontitis. Six patients were smokers (i.e. smoking more than 10 cig/day). The site level analysis showed that only 17 (6%) of the 281 teeth present had >or=1 pocket of >or=6mm, compared to 58 (53%) of the total 109 implants (28 ITI and 81 Brånemark); 74% of the implants had no accessibility to proper oral hygiene. High proportion of implants with diagnosis of peri-implantitis were associated with no accessibility/capability for appropriate oral hygiene measures, while accessibility/capability was rarely associated with peri-implantitis. Indeed 48% of the implants presenting peri-implantitis were those with no accessibility/capability for proper oral hygiene (65% positive predict value) with respect to 4% of the implants with accessibility/capability (82% negative predict value). The results of the study indicate that local factors such as accessibility for oral hygiene at the implant sites seems to be related to the presence or absence of peri-implantitis. Peri-implantitis was a frequent finding in subjects having signs of minimal loss of supporting bone around the remaining natural dentition and no signs of presence of periodontitis (i.e. presence of periodontal pockets of >or=6 mm at natural teeth). Only 6 of the examinated subjects were smokers. In view of these results we should like to stress the importance of giving proper oral hygiene instructions to the patients who are rehabilitated with dental implant and of proper prosthetic constructions that allow accessibility for oral hygiene around implants.

Palatal Mini-Implants to Increase Retention and Stability of Implant-Retained Maxillary Overdentures: A Case Report

Maxillary edentulous patients have been successfully treated with implant-supported fixed and removable dental prostheses. The fixed implant-supported dental prosthesis has been used for >20 years. It has lost popularity because the design of this restoration requires special access for oral hygiene around the abutment cylinders creating an esthetic quandary in the maxilla. The use of the mid-sagital palatal suture to osseointegrate anchorage devices for orthodontic purposes has shown satisfactory results. This clinical case documents the successful use of mid-palatal implants as an extension of orthodontic anchorage to gain accessory support and retention for a maxillary complete removable dental prosthesis.

Plastic Temporary Abutments with Provisional Restorations in Immediate Loading Procedures: A Clinical Report

A provisional restoration in combination with an implant-retained restoration provides many of the same benefits as nonimplant-retained fixed restorations. Provisional restorations serve as a diagnostic tool to confirm esthetics, contours, accessibility for oral hygiene, and can be used to duplicate the definitive restoration. A provisional restoration allows for communication between the patient, dentist, and technician. The soft tissue around the implants can heal according to the contours of the provisional restoration. However, implant-retained treatment can require an extended period of osseointegration, and provisional treatment can be a challenge if a removable prosthesis is provided because adjustments of the denture may become necessary during healing. This article presents a case report that describes the simultaneous placement of implants with the connection of fixed provisional restorations to prefabricated plastic provisional abutments.

Periodontal relevance of anterior crowding.

The periodontal relevance of anterior and posterior crowding concerns 3 main aspects: 1. oral hygiene/plaque retention, 2. altered topography of gingiva, septum and orofacial alveolar bone and 3. periodontal therapy (scaling, root planing, regenerative approaches). These aspects are discussed with regard to the literature and to the author's own clinical and histological findings. Present-day knowledge suggests that the following positive periodontal effects can be expected from correction of orthodontic crowding: better access for oral hygiene, improved morphology of soft and hard periodontal tissues; future research has to substantiate the value of this benefit, simplified mechanical and surgical therapy (scaling, root planing, curettage), more favorable conditions for periodontal regeneration.

Surgical management of microstomia in the dental office

Scarring of the oral stoma is usually a consequence of burns of the circumoral region. The subsequent contractural decrease in the width and general size of the opening is deforming, interferes with eating, makes dental treatment extremely difficult, prevents access for oral hygiene, and makes general anesthesia hazardous. A case report demonstrates the relative ease and safety of performing a commissurotomy in the dental office with local anesthesia alone so that access is facilitated and the dentition of these patients can be rehabilitated.