Periodontal considerations for direct/indirect restorations Associate Professor Leticia A Miranda & Dr Anna Hughes #### Course Presenters - **Associate Professor Leticia A Miranda** - **Dr Anna Hughes** - **Perio OR Resto ... or .... Perio AND Resto?** Comprehensive dental therapy is founded on team works. Interdisciplinary approach is mandatory in modern Dentistry. Perio and Resto/Pros share an intimate and inseparable relationship in: - Treatment plan - Procedures execution - Outcome achievement - Maintenance  Comprehensive dental therapy is founded on teamwork. An interdisciplinary approach is mandatory in modern dentistry. Periodontics and Restorative/Prosthodontics share an intimate and inseparable relationship in: - Treatment planning - Execution of procedures - Achievement of outcomes - Long-term maintenance Abstract geometric background with a gradient of warm and cool colors, featuring polygonal shapes in shades of orange, red, blue, and white, serving as a decorative element on the right side of the slide. ```markdown **Perio OR Pros ... or Perio AND Pros??** • Why consider both together? • Perio Tx aims to control biofilm and inflammation and to prepare sites for ideal prosthetic work, providing a solid foundation for successful pros outcomes and aiding in the longevity of restorations • Pros aims to achieve proper restorative margins, shapes and contacts, in order to obtain harmony between the periodontium and reconstructions. • Hsu et al 2015 ``` #### Rationale for Interdisciplinary Integration - **Periodontal Treatment Goals:** Aims to control biofilm and inflammation to prepare sites for ideal prosthetic work. This provides a solid foundation for successful outcomes and aids in the longevity of restorations. - **Prosthodontic Goals:** Aims to achieve proper restorative margins, shapes, and contacts to obtain harmony between the periodontium and reconstructions. (Hsu et al. 2015) Perio OR Pros ... or Perio AND Pros?? • PERIO & • RESTO/PROS • Obviously the answer is ...both  The relationship between Periodontics and Restorative/Prosthodontics is not an "either/or" choice; successful clinical outcomes require the integration of both disciplines. A large red heart shape dominates the center of the slide, containing two bullet points: 'PERIO &' and 'RESTO/PROS'. The heart visually represents the combination of periodontal and restorative/prosthetic approaches, with the text below stating 'Obviously the answer is ...both', reinforcing the idea that both disciplines are needed. The figure is part of a presentation from The University of Western Australia. Our lecture today ... - Impact of periodontal health on restorative therapy - Impact of restorative factors on periodontal health - Margins (location and fit) - Biological width or supracrestal attachment maintenance - Contours - Surface finish Topics covered later - Proximal relationship (contact point/papillary relationship) - Retraction techniques and the periodontium - Trauma from occlusion - Reduced periodontium #### Core Lecture Topics 1. **Impact of Periodontal Health on Restorative Therapy** 2. **Impact of Restorative Factors on Periodontal Health** - Margins (location and fit) - Biological width or supracrestal attachment maintenance - Contours - Surface finish #### Additional Considerations - Proximal relationships (contact point/papillary relationship) - Retraction techniques and the periodontium - Trauma from occlusion - Management of the reduced periodontium Impact of periodontal health on resto therapy Periodontal health is the sine qua non, a prerequisite, of successful comprehensive dentistry. To achieve the long-term therapeutic targets of comfort, good function, treatment predictability, longevity, and ease of restorative and maintenance care, active periodontal infection must be treated and controlled before the initiation of restorative, aesthetic, and implant dentistry. Melnick & Takei, 2019 Periodontal health is the *sine qua non*—a prerequisite—of successful comprehensive dentistry. To achieve long-term therapeutic targets of comfort, good function, treatment predictability, longevity, and ease of restorative and maintenance care, active periodontal infection must be treated and controlled before the initiation of restorative, aesthetic, and implant dentistry. (Melnick & Takei, 2019) # Impact of periodontal health on resto therapy - Active disease and contributing factors should be controlled before Pros Tx - Biofilm control compatible with health - Absence of inflammatory signs - Absence of progressing attachment loss - Reduction in probing depths - If not controlled-long term consequences may be - progressive attachment loss and tooth loss - soft tissues changes = impaired esthetic outcomes - Compromised prognosis (individual tooth and overall dentition) - Soft and hard tissue management to prepare sites for Pros tx - E.g. Soft tissue grafts - E.g. Bone augmentation - Maintenance program #### Clinical Requirements for Control Active disease and contributing factors should be controlled before Prosthodontic treatment, ensuring: - Biofilm control compatible with health - Absence of inflammatory signs - Absence of progressing attachment loss - Reduction in probing depths #### Risks of Uncontrolled Disease If periodontal disease is not controlled, long-term consequences may include: - Progressive attachment loss and tooth loss - Soft tissue changes resulting in impaired aesthetic outcomes - Compromised prognosis for both individual teeth and the overall dentition #### Site Preparation and Maintenance - Soft and hard tissue management (e.g., soft tissue grafts, bone augmentation) to prepare sites for Prosthodontic treatment. - Implementation of a structured maintenance program. # Impact of periodontal health on resto therapy Why do we need to establish periodontal health before performing restorative dentistry? Tissues that **do not bleed** during restorative manipulation allow for a more predictable restorative and aesthetic result. Periodontal treatment is undertaken to ensure the establishment of **stable gingival margins** before tooth preparation. Non-inflamed, healthy tissues are **less likely to change** (e.g., shrink) as a result of subgingival restorative treatment or post-restoration periodontal care. <img src="https://i.imgur.com/placeholder.png" alt="University of Western Australia logo">  #### Predictability and Stability - **Hemorrhage Control:** Tissues that do not bleed during restorative manipulation allow for a more predictable restorative and aesthetic result. - **Margin Stability:** Periodontal treatment is undertaken to ensure the establishment of stable gingival margins before tooth preparation. - **Tissue Integrity:** Non-inflamed, healthy tissues are less likely to change (e.g., shrink) as a result of subgingival restorative treatment or post-restoration periodontal care. The University of Western Australia logo, featuring a blue and yellow shield with a swan emblem and the text 'THE UNIVERSITY OF WESTERN AUSTRALIA' alongside the motto 'SEEK WISDOM'. # Impact of periodontal health on resto therapy Why do we need to establish periodontal health before performing restorative dentistry? Periodontal therapy should antecede restorative care because the **resolution of inflammation** may result in the repositioning of teeth or in soft tissue and mucosal changes. Failure to anticipate these changes may interfere with prosthetic designs planned or constructed before periodontal treatment. Certain periodontal procedures are designed to provide for **adequate tooth length for retention**, **access for tooth preparation**, impression making, tooth preparation, and finishing of restorative margins in anticipation of restorative dentistry. Failure to complete these procedures before restorative care can add to the complexity of treatment and introduce unnecessary risk for failure. #### Impact on Prosthetic Design Periodontal therapy should antecede restorative care because the resolution of inflammation may result in the repositioning of teeth or in soft tissue and mucosal changes. Failure to anticipate these changes may interfere with prosthetic designs planned or constructed before periodontal treatment. #### Access and Retention Certain periodontal procedures are designed to provide: - Adequate tooth length for retention - Access for tooth preparation and impression making - Proper finishing of restorative margins Failure to complete these procedures before restorative care can add to the complexity of treatment and introduce unnecessary risk for failure. # Overhanging Restorations - Overhanging restorations will hinder plaque removal and hence predispose to periodontal inflammation (Lang et al. 1983, Pack et al., 1990, Jansson et al. 1994, Matthews & Tabesh, 2004). - Association between overhang restorations and a shift to the more virulent microflora and more gingivitis had been shown by Lang et al. (1983) in a study using gold onlays. - Dental restorations, if poorly designed or compromised may be predisposing factors by retaining or hindering the removal of plaque. #### Plaque Retention and Inflammation - Overhanging restorations hinder plaque removal and predispose the site to periodontal inflammation (Lang et al. 1983, Pack et al. 1990, Jansson et al. 1994, Matthews & Tabesh 2004). - Dental restorations, if poorly designed or compromised, may be predisposing factors by retaining or hindering the removal of plaque. #### Microbiological Shifts - An association between overhang restorations and a shift to more virulent microflora and increased gingivitis has been demonstrated (Lang et al. 1983). # Impact of prosthetic factors on perio health - Defective restorations (overhangs, poor contacts, deficiencies) contribute to PD establishment and progression: - Increase plaque accumulation - Invasion of biological width <img src="https://i.imgur.com/5JZJZJZ.png" alt="X-ray image showing dental restoration with overhangs and bone loss">  Defective restorations (overhangs, poor contacts, deficiencies) contribute to the establishment and progression of periodontal disease by: - Increasing plaque accumulation - Invading the biological width X-ray image showing a dental restoration with overhangs and associated bone loss, illustrating the impact of defective restorations on periodontal health. The image visually supports the text's claim that such defects contribute to periodontal disease by increasing plaque accumulation and invading the biological width. ```markdown Location of restorative margins One of the most important aspects of understanding the periodontal–restorative relationship is the location of the restorative margin to the adjacent gingival tissue. Subgingival Equigingival Supragingival <img src="https://i.imgur.com/5XjZQzL.png" alt="Diagram showing biologic width, connective tissue, junctional epithelium, sulcus, and restorative margin positions"/> ```  One of the most important aspects of understanding the periodontal–restorative relationship is the location of the restorative margin relative to the adjacent gingival tissue. Margins are classified as: - **Subgingival** - **Equigingival** - **Supragingival** A diagram illustrating the location of restorative margins relative to gingival tissue, showing the biologic width with components like connective tissue (1.0 mm), junctional epithelium (1.0 mm), and sulcus (1.0 mm), along with the restorative margin positioned subgingivally, equigingivally, or supragingivally. **BIOLOGIC WIDTH- DEFINITION** The dimension of the **soft tissue** attached to the portion of the tooth coronal to the crest of the alveolar bone=epithelial attachment + connective tissue attachment. <img src="https://i.imgur.com/5ZvZvZv.png" alt="Diagram showing biologic width with measurements: Sulcus 0.69 mm, Epithelial Attachment 0.97 mm, Connective Tissue Attachment 1.07 mm, and total Biologic Width 2.04 mm."/>  The biologic width is defined as the dimension of the soft tissue attached to the portion of the tooth coronal to the crest of the alveolar bone. It is comprised of: - **Epithelial attachment** - **Connective tissue attachment** A diagram illustrating the biologic width of dental tissue, showing measurements for sulcus (0.69 mm), epithelial attachment (0.97 mm), and connective tissue attachment (1.07 mm), with a total biologic width of 2.04 mm. The diagram is highlighted with a red box and labeled with anatomical terms. **BIOLOGIC WIDTH- DIMENSION** **Gargiulo (1961)** | | Average Measurement in mm. | |---|---| | Sulcus Depth (A) | .69 mm. | | Length of Epithelial Attachment (B) | .97 mm. | | Connective Tissue Attachment (F) | 1.07 mm. | <img src="https://i.imgur.com/7ZqQ9Xr.png" alt="Diagram illustrating biologic width with labeled measurements: Sulcus 0.69 mm, Epithelial Attachment 0.97 mm, Connective Tissue Attachment 1.07 mm, and total Biologic Width 2.04 mm." /> Journal of Periodontology. 1961;32(3):261-7   #### Gargiulo (1961) Average Measurements - **Sulcus Depth:** 0.69 mm - **Length of Epithelial Attachment:** 0.97 mm - **Connective Tissue Attachment:** 1.07 mm - **Total Biologic Width:** 2.04 mm (Journal of Periodontology. 1961;32(3):261-7) A diagram illustrating the biologic width dimension, showing the sulcus depth (0.69 mm), epithelial attachment (0.97 mm), and connective tissue attachment (1.07 mm), with a total biologic width of 2.04 mm. The diagram includes labeled components of the periodontal structure, such as the sulcus, epithelial attachment, and connective tissue attachment, with a red box highlighting the biologic width. A table summarizing the average measurements in millimeters for the biologic width, including sulcus depth (0.69 mm), length of epithelial attachment (0.97 mm), and connective tissue attachment (1.07 mm). The table is presented alongside the title 'BIOLOGIC WIDTH- DIMENSION' and references Gargiulo (1961). ```markdown **BIOLOGIC WIDTH- DIMENSION** • Schmidt et al 2013- Biologic width dimensions • **Mean** values of the biologic width ranged from **2.15 to 2.30 mm** • large intra- and inter-individual **variances** were observed (range: **0.2 – 6.73 mm**) **No universal dimension of the biologic width appears to exist** J Clin Periodontol 2013; 40: 493–504 ``` #### Variability in Dimensions According to Schmidt et al. (2013): - Mean values of the biologic width ranged from **2.15 to 2.30 mm**. - Large intra- and inter-individual variances were observed, with a range of **0.2 to 6.73 mm**. **Conclusion:** No universal dimension of the biologic width appears to exist. (J Clin Periodontol 2013; 40: 493–504) # BIOLOGIC WIDTH- FUNCTION Creates a natural seal (cuff) around teeth protecting them from microbial invasion and traumatic insult. The Biological width should not be violated! The biologic width creates a natural seal (cuff) around teeth, protecting them from microbial invasion and traumatic insult. This biological width should not be violated. # BIOLOGIC WIDTH Composed of: - Junctional epithelium- hemidesmosomes - Connective tissue- gingival fibers Supra-crestal tissue attachment <img src="https://i.imgur.com/1234567.png" alt="Diagram of Biologic Width showing Gingival Margin, Enamel, Junctional Epithelium, Outer Gingival Epithelium, Connective Tissue, Cemento-Enamel Junction, Acellular Extrinsic Fibrillar Cementum, and Alveolar Bone Crest." />  The biologic width, also referred to as **supra-crestal tissue attachment**, is composed of: - **Junctional epithelium:** Attached via hemidesmosomes. - **Connective tissue:** Comprised of gingival fibers. A detailed anatomical diagram illustrating the biologic width of the gingiva, showing labeled structures including the gingival margin, enamel, junctional epithelium, outer gingival epithelium, connective tissue, cementoenamel junction, acellular extrinsic fibrillar cementum, and alveolar bone crest. The diagram visually explains the supra-crestal tissue attachment and the components of the biologic width. ```html <table border="1" cellpadding="5" cellspacing="0" style="border-collapse: collapse; width: 100%;"><tr><td style="text-align: left; vertical-align: top;"><img src="https://i.imgur.com/3ZJZzQm.png" alt="Diagram of periodontal anatomy showing gingiva, junctional epithelium, connective tissue attachment, periodontal ligament, and cementum with measurements." /></td><td style="text-align: left; vertical-align: top;"><img src="https://i.imgur.com/3ZJZzQm.png" alt="Diagram of periodontal anatomy showing gingiva, junctional epithelium, connective tissue attachment, periodontal ligament, cementum, and bone with measurements." /></td></tr></table> ```  #### Anatomical Components - Gingiva - Junctional epithelium - Connective tissue attachment - Periodontal ligament - Cementum - Alveolar bone Two side-by-side diagrams illustrating periodontal anatomy, showing cross-sections of a tooth and surrounding tissues. The left diagram highlights the gingiva, junctional epithelium, connective tissue attachment, periodontal ligament, and cementum with measurements. The right diagram includes an additional label for bone and shows a gingival sulcus with a measurement of 0.69 mm. - 2017 World Workshop - Classification of Periodontal and Peri-Implant Diseases and Conditions - Workgroup 1 - Biologic Width - Supra-crestal attached tissues #### 2017 World Workshop Classification According to the Classification of Periodontal and Peri-Implant Diseases and Conditions (Workgroup 1), the term "Biologic Width" is now formally referred to as **Supra-crestal attached tissues**. What happens if it is violated? – Microbiota shift – Tissue inflammation – Attachment and bone loss – Gingival recession • Inflammatory process tries to more apically and re-structure the lost dimmensions Parma-Benfenati et al 1985  Violation of the biologic width triggers an inflammatory process as the body attempts to move apically and restructure lost dimensions. Consequences include: - Microbiota shift - Tissue inflammation - Attachment and bone loss - Gingival recession (Parma-Benfenati et al. 1985) A medical diagram illustrating the effects of periodontal disease, showing a cross-section of teeth with labeled areas of inflammation and bone loss. The diagram depicts the progression of tissue damage, including microbiota shift and attachment loss, as described in the surrounding text. Violation of the BW (SCAT)  Clinical evidence demonstrates that violation of the Biologic Width (Supra-crestal Attached Tissues - SCAT) leads to localized periodontal destruction. A close-up photo showing a dental condition labeled as 'Violation of the BW (SCAT)'. The image displays inflamed, reddish gums with visible swelling around the upper front teeth, indicating a potential periodontal issue or gingival overgrowth. # Location of restorative margins What determines the location of the margins? – Extension of damage – Retention/resistance – Esthetics • Subgingival restorative margins have been associated with increased dental plaque accumulation that leads to gingival inflammation and periodontal pocket formations (de Waal & Castellucci, 1994, Schatzle et al. 2001). • Apart from their effect on inflammatory process, subgingival margins may cause damage to attachment apparatus by violation to the biological width as shown in humans (Tarnow et al. 1986) and animal studies (Tal et al. 1989). • Experimental studies have shown that supragingival margins should be chosen whenever possible during cavity or crown preparation, and furthermore, that restoration margins already placed subgingivally should be re-exposed by surgical crown lengthening of the clinical crown (Padbury et al., 2003). #### Determinants of Margin Location - Extension of damage (caries/fracture) - Retention and resistance form - Aesthetics #### Risks of Subgingival Margins - Associated with increased plaque accumulation, gingival inflammation, and pocket formation (de Waal & Castellucci 1994, Schatzle et al. 2001). - May cause damage to the attachment apparatus by violating the biological width (Tarnow et al. 1986, Tal et al. 1989). #### Clinical Recommendations - Supragingival margins should be chosen whenever possible. - Subgingival margins already in place may require surgical crown lengthening to re-expose the margin (Padbury et al. 2003). **SUPRA-CRESTAL ATTACHED TISSUES- SIGNIFICANCE**    The significance of maintaining Supra-crestal Attached Tissues (SCAT) is paramount for long-term periodontal stability. A dental X-ray image showing a tooth with a radiolucent area indicating a possible infection or lesion, highlighted by a red box. Another dental X-ray image displaying a tooth with a radiolucent lesion at the apex, enclosed in a red box, suggesting a pathological condition. A clinical intraoral photograph showing a tooth with a visible cavity or restoration, with surrounding gingival tissue, highlighted by a red box. **SUPRA-CRESTAL ATTACHED TISSUES- SIGNIFICANCE** Alveolar bone loss, pathological pocket and inflammation <img src="https://i.imgur.com/7QZlZ7s.png" alt="Gingival inflammation and pathological pocket"> <img src="https://i.imgur.com/8Xr8r8r.png" alt="Bone loss">    Violation of the attachment often results in: - Alveolar bone loss - Formation of pathological pockets - Chronic inflammation A clinical photograph showing gingival inflammation and a pathological pocket around teeth numbered 15 and 16, illustrating the impact of periodontal disease on supra-crestal attached tissues. A clinical photograph depicting a pathological pocket adjacent to tooth 16, with visible inflammation and loss of attached gingiva, highlighting the consequences of alveolar bone loss. An X-ray image showing bone loss around teeth, with red lines outlining the alveolar bone level, demonstrating the extent of periodontal bone destruction. **SUPRA-CRESTAL ATTACHED TISSUES- SIGNIFICANCE** Alveolar bone loss + recession of the FGM -------->Poor aesthetics <img src="https://i.imgur.com/8ZzQ9zL.jpg" alt="Image showing teeth with visible alveolar bone loss and recession of the free gingival margin, leading to poor aesthetics."/>  #### Aesthetic Failures Encroachment on the attachment leads to alveolar bone loss and recession of the Free Gingival Margin (FGM), resulting in poor aesthetic outcomes. A clinical photograph showing a dental condition with alveolar bone loss and recession of the free gingival margin (FGM), illustrating poor aesthetics as described in the accompanying text. **SUPRA-CRESTAL ATTACHED TISSUES- SIGNIFICANCE** - Subgingival restoration - Plaque accumulation - Chronic inflammation - Recurrent caries - Challenging to take an impression!   #### Clinical Challenges Subgingival restorations often present the following complications: - Persistent plaque accumulation - Chronic inflammation - Recurrent caries - Difficulty in obtaining accurate impressions A close-up photograph of inflamed gingival tissue surrounding teeth, illustrating supra-crestal attached tissues and highlighting issues like subgingival restoration and chronic inflammation as mentioned in the text. Another close-up photograph showing a different view of inflamed gums and teeth, emphasizing the challenges of taking impressions due to supra-crestal attached tissues and potential recurrent caries. ```markdown **EVIDENCE OF ADVERSE EFFECT OF SUBGINGIVAL RESTORATIONS AND ENCROACHMENT OF SCAT** **ANIMAL STUDIES** **Parma-Benfenati (1986)** - Beagle dogs - Restorative margins placed at the alveolar crest - Gingival inflammation and loss of attachment - Approximately 5 mm of osseous resorption *International Journal of Periodontics & Restorative Dentistry 6, 65–75* ``` #### Parma-Benfenati (1986) - **Study Model:** Beagle dogs - **Method:** Restorative margins placed at the level of the alveolar crest. - **Results:** Observed gingival inflammation and loss of attachment. - **Finding:** Approximately 5 mm of osseous resorption occurred. *(International Journal of Periodontics & Restorative Dentistry 6, 65–75)* # EVIDENCE OF ADVERSE EFFECT OF SUBGINGIVAL RESTORATIONS AND ENCROACHMENT OF SCAT ## HUMAN STUDIES **Broadbent 2006** - Long standing cohort study in New Zealand - 884 study members. - Where a **caries/restorative event** had occurred on an **inter-proximal** tooth surface, the **attachment loss** at the corresponding periodontal site was approximately **twice more likely** to be ≥3 mm than if the adjacent tooth surface had remained sound. **J Clin Periodontol, 2006, 33(33), 803-10** #### Broadbent (2006) - **Study Type:** Long-standing cohort study in New Zealand (884 members). - **Findings:** Where a caries or restorative event occurred on an inter-proximal surface, attachment loss at that site was approximately **twice as likely** to be ≥3 mm compared to sound adjacent surfaces. *(J Clin Periodontol, 2006, 33(33), 803-10)* ```markdown **EVIDENCE OF ADVERSE EFFECT OF SUBGINGIVAL RESTORATIONS AND ENCROACHMENT OF SCAT** **HUMAN STUDIES** **Schatzle M, Lang NP 2000** - 26 years longitudinal study! - Compared periodontal parameters in sites with subgingival margins and supragingival margins. - Confirmed detrimental effect of subgingival margins to gingival and periodontal health. - The increased loss of attachment is a slow process and **could be detected clinically 1 to 3 years** after the fabrication and placement of the restorations. **J Clin Periodontol 2000; 28: 57–64** ``` #### Schatzle M, Lang NP (2000) - **Study Type:** 26-year longitudinal study. - **Comparison:** Periodontal parameters of subgingival vs. supragingival margins. - **Findings:** Confirmed detrimental effects of subgingival margins on gingival and periodontal health. - **Timeline:** Increased loss of attachment is a slow process, typically detected clinically **1 to 3 years** after restoration placement. *(J Clin Periodontol 2000; 28: 57–64)* # EVIDENCE OF ADVERSE EFFECT OF SUBGINGIVAL RESTORATIONS AND ENCROACHMENT OF SCAT ## HUMAN STUDIES **Flores De-Jacoby 1989** - Microbiological study - Subgingival margins demonstrated increased plaque and gingival scores and probing depths. - More **spirochetes, fusiforms, rods, and filamentous bacteria** were found to be associated with subgingival margins. **Int J Periodontics Restorative Dent. 1989;9:197-05** #### Flores De-Jacoby (1989) - **Study Type:** Microbiological analysis. - **Findings:** Subgingival margins showed increased plaque scores, gingival scores, and probing depths. - **Microflora:** Higher concentrations of spirochetes, fusiforms, rods, and filamentous bacteria were associated with subgingival margins. *(Int J Periodontics Restorative Dent. 1989;9:197-05)* - Always aim for **supragingival restorative margins**. - In aesthetic zone, it is suggested that restorative margins should not be placed more than 0.5 mm below the gingival tissue (**Nevins 1984**). The International journal of periodontics & restorative dentistry. 1984;4(3):30-49 - Always aim for **supragingival restorative margins**. - In the aesthetic zone, it is suggested that restorative margins should not be placed more than **0.5 mm** below the gingival tissue (Nevins 1984). *(The International Journal of Periodontics & Restorative Dentistry. 1984;4(3):30-49)* ```markdown Location of restorative margins **SUPRAGINGIVAL LOCATION** Ideal for perio because it is easy to clean and no interference with SACT But what about aesthetic?? More translucent materials, adhesive dentistry, resin cements, finishing quality allow for supra placement too. **EQUIGINGIVAL** If **SUBGINGIVAL** margins are required: - Conservative subgingival extension of margins - Sufficient width of KT (at least 2 mm including 1 mm attached gingiva) - Smooth restorative surfaces with proper finished margins - Avoid BW breach ``` #### Supragingival Location Ideal for periodontal health as it is easy to clean and does not interfere with Supra-crestal Attached Tissues (SCAT). Modern translucent materials and adhesive dentistry often allow for supragingival placement even in aesthetic areas. #### Equigingival Location Margins placed at the level of the gingival crest. #### Subgingival Location Requirements If subgingival margins are required, the following must be observed: - Conservative subgingival extension. - Sufficient width of Keratinized Tissue (KT) (at least 2 mm, including 1 mm of attached gingiva). - Smooth restorative surfaces with properly finished margins. - Avoidance of Biologic Width (BW) breach. - But situations exist when subgingival margins are already present or the crowns are short Subgingival caries Fractures Root resorption Perforations Subgingival marging preparations Short clinical crowns Aesthetics  Subgingival margins may be necessary in the following clinical situations: - Subgingival caries - Tooth fractures - Root resorption - Perforations - Existing subgingival preparations - Short clinical crowns requiring increased retention - Aesthetic requirements The image contains a list of dental conditions and considerations presented as a table-like structure, including subgingival caries, fractures, root resorption, perforations, subgingival margin preparations, short clinical crowns, and aesthetics. The text is organized in a vertical list format with no visible borders or grid lines, resembling a simple bullet-pointed list rather than a traditional table. **QUESTION?** Can I just “snip off” the gingiva using a bur, scalpel, laser machine or electro surgery to improve my access? - The restoration becomes supragingival only temporarily. - FGM will also grow back and the restoration will then become subgingival - SCAT space has still been invaded and the rest. margins are in close proximity to the alveolar bone.  #### Limitations of Simple Tissue Removal Using a bur, scalpel, laser, or electrosurgery to "snip off" gingiva for access is often insufficient because: - The restoration becomes supragingival only temporarily. - The Free Gingival Margin (FGM) will grow back, returning the restoration to a subgingival position. - The SCAT space remains invaded, and margins remain in close proximity to the alveolar bone. A dental X-ray image showing a tooth with a restoration, illustrating the proximity of the restoration margins to the alveolar bone. The image is positioned next to text discussing gingival management and access improvement in dental restorations. Treatment options Surgery +/- osseous recontouring Orthodontic extrusion Or both To manage subgingival margins effectively, the following treatment options are available: - Surgery (with or without osseous recontouring) - Orthodontic extrusion - A combination of both ```markdown Managing subgingival margins-the basics | Establish | Measure | Measure | | :--- | :--- | :--- | | Establish the position of final margin (eg after caries removal) and provide provisional restoration if required | Measure margin to bone and supracrestal tissue attachment (Biological Width) | Measure keratinized tissue width | ```  #### Clinical Assessment Steps 1. **Establish Position:** Determine the final margin position (e.g., after caries removal) and provide a provisional restoration if required. 2. **Measure BW:** Measure the distance from the margin to the bone and assess the supracrestal tissue attachment. 3. **Assess KT:** Measure the width of the keratinized tissue. A flowchart diagram illustrating the three steps in managing subgingival margins: 'Establish' (position of final margin and provide provisional restoration if required), 'Measure' (margin to bone and supracrestal tissue attachment, Biological Width), and 'Measure' (keratinized tissue width). The diagram uses a three-step arrow design with text boxes for each stage. ```markdown # Guidelines to managing Pros procedure Carvalho et al 2016 <!-- Flowchart in HTML table format --> <table border="1" cellpadding="5" cellspacing="0" style="border-collapse: collapse; width: 100%; table-layout: fixed;"> <tr> <td style="text-align: center; background-color: #f5d740; font-weight: bold;">Initial procedures</td> </tr> <tr> <td style="text-align: center; background-color: #1e88e5; font-weight: bold;">No BW invasion</td> <td style="text-align: center; background-color: #f5d740; font-weight: bold;">BW invasion</td> </tr> <tr> <td style="text-align: center; background-color: #1e88e5; font-weight: bold;">Surgical</td> <td style="text-align: center; background-color: #ff4081; font-weight: bold;">Surgical</td> </tr> <tr> <td style="text-align: center; background-color: #f5d740; font-weight: bold;">Basic procedures</td> <td style="text-align: center; background-color: #f5d740; font-weight: bold;">Ortho extrusion</td> </tr> <tr> <td style="text-align: center; background-color: #1e88e5; font-weight: bold;">Adequate KT</td> <td style="text-align: center; background-color: #ff4081; font-weight: bold;">Adequate KT</td> <td style="text-align: center; background-color: #1e88e5; font-weight: bold;">Non adequate KT</td> <td style="text-align: center; background-color: #ff4081; font-weight: bold;">Non adequate KT</td> </tr> <tr> <td style="text-align: center; background-color: #1e88e5; font-weight: bold;">Gingivectomy or flap with marginal excision but no osteotomy</td> <td style="text-align: center; background-color: #1e88e5; font-weight: bold;">Apically positioned flap no osteotomy</td> <td style="text-align: center; background-color: #ff4081; font-weight: bold;">Flap with marginal excision and osteotomy</td> <td style="text-align: center; background-color: #ff4081; font-weight: bold;">Apically positioned flap and osteotomy</td> </tr> </table> ```   #### Management Guidelines (Carvalho et al. 2016) **If No BW Invasion:** - **Adequate KT:** Gingivectomy or flap with marginal excision (no osteotomy). - **Inadequate KT:** Apically positioned flap (no osteotomy). **If BW Invasion is Present:** - **Adequate KT:** Flap with marginal excision and osteotomy. - **Inadequate KT:** Apically positioned flap and osteotomy. *Note: Orthodontic extrusion is also a viable alternative for managing BW invasion.* A flowchart titled "Guidelines to managing Pros procedure" by Carvalho et al 2016, illustrating a decision-making process for surgical procedures based on the presence of bone wall (BW) invasion and keratinized tissue (KT) adequacy. The diagram branches from initial procedures into non-surgical and surgical pathways, with further decisions based on KT status leading to specific treatments like gingivectomy, flap procedures, or orthodontic extrusion. A table formatted as a flowchart, presenting a decision tree for managing Pros procedures. It categorizes treatments based on the presence or absence of bone wall invasion and the adequacy of keratinized tissue, with color-coded boxes for different procedures such as gingivectomy, flap surgery, and orthodontic extrusion. Orthodontic extrusion can change the position of the margin from subgingival to supragingival      Orthodontic extrusion can effectively change the position of the restorative margin from subgingival to supragingival by moving the tooth structure coronally. A clinical photo showing a tooth with a subgingival margin before orthodontic treatment, highlighting the initial condition of the tooth and surrounding gingiva. An X-ray image showing the root and surrounding bone structure of a tooth, illustrating the position of the tooth before orthodontic extrusion. A clinical photo showing the same tooth after orthodontic extrusion, with the margin now positioned supragingivally, demonstrating the change in tooth position. A clinical photo showing the tooth with orthodontic brackets and wires, illustrating the orthodontic extrusion process in progress. A clinical photo showing the tooth after orthodontic extrusion, with the margin now supragingival, demonstrating the successful outcome of the treatment.  Clinical cases demonstrate the efficacy of combined periodontal and orthodontic approaches in managing compromised tooth structure. The diagram illustrates two cross-sectional views of teeth, comparing gingival tissue levels. The left side shows a tooth with 5 mm of soft tissue between the bone and gingival margin, indicating a condition where gingivectomy may be performed. The right side shows a tooth with a reduced soft tissue level, labeled as '3', suggesting the outcome after gingivectomy. The diagram is used to explain the criteria for performing gingivectomy based on tissue thickness. ```markdown **CROWN LENGTHENING-DEFINITON** A procedure where the **controlled displacement** of the alveolar bone, the supra-crestal attached tissues (CT and JE) and FGM is carried out to allow for supragingival placement of restoration with minimum future changes in the surrounding periodontium. ``` Crown lengthening is a procedure involving the **controlled displacement** of the alveolar bone, the supra-crestal attached tissues (Connective Tissue and Junctional Epithelium), and the Free Gingival Margin (FGM). **Goal:** To allow for supragingival placement of a restoration with minimum future changes in the surrounding periodontium. # CROWN LENGTHENING- DEFINITION Therefore, In the early stages of restorative treatment planning, if the clinician believes that the margin of the final restoration will be subgingival and/or in close proximity to alveolar bone crest, crown lengthening should be recommended. In the early stages of restorative treatment planning, crown lengthening should be recommended if the clinician anticipates that the final restoration margin will be subgingival or in close proximity to the alveolar bone crest. ```markdown Biological Width = Supracrestal tissue attachment **DIAGNOSIS:** Measuring the BW - Transgingival/periodontal probing - Anaesthesia - PA radiographs - CBCT <img src="https://i.imgur.com/placeholder.jpg" alt="Clinical image showing periodontal probing with a probe inserted into the gingival sulcus of teeth, with a yellow oval overlay indicating '2 to 3 mm'." /> 2 to 3 mm <!-- Table: Figures --> <table border="1" cellpadding="5" cellspacing="0"> <thead> <tr> <th>Figure</th> <th>Description</th> </tr> </thead> <tbody> <tr> <td>Fig 2</td> <td>Esquema representativo da identificação da JCE em dente íntegro através da sondagem periodontal. Esta medida clínica corresponde, histologicamente, ao epitélio do sulco e epitélio juncional em condições fisiológicas normais, em média 2 mm.</td> </tr> <tr> <td>Fig 3</td> <td>Avaliação clínica da identificação da JCE em dente íntegro através da sondagem periodontal. Esta medida clínica corresponde, histologicamente, ao epitélio do sulco e epitélio juncional em condições fisiológicas normais, em média 2 mm.</td> </tr> <tr> <td>Fig 4</td> <td>Esquema representativo da identificação da COA em dente íntegro através da sondagem periodontal transgingival. Esta medida clínica corresponde, histologicamente, ao epitélio do sulco, epitélio juncional e inserção conjuntiva em condições fisiológicas normais, em média 3 mm.</td> </tr> <tr> <td>Fig 5</td> <td>Avaliação clínica da identificação da COA em dente íntegro através da sondagem periodontal transgingival. Esta medida clínica corresponde, histologicamente, ao epitélio do sulco, epitélio juncional e inserção conjuntiva em condições fisiológicas normais, em média 3 mm.</td> </tr> </tbody> </table> ```    #### Diagnostic Methods for Measuring BW - **Transgingival/Periodontal Probing:** Performed under anesthesia to identify the Cemento-Enamel Junction (CEJ) and Bone Crest (COA). - **Radiographic Evaluation:** Periapical (PA) radiographs or CBCT. #### Clinical Benchmarks - **Sulcus/Junctional Epithelium:** Typically measures ~2 mm. - **Total Supracrestal Attachment (including CT):** Typically measures ~3 mm. The image contains four figures (Fig 2, Fig 3, Fig 4, Fig 5) illustrating the measurement of biological width. Fig 2 and Fig 3 depict the clinical identification of the junctional epithelial crest (JCE) in a healthy tooth through periodontal probing, corresponding to a clinical measurement of 2 mm, which histologically represents the sulcular epithelium and junctional epithelium. Fig 4 and Fig 5 show the clinical identification of the connective tissue attachment (COA) in a healthy tooth, with a clinical measurement of 3 mm, histologically corresponding to the sulcular epithelium, junctional epithelium, and connective tissue attachment. The figures are presented as a combination of diagrams and clinical photographs. A close-up clinical photograph showing a periodontal probe inserted into the gingival sulcus of a tooth, illustrating the measurement of biological width. The probe is placed between two teeth, with the gingival tissue appearing healthy and the probe indicating a depth of 2 to 3 mm. A diagram showing a yellow oval with the text '2 to 3 mm' in blue, representing the normal biological width measurement. This diagram is used to visually summarize the clinical findings related to periodontal probing, corresponding to the histological structures of the sulcus and junctional epithelium. **Flap + osseous recontouring = CL** With less than 3 mm of soft tissue between the bone and gingival margin, or less-than-adequate attached gingiva, a flap procedure and osseous recontouring are required for crown lengthening. <img src="https://i.imgur.com/5XZJfLm.png" alt="Diagram showing crown lengthening procedure with 2 mm and 3 mm measurements between bone and gingival margin." />  #### Indications for Flap and Osseous Surgery A flap procedure and osseous recontouring are required for crown lengthening when there is: - Less than 3 mm of soft tissue between the bone and the planned gingival margin. - Less-than-adequate attached gingiva. A diagram illustrating crown lengthening procedures, showing two scenarios with 2 mm and 3 mm of soft tissue between the bone and gingival margin. The left side depicts a case with 2 mm of tissue, requiring a flap and osseous recontouring, while the right side shows a case with 3 mm, indicating adequate attached gingiva. Both diagrams highlight the bone structure and the relationship between the tooth, gingiva, and bone.  Surgical planning must account for the biological requirements of the soft tissue seal to prevent chronic inflammation post-restoration. A labeled anatomical diagram of the human gingival tissue, showing various structures such as the alveolar mucosa, mucogingival junction, attached gingiva, free gingival groove, free gingiva, and interdental gingiva. The image is a clinical photograph with annotations, illustrating the importance of keratinized tissue and phenotype in periodontal health. # Aesthetic crown lengthening  Aesthetic crown lengthening is utilized to correct "gummy smiles" or uneven gingival levels, ensuring the clinical crown height is harmonious with facial aesthetics. A side-by-side comparison of a patient's smile before (a) and after (b) aesthetic crown lengthening, showing improved gingival symmetry and tooth exposure. The images highlight the clinical outcome of the procedure on the upper anterior teeth.     Pre-surgical assessment must include an evaluation of the biological width to ensure the resulting gingival architecture remains stable over time. Close-up view of a patient's mouth showing discolored and decayed teeth, with visible gum inflammation, labeled as 'a'. Intraoral photograph showing multiple teeth with extensive carious lesions and missing teeth, labeled as 'b'. Another intraoral view of a patient's mouth with discolored teeth and gingival inflammation, labeled as 'c'. Close-up of a patient's mouth showing teeth with decay and possible restorations, labeled as 'd'. **Lack of KT & difficulty in cleaning** <img src="https://i.imgur.com/5JZjZjL.png" alt="Image showing dental condition with lack of KT and difficulty in cleaning, featuring two close-up views of teeth." />   #### Keratinized Tissue (KT) Considerations A lack of KT can lead to difficulty in cleaning and increased susceptibility to recession, especially around restorative margins. Close-up photo of a dental condition showing a lack of keratinized tissue (KT) and difficulty in cleaning, with visible inflammation and gum recession around the teeth. Close-up photo showing a dental implant with surrounding tissue, illustrating the challenges in cleaning due to the lack of keratinized tissue, labeled as (a). ```markdown CL procedures Surgical Soft tissues - Gingivectomy - NO BW invasion Soft and hard tissues - Gingivectomy and osteotomy - BW invasion **HEALING = minimum 3 months up tp 6 months** Lanning et al 2003 Pontoriero et al 2001 Bragger et al 1992 ``` #### Surgical Techniques - **Soft Tissue Only (Gingivectomy):** Indicated when there is no BW invasion and sufficient attached gingiva exists. - **Soft and Hard Tissue (Gingivectomy and Osteotomy):** Indicated when BW invasion is present or expected. #### Healing Timelines Final restoration should be delayed to allow for tissue stabilization: - **Minimum:** 3 months - **Ideal:** Up to 6 months (Lanning et al. 2003, Pontoriero et al. 2001, Bragger et al. 1992) ## Crown-Lengthening Procedures Note increased clinical crown. (C) Buccal view after surgery. (D) Final restorations. <img src="https://i.imgur.com/5XQzKlH.png" alt="Crown-Lengthening Procedures: A, B, C, D images showing dental procedures." />  Crown lengthening procedures result in an increased clinical crown height, providing the necessary tooth structure for stable final restorations. A composite image showing four stages of crown-lengthening procedures on teeth, labeled A, B, C, and D. Image A shows the initial state with exposed dental work, B shows the buccal view after surgery with sutures, C shows a buccal view after surgery, and D shows the final restorations with increased clinical crown height. Apically repositioned flap-if insufficient keratinized tissue present <img src="https://i.imgur.com/3XJZj8l.png" alt="Fig. 32-66 Apically positioned flap. Dimensional changes. (a) Preoperative dimensions. The dashed line indicates the border of the elevated mucoperiosteal flap. (b) Bone recontouring has been completed and the flap repositioned to cover the alveolar bone. (c) Dimensions following healing. Minor resorption of the marginal alveolar bone has occurred as well as some loss of connective tissue attachment."/>  #### Apically Repositioned Flap This technique is used if insufficient keratinized tissue is present. It involves: - Elevating a mucoperiosteal flap. - Bone recontouring. - Repositioning the flap to cover the alveolar bone while preserving or increasing the zone of attached gingiva. Figure 32-66 illustrates the apically positioned flap procedure, showing dimensional changes in three stages: (a) preoperative dimensions with a mucoperiosteal flap, (b) post-bone recontouring with the flap repositioned to cover the alveolar bone, and (c) post-healing dimensions with minor resorption of marginal alveolar bone and loss of connective tissue attachment. # Marginal fit Poorly adapted restorations clearly have been implicated in producing an inflammatory response in the periodontium. Open margins (several tenths of a millimetre) are capable of harbouring large numbers of bacteria. Figure 1. A, Microscopic image (cross-sectional view) at buccal margin. B, Confocal laser scanning microscopy (CLSM) in combination with scanning electron microscopy (SEM). C, CLSM alone demonstrating presence and formation of biofilm (red area). Figure 2. A, Microscopic image (cross-sectional view) at lingual margin. B, Confocal laser scanning microscopy (CLSM) in combination with scanning electron microscopy. C, CLSM alone demonstrating presence and formation of biofilm (red area). Figure 3. A, Cross-sectional view of interface between restoration and tooth structure at occlusal surface of tooth. B, Confocal laser scanning microscopy (CLSM) in combination with scanning electron microscopy. C, CLSM alone confirming formation of biofilm in area with low accessibility to nutrients and oxygen. THE JOURNAL OF PROSTHETIC DENTISTRY CLINICAL REPORT Biofilms in restorative dentistry: A clinical report Vincent Torresyap, DDS, a Alireza Moshaverinia, DDS, MS, PhD, b and Winston W. Chee, DDS c  #### Impact of Poor Adaptation Poorly adapted restorations produce an inflammatory response in the periodontium. Open margins (even those measuring several tenths of a millimeter) can harbor large numbers of bacteria. #### Biofilm Formation Confocal laser scanning microscopy (CLSM) and SEM imaging confirm the formation of biofilms at the interface between restorations and tooth structure, even in areas with low accessibility to nutrients and oxygen. *(The Journal of Prosthetic Dentistry: Torresyap, Moshaverinia, & Chee)* The image contains three figures (Figure 1, Figure 2, and Figure 3) showing microscopic and confocal laser scanning microscopy (CLSM) images of dental restorations. Figure 1 displays a cross-sectional view at the buccal margin, Figure 2 at the lingual margin, and Figure 3 at the occlusal surface, all demonstrating the presence and formation of biofilm (indicated by red areas) in areas with poor marginal fit. The figures illustrate how open margins can harbor bacteria and form biofilms, contributing to periodontal inflammation. ## Contours Ideally: crown contours should provide protection of gingival margins, allow cleansing action of the musculature and facilitate access to oral hygiene Overcontour has negative effects on the periodontium due to plaque accumulation as well; Try to overcome this with adequate crown reduction for the type of material to be used. <img src="https://i.imgur.com/7XZvJ8l.png" alt="Three diagrams labeled A, B, and C showing different crown contour designs on teeth, with arrows indicating gingival margins." />  #### Ideal Crown Contours Crown contours should: - Provide protection of gingival margins. - Allow for the cleansing action of the musculature. - Facilitate access for oral hygiene. #### Risks of Overcontouring Overcontouring has negative effects on the periodontium due to plaque accumulation. This should be mitigated by ensuring adequate tooth reduction for the specific restorative material being used. Three labeled diagrams (A, B, C) illustrating different crown contour designs on teeth, showing the relationship between the crown and gingival margin. Diagram A shows a normal contour, B shows an overcontour with plaque accumulation, and C shows a reduced contour to avoid negative effects on the periodontium. # Restorative materials – surface finish Every finished surface of restorative materials has different capacity for retaining plaque (Bollen et al. 1997, Ababnaeh et al., 2011). Surface characteristic of restorative materials - surface roughness and surface free energy inherent in the materials. The rough surface of restorative materials especially on the interproximal and marginal can become predisposing factors for plaque accumulation and lead to destruction of periodontium (Pneumas et al. 1998, van Dijken et al. 1987). These studies found that, finishing on the interproximal of composite resins were difficult to achieve and marginal defect frequently detected; resulting of highly bacterial plaque accumulation. Highly glazed porcelain is less plaque retentive than enamel, whereas on the other hand, metal pontic or composite restoration tends to encourage plaque formation (Wise & Dykema 1975). #### Plaque Retention and Roughness Every restorative material has a different capacity for retaining plaque based on surface roughness and surface free energy (Bollen et al. 1997, Ababnaeh et al. 2011). - **Rough Surfaces:** Especially on interproximal and marginal areas, these act as predisposing factors for plaque accumulation and periodontal destruction (Pneumas et al. 1998, van Dijken et al. 1987). - **Material Specifics:** Highly glazed porcelain is less plaque-retentive than enamel. Conversely, metal pontics or composite restorations tend to encourage plaque formation (Wise & Dykema 1975). **To finalize ...** For restorations to survive long term, the periodontium must remain healthy so that the teeth are maintained. <img src="https://i.imgur.com/9V9zX8L.png" alt="Close-up of healthy teeth and gums"> For the periodontium to remain healthy, restorations must be critically managed in several areas so that they are in harmony with their surrounding periodontal tissues. THE UNIVERSITY OF WESTERN AUSTRALIA  For restorations to survive long-term, the periodontium must remain healthy so that the teeth are maintained. Restorations must be critically managed in several areas—margins, contours, and surface finish—to ensure they exist in harmony with the surrounding periodontal tissues. Close-up photograph of healthy teeth and gums, illustrating the importance of periodontal health for the long-term survival of dental restorations. Thank you!!! The University of Western Australia <img src="https://i.imgur.com/1Q8q5hF.png" alt="The University of Western Australia logo with a swan and motto 'Seek Wisdom'"/>  The successful integration of periodontal health and restorative excellence is the foundation of modern interdisciplinary dentistry. A logo of The University of Western Australia featuring a shield with a swan and the motto 'Seek Wisdom' against a starry night sky background. # Reading Resources ## 2017 WORLD WORKSHOP ### Dental prostheses and tooth-related factors Carlo Ercoli¹ | Jack G. Caton² ## Interdisciplinary interface between fixed prosthodontics and periodontics JAFAAR ABDUO & KARL M. LYONS ## The periodontal restorative interface: esthetic considerations VINCENT BENNANI, HADEEL IBRAHIM, LATFIYA AL-HARTHİ & KARL M. LYONS   #### 2017 World Workshop - **Dental prostheses and tooth-related factors** - Authors: Carlo Ercoli and Jack G. Caton #### Clinical Research and Literature Reviews - **Interdisciplinary interface between fixed prosthodontics and periodontics** - Authors: Jafaar Abduo and Karl M. Lyons - **The periodontal restorative interface: esthetic considerations** - Authors: Vincent Bennani, Hadeel Ibrahim, Latfiya Al-Harthi, and Karl M. Lyons The figure is a journal cover for 'Periodontology 2000' from 2017, featuring the article titled 'Interdisciplinary interface between fixed prosthodontics and periodontics' by Jaafar Abduo & Karl M. Lyons. The cover includes the journal's logo and publication details. The figure is a journal cover for 'Periodontology 2000' from 2017, featuring the article titled 'The periodontal restorative interface: esthetic considerations' by Vincent Bennani, Hadeel Ibrahim, Latfiya Al-Harthi & Karl M. Lyons. The cover includes the journal's logo and publication details. [^1]: Original PDF page 1: [[L4 Perio resto.pdf#page=1|L4 Perio resto, p.1]] [^2]: Original PDF page 2: [[L4 Perio resto.pdf#page=2|L4 Perio resto, p.2]] [^3]: Original PDF page 3: [[L4 Perio resto.pdf#page=3|L4 Perio resto, p.3]] [^4]: Original PDF page 4: [[L4 Perio resto.pdf#page=4|L4 Perio resto, p.4]] [^5]: Original PDF page 5: [[L4 Perio resto.pdf#page=5|L4 Perio resto, p.5]] [^6]: Original PDF page 6: [[L4 Perio resto.pdf#page=6|L4 Perio resto, p.6]] [^7]: Original PDF page 7: [[L4 Perio resto.pdf#page=7|L4 Perio resto, p.7]] [^8]: Original PDF page 8: [[L4 Perio resto.pdf#page=8|L4 Perio resto, p.8]] [^9]: Original PDF page 9: [[L4 Perio resto.pdf#page=9|L4 Perio resto, p.9]] [^10]: Original PDF page 10: [[L4 Perio resto.pdf#page=10|L4 Perio resto, p.10]] [^11]: Original PDF page 11: [[L4 Perio resto.pdf#page=11|L4 Perio resto, p.11]] [^12]: Original PDF page 12: [[L4 Perio resto.pdf#page=12|L4 Perio resto, p.12]] [^13]: Original PDF page 13: [[L4 Perio resto.pdf#page=13|L4 Perio resto, p.13]] [^14]: Original PDF page 14: [[L4 Perio resto.pdf#page=14|L4 Perio resto, p.14]] [^15]: Original PDF page 15: [[L4 Perio resto.pdf#page=15|L4 Perio resto, p.15]] [^16]: Original PDF page 16: [[L4 Perio resto.pdf#page=16|L4 Perio resto, p.16]] [^17]: Original PDF page 17: [[L4 Perio resto.pdf#page=17|L4 Perio resto, p.17]] [^18]: Original PDF page 18: [[L4 Perio resto.pdf#page=18|L4 Perio resto, p.18]] [^19]: Original PDF page 19: [[L4 Perio resto.pdf#page=19|L4 Perio resto, p.19]] [^20]: Original PDF page 20: [[L4 Perio resto.pdf#page=20|L4 Perio resto, p.20]] [^21]: Original PDF page 21: [[L4 Perio resto.pdf#page=21|L4 Perio resto, p.21]] [^22]: Original PDF page 22: [[L4 Perio resto.pdf#page=22|L4 Perio resto, p.22]] [^23]: Original PDF page 23: [[L4 Perio resto.pdf#page=23|L4 Perio resto, p.23]] [^24]: Original PDF page 24: [[L4 Perio resto.pdf#page=24|L4 Perio resto, p.24]] [^25]: Original PDF page 25: [[L4 Perio resto.pdf#page=25|L4 Perio resto, p.25]] [^26]: Original PDF page 26: [[L4 Perio resto.pdf#page=26|L4 Perio resto, p.26]] [^27]: Original PDF page 27: [[L4 Perio resto.pdf#page=27|L4 Perio resto, p.27]] [^28]: Original PDF page 28: [[L4 Perio resto.pdf#page=28|L4 Perio resto, p.28]] [^29]: Original PDF page 29: [[L4 Perio resto.pdf#page=29|L4 Perio resto, p.29]] [^30]: Original PDF page 30: [[L4 Perio resto.pdf#page=30|L4 Perio resto, p.30]] [^31]: Original PDF page 31: [[L4 Perio resto.pdf#page=31|L4 Perio resto, p.31]] [^32]: Original PDF page 32: [[L4 Perio resto.pdf#page=32|L4 Perio resto, p.32]] [^33]: Original PDF page 33: [[L4 Perio resto.pdf#page=33|L4 Perio resto, p.33]] [^34]: Original PDF page 34: [[L4 Perio resto.pdf#page=34|L4 Perio resto, p.34]] [^35]: Original PDF page 35: [[L4 Perio resto.pdf#page=35|L4 Perio resto, p.35]] [^36]: Original PDF page 36: [[L4 Perio resto.pdf#page=36|L4 Perio resto, p.36]] [^37]: Original PDF page 37: [[L4 Perio resto.pdf#page=37|L4 Perio resto, p.37]] [^38]: Original PDF page 38: [[L4 Perio resto.pdf#page=38|L4 Perio resto, p.38]] [^39]: Original PDF page 39: [[L4 Perio resto.pdf#page=39|L4 Perio resto, p.39]] [^40]: Original PDF page 40: [[L4 Perio resto.pdf#page=40|L4 Perio resto, p.40]] [^41]: Original PDF page 41: [[L4 Perio resto.pdf#page=41|L4 Perio resto, p.41]] [^42]: Original PDF page 42: [[L4 Perio resto.pdf#page=42|L4 Perio resto, p.42]] [^43]: Original PDF page 43: [[L4 Perio resto.pdf#page=43|L4 Perio resto, p.43]] [^44]: Original PDF page 44: [[L4 Perio resto.pdf#page=44|L4 Perio resto, p.44]] [^45]: Original PDF page 45: [[L4 Perio resto.pdf#page=45|L4 Perio resto, p.45]] [^46]: Original PDF page 46: [[L4 Perio resto.pdf#page=46|L4 Perio resto, p.46]] [^47]: Original PDF page 47: [[L4 Perio resto.pdf#page=47|L4 Perio resto, p.47]] [^48]: Original PDF page 48: [[L4 Perio resto.pdf#page=48|L4 Perio resto, p.48]] [^49]: Original PDF page 49: [[L4 Perio resto.pdf#page=49|L4 Perio resto, p.49]] [^50]: Original PDF page 50: [[L4 Perio resto.pdf#page=50|L4 Perio resto, p.50]] [^51]: Original PDF page 51: [[L4 Perio resto.pdf#page=51|L4 Perio resto, p.51]] [^52]: Original PDF page 52: [[L4 Perio resto.pdf#page=52|L4 Perio resto, p.52]] [^53]: Original PDF page 53: [[L4 Perio resto.pdf#page=53|L4 Perio resto, p.53]] [^54]: Original PDF page 54: [[L4 Perio resto.pdf#page=54|L4 Perio resto, p.54]] [^55]: Original PDF page 55: [[L4 Perio resto.pdf#page=55|L4 Perio resto, p.55]] [^56]: Original PDF page 56: [[L4 Perio resto.pdf#page=56|L4 Perio resto, p.56]]