Kaohsiung Journal of Medical Sciences (2018) 34, 194e201

Available online at www.sciencedirect.com

ScienceDirect

journal homepage: http://www.kjms-online.com

Review Article

Periodontal prosthesis in contemporary dentistry

Chiun-Lin Steven Liu a,b,c,*

a
Main Line Dental Implant Center, Berwyn, USA
b
Aesthetic Restoration and Implant Dentistry, School of Dental Medicine, University of
Pennsylvania, USA
c
Department of Academic, School of Dental Medicine, University of Pennsylvania, USA

Received 28 October 2017; accepted 12 January 2018

Available online 12 February 2018

KEYWORDS Abstract In the last 5 decades, the developments of osseointegrated titanium implants
Implants; (since 1965) have led to the success of contemporary dentistry. Endosseous implant-
Periodontics; supported restorations delivered in accordance with the traditional Branemark protocol have
Periodontal proven to be highly predictable. Today, implants are becoming increasingly common in dental
prosthesis care and provide more therapeutic options, but treatment planning and the sequencing of
therapy are critical in implant-assisted and implant-supported cases. Implant prostheses give
patients and dentists more options in treatment planning, but also present challenging deci-
sions regarding implant surgery. In essence, the emerging thought is that teeth are expend-
able, as we now have implants to solve these problems. The fact that peri-implantitis is no
simple problem to treat does not seem to affect many who hold that thought. In this article,
the authors explain how to properly apply the periodontal prosthesis philosophy, concepts,
principles, and techniques in contemporary dentistry. (This article is an update from the
article was published in 2005) [1].
Copyright ª 2018, Kaohsiung Medical University. Published by Elsevier Taiwan LLC. This is an
open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/
by-nc-nd/4.0/).

Introduction Periodontal Prosthesis Program was founded by Drs. Morton

Amsterdam & Walter Cohen in 1955. As we reflect on where
It is interesting to look back upon the past sixty years spent we were and where we are at present, we begin to see in
in the study, practice, and teaching of dentistry after the perspective how and why we evolved as we did.
Our own introduction to dentistry was definitely pros-
thetically oriented. We were given a sound and intense
Conflicts of interest: The author declares no conflicts of
program of study in the basic sciences, but there was
interests. little if any correlation to that which we did in preclinical
* Main Line Dental Implant Center, 1257 Lancaster Ave, Berwyn, and clinical dentistry. Not only was that correlation
PA, 19312, USA. lacking but there was little if any correlation between the
E-mail address: stevendmd@gmail.com. various aspects of clinical dentistry. We wonder just how

https://doi.org/10.1016/j.kjms.2018.01.008
1607-551X/Copyright ª 2018, Kaohsiung Medical University. Published by Elsevier Taiwan LLC. This is an open access article under the CC
BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Periodontal prosthesis in contemporary dentistry 195

far we have come today in solving this problem (Dr. 2. Type of osseous defect
Morton Amsterdam) [2].
The principles of periodontal prosthesis developed in the If the tooth is contained within the envelope of the residual
1950se1970s by Drs. Amsterdam, Abrams, and Weisgold bony walls, the same good prognosis will apply to an im-
explained in Periodontal Therapy, edited by Drs. Goldman mediate implant placed within the envelope of bone in an
and Cohen, provide relevant diagnostic and therapeutic extraction socket.
criteria and guidelines that apply to teeth as well as
implants. 3. Decontamination of the natural root
The technique of periodontal prosthesis allows multiple
pontic replacement in fixed bridge often on severely mo- A decontaminated root surface must be obtained to achieve
bile, compromised and reduced number of abutment teeth. new attachment. As it compares with the use of a sterile
The science is overwhelmingly in favor of this type of bridge implant in implant therapy.
in certain situations where conventional dentures and im- As a consequence, there is no reason to proceed with
plants are not possible for whatever reasons. The technique placement of an artificial tooth, such as an implant, as a
relies on good oral hygiene and periodic maintenance, a substitute for a natural tooth if the potential for repair and
reduced but healthy periodontal condition, multiple can- the surgical treatment of the site are the same for both
tilevers often with couple pontics cantilevered off the last procedures (Table 1).
remaining abutment, subgingival (75e80%) and/or supra- “Periodontal Prosthesis” is defined as those restorative
gingival (20%) margins, acrylic, composite or porcelain and prosthetic endeavors that are essential in the treat-
veneering material on a metal framework and with a nar- ment of advanced periodontal disease. It refers to the
rower occlusal table and shorter/shallower cusps to reduce treatment of the dentition mutilated by periodontal dis-
horizontal force and occlusal trauma. Full arch splinting ease, including the concepts, principles, and techniques
design can stabilize the mobile abutment teeth. This type that may be used in any restorative or tooth replacement
of bridge has increased but not increasing mobility and procedure involving the natural dentition [2].
excellent long term success rates. The principles in the past These practices are just as applicable to implant
are still valuable and do apply to contemporary dentistry restorations, from diagnosis, treatment plan, esthetics,
including implant restoration. periodontal/peri-implant perspectives, periodontal biotype,
For these situations, occlusal, restorative, surgical, surgical perspectives, restorative perspectives, orthodontic
esthetic, biomaterial, pharmacologic, and psychologic skills perspectives, occlusal concepts and splinting perspectives,
must be carefully combined for optimal results [3]. failures and complications management, maintenance,
The first osseointegrated titanium implant was inserted sequence of therapy, to the emergence profile of the abut-
into a human jaw by Branemark in 1965 [4,5]. Endosseous ment restoration [7].
implant-supported restorations delivered in accordance In this article, the authors explain how to properly apply
with the traditional Branemark protocol has proven to be the periodontal prosthesis philosophy, concepts, principles,
highly predictable. This type of restoration is becoming and techniques to contemporary dental therapy.
more and more popular today. Implant-supported prosthe-
ses have been used for fully edentulous, partially edentu-
lous, and single-tooth implants, and surgical and Indication for implant placement
restorative approaches for implant prostheses have greatly
improved in the past 50 years [6e9]. In essence, the One of the great uses for implants is when individuals have
emerging thought is that teeth are expendable, as we now lost all their teeth. Another is when replacing bridges; the
have implants to solve these problems. The fact that peri- pontic area can now be restored with an implant. But with
implantitis is no simple problem to treat does not seem to all of the wonderful restorative materials today, teeth that
affect many who hold that thought. have broken down many times can be treated and main-
The dilemma for the ethically oriented professional is tained indefinitely.
whether to save the natural dentition or to replace it with Since the advent of bonded composite resins in the late
an implant. In 2011, “Three diagnostic criteria” for single- 1980s, the success rate of restoring tooth surfaces in
rooted teeth have been suggested from a periodontal point comprehensive perio-restorative cases has seen a major
of view to solve this problem by Dr. Ricci’s group and direct improvement; and due to the continuing evolution of
the clinician toward the proper biologically and ethically wonderful restorative materials [11,12], every day we get
oriented treatment [10].

Table 1 Requirements for regenerative periodontal

Three diagnostic criteria are as follows therapy on natural teeth vs requirements for immediate
implant placement [10].
1. Tooth stability
Tooth Implant
From a periodontal point of view, stability, vitality, Stable Primary stability
and integrity (The SVI rule: stable, vital, intact). Of a tooth Contained within envelope Contained within envelope
are definitive indications to maintain it and to proceed of bone of bone
with regenerative therapy, even in a very compromised Decontaminated Sterile implant
situation.
196 C.-L.S. Liu

better and better results that continue to stand the test of 4. Placement of a provisional to allow for ideal contours
time. Yet here we are today, extracting teeth and replacing and tissue health. The provisional is critical, as it allows
them with implants at an incredible rate never seen before. the surgeon vertical access to the underlying periodontal
tissues.
5. Surgical procedures are undertaken to remove pocket-
Saving natural teeth ing. Surgery should encompass the creation of a para-
bolic architecture of the bone, biologic shaping of each
In essence, healthy, functional and cosmetic restoration of tooth for long-term maintenance, and the addition of an
severely compromised natural teeth can be achieved abundance of connective tissue for protection of the
without implant treatment in some clinical situations by periodontium. The end result of the surgery must permit
following this workflow [13]: the restorative dentist to place a clear margin in his or
her final restorations.
1. Patient presents with decayed tooth. 6. At four weeks, a reline or remake of the provisionals is
2. Diagnosis to ensure trying to keep a tooth or teeth undertaken, creating a 1-mm gap coronal to the existing
does not negatively affect existing healthy teeth. tissue. No margination is to be undertaken at this time.
3. Removal of decay through proper methods and then 7. Fourteen weeks from the day of surgery the final margins
replacing lost tooth structure with bonded composite are placed. A feather edge [13] is recommended when
resins. the crown finish line is located at root surface.

Table 2 Periodontal prosthesis vs Implant prosthesis.

Periodontal Prosthesis Implant Prosthesis
Anchorage [14] Periodontal ligament: OsseointegrationdRigid (as in ankylosis)
proprioceptordFlexible
Attached gingiva Required Required (especially for rough surface implant)
Biological width [15] Supracrestal, 2.04 mm:(from crest of Subcrestal, 2.5 mm:
alveolar bone to coronal part of tooth) (from junction of implant head and abutment
to apical of implant)
Supracrestal (possible in platform switch implant)
Surgical procedure Less trauma More trauma
Crown to root/implant ratio Poor Once osseointegration is achieved,
Longer clinical crown crown-to-implant ratio may not be important
Occlusion Narrow occlusal table; reduce lateral Narrow occlusal table; reduce lateral forces
forces
Impression technique More complicated Simple, with impression coping
Complications [16] Periodontitis, occlusal trauma, root Periimplantitis, fistula, fixture/screw failure, prosthesis
caries, root fracture failure. More complicated.
Cosmetic concern Difficult Difficult, especially with 2 implants adjacent to each
Papilla preservation other Improved by pink esthetic (pink porcelain)
Function of final restoration Good Good
Preparation of ridge Orthodontic therapy to improve bony Orthodontic therapy to build up implant site;
defect, GTR increase bone and soft tissue volume, GBR
Soft tissue augmentation PRGF, PRP, PRF
Occlusal wear Erupt to compensate for wear because of No eruption to compensate for wear; problem especially
cementum/bone in single tooth implant
Root caries Yes No
Periodontal maintenance Every 3e4 months; requires excellent Every 6 months; requires excellent oral hygiene
oral hygiene
Long-term follow up Up to 50 + years Single tooth implant: 40 + years
Long span C&B: Up to 24 years
Influence of the 3-D [14] Not critic Critic
Bone-to-Implant/tooth As long as there is no attachment loss 2 mm buccal plate (prefer 2e4 mm)
Relationship on Esthetics:
Proximity [17e19] Tooth and tooth 1.0 mm Tooth and implant
1.50 mm without platform switching
1.25 mm with platform switching (possible)
Implant and implant
3.0 mm without platform switching
2.5 mm with platform switching (possible)
Periodontal prosthesis in contemporary dentistry 197

8. Final placement of restorations, with care taken to make Orthodontic therapy can now be used to create or
sure they are properly contoured with full 360-degree develop the future implant site by using forced eruption of
margin closure. Special care of proper contours where hopeless teeth to alter or increase the soft and hard tissues
furcations have been removed is critical. before implant placement. It also can be used to recreate
lost interproximal papillae.

Lessons and guideline from periodontal Site development

prosthesis [13] (Table 2)
In 1998, Salama, Garber, Rosenberg. et al. [9] explored the
Orthodontic perspectives roots of the concept of implant site development within the
philosophy and principles of periodontal prosthesis. In
addition, the myriad of techniques that are presently
Orthodontics has always played a major role in periodontal
collectively referred to as site development are systemat-
prosthesis. For example, orthodontics was used in the past
ically classified into a sequential four-tiered approach:
to retract maxillary and mandibular anterior teeth that had
splayed, which was done with removable appliances
(Fig. 1). Fixed orthodontic appliances were used to upright 1. Space management
mesially tilted posterior teeth when bodily movement 2. Osseous related management and enhancement
required a more stable appliance. As research began to 3. Soft tissue enhancement
show that tooth position has a significant affect on soft and 4. Developing the restorativeegingival interface that opti-
hard tissues, orthodontics began to be used to reformat the mizes their efficient application as well as overall
periodontium and align teeth. success.
Today, implants are used when natural teeth are seriously
compromised. Forced eruption before crown lengthening The principles of occlusion
procedures, molar uprighting, and realignment of anterior
teeth are all examples of situations in which implants can be Because of the periodontium is compromised in most peri-
used. When implants are used to anchor orthodontic teeth odontal prosthesis cases, the narrower occlusal table was
movement the therapeutic period is decreased [7]. suggested and the lateral occlusal forces reduced. In most

Figure 1. a. Posterior bite collapse after missing upper and lower 1st molars. Maxillary anterior teeth had splayed. b. Modified
Hawley bite plane was applied to disarticulate posterior teeth. c. After posterior teeth passive erupt, temporary build-up and/or
temporary bridges are inserted. d. When posterior support is set up and the occlusal vertical dimension is decided, retract
maxillary anterior teeth that had splayed by using fixed or removable appliances. Final restoration (either C & B or implant
restoration) can be done.
198 C.-L.S. Liu

Figure 2. a. Mechanical modifications in occlusal form as a modified cusp in periodontal prosthesis. Note comparison between
buccolingual width of occlusal table of unworn tooth and that of restored tooth. b. Comparison in a lower posterior tooth between
unworn natural tooth and restored tooth with therapeutic cuspal modification. c. Decreasing posterior cusp height will cause
occlusal table to be widened (upper left, lower left). After cuspal height reduction, a compensatory narrowing of occlusal tables is
necessary (upper right, lower right). d. Comparison of cusp height of natural unworn tooth and that of restored dentition. e. Left:
Occlusal relations of unrestored canine, direction of transmission of occlusal load in this case is predominantly horizontal (arrow).
Right: Centric hold created in restored canine permits occlusal load (arrow) to be transmitted axially.

cases, it is necessary to decrease posterior cusp height to 1. The teeth should be in maximum occlusion when the
accommodate a decrease in incisal guidance. Modified jaws are in centric relation at an acceptable vertical
canine plane forms were created to permit occlusal loads to dimension, allowing for an adequate interocclusal
be transmitted axially (Fig. 2) [20,21]. The same concept distance.
will fit the implant prosthesis. Weinberg and Kruger [22] 2. The mandible should have freedom to move to and from
suggested using flat cuspal inclinations and minimizing centric relation without restraint.
cantilever lengths, and suggested that maxillary molars 3. The healthy, functional and esthetic pattern should
placed in cross-occlusion and occlusal anatomy be modified satisfy the needs of the patient.
to decrease torque. 4. The cuspal relations of the teeth in both anterior and
posterior directions should allow the mandible to move
Immediate loading implant dentistry to and from centric relation without restraint.
5. Inclined plane control of the mandibular excursive
The combination of the guidelines of periodontal prosthesis movements should be supplied by the anterior teeth
with state-of-the-art implant dentistry can lead to pre- (especially the canines) and the buccal cusps unilater-
dictable, beneficial, and efficient treatment, even for the ally on the working side. No posterior tooth contact is
most difficult patients and circumstances at immediate required or desired during protrusive movements.
loading implant cases (Ganeles et al.) [3]. The principles of 6. Mechanical modification of the total occlusal restorative
occlusion derived from periodontal prosthesis are summa- design is mandatory in the execution of periodontal
rized as follows [23]: prosthesis. These modifications have as a basic intent of
Periodontal prosthesis in contemporary dentistry 199

the reduction and control of occlusal leverage and the Periodontal biotype perspectives
axial radicular transmission of occlusal load.
7. Reduction of horizontal overloading of the posterior According to Weisgold’s study, there are two major peri-
teeth may be greatly enhanced by shortening cusp odontal biotypes: thin-scalloped and thick-flat [24,25].
height. The occlusal design should provide a decrease in Their characteristics are as follows:
the height of bucco-lingual cuspal angulations and at the
same time present the proper form necessary to do the
Thin-scalloped
following:
a) permit the posterior teeth to stabilize the mandible
- distinct disparity between height of gingival margin on
in centric relation;
direct facial and height of gingival margin on the inter-
b) permit mandibular freedom of movement to and from
proximal surface
centric relation;
- delicate and friable soft-tissue curtain
c) prevent non-working interference (prevent non-
- underlying osseous form scalloped, dehiscences and
functional or balancing occlusal contact in lateral
fenestrations often present
jaw movement);
- small amount of attached masticatory mucosa (quanti-
d) prevent protrusive interference (prevent posterior
tative and qualitative)
occlusal contact in protrusive jaw movement); and,
- reacts to insult by recession
e) prevent parting of the anterior teeth during all
- subtle, diminutive convexities in cervical thirds of facial
mandibular glide patterns.
surfaces

Figure 3. a. Computer images of thin-scalloped type periodontium (A). B. Immediately after extraction of maxillary left central
incisor; C. 2 months post extraction (note loss of interproximal papillae); D. placement of fixture; E. crown on fixture (note “black
triangle”); F. attempt to hide black triangles by making a more square tooth form. (Reproduced with permission from Dr. Arnold
Weisgold [6]). b. Computer images of thick-flat type periodontium (A). B. Immediately after extraction of maxillary left central
incisor; C. 2 months post extraction (note interproximal papillae are intact); D. placement of fixture; E. crown on fixture.
(Reproduced with permission from Dr. Arnold Weisgold [7]).
200 C.-L.S. Liu

more complicated decision regarding when to execute the

Table 3 Salama et al. classification of predicted height of
implant surgery. Applying the periodontal prosthesis phi-
interdental papillae [9].
losophy, concepts, principles, and techniques to the
Class Restorative Proximity Vertical soft tissue implant-supported prosthesis provides clinicians with
environment limitations (mm) limitations (mm) guidelines for performing this type of procedure, and
1 Toothetooth 1.0 5.0 offers an alternative to using conventional periodontal
2 Toothepontic N/A 6.5 prostheses.
3 Ponticepontic N/A 6.0
4 Tootheimplant 1.5 4.5
5 Implantepontic N/A 5.5
Acknowledgement
6 Implanteimplant 3.0 3.5
This article is dedicated to the late Morton Amsterdam,
DDS, ScD, Leonard Abrams, DDS, Jay Seibert, DDS and Cyril
Evian DDS in Periodontics and Periodontal Prosthesis. The
- contact areas of adjacent teeth located toward the authors are grateful to Drs. Walter Cohen, Edward Rosen-
incisal or occlusal thirds berg, Louis Rose and Arnold Weisgold for their contributions
- teeth triangular in shape to this article. Courtesy and graph designed by Abram CC
- small contact areas of adjacent teeth faciolingually and Chang, DDS and Steven Liu DDS, DMD.
incisogingivally

References
Thick-flat
[1] Liu CL. The impact of osseointegrated implants as an adjunct
and alternative to conventional periodontal prosthesis. Comp
- not as great a disparity between height of gingival
Cont Educ Dent 2005;26:653e60.
margin on direct facial surface and height of gingival [2] Amsterdam M. Periodontal prosthesis. Twenty-five years in
margin on interproximal surface retrospect. Alpha Omegan 1974;67:8e52.
- denser, more fibrotic soft-tissue curtain [3] Ganeles J, Rose LR, Norkin FJ, Zfaz S. Immediate loading
- underlying osseous form is flatter and thicker implant dentistry strategies have their origins in periodontal
- large amount of attached masticatory mucosa (quanti- prosthesis. Clin Adv Periodontics 2013;3:79e87.
tative and qualitative) [4] Branemark PI, Hansson BO, Adell R, Breine U, Lindstrom L,
- reacts to insult by pocket depth Hallen O, et al. Osseointegrated implants in the treatment of
- more prominent, bulbous convexities in cervical thirds of the edentulous jaw. Experience from a 10-year period. Scan-
facial surfaces dinavian journal of plastic and reconstructive surgery. Sup-
plementum 1977;16:1e132.
- contact areas of adjacent teeth located more toward
[5] Roberts RA. A 24-year retrospective study of bone growth
the apical after implant placement. J Oral Implantol 2005;31:98e103.
- teeth more square in shape [6] Amsterdam M. Implants for the partially edentulous. Dent
- large contact areas of adjacent teeth faciolingually and Implant Update 1992;3:4e5.
incisogingivally [7] Amsterdam M, Weisgold AS. Periodontal prosthesis: a 50-year
perspective. Alpha Omegan (Millennium Issue) 2000;93:
The periodontal biotype not only affects the natural 23e30.
dentition, it will affect the esthetic result in an implant- [8] Amsterdam M. The diagnosis and prognosis of the advanced
supported prosthesis as well. periodontally involved dentition. J Calif Dent Assoc 1989;17:
In most cases when the patient has a thick-flat perio- 13e24.
[9] Salama H, Garber DA, Salama MA, Adar P, Rosenberg ES. Fifty
dontium, the papillae can be preserved. When the patient
years of interdisciplinary site development: lessons and
has the thin-scalloped periodontium, there is often papil- guidelines from periodontal prosthesis. J Esthet Dent 1998;10:
lary recession (Fig. 3) (Table 3). 149e56.
[10] Ricci G, Ricci A, Ricci C. Save the natural tooth or place an
implant? Three periodontal decisional criteria to perform a
Conclusion correct therapy. Int J Periodontics Restor Dent 2011;31:
29e37.
Four decades after Dr. Amsterdam’s monograph (since [11] Vaidyanathan TK, Vaidyanathan J. Recent advances in the
1974), the basic tenets associated with periodontal pros- theory and mechanism of adhesive resin bonding to dentin: a
thesis, interdisciplinary therapy continues to guide restor- critical review. Part B, Applied biomaterials. J Biomed Mater
ative and reconstructive efforts even as we move into the Res 2009;88:558e78.
new millennium. Combining the guidelines of periodontal [12] Strupp Jr WC. Crown & Bridge Update 1999;4(1):1e7.
prosthesis with implant dentistry can lead to predictable, [13] Melker DJ. The lost art of saving natural teeth that have been
severely compromised. Chairside Mag 2015;10:35e49.
beneficial, and efficient treatment, even for the most
[14] Grunder U, Gracis S, Capelli M. Influence of the 3-D bone-to-
difficult patients and circumstances. implant relationship on esthetics. Int J Periodontics Restor
The developments of osseointegrated titanium im- Dent 2005;25:113e9.
plants have led to the success of contemporary dentistry. [15] Gargiulo AW, Wentz FM, Orban B. Dimensions and relations of
Implant prosthesis give patients and dentists more options the dentogingival junction in humans. J Periodontol 1961;32:
in treatment planning; at the same time, it creates a 261e7.
Periodontal prosthesis in contemporary dentistry 201

[16] Baumgarten H, Chiche G. Diagnosis and evaluation of com- [22] Weinberg LA, Kruger B. A comparison of implant/prosthesis
plications and failures associated with osseointegrated im- loading with four clinical variables. Int J Prosthod 1995;8:
plants. Compend Contin Educ Dent 1995;16:814e23. 421e33.
[17] Tarnow DP, Magner AW, Fletcher P. The effect of the distance [23] Amsterdam M, Abrams L. Periodontal prosthesis. In:
from the contact point to the crest of bone on the presence or Goldman H, Cohen DW, editors. Periodontal therapy. 5th ed.
absence of the interproximal dental papilla. J Periodontol St. Louis: C.V. Mosby; 1973.
1992;63:995e6. [24] Becker W, Ochsenbein C, Tibbetts L, Becker BE. Alveolar bone
[18] Tarnow D, Elian N, Fletcher P, Froum S, Magner A, Cho SC, anatomic profiles as measured from dry skulls. Clinical rami-
et al. Vertical distance from the crest of bone to the height of fications. J Clin Periodontol 1997;24:727e31.
the interproximal papilla between adjacent implants. J [25] Weisgold AS. Contours of the full crown restoration. Alpha
Periodontol 2003;74:1785e8. Omegan 1977;70:77e89.
[19] Tarnow DP, Cho SC, Wallace SS. The effect of inter-implant
distance on the height of inter-implant bone crest. J Perio-
dontol 2000;71:546e9.
Appendix A. Supplementary data
[20] Amsterdam M, Abrams L. Periodontal prosthesis. In:
Goldman H, Cohen DW, editors. Periodontal therapy. 3rd ed. Supplementary data related to this article can be found at
St. Louis: C.V. Mosby; 1964. https://doi.org/10.1016/j.kjms.2018.01.008.
[21] Amsterdam M, Fox L. Provisional splinting-principles and
techniques. Dental Clin North Am 1959:73e99.