BIOLOGIC SHAPING (OPEN FLAP)

A Synopsis of the Precise Clinical Protocols

That Must Be Followed for Success in
Advanced Perio-Restorative Dentistry

The primary objective of biologic shaping is to provide the patient with

a restored case that is maintainable for the long term. This means
easy plaque removal around every abutment tooth. It also means
restorative margins that are not in violation of the biologic width and
root surfaces apical to the restorative margins that are extremely
smooth and devoid of imperfections which could lead to periodontal
breakdown due to plaque accumulation that could not easily be
removed. It also presupposes the dentist understands how to
distribute occlusal forces onto teeth that have appropriate bone
support through a thorough understanding of occlusal management of
compromised dentitions. It also presupposes the dentist understands
and can achieve the role of CR, VDO and the correct horizontal plane
of the case.

These protocols are critical and there are no short cuts to a successful
outcome. Not paying attention to the precise details in the protocols
will result in a severe compromise for the patient and at best a short
term success. If a restorative dentist and periodontist follow these
protocols exactly, many teeth that would be extracted for implant or
bridge placement can be easily saved for decades. Before starting on
the road to biologic shaping it is critical for both the restorative dentist
and the periodontist to understand what caused the periodontal
pathology with which the patient presented. The cause is usually
simple…plaque accumulates and causes inflammation which in turn
causes deterioration of the soft tissues and subsequently loss of bone.
The degree of destruction is primarily host dependent. Therefore the
need for the patient to understand their role in plaque control to
interrupt the disease process is mandatory. Compliance in
performing plaque control likewise is mandatory. If patients will not or
cannot adequately control plaque (plaque score of <20%?) then they
are not candidates for any type of periodontal surgery especially
where biologic shaping is concerned. Continued plaque control and 3
month recalls for effective supportive periodontal therapy is
fundamental to long term success after the final restorations are
placed.

Danny Melker and I developed and evolved these protocols over 35

years working together using trial and error methods to modify and
improve the clinical outcome of cases. The basic biologic principles
upon which these protocols are predicated have not changed. The
technique has evolved however because of innovations in dental
materials and bonding protocols. We debated and challenged each
other over these protocols because the "periodontist did not
understand the restorative dentist's needs and the restorative dentist
did not understand the periodontist's needs" when we started treating
cases with this protocol. It was only when we gained a mutual
appreciation, understanding and respect for each other's needs that
the protocol of biologic shaping as an adjunct to advanced perio-
restorative dentistry began to become the predictable and preferred
method to manage teeth that have been compromised by periodontal
disease. Although the protocols were established for cases that
required splinting, we have evolved our diagnosis and treatment
planning to eliminate the need for bridges and splinted cases. Almost
all natural teeth are now restored as single units with implant
restorations used to replace missing teeth.

Dentin bonding became a reality in the early 1980's which was a

major breakthrough in the biologic shaping protocol because resin
composite core buildups could be used to replace all decayed or
missing tooth structure. Core buildups could be bonded to dentin
without contamination from blood, serum or saliva even in deep
subgingival zones without the use of a rubber dam. The presence of a
hermetically sealed buildup allowed the periodontist to avoid needless
bone destruction chasing the fallacy of the ferrule effect. The core
buildup is considered the mechanical equivalent to dentin from the
restorative perspective and no ferrule is required therefore the
periodontist did not need to weaken the tooth by removing bone to
achieve it. The most apical interface where the core buildup meets
sound tooth structure thus marked the apico-coronal level of where a
new margin would be placed after healing. Margin placement of no
more than 0.1 mm apical to the core buildup is perfectly acceptable.
Needless removal of bone was avoided because of these
developments. The core/tooth interface guides the periodontist to
accomplish surgery to appropriately provide sound tooth structure at
the gingival crest by delineating a precise point for the new margin
and showing exactly how much space is necessary for the biologic
width. Because of this there was less pulp pathology and more
stability for teeth that were managed with the biologic shaping protocol
as opposed to classical "crown lengthening" surgeries where bone
had to be removed. Understanding the benefits of biologic shaping,
which are varied and many, is fundamental to understanding the
protocols. Each benefit must be kept in mind as the protocol is
followed.

The simplified outline that follows is a synopsis of the biologic shaping

protocol which has been developed, tested and validated for over 35
years of clinical use:

1) The Restorative Dentist and the Periodontist: Diagnosis and

treatment planning and communication of the restorative and surgical
treatment plans (full coverage vs. partial coverage, grafts, biologic
shaping, extraction, implant placement, etc.). Long term
provisionalization with partial coverage preps on anterior teeth is
difficult and fraught with clinical complications and therefore should be
avoided.

2) The Restorative Dentist: Preventive dentistry protocols for the

patient (home care techniques, Pure 4% CHG scrubs, proof of
proficiency in home care protocols).

3) The Restorative Dentist: Surgical provisionals and core buildups as

required by the periodontist (properly fabricated, segmented and
cemented with Durelon). The periodontist must be definitive in a
request on where to place surgical provisionals. It is not the decision
of the restorative dentist to tell the periodontist where surgical
provisionals should be placed. It is important the surgical provisionals
be made in small segments as opposed to 14 splinted units. Posterior
quadrants are usually divided into 2 segments (bicuspids together and
molars together). Anterior segments can be divided into 2 or 3
segments (for 2 segments: cuspid, lateral, central...cuspid, lateral,
central. For 3 segments: cuspid, lateral...central, central...cuspid,
lateral) This allows easy removal by
the periodontist without stress on weak teeth with large core buildups.
Proper management of endodontically treated teeth is done just prior
to this phase. The use of posts is avoided wherever possible.

4) Heal 2 weeks: This allows soft tissue healing and pulps to settle
down before biologic shaping surgery.

5) The Periodontist: Gentle removal of the surgical provisionals is

done by rocking the surgical provisionals with mosquito hemostats to
microfracture the Durelon cement. Surgery with biologic shaping, root
surface smoothing and grafting, open tubule management,
modification of surgical provisionals to allow healing, re-cementation
with Durelon, instructions in home care and use of fluoride as well as
other meds to minimize sensitivity, infection and surgical discomfort. It
is imperative that the margins of the existing provisionals be changed
by the Periodontist to allow a 1.0-2.0 mm space
between the provisional margin and the tissue. This will prevent any
irritation by the provisionals and also allow for the uptake of the
fluorides used post surgically on the reshaped root surfaces. Home
care instructions include the daily use of 0.2% CHG and Prevident.
0.2% CHG is used a minimum of 4 times daily, rinsing for 1 minute
and expectorating. Prevident is placed on the teeth then expectorated
2-3 times daily.

6) The Restorative Dentist and/or the Periodontist: Surgical follow-up

with weekly plaque removal and Pure 4% CHG scrubs. The patient is
allowed to brush after two weeks and then sensitive root surfaces can
be treated with fluoride varnish. Varnish must be removed 4 hours
later as it will become sticky and actually attract plaque accumulation.
Suture removal as required by the surgical technique used.
7) Heal 4 weeks after surgery.

8) The Restorative Dentist: Remake provisionals with supragingival

margins (1.0-2.0 mm), smooth root surfaces with silicon polishers,
open tubule management, evaluation for surgical success especially
in the cosmetic zone and cement provisionals with Durelon. It is
paramount that the provisionals be placed at least 1.0mm short of the
gingival collar to allow for the continued coronal migration of the
biologic width. It is also
critical that no preparation of the teeth be undertaken at this time as
the new biologic width will not be established for at least 3 more
months and the apico/coronal position of a new margin cannot be
established until appropriate healing has occurred. If the desired
cosmetic gingival results were not achieved the patient is seen by the
periodontist for a follow-up surgery to achieve appropriate results.

9) The Restorative Dentist: Monthly doctor checks are done for 3 more
months to evaluate healing, sensitivity, pulp health, occlusion and
home care. Pure 4% CHG scrubs, which vastly improve the healing
process, are done at these appointments.

10) The Restorative Dentist: Four months after surgery and 2 days
before the final preps perform a Pure 4% CHG scrub.

11) The Restorative Dentist: Final preparations, margination, margin

design (0.3-0.5 mm chamfer is the preferred design), cosmetic needs,
impressions, provisionals, bite records, photographs, opposing model.
Because the previous margin was removed by biologic shaping, the
restorative dentist can place a new margin just coronal to the gingival
crest.
Frequently this new margin is coronal to the original margin which may
have been in violation of the biologic width. There are occasions
where the core
buildup/sound tooth interface is quite subgingival. If this occurs it is
perfectly acceptable to place the final margin of the restoration on the
core buildup. This presupposes the core buildup was done without
contamination and that it was smoothed to perfection during the
surgical phase. Silicon polishes accomplish this nicely.

12) Heal 1 week

13) The Restorative Dentist: Cement removal, Pure 4% CHG scrub,

home care instructions, cosmetic evaluation, photos, model of
provisionals, input to lab, verification of shade, occlusal force
distribution and other final decisions about every aspect of the
laboratory case.

14) Heal 3 weeks.

15) The Restorative Dentist: 2 days before cementation perform a

Pure 4% CHG scrub.

16) The Restorative Dentist: Cement the final case with resin cement.

17) Heal 1 week.

18) The Restorative Dentist: Post-cementation protocol to evaluate

success and request referrals.

BIOLOGIC SHAPING (CLOSED FLAP)

1. Remove all decay/fractured tooth structure

2. Isolate and control hemorrhage.
3. Place core buildups
4. Use G-80 or G-100 [Pollard] diamonds to biologically shape the
teeth. Then polish with composite polishing points and cups.
Silicone polishers are also used to highly polish the prepared root
surface and core buildup.
5. Control hemorrhage and make a VPS impressions
 6. Pour impression in Snap Stone [Whip Mix].
7. Fabricate provisionals with margins finished 1.0-2.0 mm
supragingival.
8. Scrub STAT using Pure 4% CHG [Best Buy] and every week for
at least 6 weeks.
7. Final prep with margins placed at (not below) the tissue level.
8. Make VPS impression for the final restorations.

ADVANTAGES OF BIOLOGIC SHAPING

1. Existing margins within the biologic width can be removed, thereby

creating minimal bone morbidity.
2. A smooth and flat biologic surface facilitates maximum maintenance
by the patient. Dental floss works on a smooth, flat surface and not
an irregular surface such as a mesial concavity of an upper first
bicuspid.
3. Smooth and flat root surfaces facilitate a better opportunity for the
hygienist to clean a root surface since the curettes will conform to a
root surface that is smooth without concavities and developmental
grooves.
4. By removing the CEJ through biologic shaping, the hygienist has a
better ability to use a curette to smooth the surfaces, since again
there is no irregularity.
5. By shaping the tooth, the biologic width can reform to it’ biologic
position on the tooth reshaped. The restorative dentist has the
ability to place the margin wherever the biologic width heals to.
Many times this is coronal to the preexisting margin of the old
crown.
6. Where previous margins ended in furcation areas, concavities or in
developmental grooves, these areas no longer exist after shaping,
thus allowing the restorative dentist to place a margin wherever he
wishes.
7. Since decay usually attacks from an apical position on the portion of
the tooth that is external and works its way internally in a coronal
direction, by shaping the existing area where a core buildup has
been placed, we can often move the location in a coronal direction
of the preexisting margin. This allows for less bone morbidity where
previous caries was a factor in the violation of the biologic width. (It
is important to understand how previous restorations were prepared
related to amalgams. The box area that was placed on the mesial
or distal root surface was always apical to the preparation on the
floor of the tooth. By shaping the box area the old location of the
margin again moves in a coronal direction.)
8. When taking impressions for final restorative cases, there is often
an inability to get an ideal impression where there are
developmental grooves. (Developmental grooves are very sharp
angles in the root surface.) Also, in casting a restoration to these
grooves, there are many times when voids remain. Cement fills the
space and the crown is seated. By shaping the tooth, there are no
longer developmental grooves and the root surface is very
receptive to an impression. The final crown will fit ideally in these
areas since the impression was perfect.
9. If the previous location of an existing margin is in the biologic width
interproximally, this will require excessive osseous recontouring on
the buccal and lingual to create a parabolic architecture. By
shaping the existing margin and removing the location, we greatly
reduce the morbidity of bone necessary to create the space for
biologic width.
10. By doing less aggressive osseous surgery and more shaping of
teeth, mobility can be greatly reduced.
11. Cosmetically, we do not end up with long teeth where excessive
bone has been removed.
 THE ENTIRE STORY OF BIOLOGIC
SHAPING

1. Traditional crown lengthening moves the bone away from the

margin. Biologic shaping moves the margin away from the bone.
2. Traditional crown lengthening usually requires osseous to re-
establish biologic width. Biologic shaping may require some
osseous, but generally avoids major osseous and still re-
establishes the biologic width. This is so because YOU have the
choice where to place your margin coronally to the old dentistry
3. Traditional crown lengthening would have opened up the above
furcation and rendered a poor prognosis. Biologic shaping
preserves the integrity of the furcation area because the aggressive
osseous was not needed.
4. Traditional crown lengthening does not eliminate flutes, concavities
and root clefts, leaving the post crown lengthened tooth at risk for
recurrence due to increased areas of plaque and calculus to harbor.
Biologic shaping leaves the subgingival areas smooth as glass. No
area for calculus to hide.
5. Traditional crown lengthening worsens crown to root ratio. Biologic
shaping maintains and even reverses and enhances crown to root
ratio.
6. Traditional perio is about pockets and probing. Biologic shaping is
about preserving bone, smoothing out the rough spots, making
restorative dentistry a joy and predictable.
So, there were questions about the protocol.

1. Remove old dentistry and caries, place cores and temporize.

2. Have periodontist root reshape and eliminate entire old margin.
Replace temps with no reline. Desensitize.
3. Four weeks post op, reline 1-1.5 mm shy of tissue. There is no
margin on tooth. Just pick a spot and fabricate the margin to it.
4. 8-12 weeks more or total of 12-16 weeks, re marginate with light
chamfer, place 1 cord, close your eyes and impress.

SEALING A PREPARED TOOTH

The purpose of sealing a prepared tooth is to:

a. Decrease dentin permeability by sealing the dentinal tubules
b. Kill bacteria
c. Prevent saliva from contacting open dentinal tubules
d. Decrease chemical insults from various dental materials
The following “sealing” procedure is done immediately after cementation
with provisional or definitive cements and after any filling is placed.
1. Scrub the root surface thoroughly (15 seconds to 1 minute) with Pure 4%
CHG [Best Buy Discount Dental Supply]. Scrub all teeth, gums, cheeks,
palate and tongue with an end tuft toothbrush [Butler] and water spray.
2. Control hemorrhage with Hemodent [Premier] in a 3-cc syringe [Best Buy
Discount Dental Supply] with an Inspiral Brush Tip [Ultradent]. Rinse.
3. Scrub for 15 seconds with Pure 4% CHG [Best Buy Discount Dental
Supply] from a 3-cc syringe [Best Buy Discount Dental Supply] with an
Inspiral Brush Tip [Ultradent]. Rinse.
4. Scrub for 15 seconds with Tubulicid Blue [Temerex] from a 3-cc syringe
[Best Buy Discount Dental Supply] with a Blue Mini Dento Infusor Tip
[Ultradent]. Rinse.
5. Scrub for 15 seconds with NaOCl [Clorox] from a 3-cc syringe with an
Inspiral Brush Tip [Ultradent]. Rinse. Dry.
6. Apply Super Seal [Best Buy Discount Dental Supply] for 30 seconds. Dry
the treated tooth surfaces before rinsing.
For perio surgery cases requiring provisionals prior to surgery, the
tooth is sealed:
a. BEFORE and after cementation of the surgical provisionals made by the
restorative dentist’s office.
b. AFTER perio surgery, before cementation and after cementation of
provisionals by the periodontist’s office.
c. BEFORE and after cementation of new provisionals remade four weeks
after surgery by the restorative dentist’s office.
d. AFTER cementation of the final provisionals.
e. AFTER cement curettage if any sensitivity is present.
For crown & bridge cases without periodontal surgery a tooth is
sealed:
a. Immediately after cementation of the provisional.
b. After cementation of the final restorations.
NOTE: Teethmate Desensitizer [Kuraray] is used for any sensitivity post
operatively. It works on non restored teeth excellently well to eliminate
sensitivity.

DESENSITIZING TREATMENTS AFTER

PERIODONTAL SURGERY

DESENSITIZERS:

1. Prednisilone Acetate Ophthalmic Suspension USP 1%

2. Super Seal Dental Desensitizer Liner
3. Prevident Gel (1.1% sodium fluoride)
4. Prevident Varnish (Vanish) 5% fluoride
5. Colgate Sensitive Pro-Relief desensitizing paste
6. 3M Cavity Shield 5% sodium fluoride
7. Sultan Topex in-office fluoride rinse
8. Teethmate Desensitizer [Kuraray]

DESENSITIZING TREATMENTS SURGERY:

Super Seal is used after suturing. Teeth must be dry and one drop is
placed on each tooth and lightly air blow dry after 30-40 seconds –
repeat 3 to 4 times. If the teeth have been severely barreled into the
furcation, a drop of Prednisilone 1% is also placed on the teeth.
Patient is given Prevident Gel 1.1% sodium fluoride to rinse with at
home twice daily.

WEEK 1:

Patient is scaled with a Universal implant scaler (double end) because

it is made with plastic and more comfortable for the Patient.
Patient is polished with Colgate Sensitive Pro-Relief desensitizing
paste – the wooden end of a cotton tipped applicator is used to spread
paste inter-proximally.
If Patient cannot brush, a drop of Prednisilone is placed on the teeth.
Patient rinses with Sultan Topex in-office fluoride rinse for 1 minute.
Patient is to keep rinsing 2x a day with Prevident Gel. Prevident Gel is
to be expectorated after use and they cannot eat, drink or rinse for 30
minutes after use.
If Patient is able to start brushing, a drop of Prednisilone is placed on
the teeth. Prevident Varnish or 3M Cavity Shield is placed on the
teeth. Patient is instructed to brush off in 4 hours with regular
toothpaste. Patient is to start brushing with Prevident Gel 2x a day for
1 minute after they have brushed with regular toothpaste. Prevident
Gel is to be expectorated after brushing and they cannot eat, drink or
rinse for 30 minutes after use.

FOLLOWING WEEKS:

All treatments are based on whether a Patient is allowed to brush or

not.
If Patient cannot brush, a drop of Prednisilone is placed on the teeth.
Patient is to keep rinsing 2x a day with Prevident Gel. Patient rinses
with Sultan Topex in-office fluoride rinse for 1 minute.
If Patient is able to start brushing, a drop of Prednisilone is placed on
the teeth. Prevident Varnish or 3M Cavity Shield is placed on the
teeth. Patient is instructed to brush off in 4 hours with regular
toothpaste. Patient is to start brushing with Prevident Gel 2x a day for
1 minute after they have brushed with regular toothpaste.
Treatments are continued until Patient is comfortable. Teethmate
Desensitizer [Kuraray] will eliminate 95% of the post-op sensitivity.
 Vertical Preps??

Carlo Poggio posted a video on Dental XP covering the Vertical

Preparation or BOPT concept. I wrote this email to him detailing the flaws
in his presentation.

Carlo,

The vertical prep protocol you covered in the video at Dental XP was well
done. You are an interesting speaker and there was a good deal of
interesting literature cited. The protocol was not covered in the detail
that I like to present when I do presentations but the general gist of it
was well presented. The presentation of so much about zirconia especially
layered zirconia was unusable for me since I rarely provide such
restorations. We almost exclusively do pressed e.max restorations which I
believe are less labor intensive to produce in my lab and provide superior
esthetic results. The studies you presented about marginal fit show results
that are unacceptable to me. Our protocol results in margins that fit at
less than 50 microns after cementation as verified with a sharp explorer. If
the margin can be felt with a sharp explorer it is greater than 50 microns.
My experience with milled restorations is that they fit poorly especially in
the barreled in furcations that we so frequently restore post perio surgery.
My background, starting in 1971, was in metal ceramics and cast gold
reconstructions post perio surgery. Before the advent of implants we
sectioned hundreds of teeth and kept isolated roots to support large rigidly
connected prostheses that often spanned 14 units. The perio-pros protocol
we (Danny Melker and I) started out using in the mid 70’s was the one
espoused by Skruow and Nevins as well as some of the protocols used by
Arne Lauritzen. It became readily apparent that the protocols were
substandard when looking at tissue results. The primary issues causing this
were relining the provisionals with a direct technique at 3 weeks post-
surgery coupled with additional margin preparation at the gingival crest. Not
only did this flaw lead to issues with “epithelial creepage”, as it was termed
in those days, the presence of a microleaking, microbial laden provisional
in the fresh wound delayed healing and left us with long junctional
epithelium zones that were not protective of the attachment apparatus from
microbial invasion. Danny was not placing subepithelial grafts at the time of
surgery in those days. The tissue would respond vehemently to the direct
use of acrylic resin monomer during the reline procedure. The tissue would
remain red and angry as the tissue re-grew coronally and the provisional
with the poor choice of provisional cement only aggravated the tissue.
Often the new margin created at reline of the provisional would actually
become in violation of the biologic width as the coronal growth of tissue
became exaggerated from Melker’s use of biologic shaping. Once the tooth
became smaller in diameter from the reshaping tissue would migrate
coronally like mad. I used this concept as a clinical technique in the final
restorations by doing rotary gingival curettage a la Rex Ingraham at the
final prep then grossly undercontouring the provisional to accommodate the
coronal “growth” of tissue as it became hyperplastic and grew into the
negative concavity of the provisional. I called this approach the theory of
“controlled gingival hyperplasia” and had myriad slides showing the results
with beautiful pink tissue. The results in thick tissue were awesome, in thin
tissue…not so much.

The following is an outline of the procedure we used then with the

approximate date of modification and changes we made over time. It is
important for you to understand that almost all of our cases were heroic
efforts to save teeth that had been previously restored with full coverage
restorations that were failing from caries and periodontal disease. I also
tried to explain the reasoning for our changes as I believe the changes we
made would be something that would make your vertical prep technique
superior in every way to what you are doing now thus bringing it into use
for less talented clinical dentists.
The evolution of the Danny Melker/Bill Strupp perio-restorative protocol mid
1970’s to the present day:

1) Diagnosis and treatment planning…decisions on hopeless teeth,

endodontic needs, need for splinting, need for removable appliances, need
for surgical provisionals cemented with Temp Bond with Eugenol. (With the
advent of implants we no longer splint teeth or make removable appliances.
All of our cases are done as single units with implants used to replace the
missing teeth. If teeth with excessive mobility do not stabilize during
treatment we remove them and place implants. We stopped using Temp
Bond with
Eugenol and went to Durelon for the provisional cement because of the
gross
micro-leakage and washout of the Temp Bond, which caused excessive
post-operative sensitivity. In addition, Durelon chemically reacted and
“bonded” to the tooth thus protecting the tubules from microbial invasion.
Durelon has zinc oxide in it and is antimicrobial up to the point that it is
broken down by plaque acids.)

2) Placement of surgical provisionals using no core buildups and using

a definitive chamfer prep on sound tooth structure in the subgingival zone
where pathology (caries, existing restorations) was present and a definitive
chamfer prep at the tissue levels in all other areas. (Once dentin bonding
became available in the late 70’s core buildups were done on every tooth.
Danny Melker started to biologically shape teeth early on in the use of this
protocol without my knowledge. He used enamel shavers and 12 fluted
carbides to do it. He did not tell me what he was doing. His clinical outcome
with the burs he was using was a hacked up, gouged out root surface that
was impossible upon which to place a decent margin. He finally fessed up
to what he was doing and I suggested a series of Vic Pollard diamonds in
varying grits with which to reshape the teeth. Once it was apparent he was
removing my definitive margin I stopped doing definitive margins and cut
the thinnest feather edge prep down to sound tooth structure that I could
cut. The diamond I used for this was the G100 or G80. This is the bur that I
think you should be using in your protocol because it was designed for Rex
Ingraham by Pollard to abrade rather than hack the tissue the way the burs
do that you use in your protocol. The results of doing this was the extreme
kindness of the diamond grit to the tissue and the resulting preservation of
large volumes of tooth structure that could then be reshaped to eliminate
the pathology that precipitated the periodontal disease in the first place,
e.g., calculus, rough CEJ’s, old margins, proximal concavities, roofs over
furcation involvements, root proximities, anatomical abnormalities, enamel
pearls, etc. He would follow his reshaping with minimal osseous contouring
to create a parabolic architecture. Because of the biologic shaping, much
less bone removal was required. Old margins did not determine the
apical/coronal position of the margin of the new crown which often would
become several mm coronal to the original margin and no longer in
violation of the biologic width. In the early days Danny did not use dentin
sealers to stop the sensitivity created by microbial invasion of the open
tubules which occurred at 5 days post-surgery when the microbes
produced enough acid to dissolve out the smear layer and open the
tubules. Patients were in agony from extreme sensitivity once the smear
layer disappeared. When he began to use SuperSeal the sensitivity issue
became better. Later he added 5 or 6 more dentin desensitizing agents that
made his surgeries dreaded much less.

In the early days he did not place sub-epithelial connective tissue grafts
but when he started to do that the tissue really became bullet proof. He
closed his surgeries by primary intention. He could do this because he
would take a split thickness flap thus preserving the periosteum to which he
could precisely position the tissue in the apical/coronal direction by suturing
to the periosteum. When he recemented the provisional he had to shorten
the gingival extent of it so it was completely above the soft tissue. If he left
it long the tissue almost always reacted poorly. If the provisional was
shortened to a level above the tissue, healing would occur that looked like
3 months instead of 4 weeks when the provisional was remade. There is a
biologic reason for this as the fibroblasts that differentiate into the
tissues that create a new connective tissue attachment are not being
influenced by microbes and a micro-leaking foreign body known as a
provisional)

3) Re-prepare the preps to the gingival line and direct reline of the
provisional at 3 weeks without re-contouring to shorten the margin out of
the tissue then re-cemented with Temp Bond with Eugenol. (The micro-
leakage of the provisionals due to the soluble cement was a real disaster
which was compounded by the provisional that extended under the tissue.
Directly relining the provisional annihilated the tissue. The chemical burn
that resulted from monomer contact was awful. It was painful for the patient
but really painful for me to look at the l month Dr. check. The raw
appearance of the tissue was compounded by the use of the acid soluble
Temp Bond. I quickly went to an indirect technique to completely remake
the provisional instead of intraoral relining and would do that at 4 weeks
instead of three.

In addition I would finish the margin of the provisional, without any more
preparation, of tooth structure 1-2 mm above the tissue level. Before
cementation with Durelon I would highly polish the accessible root surfaces
to a glass like finish then seal the tubules with SuperSeal both before and
after cementation. This protocol changed made a huge difference in the
comfort for the patient and the health of the tissue.
4) Final prep the case at 3 months post-surgery. Three months are
required for a new connective tissue attachment to form but at 3 months it
is not a mature attachment, i.e., one that could resist pressure from
retraction cord placement without risking damage to the newly formed
attachment. In addition if my new margin were to be placed subgingivally
the tissue needed to heal for a minimum of 6 months so as not to create
excessive tissue growth in a coronal direction. Many of the cases we did in
later years where I finished my margin above the tissue level at 4 months
post-surgery would wind up with subgingival margins of as much a 2 mm
some 10 years later as a result of “epithelial creepage”. A lot of this coronal
growth of tissue was related to the sub-epithelial connective tissue grafts
that Danny placed which added exceptional thickness. This coupled with
margins for the final restorations that fit at less than 50 microns and were
cemented with non-microleaking resin cement caused the tissue simply to
not know the crowns were there. The fallacy of subgingival cementation is
that moisture control cannot be done for more than a few seconds and the
only cement that works for that to not be an issue is Panavia.

5) Final placement of the case. (Since all margins were prepared at or

above the tissue except in the cosmetic zone, isolation was easy. (This
continues to be the case today with the newer all-ceramic materials like
e.max which allow partial coverage preps with equigingival margin designs
facially and never preparing the lingual surfaces of teeth that did not
already have full coverage restorations, pathology, or a need to change the
anterior envelope of function at an increase vertical dimension of
occlusion. Jason constantly presents cases where partial coverage would
have been a better choice yet he is using the vertical prep approach on
tooth structure that should never be prepared)

Approximately 10 years ago I started doing closed flap biologic shaping

with the aforementioned Pollard diamonds to avoid periodontal referral in
select cases. During that time I have completed several hundred cases in
every type of tissue imaginable. The protocol was designed to remove
pathology causing periodontal disease as mentioned above
as well as to avoid bone removal where caries extended to the bone. The
shortfalls of the protocol were attached gingiva could not be added at the
time of surgery and parabolic osseous shaping was not possible unless a
flap was taken. If such clinical conditions required correction referral to a
periodontist to take a flap would be necessary, however this could be done
after the biologic shaping was completed by the restorative dentist. The
steps in this protocol for when no osseous or soft tissue issues existed
were:

1) Remove the old dentistry and caries

2) Place a core buildup (even if caries extended to the crest of the
bone)
3) Use G80 and G100 diamonds to vertically prep the tooth 360 degrees
to the crest of the bone creating the thinnest feather edge possible while
mildly abrading the tissue with the Pollard diamond specifically designed
not to shred tissue
4) Polish all prepared tooth surfaces to a glossy glass like finish
5) Make an impression and fabricate a surgical provisional ending the
margin 1-2 mm above the tissue (this is where our protocols differ in that
you and Jason advocate making a provisional margin finish subgingivally
which creates the aforementioned “bamboo shoot under the fingernail”
condition that will not allow CT fibers in the biologic width to reattach
without microbial influence from the “bamboo shoot”
6) The provisional is cemented with Durelon after sealing the cut
tooth surfaces with SuperSeal. All cement must be removed
7) Immediately scrub the sulcus all the way to the bone with Pure 4%
CHG dispensed from a 3 cc syringe using an Inspiral Brush Tip
8) The patient is seen weekly thereafter for a minimum of 6 weeks for
Pure 4% CHG scrubs where all plaque must be removed from the
reshaped tooth
surface. On the first and second visits post operatively the “scab” formed
on the surface of the tissue is scrubbed away and any granulation tissue
that is hypertrophic is removed with a scaler. No plaque can be allowed to
remain attached to the cut tooth surface or the cut core buildup for longer
than one week. Each week all plaque must be removed. Aggressive home
care
must start within 2 or 3 days post operatively and interproximal brushing is
mandatory to prevent hypertrophy of tissue. Patients are virtually in no
pain with this approach
9) At 6 weeks a new margin can be prepared at the crest of the tissue
with no subgingival extension even if this margin ends on the core buildup.
If subgingival margination is required, 10-12 weeks of healing is preferred
but not completely mandatory

Your protocol requires the placement of a provisional

restoration into the newly created wound which in my opinion is simply the
wrong thing to do. If you let the tissue heal from your vertical prep in the
absence of the foreign body your clinical results would be better than the
current approach which you advocate. In addition, if you used a superior
shaped diamond with a less abusive grit which is designed to be kind to
tissue the patient would suffer less and the tissue would heal faster.
Furthermore, the use of the vertical prep technique when the tissue is
already perfect, as was the case that Jason presented, is costly to the
dentist, the patient and the tissue. The case he presented in my office
would have been completed with ease on one appointment with no need to
make a surgical provisional and allow the tissue to heal. He added
expense, time and unnecessary discomfort to the treatment. All in all it was
an inferior way of completing simple dentistry. In my opinion, the vertical
prep technique is useful for cases with periodontal pathology but it should
not be used as the standard approach for routine crown and bridge
dentistry.