Jounia} of Clinical Periodonlohgy 1982: 9: 409-414 Short Communication

Key words: Ahuliucui teeth - Hxcci hridi^cwork - pcriodtmiiil ns.\iit' .suppan.

Accepted ibr pLibliciUion June 1. 1981

The capacity of reduced periodontal tissues

to support fixed bridgework
SiuRi: NYMAN AND INGVAR EKICSSON

Department of Pciiodontology, Faculty of Odontology, University of Gothenburg, Gothenburg, Sweden

Abstiaci. The total area of periodontal ligament around the abutment teeth in 60 fixed bridges, inserted
in patients treated tor advanced periodontal disease, was calculated and compared with the total
"periodontal ligament area" ofthe teeth replaced by pontics. The calculations revealed that only in 8%
of the bridge restorations did the periodontal ligament area ofthe abtitment teeth equal or exceed that of
the replaced teeth. In 57% of the bridge material the periodontal ligament area ofthe abutments was less
than 50% ofthe anticipated normal ligament area ofthe ponties. Despite the fact that the periodontal
support for the restorations was dramatically reduced, all bridges have functioned properly for 8-11
years and the periodontal tissues around the abutment teeth have not sul fered further loss of attachment
during the period of maintenance care.

Frequently in cases of advanced periodoiital with principles presented in textbooks (Tylman

disease, in one or several parts ofthe dentition,
the destruction of the supporting tissues has
progressed to a level which calls for extraction
of several teeth. Following treatment of such
cases only a few teeth may remain, teeth which
do not only have a minimum of periodontal
tissue support left, but which also often show
signs of rnarkedly increased mobility. The re-
habilitation of this type of patients often in-
volves procedures such as splinting of the
remaining teeth, and/or prosthetic replacement
of lost teeth. As a rule, in a patient with
pronounced loss of periodontal support the
fixed bridge is to be preferred to the removable
partial denture, because the fixed bridge is more
rigid and may provide tnore favourable distri-
bution over the remaining periodontiimT ofthe
mastication forces than a removable partial
denture (Nyman & Lindhe 1979), However, the
use of teeth with stnall amounts of periodontal
tissue support as abutments for fixed bridge-
work is controversial and in obvious contlict
&Tylman 1960, Johnston et al, 1971,Tyltnian&
Malone 1978), Johnston et al, (1971) claitn that
the abutment teeth in a fixed bridge must not
only be favourably distributed in the dental
arch in relation to the extension of the bridge,
but, in addition, their crown-root ratio or
periodontal support should rneet the criteria
outlined in the so-called "Ante's law". Ante
(1926, 1936, 1938), in discussing the properties
required for abutment teeth of fixed bridge-
work, pointed out that "the combined perice-
niental area of the abutment teeth should be
equal to or greater in pericetnental area than the
tooth or teeth to be replaced".
Following tneasurements of a large number
of teeth, Jepsen (1963) specified (in square mm)
the average root surface area of the various
teeth in the hutnan dentition. The data reported
by Jepsen (1963) make it possible to calculate
the periodontal ligatnent area of trhe abutments
in a fixed bridge in a "periodontal case" after
assessments in radiographs of the height ofthe

0303-6979/82/050409-06 $02,50/0 «• 1982 Munksgaard, Copenhagen

410 NYMAN AND ERICSSON

remaining alveolar bone of the individual abut- "pericemental area" of the teeth replaced by
ment teeth. The calculated area of the remain- pontics.
ing periodontal ligament of the abutments can The aim of the present retrospective study
be related to and compared with the total was to compare the calculated size of the

PERIODONTAL LIGAMENT AREA (PLA)

Reduction of
Abutment Normal PLA bone height Remaining PLA Replaced Normal PLA
teeth (sq. mm) % (sq. mm) teeth (sq. mm)
46 352 30 246 45 135
43 159 70 48 44 130
33 159 50 80 42 124
35 135 60 54 41 103
Total 805 Total 428 31 103
32 124
34 130
Total 849

Fig. I. Radiographs obtained prior to treatment (top) and at the final examination (middle). Tooth 45 was
extracted, all other teeth were treated for periodontal disease and maintained as abutments for a fixed bridge
46-35. Calculations (bottom) of the area of remaining periodontal ligament of the abutment teeth in relation to
the "periodontal ligament area" ofthe teeth replaced by pontics. The periodontal ligament area of the abutments
represents 50% of the corresponding area of the replaced teeth.
Ronlgenstatus vor der Behandlung (obeti) und bei der absehliessenden Untersuelmng (Mitte). Der Zahn 45 wurde
extrahiert, alle anderen Zdhne wurden parodontal behandelt utid als Pfeilerzdhne ciner festen Briicke 46-35
erhalten. Die erreehnete Fldehe des verbliebenen parodontalen Stiitzgewebes (unten) wird itn Vergleich mit der
"parodontalen Stutzflaehe" der Zdhne angegeben. die bei den durch Briickenglieder ersetzten Zdhne vorgelegen
hdtte. Die Fldehe des parodontalen Stiitzgewebes der noch vorhandenen Briickenpfeiler betrdgt niir 50% der entspr.
Fldehe der ersetzten Zdhne.
Radiographies obtenues avant le traitement (au-dessus) et tors du dernier exatnen (au milieu). La dent 45 a etc
extiaite et toutes les autres dents ont ete traitees pour leur maladieparodontale et maintenues pour servir de piliers a
un bridge allant de la 46 d la 35. Caleuls (en-dessous) de I'aire du reste du ligament parodontal des dents piliers en
t elation avee l"'aire du ligament patodontaF des dents remplacees par le bridge. L'aire du ligantent parodontal des
dents piliers reprcsente 50% de l'aire eoriespondanle des dents remplaeees.
 REDUCED PERIODONTIUM AND FIXED BRIDGEWORK
periodontal ligament area of the abutment teeth
with the size of the anticipated normal perio-
dontal ligament area of the teeth replaced by
pontics in bridgework placed in patients treated
for advanced periodontal disease.
Material and Methods
The material consisted of 60 bridges, randomly
selected from a total of 332 bridges, placed in
251 patients who during the period 1969-1973
were treated for advanced periodontal disease
including prosthetic replacement of lost teeth.
The periodontal status of these patients im-
mediately after the active phase of treatment,
and 5 and 8 years after therapy, as well as a
detailed description of the therapeutic proce-
dures used have been reported previously
(Lindhe & Nyman 1975, Nyman & Lindhe
1979). Following the active phase of treatment
all patients were enrolled in a maintenance care
program which included recall appointments
for prophylaxis every 3-6 months.
The height of the alveolar bone around each
individual abutment tooth in the various bridges
was assessed in radiographs, obtained immedi-
ately after the completion of active treatment,
and was expressed as percentage of the length of
the root in accordance with the method de-
scribed by Bjorn et al. (1969). The area of the
remaining periodontal membrane of each abut-
ment tooth (in square mm) was calculated from
the figure given for the total root surface area of
the particular tooth by Jepsen (1963). The total
area of the supporting tissues of each individual
bridge was derived by adding the figures repre-
sentative of each abutment tooth. In addition,
the "normal periodontal ligament area" of the
teeth replaced by pontics was calculated. The
total area of the remaining periodontium
around the abutment teeth was finally expressed
as percentage of the periodontal ligament area
of the replaced teeth. The calculations described
are exemplified in Fig. 1.
In addition, alterations in the height of the
proximal alveoler bone of all abutment teeth.
411
which occurred during the observation period,
were assessed in radiographs in a periodic-
reproducible manner using a method described
by Eggen (1969). Individual mean Bone Scores
were calculated according to a technique used
by Bjorn et al. (1969).
The bridge material was divided into five
different groups with respect to the size of the
remaining periodontal ligament area of the
abutment teeth.
Analysis of variance was used for testing
alterations in alveolar bone height with time.
Results
The size of the area of the remaining periodon-
tal ligament of the abutment teeth, expressed as
the percentage of the periodontal ligament area
of the teeth replaced by pontics, is presented in
Fig. 2. In 12 out of the 60 bridges examined
(Group 1), the total periodontal ligament area
of the abutment teeth was less. than 25%
(16-24%) of the corresponding area of the
pontics. Only in five bridges out of the 60
bridges examined (Group 5) did the periodontal
ligament area of the abutment teeth equal or
exceed that of the teeth replaced (106-132%). In
22 bridges (Group 2) the area of the periodontal
ligament of the abutments represented 25-49%)
of that of the pontics and in 13 cases (Group 3)
the periodontal support was in the range 50-
74%. Eight bridge restorations (Group 4) had a
total area of periodontal ligament which a-
mounted to 75-99% of the corresponding area
of the replaced teeth.
The results of the measurements of altera-
tions in proximal alveolar bone height are also
given in Fig. 2. The data show that in all bridges
the bone height was maintained unchanged
during the entire observation period.
Discussion
The present study demonstrated that teeth with
periodontai tissue support, reduced far beyond
that which is generally accepted to be sufficient
412 NYMAN AND ERICSSON
NO OF BRIDGES
26-
20-
ABUTMENTS
f''-* PONTICS
16-
—
1 0-
6-
GROUP
<25
1 2
25-49 50-74
3
nn
75-99
4
>100
w criterion "the total area of periodotital ligament
^ BONE SCORE A
^M BONE SCORE B
BONE SCORE
Fig. 2. Number of bridges ranged in live dilTereiit
groups with respect to size of the total area of
periodontal ligament of the abutments as percentage
of corresponding area of the replaced teeth (top).
Bone height alterations during the observation
period in the five groups of bridgework (bottom).
Bone Score A = bone height (individual mean Bone
Score + s.d.) assessed immediately after bridge inser-
tion. Bone Score B = bone height (individual mean
Bone Score + s.d.) assessed at the final examination
(8-11 years alter treatment).
Die hier i}eurieilicn Biiicken. je nach Ausc/ehining cier
parodoniaien Sliiizflaclie der Pfeilcrzahne. in fiinf
Gruppen aufgegliederl - die Sliiizflachen werdm in
Prozent liererreclmelenSliiizflcichedererselzlenZliiine
angegeben (oben).
Die Verdnderungen der Knoelienlwhe in diesen fi'inj'
Probandengnippen wiiiirend der Beobaehiungszeii (un-
ten).
Knochen-Beuneiliingseinheii (Score) A = K'noe/ien-
hohe (individuelle miitlere Knoeiien Seore+s.d.) direi<l
nach der Briickeniniwrporaiion. Knociien-Beiirieil-
ungseinheit (Score) B= Knochenhohe (individiieile
miltlere Knochen Score + s.d.) bei der cibscljliessenden undue stress concentrations in the remaining
Untcrsuchung (8-11 .lahre naeh der Behandlung).
Nombre de bridge.^' repartis en cinq groupes dijfercnis
suivant la grandeur de I'aire toiaie dii liganwnt paro-
donlal des dents piliers en poiircenlage de ia zone
correspondanie des denis rentplacees (mi-dessiis).
Alli'raiioiis de la huiileur de i'os diirani la pcriode
d'observation dans ies cinq groupes de bridges (an
milieu).
Bone Score A = hauieur osscuse (score osseu.x nioyen
* individuelizs.d.) enregisiree immediatemeni apres I'in-
sertion du bridge. Bone Score B = hauieur osseuse
'score osseux moyen individuel+s.d.) enregistree lors
de I'exanwn final (H all ans apres le iraitentent).
5
as support for fixed bridgewori^ (e.g. Ante 1926,
Tylman & Tylman 1960, Smith 1961, Reynolds
1968, Johnston el al. 1971, Tylman & Malone
1978), can indeed be successfully used as abut-
ments. In the present material, only live bridges
(8%) out oi' the 60 cases examined were sup-
ported by abutment teeth which met the
should be equal to or exceed that of the teeth
replaced", i.e. fulfilled the detnands for perio-
dontal support outlined in Ante's law. In the
majority of the cases (57% of the total material)
the bridge restorations were supported by teeth
surrounded by a periodontium which was less
than 50% of that of tlie replaced teeth. Despite
the markedly reduced periodontal support,
however, all the bridges examined have func-
tioned for 8-11 years without further loss of
attachment around the abutment teeth (Figs. I,
2).
There are two important factors which may
explain the success of the treatment described.
One factor is the proper elimination of all
bacterial deposits from the teeth and the root
surfaces during the active phase of therapy,
supplemented with the maintenance of a denti-
tion free from gross deposits of .subgingival
plaque over the total observation period. These
procedures arrested the progressive, plaque
associated periodontal disease and prevented
recurrence of periodontitis (Nyman & Lindhe
1979). The second factor is the proper occlusal
design of the bridgework which precluded
periodontal tissues. For a detailed discussion
regarding the design of the occlusion the reader
is referred to previous publications by Nyman et
al. (1975) and Lindhe & Nyman (1977).
 REDUCED PERIODONTIUM AND FIXED BRIDGEWORK
The present study comprised a random selec-
tion of 60 bridge restorations out of a total
material of 332 bridges. It should be stressed
that at the re-examination ofthe patients after
5-8 years (Nyman & Lindhe 1979), none of the
patients had lost their bridgework as a result of
recurrent periodontitis or occlusal overload ol'
the reduced periodontium. Technical failures
had occurred, however, in 26 ofthe 332 bridges
(8% ofthe total material) during the observa-
tion period. These failures appeared as loss of
retention of retainer crowns from abutment
teeth (11 bridges, 3.3%), fracture of bridgework
(7 bridges, 2.1%), and fracture of abutment
teeth (8 bridges, 2.4%). Henee, the results ofthe
study by Nyman & Lindhe (1979) together with
the findings ofthe present retrospective analysis
show that the limitations for fixed bridgework
in patients with few abutment teeth and reduced
periodontal tissues around these teeth are re-
lated to the technical and biomechanieal prob-
lems involved in the fabrication of the bridges
rather than to the biological capacity of the
retnaining periodontium to support the btidges
successfully.
Zusammenfassung
Die Siiitzkapazitdt reduzierter parodontaler Cewebe
bei funktionetler Beanspruehung fester Biiieketi
Die desmodontale Gcsamtflache der Pfeilerziihne von
60 Briicken, die bei Patienten mit fortgeschrittenen
parodontalen Krankheiten eingegliedert worden
waren, wurde errechnet und mit der geschatzten
"desmodontalen Gesamtflache" der Zahne vergli-
chen, die durch Zwischen- oder freiscliwebende
Bruckenglieder ersetzt worden waren. Die Ergebnissc
zeigten, dass die desmodontale Gesamtniiche der
Pfeilerzahne bei nur 8% der mit Brucken behandelten
Fiille die erreehnete periodontale Ligamentllache der
dureh Zwischen- oder Freiendbruckenglieder er-
setzten Zahne erreichte oder uberstieg. In 57% des
untersuchten Briickenmateriales war die desmodon-
tale Gesamtflache der Pfeilerzahne um etwa 50%
geringer als die gcschiUzte Fliiclie des im Normalfall
vorhandenen periodontalcn Ligamentes dcr ersetzten
Zahne. Trotz oft dramatisch reduzierter parodontaler
Stiitzc funktionierten die hier beurteilten Brucken
8-11 Jahre nach ihrer Inkorporation ohne Komplika-
413
tionen. Weiterhin wurde wiihrend der Nachsorge-
periode kein weiterer Attachmcntvcrlust an den vor-
handenen parodontalen StCitzgcweben ihrer Pfeiler-
zahne festgestellt.
Resume
Capaeite des tissus parodontaux rcduits a supporter des
bridges
L'aire totale du ligament parodontal entourant les
dents piliers de 60 bridges insercs chez des patients
traites pour maladie parodontale avancec a etc cal-
culee ct comparee a l""aire totale du ligament paro-
dontal" des dents remplacees par les bridges. Les
caleuls ont rcvele que dans seulement 8% de ees
restaurations prothetiques l'aire de ligament paro-
dontal des dents piliers etait egale ou superieure a celle
des dents remplacees. Dans 57%) des cas, l'aire du
ligament parodontal des dents piliers etait infcrieure
a 50% de sa valeur initiale normale. Bien que le
support parodontal des restaurations ait eteenorme-
ment reduit, tous les bridges out fonctionne con-
venablemcnt pendant 8 a 11 ans et les tissus paro-
dontaux autour des dents piliers n'avaient pas accuse
de nouvelles pertes d'attache durant la periode de
maintenance.
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414 NYMAN AND ERICSSON

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