CLASSIC ARTICLE

Current theories of crown contour, margin placement, and pontic design

Curtis M. Becker, DDS, MSD,a and Wayne B. Kaldahl, DDSb University of Colorado, School of Dentistry, Denver, Colo, and University of Nebraska, School of Dentistry, Lincoln, Neb

ne of the prime goals of restorative therapy is to establish a physiologic periodontal climate and facilitate the maintenance of periodontal health. Crown contour, margin placement, and pontic design all affect periodontal health. This article reviews the current theories of all three of these.

CROWN CONTOUR
The contours for full and partial coverage restorations play a supportive role in establishing a favorable periodontal climate. Three prominent theories of crown contour have evolved: (1) ginvial protection, (2) muscle actions, and (3) access for oral hygiene.

Gingival protection theory

The gingival protection theory advocates that contours of cast restorations be designed to protect the marginal gingiva from mechanical injury (Fig. 1). The concept of protecting the gingiva has been with dentistry for many years.1,2 A number of dental anatomy textbooks,3,4 periodontal textbooks,5,6 and respected clinicians1,7,8 advocate the concept of gingival protection with little or no supporting scientic evidence. Statements in support of gingival protection appear to be primarily empirical. Wheeler9 has stated, The gingiva is apt to be stripped or pushed apically through lack of protection and consequent overstimulation. The axiom of gingival protection has become so ingrained in the dental literature and teaching that for years this concept was seldom challenged. Some dentists and laboratory personnel apparently have reasoned that, if a little gingival protection is good, then more is better. This theory and the increased use of full coverage veneer crowns have produced an era of overcontoured restorations. Wheeler9 has remarked that, when molars have curvatures in excess of normal, the gingiva will be overprotected and will suffer from lack of proper stimulation. Wheelers warning was based on protection of the gingiva.
Clinical Assistant Professor, Department of Restorative Dentistry, University of Colorado, School of Dentistry. b Assistant Professor, Department of Periodontics, University of Nebraska, School of Dentistry. Reprinted with permission from J Prosthet Dent 1981;45:268-77. J Prosthet Dent 2005;93:107-15.
a

Fig. 1. Double deecting contours have been advocated by some authors, allegedly to protect the marginal gingiva from mechanical injury.

The gingival protection theory has been defended primarily on the basis of three elements: protection of gingival margins, gingival stimulation, and self-cleansing contours.10 Protection of gingival margins. This concept implies that undercontouring of the clinical crown will cause deection of masticated food onto the gingival margin, forcing it into the sulcus, thus initiating gingivitis. This concept may have originated from the observation that interproximal food impaction occasionally can initiate acute inammation. However, numerous studies have demonstrated a cause-and-effect relationship between plaque and gingivitis,11-13 and in comparison, the interrelationship of periodontal disease and food impaction appears slight. Many authors14-17 have
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Fig. 2. The temporary crown on this molar has been missing for 8 weeks; in spite of the obvious lack of contour, there is no evidence of marginal inammation, food impaction, or gingival stripping.

Fig. 3. The evidence of plaque accumulation at the gingival one third of this patients teeth emphasizes that self-cleansing contours in this area are nonexistent, regardless of diet.

Fig. 4. Buccal and lingual contours of full and partial coverage cast restorations should be kept at to facilitate plaque control and maintain gingival health.

Fig. 5. The embrasure space with restorations such as these maxillary crowns should be kept open to allow access to the interproximal spaces for plaque control and for natural architecture of the interdental papilla.

reported situations where crowns or temporary xed partial dentures have been lost or removed for long periods of time with no apparent ill effects to the surrounding gingiva (Fig. 2). Schluger et al18 stated, in discussing crown contours, the so-called protective cervical bulge that hypothetically protects the human gingival crevice protects nothing but the microbial plaque. Koivumaa and Wennstrom19 studied the histologic effects of crown contour on human gingiva. They found that there was an increase in inammation adjacent to bulbous articial crowns but that properly contoured articial crowns exhibited no such increase at the adjacent gingiva. Perel,20 in studying dogs, cut Class V preparations 0.5 mm above the buccogingival crest. He then overcontoured some restorations and undercontoured other
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restorations. After 9 weeks, he found no clinical or histologic changes with the undercontoured restorations; but with the overcontoured restorations, he reported evidence of inammation and hyperplasia both clinically and histologically. Thus, there appears to be no evidence to support crown contours designed to protect the gingival margins. Gingival stimulation. This concept reasons that, as food is masticated, it will pass over the gingiva, stimulating it and causing increased keratinization of the epithelium. The keratinized epithelium would be more resistant to periodontal breakdown. Several authors21-24 have shown that the gingival margin is not in the path of masticated food. Even if the food passing over the teeth were to increase keratinization (there is little evidence to back this assumption),
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Fig. 6. Contacts between restored teeth should be kept at the incisal one third of the tooth to facilitate an accessible embrasure space. The anatomy from the contact area to the margin of the restoration should be at or concave (never convex).

Fig. 7. Contacts (C) between natural teeth are buccal to the central fossa (CF) except between molars. This allows space for the relatively large lingual papilla (P).

Theory of access for oral hygiene

This theory is based on the concept that plaque is the prime etiologic factor in caries30-32 and gingivitis.11,29,33 Thus crown contour should facilitate plaque removal, not hinder it.18 When crowns were overcontoured experimentally, 64.3% of the test sites demonstrated an increase in periodontal inammation. This was attributed to decreased access for oral hygiene.34 The four guidelines to contouring crowns with emphasis on access for oral hygiene will be described. Buccal and lingual contoursat, not fat! (Fig. 4). Numerous authors17,18,21,25 have demonstrated that plaque retention on the buccal and lingual surfaces occurs primarily at the infrabulge of the tooth. Reduction or elimination of the infrabulge would reduce plaque retention.18 Perel20 demonstrated that in actuality undercontouring may promote gingival health. Ramfjord,35 Yuodelis et al,17 and an increasing number of other authors have come to the realization that overcontouring is a greater periodontal hazard than undercontouring. The normal buccolingual contour of teeth without caries is quite at. Most authors who have studied normal tooth contours2-4,9,36,37 have reported that rarely is the buccolingual width of these teeth more than 1 mm wider than the cementoenamel junction (CEJ). Thus, a normal tooth at the buccocervical bulge is usually # 0.5 mm wider than the CEJ. Open embrasures. If plaque is a primary etiologic factor in gingivitis,18,33,38 then every effort should be made to allow easy access to the interproximal area for plaque control.18,35,39 Open embrasure spaces will allow for this easy access (Fig. 5). An overcontoured embrasure will reduce the space intended for the gingival papilla. The result is a broadening of the col area, causing pressure and irritation on the papilla. This also
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this stimulation would only occur at the buccal and lingual surfaces, leaving the interproximal tissues without proper stimulation. It appears that, under normal circumstances, the mechanics of mastication has very little effect on gingival health. Self-cleansing contours. This concept asserts that, as food passes over the tooth during mastication, the tooth will be cleansed. While certain prominent buccal and lingual surfaces of teeth do not accumulate plaque even in neglected mouths, numerous authors21,22,24 have shown that mastication does not remove plaque at the gingival margins of teeth. Neither does mastication have any effect on the progress of gingivitis.22 Thus, self-cleansing crown contours apparently are nonexistent at the gingival margins of the teeth (Fig. 3).

Muscle action theory

Morris15,16 was one of the rst to question the rationale of the gingival protection theory. He and others25-28 have suggested that overcontouring prevents the normal cleansing action of the musculature and allows food to stagnate in the overprotected sulcus. Lindhe and Wicen,22 Loe,11 and others29 have all demonstrated that, in the absence of oral hygiene, self-cleansing mechanisms do nothing to prevent gingivitis. Even if there were some cleansing of the buccal and lingual surfaces from muscle action, interpoximal cleansing still would be impossible. Some proponents of the gingival protection theory also concur with the muscle action theory.5,6,14,27,28 These authors strive for an intermediate design of crown contour which allows for both gingival protection and muscular action.
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Fig. 9. A cast restoration which utes into the furcation of a periodontally involved molar (A) can effectively reduce the triangular plaque trap region that results from restoring the original anatomy of the crown (B).

Fig. 8. Furcations should be beveled from the margin of the restoration to the occlusal surface. This reduces plaque traps created by the anatomy of the furcation region and facilitates plaque control. A, Mandibular crown contour of buccal furcation. B, Maxillary crown contours of lingual furcations.

inhibits effective oral hygiene.40,41 Several authors35,36,42-46 have suggested or implied that an interproximal space that is slightly larger than normal may be desirable since it provides adequate room for the gingival papilla and is a more accessible area to clean. Some authors5,42,43,47 have reported the fear of creating an environment which promotes lateral food impaction when open embrasures are employed. Townsend48 has observed that, even with grossly undercontoured, open embrasure spaces, lateral food impaction rarely occurs as long as interproximal tooth contacts are properly maintained. Several authors49-51 have demonstrated that the most effective method of interproximal plaque control in gingival recession is the use of an interproximal brush. When the interproximal brush is used, the space between two adjacent proximal surfaces must be wide enough to allow it to pass through with relative ease. Location of contact areas. Contacts should be high (directed incisally) (Fig. 6) and buccal in relation to the
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central fossa (except between maxillary rst and second molars) (Fig. 7). Several authors3,36,52,53 have demonstrated that the contact areas on natural teeth occur at the incisal one third of the tooth. Many agree that natural teeth are straight or slightly concave interproximally from the CEJ to the contact area.1,3,4,18 This tends to open the embrasure, particularly if the contact area is high (in the incisal direction). Many authors36,37,43,44,53 have pointed out that the contact area of all teeth, except between the maxillary rst and second molars, should be buccal to the central fossa. This creates a large lingual embrasure for optimum health of the lingual papilla. Hazen and Osborne45 have warned of the consequences of an oversized col resulting from broad (buccolingual) contacts. The col is a nonkeratinized area which is thought to be more susceptible to plaque. The broad contact produces a larger col, thereby leading to increased chance of inammation. Ramfjord35 recommends placement of contact areas as far occlusally as possible to facilitate access for interproximal plaque control. Furcations involvement. Furcations that have been exposed owing to loss of periodontal attachment should be uted or barreled out (Fig. 8). The concept of uting into molar furcations is based on the desire to eliminate plaque traps and facilitate plaque control.18 Yuodelis et al,17 in discussing molar furcations, warn that the nal restoration should not follow the anatomy of the original clinical crown but should be an extension of the contours of the periodontally exposed roots. When this approach is properly executed, the triangular
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Fig. 10. Supragingival margins generally provide a more favorable environment to resist disease than subgingival margins.

Fig. 11. Ridge-lap pontics can create gingival inammation, bleeding, and severe discomfort.

Fig. 12. A, Diagram of modied ridge-lap pontic design for posterior teeth. Note that the pontic does not contact the tissues lingual to the crest of the ridge. B, The modied ridge-lap pontic (rst molar). Note the open embrasures, minimal tissue contact, and gingival health.

region that is created by the roots and the cervicular bulge is eliminated (Fig. 9). This triangular region is the most difcult area to maintain in a plaque-free condition with conventional brushing techniques. We have found that by recontouring the furcation to eliminate the triangle, plaque control with normal brushing is greatly facilitated (Fig. 8).

MARGIN PLACEMENT
The concept of subgingival margins is a natural outgrowth of G. V. Blacks54 extension for prevention and the caries-free zone. Locations for marginal placement for cast restorations have included: (1) the base of the gingival crevice55; (2) half the distance between the base of the gingival crevice and the gingival margin56; (3) slightly below the gingival margin25,41; (4) the crest of the gingival margin57; and (5) supragingivally.14,18,58,59 With each of these margin locations, the authors have reported clinically healthy periodontal
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tissues when quality restorations were combined with effective plaque control. As early as 1941, Orban60 proposed supragingival margins for improved periodontal health. Orban60 and other researchers61,62 discovered that the caries-free or clean subgingival zone, which had been observed previously on extracted teeth, was nothing more than the location of the epithelial attachment. This epithelial attachment will not attach to the margin of a cast restoration. Thus the concept of routine subgingival margins was questioned as more scientic evidence appeared (Fig. 10). Plaque accumulation, inammation, and gingivitis are reported to occur more frequently in teeth with subgingival crown margins than in those with supragingival margins.18,57,59,63-69 Oral hygiene instructions do not seem to alter this pattern.23,66,70 Few incidences of new caries associated with supragingival margins have been reported because of improved access for plaque control.69 Christensen71 has
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Fig. 13. A, Diagram of ridge-lap facing pontic design for anterior teeth. Note that the pontic does not contact the tissue lingual to the crest of the ridge. B, The ridge-lap facing pontic (left lateral). Note the open embrasures, minimal tissue contact, and gingival health.

Fig. 14. The cusp tip-to-cusp tip width of a posterior pontic (P) should be the same width as the original missing tooth.

demonstrated that the visually accessible margin (supragingival) can be, and is, tted more accurately than the visually inaccessible margin (subgingival). Based on these and other ndings,18,72-76 subgingival margins should be avoided except for the following specic situations: (1) esthetic demands, (2) caries removal, (3) subgingival tooth fracture, (4) to cover existing subgingival restorations, (5) to gain needed crown length, and (6) to provide a more favorable crown contour (that is, furcation involvement).

PONTIC DESIGN
The design of pontics for xed partial dentures has been clouded by empirical judgment. The so-called sanitary pontic is not new to dentistry.5,77,78 The bullet-shaped pontic has been advocated by some authors5,78,79 as a desirable design to reduce food accumulation. Nearly all authors agree that the ridge-lap pontic is undesirable from the point of view of tissue health (Fig. 11).
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Fig. 15. A, The embrasure space between two adjacent pontics can be closed to gain strength and reduce plaque accumulation. B, Closing the embrasure between two adjacent pontics does not affect esthetics. Note that the embrasures are kept open next to the abutment teeth to facilitate access for oral hygiene.

Numerous investigators7,51,80,81 have reported that inammation of the edentulous mucosa adjacent to pontics is probably a response to plaque accumulation
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Fig. 16. A, Modication (m) of tooth preparation to allow for placement of attachment system within the normal contour of the tooth. B, Castings with precision attachments for patient in Fig. 15, a. Note the open embrasures, high contacts, atnot-fat contours, and the intracoronal attachments are within the connes of the normal crown contour.

Fig. 17. The coping approach to reconstruction can be designed to facilitate the access for oral hygiene guidelines. A, Copings in place. B, Suprastructure cemented onto copings. Note the open embrasures, at buccolingual contours, and uted molar furcations.

on the surface of the pontics. Many authors5,78,82-88 feel that glazed porcelain is the material of choice for contact against the edentulous ridge. Other investigators7,81,87-89 have shown that there is no clinical or histologic difference in the response of the mucosa to pontics properly constructed of cast gold, acrylic resin, or glazed or unglazed porcelain. Steins81 classic article on pontic design was largely responsible for a change in philosophy from a sanitary or bullet-shaped design to what is now commonly called a modied ridge-lap design. The modied ridge-lap design in the posterior region (Fig. 12) and the ridge-lap facing design in the anterior region (Fig. 13) offer minimal tissue contact, acceptable cosmetic value, proper cheek support, and accessibility for adequate oral hygiene.14,18,44,81 It has now been established that the design of the pontic may be the most important factor in preventing inammatory reactions,81,89 not the material used in the pontic.
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In addition to properly designing the undersurface of pontics, it is imperative to open embrasure spaces adjacent to abutments to allow room for interproximal tissue and access for oral hygiene (Figs. 12 and 13, part B).15,18,61,78,90,91 The occlusal surface should not be narrowed arbitrarily18 since this may create a food impaction and/or plaque retention situation similar to that of mal posed teeth (Fig. 14).5,81 The embrasure space between two adjacent pontics usually is closed to provide added strength, reduce food and plaque retention, and facilitate oral hygiene procedures under pontic areas (Fig. 15).92 Basic guidelines for the access-for-oral-hygiene theory of crown contour, margin placement, and pontic design can be applied to nearly all xed restorative procedures. These guidelines apply to full porcelain coverage restorations (Figs. 12, B, 14, and 15, B), precision attachments (Fig. 16), and coping reconstructions (Fig. 17). Occasionally tooth preparations must be modied to allow for the added bulk needed for
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attachments, occlusal porcelain, and copings (Fig. 16, A). If proper tooth reduction is achieved, physiologic crown contours can be developed easily, regardless of the prosthesis being used.

SUMMARY
Crown contours which promote favorable tissue response follow these guidelines: (1) buccal and lingual contours are at; (2) embrasure spaces should be open; (3) contacts should be high (incisal one third) and buccal to the central fossa (except between rst and second molars); and (4) furcations should be uted or barreled out. Margins should be supragingival where possible. The pontic design of choice is the modied ridge lap for posterior spaces and the ridge-lap facing for anterior spaces.
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