Journal of the International Academy of Periodontology 2015 17/4: 116–122

Clinical and Radiographic Evaluation of the

Periodontium with Biologic Width Invasion
by Overextending Restoration Margins
- A Pilot Study
Dhelfeson Willya Douglas de Oliveira1, Marina Natássia Pache-
co Maravilha2, Thaís Nascimento dos Anjos2, Patrícia Furtado
Gonçalves3, Olga Dumont Flecha3 and Prof. Karine Tavano3

1
Post-Graduate Program in Dentistry, Federal University of
Minas Gerais, Belo Horizonte - MG, Brazil; 2Private Practice,
Minas Gerais, Brazil; 3Department of Dentistry, Federal Univer-
sity of Jequiti and Mucuri Valleys, Diamantina - MG, Brazil

Abstract
Aim: The aim of this study was to correlate radiographic examination with the clinical
periodontal condition in cases of biologic width invasion by overextending restoration
margins in restored premolars and molars.
Materials and methods: The present pilot study involved nine people (mean age 32
years) with biologic width invasion by 21 surfaces overextending restoration margins
in restored premolars and molars. Radiographs were made in a standardized unit
using the interproximal technique and were evaluated by a single calibrated
investigator. The clinical periodontal parameters were analyzed with the use of
a computerized periodontal probe. Exploratory analysis and Spearman’s correlation
were used to perform statistical analyses (SPSS, p < 0.05).
Results: The most prevalent teeth with biologic width invasion were second
premolars and first molars. Mean plaque index was 30.76%, and bleeding on probing
was 27.0%. The mesial surface was invaded in 47.6% of cases and the distal surface in
52.4%. The 21 sites with biologic width invasion were found in patients with the following
periodontal status: periodontal health (11 sites), gingivitis (2 sites), mild periodontitis (7 sites)
and moderate periodontitis (1 site). There was a correlation between plaque index and
bleeding on probing with the horizontal component of the bone level.
Conclusions: There was correlation between the radiographic parameters of biologic
width invasion and clinical conditions. The measure of the bone crest level correlated
with the gingival recession. The horizontal component of bone defect correlated with
plaque index and bleeding on probing.

Key words: Biologic width invasion, radiography, pilot study

Introduction et al., 2013; Rosenberg et al., 1999). The dimension of

biologic width is not constant; it depends on the location
The periodontal biologic width is defined as the dimen-
of the tooth in the alveolus, varies from tooth to tooth
sion of the soft tissue that is attached to the portion of
and from surface to surface of a specific tooth. A clini-
the tooth coronal to the crest of the alveolar bone (Tomar
cally average dimension is 3 mm from the alveolar bone
crest up to the cementoenamel junction (CEJ) in healthy
conditions, or up to the margins of the restoration in
restored teeth. The average sulcal depth is 0.69 mm, the
Correspondence to: Dhelfeson Willya Douglas de Oliveira, average length of epithelial attachment is 0.97 mm, and
Federal University of Minas Gerais, Av. Antonio Carlos, 6.627, the average length of connective tissue attachment is 1.07
Pampulha, Belo Horizonte, Minas Gerais, Brazil, CEP 31270901; mm (Khuller and Sharma, 2009; Gargiulo et al., 1961).
Phone/Fax: +55 31 3409-2470, E-mail: [email protected]

© International Academy of Periodontology

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These distances allow the appropriate biologic width aim of this study was to correlate the radiographic
even when the restoration margins are placed 0.5 mm examination with the clinical periodontal condition
within the gingival sulcus (Nugala et al., 2012; Oh, 2010). in cases of periodontium with biologic width inva-
The existence of the biologic width is fundamental sion by overextending restoration margins in restored
to the insertion of the junctional epithelium and the premolars and molars.
connective tissue fibers to teeth, and these periodontal
structures should be respected during restorative pro- Materials and methods
cedures in order to preserve periodontal health (Jorgic-
This study was approved by the Research Ethics Com-
Srdjak et al., 2000; Makigusa, 2009). The placement of
mittee of the Federal University of Jequitinhonha and
a restoration margin seems to be of importance for
Mucuri Valleys (UFVJM; protocol #026/12). The study
periodontal health (Amiri-Jezeh et al., 2006). In addition
was conducted in accordance with the Declaration of
to the influence of several risk factors, the position of
Helsinki, 1975, revised in 2013.
the restoration margin may affect the initiation and pro-
The participants were diagnosed as periodontally
gression of periodontal diseases (Kosyfaki et al., 2010).
healthy or not in accordance with the American Academy
When the restoration margin levels are being evalu-
of Periodontology classification system for periodontal
ated with a periodontal probe and the patient feels dis-
diseases and conditions (Armitage, 1999). They were in-
comfort in the gingiva close to a restoration, it may be
formed about the purpose of the study, as well as benefits
suggestive that the margin extends into the attachment
and risks of participating in the research. Afterward, they
and that a biologic width invasion has occurred (Galgali
received and signed an informed consent form.
and Gontiya, 2011). The signs of invasion of the biolog-
The inclusion criteria of this study were patients
ic width are chronic progressive gingival inflammation
aged 18 years or more, in good general health, present-
around the restoration, bleeding on probing, localized
ing restored posterior teeth with biologic width invasion
gingival hyperplasia, gingival recession, pocket forma-
in the mesial or distal surface, diagnosed clinically and
tion, gingivitis and clinical attachment loss (Felippe et
radiographically. According to this criteria, 21 cases with
al., 2003). Gingival recession is more often found in thin
biologic width invasion were selected. The participants
periodontium and periodontal pockets are commonly
were of both genders, with dental records in the UFVJM
formed in thicker periodontium (Felippe et al., 2003).
dental clinic.
Interproximal radiographic examination can identify
Interproximal x-rays were used for the radiographic
interproximal biologic width invasion, and bitewing radi-
analysis. The radiographs were made in a single appli-
ographies are considered the ideal technique for a more
ance with a standardized time of 0.63 ms by the tech-
accurate assessment (Shobha et al., 2010). Biologic width
nique of parallelism and with the use of a holder aid.
violations can be corrected by either surgically removing
All patients were dressed according to the standard of
bone proximal to the restoration margin or orthodonti-
biosecurity. The film processing was performed with
cally extruding the tooth and thus moving the margin
the time/temperature method (Lannucci and Jansen,
away from the bone (Felippe et al., 2003; Khuller and
2011). This procedure was carried out by one trained
Sharma, 2009). In such cases, the clinical crown increases
researcher (TNA). The x-rays were assessed by another
and the biologic width is re-established. Then, biological
properly calibrated single researcher (MNPM). To im-
dimensions for connective tissue attachment, epithelial
prove image-viewing conditions, black masking was used
attachment and gingival sulcus are properly sized and
in order to act as an overlay on the areas outside of the
arranged around the tooth in order to physiologically
collimated exposure field.
keep the supracrestal distance [average 3 mm (Robbins,
Before the study began, the investigator (MNPM)
2007; Pontoriero and Carnevale, 2001)].
in charge of radiographic assessments was trained and
The suggested physiological function of the biologic
calibrated for intraexaminer repeatability. The examiner
width is that of a protective barrier for the subjacent
measured a set of randomly chosen radiographic sites
periodontal ligament and the supporting alveolar bone
twice, with an interval of 7 days between the measure-
from the attack of a pathogenic biofilm present in the
ments. The intraclass correlation coefficient was 0.98.
oral cavity (Bosshardt and Lang, 2005). Evidence from
Because there is no consensus in the literature for
a recent review suggests that a breach of the biologic
biologic width invasion determination, the diagnostic
width may have an impact on periodontal health by
method of this condition was based on a systematic
affecting the homeostasis of the periodontal tissues
review (Schmidt et al., 2013). Briefly, the attachment
(Schmidt et al., 2013).
level was measured by periodontal probing, and the
However, several views and/or data exist concern-
evaluation of the restoration margin and alveolar bone
ing the ideal dimensions of the biologic width, lead-
level was made by X-rays. The cut-point to determine
ing to difficulties with respect to the development of
biologic width invasion was a distance ≤ 3 mm between
clinical recommendations (Schmidt et al., 2013). The
the bone crest and the restoration margin (Figure 1).

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Figure 1. Interproximal radiography of biologic Figure 2 (Adapted from Parashis et al., 2012). Radiographic
width invasion by overextending margin restoration. parameters evaluated: intrabony component (yellow
line), bone crest level (blue line), bone defect level
(yellow + blue lines), horizontal component (red line).
The clinical parameters analyzed were:
1. plaque index (PI; Loe, 1967)
2. bleeding on probing (BP; Mühlemann and Son, In cases of intrabony defects, the following radio-
1972) graphic parameters were evaluated (Parashis et al., 2012):
3. probing depth (PD), determined by the distance 1. bone defect level (BDL), vertical distance from
from the gingival margin to the base of the gin- the CEJ to the base of the bone defect at which
gival sulcus clinically detectable and measured the periodontal ligament space appeared normal
with a computerized periodontal probe (Florida (Figure 2, yellow + blue lines)
Probe®, Gainesville, FL, USA) 2. bone crest level (BCL), vertical distance between
4. height of the gingival recession (HGR), which the CEJ and the bone crest (Figure 2, blue line)
is the distance from the CEJ to the apical exten- 3. intrabony component (INTRA), defined by
sion of the gingival margin. In cases of biologic subtracting BDL-BCL, i.e., the vertical distance
width invasion, the more apical extension of the from the bone crest to the base of the defect
restoration was used as a reference (Figure 2, yellow line)
5. clinical attachment level (CAL), given by the sum 4. horizontal component (HC), horizontal dis-
of the PD with the HRG; tance from the bone crest to the root surface
6. width of the gingival recession (WGR), given in a perpendicular line to the axis of the tooth
by the distance between the mesial and distal with biologic width invasion (Figure 2, red line).
gingival margins of the tooth with gingival reces-
sion (on a horizontal line tangential to the CEJ) As the present study used teeth with overextending
7. keratinized tissue height (KTH), which is the distance restorations, the more apical extension of the restora-
from the gingival margin to the mucogiengival line tion was used as a reference instead the CEJ. These
8. keratinized tissue thickness (KTT), measured measures were taken with a drypoint compass and
using a digital endodontic spreader (Dentsply, measured in millimeters with the aid of a caliper to two
Rio de Janeiro, RJ, Brazil) perpendicular to a decimal places, for greater precision and reliability. These
midpoint between the gingival margin and mu- measures (Figure 2, adapted from Parashis et al., 2012)
cogingival junction and through the soft tissue were obtained by a single researcher (MNPM), properly
with light pressure until a hard surface was felt. calibrated and trained.
The statistical analyses were conducted using the sta-
The HGR, WGR, KTH and KTT were determined tistical package SPSS® (Statistical Package for the Social
with manual probes and measured in millimeters on the Sciences Inc, IBM, Armonk, NY, USA) version 22.0.
buccal surface. The PI and BP parameters were analyzed Exploratory analysis of the data provided frequencies, aver-
throughout the oral cavity and were measured with a ages and standard deviations. The 95% confidence interval
computerized periodontal probe at six gingival sites: mesio- and 5% significance level were used. The evaluation of
buccal, mid-buccal, disto-buccal, mesio-lingual, mid-lingual, normality of the data was checked by the Shapiro-Wilk test.
and disto-lingual. The other variables were collected only Spearman’s rank correlation coefficient was used to verify
in regions that had invasion of the biologic width. the association between clinical and radiographic findings.

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Results The 21 sites with biologic width invasion were found

in patients with the following periodontal status: peri-
The sample consisted of 8 women (88.8%) and 1 man
odontal health (11 sites), gingivitis (2 sites), mild peri-
(11.2%), with an average age of 32.10 ± 1.65 years
odontitis (7 sites) and moderate periodontitis (1 site).
(range 29 to 34 years). The teeth with higher prevalence
Two teeth presented with mobility class I, correspond-
of biologic width invasion were second premolars and
ing to 9.5% of the teeth with biologic width invasion.
first molars, followed by first premolars, and the teeth
No teeth with biologic width invasion presented with
with lower prevalence were second molars (Table 1).
furcation defects.
The average plaque index was 30.76 ± 8.01%, and the
The correlation between the clinical and radiographic
bleeding on probing was 27.0 ± 7.0%.
findings is shown in Table 3. There was a significant posi-
In the teeth that showed biologic width invasion,
tive correlation between the plaque index and bleeding
the mesial surface was involved in 47.6% (n=10) and
on probing with the horizontal component, as well as
the distal surface in 52.4% (n=11) of the cases (Table
the height and width of the gingival recession with the
1). The radiographic findings are presented in Table 2.
bone crest level.

Table 1. Prevalence of biologic width invasion by Table 2. Average of the parameters related to the sites
tooth type and dental surface. probed (n = 21).
Parameter Total Parameters related to the sites probed Mean ± SD (mm)
N % Probing depth 2.23 ± 0.18
Tooth Clinical attachment level 2.23 ± 0.18
First pre-molar 3 14.3 Height of gingival recession 0.50 ± 0.18
Second pre-molar 8 38.1 Width of gingival recession 1.38 ± 0.52
First molar 8 38.1 Keratinized tissue height 4.85 ± 0.30
Second molar 2 9.5 Keratinized tissue thickness 1.40 ± 0.16
Surface Level of bone defect 2.81 ± 0.13
Mesial 10 47.6 Bone crest level 1.98 ± 0.08
Distal 11 52.4 Intrabony component 0.83 ± 0.10
Horizontal component 1.05 ± 0.15

Table 3. Spearman rank correlation coefficient (rs) of clinical and radiographic findings.

Clinical parameters Radiographic parameters

Level of bone Bone crest Intrabony Horizontal
defect level component component
rs p rs p rs p rs p
Tooth 0.289 0.102 -0.078 0.369 0.289 0.102 -0.240 0.148
Site -0.182 0.215 0.103 0.329 -0.333 0.070 -0.356 0.057
Plaque index 0,150 0.258 -0.065 0.390 0.267 0.121 0.555 0.004*
Bleeding on probing 0.058 0.401 0.005 0.492 0.189 0.206 0.558 0.004*
Probing depth 0.261 0.127 0.096 0.339 0.100 0.333 0.291 0.101
Clinical attachment level 0.217 0.172 0.033 0.444 0.050 0.414 0.259 0.128
Height of gingival recession 0.198 0.195 0.393 0.039* 0.134 0.281 -0.272 0.117
Width of gingival revession 0.134 0.281 0.426 0.027* 0.032 0.445 -0.327 0.074
Keratinized tissue height 0.166 0.237 -0.096 0.339 0.336 0.068 0.176 0.223
Keratinized tissue thickness 0.151 0.257 -0.195 0.198 0.258 0.130 -0.097 0.337
Diagnosis -0.085 0.357 0.068 0.385 0.103 0.328 0.247 0.140
*Statistically significant correlation

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Discussion Moreover, the placement of slightly overextend-

ing restoration margins was shown to result in a
In daily practice, overextending margins of dental res-
change of the subgingival microbiota adjacent to the
torations are a problem frequently observed (Schätzle et
subgingival restoration, favoring the colonization of
al., 2001). Periodontal health is preserved by the correct
Gram-negative, strictly anaerobic rods (Schmidt et al.,
insertion of the junctional epithelium and the connec-
2013). It is suggested that the shift of the composition
tive tissue fibers to the tooth along the biologic width.
of the subgingival microbiota towards an increased
There are several studies focused on the relationship
proportion of periodontopathic microorganisms will
between periodontal tissues (clinically assessed) and
eventually lead to loss of periodontal support (Schätzle
overhanging prosthetic restorations; however, there is
et al., 2001).
a lack of knowledge about the relationship of clinical
Other possible parameters relating to adverse effects
periodontal parameters with radiographic findings in
of dental restorations on the supportive tissue have also
biological width invasion in posterior tooth sites. The
been identified in the literature (Valderhauge et al., 1993),
present research showed a correlation between the
such as the contour (Grosso et al., 1984), the surface
radiographic parameters of biologic width invasion
roughness of the crown or the cement (Sorensen, 1989),
and the clinical conditions, mainly the plaque index
and the time of restoration existence since its insertion
and bleeding on probing.
(Schätzle et al., 2001). To what extent these factors have
When the periodontium is disturbed by clinical
influenced the present results is unpredictable.
procedures and techniques such as cavity fillings, de-
Many studies describe the importance of radiograph-
finitive restorations, provisional restorations and dental
ic examination for diagnosis of biologic width violation.
impressions, tissues can respond with an inflamma-
However, a standard technique for such evaluation has
tory process, eventually followed by apical migration
not been established. In this study, the interproximal
of junctional epithelium and formation of pockets,
technique was used because there is less distortion when
if other factors favor biofilm formation. Excessive
compared to other techniques, and it allows a greater
inflammation of the periodontium usually leads to
approximation of reality when probe measurements are
gingival recession in free facial and interproximal
compared (Pimentel et al., 2006). The clinical examina-
surfaces (Sanavi et al., 1998). Gingival recession and
tion of dental restorations should be done in addition
inflammation were notably observed in this study.
to radiographic examination in order to raise the validity
The increase in the width and height components of
of the diagnostic of biologic width invasion.
gingival recession is correlated with increased bone
Studies in this area are important to the establish-
crest level.
ment of the diagnosis of biologic width invasion when
Measurements on the buccal surface were per-
there is a need for restoration procedures in posterior
formed because all periodontal tissues of the neigh-
teeth. Some factors are requisites for the success of
boring tooth may also be affected in cases of biologic
tooth restorations, including soft tissue integrity and
width invasion in the proximal surfaces (Albandar,
non-violation of the biologic width. Therefore, an un-
2002; Albandar et al., 1995). The inflammatory process
derstanding of the anatomy and physiology of gingival
in the mesial/distal surfaces probably spreads through-
tissue regarding the teeth and margins of restorations is
out surrounding tissues. Thus, signs of periodontal
necessary to achieve satisfactory mastication, aesthetics,
damage, such as gingival inflammation and gingival
and a healthy interface between the restoration and the
recession, occur at the free surfaces.
surrounding soft tissues (Sanavi et al., 1998; Sadan and
It has been accepted that overextending restorations
Adar, 1998).
promote gingivitis by promoting local accumulation of
The present results show that gingival inflammation
bacterial biofilm rather than resulting in mechanical ir-
and bone crest resorption are common findings in cases
ritation (Schätzle et al., 2001). In the present study, the
of restored posterior teeth with biologic width invasion.
high plaque index may be due to the plaque-retaining
Considering the natural history and etiopathogenesis of
properties of the rough surface areas brought into
periodontal disease (Tatakis and Kumar, 2005), it might
the gingival sulcus when indirect restorations were
suggest that in cases of posterior restored teeth the
cemented. This condition could potentially lead to
presence of intense bleeding and plaque accumulation
more severe gingival inflammation followed by peri-
lead to bone resorption and may cause interproximal
odontal destruction with increased pocket depth, loss
bone defects. The present study has corroborated the
of attachment and gingival recession (Schmidt et al.,
long-held concept that restorations placed below the
2013; Kosyfaki et al., 2010), increasing the vertical bone
gingival margin are detrimental to gingival health (Schät-
resorption and then raising the horizontal component.
zle et al., 2001). Clinicians should pay attention in these
It was not possible to correlate the findings of this
clinical conditions in order to prevent the evolution of
study with the literature, as the literature reported
bone loss.
studies using anterior teeth (Sadan and Adar, 1998).

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121

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