journal of prosthodontic research 63 (2019) 415–420

Journal of Prosthodontic Research

Original article

Periodontal and prosthetic outcomes on teeth prepared with

biologically oriented preparation technique: a 4-year follow-up
prospective clinical study
Blanca Serra-Pastora , Ignazio Loib , Antonio Fons-Fontc, M. Fernanda Solá-Ruíza,c ,
Rubén Agustín-Panaderoa,*
a
Department of Stomatology, Faculty of Medicine and Dentistry, Valencia University, Valencia, Spain
b
Private Practice, Cagliari, Italy
c
Department of Dental Medicine, Faculty of Medicine and Dentistry, Valencia University, Valencia, Spain

A R T I C L E I N F O A B S T R A C T

Article history: Purpose: To evaluate the clinicaland biological behavior of full coverage restorations on teeth prepared
Received 24 July 2018 without finish line during a 4-year follow-up.
Received in revised form 15 March 2019 Methods: This prospective study included 149 teeth treated using biologically oriented preparation
Accepted 18 March 2019
technique (BOPT). The sample (149 teeth) was divided into two groups: Seventy four teeth restored with
Available online 8 April 2019
crowns, and 75 teeth supporting fixed partial dentures (FPD). Restorations were fabricated with
zirconium oxide cores and ceramic coverings. Patients attended regular annual check-ups when probe
Keywords:
depth, presence of inflammation with bleeding on probing, presence of plaque, gingival thickness,
BOPT
dental preparation
marginal stability, biological or mechanical complications, and the patient’s level of satisfaction were
dental crown registered over a 4-year follow-up.
zirconia Results: After the 4-year follow-up, 2.1% of teeth underwent increases in probing depth; 12% of the sample
periodontal health presented inflammation and bleeding on probing; 20% of the restored teeth presented plaque; gingival
thickening increased a 32.5%; 98.6% of teeth presented marginal stability; the restoration survival rate
was 96.6%, with 2% of biological complications and 1.4% of mechanical complications. General
satisfaction score was 80.73.
Conclusions: Restorations placed on teeth prepared using BOPT present good periodontal behavior,
increase of gingival thickening, and marginal stability over a 4-year follow-up. High survival rates after
4 years show that the technique produces predictable outcomes.
Clinical significance: The BOPT technique is a good treatment option in cases where replacement of an old
restoration is required; presenting good periodontal behavior, gingival thickening, and marginal stability.
© 2019 Japan Prosthodontic Society. Published by Elsevier Ltd. All rights reserved.

1. Introduction effects produced during dental preparation or as a result of poor

prosthetic fit; it will compromise esthetics, and so is particularly
A healthy relationship between dental restorations and the detrimental in the anterior region [3–8].
periodontium is of prime importance for the clinical longevity and Dental preparation for fixed prostheses can take various forms
esthetic harmony of full coverage restorations [1,2]. classified as horizontal preparation with a defined margin
One of the most common complications, derived from fixed (chamfer), or vertical, or feather-edge, without a margin/finish
prostheses is gingival recession, which constitutes an important line [6,9,10].
clinical concern. This problem is largely associated with iatrogenic Subgingival horizontal preparations have been conventionally
indicated in cases of aesthetic demand; however, they have been
related to adverse periodontal reactions, such as inflammation,
* Corresponding author at: Departamento de Prótesis, Facultad de Odontología, bleeding, deeper probing and recession [11–13].
Universidad de Valencia, Clínicas Odontológicas, Gascó Oliag 1, 46010, Valencia, Loi described in 2013 [6] the biologically oriented preparation
Spain.
technique (BOPT); which is a vertical preparation and consists of
E-mail addresses: [email protected] (B. Serra-Pastor),
[email protected] (I. Loi), [email protected] (A. Fons-Font), [email protected] the elimination of the cemento-enamel junction (CEJ) so that
(M. F. Solá-Ruíz), [email protected] (R. Agustín-Panadero). the prosthesis creates a new crown emergence that imitates the

https://doi.org/10.1016/j.jpor.2019.03.006
1883-1958/ © 2019 Japan Prosthodontic Society. Published by Elsevier Ltd. All rights reserved.
416 B. Serra-Pastor et al. / journal of prosthodontic research 63 (2019) 415–420

natural tooth [6,14–17]. According to clinical reports, [6,15–17], the

technique produces increases in gingival thickness and greater
stability of the gingival margin (less chance of suffering
recessions). In addition, vertical preparation is characterized by
being more conservative with dental structure (especially peri-
odontal teeth), taking impressions is easier (since it is a finish area
and not a defined line), and they are also associated with a good
marginal fit [18–20].
Unfortunately, there is insufficient scientific evidence in
support of BOPT, which highlights the need for medium- to
long-term longitudinal clinical trials.
Fig. 1. Prosthetic treatment needed to be replaced due to biological and esthetic
The aim of this study was to evaluate the clinical behavior over a problem.
four-year follow-up of restorations placed on teeth prepared
without finish line, monitoring periodontal status as well as the
prostheses themselves in order to assess stability and treatment
predictability.

2. Materials and methods

A patient sample was selected from among patients attending

the clinic at the Department of Stomatology, Faculty of Medicine
and Dentistry, University of Valencia (Spain), treated between
January 2013 and January 2014. Inclusion criteria were as follows:
adult patients (aged over 18 years), non-smokers, periodontally
healthy or periodontally managed, patients who had undergone
restoration with fixed prostheses (one-piece crowns or fixed
partial dentures FPDs) in the aesthetic zone (incisors, canines,
premolars, first molars), which needed to be replaced due to
biological, esthetic or some other type of problem (Fig. 1). Patients
who were smokers, presented unmanaged parafunctional habits,
or severe systemic diseases were excluded.
The trial was approved by the University of Valencia Ethics
Committee for Research Involving Human Subjects (Registration
Number: H1448361523684). All patients gave their informed
consent to take part in the trial, signing an informed consent form.
The sample consisted of 52 patients, 22 men and 30 women. A
total of 101 treatments were carried out (74 crowns and 27 FPD)
and thereafter monitored annually during a 4-year follow-up.
Fig. 2. (a) Teeth prepared with conventional chamfer. Vestibular view. (b) Teeth
Patients were divided into two groups corresponding to the type of prepared with conventional chamfer. Occlusal view.
treatment they received, one-piece crowns or 3-6-piece FPDs, and
were analyzed both individually and as groups. To make the
analysis of FPDs comparable with crown analysis, each restored
tooth was analyzed individually.
Before treatment, patients who needed underwent periodontal
maintenance treatment to obtain optimal gingival health. Patients
who did not require periodontal treatment underwent conven-
tional oral hygiene with ultrasound. Oral hygiene instructions were
given to all patients.
Dental preparation, provisionalization, and laboratory phases,
were performed following the simplified BOPT guidelines de-
scribed by Agustín and Solá [14]; and everything was done by the
same prosthodontist (specialist, trained in BOPT technique). Before
the removal of the old restorations a double probing (gingival
Fig. 3. BOPT preparation technique. From left to right: First step introduce the bur
sulcus probing and bone probing) was performed to determine the with an angulation of 10-15 with respect to the dental axis (tip of the bur in the
preparation limit and to situate the location of the provisional direction of the tooth); second step, introduce the bur parallel to the dental axis;
restoration (0.5–0.8 mm below the edge of the gingiva) so as not to and third last step, introduce the bur with a 3-6 angulation with respect to the
invade the biological space at any time. After the removal of the old dental axis.
restorations (Fig. 1), BOPT preparation eliminated the pre-existing
finish line (situated supragingival) (Fig. 2a and b) using a turbine introduced parallel to the dental axis, in order to eliminate the
and 100/200 mm cone diamond bur of 1.2 mm diameter preexisting finish line. In the third and last step, the bur was
(862.534.012, BOPT drills; Sweden & Martina, Due Carrere, Padua, introduced with a 3–6 angulation with respect to the dental axis
Italy). For the realization of the BOPT preparation technique, the to give it the necessary convergence (Figs. 3 and 4). Afterwards an
bur was first introduced with an angulation of 10–15 with respect interim prosthesis was fabricated with self-polymerizing acrylic
to the dental axis (tip of the bur in the direction of the tooth). This resin (Sintodent, Sintodent s.r.l., Roma Italy). The interim
first step aims to open the dental groove, and eliminate de prosthesis creates a new cement-enamel-prosthetic junction,
emergence of the anatomic crown. In the second step, the bur was situated in the gingival sulcus at a depth of 0.5–0.8 mm, with
 B. Serra-Pastor et al. / journal of prosthodontic research 63 (2019) 415–420 417

Fig. 4. BOPT technique, immediately after preparation.

Fig. 7. Measurement of the gingival thickness with a transparent split and a

periodontal probe with a rubber stop, 2 mm above the gingival margin.

4 years: initial situation after placement of the definitive prosthesis

(T0), 1 year after treatment (T1), 2 years (T2), 3 years (T3), and
4 years (T4). Patients undergoing periodontal treatment (peri-
odontal revisions and maintenance, as well as oral hygiene)
continued to attend their regular maintenance appointments,
independently of appointments for review of prosthetic treatment.
The following parameters were evaluated: presence or absence
of plaque by means of visual inspection with a conventional dental
exploratory probe (Hu-Friedy EPD6578XTS, Hu-Friedy, Chicago,
ILL, USA); periodontal probing depth around each tooth using a
millimeter-calibrated periodontal probe (Hu-Friedy PCPUNC156),
Fig. 5. (a) Maturation of gingival tissue after a provisional phase of 8–12 weeks. (b)
Gingival sulcus in teeth prepared with BOPT. (c) Emergence profile with BOPT presence or absence of gingival inflammation with bleeding by
provisional restoration. means of visual inspection, biological or mechanical complica-
tions, and the patient’s level of satisfaction with treatment
assessed by means of a visual analogue scale (VAS). Gingival
thickness was measured and marginal stability (presence of
gingival recession) was monitored over time. The thickness of
the gum around each tooth was measured using a transparent
splint with an aperture situated 2 mm below the vestibular
gingival margin using a millimeter-calibrated periodontal probe
(Hu-Friedy PCPUNC156) (Fig. 7) [17]. Marginal stability was
evaluated by measuring the distance in millimeters (mm) from
the new prosthetic cemento-enamel junction (PCEJ) to the edge of
the gingival margin using a periodontal probe. Marginal stability
was carried out once the definitive BOPT prosthesis was placed
Fig. 6. Final prostheses with BOPT technique.
(T0), but gingival thickness was first measured with the old
restorations before treatment (BT). The evaluation was carried out
consideration of the biological width. Interim restorations were in each follow-up revision (T1-T2-T3-T4).
not removed until the soft tissues had completely matured – a
period of 8–12 weeks (Fig. 5a, b, and c). At this point, impressions 2.2. Statistical analysis
were taken to fabricate the definitive prosthesis using the two-step
impression technique, placing double gingival retraction cord to Statistical analysis was made with SPSS 21.0 (for descriptive
prevent gingival collapse. analysis) and R 3.5.1 for inferential (R Core Team (2018) R, Austria). It
The definitive restorations were fabricated with a zirconia core was found that the thickness and the recession are not distributed
(Lava Frame Zirconia, 3M Espe, Seefeld, Germany) and feldspathic according to the normal pattern (Kolmogorov-Smirnov); but the size
ceramic covering (Lava Ceram, 3M Espe,) applied in layers with a of the sample (n = 144) allowed us to approach the analysis using a
stratification technique. All restorations were cemented with parametric approach.
temporary cement (Temp Bond Clear, Kerr Dental, Orange, CA, The gingival thickness and the recession in mm were the
USA) during the first 2 months. After this time, restorations were dependent variables in both linear regression models as a function
cemented with glass ionomer cement (Ketac Cem, 3M Espe) of the time of revision and type of prosthesis. The regression was
(Fig. 6). estimated from generalized estimation equation models (GEE) to
control the intra-subject correlation because each patient contrib-
2.1. Clinical follow-up utes several teeth to the investigation. The Bonferroni correction
was applied to multiple comparisons.
A protocol was established whereby patients were evaluated The binary variables, inflammation and bleeding, are studied
before treatment (BT) and after placement of the definitive with logistic regression, also using GEE methodology and for the
prosthesis; thereafter, annual check-ups were scheduled for same reason above.
418 B. Serra-Pastor et al. / journal of prosthodontic research 63 (2019) 415–420

Table 1. Results of all the measured parameters during 4-year follow-up

Clinical results
T0 T1 T2 T3 T4 Statistical significance Differences
Crowns-FPD
Presence of No 38,9 38,9 21,45 20,1 YES NO
Plaque % (p < 0001) (p = 0757)
ATS test Brunner–Langer model
Increasing No No 0,7 1,4 2,1 NO NO
Probing depth % (p = 0135) (p = 0445)
ATS test Brunner–Langer model
Presence of Inflammation- bleeding % No 6,3 19,5 13,3 12 YES (p < 0001) NO
Chi2 Wald test GEE model (p = 0153)
Gingival thickness 1,20a 1,44 1,59 1,59 1,59 YES (p < 0001) NO
(mm) Chi2 Wald test GEE model (p = 0419)
Variations in gingival margin stability % no No no 1,4 1,4 NO NO
(p = 0154) (p = 0145)
ATS test Brunner–Langer model
Mechanical and biological complications % No No 2 3,4 3,4 NO NO
(p = 0167) (p = 0274)
ATS test Brunner–Langer model
a
Measures before treatment (BT) for gingival thickness.

For other ordinals (plaque, probing) or binaries with no or very Teeth restored with crowns presented a gingival thickness BT of
little incidence (pulpitis, extraction, failure . . . ) a Brunner-Langer 1.26  0.48 mm, which increased to 1.52  0.52 mm at T1 and to
nonparametric model was used for longitudinal data with 1.67  0.58 mm in T2. In T3 and T4 remained stable with 1.7  0.59.
independent factor type of prosthesis. For teeth supporting FPDs, gingival thickness BT was
The level of reference significance was 5% (p < 0.05) and the 1.14  0.42 mm, also increasing at T1 and T2 to 1.36  0.36 mm
power achieved with the study was 85% for an average effect size. and 1.52  0.43 mm respectively. In T3 there was a small decrease
to 1.49  0.41 mm, remaining stable during T4. For all 144 teeth,
3. Results mean gingival thickness BT was 1.20  0.46 mm, increasing to
1.44  0.45 in T1 and 1.59  0.52 in T2. In T3 and T4 the measures
A sample of 52 patients were selected (22 men, 30 women), remained stable. The overall increase in gingival thickness was
aged between 18 and 65 years. A total of 74 crowns and 27 FPDs statistically significant (p < 0.001) and it was evident that the most
were used to restore teeth and evaluated over a 4-year follow-up. relevant change was produced during the first year after
Of the 52 patients, one patient was lost due to failure to attend the restoration in both groups (p < 0.001). After the second year,
third year follow-up; so the final sample at 4 year was 144 teeth in mean thickness did not change (p = 1.000). Teeth restored with
the aesthetic zone (incisors, canines, premolars, first molars) (71 crowns presented a slightly larger increase in thickness than teeth
teeth supporting crowns and 73 teeth supporting FPDs). supporting FPDs, but without significant difference between the
After analyzing the plaque data obtained, 38.9% of the restored treatment types (p = 0.419).
teeth presented plaque after T1 and T2, which then decreased to As for gingival margin stability, an important finding was that
21.45% and 20.1% in T3 and T4 consecutively, this decrease was at the end of the 4-year follow-up, 98.6% of the restored
statistically significant (p < 0.001). The decrease in plaque was teeth remained stable without recessions. At T1 and T2 neither
more evident in the group of crowns than FPDs although without teeth bearing crowns nor teeth supporting FPDs presented
significant difference between the two restoration types recessions, but in T3 two teeth restored with crowns presented
(p = 0.757). recessions of 0.5 mm and 1 mm; although these data were not
With regard to probing depth, in T0, all teeth had a probing statistically significant (p = 0.154).
between 0–3 mm. In T1 no teeth presented variations; only 0.7% of With regard to the success and survival of the restorations, 2%
teeth suffered an increase (from 0 to 3 mm to 3–6 mm) in probing suffered biological complications at T2, 2 cases of pulpitis and 1
depth in T2; during T3, probing depth data increased in the 1.4% of extraction due to vertical fracture; during T3 year 1.4% suffered
the sample, and at T4, probing depth had increased in 2.1% of teeth. mechanical complications consisting of 2 restoration fractures
The overall increase was not statistically significant (p = 0.135). No (chipping of the veneering porcelain and a connector fracture in
differences between crowns and FPDs were found for this one FPD). No complications occurred during T4. The overall success
parameter (p = 0.445). rate was 96.6% (Table 1).
Inflammation with presence of bleeding was observed in 6,3% The level of satisfaction with the treatment was 80.65  10.17,
of the sample in T1; increasing in T2 to 19.5% of teeth. In T3 and with a median value of 90 (half of the patients scored 90 or more).
T4 there was a decrease with results of 13.3% and 12% In the group of crowns, the average satisfaction rises to 90.03,
respectively. Statistical analysis confirms significant variation greater than that of the group of teeth supporting FPDs (80.27),
in inflammation over time (p = 0.001). Nor were any significant obtaining significant differences (p = 0.022).
differences identified between the two types of prosthesis
(p = 0.153). 4. Discussion
In the measurement of the gingival thickness before treatment
(BT) and after the treatment (T1-T4), there were findings of great A good relationship between dental restorations and the
interest. In the measurement of the gingival thickness BT, values periodontium is of fundamental importance to ensure clinical
between 0.5 and 2.5 mm were found. 71% of the patients had a BT success both in terms of function and esthetics [21,22].
thickness between 0.5–1 mm (thin gingival thickness), 27% a BT According to clinical reports [6,15–17], BOPT provides increases
thickness between 1–2 mm (average gingival thickness), and 2% a in gingival thickness, greater stability of the gingival margin (less
BT thickness of more than 2 mm (thick gingival thickness). chance of suffering recessions), an easier way to take impressions
 B. Serra-Pastor et al. / journal of prosthodontic research 63 (2019) 415–420 419

(since it is a finish area and not a defined line), and they are also curettage. At this time there is a contraction of the myofibroblasts
associated with a good marginal fit [18–20]. However, it is a more around the tooth; and thanks to the conical dental preparation
complex technique than the conventional one; which requires a there is a migration of the soft tissues towards coronal (from the
higher learning curve. Likewise, it is a technique that requires prior area of greater diameter (apical) to the area of minor (coronal)). In
learning by the laboratory technician, since there is no dental this stage it has been described that tissue growth occurs due to a
termination line and it is the dental technician (together with the transduction mechanism [30,31]. The connective tissue fibroblasts
clinician) who decides where to place the prosthetic finish line detect mechanical stimuli (chewing, provisional pressure, lip
according to each patient different situation [15–17]. pressure when speaking) in their extracellular matrix; these
The present study included 51 patients, similar to studies by, stimuli are converted into chemical information that stimulates
Valderhaugh [23], Pippin [24], Peláez [11], and Paniz [12]; who cell growth and proliferation [31].
conducted prospective studies of between 3 and 5 years to analyze The survival rate of the ceramic restorations in the present
the relations between restorations and periodontium. study was 96.5%. Only one patient presented a connector fracture
Oral hygiene was managed before treatment and in each annual three years after restoration, while another presented vestibular
follow-up visit with oral hygiene instructions and a professional porcelain chipping after three years. The fractured FPD connector
cleaning like in other studies in the literature [11,12]. was in an area of maximum esthetics (between maxillary central
Various parameters were evaluated during the follow-up: incisor and maxillary lateral incisor). In this area the connector
gingival thickness, inflammation with presence of bleeding, area was reduced for aesthetic reasons, resulting in a decrease in
plaque, marginal stability, complications and patients’ satisfaction resistance at this point. These findings are similar to Schmitt [32]
with treatment. These parameters have been assessed in other who obtained a survival rate of 100% in teeth prepared with
studies by Valderhaugh [23], Müller [25], Paniz [12,13], and Tunner feather-edged with 3-year follow-up. Regarding preparations with
[26]. However, only one other work by Agustin [17] has monitored finish line in zirconia restorations, Tunner [26] got similar results
changes in gingival thickness around restorations placed on teeth with a survival rate of 95%.
prepared using BOPT. The present study assessed patients’ satisfaction with the
Plaque was found to affect 20% of the teeth after 4 years, a restorative treatment received by means of a VAS on a scale of 0–
similar finding to Paniz [12], who registered the presence of 100, obtaining mean satisfaction of 80.73. In the study by Paniz
plaque on 17% of restorations prepared also with BOPT technique. [12] satisfaction was higher, with a value of 96.5% for esthetics and
In BOPT restorations there is no discrepancy between the 98% for function, but this study is only after 6-month follow-up.
termination line and the restoration since there is no chamfer.
This fact also helps to have less plaque retention in this area. 5. Conclusion
Comparing these results with preparations made with chamfer,
similar findings were found, such as Paniz [12] with 18% plaque Having evaluated the clinical and periodontal behavior of full
after 12 months of follow-up. However, significantly higher coverage restorations placed on teeth prepared using BOPT, it may
results also appear as those of Sjögren [27] and Pelaez [11] with be concluded that:
28% and 60% plaque respectively. Restorations on teeth prepared with BOPT show a general
In the present study, an increase in probing depth (more than survival rate of 96.5%; 97.2% in teeth supporting simple-unit
3 mm) was observed only in 3 teeth after 4 years follow-up (only in crowns, and 95.9% in teeth supporting FPDs. Mechanical and
1 patient). These data are similar to a study by Eliasson [28] and biological failures are scarce, which shows that this preparation
Paniz [12] in which the periodontal status did not change over technique produces predictable results over a 4-year follow-up.
time. Regarding teeth prepared with chamfer, Paniz [12] also found Periodontal behavior around restored teeth prepared using
similar results; however, Tunner [26] got higher rates of probing BOPT is good, obtaining low rates of gingival inflammation with
depth with a 23% of the sample with more than 5 mm after 6 years. bleeding (12%), low increases in probing depth (2.1%), and low
Gingival inflammation with bleeding affected 12% of teeth after presence of plaque (20%).
4 years, a result that differs from Paniz [12] in which 41.3% of BOPT is the technique of choice in cases of retreatment with
zirconia crowns on teeth prepared with knife-edge finish line fixed prosthesis due to problems of marginal fit or recession in the
presented inflammation and 52.5% presented bleeding on probing. anterior sector, since it produces an increasing of gingival
As for preparations with chamfer, Pelaez [11] obtained a high thickening, mainly during the first year follow-up. Moreover, it
percentage (70%) of inflammation after 4 years, and Tunner [26] promotes marginal stability, it has a high survival rate, and it has a
found a bleeding on probing of 38.1% after 6 years. good periodontal behavior over time.
Gingival recession was only observed in two of the teeth assessed
(1.4%); however, this result was associated with an aggressive oral
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