Periodontology 2000. Val.

11, 1996,29-38 Copyright 0 Munksganrd 1996

.~
Printed in Denmark. All rights reserued
PERIODONTOLOGY 2000
ISSN0906-6713

The restorative-periodontal
interface: biological parameters
JOHN C. KOIS

Achieving periodontal health at times seems dia- The contours of the artificial crowns appear simi-
metrically opposed to the requirements of restor- lar: are they biologically acceptable?
ative dentistry. Traditional restorative mechanical How far apical to the free gingival margin can the
prerequisites of incisal and occlusal reduction, crown margin be placed while retaining gingival
length of preparation and adequate sound tooth health?
structure are obviously more predictably managed Can the restorative interface be predictably man-
when the margin of the preparation can be placed aged to prevent aberrant gingival sequelae (Fig.
supragingivally. However, occlusal gingival space 2-5)?
limitations, previous hard and soft tissue destruc-
tion and patient aesthetics concerns for root cover-
age, margin display, and closure of interproximal Bacterial plaque accumulation
“black holes” can create formidable challenges for
the restorative dentist. The relationship between bacterial plaque accu-
Clinical dogma has popularized common myths mulation and gingival inflammation has been doc-
regarding the gingival response to restorative umented since at least 1965 (21).However, the lim-
materials and the limitations of intracrevicular itations of subgingival scaling and root planing
tooth preparation. Unfortunately, because tissue have been well illustrated (18, 30). The control of
components cannot be visualized, the guidelines pathogenic dental plaque may require care with
of sulcus depth are often misunderstood and special mechanical devices, antimicrobial rinses
clinically mismanaged. and even systemic antibiotic therapy (3, 15,25).
Clinical doctrines of perfect margins, biological Patient susceptibility to gingival inflammation is
contours and atraumatic technique cannot be not based solely on the mere quantity of dental
quantified and are not always clinical necessities. plaque but also on the virulence of the resident
The most critical concern may be the restorative plaque microorganisms. The bacterial biota of
interface in an intracrevicular margin location. dental plaque is dynamic and the pathogenicity is
Understanding more realistic biological subject to change over time. Also, contributing
parameters of bacterial plaque accumulation, factors to plaque formation must be considered.
margin integrity, contour, alloy sensitivity, and The plaque accumulation on crowns made of
margin location are the keys to developing a various materials has been evaluated extensively
differential diagnosis that will ensure a successful (1, 10,27,31).In general, plaque retention depends
treatment result. on the surface roughness and the surface energy of
The patient in Fig. 1with severe gingivitis on the the restorative material (28). Rougher material
right central incisor demonstrates the dilemma should experience a statistically greater incidence
facing the dentist: of gingival inflammation. It is therefore an enigma
that provisional restorations often enjoy a
Is it logical that the patient is not providing nec- favorable gingival response (2,36).Compared with
essary oral hygiene procedures to only the right definitive restorations they are less acceptable in
central incisor? terms of fit, roughness and contour. Provisional
Is the margin integrity very much different on the restorations have the potential to accumulate more
right and the left central incisor? plaque, especially because patients tend to shy

29
KOis

Fig. 1. Fifteen-year-old
metal ceramic crowns on
teeth 8 and 9. Note gingival
redness around tooth 8.
Fig. 2. Current radiograph.
Note the appearance of
normal osseous architec-
ture.

Fig. 3. Immediate removal of metal ceramic crowns reveals

feather edge finish line configuration with 1 mm of the os-
seous crest on the distal.
Fig. 4. Revised tooth preparation with more coronally lo-
cated finish line - 3 months later
Fig. 5. Final all-ceramic crowns 1 month later. Note the re-
turn of gingival health.

away from aggressively performing oral hygiene disruption of the junctional epithelium and
procedures around them. However, the short-term connective tissue attachment. The subsequent
positive gingival response of provisional healing may lead to a temporary change in the
restorations may not be a good indicator of the dentogingival complex (161, which may be
long-term gingival health. confused with tissue shrinkage or recession. The
Restorative procedures such as tooth gingival tissue may then appear healthy until the
preparations, tissue management with or without biological width reforms and the tissue attachment
chemical agents, electrosurgery and installment of matures.
provisional restorations may influence the It is important to assess the contribution of
composition and the pathogenicity of the bacterial plaque by itself when the gingival health
periodontal microbiota. In addition mechanical around restorations is compromised. This may be
insults such as paclung cord, copper bands and accomplished by the following clinical procedures.
retraction clamps create a wound that may involve A patient should be given the conventional

30
 Restorative-periodontal interface

Fig. 6. Metal ceramic crowns on teeth 6-1 1 with severe gin- Fig. 8. Gingival response with 1-year-old provisional that
gival redness, swelling, and bleeding with gentle periodon- had evidence of cement washout.
tal probing. Fig. 9. Antimicrobial pre-seating cream (E-Z Seat, phar-
Fig. 7. Same metal ceramic crowns following initial ther- macy-prepared antimicrobialcream) placed in final metal
apy, two weeks of antimicrobialrinsing and use of a Soni- ceramic crowns.
care@(Optiva Corp., Bellevue,WA) toothbrush.

regimen of initial therapy including instruction in degree of marginal opening may be related to ce-
toothbrushing and possibly subgingival irrigation ment dissolution, wear, and gingival inflammation
to control local factors. Also, a 2-week rinse of but does not directly correlate with microleakage,
0.12% chlorhexidine gluconate might be instituted recurrent caries, or the progression of periodontal
to improve gingival health (29) (Fig. 6, 7). These disease (4, 35). This statement is not given to sup-
steps possibly might be able to determine the port dentistry below a standard of excellence but
degree of resolution of gingivitis obtained by rather to reinforce the fact that most patients are to
controlling bacterial plaque alone in a 2-week a great extent resistant to periodontal disease pro-
period. gression. Only 7-15% of adults in the United States
are susceptible to severe loss of periodontal attach-
ment (14).The restorative interface is always impli-
Marginal integrity of restorations cated in periodontal disease progression but has
not been shown statistically to constitute a high-
Although it seems logical to assume that ill-fitting risk factor in periodontal disease or caries. Re-
margins will inevitably lead to a myriad of undes- search is needed on the importance of marginal in-
ired clinical effects, this is not easily predictable. tegrity in patients susceptible to dental diseases.
Consider an ill-fitting stainless steel crown present Until then, the dentist must rely on imprecise clini-
for more than 25 years with localized gingival in- cal measurements of how margins look and feel (5).
flammation but with no appreciable loss of attach- Scientific data indicate that virtually all margins
ment. Clinical parameters of what constitutes ac- are open. The average opening is about 100 pm,
ceptable margins have never been established. The with a range from 25 to 500 pm; 62% of restorations

31
KOis

have an opening of at least 200 pm. Since bacteria increased in 0.5-mm increments to 1.5 mm greater
are 1 to 5 pm in size, there is clearly enough room than the original dimension of the tooth, papillary
to harbor bacterial plaque even around the best bleeding increased. The conclusion dictated strict
fitting margins of a restoration. However, many of adherence to following the tooth emergence profile
these restorations can still be considered clinically to ensure the maintenance of gingival health.
successful, suggesting that microbial virulence and The difficulty in the experiment above lies in not
patient resistance play a more important role in being able to specify the influence of the margin
maintaining health than the mechanical aspects of location. For an artificial crown to be 1.5 mm
the margin design. greater facial-lingually at the free gingival margin,
Dental laboratory technicians have developed it would either have to have a significant bulge that
the capability to provide metal and ceramic would trap plaque or have a margin location far
margins with less than 20 pm opening to our apically of the free gingival margin. For
working dies. However, dentists must ensure that restorations with only supragingival margins, the
the crowns completely seat on the tooth in the contour only becomes a problem when the space is
same manner as the working die. Failure to remove not readily accessible for plaque removal (26). One
any sharp edges or corners not reproduced study demonstrated that the facial-lingual width
accurately on the stone die can create greater after tooth restoration was always larger than the
marginal discrepancies than variations in the original natural tooth (6). This lends credence to
shape of bevel or butt joint finish lines. the notion that gingival health can be maintained
Dentists strive for the least marginal opening in the presence of a broad range of contour values,
achievable, but excellent margins may do more for ranging from +1 mm to -1 mm in deviation from
the dentist emotionally than for the patient the original tooth (12).
biologically. Research is needed to help dentists to The location of the proximal surfaces of adjacent
better define the concept of “reasonable fit of a teeth also seems to be a critical factor in gingival
restoration”. health. The closer the approximation of roots, the
more the interproximal contour will influence the
gingival status. With close root proximity, even
Contour slight deviations from the original contour may
compromise the complex relationship of the
The relationship between the coronal contour of interproximal gingival tissue. When roots are
an artificial crown and the gingival form and further apart, the clinician has more flexibility to
shapes is well documented (34, 37). The relation- alter interproximal coronal form and still preserve
ship between the coronal contour and gingival gingival health. The clinical application of this
health appears to be more illusive. Controversies notion is evident when an attempt is made to close
exist between a bulge design and flat emergence gingival embrasures or diastemata with additional
profile. It seems logical that the most predictable restorative material.
gingival response will occur when the artificial Dental laboratory technicians play an important
crown portion mimics as much as possible the role in preventing problems with poor contour of a
original shape of the tooth. This concept offers no restoration. The facial or lingual surface of a
flexibility to the restorative dentist to “stretch” restoration should not have more than a 0.5-mm
contours, close diastemata or close open gingival bulge from the gingival margin because this may
embrasures (“blackholes”).Yet it is possible to de- interfere with adequate plaque removal. The use of
viate somewhat from the original tooth shape and a gingival tissue model or solid stone model will
still obtain a satisfactory clinical outcome. Coronal help in determining the interproximal contour
contour requirements must focus on not only necessary and in minimizing unwarranted open
mimiclung natural teeth but also on defining how gingival embrasures. Caution must be exercised
variations in the contour of the artificial crown in- with these estimations because the gingival tissue
fluence gingival health. contour may have been altered during the
The definition of an undercontoured or impression procedures and may not exactly mimic
overcontoured restoration is not clear. One study the normal gingival architecture. To reduce
(8) evaluated the facial-lingual width in relation to potential gingival health problems related to the
changes in gingival bleeding. As crown contour contour of a restoration, the dentist should check

32
 Restorative-periodontal in terface

the facial profile of a restoration with an explorer States population are hypersensitive to nickel, with
and be able to pass it through the interproximal women being 10 times more sensitive then men
space, provided enough root separation is (23). However, alloy reactions responsible for aber-
available. rant gingival changes still appear to be very rare.
When the coronal contour of a restoration Salivary glycoproteins may neutralize some of the
prevents access for oral hygiene or creates effects of alloy hypersensitivity.
mechanical pressure on the gingival tissue, gingival Since contact dermatitis is the most common
health is likely to be compromised. Other aspects mode of adverse reactions (111,the removal of the
of the coronal contour of a restoration are of offending restoration should result in rapid
relatively less importance for gingival health. resolution (1 week) of the gingival irritation.
Gingival redness also should be limited to the area
of direct contact. Patch testing by an allergist may
Alloy sensitivity be helpful but, unfortunately, is often not reliable.

Unfavorable gingival reactions to alloys used in the

oral environment have been documented (20,241. Margin location
In addition, certain metals have been shown to
leach out from alloys used for indirect restorations The effect of the location of an artificial crown
(32). Nickel-containing alloys appear to carry the margin on plaque accumulation and gingival
greatest risk. Approximately 10% of the United health is well documented (7). A margin location

Fig. 10. Initial: note the gingival scallop supported by prox- Fig. 11. Total dentogingival complex of 3 mm on facial as-
imal contact on mesial, flatter on distal due to missing pect representing the relationship between the normal os-
teeth. Gingival response within 24 h with use of pre-seating seous crest and free gingival margin.
cream. Tissue health now acceptable to consider find ce- Fig. 12. Total dentogingival complex of mm on the inter-
mentation. proximal aspect. The gingival tissue shows a greater scal-
lop relative to the osseous crest.

33
 Fig. 13. Margin location at 0.5 mm apical to the free gingi-
val margin on the facial surface followingthe scallop archi-
tecture of the gingival interproximally. Margin location of
2.5 mm coronally to the alveolar bone. Note pontic recep-
tor site established in the gingival tissue to accept ovate
pontic form.
Fig. 14. Final result. Metal ceramic fmed partial dentures
on teeth 7-10.
Fig. 15. Biological variation possible with normal location
of gingival levels.

apical to the gingival tissue tends to adversely af- the junctional epithelium due to the degree of
fect gingival health. The most critical factor in mar- force used, the level of gingival inflammation and
gin location seems to be the relationship to the su- the location on the tooth. It is also known that indi-
pracrestal fiber attachment. A margin placed apical viduals vary in connective tissue attachment, junc-
to the base of the periodontal pocket into the zone tional epithelium and sulcus depth (13,331.There-
of biological width, specifically, into connective tis- fore, the reported measurements of the biological
sue attachment, violates important biological prin-
ciples with adverse consequences for long-term
gingival health. Therefore, the most important con- Fig. 16. 'helve-year-old metal ceramic crowns on teeth 8
sideration for intracrevicular restorative dentistry and 9.
is locating the base of the gingival sulcus or peri- Fig. 17. Crowns removed. Note margin location relative to
odontal pocket (22). the free gingival margin.
The dentogingival complex comprises three Fig. 18. Unable to pack cord without anesthesia due to
definitive components: margin location too far apically precisely at the mesial line
angles.
the connective tissue fibrous attachment Fig. 19. Margin location relative to bone only 1.5 mm. Does
the junctional epithelium or epithelial attach- not follow scallop of underlying bone.
ment Fig. 20. Osseous resection through the gingival tissue with-
the gingival sulcus or periodontal pocket. out mucoperiosteal flap using a Gracey 718 curette.
Fig. 21. Margin location corrected to the 2.5 mm coronal to
Gargiulo et al. (9) found a vertical measurement of bone only at the line angle where the violation of biological
2.04 mm for biological width. They also reported a width occurred.
vertical measurement of 0.69 mm for the depth of Fig. 22. Gingival health returns with original tooth prepa-
the gingival sulcus. However, clinicians experience ration.
vastly different depths. It is well known that varia- Fig. 23. Final all-ceramic crowns at 2-year follow-up. Note
tion exists in periodontal probe penetration into gingival health and normal gingival architecture.

34
Restorative-periodontal interface

35
width and the gingival sulcus are to be considered mm, a high alveolar crest occurs and caution must
as averages, with considerable variation. be used. Margin location should be at the level of
Understanding and clinically managing the the free gingival margin or no more than 0.5 mm
concept of biological width is the key to creating apically, to avoid the risk of violating the biological
gingival harmony with dental restorations. The width. When the total dentogingival complex
restorative dentist must be able to determine the measures more than 3 mm in height, a low alveolar
base of the sulcus for intracrevicular margin crest situation exists. The margin may then be
location. The histological sulcus depth ranges from located greater than 1 mm apical to the free
0.5 to 1 mm, whereas the clinical sulcus depth gingival margin. The risk in this situation is not in
measures from 1 to 4 mm in health. Since the violating the biological width, but rather in gingival
periodontal probe is not a reliable way to recession regardless of how “atraumatically” the
determine the base of the gingival sulcus, dentists tissue is managed. The relative thinness of the
have successfully worked with the total tissue and the amount of connective tissue
dentogingival complex dimension rather than with attachment versus junctional epithelium are
the individual components of the complex. critical factors for potential gingival recession.
Measurements can be made from the free gingival Overall, the tooth preparation should follow or be
margin to the osseous crest with a periodontal greater than the normal scallop of the base of the
probe. In health, the facial aspect has sulcus interproximally (Fig. 13). Tissue
approximately a 3-mm depth, and the management procedures that focus on the
interproximal surfaces have depths ranging from 3 position of the osseous alveolar crest rather than
to 4.5 mm. The interproximal variation depends on on gingival anatomy will provide the most
the amount of the scallop of the gingival tissue successful clinical outcome.
relative to the scallop of the interproximal alveolar Thus, it is important to evaluate the location of a
bone. The gingival scallop is always equal to or margin of a restoration circumferentially around
greater than the underlying osseous scallop (16). the tooth (Fig. 13-15). Otherwise, it is possible to
The osseous scallop parallels the violate the biological width in the interproximal
cementoenamel junction circumferentially. The region and compromise the health of the facial
osseous scallop is thus greatest for the maxillary gingival tissue (19). The facial gingival changes
anterior teeth and flattens out posteriorly (9). The usually start interproximally or at the line angles
biological width follows the osseous scallop. (Fig. 16-22). Importantly, the location of a margin
Therefore, the inappropriate use of a more of a restoration relative to the crest of the alveolar
horizontal tooth preparation margin as opposed to bone is more critical for preserving gingival health
a scalloped margin on anterior teeth will often than its distance below the free gingival margin
violate the biological width in the interproximal (17).
area. The clinician must visualize that the facial
aspect of the free gingival margin in periodontal
health is at a similar vertical position as the Violation of biological width
interproximal osseous crest. Some latitude exists
interproximally as the gingival tissue has a slightly In clinical practice, intentional and inadvertent vi-
greater scallop than the underlying osseous crest olations of the biological width occur, causing diffi-
(16). This anatomic difference is due to the cult impressioning and hygiene procedures and
proximal contours of adjacent teeth and their unacceptable coronal contours of the final restora-
ability to support an additional height of gingival tion. The reasons for violation of the biological
tissue in the interproximal area. width include attempt to access sound tooth struc-
It is important to know the total dentogingival ture, increased need for preparation length, previ-
complex measurement when preparing teeth. ous restorations, existing caries, resorption defects,
Assuming the normal 3 mm from the alveolar bone traumatic injury, iatrogenic insults and improper
crest to the free gingival margin, intracrevicular identification of sulcus depth.
margins might be located 0.5-1 mm apical to the Attempts should be made to correct the reasons
free gingival margin or 2-2.5 mm coronal to the for violating the biological width. However,
osseous crest (Fig. 10-12). When the total treatment to re-establish biological width, whether
dentogingival complex has a length of less than 3 it involves osseous resection or vertical tooth

36
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Restorative-periodontal interface

movement, also creates loss of attachment. 5. Christensen GJ. Marginal fit of gold inlay castings. J
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