WIDTH

BIOLOGIC
A compilation of articles by
Frank Spear, D.D.S., M.S.D.
CONTENTS
4 Fundamental Concepts
6 The Term “Biologic Width”
8 Restorative Margin Placement
10 Possible Gingival Presentations
12 Subgingival Margin Placement in Shallow Sulcus Patients
14 Part 1: Margin Placement for Deep Sulcus Patients
16 Part 2: Margin Placement for Deep Sulcus Patients
20 Diagnosing a Biologic Width Violation
22 Surgical Correction of a Biologic Width Violation
24 Managing Interproximal Biologic Width Violation
on the Facial Surface Only
28 Managing Facial and Interproximal Biologic Width
Violations on Multiple Adjacent Teeth
Introduction
I often hear restorative dentists say
they don’t need to know about the
biology because they don’t perform
surgery in their office.

It goes without saying that for surgical procedures

designed to move tissue (e.g., gingivectomy,
crown lengthening, root coverage), understanding
how the biologic system impacts the treatment
plan and outcome is critical. However, the
reality is that there are numerous “non-surgical”
procedures performed every day in a restorative
practice that also require knowledge of the
biologic width. In fact, any time you are working
near the gingiva and have to think about tissue
retraction, the biology needs to be considered.

When preparing a tooth for a full-coverage

restoration, how do you decide where the crown
margin should be placed? If the margin is not
placed deep enough under the tissue, there is a
risk for recession and potential exposure of the
crown margin, which may be esthetically
unacceptable. On the other hand, if the margin
is placed too deep under the tissue, there is a risk
for possible biologic width impingement, which is
a significantly greater problem. Ultimately, where
the restorative margin is placed relative to the
tissue and the subsequent response of the tissue
is determined by the biology itself. Hence, it is
imperative for restorative dentists to understand
“biologic width.”

When it comes to integrating basic biologic

concepts with restorative dentistry, I believe that
there is no one better than Dr. Frank Spear. This
is in part due to his dual perio-prosth degree, but
mainly it is his unique ability to impart complex
SPEAR | BIOLOGIC WIDTH

clinical processes in a logical, systematic and clear

methodology, that is based on empirical research
as well as his own clinical experience.

- Greggory Kinzer, D.D.S., M.S.D.

 Biologic Width: Biologic width describes the combined
heights of the connective tissue and

Fundamental epithelial attachments to a tooth. The

dimensions of the attachment were

Concepts described in 1961 by Garguilo, Wentz and

Orban in a classic article on cadavers.
By Frank Spear, D.D.S., M.S.D. Their work showed the connective tissue
attachment having an average height of
1 mm, and the epithelial attachment also
having an average height of 1 mm,
leading to the 2 mm dimension often
quoted in the literature for biologic width.
In addition, they found the average facial
sulcus depth to be 1 mm, leading to a
total average gingival height above bone
of 3 mm on the facial. (Figure 1)

4
 Classic illustration of the average human attachment apparatus
as described by Gargiulo, Wentz, and Orban in 1961.

The Connective tissue attachment and epithelial attachment form

“Biologic Width” averaging 2 mm in most patients.

Figure 1
SPEAR | BIOLOGIC WIDTH
 In 1994, Vacek did further cadaver studies on
biologic width that helped give some insight into
the clinical findings many of us had seen. He found
that biologic width was relatively similar on all
the teeth in the same individual from incisors to
molars, and also around each tooth. He also found
the average biologic width to be 2 mm as the
Garguilo group did. What Vacek found that is

The Term
clinically important was that biologic width varied
between individuals, with some having biologic
widths as small as .75 mm, and others as tall as
‘Biologic Width’ 4 mm, but statistically the majority followed the
2 mm average.
By Frank Spear, D.D.S., M.S.D.
The primary significance of biologic width to
For historic accuracy, it is interesting
the clinician is its importance relative to the
to note that Garguilo, Wentz and
position of restorative margins, and its impact
Orban didn’t use the term “biologic
on post-surgical tissue position. We know that if a
width” in their 1961 article; the actual restorative margin is placed too deep below tissue,
name, biologic width, came in 1962 so that it invades the biologic width, two possible
from Dr. D. Walter Cohen at the outcomes may occur. One, there may be bone
University of Pennsylvania. resorption that recreates space for the biologic
width to attach normally. This is the typical
response seen in implants to allow the formation
of a biologic width, the so-called funnel of bone
loss to the first thread.

Around teeth, the most common response to a

biologic width violation is gingival inflammation,
a significant problem on anterior restorations.
(Figure 1)

6
Figure 1: A patient who presented with porcelain bonded crowns placed six months earlier is unhappy with their appearance and the
severe gingival inflammation. All margins are within 1 mm of bone.

The importance of biologic width to surgery

relates to its reformation following surgical
intervention. Research shows it will reform “The primary significance of biologic
through coronal migration of the gingiva to
width to the clinician is its importance
recreate not just the biologic width, but also a
sulcus of normal depth. This means if the relative to the position of restorative
surgery doesn’t consider the dimensions of
margins, and its impact on post-surgical
biologic width when placing the gingiva relative
to the underlying bone, the gingival position tissue position.”
won’t be stable, but instead will migrate in
~ DR. FRANK SPEAR
coronal direction. In this example, it also has a
strong influence on when and where restorative
margins should be placed post-surgically.
SPEAR | BIOLOGIC WIDTH
 YOUR OPTIONS AND
BIOLOGIC WIDTH

The first option to consider when placing a

restorative margin is to decide if the margin can
be left supra– or equigingival, or must be placed
subgingival. If the margin can be placed supra– or
equigingival, the concerns over biologic width

Restorative don’t exist – assuming the gingiva is healthy and

mature. Today if the tooth color is acceptable

Margin Placement and there is no structural reason to extend below

tissue, such as caries, cervical erosion, old
restorations or a need to extend for ferrule, the
By Frank Spear, D.D.S., M.S.D.
use of a translucent material, such as Lithium
Earlier I described the fundamental Disilicate, can get an esthetically acceptable

concept of biologic width, the height result without the need to go below tissue.

of the combined connective tissue

and epithelial attachment above
bone, averaging 2 mm in most
patients. I also mentioned the two
possible outcomes that can occur if a
restorative margin is placed too close
to bone: one being bone loss, the
other being gingival inflammation,
with the inflammation being far
more common.

Figure 1: Patient with a severely discolored left central requiring

subgingival margin placement. The right central margin was
also carried subgingival, the centrals were restored with
8
zirconia-cored crowns, while the lateral and canine restorations
were left supragingival and restored using a translucent
material, feldspathic porcelain.
There are times, however, when it is necessary
to place margins below tissue, specifically if
structural issues exist, the tooth is extremely
discolored, or you need to use a more opaque
restoration such as zirconia or metal ceramics. In
these instances, a subgingival margin is necessary
and the concern of going too far below tissue and
violating the attachment exists. (Figures 1 and 2)

When I believed biologic width was the same for

every patient, the 2 mm described by Gargiulo in
1961, I thought the solution to margin placement
was simple: place the margin 2.5 mm from bone.
This would be far enough away from bone that it
didn’t violate the attachment, but also leave the
margin subgingival, as the facial gingival margin
is normally at least 3 mm above bone.

The truth was the 2.5 mm distance worked well

for most patients; I would simply use a perio
probe and sound to bone to be sure my margin
was, in fact, 2.5 mm away from the bone as I
prepped. But in many patients, the gingiva Figure 2: Patient demonstrating the risks of using supragingival

became very inflamed following treatment. margins with more opaque materials, in this case zirconia. He
was treated with lithium disilicate using subgingival margins
The reason was related to what Vacek found
due to the color of the left central and lateral.
in 1994, that, “biologic width is not the same
between patients, some having attachment
heights as tall as 4 mm.” In these patients my
2.5 mm distance from bone was in their biologic
attachment. (Figure 3)

Where we really want a subgingival margin is

actually easy to describe. We want it below
the gingival margin, but above the epithelial
attachment – in the sulcus, if you will. The key Figure 3: An example of a patient I treated in 1983. The left
central prep was done by sounding to bone and placing the
though, is we can’t use bone consistently as a
margin 2.5 mm from bone, the tissue became inflamed within
reference unless we actually know that individual
SPEAR | BIOLOGIC WIDTH

12 weeks. This photo was taken 12 years later; the tissue still
patient’s attachment height. inflamed. The illustration shows one possibility, a taller than
normal biologic width. In this example, 3 mm. My margin being
2.5 mm from bone would have violated the attachment.
In the next part of this series, I’ll describe how I
have placed subgingival margins since reading
Vacek’s article in 1994 to predictably achieve the
desired position.
 In this article, I’ll describe the two different types
of gingival presentations we encounter when
approaching subgingival margin placement, as
well as the risks of each. Whenever I contemplate
placing a margin subgingival, I always start by
probing the facial sulcus of the teeth I will be placing
the restorations.

It is important to realize that when we probe the

sulcus, the probe routinely enters the epithelial
attachment .5 mm, meaning the actual sulcus is
typically .5 mm less than the probed depth. In
patients with inflamed tissue, the probe penetrates
even deeper into the attachment.

Possible Gingival In patients with normal or shallow facial sulcus

Presentations
depths, typically 1 mm to 1.5 mm, the risk in
subgingival margin placement is going too deep
and violating the attachment, as the histologic
By Frank Spear, D.D.S., M.S.D. sulcus depth is probably less than 1 mm. The good
news is these patients do not typically present a
Previously, I discussed the concept of
high risk of recession following placement of the
biologic width and the concerns about
restoration since the gingival dimension above
placing restorative margins too deep,
bone is commonly 3 mm on the facial, similar to
violating the attachment and
the Gargiulo diagram in my previous articles. This
subsequently producing gingival
means there would have to be bone loss for the
inflammation or bone loss. tissue to recede apically. So going below tissue
more than .5 mm to .7 mm is unnecessary, and it is
unlikely the margin will violate the attachment or
be exposed from future recession.
(Figures 1 and 2)

10 Figures 1 and 2: A female patient, 50 years of age, with very healthy gingiva and facial sulcus depth of 1 mm. The preps are .5 mm
to .7 mm below gingiva to mask the discolored roots of the left central and lateral. The other preps were also carried .5 mm to .7
mm below tissue, to produce a uniform appearance across the anterior.
1 MONTH AFTER SEATING

Connect Tissue – 1 mm

Epith Attach – 1 mm

Sulcus – 3 mm

Figure 5

10-YEAR FOLLOW-UP

Figures 3 and 4: These are images of the final restorations

from the patient in Figures 1 and 2. On the top, a month after
seating, on the bottom, 10 years later. Patients with shallow
sulcus depths rarely get recession long-term unless they
lose bone.

The second presentation is a patient with much

Figure 6: After removing the old crown and probing the
deeper facial sulcus depths, 2 mm to 4 mm – or
sulcus on the left central, it is easy to see that for the gingiva
even more. This patient presents a much higher to have covered the margin, the sulcus depth six months ago
risk of recession following restoration unless the would have had to be at least 3.5 mm (green arrow).

margin is placed farther below tissue. The reason

for the risk of recession is due to the fact that
there are several millimeters of unattached
gingiva above the biologic width. The thickness of
the unattached tissue has an influence on the risk
of recession; the thinner the tissue and deeper
the sulcus, the greater the risk of recession. The
good news is it is very difficult to violate the
SPEAR | BIOLOGIC WIDTH

biologic width on these patients as you would

need to prep 2 mm to 4 mm below gingiva to
reach the attachment. (Figures 5 and 6)
 Subgingival
Margin
Placement
in Shallow
Sulcus Patients
By Frank Spear, D.D.S., M.S.D.

In patients with sulcus depths less

than 1.5 mm, the risk in subgingival
margin placement is going too deep
and violating the attachment. For
these patients, my goal for margin
placement, if a subgingival margin
is necessary, is to place the margin
.5 mm to .7 mm below tissue. This
protects the attachment, but still
leaves the margin covered by gingiva.
And since the risk of recession is low,
the .5 mm to .7 mm subgingival
placement hides the margin visually.
12
I’ve listed the steps I take to achieve the
correct subgingival margin placement
are as follows:

1. Prep the tooth completely, right to

the existing gingival margin level,
Figure 1
leaving only the subgingival margin.

2. Probe the sulcus and identify that

the probing is 1.5 mm or less. (Figure 2)
placement to be completed.
(Figure 1)

3. I am a fan of retraction cord for Figure 2

controlled subgingival margin
placement on anterior teeth, even
though I know many clinicians
prefer not to use it. I would now
place an Ultradent Ultrapak cord,
#00 (thin tissue), or #1 (most
tissue). The key is that the cord is Figure 3

placed .5 mm to .7 mm apical to the

prep margin, which was left at the
height of the gingival margin. The
cord is damp, not soaked, with
aluminum chloride solution. (Figure 3)

4. The first cord retracts the tissue, and Figure 4

also represents the correct position
for the final prep margin, .5 mm to
.7 mm subgingival. Prep to the top
of the cord using the bur that
provides adequate depth and shape
for your finish line. (Figure 4)
Figure 5

5. Place a second layer of cord, pushing

it apically so it sits at the level of
the prepped margin. If you can’t
see the second layer of cord it has
been placed too deep; you want to
visualize the second cord all around
Figure 6
SPEAR | BIOLOGIC WIDTH

the tooth.

6. Wet the top cord with water, remove

it, air dry and impress, traditionally
or optically. (Figures 5 and 6)

7. Completed restorations. (Figure 7)

Figure 7
 I have also described the fundamental concept
of biologic width; the height of the combined
connective tissue and epithelial attachment above
bone, averaging 2 mm in most patients. I also
mentioned the two possible outcomes that can
occur if a restorative margin is placed too close
to bone: one being bone loss, the other being
gingival inflammation, with the inflammation being
far more common.
Part 1:
Margin
Placement for
Deep Sulcus
Patients 104%
By Frank Spear, D.D.S., M.S.D.
Figure 1

Previously, I presented a step-by-step

approach for the management of Patient at initial presentation. Her dentist had
placed the crowns from canine to canine six
margin placement when a shallow
months earlier; the margins at the time of
facial sulcus is present (less than
placement were covered by gingiva, but within
1.5 mm), and a subgingival margin two months the tissue had receded and the
is needed. margins exposed.

The facial sulcus on the right central is 3 mm,

and the width- to-length ratio is 104 percent; the
diagnosis is altered passive eruption. She is a
perfect candidate for gingivectomies to reduce
the facial sulcus down to 1 mm to 1.5 mm, minimizing
the risk of future recession, and improving the
width-to-length ratios as well.

14
 Figure 3
Figure 2

The current facial sulcus on the left central is 2.5 mm. Following the gingivectomies, I prepped the
To have covered the margin the sulcus would have margins .5 mm to .7 mm below the tissue and
been at 3.5 mm six months earlier, a high-risk placed provisionals. The upper right image is the
situation for future recession, as she experienced. provisional eight weeks after placement. On the
I have performed gingivectomies on both centrals bottom right is what the tissue looked like after
correcting their length and leaving 1 mm to 1.5 mm removing the provisionals and prior to the final
of sulcus depth. impression; the facial sulcus depths are between
1 mm and 1.5 mm.
Option 1 is altered passive eruption. Essentially,
the gingiva has not receded to a normal position The second option for a deep facial sulcus is bone
relative to the bone and CEJ. The hallmark of this loss, and a lack of recession, effectively created
is the appearance of the teeth having short clinical by the attachment migrating apically with the
crown length. If one measures the width-to-length bone loss but the gingiva not following – a pocket
ratio of central incisors with altered passive formation, if you will. In these patients, the clinical
eruption, the ratios may be in the 90 percent to crown lengths are typically normal, so eliminating
100 percent range, or even higher, as opposed to the deep sulcus with a gingivectomy would
the more normal 75 percent to 80 percent. actually create excessively long and narrow
clinical crowns.

These patients are typically a greater risk to

restore than the altered passive eruption patients,
SPEAR | BIOLOGIC WIDTH

as the sulcus depth can’t be easily reduced with

a gingivectomy to minimize the risk of recession.
I’ll cover how I approach this type of patient in my
next article.
 In this article, I’ll present a more challenging
problem: the patient with deep facial sulcus
depths, but the gingiva is at an ideal position.
This means that the use of a gingivectomy to
reduce the sulcus depth will result in the clinical
crown appearing too long. This is typically a
patient who has had some facial bone loss, and
apical migration of the attachment, but no
subsequent recession of the gingiva.
Part 2:
You generally have two options with these

Margin Placement patients to reduce the risk of exposed margins

from future recession. The first, and often best

for Deep option, is to place your margin supragingival, not

inducing any trauma to the gingiva. This can be

Sulcus Patients
readily accomplished if translucent all-ceramic
materials can be used, especially if the existing
tooth color is acceptable. Now any future
By Frank Spear, D.D.S., M.S.D. recession really isn’t very noticeable, as the
margin was already above tissue.
Earlier, I discussed the risk of recession
when placing anterior restorations on
If you must go below tissue because of a
patients with deep facial probing depths. discolored tooth, or because you need to use a
I also showed an example of a patient more opaque restorative material (metal ceramics
who had altered passive eruption as the or zirconia for example in the case of an FPD), the
cause of the deep facial sulcus depth. risk of future margin exposure is definitely a risk.
Additionally, I demonstrated how simple My approach in these instances is to place the
margin below tissue half the depth of the probing.
gingivectomies could be used to produce
So for a 3 mm facial sulcus depth, I would place
a normal sulcus depth, eliminating the
the margin 1.5 mm below tissue. The purpose of
risk of future recession, and improving this is to minimize the risk of margin exposure if
the length of the anterior teeth. some recession occurs, but it can’t completely
prevent the risk.

Remember, in these deep sulcus patients,

violating the attachment is not a risk like it is in
shallow sulcus patients. Therefore, going half the
depth of the sulcus below tissue is biologically
acceptable, but the challenge is how to do it and
not overly traumatize the tissue in the process. The
case I am including will show you the step-by-step
approach I use to place the margin at the correct
16 depth, and protect the tissue at the same time.
Female patient in her 50s who presents unhappy
with the appearance of her old crowns, and who
needs the left lateral removed due to a vertical
root fracture.

She has refused an implant to replace the left

lateral, so an FPD will be used instead. If the centrals
were structurally healthy, I would have considered
cantilevering the left lateral off of both centrals, but
they have large post and cores, and have had apical
surgeries as well. I’m going to utilize the canine as
an abutment to replace the lateral.

The left canine has a 3 mm facial sulcus, and is the

same length as the right canine. A gingivectomy to
reduce the sulcus depth would make the canine too
long. Instead, I will place the margin half the depth
of the sulcus below gingiva, in this case 1.5 mm,
to minimize the risk of future margin exposure
from recession.

First tooth is prepped completely right to the

gingival margin.

Next, two layers of cord are placed, in this case a

layer of Ultrapak #1 first, followed by a layer of
Ultrapack #2. I’m using a probe to show that the
top of the second cord is 1.5 mm below the previously
prepped margin, which means the top of the cord is
1.5 mm below the gingival margin.

With the cords retracting the tissue out of the way,

the prep margin is now dropped to the top of the
cord, 1.5 mm below the starting gingival margin level.
SPEAR | BIOLOGIC WIDTH
 A third layer of cord is now placed on the canine, in
this case another Ultrapak #1. The cord is placed so
it sits between the prep margin and the gingiva, no
deeper. It should be easily seen all around the tooth.

The third or top layer is now removed to allow for

an impression. Note how the margin, which is 1.5 mm
below gingiva, is readily visible, and the tissue
hasn’t been traumatized. In this case, I’m making
the impression to allow for a provisional to be
fabricated indirectly prior to removing the lateral.

The lateral was removed after fabricating the

provisional, which extended 2 mm into the
extraction site.

“... I would have considered cantilevering the left lateral

off of both centrals, but they have large post and cores,
and have had apical surgeries as well.”
~ DR. FRANK SPEAR

18
 The provisional on the day of placement.

The provisional on the left, nine months after

placement. On the right, what the tissue looked like
after provisional removal. Note the margin depth
below tissue on the canine, but the tissue health
is excellent.

On the left, the final restoration a few months after

placement. On the right, a 10-year follow-up. In this
patient there has been almost no recession on
the canine.

Free Lesson – ‘5 Dimensions of Tooth Problems’

This lesson — one of three in the Outcome-Based Restorative
Concepts course — highlights how to replicate tooth structure
with restorative materials while preserving tooth structure
and using the least invasive procedures.

Visit content.speareducation.com/
5-dimensions-of-tooth-problems to learn:
• The concepts of outcome-based
preparation design
SPEAR | BIOLOGIC WIDTH

• Five dimensions of tooth problems

that may exist and need to be resolved
• Where to position preparation finish lines
for full-and partial-coverage restorations
 When we see an anterior restoration, particularly a
full crown that has significant gingival inflammation,
a series of possible diagnoses exist:

• It could be plaque control, but if the adjacent

teeth have healthy gingiva, that is unlikely
• It could be marginal fit, which can be examined
with an explorer and radiograph
• It could be poor contour, preventing adequate

Diagnosing a •
hygiene, again possible to examine
It could be an allergic response to the restorative
material, especially if the restoration was done
Biologic in the ’80s or ’90s using a nickel-containing
alloy, and the patient is female

Width Violation But it could be because the margin is placed too

close to bone, violating the biologic width. (Figures 1-4)
By Frank Spear, D.D.S., M.S.D.

In previous articles, I have discussed Ideally, if the existing restoration is removed, and
what biologic width is, and described a well-fitting temporary placed for at least three
months without the return of any gingival
how I place restorative margins
inflammation, you would assume the margin
based upon the presenting sulcus
location was not the problem, and one of the other
depth and thickness of the gingiva. etiologies applied. The reason for the three-month
This article will start to address how wait is that it is not unusual to damage the
to diagnose inflammation around attachment apparatus when removing an old
restorations that exists because the restoration and placing a temporary. You may see
margins have been placed too deep, perfectly healthy-looking tissue until it heals and
violating the attachment. matures, which is usually between eight and 12
weeks, and then the inflammation returns.

Figure 1: Female patient in her 40s who presents with four

bonded all-ceramic crowns on her maxillary incisors.
She is unhappy with the appearance of the restorations, but
especially unhappy with the inflamed appearance of the
20
gingiva, particularly the right central and lateral.
 Of course not every patient wants you to take off
their restoration to make a diagnosis, so here are
some other options to assist in deciding if the
margin location is the problem:

First, simply place a perio probe in the sulcus until

it reaches the margin; do this circumferentially
around the tooth. What you are looking for is pain:
a margin in the sulcus will result in no response, a
margin in the connective tissue attachment will be
Figure 2: I removed the old crowns to place long-term
painful to probe.
temporaries and see how the tissue would respond. After
removing them, I measured the distance from margin to
bone; the probe is on bone showing the margin barely 1 mm Next, anesthetize the tooth you are concerned
away, a definite biological width violation. about. Place the perio probe on the restorative
margin, and read the distance from there to the
gingival margin. Keeping the probe against the
root laterally, slide the probe down to bone,
allowing you to compare the previous probe
readings vs. when the probe is on bone.

Third, use a periapical radiograph. While it won’t

let you see the margin location relative to bone
on the facial, it will on the interproximal.

If the margin is painful to probe, is within 2 mm of

the bone when measuring it, or on a radiograph,
you probably have a biologic width violation, and
the only thing you will be able to do to eliminate
the inflammation is to correct the problem.

Figures 3 and 4: Her biologic width violation was corrected

surgically. Before and two years after final restoration.
SPEAR | BIOLOGIC WIDTH
 There are two ways to move the margin away
from bone, one is orthodontic extrusion, which
will be looked at it in my next article, the other
is to do so-called “root reshaping,” where the
old margin is smoothed away, and a new margin
prepped at a more coronal and correct level.
This approach can be very useful when the
previous tooth preparation was done with
minimal tooth reduction, but is much more
Surgical difficult if a heavy chamfer or shoulder had
been previously prepared.

Correction The more common solution for biologic width

of a Biologic
violations is to move the bone away from the
margin with osseous surgery. The challenge with
the osseous surgery is the risk of recession
Width Violation occurring. If you were dealing with a single
central incisor that had the margin placed too

on the Facial deep on the direct facial, surgery would

definitely be my first choice, lay a facial flap,

Surface Only remove the necessary facial bone and replace

the flap to its original position. (Figures 1-5)

By Frank Spear, D.D.S., M.S.D.

If the tissue is normal in thickness it is rare to see
When a restorative margin is placed much, if any recession. If the tissue is thin, the risk
is higher, but it is always possible to come back
too close to bone, and gingival
with a connective tissue graft to cover the root
inflammation occurs, the only
and margin.
solutions to eliminate the inflammation
are to move the margin away from The real challenge is if you were dealing with
bone, or move the bone away from a single central restoration that has a biologic
the margin. In most instances the width violation on the interproximal. Now if you
classic measurements from Garguilo, remove bone to correct the violation, there is a
much higher incidence of getting some loss of
Wentz and Orban would be used for
papilla and opening of the gingival embrasure.
the correction; in other words, create
2.5 mm to 3 mm of space between I will look at how to manage the interproximal
the margin and bone. violation in my next article.

22
Figure 1: I first placed the left central incisor crown in 1983,
Figure 3: Osseous surgery - We decided to go ahead and do
replacing an existing crown with a deep facial margin, and
the crown again, but also remove facial bone to correct the
significant gingival inflammation. This photo was from 1995,
margin-to-bone relationship (biologic width). Because the
12 years later, the gingiva is still inflamed, and I have redone
margin was fine relative to interproximal bone, only a facial
the crown three times with different materials. This is a
flap was raised; the facial bone was removed to create a
classic example of a biologic width violation.
3 mm space between the facial margin and bone.

Figure 2: Probing findings - The bone is 3.5 mm – 4 mm Figure 4: The gingival appearance three months post-surgery.
apical to the gingival margin (yellow line) The sulcus on the
right central, top of the attachment, is about 1.5 mm deep
(green line) The margin on the left central is 1.5 mm to
2.5 mm from bone (black line).
SPEAR | BIOLOGIC WIDTH

Figure 5: Final restoration 10 years post–surgery and

placement, note the gingival health.
 It is important to remember the desired outcome
for the correction of the biologic width violation,
the margin 2.5 mm from bone, and if it is a tooth
with endo and a post and core, an additional
1.5 mm of tooth structure exposed for adequate
ferrule. So for teeth with endo and post and cores
4 mm of tooth structure must be exposed coronal
to the bone. (Figure 3)

Managing THERE ARE TWO WAYS TO

Interproximal ACCOMPLISH THE EXTRUSION:

Biologic Width
1: Slow extrusion of .5 mm to 1 mm per month,
which allows the bone and gingiva to follow the
tooth. This is then followed by osseous surgery
Violations to reposition the bone and gingiva ideally, which
exposes the tooth as well. This approach is highly

on Single predictable, and is generally chosen, especially

when there are other orthodontic concerns as well.

Anterior Teeth 2. The second approach, which is normally

chosen only when a single tooth needs treatment,
By Frank Spear, D.D.S., M.S.D.
i.e., no other orthodontic needs, or other teeth
Earlier I described how osseous with biologic width violations adjacent to the
tooth you desire to treat, is to use rapid extrusion,
surgery to remove bone was a viable
generally all of the movement within four weeks.
option for correcting a biologic width
The key to this approach is to perform supracrestal
violation on the facial of a single fiberotomies weekly, to discourage the bone and
anterior tooth, but was rarely a good gingiva from following. But it is necessary to retain
option if the violation was on the tooth in position for at least 12 more weeks
the interproximal. to prevent re-intrusion, and to evaluate if osseous
surgery is necessary due to the bone and gingiva
creeping in a coronal direction. (Figures 4-7)

24
 1

Finally, in all cases where forced extrusion is being

used to resolve a biologic width violation, the
amount of root in bone is being reduced by the
amount the tooth is being extruded. While often
clinicians worry about keeping a 1/1 crown-to-root
ratio at a minimum, my experience has been that
leaving 8 mm to 9 mm of root in bone has
provided a successful long–term solution. In my
next article, we will address the most difficult
biologic width problem, both interproximal and
Figure 2: In order to expose the 4 mm of tooth necessary to
facial violations on all the anterior teeth.
predictably restore the right central, the interproximal bone
between the centrals would need to be removed, and would
be esthetically unacceptable.

Margin to
bone 2.5 mm
Ferrule 1.5 mm

Figure 1: A 23-year-old female who fractured her right central

incisor below the crest of bone on the mesial interproximally,
as well as below bone across the plate. Her dentist performed
Figure 3
endo, a post and core, and placed a temporary to manage
the esthetics, but the biologic width violation must
To predictably restore a tooth fractured at or
be corrected.
below the crest of bone, room must be created
between the future margin of the restoration and
the bone. 2.5 mm is needed to accommodate
the biologic width, and an additional 1.5 mm
is required to have an adequate ferrule for
the restoration.

This means that 4 mm of tooth must be

exposed above the crest of bone to satisfy these
SPEAR | BIOLOGIC WIDTH

requirements. This can be done through bone

removal, orthodontic extrusion followed by
osseous surgery, or sometimes just rapid
orthodontic extrusion.
 Figure 5

There are two ways to approach the extrusion.

Slow, .5 mm to 1 mm per month, to allow the bone
and tissue to follow, followed by osseous surgery
to reposition the bone and tissue correctly, very
predictable. Or rapid, with weekly coronal
fiberotomies to try and prevent the bone and
Figure 4 tissue from following, much less predictable.

Removing the temporary shows the fracture

extends .5 mm below bone from the mesial, around
the palate, and to the distal. The goal will be
4.5 mm of extrusion so that 4 mm of tooth can
be exposed above bone.

Figure 6

26
 Figure 9

The completed smile above, the presentation

Figure 7 radiograph on the lower left. Note in the final smile
the papilla levels are level from canine to canine.
Following the extrusion, the tooth was retained This would not have been possible had
in position three months, to be sure the bone and interproximal bone been removed.
gingiva did not creep down in a coronal direction,
and to prevent the tooth from re-intruding. With
the temp off, we can now see healthy gingiva, and
an adequate ferrule all around tooth. The laterals
and left central were prepared for veneers as well.

SPEAR | BIOLOGIC WIDTH

Figure 8
 Managing
Figure 1: Patient had full crowns placed six months ago from
first premolar to first premolar, all preps are within 1 mm to
1.5 mm of bone on the facial and interproximal. She has

Facial and significant gingival inflammation from the biologic width

violations across all the anterior teeth. Note the dark gray
cervical areas of tall the crowns, evidence of leakage and

Interproximal bacterial growth under the restorations.

Biologic Width
Violations
on Multiple
Adjacent Teeth
By Frank Spear, D.D.S., M.S.D.
Figure 2: When the biologic width violation extends across
the facial and through the interproximal on multiple teeth,
Patients with multiple adjacent existing
osseous surgery to remove bone is the most common option
anterior crowns, prepped essentially for correction. The risk is the unknown of how much facial and
to bone, are some of the most interproximal recession may occur following bone removal to
position the bone an acceptable distance from the margins.
challenging esthetic cases to treat.
There is usually significant gingival
inflammation, and if the crowns were The only solution that I have found successful in
bonded, there is often significant black these cases is to start by addressing the biologic
width problem first, the margins being too close
staining from the bacterial growth that
to bone. This is done with osseous surgery, by
occurs when attempting to bond in
correcting the bone-to-margin distance. The bone
a highly contaminated environment, removal creates the risk of recession, and this risk
heaviest in the cervical 1/3, and is especially high when bone has to be removed on
showing through the translucent both the facial and interproximal. (Figure 2)
crowns. (Figure 1)

28
 Figure 4: Temps in place, prior to bone removal, the margins
are all within 1 mm - 1.5 mm of the bone.
Figure 3: Removing the crowns reveals significant leakage
due to the dentist attempting to bond the restorations in a
deep and inflamed environment.

On these patients, my first step is to remove

the old crowns so I can visualize the quality of
each tooth, and also assess the distance from
the margin to bone using a probe 360 degrees
around the tooth. Additionally, it lets me see
how heavy the prior tooth reduction was, and if
the reduction at the margin was minimal. For
example, with a slice type finish line, it is often
possible to do minor “root reshaping,” by Figure 5: To make sure there was adequate space for biologic
essentially smoothing out the old margin. This width, the bone was moved both facially and interproximally
needs to be followed by re-prepping a new 3 mm from the margins.

margin the correct distance from bone, and

The amount of bone removal is dictated by how
eliminates the need for any bone removal.
close the existing margins are to the bone, and
When the preps are heavy shoulders or chamfers,
whether all the teeth were prepped the same or
bone removal becomes mandatory. (Figure 3)
not. As a rule, I would move the bone 2.5 mm to
3 mm away from the existing margins all the way
around the teeth to accommodate the biologic
width. It would be unusual for a patient to need
more space than that. (Figures 4 and 5) SPEAR | BIOLOGIC WIDTH
 At the time of suturing, assuming the
pre-treatment crown length was acceptable,
i.e., no crown lengthening was desired, the flap
should be replaced exactly where it was
pre-surgically, not apically positioned. The goal
is to hope for a longer attachment apparatus
rather than a deeper pocket followed by
recession. (Figure 6)
Figure 7: Six months post-surgery, still in provisionals, no
inflammation, and no recession. Recession in these cases is
I often get asked about how long to wait
highly influenced by the thickness of the periodontium.
following healing before proceeding in these
types of patients. Remember, this is not a typical
crown-lengthening case; the bone has been
moved apically, but the tissue has not, so the risk
of recession is much higher. Also, we are usually
treating a patient who is unhappy about the need
for the treatment. I typically wait six months
minimum before moving forward. (Figure 7)

Depending upon the patient’s gingival thickness,

it can be surprising how often no recession
occurs on either the facial or interproximal, even
when 2 mm of bone has been removed around
the teeth. (Figures 8 and 9)

Figure 8: Pre- vs. five years post-treatment, note the lack of

inflammation or recession on bottom image.

Figure 6: The flaps were sutured back to their pre-surgical

position; time will tell if some recession occurs and if slow
ortho extrusion is necessary. Figure 9

30
Interdisciplinary
Case Management
Learn how to implement a team approach to achieve
optimal patient outcomes regardless of case complexity
In Spear’s Interdisciplinary Case Management seminar, four of the world’s most
respected clinicians explain how individual specialist roles relate to patient
evaluation and management.

INSTRUCTORS:

Greggory Kinzer Rebecca Bockow Michael Gunson Jim Janakievski

D.D.S., M.S.D. D.D.S., M.S. D.D.S., M.D. D.D.S., M.S.D.

You’ll develop the confidence to interpret patients’ diagnostic

information to aid in treatment planning while recognizing
how each dental specialty views and evaluates common
esthetic dilemmas.

• Discover how to determine if a restricted airway is an etiology

to consider in treatment planning and options to address
airway concerns

• Understand how function and esthetics are inseparably

linked and necessary for achieving long-term, stable results
and the importance of defining the desired tooth position
as the first step in any interdisciplinary treatment plan

• Gain key diagnostic and treatment planning tools

to evaluate facial development, profile and esthetic
appearance to identify patients who may be best
treated with orthognathic surgery
SPEAR | BIOLOGIC WIDTH

Interdisciplinary Case Management

Spear Campus | Scottsdale, Arizona | 2 days | 14 CE credits

Register for your ideal dates at

CAMPUS.SPEAREDUCATION.COM/SEMINARS/INTERDISCIPLINARY-CASE-MANAGEMENT
 The Gateway to Great Dentistry
Dentistry’s Most Innovative Online Learning Resource

Membership to Spear Online provides your entire practice team with:

PATIENT EDUCATION TEAM TRAINING AND

Make chairside case presentation more MEETING RESOURCES
engaging with our new tablet app, or stream Utilize tools designed for your front office,
animated videos to your lobby monitors via hygienists and assistants. When your staff
Fire TV Stick and Apple TV — options designed understands and communicates the value
to empower even the most hesitant patient to of the dentistry you provide, patients are
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CLINICIAN EDUCATION SPEAR TALK

Increase your skills and earn continuing Connect with thousands of like-minded
education credits on your own schedule colleagues in a safe, supportive, clinician-
with more than 1,500 clinical and practice only environment meticulously monitored by
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most respected clinicians. answers to any clinical or practice challenge.

32
Discover how Spear Online impacts your entire practice:
855.625.2333 | online@speareducation.com | speareducation.com/spear-online
ABOUT SPEAR Based in Scottsdale, Arizona, Spear Education
is an innovative dental education company that
includes the following practice-building,
member-based services:

Spear Campus
Thousands of dentists visit Spear’s Scottsdale
campus annually for continuing education seminars
and courses. Members attend sessions in a
state-of-the-art, 300-person lecture hall and
receive hands-on training in the Spear laboratory.

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Dentistry’s most innovative online growth platform
has been proven to help increase case acceptance,
create a united team and maximize patient care for
thousands of dentists and their teams.

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This is designed as a prestigious community of
doctors who share the journey to Great Dentistry
with others committed to continued learning,
professional growth and providing the best patient
care. This group is at capacity and acceptance is
on a wait-list basis.

Spear Study Club

Spear’s Study Club model involves small groups
of peers that meet locally as many as eight times
a year to collaborate on real-world cases, improve
their clinical expertise and discuss improving
interdisciplinary care. Spear has the largest network
of study clubs, with active clubs in more than 40
states and six countries.

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The technology-enabled consulting platform
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and real-time analytics to help your practice reach
its full potential.