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Review Article The perio-restorative interrelationship-

expanding the horizons in esthetic dentistry
Priya John, Majo Ambooken, Anu Kuriakose, Jayan Jacob Mathew
Department of Periodontics, Mar Baselios Dental College, Thankalam, Kothamangalam, Kerala, India

Address for correspondence: Dr. Priya John, E-mail: priyajoseph226@gmail.com

ABSTRACT
The astute clinician strives to create a beautiful smile paying due heed not only to the gleaming white teeth, but also to the
health of the surrounding tissues. A sound periodontium provides a firm foundation for an esthetic and functional prosthesis.
Conversely, when restorations are designed to be self-cleansing and promote gingival health, the tissues present a harmonious
esthetic blend at the restorative -gingival interface. This review paper aims at exploring the potential of an interdisciplinary
approach to achieve this end. This involves incorporating a comprehensive treatment plan, paying close attention to both soft and
hard tissues around teeth and implants before, during, and after restorative procedure. Key aspects of the restoration and partial
denture design that have a direct effect on the periodontium include restoration contour, margin adaptation, margin placement,
prosthetic and restorative materials, design of fixed and removable partial dentures, restorative procedures and occlusal function.
Special emphasis is paid to the consequences of violation of biologic width, that leads to incessant inflammation, possible
recession and unsightly exposure of crown margin. Periodontal considerations include control of periodontal inflammation,
correction of the gingival architecture, and periodontal maintenance. A search of articles from “Pubmed” and “Medline” with
the keywords restorative-alveolar interface, methods of gingival retraction and biologic width was conducted. A total of 430
abstracts were collected, of which most relevant articles were included in this paper.

CLINICAL RELEVANCE TO INTERDISCIPLINARY DENTISTRY

• To promote restoration and pontic designs that promote favorable tissue response.
• To stress the importance of preserving biologic width to all dental practitioners
• To shed light on iatrogenic damage to the periodontium from certain materials and procedures.
• To unveil the potential of periodontal plastic surgery techniques like augmenting attached gingiva and esthetic crown
lengthening prior to restorative procedures when indicated.
• To emphasize the need for recall and maintenance therapy.
All the above concepts can be successfully implemented into clinical practice.

Key words: Methods of gingival retraction, biologic width, restorative-alvelolar interface

INTRODUCTION restorative treatment may have adverse effects

on the periodontium by increasing accumulation

A beautiful smile can be crafted only against

a backdrop of healthy gingiva. A sound
periodontium provides a firm foundation for an
of plaque while untreated periodontal disease will
compromise the success of restorative dentistry.[1]
When restorations are designed to be self‑cleansing
esthetic and functional prosthesis. The practice of and promote gingival health, the tissues present a
restorative dentistry has a reciprocal relationship harmonious esthetic blend at the restorative‑gingival
with the maintenance of periodontal health. Poor
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DOI: How to cite this article: John P, Ambooken M, Kuriakose A, Mathew JJ. The
10.4103/2229-5194.162745 perio-restorative interrelationship-expanding the horizons in esthetic
dentistry. J Interdiscip Dentistry 2015;5:46-53.

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John, et al.: The perio-restorative interrelationship

interface. The purpose of this review is to explore the • An unesthetic emergence profile of a restoration is
effects of contemporary restorative procedures and created. The emergence profile is the shape of the
materials on the periodontium. On the other hand, the restoration in relation to the gingival tissues. Stein and
clinical relevance of some periodontal plastic surgery Kuwata described the part of the axial contour that
procedures for a healthier restorative‑alveolar interface extends from the base of the gingival sulcus past the
is outlined. free margin of the gingiva as the emergence profile
that was straight in the gingival third.[9]

RESTORATIVE CONSIDERATIONS Schluger et al. felt the cervical bulge overprotects the
THAT IMPACT THE PERIODONTIUM microbial plaque. Schluger et al. have advocated “flat”
not “fat” contours.[8] Over contouring is potentially more
• Restoration contour and contact areas detrimental to the periodontium than under contouring.[10]
• Margin adaptation and defects
• Location of margin Contact areas
• Role of provisional restorations
• Design of fixed and removable partial dentures (RPDs) • Should be in the coronal third of the crown and buccal
• Occlusal function in relation to the central fossa
• Prosthetic and restorative materials and alloy • Proximal contact points are buccal to the central
hypersensitivity fossa line, except for maxillary molars founds at the
• Iatrogenic damage from restorative procedures. middle third. This creates a large lingual embrasure
for optimum health of the lingual papilla.[2,5]
Contour and contact areas
Problems with misplaced contacts
Clinical longevity of any prosthesis is directly related to
achieving proper restorative contours.[2] It is the function of • Horizontal food impaction is produced by the action
the axial form of teeth to afford protection and stimulation of the tongue, lips, cheeks and results from poorly
to the marginal periodontium.[3,4] contoured interproximal surfaces. Lower fixed
partial dentures usually collect more food than upper
Physiologic tooth contouring dentures, particularly in the molar region
• Lifting and rotating forces on dentures
• Allows for self‑cleansing mechanisms of cheek, • Deflective occlusal contacts.[11]
tongue, etc. For instance, the bucco‑lingual bulge
should be <0.5 mm wider than the cemento‑enamel Marginal adaptation and defects
junction[3,5,6]
• There must be sufficient space: Cervically to create • Scientific data indicate that even clinically successful
the correct contour that facilitates plaque removal, crowns have margins that are open. The average
occlusally to allow the restoration of a proper opening is about 100 nm, which tends to harbor
occlusion, and axially to provide a proper thickness bacterial plaque even around the best fitting margins
of veneering material to achieve an esthetically of a restoration causing inflammation[4,5]
acceptable prosthesis. • Roughness of the tooth‑restoration interface from
scratches in the surface of carefully polished acrylic
Insufficient preparation of abutment teeth is often done and ceramic crowns, inadequate marginal fit of the
to preserve sound tooth structure, but often results in restoration, dissolution and disintegration of the
over contouring. luting material causing crater formation between the
preparation and the restoration and inflammation of
Problems with over contouring gingiva[12]
• Sharp edges or corners in the preparation not
• “Food traps” from open contacts, overhangs, or reproduced accurately on the stone die can create
plunger cusps may occur marginal discrepancies. Dentists must ensure that the
• Poor occlusal design, and poor esthetics[5,6] crowns completely seat on the tooth.
• When the coronal contour of a restoration prevents
access for oral hygiene or creates mechanical pressure Preparation margin designs for metal ceramic
on the gingival tissue, gingival health is likely to be
crowns
compromised[7]
• Plaque accumulation, inflammation, bleeding, and • The chamfer: The thin metal collar may distort during
potential bone loss. Plaque is the primary factor in the firing of porcelain, thus producing inaccurate
gingivitis[8] margins

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John, et al.: The perio-restorative interrelationship

• Feather‑edge margin: Used for cast crowns and The concept of biologic width, and its applications
veneers. But finish line is hard to read and not in placement of gingival margins
amenable to thorough finishing and polishing
Understanding and clinically managing the concept of
• A shoulder with bevel is more conservative than a full
biological width is the key to creating gingival harmony
shoulder preparation, but the presence of the metal
collar necessitates an intra‑crevicular preparation in with dental restorations. The biologic width is defined
esthetic areas as the dimension of space occupied by the soft tissues
• A shoulder preparation allows for sufficient bulk above the level of the alveolar crest. The connective
for porcelain to produce esthetically pleasing tissue attachment occupied 1.07 mm above the level of
restorations.[11,13] the crestal bone, junctional epithelium attachment below
the base of the gingival sulcus to be 0.97 mm, and an
Location of margin: The clinical significance average sulcus depth of 0.69 mm. In the average human,
this 2–3‑mm distance remains constant in health and
of margin placement
disease.[21,22] Encroachment on the biological width by
Eissman et al.’s design criteria for fixed partial dentures tooth preparation, caries, fracture, restorative materials
state that crown margins should be placed on tooth or orthodontic devices can lead to bacterial accumulation,
surfaces that are fully exposed to cleansing action, persistent gingival inflammation eventually resulting in
preferably supragingival or slightly into the sulcus. [3] increased probing depths, gingival recession or pocket
Vigorous tooth brushing was effective up to 0.7 mm below formation.
the gingival margin, suggesting that the submarginal
extension of restorations should be limited to no more Assessment of biologic width
than this distance.[7] Restorative requirements frequently
necessitate subgingival margin placement in order to gain Wilson and Maynard have described the concept of
resistance or retention form to alter tooth contour, for intra‑crevicular restorative dentistry. Intra‑crevicular
caries for subgingival tooth fracture removal, in furcation margins are defined as those confined within the
involvement and to hide the tooth‑restorative interface gingival crevice.[23] The restorative dentist must be able
or have contacts that need to be lengthened apically to to determine the base of the sulcus for intra‑crevicular
avoid black triangles.[8] In such cases, subgingival margin margin location. Kois suggested that the restorative
placement is necessary, marginal fit should be optimal dentist must determine the total distance from the
because rough restorations or grossly open margins lead gingival crest to the alveolar crest.[4] This procedure is
to an accumulation of bacterial plaque.[12] termed bone sounding. The tissues are anesthetized,
and the periodontal probe is placed in the sulcus and
Advantages of supragingival margins over pushed through the attachment apparatus until the
subgingival margins tip of the probe engages alveolar bone. Based on this
measurement, the three categories of biologic width
• Supragingival margins improved periodontal health[14] described are:[24]
• Subgingival margins demonstrated increased plaque, • Normal crest: A biologic width of 3 mm on the
gingival index score, and probing depths[15] labial aspect allows for a crown margin that is placed
• Furthermore, more spirochetes, fusiforms, rods and 0.5 mm subgingivally
filamentous bacteria were found to be associated with • High crest: Measurement lesser than 3 mm does not
subgingival margins[16‑18] allow for subgingival margins without bone removal
• Violation of the connective tissue attachment; and • Low crest: Measurement of more than 3.0 mm. It
greater pathogenicity of the subgingival plaque are is most susceptible to recession secondary to the
documented with subgingival margins[17] placement of an intra‑crevicular crown margin in the
• Supragingival margins stay away from the periodontal presence of a thin periodontium.
tissues, and thus, they are easier to prepare, record
and maintain.[13,19] This is an attempt of the body to recreate room above the
alveolar crest for tissue reattachment.
Current trends favor equigingival margins over older
concepts of subgingival margins for crowns, which are
Correction of violation of biologic width
kinder to the periodontium. Furthermore, advances with
emerging translucent restorative materials adhesive To restore gingival health, it is necessary to reestablish the
dentistry, and r esin cements, pr omote polished space clinically between alveolar bone and the gingival
margins that esthetically blend with the tooth for a margin. For this purpose, either surgery to alter bone
healthy tooth‑restorative interface even when placed level[25,26] or orthodontic extrusion of the tooth to move
equigingival.[20] the restoration margin away from the bone level.

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John, et al.: The perio-restorative interrelationship

Margin placement guidelines construction. The undersurface of pontics in fixed bridges

should barely touch the mucosa. When the contact is
• Rule I: If the sulcus probes 1.5 mm or less, place the
excessive, it prevents cleaning. The “modified ridge‑lap”
restoration margin 0.5 mm below the gingival tissue
pontic has pinpoint, pressure‑free contact on the facial
crest
slope of the ridge, and all surfaces should be convex,
• Rule II: If the sulcus probes more than 1.5 mm, place
smooth, and highly polished or glazed.[11,32,33] The sanitary
the margin one‑half the depth of the sulcus below
pontic is most hygienic, but ovate pontic combines both
the tissue crest. This places the margin enough below
esthetics and hygiene.
tissue so that it is still covered if the patient is at higher
risk of recession
Crowns for root‑resected teeth
• Rule III: If the sulcus >2 mm is found, especially on the
facial aspect of the tooth, then evaluate to see whether Root resection may be indicated in multirooted teeth with
a gingivectomy could be performed to lengthen the advanced Grade II to III furcation involvements.[26] Crowns
teeth and create a 1.5 mm sulcus. Then the patient that are placed on upper molars that have undergone root
can be treated as mentioned in rule I.[25] resection must be contoured in a specific way to ensure
that the patient has access for oral hygiene measures. The
Gingival retraction preparation eliminates residual ledges, roots, furcation
lips or horizontal components or the furcation.[33,34] The
It can be achieved mechanically using retraction cords,
gingival embrasure form created in the restoration must be
copper bands or cords.
fluted into these areas so that the surfaces can be accessed
an interdental brush, a knife edge or chamfer margin is
• A single‑cord technique is the least traumatic option
indicated[9] [Figure 1].
than two cord technique and is normally employed
when the sulcus, is shallow, and the margin is
A cast post and core may be indicated to create an
placed only minimally in the crevice in areas of root
adequate foundation for the final restoration.[33] When
proximity.[25,27]
palatal root has been resected, re‑contouring of the crown
results in a much thinner crown buccopalatally. After root
Chemicals used for the treatment of chords diffuse in
separation, close proximity of the roots should be relieved
blood circulation through crevicular epithelium, help to
using one of the following options.
control seepage of blood or gingival fluid but Can cause
• Partial instead of full‑coverage restorations to avoid
damage to gingiva if used injudiciously.[20,25] Newer and
preparing and restoring the side of the tooth with the
safer materials like biocompatible polymer – hydroxylate
proximity problem
polyvinyl acetate (Merocel) absorbs intraoral fluids and
• More apical placement of the restorative margin if the
is soft and adaptable. Expasyl is a paste that not only
root trunk tapers apically or an odontoplasty with a
opens the sulcus but also leaves the field dry. It is mainly
flame‑shaped bur to increase the separation
composed of micronized kaolin, aluminum chloride and
• Orthodontic movement to separate the teeth; and
water.[28]
strategic extractions.[20]
Role of provisional restorations Lateral forces are controlled by minimizing cuspal inclines
Provisional restorations are needed to protect the on the resected molar and the teeth stabilizing it. Bergman
prepared teeth, to reduce the sensitivity of the vital
abutments, and to prevent tooth migration. They are
used to correct esthetics, phonetics and occlusal scheme
before fabrication of the definitive restoration. Provisionals
should have good marginal fit and polish. This prevents
plaque accumulation and related inflammatory gingival
overgrowth or recession.[1,29,30]

Design of fixed and partial dentures and

crowns for root‑resected teeth
A bridge should be designed to minimize accumulation
of dental plaque and food debris and to maximize access
for cleansing by the patient. It should also provide
embrasures for the passage of food and protection of Figure 1: Treatment of Grade II furcation involvement with root
gingival crevices.[31] Stein concluded that the pontic design resection. Contour of crown modified to prevent ledge formation.
was more important than the material used in the pontic Occlusal platform reduced

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John, et al.: The perio-restorative interrelationship

et al. (1982) also reported that RPDs did not compromise • Hemisection with fixed bridges in cases of extensive
long‑ter m dental health. Conventional RPDs were bifurcation involvement.[27]
designed and fabricated to keep denture bases, clasps,
and bars as far from the gingiva as possible.[35] The purpose of restorative dentistry is to restore and
maintain health and functional comfort of the natural
Occlusion dentition combined with satisfactory esthetics. Thus,
all dental restorations should comply with established
Occlusal discrepancies in a restoration appear to be
requirements for periodontal physiology and health, both
a significant risk factor that contributes to more rapid
with regard to surface and functional characteristics.[39]
periodontal destruction and that treatment of occlusal
discrepancies seemed to slow periodontal destruction.[36]
Cantilever designs often result in fractures of casting and
PERIODONTAL CONSIDERATIONS
roots and periodontal inflammation around abutment
tooth. Occlusal evaluation is to be done after inflammation Periodontal therapy to resolve inflammation must be
due to periodontitis has subsided due to changes in completed before restorative dentistry.
tooth‑tissue relationship. Occlusal appliance therapy may
be used before occlusal adjustment for acute issues. Use Importance of a healthy periodontium:
cantilevers sparingly and with light occlusal contact if
A firm foundation for precise and lasting
needed with multiple abutments.[33]
restorations
Restorative materials and alloy sensitivity • Healthy gingival margins do not shrink after tooth
preparation and enable accurate impressions[40,41]
Self‑curing acrylics are less tissue friendly. Improperly
• There are less chances of bleeding after preparation,
finished composites may become rough. Phosphate
which aids visibility and making impressions[42]
cements and silicates are irritant. Lab cast and high
• Stable tissues, free of inflammation ensures predictable
polish of restorations is important in preventing plaque restorations[43]
accumulation.[37] Unfavorable gingival reactions to alloys • Trauma from occlusion on teeth with untreated
used in the oral environment have been documented.[38] periodontitis may increase tooth mobility and rate of
The fine marginal fit of glass ceramics and porcelain veneers attachment loss[44]
have least gingival irritation. • Quality and topography of the periodontium should
be improved to prevent negative changes once the
Iatrogenic damage from procedures restorations have been placed.[2] For instance, a wider
Special care should be directed to minimize mechanical zone of attached gingiva is needed around abutment
and chemical trauma to the natural dentition and to the teeth and in those with subgingival restorations
periodontium during restorative procedures. Injudicious as less inflammation is reported than in teeth with
use of electrosurgery, cryosurgery and laser can cause narrow zones.[45] It is useful in areas of esthetic margin
excessive necrosis of the gingiva and in extreme cases, placement, to facilitate impressions, and in some cases,
the underlying bone. Excessive pressure while trimming to increase patient comfort. Thicker tissues have been
and fitting bands may sever or traumatize the gingival found to provide adequate protection against recession.
attachment and lead to irreversible gingival recession.[27]
The residual material of retraction cords left in the crevice Periodontal therapy
can lead to periodontal abscess later. Injury from rubber • A thorough periodontal evaluation is indicated in the
dam clamp and disks can lead to gingival inflammation. planning stages prior to fabrication of the prosthesis.
Selection of abutment teeth is based on prosthodontic
and periodontal considerations, including bone
CURRENT TRENDS IN PERIODONTAL support and architecture, width of attached gingiva,
ASPECTS OF RESTORATIVE tooth mobility, root anatomy, and tooth position
DENTISTRY • Controlling or eliminating periodontal disease
with cause‑related therapy and surgical therapy to
• Supragingival placement of margins of restorations eliminate pockets
• Avoidance of over contoured restoration, and minimal • Correction of the gingival architecture that may favor
concern with lack of contour disease, impair esthetics, or impede placement of
• Occlusal stability through precise occlusal adjustment prosthesis with preprosthetic surgery
and accurate reconstruction of occlusal anatomy in • Periodontal maintenance and motivation for oral
single restorations hygiene should be given during treatment and interim
• Restricted indications for splinting of mobile teeth periods.[27]

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John, et al.: The perio-restorative interrelationship

Cause‑related therapy eliminates tension on marginal gingiva in the area of

a frenum
Plaque control, calculus removal, and the removal of any
• Removal of gingival excess and maintaining biologic
inadequate dental restorations in the gingival environment,
width: In situations in which a tooth has a short
treatment of food impaction, correction of trauma from
clinical crown deemed inadequate for retention of a
occlusion, and orthodontic tooth movement, motivation
required cast restoration, it is necessary to increase
for oral hygiene, as well as extraction of hopeless teeth
the size of the clinical crown using periodontal surgical
can be done.
procedures [Figure 5].
Surgical therapy This can be done surgically or orthodontically while
• Periodontal flap surgery may be necessary to gain maintaining the biologic width. To select the proper
access for debridement, to reduce pockets and treatment approach for crown lengthening, an analysis
for periodontal regenerative therapy with bone of the individual case with regard to crown‑root alveolar
grafts [Figure 2] bone relationships should be done.
• Preprosthetic surgery: Gingival augmentation: It can
be done using a free gingival graft or connective tissue • External bevel gingivectomy: This can be done when
graft or acellular dermal matrix[16] there is more than adequate attached gingiva and at
• A vestibuloplasty may be required in areas where least 5 mm excessive suprabony gingival tissue is
a shallow vestibule complicates oral hygiene. present and no bone involvement [Figure 6]
Correction of shallow vestibule also facilitates gain
in attached gingiva. Vestibuloplasty by periosteal
fenestration [Figure 3], and vestibuloplasty with free
gingival graft [Figure 4]. Removal of aberrant frena
improves vestibular depth, attached gingiva and

Figure 3: Vestibuloplasty with periosteal fenestration for treatment of

shallow vestibule and insufficient width of attached gingiva

Figure 2: Flap surgery with bone grafting

Figure 5: Crown lengthening with osteoplasty done for unesthetic

Figure 4: Vestibuloplasty with free gingival graft. Incision given, gingival margins and reduced height of clinical crown. Vertical and
recipient bed, and template for graft prepared. Free gingival graft internal bevel incisions are given. Flap raised and bone recontoured
harvested and sutured in place to prevent violation of biologic width

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John, et al.: The perio-restorative interrelationship

Figure 7: Internal bevel gingivectomy with osseous contouring for

prosthetic restoration of fractured tooth. Core buildup done and crown
is in place
Figure 6: Esthetic gingival recontouring with external bevel incision
for unesthetic gingival margins. Gingival margins established in golden
proportions tissue. Ridge reduction surgery may be required to
increase the vertical clearance between the residual
• Internal bevel gingivectomy: Reduction of excessive ridge and opposing occlusion.
pocket depth and exposure of additional coronal
tooth structure in the absence of a sufficient zone
of attached gingiva with or without the need for SUPPORTIVE PERIODONTAL
correction of osseous abnormalities requires a THERAPY
surgical procedure, wherein the flap must always be
internally beveled so as to expose the supporting Maintenance recalls are essential to the long‑term success
alveolar bone [Figure 7] of fixed and removable prosthesis especially overdenture
• Apically positioned flap with bone re‑contouring: It abutments. Hygiene adjuncts using end‑tufted brushes and
is used to expose sound tooth structure in cases of daily application of fluoride are beneficial.
tooth fracture or caries. As a general rule, at least
4 mm of sound tooth structure must be exposed at
the time of surgery. It is indicated for multiple teeth in CONCLUSION
the nonesthetic zone.[25,26] Esthetic crown lengthening
can be done using flap surgery with bone removal An interdisciplinary approach requiring coordinated efforts
using a surgical guide. The golden proportion has by the restorative dentist and periodontist is the need
been recommended as a guide for an esthetic tooth/ of the hour. Close attention paid to both soft and hard
restoration: The mesial‑distal width of a tooth is tissues around teeth and implants before, during, and after
approximately 75% of its height. Allen recommended restorative produces a successful outcome. It also gives
having the gingival margins on incisors peak slightly the patient the benefit of comprehensive treatment with
distal to the midline of the teeth. Central incisors, with precise and lasting and restorations.
an average length of 11–12 mm, should be 1.5 mm
longer than laterals[46] Financial support and sponsorship
• Pontic ‑ soft tissue relationships: If soft tissue form
Nil.
and surface characteristics are deemed unacceptable,
corrections should precede fabrication of the
Conflicts of interest
restoration. Pontics should preferably be placed
over keratinized tissue rather than alveolar mucosa. There are no conflicts of interest.
Ridge augmentation may be accomplished by
internal connective tissue grafts, free soft tissue
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