Periodontology Applied To Operative Dentistry

11
Periodontology Applied to
Operative Dentistry
PATRICIA A. MIGUEZ, THIAGO MORELLI
T
his chapter presents an overview of the periodontal structures The attached gingiva is firmly attached to the periosteum of the
and their importance in restorative dentistry. Following a alveolar process. The attached gingiva is clinically characterized by
review of the anatomy and physiology of the periodontal a firm and pink gingiva surrounding the dentition and separated
tissues, periodontal contributory factors affecting restorative dentistry from the mucosa by the mucogingival junction. In a series of
are discussed. The impact of periodontal therapy as part of the radiographic studies, Ainamo and colleagues demonstrated the
restorative treatment and the effect of the restorative treatment on relative stable position of the mucogingival junction over time and
the periodontium will also be presented. suggested that the zone of attached gingiva increases with age due
The proximity of many dental restorations to the periodontium to teeth and alveolar process eruption.3-5 The widest band of attached
makes their relationship inseparable. To maintain a healthy peri- gingiva is present on the buccal aspect of central and lateral incisors;
odontium and avoid chronic periodontal inflammation, restorations the narrowest band is present at the buccal area of canines and
should be designed and performed properly. Dental restorations first premolars.
that reestablish function and esthetics, when required, and are The interdental gingiva consists of the gingival tissues that fill
supported by a healthy periodontium should be the goal of any the embrasures below the interproximal contact points in anterior
restorative procedure. teeth. In posterior teeth where the interproximal contact points
When necessary, periodontal therapy to eliminate or control are broad, the interdental gingiva is formed from the buccal and
the etiologic factors that contribute to periodontal disease should lingual papillae bridged by the col.
be performed prior to restorative procedures. Timely periodontal
therapy can avoid unesthetic results such as undesired position of The Cementum
the gingival margins. Healthy gingival tissues that frame the denti-
tion are crucial to maintain the oral health and to enhance The cementum is an avascular, multiunit, mineralized connective
esthetics. tissue with variable phenotypes (i.e., cellular, acellular, fibrillar,
afibrillar) and functions. The principal function of the cementum
is tooth anchorage (Fig. 11.2). Due to its dynamic restorative
Basic Concepts of the Periodontium nature and adaptability, the cementum is important for the
maintenance of the occlusal relationships and for the integrity of
Relevant for Restorative Dentistry the root surface.6
The Gingiva
The Alveolar Bone
From an anatomic point of view, the gingiva represents the mastica-
tory mucosa that is bound to the teeth and covers the alveolar The alveolar processes house the teeth and are composed of the
processes. The gingiva involves the alveolar crest, the interdental outer cortical plates of compact bone, the trabecular bone, and
bony septa, and part of the alveolar process to the mucogingival the alveolar bone proper (the bundle bone around teeth)7 (see Fig.
junction in continuity to the lining alveolar mucosa.1 11.2). The cortical plates are built from bony lamellae and are
The gingiva is described as free, attached, and interdental gingiva, thinner in the maxilla and thicker in the posterior mandible. The
with the free gingival groove and mucogingival junction as main alveolar bone proper is located adjacent to the periodontal
anatomical landmarks (Fig. 11.1). The free gingiva is unattached ligament.
and often characterized by the sulcus depth. It can be distinguished
from the attached gingiva by the free gingival groove. The free The Periodontal Ligament
gingival groove is present in only about one third of the normal
gingiva with similar occurrence between different genders and The periodontal ligament (PDL) occupies the space between the
deciduous/permanent dentitions.2 cementum and the alveolar bone (see Fig. 11.2). The PDL is a
415
416 C HA P T E R 1 1 Periodontology Applied to Operative Dentistry
0*-
$*
)*
)**
• Fig. 11.1 Free gingiva (FG) and attached gingiva (AG) are parts of the gingiva and limited by the
anatomical landmarks mucogingival junction (MGJ) and free gingival groove (FGG).
multifunctional unit of connective tissue that contains numerous most consistent dimension. The junctional epithelium was the
cells, fibers, rich vasculature, and cellular components—osteoblasts, most variable area.13 Years later, Vacek and colleagues focused on
osteoclasts, fibroblasts, epithelial rests of Malassez, odontoblasts, the implication of biologic width dimensions for restorative dentistry.
cementoblasts, macrophages, and undifferentiated mesenchymal They conducted another cadaveric study in pursuit of the minimum
cells. The extracellular matrix consists of collagen fibrils and other biologic dimensions that can be tolerated by the tissues. The authors
noncollagenous proteins8 and pluripotent dynamic stem cells.9 confirmed the findings of the previous study in terms of the vari-
From a functional point of view, the PDL participates in tooth ability of the individual components. In addition, they recognized
anchorage, bone tissue development and homeostasis, nutrition- that the biologic width was greater in posterior teeth and the
metabolic circulation, and innervation.7 Its width varies from 0.15 junctional epithelium was significantly longer in teeth with restora-
to 0.4 mm and is adapted to functional demands within this narrow tions.14 The mean biologic width was found to be 1.91 mm, which
range.8 consisted of junctional epithelium (1.14 mm) and connective tissue
attachment (0.77 mm). The mean sulcus depth was found to be
1.32 mm (Table 11.1; see Fig. 11.3).
The Biologic Width Violating the biologic width by placing restorative margins
The term biologic width, a genetically driven structure, refers to within or apical to the junctional epithelium will lead to disturbance
the combined vertical dimension of the junctional epithelium and of the biologic seal and penetration of bacteria and their by-products
the supraalveolar connective tissue (Fig. 11.3). This dentogingival leading to gingival inflammation, attachment loss, and recession
complex acts as a seal around the cervical portion of the tooth or pocket formation. In that event, the biologic width can only
and has a self-restoration capacity. For instance, epithelial attachment be restored by apical reestablishment of the supracrestal connective
mechanically separated from the tooth surface during periodontal tissue.15
probing or flossing reattaches to the original level in approximately
5 days.10 In health, the epithelial attachment terminates at the The Gingival Display
apical end of the junctional epithelium. In diseased tissues, it
terminates at the coronal aspect of the connective tissue, or apical In a healthy smile, the lip rises to the level of or slightly apical to
to the junctional epithelium.11,12 the gingival margins of the maxillary anterior teeth, revealing 1
Gargiulo and colleagues studied the dentogingival dimensions to 2 mm of gingiva. When more than 2 mm of gingival tissue is
in healthy human specimens using autopsy material from 30 shown upon smiling this is described as a “gummy smile” and
subjects, completing measurements in a total of 287 teeth. One considered unesthetic. Different etiologic factors have been described
of their observations was that the epithelial–connective tissue in the literature for this excessive gingival display (Fig. 11.4).16
complex as a whole migrates apically during passive eruption. Excessive gingival display has been associated with excessive
Moreover, they noted that during the different phases of develop- maxillary bone growth. In this case individuals may have longer
ment and passive eruption, the connective tissue zone had the lower third facial height, shorter upper lips, and consequently
CHAPTER 11 Periodontology Applied to Operative Dentistry 417
2UDOVXOFXODU
HSLWKHOLXP
(
-XQFWLRQDO
HSLWKHOLXP
2UDO
HSLWKHOLXP
* &RQQHFWLYH
WLVVXH
3/
%%
%RQH
&
• Fig. 11.3 The biologic width combines the vertical dimension of the
junctional epithelium and the supraalveolar connective tissue. The oral
sulcular epithelium lines the clinical gingival sulcus, which is occlusal to
$3 the biological width. E, enamel.
• Fig. 11.2The periodontium surrounds and supports the teeth and is

composed of gingiva (G), periodontal ligament (PL), bundle bone (BB),
cementum (C), and alveolar process (AP).
TABLE 11.1 Biologic Width Components and

Dimensions (mm and Range)
Gargiulo et al. 1961 Vacek & Gher 1994
Sulcus 0.69 (0.61–1.76) 1.32 (0.26–6.03)
• Fig. 11.4 “Gummy smile” showing more than 2 mm of gingival tissue
Junctional epithelium 0.97 (0.71–1.35) 1.14 (0.32–3.27) during smile. (Courtesy Dr. Tony Crivello.)
Connective tissue 1.07 (1.06–1.08) 0.77 (0.29–1.84)

Biologic width 2.04 1.91 results in excessive gingival display (Fig. 11.5). Surgical intervention
is usually beneficial in individuals with thick, fibrotic, and non-
inflamed gingival tissue with a probing depth of 3 to 4 mm coronal
to the CEJ. To ascertain the type of surgical intervention needed,
more eruption of the maxillary teeth. A multidisciplinary approach the clinician is referred to the classification and treatment recom-
including potentially combined orthodontic therapy and orthog- mendations described by Coslet and colleagues.19 Considerations
nathic surgery is indicated to move the maxillary complex apically in the decision between crown lengthening and gingivectomy are
and address this esthetic concern. Recently, surgical techniques described later in this chapter.
for lip repositioning have been described as alternatives to orthog-
nathic surgery.17,18 A comprehensive evaluation is always indicated Challenges in Periodontal Health Affecting
to avoid frustration with unexpected results.
Another etiologic factor for excessive gingival display is the Restorative Dentistry
delayed migration of the gingival margin commonly known as Periodontal Disease
altered passive eruption. As teeth erupt, the gingival margin migrates
apically to a level at or about 1 mm coronal to the cementoenamel Periodontitis is an immune-inflammatory infection of the tooth-
junction (CEJ). The failure of gingival tissues to move apically supporting structures and a major cause of tooth loss among adults.
• Fig. 11.5 Example of altered passive eruption where the gingival • Fig. 11.6 Thin and scalloped biotype often shows transparency within
margin failed to move apically and closer to the cementoenamel junction, the clinical gingival sulcus when a periodontal probe is inserted. It is often
resulting in excessive gingival display. (Courtesy Dr. André Ritter.) associated with tapered or triangular anatomic crown shapes with small
interproximal contact areas.
It has been recognized as one of the current most prevalent infectious Furthermore, the decision to extract a tooth is subjective and may
diseases, affecting nearly 50% of the American population.20 depend on the preference and philosophy of the practitioner.
Associations with overall systemic conditions and numerous risk Nevertheless, studies have shown that patients in periodic main-
factors or indicators such as diabetes, smoking, age, genetics, tenance therapy preserve more teeth than those who fail to
immunosuppression, and obesity have been identified as these may comply.23,24 Changes in attachment level and probing depth are
increase the severity and distribution of periodontal disease.21 surrogate end points and are objective; however, the cutoff point
A healthy periodontium is important to achieve long-term determines the sensitivity of the parameters used. Longitudinal
success with optimum comfort, function, and esthetics for any studies indicate that patients in a periodic maintenance therapy
restorative procedure. In the presence of active periodontal diseases, schedule may have less mean annual attachment loss than non-
such as gingivitis or periodontitis, periodontal therapy should be compliant patients.25,26
performed prior to most restorative procedures in order to eliminate Although maintenance therapy can be very effective in stabilizing
and/or control the etiologic factors contributing to tissue damage. the progression of periodontal disease in most patients, a subset
Active periodontitis is diagnosed by clinical and radiographic of patients (2%–4%) and sites may suffer from progressive attach-
evaluations. It is characterized clinically by deep probing depths, ment loss regardless of regular maintenance schedule.27,28 As
inflammation (bleeding on probing or visual bleeding), and mentioned earlier, several risk factors such as smoking, stress, and
subgingival calculus. Radiographically, active periodontitis is genetic background can influence disease progression.29
characterized by alveolar bone loss. Signs of successful periodontal
therapy are the resolution of gingival inflammation, which can be Gingival Biotypes
achieved with efficient oral hygiene habits and nonsurgical and/
or surgical periodontal therapy. Administration of antibiotics is The gingival architecture depends on the type of gingival biotype.
indicated in some situations.22 Generally the periodontium has been described as having two
Similar to periodontitis, gingivitis is also diagnosed by gingival basic forms: a thick and flat biotype or a thin and scalloped
inflammation characterized by edematous, spongy, and red gingiva. biotype.30,31 Each biotype has its own distinct characteristics and
Bleeding on probing is usually present as well. However, there the clinician must be mindful of these to achieve a stable dento-
is no loss of the periodontal attachment often characterized by gingival complex.
radiographic bone loss. Different than periodontitis, gingivitis may The thin and scalloped biotype frequently responds to gingival
be controlled with adequate oral hygiene and adult prophylaxis inflammation with gingival recession and is usually associated with
only. Periodontitis requires scaling and root planing to remove tapered or triangular anatomic crown shapes with small interproxi-
subgingival plaque and calculus deposits. Severe cases may mal contact areas (Fig. 11.6). Thin bone support with underlying
require concomitant antibiotic therapy and periodontal surgery dehiscences and/or fenestrations is a common finding in individuals
to reestablish a healthy periodontium. A healthy periodontium is with thin biotype. On the other hand, thick and flat biotype often
important to establish a controlled and clean field for restorative responds to gingival insults with deep pocket depth formation,
procedures and to maintain the integrity and esthetics of restorative and it is usually associated with square anatomic crowns with
treatments. broad interproximal contact areas (Fig. 11.7). The stability of the
bone crest and position of the free gingival margin are positively
correlated to the thickness of the alveolar bone and gingival tissue.
The Importance of Maintenance Therapy This was confirmed by Stetler and Bissada who showed that there
The end of active periodontal treatment, nonsurgical or surgical, was less inflammation and shrinkage when subgingival restorations
is not the end of periodontal therapy. Only maintenance therapy were placed in individuals with thick gingival biotype.32
can secure the long-term success of periodontal treatment. The
effect of maintenance therapy is evident when comparing tooth Furcation Involvement
loss, amount of bone loss, changes in attachment level and probing
depth, tooth mobility, and the progression of furcation involvement The furcation forms with the presence of two or more roots in a
between patients with and without regular maintenance visits. It tooth and is therefore most common in molars. It is assumed that
should be noted that tooth loss, while being the ultimate end furcations increase the surface area of teeth for periodontium
point, may occur for reasons other than periodontal disease. attachment and thus provide additional periodontal support.
However, this unique structure also renders neighboring periodon- of the furcation involvement. Several classification systems have
tium more susceptible to destruction. been designed to determine the severity of furcation-involved teeth.
Exposure of the furcation with its involvement may occur as a The most commonly used is the Hamp classification. It classifies
result of bone loss during progression of periodontal disease or of furcation involvement into three different grades:
surgical treatment as part of the restorative therapy. The diagnosis • Grade I: horizontal penetration of the Nabers probe less than
of furcation involvement is crucial because it is related to tooth 3 mm
prognosis. The degree of furcation involvement dictates the treatment • Grade II: horizontal penetration of the Nabers probe more than
for the tooth, as there is an association between the severity of 3 mm, but not through the furcation
furcation involvement and tooth longevity.33 For proper diagnosis, • Grade III: through penetration of the Nabers probe from buccal
thorough clinical and radiographic examinations must occur. Usually to lingual34 (Fig. 11.9).
the furcation is examined with a specific probe such as the Nabers Other factors, such as size and divergence of roots, root trunk
probe (Fig. 11.8), a 12-mm curved probe with 3-mm markings. length, crown-root ratio, and volume of remaining bone, are also
Placing the tip of the Nabers probe against the tooth and moving important. Grade I furcation is generally treated with scaling and
it in an apical direction aids in detection of furcation involvement. root planing. A clinical study evaluated the efficacy of scaling and
The depression of the furca may also be examined in a similar root planing in Grade I furcation involvement and showed a 100%
manner. survival rate during a 5-year evaluation series.34 Open flap debride-
Unfortunately, even though special care is taken during clinical ment and furcation plasty may be indicated in some situations
examinations, furcation involvement, especially in maxillary molars, where prosthetic treatment is needed. Grades II and III furcations
is difficult to detect. The assessment of furcation areas tends to be are also treated initially with scaling and root planing. However,
inaccurate because of great variations in root anatomy. It is further the need for surgical treatment, such as open flap debridement or
complicated by limited access due to adjacent teeth or soft tissue guided tissue regeneration, may be indicated to improve tooth
coverage. Radiographs provide an essential aid to clinical examina- prognosis. An investigation on the effects of nonsurgical treatment
tions; however, there are also limitations associated with the diagnosis on periodontally involved teeth with furcation involvement showed
of furcation involvement using radiographic images. The inherent a 90.7% survival rate during a 5- to 12-year period. Out of the
two-dimensional presentation of conventional radiographic images failures, 60% were on teeth with Grade III furcation and 30% on
limits the recognition of furcations. teeth with Grade II furcation. That demonstrates the limitations
Treatment options for furcation-involved teeth are generally of nonsurgical therapy to treat severe furcation involvement.35 A
based on the nature and extent of the furcation involvement. In retrospective study looking at the long-term survival of maxillary
general, treatment modalities are selected based on the classification furcation-involved teeth in patients who had received treatment
and were on maintenance showed decent prognosis with only 12%
of involved molars being lost in 24 years.33
Open Proximal Contacts

Interestingly, open proximal contacts do not have a direct effect
on periodontal disease progression despite its reported indirect
impact on the periodontium. In 1980, Hancock and colleagues
analyzed 40 males with open proximal contacts between their
teeth and could not demonstrate a significant correlation between
open contacts, gingival inflammation, and deep probing depths.
On the other hand, open contacts were significantly related to
food impaction, which demonstrated a significant correlation with
• Fig. 11.7 Thick and flat biotype often shows more pronounced higher gingival inflammation and deeper probing depths.36 Jernberg
“orange peel” surface characteristics of the attached gingiva. It is often and collaborators reported similar findings in regard to gingival
associated with square anatomic crowns with broad interproximal contact inflammation and pocket depths. In their study, however, open
areas. proximal contacts demonstrated direct effect on the development
&ODVV, &ODVV,, &ODVV,,,
• Fig. 11.8 Furcation involvement classified into three different grades or Classes by Hamp. Usually the
furcation is examined with a specific probe such as the Nabers probe. The probe is placed against the
tooth and moved in an apical direction as to try to find the entrance of the furcations.
F0 F1 F2 F3
A B C D
• Fig. 11.9 A, F0 indicates no furcation penetration with the Nabers probe. B, F1 grade or Class I
indicates horizontal penetration of the Nabers probe up to 3 mm. C, F2 grade or Class II indicates hori-
zontal penetration of the Nabers probe more than 3 mm, but not through the furcation. D, F3 grade or
Class III indicates through penetration of the Nabers probe from buccal to lingual.
of periodontal disease. A total of 104 adults were evaluated and

open proximal contacts were found to be significantly correlated
with deeper probing depths and higher clinical attachment loss.37
To reduce the influence of open proximal contacts, it is appropri-
ate to restore (close) them as long as overhangs are not created.
Adequate oral hygiene instructions should always be part of the
therapy.
Enamel Pearls
Enamel pearls are ectopic globules of enamel adherent to the tooth
found most often in furcation regions of maxillary second and
third molars.38 They consist primarily of enamel, but dentin and
even pulpal tissues can be found in some cases. The mean occurrence
of enamel pearls in humans is 2.9% with a high occurrence of
9.7% among the Eskimo population.38 Ectopic enamel such as • Fig. 11.10 Cervical enamel projection present on the furcation of a
enamel pearl is highly associated with attachment loss39 and its mandibular molar. Note the furcation defect caused by lack of connective
removal is therefore indicated. Histologic observations demonstrate tissue attachment to the apically located enamel leading to increased
that enamel pearls have most of the structural features of enamel bacterial colonization and apical migration in the furcation. (Courtesy Dr.
Tony Crivello.)
but with less orderly organization.40 Its development is not well
understood.
• Grade 1: Short but distinct change in the contour of CEJ

Cervical Enamel Projection extending toward the furcation
Cervical enamel projections (CEPs) are ectopic deposits of • Grade 2: CEP approaches the furcation, without making contact
enamel apical to the CEJ with a tapering form and extending with it
toward or entering the furcation. Since connective tissue does • Grade 3: CEP extends into the furcation
not attach to enamel, CEPs have been demonstrated to be an Considering CEPs are a contributory factor to periodontal
etiologic factor in furcation defects (Fig. 11.10). Bissada and disease, especially in furcation areas, its removal or at least reduction
Abdelmalek analyzed 1138 molars in Egyptian skulls and showed is indicated. However, this should be done carefully to avoid
that CEPs were present in 8.6% of the cases. CEPs were present in irreversible damage to the tooth.
approximately 50% of the cases where the furcation was involved.41
The authors reported that CEPs were more frequently present in Cemental Tears
mandibular second molars followed by maxillary second molars.
In another study CEPs were present in 67.9% of the studied The cemental tear is a fragment of cementum that detaches from
population (45.2% molars). Molars with furcation involvement the tooth, usually after trauma, causing isolated bone loss (vertical
had CEPs in 82.5% of the cases, whereas molars without furcation bone defects) (Fig. 11.11). It should be taken into consideration
involvement had CEPs in 17.5% of the cases. The most affected as a differential diagnosis for root fracture. Due to its low incidence,
tooth was the mandibular first molar followed by the maxillary most studies available are case reports. Treatment involves surgical
first molar.42 debridement, removal of the cementum fragment, and periodontal
The impact of CEPs on periodontal health depends on the regeneration, if indicated. Several case reports demonstrate that
extent of the projection. In 1964 Masters and Hoskins introduced the area can be successfully maintained after surgical
a classification system for CEPs, which is still in use43: treatment.44,45
A
B
E
• Fig. 11.11 Clinical case showing cemental tear (A) preoperatively, (B) upon surgical exposure, and
(C) fractured cement. The mesiofacial root area on tooth No. 9 after removal of cemental tear is shown
in D. Radiographic diagnosis may not always be possible (E). (Courtesy Dr. David Semeniuk.)
Palatoradicular Grooves Tooth Position

The radicular or palatal groove is a developmental anomaly in Various parameters of tooth malposition have been correlated with
which an infolding of the inner enamel epithelium and Hertwig periodontal disease.48 The main influence of tooth malposition is
epithelial root sheath create a groove that passes from the cingulum the effect on plaque accumulation due to more difficult hygiene
of maxillary incisors apically onto the root.46 Palatal grooves may around malpositioned teeth. However, when oral hygiene is properly
act as funnels, which facilitate the accumulation of biofilm in the done, tooth malposition is not a significant factor causing plaque
depth of the groove. The area is inaccessible to both patients and accumulation and consequent gingival inflammation.49
clinicians, and the prognosis for involved teeth, with diagnosed
bone loss around the area, is poor. Hou and Tsai evaluated 404 Occlusion
maxillary incisors and reported that the palatal groove was present
in 30.2% of lateral incisors, 5.9% of central incisors, and 4% of The role of traumatic occlusion in periodontal disease is extremely
both maxillary incisors.47 When indicated, treatment consists of controversial. Consensus exists, however, that traumatic occlusion
odontoplasty to remove or reduce the groove. When odontoplasty is not an initiating factor but can act as a contributory factor for
is not possible, the groove may be restored with a biologically periodontal disease. Nunn and Harrel evaluated the effects of
acceptable restorative material (see Materials, later in this chapter). traumatic occlusion on periodontal disease and concluded that
occlusal discrepancy is an independent risk factor for periodontal aim for a 5-mm distance from bone to the restorative margin when
disease.50 Records from 24 years showed that teeth with initial possible.56 The challenge is that periodontists have a tendency to
occlusal discrepancies demonstrate significantly worse prognosis, remove less bone than needed due to the nature of their specialty
and deeper probing depths and mobility. Trauma from occlusion (i.e., preservation of the periodontium).57 Thus aiming for 5 mm
has also been linked to higher risk for furcation involvement.51 will direct the surgeon to achieve the necessary removal of the
Based on the evidence suggesting that traumatic occlusion may minimum 3 mm. Other authors have also discussed that individual
influence the course of periodontal disease, minor occlusal adjust- variations in biologic width dimensions will be accounted for if
ments with the purpose of achieving better periodontal treatment more than 3-mm distance is ensured after surgery.58 Several studies
outcomes are recommended.52 have reported that subgingival margins of restorations, even without
overhangs, have more plaque accumulation, gingival inflammation,
and development of periodontal pockets than supragingival ones.59,60
Periodontal Procedures Relevant to In a 26-year prospective cohort, Schatzle and colleagues showed
a 0.5-mm increased mean loss of attachment in patients with
Restorative Dentistry restorations with subgingival margins after 10 years of
function.61
Crown Lengthening It is important to remember that the periodontium biotype
A healthy periodontium is important to achieve long-term success plays a key role in the periodontal response. Normally if the
and optimum comfort, function, and esthetics for any restorative periodontium is thin and scalloped, recession will follow the
procedure. As mentioned earlier, the relationship between restora- inflammatory process caused by the restoration margin. If
tions and periodontium must be respected for a successful treatment the periodontium is thick and flat and thus soft tissue stability is
outcome. Even if gingivitis or periodontitis are not present, one more likely, there is a higher likelihood of a moatlike lesion around
should not proceed with restorative treatment without further the tooth to appear on the alveolar bone, leading to increased
consideration of the future relationship between restoration and bleeding, sensitivity on probing, and pocket formation.53,62 Timely
supporting tissues. In this regard, biologic width preservation is recommendation of crown lengthening to avoid such issues is a
critical. crucial step toward tissue health, predictable esthetics, and patient
When violation of the biologic width—namely placement of satisfaction.
the restorative margin beyond the gingival sulcus and invading There are situations, however, where clinical crown lengthening
the junctional epithelium and connective tissue boundaries—is may not be indicated and alternative treatment options should be
anticipated, crown lengthening of the tooth in question needs to explored. These include limitations caused by position of the furca-
be performed so the margin of the restoration is coronal to these tion, reduced attachment levels, and esthetic issues. For instance,
biologic structures. As previously described, the mean depth of a tooth with a short trunk may limit the amount of crown
the sulcus is 1.32 mm; thus placing a restoration beyond 1 mm lengthening that can be performed as the procedure could expose
into the sulcus is potentially disruptive of the biologic width. the furcation and compromise tooth prognosis (Fig. 11.12). In
Crown lengthening is defined as the removal of bone tissue that event, avoiding violation of biologic width may not be possible
with concomitant removal or repositioning of the soft tissue around and the surgical procedure may not be performed or may be only
the tooth. The goal of this therapy is to increase the clinical crown partially performed, leading to a compromised restorative treatment.
and consequently preserve the biologic width. Typically, crown In general, all subgingival margins compromise and impact the
lengthening is needed to avoid impingement of the biologic width periodontium. Herrero and colleagues found that in areas of difficult
often occurring due to presence of subgingival caries or deep access such as the lingual and distolingual surfaces of molars,
restorative margins. The procedure may also be recommended to surgeons removed an average of 0.4 mm of bone short of the
correct esthetic unpleasant situations such as a “gummy smile.” 3-mm goal. A higher degree of inflammation leading to bone loss
Failing to recognize the need for crown lengthening prior to is expected in these areas since proper crown lengthening was not
restorative procedures often leads to invasion of biologic width performed.57
leading to inflammation (gingivitis) and bone loss (periodontitis), Another common scenario where biologic width is violated and
pain associated with inflammatory remodeling of the periodontium, difficult to manage is crown fractures extending below the gingival
local soft and hard tissue defects, compromised esthetics, and margin. Crown lengthening is often necessary for proper restoration
problematic retention of restoration in some instances. of fractured teeth (Fig. 11.13). In the case of fracture of anterior
Padbury and colleagues suggested that the biologic width is teeth, crown lengthening surgery will significantly impact the tooth
preserved when the restoration is placed allowing for approximately clinical and consequently esthetic display (as well as of the adjacent
2 mm for the connective tissue and junctional epithelium and teeth) due to the removal of bone and subsequent apical reposition-
1 mm for the sulcus. Further, ideally an additional 0.5 to 1 mm ing of the gingival margin (Fig. 11.14). There are situations where
should be added coronally to create a safe distance from the alveolar orthodontic extrusion is indicated to minimally affect the gingival
bone crest to the restorative margin. A 3- to 4-mm distance from margin levels in the anterior sextant or esthetic area. Crown
gingival margin to the alveolar crest ensures periodontium healing lengthening may follow the orthodontic extrusion. Camargo in
after tooth preparation with quick reestablishment of the junctional 2007 stated that forced tooth eruption via orthodontic extrusion
epithelium and connective tissue integrity, which avoids continuous is the technique of choice when clinical crown lengthening is
inflammation around the tooth.53,54 necessary on isolated teeth in the esthetic zone.63
Current research and clinical observations show that there is For optimal outcome, proper healing of the periodontal tissues
variation in biologic width measurements among individuals and after crown lengthening is necessary. The type of periodontium
teeth, and that the 3-mm distance is the minimum necessary to (thick and flat versus thin and scalloped) and the location (anterior
avoid periodontal breakdown around subgingival restorative versus posterior) generally dictate the extent of healing time. Direct
margins.55 Wagenberg and colleagues, in fact, have suggested to restorations can be made as soon as there is initial tissue shrinkage
A A
B B
• Fig. 11.13 A, Endodontically treated bicuspid presents with a large
coronal subgingival fracture. B, Poor crown–root ratio can be appreciated
indicating that crown lengthening would not be recommended on this
tooth to expose the fractured surface for restoration. Extraction was
recommended.
• Fig. 11.12 A, Tooth No. 30 with secondary caries on the mesial

surface leading to invasion of biologic width (beyond the clinical gingival
sulcus). Note that tooth No. 29 has a restoration with deep and open
margin violating the biologic width on the distal surface. B, After compro-
mised crown lengthening surgery and crown replacement. To avoid furca-
tion exposure (note the short trunk of tooth No. 30), the amount of crown
lengthening was limited. C, Another clinical case showing an example of
a long trunk on teeth No. 30 and No. 31, which would allow for a non- • Fig. 11.14 Fractured anterior tooth No. 7. Esthetics must be carefully
compromised crown lengthening surgery since furcation would likely not considered when treatment planning the restoration of anterior fractured
be at a risk of exposure. teeth. Crown lengthening may compromise the esthetic outcome and be
contraindicated. (Courtesy Dr. Eduard Epure.)
if the margin is supragingival and hemostasis/trauma to the tissue gingiva tends to bulk postoperatively prior to moving coronally
is not anticipated. For indirect full-coverage restorations, clinical and flatten as maturation occurs in the first 6 to 8 weeks. Further
studies indicate that the clinician should wait approximately 6 to flattening may continue to occur beyond the initial maturation
8 weeks before proceeding with final preparation and impression phase. In a thin and scalloped periodontium, there is usually
in posterior teeth.64 In anterior esthetic cases, the periodontal recession immediately after surgery and in some cases “creeping
biotype needs to be taken into consideration before proceeding attachment” occurs in the months after initial maturation. One
with restorative treatment. In a thick and flat periodontium, the study demonstrated that probing depths stabilized at 6 weeks but
recession ranging from 2 to 4 mm continued to develop between

6 and 24 weeks.65 Thus, in areas of esthetic concern, postponing
final margin placement and restoration for 6 to 8 months may be
desirable to ensure gingival margin stability. To better predict results,
an accurate diagnosis of thick versus thin biotype should be done.66
Finally it is important to be knowledgeable of situations where
crown lengthening is not indicated. Besides the previously men-
tioned risk of exposing furcation and causing esthetic issues in the
anterior dentition, other limitations/contraindications are teeth
with significantly reduced periodontal support; endodontically
infected teeth that should not be treated prior to resolution of the
A
periapical lesion; extensive need for osseous removal, which would
compromise the stability of adjacent teeth; and inadequate crown-
to-root ratio after surgery.
Gingivectomy
Unlike crown lengthening, gingivectomy does not involve hard
tissue but rather just gingival excess removal to expose the clinical
crown. For a successful gingivectomy procedure, careful treatment
planning after detailed examination is crucial. Diagnosis and
management of the etiology are critical for a positive outcome. In
the case of gingival overgrowth, the soft tissue should not rebound
provided the etiology for overgrowth is addressed (e.g., triggering
medications, local trauma) and good oral hygiene is exercised.
Plaque control is critical for overgrowth control in cases involving
drugs that may stimulate tissue reaction and where medication
replacement is not possible.67 In the case of altered passive eruption,
where there is excess of soft tissue due to altered apical migration B
of the gingiva, the tissue removed does not regrow provided absence
of coronal positioning of the bone. When gingival tissue is removed • Fig. 11.15 A, Subgingival caries on teeth No. 6, No. 28, and No. 29.
to expose the clinical crown but the removal alters the dimension Ideally the cavitated areas need to be exposed surgically to allow for
proper restoration. Further, a 3-mm distance for biologic width establish-
of the sulcus and junctional epithelium, the tissue regrows to
ment is needed from the margin of the tooth preparation to the alveolar
establish at least approximately 1 mm of junctional epithelium bone crest to promote best tissue health. B, Tooth No. 6 with caries
and 1 mm of sulcus. However, this can be affected by genetically excavated, immediately after crown lengthening procedure. (Courtesy Dr.
predetermined dimensions. Crown lengthening would be indicated Bruno Herrera.)
to remove the bone and reposition the gingival margin apically.
Some of the clinical scenarios to consider gingivectomy versus
crown lengthening are (1) subgingival caries/access for proper
restoration, (2) tooth fracture, (3) inadequate retention, (4) altered months, the periodontium and bone remodel on the site, moving
passive eruption, and (5) other esthetic concerns such as gingival away from the fracture margin, creating a bony ledge and a crater
overgrowth or defects. (moatlike defect) around the tooth. The area is likely to stay inflamed
and become uncomfortable for the patient if not corrected.
Subgingival Caries/Access for Proper Restoration
When subgingival caries present, at least 3 mm of sound tooth Inadequate Retention
structure are needed from the margin of the final cavity preparation Extensively compromised teeth due to extensive fractures and/or
(not the caries lesion) to the alveolar bone crest (Fig. 11.15); caries lesions often need to be altered prior to final restoration.
otherwise crown lengthening is recommended. It is important to When there is a need to create a ferrule in a tooth that will receive
emphasize that open flap and bone contour correction is warranted a post-and-core restoration, crown lengthening may be needed to
if periodontal breakdown with evidence of osseous defect due to facilitate its placement without violation of the biologic width and
caries impinging the biologic width is present. adequate retention form. There is an overall consensus that 1.5 to
2 mm of ferrule is necessary for adequate retention of crowns and
Tooth Fracture protection of the integrity of the remaining tooth structures. Crown
Crown lengthening is almost always necessary for subgingival lengthening may not be necessary if adequate ferrule can be achieved
crown-root fractures, to avoid continuous periodontal breakdown without violation of the biologic width. However, additional
in the site. Subgingival fractures are normally already affecting retention may be necessary; otherwise gingivectomy may be per-
biologic width considering their presentation. In the unusual situ- formed to temporarily remove gingival tissue.68
ations where the biologic width is adequate after a subgingival Gegauff highlighted that an attempt to gain adequate ferrule
fracture, it is very likely that crown lengthening will be necessary via crown lengthening procedure can negatively affect the tooth
after tooth preparation for a crown, for instance, because the crown mechanical properties.69 The apical relocation of the crown margin
preparation is often placed more apically to where the fracture after crown lengthening procedures leads to a thinner cross section
happened. When the fracture is not treated for several weeks or in the ferrule area. Further, there is a reduction in the crown-to-root
• Fig. 11.17 Tooth No. 2 with ill-fitting amalgam restoration at the sub-
gingival distal margin. Distal wedge should have been performed prior to
restoration to facilitate access for proper restorative treatment.
CEJ to the alveolar crest, there is enough keratinized tissue, and

B there is no evidence of bone defect (see Fig. 11.16B and C). The
location of the bone in relationship to the CEJ and the mucogingival
junction are important parameters in treatment of altered passive
eruption. They can be determined with bone sounding and clinical
and radiograph examination. Gingivectomy is not advised when
the band of keratinized tissue is insufficient (<3 mm).
Distal Wedge
Distal wedge is commonly performed on the distal surface of
molars (tuberosity or the retromolar pad) to facilitate hygiene,
access and help eliminate periodontal pockets, or facilitate access
C for proper restorative treatment (Fig. 11.17). The procedure is
either complete removal of the tissue (if there is abundant amount
• Fig. 11.16 Altered passive eruption often results in a flat gingival of keratinized tissue even after removal) or partial ablation of tissue
contour and squared-shaped anterior teeth (A) or uneven gingival con- (to spare keratinized tissue). In any case, after tissue removal, soft
tours such as the case in B, where discrepancies can be noted between tissue coverage of the bone and more coronal tooth exposure is
teeth No. 7 and No. 10, and teeth No. 8 and No. 9. Case (B) with gingival achieved. A direct restoration can be performed immediately after
discrepancy corrected by gingivectomy (C). (A, Courtesy Dr. André Ritter; the surgical procedure provided adequate operating field isolation
B, C, Photo credit: Dr. Akshay Kumarswamy, Mumbai, India.)
is achieved.
Noncarious Cervical Lesions and

ratio that also may negatively affect the outcome of the treatment.
Orthodontic extrusion may be another option to expose tooth Mucogingival Surgery
structure in some clinical situations of inadequate retention. Yet Noncarious cervical lesions (NCCLs) are characterized by the loss
crown-to-root ratio and apical location of the ferrule also will of tooth structure at the cervical area of a tooth due to abfraction,
occur in orthodontic extrusion. abrasion, and/or erosion (Fig. 11.18). These lesions are noncarious
but may need to be managed provided one or more of these factors
Altered Passive Eruption are present: (1) The patient is concerned with esthetics, (2) there
Crown lengthening or gingivectomy can also be indicated for is substantial tooth sensitivity that does not resolve with other
esthetic reasons only or before restoring a tooth that has altered treatment options (i.e., desensitizing agents), (3) the lesion is
passive eruption. Altered passive eruption is the diagnosis when a progressing and there is risk of pulpal exposure, or (4) the lesion
significant amount of anatomic crown is covered by gingiva due is progressing and the tooth integrity is at risk.
to failure of proper apical migration of the soft tissue that covers To deliver the best possible treatment preserving the natural
the crown of the tooth. Often the patient displays a gummy smile contour and integrity of the gingival tissues around the affected
with squared-looking teeth (Fig. 11.16A).70 This condition affects tooth or teeth, options other than restoration only are available
esthetics and also increases plaque accumulation as the sulcus depth and should be considered. In the event of gingival recession and/
promotes easy apical plaque migration.71 Gingivectomy may be or lack of keratinized/attached gingiva with concomitant presence
performed when there is a distance of more than 3 mm from the of a NCCL, careful evaluation of the site should be performed to
determine the appropriate treatment: restoration, soft tissue coverage

(graft), or a combined approach.
Predictable soft tissue root coverage of recessions with subcutane-
ous connective tissue graft can be accomplished with recessions
that fall under the Miller classification of Class I and Class II.72
The Miller classification has been widely used to classify recessions
based on the amount of tissue loss in relationship to the muco-
gingival junction, width of the tissue loss around the facial or
lingual aspect of the tooth, and loss of soft and hard interproximal
tissue73 (Fig. 11.19):
• Class I: Marginal tissue recession that does not extend to the
mucogingival junction. There is no periodontal loss (bone or
• Fig. 11.18 Noncarious cervical lesions are characterized by the loss
soft tissue) in the interdental area, and 100% root coverage can
of tooth structure at the cervical area of a tooth and multifactorial etiology. be anticipated.
Treatment may involve soft tissue grafting of the area depending on extent • Class II: Marginal tissue recession that extends to or beyond
of lesion and periodontal condition with or without concomitant tooth the mucogingival junction. There is no loss of interdental bone
restoration. or soft tissue, and 100% of root coverage can be expected.
&ODVV, &ODVV,,
0*- 0*-
&ODVV,,, &ODVV,9
0*- 0*-
• Fig. 11.19 Miller classification of gingival recessions. Class I: recession does not extend to the muco-
gingival junction (MGJ). Class II: recession extends to or beyond the MGJ; 100% of root coverage can
be expected for Class I and II. Class III: recession extends to or beyond the MGJ with loss of interdental
tissue or there is malpositioning leading to inability to cover 100% of the root surface. Class IV: recession
extends to or beyond the MGJ where there is advanced loss of interdental tissues and root coverage is
not anticipated.
• Class III: Recession that extends to or beyond the mucogingival attached gingiva band may be necessary to avoid gingival recession.79
junction. There is loss of interdental bone and/or soft tissue or This is particularly significant for patients with thin periodontium.
there is malpositioning of the teeth leading to inability to cover Despite this, teeth should always be moved inside of their alveolar
100% of the root surface. housing to minimize chances of recession. Recessions cannot be
• Class IV: Marginal tissue recession that extends to or beyond predictably covered when the position of the tooth in the arch is
the mucogingival junction where there is advanced loss of far outside the alveolar plate. Soft tissue grafting may be of different
interdental tissues and root coverage is not anticipated. types and have different indications such as free gingival graft,
After gingival grafting, full root coverage can usually be expected connective tissue graft, pedicle flap, among others.
up to the level of the interdental bone. However, soft tissue coverage
of a cervical lesion that is located mostly in enamel is not recom-
mended.74 Indeed, no true tissue–tooth attachment is expected to Effect of Restorative Treatment on the
happen between the grafted soft tissue and the tooth enamel to Periodontium
help stabilize the graft. Further, such location is typically at a far
distance from the bone, which restricts vascular supply to support In the previous section we reviewed the impact and indications
the grafted tissue in that area. Clinical researchers have reported of surgical procedures in restorative dentistry such as crown
that NCCLs, just like interdental tissue loss, are a significant negative lengthening, gingivectomy, distal wedge, and mucogingival surgery.
factor in the prognosis of gingival root coverage.75 The authors Often these procedures are crucial prior to proper restorative
did not elaborate on the possible reason. It is possible that occlusion treatment. Conversely, it is also important to understand the impact
and hygiene factors are involved in the lower success of grafting of restorative procedures on periodontal health to prevent peri-
of NCCLs. odontal breakdown. It is critically important to understand the
The following rationale is followed when treating a NCCL. possible effects of restorative therapy (e.g., biologic width violation,
Lesions that exceed approximately 2 mm in axial depth typically materials, margins of restorations, provisional restorations, retraction
need restoration. This will depend on progression rate, symptomatol- cord trauma) on the periodontium.
ogy, and desire to restore. Aside from diagnosing and treating the
etiology, fast-developing lesions should be restored. Restoration Biologic Width Violation
also may be indicated for NCCLs that continue symptomatic after
attempts to reduce sensitivity with desensitizing products. Soft Much has already been discussed in this chapter about the impor-
tissue grafting in addition to restoration may be recommended tance of biologic width preservation. Violation of the biologic
when there is lack of attached gingiva or a thin tissue biotype.74 width is often a result of caries removal and consequent preparation
Grafting only is indicated in cases of limited tooth loss (lesion of the tooth for direct or indirect restorations leading to damage
depth <2 mm). That is based on the need for grafting due to of the junctional epithelium and the connective tissue above the
recession or lack of keratinized/attached gingiva. While Miller alveolar crest. The contact of the restoration margin with the
Class I and Class II cases have good prognosis, the long-term stability junctional epithelium or the connective tissue below the gingival
has been questioned.75 That said, the patient may opt for periodic sulcus allows for bacterial colonization of the area. Recruitment
application of desensitizing products in lieu of the surgical proce- of inflammatory cells and chronic inflammation of the site follow.55
dure. A randomized clinical trial evaluating the outcome of con- While polishing of the restoration may alleviate plaque accumulation
nective tissue graft and resin-modified glass ionomer restorations and inflammation, there is extensive evidence of inflammation
for the treatment of gingival recession and NCCLs concluded that leading to bone resorption in sites with biologic width violation.
graft alone or graft with restoration showed increased attachment The inflammatory process is usually aggravated with indirect restora-
level and soft tissue coverage for up to 2 years in patients with tions as the marginal gap of a well-fitted crown is normally larger
Miller Class I recessions.76 than that of a direct restoration. Sorensen and colleagues reported
When considering mucogingival surgery, the keratinized tissue on marginal fit in relation to percentage bone loss and gingival
and attached gingiva levels must be evaluated. There is a difference flow and found positive correlation between marginal discrepancy
between attached and keratinized gingiva. Keratinized gingiva of restorations and periodontal defects.80 In summary, proper
involves the attached and the free gingival tissue. Since the attached placement of the margin of the restoration (direct or indirect) in
gingiva is bound to the underlying periosteum, the clear presence respect of the biologic width is critical.
of keratinized gingiva is seen as protective of the periodontium
against inflammation and bone loss. Recommendations have been Materials
made to increase the band of keratinized/attached gingiva prior
to subgingival restorations that will be in close proximity with the Besides careful placement of restorations to avoid marginal over-
gingival margin (or subgingivally after grafting). The presence of hangs, voids, and rough restorations in close proximity to the
a narrow keratinized tissue band (i.e., less than 2 mm) has been periodontium, biocompatible materials should be favored.
linked to an increased chance of gingivitis.32 However, others have Mineral trioxide aggregate (MTA) appears to have a significant
found that gingival health can be maintained with little or no improved tissue response and bone formation compared to com-
keratinized tissue in the absence of plaque accumulation and posite resins, amalgams, and glass ionomers.81 The common response
inflammation.77,78 Soft tissue grafting to increase the band of from other materials is the formation of fibrous connective tissue
keratinized/attached gingiva may be recommended in patients that will connect them to the alveolar bone. Despite this, MTA
with poor hygiene and restorations in close proximity to the gingival is not the material of choice for situations where the material is
tissues. close to the gingiva, as it does not have the mechanical properties
Another indication for mucogingival surgery includes teeth required to sustain occlusal stresses.82 Further, a coronal restoration
that lack adequate band of keratinized/attached gingiva and that in contact with soft tissues would not need to promote bone
will undergo orthodontic therapy. Increasing of the keratinized/ growth but rather a healthy soft tissue response.
A B
• Fig. 11.20 A, Cervical caries lesion on teeth No. 26

and No. 27. B, The lesions exposed and restored with
C Geristore. C, Two-month follow-up with excellent tissue
health. (Courtesy Dr. Luis Perez.)
Gomes and colleagues reported that the periodontal response compared to Ketac Fil (3M Oral Care, St. Paul, MN) and IRM
to resin-modified glass ionomers was more favorable than the (Dentsply Sirona, York, PA).90
response to amalgam and composite resins in an animal study Gupta and colleagues showed that Geristore had superior
after 124 days.83 In another more recent study, Sakallioglu and biocompatibility compared to MTA and glass ionomer when tested
colleagues studied the release of inflammatory markers in gingival on human periodontal ligament cells.89 A clinical study by Dragoo
crevicular fluid in humans after restorations with metaloceramic, showed that Geristore was not different in terms of probing depth
composite resin, and amalgam restorations. Results showed a and gingival inflammation than other resin-based materials such
significant increase in certain inflammatory peptides compared to as Dyract (Dentsply Sirona) and Photac Fil (3M Oral Care).92 It
controls (enamel surface) for all groups with amalgam showing was concluded that a material with biocompatibility, dual-cure
the highest levels after 4 weeks.84 capability, insolubility in oral fluids, low coefficient of thermal
Known for its biocompatibility, Geristore (DenMat, Lompoc, expansion, low polymerization shrinkage, and low microleakage
CA) is a dual-cure, hydrophilic resin-modified glass ionomer often is ideal for subgingival restorations. Such properties are found in
recommended when the periodontium is extensively involved. Its Geristore, which appears to be the preferred material among clini-
manufacturer recommends it as liner, in direct pulp capping, in cians for cases where teeth are in need of subgingival restorations93
Class V and conservative Class I and Class II restorations, in root (Fig. 11.20).
caries lesions, in subgingival restorations for fractured roots and
resorption lesions, in root perforations, and as retrograde filling Provisional Restorations and
material. Research has shown that Geristore has better or similar
adhesion to tooth structures than some of the other glass ionomers Restorative Margins
and presents low microleakage.85-88 Its biocompatibility has been The margins of indirect restorations are often placed subgingivally
extensively studied with mostly positive results being reported.89-91 for esthetic purposes, to provide preparation margin in tooth
Geristore has shown to allow for better growth and cell morphology, structure rather than in restorative material (restorative foundation),
and has improved toxicity profile of human gingival fibroblasts or for additional retention. However, even when placed at gingival
on supragingival margins. This early provisionalization can help

with the soft tissue contouring and maintenance or papilla regrowth
during the healing phase.96 Further, some have advocated immediate
provisionalization after crown lengthening surgery.97 Such practice
is only advised to extremely experienced periodontal-restorative
teams and mostly indicated for patients with well-known positive
tissue response to restorative procedures. Finally, to obtain a well-
A fitting provisional, it is important to understand that the tooth
preparation/restoration margins need to be easily visualized and
have enough intracoronal depth to allow for thickness of material
without overhanging margins.
Besides provisional restorations, any final indirect or direct
restoration (even well fitting) harbors more plaque and bacteria
than enamel and challenges the supportive periodontium.98 Thus
in the case of a poorly contoured restoration, periodontal breakdown
B
and recurrent caries at the restoration–tooth interface is probable
• Fig. 11.21 A, Full-coverage restorations on teeth No. 8 and No. 9 with in the long term.
inadequate marginal preparation, crown adaptation, and invasion of bio-
logic width causing gingival inflammation. B, Improved tissue health after
crown lengthening to reestablish the biologic width and well-adapted
Retraction Cord and Impressions
temporary restoration. When the tooth is receiving an indirect restoration, gingival displace-
ment is usually needed to adequately capture the preparation margins
level or slightly into the sulcus, some inflammatory tissue reaction with either physical or digital impression methods.99 This gingival
will occur94 (Fig. 11.21A). The presence of localized periodontal displacement, or retraction, can be done mechanically, chemically,
pathology has been found with indirect metaloceramic restorations or surgically (electrosurgery or laser). Retraction cords have been
independently of the supragingival or subgingival location of the shown to cause a reversible gingival displacement that is greater
margin. However, marginal adaptation is correlated with severity than other types of materials (i.e., paste or foam).100 Others have
of inflammation.94 To minimize the probability of tissue recession found that all retraction techniques cause temporary gingival
or chronic local inflammatory response, a well-adapted provisional displacement with inflammation with Ultrapak (Ultradent Products,
restoration should always be placed and tissue reaction ideally Inc., South Jordan, UT) cord without impregnation of hemostatic
observed for several weeks prior to final impression and placement agent causing most bleeding but fastest recovery compared to Magic
of the final restoration. A tissue that is healthy after the provisional FoamCord (Coltène, Altstätten, Switzerland) and Expasyl (Kerr
restoration is in place for several days or weeks is a good indication Corporation, Orange, CA).101 In this study, all retraction techniques
of no violation of the biologic width and that the periodontium caused an acute injury after 1 day of retraction, which took 1 week
will respond well to the final restoration margins (Fig. 11.21B). to heal in the Ultrapak and the Magic FoamCord groups. The
A well-adapted provisional restoration also will facilitate gingival Expasyl group had the highest gingival index of inflammation and
retraction and final impression and ensure that the tissue will showed the slowest healing. Its use may also cause tooth sensitivity.
rebound atraumatically (after impression). In another study, the Magic FoamCord system was a less traumatic
When a poorly contoured provisional restoration is placed, the method of gingival retraction compared to cords in slightly sub-
inflammatory process starts and can be perpetuated after the final gingival preparations. However, the material was less effective than
restoration is cemented as the area remains injured.95 It is important the single cord retraction technique in preparations with margins
to correct margins and roughness of any provisional as soon as deeper than 2 mm.102
detected to prevent and/or reverse damage leading to loss of When evaluating gingival retraction cords versus electrosurgery,
periodontal attachment. Wostmann and colleagues did not find any significant difference in
Further, placement of provisional restorations prior to proper the quality of the marginal fit of the crowns as long as the impression
initial healing after crown lengthening or gingivectomy can be technique utilized two (light and heavy) impression materials.103 To
problematic as it is not easy to determine the exact location where date there is no comparison between laser, electrosurgery, cord, and
the alveolar crest and the biologic width will be reestablished. cordless materials in regard to gingival health and quality of impres-
Despite the periodontal procedure performed, the result may still sion. It is currently accepted that retraction systems cause some
be violation of the biologic width with development of an inflam- temporary damage to the integrity of the gingival tissues; however,
matory lesion after surgery. When there is need for immediate or the soft gingival tissue heals in a few days provided there is adequate
early provisionalization after surgery, the restoration should rest marginal adaptation of the temporary restoration.
Summary
When planning restorations, thorough evaluation of periodontal undiagnosed periodontal defects in teeth that will be restored can
health, impact of restorative treatment on periodontium, and patient complicate treatment and lead to further disturbance of periodontal
perceptions of esthetics and understanding of oral health is war- health. Although periodontal disease is primarily caused by dental
ranted. Respecting the periodontium boundaries while restoring plaque, there are modifying and significant alterations caused by
tooth structures is vital for the success of the restorative treatment restorative treatment that contribute to the establishment and
and the overall oral homeostasis. Ill-fitting restorations and progression of periodontal breakdown.
References 26. Rosling B, Serino G, Hellstrom MK, et al: Longitudinal periodontal

tissue alterations during supportive therapy. Findings from subjects
1. Schroeder HE, Listgarten MA: The gingival tissues: the architecture with normal and high susceptibility to periodontal disease. J Clin
of periodontal protection. Periodontol 2000 13:91–120, 1997. Periodontol 28(3):241–249, 2001.
2. Ainamo J, Loe H: Anatomical characteristics of gingiva. A clinical 27. Hirschfeld L, Wasserman B: A long-term survey of tooth loss in
and microscopic study of the free and attached gingiva. J Periodontol 600 treated periodontal patients. J Periodontol 49(5):225–237, 1978.
37(1):5–13, 1966. 28. McFall WT, Jr: Tooth loss in 100 treated patients with periodontal
3. Ainamo A: Influence of age on the location of the maxillary disease. A long-term study. J Periodontol 53(9):539–549, 1982.
mucogingival junction. J Periodontal Res 13(3):189–193, 1978. 29. Fardal O, Linden GJ: Tooth loss and implant outcomes in patients
4. Ainamo J, Talari A: The increase with age of the width of attached refractory to treatment in a periodontal practice. J Clin Periodontol
gingiva. J Periodontal Res 11(4):182–188, 1976. 35(8):733–738, 2008.
5. Ainamo A, Ainamo J: The width of attached gingiva on supraerupted 30. Ochsenbein C, Ross S: A reevaluation of osseous surgery. Dent Clin
teeth. J Periodontal Res 13(3):194–198, 1978. North Am 13(1):87–102, 1969.
6. Bosshardt DD, Selvig KA: Dental cementum: the dynamic tissue 31. Weisgold AS: Contours of the full crown restoration. Alpha Omegan
covering of the root. Periodontol 2000 13:41–75, 1997. 70(3):77–89, 1977.
7. Hassell TM: Tissues and cells of the periodontium. Periodontol 2000 32. Stetler KJ, Bissada NF: Significance of the width of keratinized
3:9–38, 1993. gingiva on the periodontal status of teeth with submarginal restora-
8. Nanci A, Bosshardt DD: Structure of periodontal tissues in health tions. J Periodontol 58(10):696–700, 1987.
and disease. Periodontol 2000 40:11–28, 2006. 33. Ross IF, Thompson RH, Jr: A long term study of root retention in
9. Seo BM, Miura M, Gronthos S, et al: Investigation of multipotent the treatment of maxillary molars with furcation involvement. J
postnatal stem cells from human periodontal ligament. Lancet Periodontol 49(5):238–244, 1978.
364(9429):149–155, 2004. 34. Hamp SE, Nyman S, Lindhe J: Periodontal treatment of multirooted
10. Taylor AC, Campbell MM: Reattachment of gingival epithelium teeth. Results after 5 years. J Clin Periodontol 2(3):126–135,
to the tooth. J Periodontol 43(5):281–293, 1972. 1975.
11. Magnusson I, Listgarten MA: Histological evaluation of probing 35. Dannewitz B, Krieger JK, Husing J, et al: Loss of molars in peri-
depth following periodontal treatment. J Clin Periodontol 7(1):26–31, odontally treated patients: a retrospective analysis five years or more
1980. after active periodontal treatment. J Clin Periodontol 33(1):53–61,
12. Fowler C, Garrett S, Crigger M, et al: Histologic probe position 2006.
in treated and untreated human periodontal tissues. J Clin Periodontol 36. Hancock EB, Mayo CV, Schwab RR, et al: Influence of interdental
9(5):373–385, 1982. contacts on periodontal status. J Periodontol 51(8):445–449, 1980.
13. Gargiulo AW, Wentz FM, Orban B: Dimensions and relations of 37. Jernberg GR, Bakdash MB, Keenan KM: Relationship between
the dentogingival junction in humans. J Periodontol 32:261–267, proximal tooth open contacts and periodontal disease. J Periodontol
1961. 54(9):529–533, 1983.
14. Vacek JS, Gher ME, Assad DA, et al: The dimensions of the human 38. Moskow BS, Canut PM: Studies on root enamel (2). Enamel pearls.
dentogingival junction. Int J Periodontics Restorative Dent A review of their morphology, localization, nomenclature, occurrence,
14(2):154–165, 1994. classification, histogenesis and incidence. J Clin Periodontol
15. Tal H, Soldinger M, Dreiangel A, et al: Periodontal response to 17(5):275–281, 1990.
long-term abuse of the gingival attachment by supracrestal amalgam 39. Hou GL, Tsai CC: Cervical enamel projection and intermediate
restorations. J Clin Periodontol 16(10):654–659, 1989. bifurcational ridge correlated with molar furcation involvements. J
16. Kokich VG: Esthetics: the orthodontic-periodontic restorative Periodontol 68(7):687–693, 1997.
connection. Semin Orthod 2(1):21–30, 1996. 40. Risnes S, Segura JJ, Casado A, et al: Enamel pearls and cervical
17. Sanchez IM, Gaud-Quintana S, Stern JK: Modified lip repositioning enamel projections on 2 maxillary molars with localized periodontal
with esthetic crown lengthening: A Combined approach to treating disease: case report and histologic study. Oral Surg Oral Med Oral
excessive gingival display. Int J Periodontics Restorative Dent Pathol Oral Radiol Endod 89(4):493–497, 2000.
37(1):e130–e134, 2017. 41. Bissada NF, Abdelmalek RG: Incidence of cervical enamel projections
18. Bhola M, Fairbairn PJ, Kolhatkar S, et al: LipStaT: The lip stabiliza- and its relationship to furcation involvement in Egyptian skulls. J
tion technique: Indications and guidelines for case selection and Periodontol 44(9):583–585, 1973.
classification of excessive gingival display. Int J Periodontics Restorative 42. Hou GL, Tsai CC: Relationship between periodontal furcation
Dent 35(4):549–559, 2015. involvement and molar cervical enamel projections. J Periodontol
19. Coslet JG, Vanarsdall R, Weisgold A: Diagnosis and classification 58(10):715–721, 1987.
of delayed passive eruption of the dentogingival junction in the 43. Masters DH, Hoskins SW: Projection of cervical enamel into molar
adult. Alpha Omegan 70(3):24–28, 1977. furcations. J Periodontol 35:49–53, 1964.
20. Eke PI, Dye BA, Wei L, et al: Update on prevalence of periodontitis 44. Chou J, Rawal YB, O’Neil JR, et al: Cementodentinal tear: a case
in adults in the United States: NHANES 2009 to 2012. J Periodontol report with 7-year follow-up. J Periodontol 75(12):1708–1713,
86(5):611–622, 2015. 2004.
21. Williams RC, Offenbacher S: Periodontal medicine: the emergence 45. Ishikawa I, Oda S, Hayashi J, et al: Cervical cemental tears in older
of a new branch of periodontology. Periodontol 2000 23:9–12, 2000. patients with adult periodontitis. Case reports. J Periodontol
22. Mombelli A: Antimicrobial advances in treating periodontal diseases. 67(1):15–20, 1996.
Front Oral Biol 15:133–148, 2012. 46. Gound TG, Maze GI: Treatment options for the radicular lingual
23. Becker W, Becker BE, Berg LE: Periodontal treatment without groove: a review and discussion. Pract Periodontics Aesthet Dent
maintenance. A retrospective study in 44 patients. J Periodontol 10(3):369–375, quiz 76, 1998.
55(9):505–509, 1984. 47. Hou GL, Tsai CC: Relationship between palato-radicular grooves
24. Axelsson P, Lindhe J: The significance of maintenance care in the and localized periodontitis. J Clin Periodontol 20(9):678–682,
treatment of periodontal disease. J Clin Periodontol 8(4):281–294, 1993.
1981. 48. Geiger AM, Wasserman BH, Turgeon LR: Relationship of occlusion
25. Wennstrom JL, Serino G, Lindhe J, et al: Periodontal conditions and periodontal disease. 8. Relationship of crowding and spacing
of adult regular dental care attendants. A 12-year longitudinal study. to periodontal destruction and gingival inflammation. J Periodontol
J Clin Periodontol 20(10):714–722, 1993. 45(1):43–49, 1974.
49. Ingervall B, Jacobsson U, Nyman S: A clinical study of the relationship 72. Tatakis DN, Chambrone L, Allen EP, et al: Periodontal soft tissue
between crowding of teeth, plaque and gingival condition. J Clin root coverage procedures: a consensus report from the AAP Regenera-
Periodontol 4(3):214–222, 1977. tion Workshop. J Periodontol 86(2 Suppl):S52–S55, 2015.
50. Nunn ME, Harrel SK: The effect of occlusal discrepancies on 73. Miller PD, Jr: A classification of marginal tissue recession. Int J
periodontitis. I. Relationship of initial occlusal discrepancies to Periodontics Restorative Dent 5(2):8–13, 1985.
initial clinical parameters. J Periodontol 72(4):485–494, 2001. 74. Allen EP, Winter RR: Interdisciplinary treatment of cervical lesions.
51. Wang HL, Burgett FG, Shyr Y: The relationship between restoration Compend Contin Educ Dent (Jamesburg, NJ : 1995) 32(Spec5):16–20,
and furcation involvement on molar teeth. J Periodontol 2011.
64(4):302–305, 1993. 75. Pini-Prato G, Magnani C, Zaheer F, et al: Influence of inter-dental
52. Burgett FG, Ramfjord SP, Nissle RR, et al: A randomized trial of tissues and root surface condition on complete root coverage following
occlusal adjustment in the treatment of periodontitis patients. J treatment of gingival recessions: a 1-year retrospective study. J Clin
Clin Periodontol 19(6):381–387, 1992. Periodontol 42(6):567–574, 2015.
53. Padbury A, Jr, Eber R, Wang HL: Interactions between the gingiva 76. Santamaria MP, da Silva Feitosa D, Casati MZ, et al: Randomized
and the margin of restorations. J Clin Periodontol 30(5):379–385, controlled clinical trial evaluating connective tissue graft plus
2003. resin-modified glass ionomer restoration for the treatment of gingival
54. Ingber JS, Rose LF, Coslet JG: The “biologic width”–a concept in recession associated with non-carious cervical lesion: 2-year follow-up.
periodontics and restorative dentistry. Alpha Omegan 70(3):62–65, J Periodontol 84(9):e1–e8, 2013.
1977. 77. Wennstrom J, Lindhe J, Nyman S: Role of keratinized gingiva for
55. Matthews DC, Tabesh M: Detection of localized tooth-related gingival health. Clinical and histologic study of normal and regener-
factors that predispose to periodontal infections. Periodontol 2000 ated gingival tissue in dogs. J Clin Periodontol 8(4):311–328,
34:136–150, 2004. 1981.
56. Wagenberg BD, Eskow RN, Langer B: Exposing adequate tooth 78. Wennstrom J, Lindhe J: Role of attached gingiva for maintenance
structure for restorative dentistry. Int J Periodontics Restorative Dent of periodontal health. Healing following excisional and grafting
9(5):322–331, 1989. procedures in dogs. J Clin Periodontol 10(2):206–221, 1983.
57. Herrero F, Scott JB, Maropis PS, et al: Clinical comparison of 79. Geiger AM: Mucogingival problems and the movement of mandibular
desired versus actual amount of surgical crown lengthening. J incisors: a clinical review. Am J Orthod 78(5):511–527, 1980.
Periodontol 66(7):568–571, 1995. 80. Sorensen SE, Larsen IB, Jorgensen KD: Gingival and alveolar bone
58. Pontoriero R, Carnevale G: Surgical crown lengthening: a 12-month reaction to marginal fit of subgingival crown margins. Scand J Dent
clinical wound healing study. J Periodontol 72(7):841–848, Res 94(2):109–114, 1986.
2001. 81. Schwartz RS, Mauger M, Clement DJ, et al: Mineral trioxide
59. Jansson L, Blomster S, Forsgardh A, et al: Interactory effect between aggregate: a new material for endodontics. J Am Dent Assoc
marginal plaque and subgingival proximal restorations on periodontal 130(7):967–975, 1999.
pocket depth. Swed Dent J 21(3):77–83, 1997. 82. Nielsen MJ, Casey JA, VanderWeele RA, et al: Mechanical properties
60. Orkin DA, Reddy J, Bradshaw D: The relationship of the position of new dental pulp-capping materials. Gen Dent 64(1):44–48,
of crown margins to gingival health. J Prosthet Dent 57(4):421–424, 2016.
1987. 83. Gomes SC, Miranda LA, Soares I, et al: Clinical and histologic
61. Schatzle M, Land NP, Anerud A, et al: The influence of margins evaluation of the periodontal response to restorative procedures in
of restorations of the periodontal tissues over 26 years. J Clin the dog. Int J Periodontics Restorative Dent 25(1):39–47, 2005.
Periodontol 28(1):57–64, 2001. 84. Sakallioglu EE, Lutfioglu M, Sakallioglu U, et al: Gingival crevicular
62. Almeida AL, Esper LA, Sbrana MC, et al: Relationship between fluid levels of neuropeptides following dental restorations. J Appl
periodontics and restorative procedures: surgical treatment of the Biomater Funct Mater 13(2):e186–e193, 2015.
restorative alveolar interface (rai)–case series. J Indian Prosthodont 85. Ashcraft DB, Staley RN, Jakobsen JR: Fluoride release and shear
Soc 13(4):607–611, 2013. bond strengths of three light-cured glass ionomer cements. Am J
63. Camargo PM, Melnick PR, Camargo LM: Clinical crown length- Orthod Dentofacial Orthop 111(3):260–265, 1997.
ening in the esthetic zone. J Calif Dent Assoc 35(7):487–498, 86. Arora R, Deshpande SD: Shear bond strength of resin-modified
2007. restorative glass-ionomer cements to dentin–an in vitro study. J
64. Dowling EA, Maze GI, Kaldahl WB: Postsurgical timing of restorative Indian Soc Pedod Prev Dent 16(4):130–133, 1998.
therapy: a review. J Prosthodont 3(3):172–177, 1994. 87. Nup C, Boylan R, Bhagat R, et al: An evaluation of resin-ionomers
65. Bragger U, Lauchenauer D, Lang NP: Surgical lengthening of the to prevent coronal microleakage in endodontically treated teeth. J
clinical crown. J Clin Periodontol 19(1):58–63, 1992. Clin Dent 11(1):16–19, 2000.
66. De Rouck T, Eghbali R, Collys K, et al: The gingival biotype 88. Stockton LW, Tsang ST: Microleakage of Class II posterior composite
revisited: transparency of the periodontal probe through the gingival restorations with gingival margins placed entirely within dentin. J
margin as a method to discriminate thin from thick gingiva. J Clin Can Dent Assoc 73(3):255, 2007.
Periodontol 36(5):428–433, 2009. 89. Gupta SK, Saxena P, Pant VA, et al: Adhesion and biologic behavior
67. Moffitt ML, Bencivenni D, Cohen RE: Drug-induced gingival of human periodontal fibroblast cells to resin ionomer Geristore: a
enlargement: an overview. Compend Contin Educ Dent (Jamesburg, comparative analysis. Dent Traumatol 29(5):389–393, 2013.
NJ : 1995) 34(5):330–336, 2013. 90. Al-Sabek F, Shostad S, Kirkwood KL: Preferential attachment of
68. Hempton TJ, Dominici JT: Contemporary crown-lengthening human gingival fibroblasts to the resin ionomer Geristore. J Endod
therapy: a review. J Am Dent Assoc 141(6):647–655, 2010. 31(3):205–208, 2005.
69. Gegauff AG: Effect of crown lengthening and ferrule placement on 91. Al-Hiyasat AS, Al-Sa’Eed OR, Darmani H: Quality of cellular
static load failure of cemented cast post-cores and crowns. J Prosthet attachment to various root-end filling materials. J Appl Oral Sci
Dent 84(2):169–179, 2000. 20(1):82–88, 2012.
70. Alpiste-Illueca F: Altered passive eruption (APE): a little-known 92. Dragoo MR: Resin-ionomer and hybrid-ionomer cements: part II,
clinical situation. Med Oral Patol Oral Cir Bucal 16(1):e100–e104, human clinical and histologic wound healing responses in specific
2011. periodontal lesions. Int J Periodontics Restorative Dent 17(1):75–87,
71. Dello Russo NM: Placement of crown margins in patients with 1997.
altered passive eruption. Int J Periodontics Restorative Dent 4(1):58–65, 93. Gultz JP, Scherer W: The use of resin-ionomer in restorative pro-
1984. cedures. N Y State Dent J 64(6):36–39, 1998.
94. Passariello C, Puttini M, Virga A, et al: Microbiological and host 100. Prasanna GS, Reddy K, Kumar RK, et al: Evaluation of efficacy of
factors are involved in promoting the periodontal failure of metalo- different gingival displacement materials on gingival sulcus width.
ceramic crowns. Clin Oral Investig 16(3):987–995, 2012. J Contemp Dent Pract 14(2):217–221, 2013.
95. Dragoo MR, Williams GB: Periodontal tissue reactions to restorative 101. Al Hamad KQ, Azar WZ, Alwaeli HA, et al: A clinical study on
procedures. Int J Periodontics Restorative Dent 1(1):8–23, 1981. the effects of cordless and conventional retraction techniques on
96. Zucchelli G, Mazzotti C, Monaco C: A standardized approach for the gingival and periodontal health. J Clin Periodontol
the early restorative phase after esthetic crown-lengthening surgery. 35(12):1053–1058, 2008.
Int J Periodontics Restorative Dent 35(5):601–611, 2015. 102. Beier US, Kranewitter R, Dumfahrt H: Quality of impressions after
97. Tseng SC, Fu JH, Wang HL: Immediate temporization crown use of the Magic FoamCord gingival retraction system–a clinical
lengthening. Compend Contin Educ Dent (Jamesburg, NJ : 1995) study of 269 abutment teeth. Int J Prosthodont 22(2):143–147,
32(3):38–43, 2011. 2009.
98. Waerhaug J: Presence or absence of plaque on subgingival restorations. 103. Wostmann B, Rehmann P, Trost D, et al: Effect of different retraction
Scand J Dent Res 83(1):193–201, 1975. and impression techniques on the marginal fit of crowns. J Dent
99. Nemetz H, Donovan T, Landesman H: Exposing the gingival 36(7):508–512, 2008.
margin: a systematic approach for the control of hemorrhage. J
Prosthet Dent 51(5):647–651, 1984.

Periodontology Applied To Operative Dentistry

Uploaded by

Copyright:

Available Formats

Periodontology Applied To Operative Dentistry

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Periodontology Applied To Operative Dentistry

Uploaded by

Copyright:

Available Formats

11

• Fig. 11.2The periodontium surrounds and supports the teeth and is

TABLE 11.1 Biologic Width Components and

Connective tissue 1.07 (1.06–1.08) 0.77 (0.29–1.84)

Open Proximal Contacts

&ODVV, &ODVV,, &ODVV,,,

of periodontal disease. A total of 104 adults were evaluated and

• Grade 1: Short but distinct change in the contour of CEJ

Palatoradicular Grooves Tooth Position

• Fig. 11.12 A, Tooth No. 30 with secondary caries on the mesial

recession ranging from 2 to 4 mm continued to develop between

CEJ to the alveolar crest, there is enough keratinized tissue, and

Noncarious Cervical Lesions and

determine the appropriate treatment: restoration, soft tissue coverage

• Fig. 11.20 A, Cervical caries lesion on teeth No. 26

on supragingival margins. This early provisionalization can help

References 26. Rosling B, Serino G, Hellstrom MK, et al: Longitudinal periodontal

You might also like