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Review Article

Biologic width: Concept and violation

M. Aishwarya, G. Sivaram
Department of Periodontics, Ragas Dental College, Chennai, Tamil Nadu, India

ABSTRACT
The tooth and its supporting structures should be viewed as one biologic unit. An
understanding of the periodontal-restorative relationship is necessary for the proper form,
function, and esthetics of restoration and comfort to the patient. The dimension of the space
that the healthy gingival tissue occupies above the alveolar crest is known as the biologic
width. The concept of biologic width gains importance in the case of extensive caries
management, subgingival margin placement, crown/root fractures, orthodontic banding,
subgingival perforation and post, and core placement in endodontic therapy. Biologic
width is important for the preservation of periodontal health which eventually decides
the success of restorative procedures. This article discusses the anatomy, categories,
evaluation, violation, and methods to correct the violation of biologic width.

Key words: Biologic width, violation of biologic width, restorative margin placement

INTRODUCTION focusing on the cause, effect, and correction of biologic

The tooth, the pulp tissue within it, and its supporting
structures should be viewed as one biologic unit. The
periodontium and pulp have embryonic, anatomic, and
functional interrelationship.
An understanding of this relationship is essential to ensure
adequate form and function of dentition and esthetics/
comfort to the patients. In case of restorations with Class
III/IV caries, fractured (traumatized), severely decayed,
partially erupted (delayed passive eruption), worn or
poorly restored teeth impingement on the periodontal
attachment apparatus, or violation of biological width can
occur. This article discusses the concept of biologic width
Address for correspondence:
Dr. Aishwarya Mahesh Kumar,
19/20 Deccan Jamuna, Kannapan Nagar, Thiruvanmiyur,
Chennai, Tamil Nadu, India.
E-mail: bhavaaishu@yahoo.co.in
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width violation.
The four aspects of restoration design which have a direct
effect on the periodontium are:[1]
Margin placement.
Margin adaptation.
Restoration contour.
Occlusal function.
It is important to have a healthy periodontium prior to
starting restorative treatment, because:
Gingiva shrinks after periodontal treatment.
The position of teeth is frequently altered in
periodontal disease. Resolution of inflammation
after treatment causes the teeth to move again, often
back to their original position. Restorations designed
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DOI:
10.4103/0976-433X.170254 How to cite this article: Aishwarya M, Sivaram G. Biologic width:
Concept and violation. SRM J Res Dent Sci 2015;6:250-6.

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Aishwarya and Sivaram: Biologic width: Concept and violation
for teeth before the periodontium is treated may
produce injurious tensions and pressures on the treated
periodontium.
Inflammation of the periodontium impairs the capacity
of abutment teeth.
Discomfort from tooth mobility interferes with
mastication and function.
It is easy to obtain accurate impressions and make
precise preparations on healthy gingiva than inflamed
one.
To minimize the risk of trauma to the gingival tissues
during preparation and impression procedures.
BIOLOGIC WIDTH
The dimension of the space that the healthy gingival tissue
occupies above the alveolar bone is called the biologic width
[Figure 1].[2]
Biologic width is essential for the preservation of
periodontium and removal of irritation that might damage
the periodontium.
The dimension of biologic width is not constant, it
depends on the location of the tooth in the alveolar,
varies from tooth to tooth, and also from one surface of
the tooth to another.
VIOLATION OF BIOLOGIC WIDTH
Violation of the biologic width leads to ultimate failure
of the restoration.
Encroachment of biologic width becomes of particular
concern when considering the restoration of a tooth that
has fractured or been carious near the alveolar crest.
Also, esthetic concerns often require hiding of restorative
margins below the gingival margin that is pushing them
down into the gingival sulcus leading to the violation of
biologic width.
Figure 1: Biologic width
SRM Journal of Research in Dental Sciences | Vol. 6 | Issue 4 | October-December 2015
Bone loss and gingival recession occur as the body attempts
to recreate room between the alveolar bone and the margin
to allow space for tissue reattachment. This is more likely
to occur in areas where the alveolar bone surrounding the
tooth is very thin. This fragile tissue recedes leading to the
gingival recession.[3]
EVALUATION OF BIOLOGIC WIDTH VIOLATION
Clinical method
If a patient experiences tissue discomfort when the
restoration margin levels are being assessed with a
periodontal probe, it is a good indication that the margin
extends into the attachment and that a biologic width
violation has occurred.
The signs of biologic width violation are [Figure 2]:[4]
Chronic progressive gingival inflammation around the
restoration.
Bleeding on probing.
Localized gingival hyperplasia with minimal bone loss.
Gingival recession.
Pocket formation.
Clinical attachment loss.
Alveolar bone loss.
Gingival hyperplasia (most frequently found in altered
passive eruption and subgingivally placed restoration
margins).
Bone sounding/transgingival probing
The biologic width can be identified by probing under local
anesthesia to the bone level (referred to as sounding to
bone) and subtracting the sulcus depth from the resulting
measurement [Figure 3].[5]
If this distance is <2 mm at one or more locations, a
diagnosis of biologic width violation can be confirmed.
Figure 2: Signs of biologic width violation inflammation and
bone loss
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Aishwarya and Sivaram: Biologic width: Concept and violation

Radiographic evaluation A patient with more substantial attachment apparatus

Radiographic interpretation can identify interproximal
violations of biologic width.
However, on the mesiofacial and distofacial line angles
of teeth, radiographs are not diagnostic because of tooth
superimposition.
Parallel profile radiographic technique has been devised
which could be used to measure both length and thickness
of the dentogingival unit with accuracy.[6]
and significantly shallower sulcus is less susceptible to the
gingival recession (stable low crest), whereas in a patient
with a deeper sulcus and narrower attachment with more of
unsupported tissue from the base of the sulcus to the gingival
crest, this amount of unsupported gingival tissue does not
tend to be stable, and this patient is susceptible to gingival
recession (unstable low crest).

CATEGORIES/PROFILES OF BIOLOGIC WIDTH

Kois proposed three categories of biologic width based on

the total dimension of attachment and the sulcus depth
following bone sounding measurements:[7,8]
Normal crest.
Low crest.
High crest.

Normal crest High crest Low crest

Midfacial measurement 3 mm <3 mm >3 mm
Proximal measurement 34.5 mm <3 mm >4.5 mm

Figure 3: Transgingival probing/bone sounding

Normal crest patient (85%)
The gingival tissue tends to be stable for a long-term. The
margin of a crown should be placed no closer than 2.5 mm
from alveolar bone [Figure 4].

Therefore, a crown margin which is placed 0.5 mm

subgingivally tends to be well-tolerated by the gingiva and
is a stable long term in the normal crest patient.

High crest patient (2%)

This is seen more often in a proximal surface adjacent to
an edentulous site. In this situation, it is commonly not
possible to place an intracrevicular margin because the
margin will be too close to the alveolar bone, resulting in
a biologic width impingement, and chronic inflammation
[Figure 5].
Figure 4: Normal crest
Low crest patient (13%)
The low crest patient has been described as more
susceptible to recession secondary to the placement
of an intracrevicular crown margin. When retraction
cord is placed subsequent to the crown preparation; the
attachment apparatus is routinely injured. As the injured
attachment heals, it tends to heal back to a normal crest
position, resulting in gingival recession [Figure 6].

All low crest patients do not react in the same way to an

injury to the attachment. Some low crest patients are
susceptible to gingival recession while others have a quite
stable attachment apparatus, the difference is based on the
depth of the sulcus. Figure 5: High crest

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Aishwarya and Sivaram: Biologic width: Concept and violation
MARGIN PLACEMENT
Ingber et al. (1977)
Ingber et al., (1977) suggested that a minimum of 3 mm was
required from the restorative margin to the alveolar crest
to permit adequate healing and restoration of the tooth.[9]
Maynard and Wilson (1979)
Divided the periodontium into three-dimensions, all
of which affect decision-making during restorative
therapy:[10]
Superficial physiologic: Represents the free and attached
gingival surrounding the tooth.
Crevicular physiologic: Represents the gingival dimension
from the gingival margin to the junctional epithelium.
Subcrevicular physiologic: Is analogous to the biologic width
described (Gargiulo et al. 1961), consisting of the junctional
epithelium and connective tissue attachment.
Nevins and Skurow (1984)
Nevins and Skurow (1984) stated that when subgingival
margins are indicated, the junctional epithelium, or
connective tissue apparatus during preparation and
impression taking. Limiting the subgingival margin extension
to 0.5-1.0 mm is to be done, because it is impossible for
the clinician to detect where the sulcular epithelium ends,
and the junctional epithelium begins. A minimum 3.0 mm
distance from the alveolar crest to the crown margin is
necessary.[11]
Margin placement Rules[12]
1. If the sulcus probes 1.5 mm or less, the restorative margin
could be placed 0.5 mm below the gingival tissue crest.
2. If the sulcus probes >1.5 mm, the restorative margin
can be placed in half the depth of the sulcus.
3. If the sulcus is >2 mm, gingivectomy could be
performed to lengthen the tooth, and create a 1.5mm
sulcus. Then the patient can be treated as per rule 1.
Figure 6: Low crest
SRM Journal of Research in Dental Sciences | Vol. 6 | Issue 4 | October-December 2015
Supragingival margin
It has the least impact on the periodontium. This margin
location has been applied in non-esthetic areas due to the
marked contrast in color and opacity of traditional restorative
materials against the tooth. With the advent of more
translucent restorative materials, adhesive dentistry, and
resin cements, the ability to place supragingival margins in
esthetic areas is now a reality [Figure 7].[13]
Advantages
1. Preparation of the tooth and finishing of the margin is
easy.
2. Duplication of the margins with impressions that can
be removed past the finish line without tearing or
deformation is the easiest with supragingival margins.
3. The supragingival margins are least irritating to the
periodontal tissue.
Equigingival margin
The use of equigingival margins traditionally was not
desirable because, they were thought to favor more
plaque accumulation, and hence result in greater gingival
inflammation and that any minor gingival recession would
create an unsightly margin display. These concerns are not
valid today, not only because the restoration margins can
be esthetically blended with the tooth but also because
restorations can be finished easily to provide a smooth,
polished interface at the gingival margin.
Subgingival margin
Restorative considerations will frequently dictate the
placement of restoration margins beneath the gingival tissue
crest because of dental caries or tooth deficiencies, and/or to
mask the tooth/restoration interface. When the restoration
margin is placed too far below the gingival tissue crest, it will
impinge on the gingival attachment apparatus, and a constant
inflammation is created and made worse by the patients
inability to clean this area. The body attempts to recreate room
between the alveolar bone and the margin to allow space for
Figure 7: Supragingival margin
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Aishwarya and Sivaram: Biologic width: Concept and violation

tissue reattachment, as a result of which gingival recession and
bone loss occurs. This is more likely to occur in areas where
the alveolar bone surrounding the tooth is very thin in width.
Highly scalloped, the thin gingiva is more prone to recession
than a flat periodontium with thick fibrous tissue. The more
common finding with deep margin placement is that bone level
appears to remain unchanged; however, gingival inflammation
develops and persists on the tooth restored [Figure 8].[14]
The alveolar bone is reduced by ostectomy and osteoplasty,
to expose the required tooth length in a scalloped fashion,
and to follow the desired contour of the overlying gingiva. As
a general rule, at least 4 mm of sound tooth structure must
be exposed, so that the soft tissue will proliferate coronally
to cover 2-3 mm of the root, thereby leaving only 1-2 mm of
supragingivally located the sound tooth structure.

If the margin must be placed subgingivally, the factors to be Healing after crown lengthening
taken into account are: In nonesthetic area: Re-evaluated after 6 weeks postsurgery.
Correct crown contour in the gingival third. In esthetic areas, a longer healing period is recommended.
Correct polishing.
Rounding of the margins.
Sufficient zone of the attached gingival.
No biologic width violation.

CORRECTION OF BIOLOGIC WIDTH VIOLATION

Surgical crown lengthening

Indications[15]
1. Inadequate clinical crown for retention due to extensive
caries, subgingival caries or tooth fracture, root
perforation or root resorption within the cervical 1/3rd of
the root in teeth with adequate periodontal attachment.
2. Short clinical crowns.
3. Unequal, excessive, or unesthetic gingival levels for esthetics.
4. Teeth with excessive occlusal wear or incisal wear. Figure 8: Subgingival margin
5. Teeth with inadequate interocclusal space for proper
restorative procedures due to supraeruption.
6. Restorations which violate the biologic width.
7. In conjunction with tooth requiring hemisection or root
resection.

Contraindications
1. Deep caries or fracture requiring excessive bone removal.
2. Tooth with inadequate crown root ratio (ideally 2: 1 ratio
is preferred). Figure 9: Gingivectomy
3. Non-restorable teeth.
4. Tooth with increased risk of furcation involvement.
5. Unreasonable compromise esthetics/adjacent alveolar
bone support.

Gingivectomy can be done in the case of [Figure 9]:

Hyperplasia or pseudopocketing (>3 mm of biologic
width).
Presence of adequate amount of keratinized tissue.

Apical repositioned flap surgery

Without osseous resection.

This procedure is done when there is no adequate width of

attached gingiva, and there is a biologic width of >3 mm
on multiple teeth:
With osseous reduction [Figure 10]. Figure 10: Flap surgery

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Aishwarya and Sivaram: Biologic width: Concept and violation
Complications after crown lengthening
Poor esthetics black triangles.
Root hypersensitivity/resorption.
Transient mobility.
Orthodontic procedures
Orthodontic extrusion can be performed in two ways
[Figure11].[16]
Slow
By applying low orthodontic force, the tooth is erupted
slowly, bringing the alveolar bone, and gingival tissue along
with it. The tooth is extruded until the bone level has been
carried coronal to the ideal level by the amount that needs to
be removed surgically to correct the biologic width violation.
The tooth is stabilized in this position and then treated with
surgery to correct the bone and gingival tissue levels.
Rapid
The tooth is erupted the desired amount over several weeks
(with supracrestal fibrotomy performed weekly in an effort
to prevent the tissue and bone from following the tooth).
Then the tooth is stabilized for atleast 12 weeks prior to
surgical correction.
Forced tooth eruption
Forced eruption should be considered in the cases where
traditional crown lengthening via ostectomy cannot be
accomplished as in anterior area, as ostectomy would lead to a
negative architecture, and also remove bone from the adjacent
teeth, which can compromise the function of these teeth.
Contraindications:
Inadequate crown-to-root ratio.
Lack of occlusal clearance for the required amount of
eruption.
Possible periodontal complications.
Figure 11: Orthodontic extrusion
SRM Journal of Research in Dental Sciences | Vol. 6 | Issue 4 | October-December 2015
Technique: Orthodontic brackets are bonded to the problem
tooth and adjacent teeth and are combined with archwire.
Power elastic is tied from the bracket to the archwire which
pulls the tooth coronally.
Forced tooth eruption with fibrotomy
If fibrotomy is performed during the forced tooth eruption
procedure, the crestal bone, and the gingival margin are
retrieved at their pretreatment location and the tooth-
gingiva interface at adjacent teeth is unaltered. Fibrotomy
is performed with a scalpel at 7-10day intervals to sever the
supracrestal fibers, thereby preventing the crestal bone form
following the root in a coronal direction.[17]
Contraindicated: Angular bone defects and ectopically
erupted teeth.
CONCLUSION
The health of periodontal tissue is dependent on properly
designed restoration. Incorrectly placed restorative margins
and poorly adapted restorations violate the biologic width.
Repeated maintenance visits, patient cooperation, and
motivation are important for the success of restorations and
maintenance of periodontal health.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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