Journal of Nepal Dental Association | Vol. 13, No.

1, January-June, 2013 (74-77)

Review Article

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on periodontal integrity
Sarandha D.L
Professor, Department of Prosthodontics, Dr Syamala Reddy Dental College and Hospital, Bangalore, India

Abstract
It is well documented that the optimal periodontal health should be ensured before initiation of prosthodontic treat-
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restoration margin on the health of periodontium is highly debated. Hence this article attempts to review literature
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lines.

Keywords%LRORJLFZLGWKHTXLJLQJLYDO¿QLVKOLQHVXEJLQJLYDOVXSUDJLQJLYDO

Introduction
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factors of which long term maintenance of periodontal
health undoubtedly forms an important aspect. Various
aspects of a restoration affect the periodontal health of
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contribution in this regard. Hence an attempt has been
made in this aspect by reviewing earlier literature to
substantiate evidence towards the effect of different
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that the margins of the crown should be placed as close
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keratinized epithelium in this region. The equigingival
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acceptability and accessible margin placement.
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early as 1941 for improved periodontal health6. It has
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periodontal health; the reasons being accessibility to
maintain hygiene, facilitation of margin placement and
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aesthetics in the anterior teeth replacement. Christensen7
has demonstrated that the visually accessible margin
as possible to the gingival attachment of the tooth, VXSUDJLQJLYDO FDQ EH DQG LV ¿WWHG PRUH DFFXUDWHO\
that is, as far subgingivally as possible1. This must than visually inaccessible margin (subgingival).
have been in support of the concept of “caries free
zone” which is not periodontally accepted. Weinberg The origin of the subgingival margin is attributed to the
suggested that all posterior restorations should be concept of “extension for prevention” and “the caries
placed up to and only slightly below the free margin of free zone” by G.V.Black6. In 1925 Gottlieb contended
the gingival (less than lmm)2. Deeper placement usually that the concept of “extension for prevention” was not
causes permanent damage to some of the gingival and valid. He stated that “the practice of extending any metal
WUDQVHSWDO¿EUHVZLWKUHVXOWDQWDSLFDOPLJUDWLRQRIWKH restoration below the gingiva will prove detrimental”8.
epithelial attachment. WFP Malone and David Koth3 Loe supported Gottlieb’s views in 19689. The theory of
recommend a position that is midpoint subgingivally caries free zone was also disputed by Orban19. Orban
between the epithelial attachment and the crest of the and other researchers discovered that the “caries free
gingiva for aesthetic anterior restoration. zone” or the “clean” subgingival zone which had been
observed previously on extracted teeth was nothing
Marcum4 VXJJHVWHG DQ HTXLJLQJLYDO ¿QLVK OLQH WKH more than the location of epithelial attachment and
VXFFHVVRIZKLFKKHDWWULEXWHGWREHWWHUPDUJLQDO¿QLVK this will not attach to the margin of the cast restoration.
Harrison5 was of the opinion that the reason for the Thus, the concept of routine subgingival margin was
Correspondence: Dr Sarandha D.L, Department of Prosthodontics, Dr Syamala Reddy Dental College, 111/1, SGR Main
road, Munnekolala, Marathahalli, Bangalore-560037, E-mail-drsarandha@gmail.com

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TXHVWLRQHG DV PRUH VFLHQWL¿F HYLGHQFH DSSHDUHG6.
Originally the term subgingival margin referred to
placement of restoration margin somewhere between
the free gingival margin and alveolar crest. However
the term “intracrevicular” is more descriptive of a
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contributing to optimum periodontal health8.
Intracrevicular margins are adapted for enhancement of
aesthetics. Extension of the preparation margin is carried
out on sound tooth structure beyond existing restorative
materials or abrasion and to enhance retention in case
of compromised height of clinical crown. Jonathan L
Ferenez11 however says that extension into gingival
sulcus is not the only way to deal with questionable
retention. Decreasing the convergence angle of the
preparation or adding retentive features such as pins or
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Many investigations have been conducted with the
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line, but with different parameters. The common
parameters have been gingival index, periodontal
index, and pocket depth, bleeding on probing and
gingival recession.
The hypothesis that “more apical the subgingival margin
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been proved by investigators. Clinical examination by
Martin A Frielich et al showed that subgingival margins
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where changes occurred between 6 months to 5
years after placement of conventional FPD’s. Pocket
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located 2-3 mm apical to the gingival crest compared
to those placed at crest or supragingival group10. A
survey conducted by Guy N Newcomb to examine
the relationship between crown margin position and
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subgingival margin approaches the base of the gingival
crevice, the more likely it is that severe gingival
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observed when subgingival margins were placed at
the gingival crest or just into the gingival crevice12.
Waerhaug reported that subgingival restorations are
likely to facilitate retention of bacterial plaque and
subgingival margins may contribute substantially to
the destruction of the periodontium13. Karlsen studied
the effect of crown locations on the gingival health of
dogs and monkeys and reported a decrease in gingival
integrity with subgingival placement9. It has been
documented in literature that chronic irritation leads
JNDA Vol. 13, No. 1, Jan.-June, 2013
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to gingival recession. The study conducted by D.A.
Orkin proved that the subgingival margins had 2.65
times higher chance of gingival recession compared to
supragingival margin. This same study also proved that
gingival tissues tend to bleed 2.42 times more frequently
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supragingival margins14. Bernd Reitemeir et al15 in their
long term study observed that in all oral hygiene index
score categories, subgingival margins were associated
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crest and supragingival margins. Investigations by
Muller, Flores-de-Jacoby and John Silness proved that
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Their studies also concluded that subgingival and
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RIJLQJLYDOLQÀDPPDWLRQ16,17,18.
A investigation by Jones contradicts the belief that
supragingival margins are superior through his study
which concluded that gingiva next to crowns with
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that associated with supragingival labial margins9.
A study by James Marcum on dogs showed that margins
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to severe gingival response caused by the crowns with
margins above the gingival crest may be due to plaque
accumulation and adherence of food debris. The slight
to severe response from crowns with margins below
the crest may be due the minute crevice between the
tooth structure and margins of restoration which may
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response shown by crowns with margins even with the
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gingival crevice4.
William G Reeves19 has summarized the factors
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subgingival margins; placement of subgingival margin
in an area with minimum to no attached gingival and
violation of biologic width.
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when developing crown contours or may be a result
of failure to remove adequate tooth structure during
tooth preparation. If restorative margin is extended
subgingivally, this will create a potential area that
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to clean19.
Open margins and subgingival margins are protected
areas where large number of pathologic organisms
accumulates. Access to these areas for effective oral
hygiene is extremely limited and thus they are generally
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greater attachment loss19.
Maynard and Wilson suggested that a band of attached
gingiva at least 3mm wide should be present before
subgingival margin is considered19. Jonathan L Ferencz
also suggests that gingival tissues should exhibit
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within the range of 1-3mm and adequate bands of
attached tissue before one commences Prosthodontic
procedures.11
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connective tissue and junctional epithelial attachment
formed adjacent to a tooth and superior to crestal
bone20. Gargiulo et at described the dimensions and
relationship of the dentogingival junction in human
autopsy specimens, which gave rise to the concept of
biologic width8.
Average sulcus depth- 0.69mm
Mean junctional epithelium- 0.97mm
Average supra-alveolar connective tissue1.07mm.
Overall dimension of connective tissue and junctional
epithelium- 2.04mm
Unfortunately determining the histological base of the
gingival crevice and the coronal border of biologic width
is not possible clinically. If the margin has been brought
to a state of optimum health, the histological crevice
depth is probably slightly more than 0.5mm deep19. The
crevice depth measured by clinical probing will always
be deeper than histologic crevice depth because of
limited resistance of junctional epithelium to even light
probing forces which accentuates in case of marginal
LQÀDPPDWLRQ19. Current standards of care dictate that
the gingiva should be brought to a state of health before
any restorative procedure is initiated. Once a healthy
gingival environment has been established, the best
rule is to assume that any margin placed more than
0.5mm subgingivally will violate the biologic width
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110
76
will eventually lead to marginal attachment loss19. It is
important to evaluate the location of restoration margins
circumferentially around the tooth. The biologic width
follows the alveolar scallop. The bone scallop parallels
the cementoenamel junction circumferentially10.
Marxkors and Figgener demonstrated that in most
cases the preparation line is located more apically at
the mesial and distal aspects than at the vestibular/oral
aspect10.
Iatrogenic damage to the gingival tissue should be
avoided during tooth preparation, since it is one of the
main causes for gingival recession. When bleeding
occurs during tooth preparation, it implies abrasion
to the epithelial lining of the sulcus and exposure of
underlying connective tissue. New epithelium will
proliferate to cover the exposed connective tissue
wound and complete healing will normally take
place within 8-14 days. However if the connective
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epithelial down growth may occur during the healing
phase, thus establishing the sulcus at a more apical
level. Jonathan L Ferenez13 suggests the placement
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surface which is adequate to accommodate retraction
cord before subgingival margin placement. Although
the inner lining of sulcular epithelium is usually
abraded during placement of the bevel, if no damage
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takes place eventually without recession. However if
gingival tissue is damaged with considerable bleeding,
the impression procedure should be accomplished after
complete wound healing. This may necessitate the need
to re-establish the subgingival margin.
Conclusion:
An attempt to retrace the past literature has provided
substantial evidence that gingival margin placement
plays an important role in regard to periodontal health.
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of gingival fmish line are periodontal consideration,
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structure apical to caries/existing restoration. Most
of the studies prove that supragingival margins are
most congruent in regard to periodontal health. Hence
it should be positively considered in non aesthetic
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in aesthetic zones with care during tooth preparation
and appropriate maintenance. In unavoidable clinical
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JNDA Vol. 13, No. 1, Jan.-June, 2013
without iatrogenic damage to gingiva and accurate biologic width, subgingival restorative margins
treatment planning for preservation of periodontal are contraindicated without periodontal surgical
health. In any event, in patients without adequate procedure.

References:
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2. Weinberg LA: Aesthetics and gingivae in full coverage. J Prosthet Dent 1960; 10: 737-744.
 0DORQH:)3.RWK'7\OPDQ¶VWKHRU\DQGSUDFWLFHRI¿[HG3URVWKRGRQWLFVWKHGLWLRQ$OO,QGLDSXEOLVKHUVDQGGLVWULEXWRUV5HJG
2004; 131.
4. Marcum JS: The effect of crown marginal depth upon gingival tissue. J Prosthet Dent 1967; 17: 479-487.
5. Gardner FM: Margins of complete crowns-literature review. J Prosthet Dent1982; 48: 396-400.
6. Becker CM, Wayne B, Kaldahl: Current theories of crown contour, margin placement, and pontic design. J Prosthet Dent 2005; 93:
107-114.
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 *XQD\+6HHJDU$7VFKHUWWLWVFKHN+*HXUWVHQ:3ODFHPHQWRIWKH¿QLVKOLQHDQGSHULRGRQWDOKHDOWK$SURVSHFWLYH\HDUFOLQLFDO
study. Int J Periodontics Restorative Dent 2000; 20: 173-81.
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 )UHLOHLFK0$1LHNUDVK&KULVWLQH(.DW]596LPRQVHQ5-3HULRGRQWDOHIIHFWVRI¿[HGSDUWLDOGHQWXUHUHWDLQHUPDUJLQVFRQ¿JXUD-
tion and margin. J Prosthet Dent1992; 67: 184-90.
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 1HZFRPE*07KHUHODWLRQVKLSEHWZHHQWKHORFDWLRQRIJLQJLYDOFURZQPDUJLQVDQGJLQJLYDOLQÀDPPDWLRQ-3HULRGRQWDO
151-54.
 :DHUKDXJ-XVWL¿FDWLRQIRUVSOLQWLQJLQSHULRGRQWDOWKHUDS\-3URVWKHW'HQW
14. Orkin DA, Reddy J, Bradshaw D: The relationship of the position of crown margins to gingival health. J Prosthet Dent1987; 57: 421-
24.
15. Reitemeier B, Hansel C, Walter MH, Kastner C, Toutenburg H: Effect of posterior crown margin placement on gingival health. J Pros-
thet Dent 2002; 87: 167-72.
 0XOOHU+37KHHIIHFWRIDUWL¿FLDOFURZQPDUJLQVDWWKHJLQJLYDOPDUJLQRQWKHSHULRGRQWDOFRQGLWLRQVLQDJURXSRISHULRGRQWDOO\
VXSHUYLVHGSDWLHQWVWUHDWHGZLWK¿[HGEULGJHV-&OLQ3HULRGRQWRO
 -DFRE\/)'=D¿URSRXORV**&LDQFLR67KHHIIHFWRIFURZQPDUJLQORFDWLRQRQSODTXHDQGSHULRGRQWDOKHDOWK,QW-3HULRGRQW5HVW
Dent 1989; 9: 197-205.
18. Silness J: Periodontal conditions in patients treated with dental bridges. Int J Periodont Rest 1970; 5: 225-229.
19. Reeves WA: Restorative margin placement and periodontal health. J Prosthet Dent 1991; 6: 73.
20. The Glossary of Prosthodontic Terms. 8th ed. J Prosthet Dent 2005; 9.

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