PERIO-RESTORATIVE

INTERRELATIONSHIP

CONTENTS

INTRODUCTION
RATIONALE FOR PERIODONTAL THERAPY
BIOLOGIC CONSIDERATIONS
MARGIN PLACEMENT AND BIOLOGIC WIDTH
RESTORATIVE FACTORS
DIRECT INJURY TO PERIODONTIUM BY RESTORATIVE
PROCEDURE
ENDODONTIC PROCEDURES
PROSTHODONTIC PROCEDURE
CONCLUSION
REFERENCES

INTRODUCTION

Treatment
predictability

Acute
periodontal
infection

Longevity &
maintenance

RATIONALE FOR PERIODONTAL THERAPY

Establishment of stable
gingival margins
before tooth
preparation

Enhance adequate tooth

length for retention,
impression making, tooth
preparation and finishing
of restorative margin.

Quality, quantity &

topography of the
periodontium

Periodontal therapy
should follow
restorative procedure.

BIOLOGIC CONSIDERATIONS

MARGIN PLACEMENT AND BIOLOGIC WIDTH

Vacek et al. 1994

THERE IS SOME CONTROVERSY AS TO WHAT THE TERM

BIOLOGIC WIDTH ENCOMPASSES.

Asif
Asif et
et al(1991)
al(1991) define
define the
the biologic
biologic width
width as
as the
the total
total dimension
dimension of
of the
the
epithelial
epithelial and
and connective
connective tissue
tissue attachment
attachment to
to the
the root
root and
and refer
refer to
to the
the study
study
by
by Gargiulo
Gargiulo et
et al
al where
where it
it was
was determined
determined that
that this
this dimension
dimension averages
averages 2.04
2.04
mm.
mm.

Nevins
Nevins and
and Skurow
Skurow (1984)
(1984) define
define biologic
biologic width
width as
as aa combined
combined sum
sum of
of the
the
space
space occupied
occupied by
by the
the supracrestal
supracrestal fibers,
fibers, junctional
junctional epithelium,
epithelium, and
and the
the
gingival
gingival sulcus,
sulcus, and
and estimate
estimate that
that these
these measure
measure aa minimum
minimum of
of 3mm.
3mm.

SUPRACRESTAL GINGIVAL TISSUE

Supracrestal gingival tissue = Junctional epithelium (0.97) +

connective tissue attachment (1.07) + sulcular depth 0.69 mm.

Total dimension of supracrestal gingival tissue (SGT) = 2.73mm.

Recommend 3 mm of supracrestal tooth structure

to allow for biologic width formation and retention
of the prosthesis.

Assif et al

Ingber et_al (1977)

and Fugazzotto(1985)

Recommend 4mm, Wagenberg et al

recommend a 5- to 5.25-mm exposure of
supracrestal tooth structures.

CLINICALLY DISRUPTION OF THE JUNCTIONAL EPITHELIUM CAN BE CAUSED

- By placement of restoration margins

too far apically,

- Exaggeration of emergence profiles of

restored teeth and
- Injudicious manipulation of the SGT
during tooth preparation or the
impression-making process.

KOIS JC ET AL; PERIO 2000; 1996

Occurs approximately 85%
of time.
The margin of a crown should
generally
Occurs approximately
13% of
be placed no closer
the time.
than
2.5 mm from alveolar bone.
Normal crest patient

Low crest

More susceptible to recession

secondary to the placement of
Occurs
approximately
2% of
an intracrevicular
crown
themargin.
time.

High crest patient

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.

EVALUATION OF BIOLOGIC WIDTH

CLINICAL METHOD

BONE SOUNDING

RADIOGRAPHIC METHOD

Ingber et al (1977)

Gingival recession

Periodontal pockets

CORRECTION OF BIOLOGIC WIDTH VIOLATION

Surgical Crown
Lengthening to remove
bone away from the
restorative margin

Orthodontic extrusion of
tooth

SURGICAL CROWN LENGTHENING

Gingivectomy
Adequate attached gingiva and more than 3mm of soft
tissue coronal to the bone crest

Flap surgery +bone contouring

Inadequate attached gingiva and less than 3mm of soft
tissue.
The bone removed by measuring distance of the biologic
width + 0.5 mm as safety zone

ORTHODONTIC EXTRUSION
Low orthodontic
forces:

Tooth erupts slowly bringing

the alveolar bone and gingival
tissue along with it.
Tooth is extruded until the
bone level has been carried
coronal to the ideal level as
recommended in an individual.

Rapid Orthodontic
Extrusion: Tooth is erupted to desired amount
in several weeks
Supracrestal fibrotomy performed
weekly in an effort to prevent the
bone and tissue from following the
tooth.
The tooth is stabilized for 12 weeks

MARGINS OF RESTORATION
Supragingival
margins

unaesthetic
Well tolerated

Earlier thought to retain plaque

Equigingival margins Well polished restorations are well
tolerated

Not accessible for cleaning and polishing

Sub gingival margins
Placed far below can violate biologic width

GUIDELINES FOR PLACEMENT OF MARGINS USING SULCUS DEPTH AS A

GUIDE

1.5mm or less

0.5mm below the

gingival crest

> 1.5mm

1/2 depth of the

sulcus below the
tissue crest

> 2mm

Evaluategingivectomy
Gorzo I et al., 1979; Highfield JE et

Margins of Restoration

Subgingival
Subgingival margins
margins typically
typically have
have aa gap
gap of
of
20
20 to
to 40
40 m
m between
between the
the margins
margins of
of the
the
restoration
restoration and
and unprepared
unprepared tooth.
tooth.
Setz et al. 1994

Demonstrated that sub-gingival restorations

had a greater chance of bleeding and
exhibiting gingival recession in comparison
to supra-gingivally placed restoration
margin.

Renggli et al in 1972

Orkin et al in 1987

showed that gingivitis and plaque

accumulation were more pronounced in
interdental areas even with welladapted sub-gingival amalgam
restorations compared to a sound tooth
structure.

Studied the effects of crown margin location on periodontal

health and bacterial morphotypes in human 6-8 weeks and 1
year post insertion. Subgingival margins demonstrated
increased in various clinical parameter such as plaque,
gingival index score and probing depths. Furthermore, more
spirochetes, fusiforms, rods and filamentous bacteria were
found to be associated with subgingival margins.

Flores-de-Jacoby et
al 1989

Subgingival
Subgingival restorations
restorations are
are plaque-retentive
plaque-retentive areas
areas that
that are
are inaccessible
inaccessible to
to scaling
scaling
instruments.
instruments. Waerhaug
Waerhaug (1978)
(1978)

Teeth
Teeth with
with subgingival
subgingival restorations
restorations and
and narrow
narrow zones
zones of
of keratinized
keratinized gingiva
gingiva
showed
showed significantly
significantly higher
higher gingival
gingival index
index scores
scores than
than teeth
teeth with
with submarginal
submarginal
restorations
restorations with
with wide
wide zones
zones of
of keratinized
keratinized gingiva.
gingiva. Stetler
Stetler &
& Bissada
Bissada (1987)
(1987)

Silness
Silness evaluated
evaluated the
the periodontal
periodontal condition
condition of
of the
the lingual
lingual surfaces
surfaces of
of 385
385 fixed
fixed
partial
partial denture
denture abutment
abutment teeth.
teeth. He
He found
found that
that aa supra-gingival
supra-gingival position
position of
of the
the
crown
crown margin
margin was
was the
the most
most favorable,
favorable, whereas
whereas margins
margins below
below the
the gingival
gingival
margin
margin significantly
significantly compromised
compromised gingival
gingival health.
health.

RESTORATIVE FACTORS

Morphologic
Features of
Restorations

Overhanging Restoration
Estimated at 2576% for all restored surfaces
(Brunsvold & Lane1990)
Overhanging restorations contribute to
gingival inflammation due to their
retentive capacity for bacterial plaque

RESTORATIVE FACTORS
demonstrated a link to the severity of the
overhang and the amount of periodontal
destruction

Jeffcoat and Howell. 1980

with overhangs, the flora changed from
gingival health to one of chronic
periodontitis with increase in black
pigmented bacteriodes.

Lang et al.1983

Highly significant association b/w bone loss

and overhanging restoration.

Jeffcoat & Howell (1980)

Morphologic
Features of
Restorations

Hakkaranein & Ainamo 1997

Removal of overhangs permits more

effective control of plaque and reduction of
inflammation and small increase in bone
height

Contour and Contacts

Overcontouring can occur in
Interdental Areas
Buccolingual Aspect
Furcation Aspects

MECHANISM BY WHICH OVERHANGS CAUSE

PERIODONTAL DESTRUCTION
Promote the
retention of
plaque
Displacement
of gingiva &
violation of
biologic width

Impinge on the
interproximal
embrasure
space

Complicate
plaque control

Increase in
the specific
periodontal
pathogens.

Contour and Contacts

Interdental Areas
Marginal ridges

Overcontouring leads to

Hyperplasia
Engorgement of marginal gingiva
Decreased keratinization
Deterioration of gingival fibers

Contour and Contacts

Greater the amount of facial and lingual
bulge of an artificial crown, the more the
plaque retained at the cervical margin.
Yuodelis et al. (1973)

Buccal and lingual crown contours should be

flat, not fat Elrich Hochman.1981

Furcation areas should be fluted or

barreled out Becker & Kaldahl .1981

 Excessively wide contacts

obliterates interdental embrasure
Hyperplastic bulging of
interdental papilla

Interdental contacts if placed too high

occlusally
Eliminate the marginal ridge & reduce
sufficient area of contact
Food Impaction

CONTACTS

Normal position and size of

proximal contact creating a
slight col

Interdental view of abnormally

widened proximal contact,
Resulting in exaggerated col
formation that is subject to
breakdown.

OCCLUSAL MORPHOLOGY OF RESTORATION

Increased Buccolingual Width of

Occlusal Table

More axial stress

transmitted to
periodontium with
wide occlusal table
than narrow

Greater incidence of
cross- arch & cross
tooth balancing
interferences during
lateral excursive forces

OCCLUSAL MORPHOLOGY OF RESTORATION

HIGH POINTS

Occlusal Morphology of Restoration

CARVING
Overcarving of occlusal anatomy to
remove centric holding areas

Erupt in new occlusal relationship

Traumatic to the periodontium during

functional and parafunctional excursive
movements

RESTORATIVE MATERIAL
Restorative materials are not themselves
injurious
Exception - self-curing acrylics (Waerhaug J et
al. 1957)

Surface of restorations should be as smooth as

possible to limit plaque accumulation

Non - precious alloys- Inflammatory gingival

response.
(Pierce LH, GoodkinRJ,1989)

Case
Case of
of alveolar
alveolar bone
bone loss
loss after
after the
the placement
placement of
of crowns
crowns with
with aa
high
high nickel
nickel content
content has
has been
been reported
reported (( Bruce
Bruce GJ,
GJ, Hall
Hall WB
WB 1995)
1995)

Surface Roughness
Silness
Silness JJ et
et al.
al. 1980
1980
Improper marginal fit

Sources
Separation of the
restoration margin
and luting material

Scratches and stripes

Dissolution and
disintegration of the
luting material

Procedures that Increase Roughness

Polishing paste on restorative material
Application of fluoride gel on porcelain
Application of fluoride gel (pH<5) or gels
containing hydrofluoric acid on titanium
implants
Air powder abrasive systems on all
materials

DIRECT INJURY TO THE

PERIODONTIUM BY
RESTORATIVE PROCEDURES

Application of Rubber Dam

Placed too subgingivally

Placed for too long

Stripping of junctional epithelium and

gingival connective tissue attachment

Ischemia to the degree that sloughing of

tissue and subsequent gingival recession

GINGIVAL
RECESSION

Cavity and Crown Preparation

Placing the Matrix/ Wedges

Placement of matrix and wedges without care
may injure the PDL.
A matrix which is not rigid and properly contoured may not prevent
intracrevicular overhangs.
Injudicious separation beyond the width of the periodontal ligament

Retraction Cords
Electrosurgical retraction

recession & loss

of attachment

Not indicated in regions of inflammation or of extremely

thin gingival tissue

Gingival recession and sequestration of bone

after electrosurgery

Electrosurgical burn on the palatal aspect of

the maxillary left canine

Provisional Restorations
Overextended
Temporary
Crowns

Underextended
Temporary
Crowns

Poor proximalcontact
relationships

Gingival
alterations in
interdental,
facial and
lingual marginal
region

Hypersensitivity
, interfering
with adequate
oral hygiene
measures

Food impaction
and retention
Drifting of the
approximating
teeth

Rough or Porous
Surface Finish
Difficult to
maintain good
oral hygiene
Plaque
accumulation

ENDODONTIC
PROCEDURES
ROOT PERFORATIONS

Crestal root perforations - most susceptible to epithelial migrations &

rapid pocket formation

Perforations in furcation areas - because of proximity to epithelial

attachment- secondary periodontal involvement

If the perforation is
located close to the
gingival sulcusperiodontal pocket

Bacterial infection
following perforation

Down growth of
epithelium, inflammation ,
bone resorption and
necrosis can result

Exacerbation of a
preexisting periodontal
lesion -development of
clinical symptoms similar
to those of a periodontal
abscess

Obturation of defects with

gutta-percha- poor seal
and subsequent bacterial
inflammation of
periodontal tissues

THE STRIP PERFORATION

Generally a surgical approach is required to repair the strip perforation

and the periodontal complex may heal by repair, rather than true
regeneration of all periodontal tissues.

THE POST PERFORATION

If the perforation is into a periodontal pocket, periodontal therapy will

be required after the perforation has been sealed, either non-surgically
or surgically.

Large perforation
dentin

cementum layer over the radicular

resorption of the root surface with time.

PROSTHODONTIC
PROCEDURES

Pontic Designs

Main concern

degree of pressure;
area of contact;
embrassure space between the abutment tooth & pontic.

Pontic Designs
RIDGE-LAP
-Least desirable periodontally
- Difficult plaque control

OVATE
-Ideal pontic design
- Easy to clean
- Esthetically satisfactory

MODIFIED RIDGE- LAP

-More open lingual form
- Better access for hygiene

Pontic
design

SANITARY
Easiest access for Hygeine
procedure
Unsthetic form

Pontic Designs
Excessive contact of
pontic with ridge

Causes initial
blanching

Atrophy of
underlying
bone
Scraping of
edentulous cast
for positive
contact

Bone resorption

Periodontal
involvement of
abutment teeth

Removable Partial Denture

FACTORS ATTRIBUTED TO PDL BREAKDOWN
Plaque Formation & Oral hygiene

Coverage of marginal gingiva by parts of RPD

Occlusal forces transmitted to the

remaining teeth & their periodontal tissues
by the prosthesis

McHenry et al 1992
Evaluated the effect of a removable partial denture
mandibular major connector design on the surrounding
gingival tissues
Framework designs like Lingual plate contribute to plaque
and altered bacterial flora

Rissin et al. (1985)

Compared abutment teeth of patients with RPDs, FPDs and
no prosthesis
RPD wearers - greatest plaque and calculus deposition,
probing depth & alveolar bone loss

Zlataric et al. (2002)

In an evaluation of 205 patients with RPDs, abutment
teeth showed more disease than non abutment with
Plaque index,
Gingival index,
Probing depth
Tooth mobility
Gingival recession

Removable Partial Denture

Ill-fitting or inadequately polished denture

Tissueborne dentures frequently sink into

the muscosa & compress the gingival tissue
causing gingival inflammation, thus they
are called gum strippers

Improperly designed removable partial

denture

Improperly designed clasps

abutment

teeth by exerting excess stress resulting in

occlusal trauma.

During placement of the posterior RPD,

it may impinge on marginal tissue of the
abutment teeth unless the denture is
supported by occlusal rests.

MISSING STRATEGIC TEETH AND THEIR NON

REPLACEMENT
Replacement of strategic teeth is often
overlooked in dental practice
Unreplaced missing teeth
Drifting
of adjacent teeth &create conditions that lead
to periodontal disease
Initial tooth movement can be aggravated by
loss of periodontal support

Failure to Replace First Molars

Role of Biologic
Width in Implants

Differences Between the peri-implant

mucosa and gingiva
Features

Biologic Width

Tooth

Implant

Supracrestal

Subcrestal

Probing Depth

Normal = 2-3 mm

Bleeding on probing

Reliable inflammatory
sign

Increased 4mm

Less reliable

Differences Between the peri-implant

mucosa and gingiva
Features

Tooth

Implant

Connective tissue
composition

Low collagen
High fibroblast

High collagen
Low fibroblast

Consequences of biologic Width violation

1. Inflammation

Newman, Takei, Klokkevold, Caranzas Clinical Periodontology 11 th edtn. P1171-1175

Consequences of biologic Width violation

2. Peri-implantitis
Its an inflammatory process affecting the tissue around osseointegrated implant in function, resulting in loss of supporting
bone.

Newman, Takei, Klokkevold, Caranzas Clinical Periodontology 11 th edtn. P1171-1175

Consequences of biologic Width violation

3. Recession
Soft tissues are thin and
not well supported.

Angulation of implant is too

far buccal causing buccal
plate resorption.

Newman, Takei, Klokkevold, Caranzas Clinical Periodontology 11 th edtn. P1171-1175

Consequences of biologic Width violation

Review of Literature
Spray et. al.
recommended the
thickness to be 2mm or
greater to support the
buccal soft tissue.
If this is not presented
pre surgical or
simultaneous site
development using
guided bone
regeneration technique
is indicated.

Consequences of biologic Width violation

5. Implant loss/ Failure

No Osseo-integration
Integration was weak
Integration was
jeopardized by infection,
movement
Impaired wound healing
Overloading
Newman, Takei, Klokkevold, Caranzas Clinical Periodontology 11 th edtn. P1171-1175

CONCLUSION
All phases of clinical dentistry are
intimately related to a common objective:
The preservation and maintenance of the
natural dentition in health. In an integrated
multidisciplinary approach to dental care,
it is logical that periodontal treatment
precede final restorative procedures.
Hence for successful oral rehabilitation of
the patient the MULTIDISIPLINARY
APPROACH is required where ideas can
be exchanged for sake of sound oral
health.

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Carranzas Clinical periodontology 11th edition.

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