SECTION VI: PERIODONTAL-RESTORATIVE INTERRELATIONSHIPS

CHAPTER 69
Preparation of the Periodontium for
Restorative Dentistry
Philip R. Melnick | Henry H. Takei

CHAPTER OUTLINE
Rationale for Therapy Control of Active Disease Conclusion
Sequence of Treatment Preprosthetic Surgery (e-only)

For online only content on preprosthetic surgery, please visit the companion website at www.expertconsult.com.

these procedures before restorative care can add to the complexity

Editors’ note: An animation (slide show) has been added of treatment and introduce unnecessary risk for failure.22
by the editors as a supplement to the chapter. It was 3. Periodontal therapy should antecede restorative care because the
produced by My Dental Hub as a patient education resolution of inlammation may result in the repositioning of
tool and covers the basic elements in a conceptual teeth46 or in soft tissue and mucosal changes.20,48 Failure to
manner. It is not intended to be a procedural guide for anticipate these changes may interfere with prosthetic designs
dental professionals. planned or constructed before periodontal treatment.
4. Traumatic forces placed on teeth with ongoing periodontitis may
increase tooth mobility, discomfort, and possibly the rate of
Periodontal health is the sine qua non, a prerequisite, of successful attachment loss.9 Restorations constructed on teeth free of
comprehensive dentistry.25 To achieve the long-term therapeutic targets periodontal inlammation, synchronous with a functionally
of comfort, good function, treatment predictability, longevity, and appropriate occlusion, are more compatible with long-term
ease of restorative and maintenance care, active periodontal infection periodontal stability and comfort (see Chapters 18 and 55).
must be treated and controlled before the initiation of restorative, 5. Quality, quantity, and topography of the periodontium may play
aesthetic, and implant dentistry. In addition, the residual effects of important roles as structural defense factors in maintaining
periodontal disease or anatomic aberrations inconsistent with realizing periodontal health. Orthodontic tooth movement and restorations
and maintaining long-term stability must be addressed. This phase completed without the beneit of periodontal treatment designed
of treatment includes techniques performed in anticipation of aesthetic for this purpose may be subject to negative changes that complicate
or implant dentistry, such as clinical crown lengthening, covering construction and future maintenance.55
denuded roots, alveolar ridge retention or augmentation, and implant 6. Successful aesthetic and implant procedures may be dificult or
site development (Video 69.1: Effects of Single Tooth Loss). impossible without the specialized periodontal procedures
developed for this purpose.

Rationale for Therapy

LEARNING BOX 69.1
The many reasons for establishing periodontal health before perform-
ing restorative dentistry include the following52: Periodontal treatment is undertaken to ensure the establishment of stable
1. Periodontal treatment is undertaken to ensure the establishment gingival margins before tooth preparation. Noninflamed, healthy tissues
of stable gingival margins before tooth preparation. Noninlamed, are less likely to change (e.g., shrink) as a result of subgingival restorative
healthy tissues are less likely to change (e.g., shrink) as a result treatment or postrestoration periodontal care. In addition, tissues that do
of subgingival restorative treatment or postrestoration periodontal not bleed during restorative manipulation allow for a more predictable
care.28,29 In addition, tissues that do not bleed during restorative restorative and aesthetic result.
manipulation allow for a more predictable restorative and aesthetic
result.22,23
2. Certain periodontal procedures are designed to provide for adequate
tooth length for retention, access for tooth preparation, impression Sequence of Treatment
making, tooth preparation, and inishing of restorative margins Treatment sequencing should be based on logical and evidence-
in anticipation of restorative dentistry.22,47 Failure to complete based methodologies, taking into account not only the disease state

696
 CHAPTER 69 Preparation of the Periodontium for Restorative Dentistry 696.e1

Abstract
Periodontal health is the sine qua non, a prerequisite, of successful
comprehensive dentistry. To achieve the long-term therapeutic targets
of comfort, good function, treatment predictability, longevity, and
ease of restorative and maintenance care, active periodontal infection
must be treated and controlled before the initiation of restorative,
aesthetic, and implant dentistry. In addition, the residual effects of
periodontal disease or anatomic aberrations inconsistent with realizing
and maintaining long-term stability must be addressed. This phase
of treatment includes techniques performed in anticipation of aesthetic
or implant dentistry, such as clinical crown lengthening, covering
denuded roots, alveolar ridge retention or augmentation, and implant
site development.

Keywords
emergency treatment
control of bioilm
scaling and root planing
reevaluation
periodontal surgery
crown lengthening
soft tissue grafting
ridge augmentation
 CHAPTER 69 Preparation of the Periodontium for Restorative Dentistry 697

A B C
Fig. 69.1 Root planing has resolved the gingival inflammation of this patient.

acute pain, especially endodontic, is the most important reason for

BOX 69.1 Sequence of Treatment in Preparing Periodontium seeking dental therapy. Therefore this aspect of therapy must be
for Restorative Dentistry properly addressed before any other therapy is instituted.
Control of Active Disease
Emergency treatment Extraction of Hopeless Teeth
Extraction of hopeless teeth Extraction of hopeless teeth is followed by provisionalization with
Oral hygiene instructions ixed or removable prosthetics. Retention of hopeless teeth without
Scaling and root planing periodontal treatment may result in bone loss around the adjacent
Reevaluation teeth.32 It is also important to consider the extraction of teeth with
Periodontal surgery a poor prognosis when implant replacement has become a predictable
Adjunctive orthodontic therapy alternative to keeping and attempting periodontal therapy.
Preprosthetic Surgery
Oral Hygiene Measures
Management of mucogingival problems
Preservation of ridge morphology after tooth extraction As indicated earlier, oral hygiene measures, when properly applied,
Crown-lengthening procedures will reduce plaque bioilm scores and gingival inlammation30,51 (see
Alveolar ridge reconstruction Chapter 48). However, in patients with deep periodontal pockets
(>5 mm), plaque bioilm control measures alone are insuficient for
resolving subgingival infection and inlammation.5,30 Hygiene alone
does not allow the brush to reach into the deep pocket area to remove
encountered but also the psychological and aesthetic concerns of the nor disturb the plaque bioilm.
patient. Because periodontal and restorative therapy is situational
and speciic to each patient, a plan must be adaptable to change Scaling and Root Planing
depending on the variables encountered during the course of treat- Scaling and root planing combined with oral hygiene measures have
ment. For example, teeth initially determined to be salvageable been demonstrated to signiicantly reduce gingival inlammation and
may be judged “hopeless,” thus altering the established treatment the rate of the progression of periodontitis3,4,31 (see Chapter 50). This
scheme.20,48 applies even to patients with deep periodontal pockets5,15 (Fig. 69.1).
Generally, the preparation of the periodontium for restorative
dentistry can be divided into two phases: (1) control of periodontal
inlammation with nonsurgical and surgical approaches and (2)
LEARNING BOX 69.2
preprosthetic periodontal surgery (Box 69.1). When the clinician is presented with a patient with any stage of periodontal
involvement, this condition must be treated before one can contemplate
any restorative dentistry.
Control of Active Disease
When the clinician is presented with a patient with different stages
of periodontal involvement, this condition must be treated before Reevaluation
one can contemplate any restorative dentistry. This step is the most After 4 weeks the gingival tissues are evaluated to determine oral
important part of preparing the periodontium for restorative dentistry. hygiene adequacy, soft tissue response, and pocket depth (see Chapter
The inlammatory state of the supporting tissues must be eliminated 47). This permits suficient time for healing, reduction in inlammation
or controlled with bioilm removal, scaling, root planing, and, if and pocket depths, and gain in clinical attachment levels. However,
necessary, periodontal surgery. in deeper pockets (>5 mm), plaque bioilm and calculus removal
The periodontal therapy is intended to control the active disease are often incomplete2,54 with risk of future breakdown8,49 (Fig. 69.2).
(see Chapters 47 to 57). In addition to the removal of bioilm and As a result, periodontal surgery to access the root surfaces for
root surface accretions that are the primary etiologic agents, secondary instrumentation and to reduce periodontal pocket depths must be
local factors, such as plaque-retentive overhanging margins and considered before restorative care proceeds.
untreated caries, must be addressed.14,19
Periodontal Surgery
Emergency Treatment Periodontal surgery may be required for some patients (see Chapters
Emergency treatment is undertaken to alleviate symptoms and stabilize 60, 62, and 63). This should be undertaken with future restorative
acute infection. This includes endodontic as well as periodontal and implant dentistry in mind. Some procedures are intended to
conditions (see Chapters 45 and 46). To the patient, the control of treat active periodontal disease successfully,12,37 and others are
698 PART 3 CLINICAL PERIODONTICS

treatment is suficient, deinitive periodontal pocket therapy may be

postponed until after the completion of orthodontic tooth movement.
This allows for the advantage of the positive bone changes that
orthodontic therapy can provide. However, deep pockets and furcation
invasions may require surgical access for root instrumentation in
advance of orthodontic tooth movement. Failure to control active
periodontitis can result in acute exacerbations and bone loss during
tooth movement.10 As long as the periodontium is periodontally
healthy, teeth with preexisting bone loss may be moved orthodontically
without incurring additional attachment loss.39,40
If teeth that are to be orthdontically moved lack keratinized
attached gingiva, soft tissue–grafting procedures are often indicated
in anticipation of orthodontic therapy. The procedure is necessary
A to increase the dimension of attached tissue to prevent the possibility
of gingival margin recession.34,55

LEARNING BOX 69.3

Periodontal surgery is performed for the treatment of active periodontal
disease as well as for the preprosthetic preparation of the periodontium.
Some procedures are intended to treat active disease successfully, and
others are aimed at preparing the mouth for restorative or prosthetic care.

Conclusion
As described in this and other sections of this textbook, the therapeutic
goals of patient comfort, function, aesthetics, predictability, longevity,
B and ease of restorative and maintenance care are attainable only by
a carefully constructed interdisciplinary approach with accurate
Fig. 69.2 (A) Before treatment. (B) After 4 weeks, oral hygiene instructions diagnosis and comprehensive treatment planning serving as the
and scaling and root planing have improved this patient’s periodontal status.
cornerstones. The complex interaction between periodontal therapy
However, inflammation associated with pockets deeper than 5 mm suggests
a need for periodontal surgery. and successful restorative dentistry only serves to underscore this
premise.

aimed at preparing the mouth for restorative or prosthetic care.55

Crown lengthening is an example of such surgery. Both types Case Scenarios are found on the companion website
of surgery are for preparing the periodontium for restorative www.expertconsult.com.
dentistry.

Adjunctive Orthodontic Therapy References

Orthodontic treatment has been shown to be a useful adjunct to
periodontal therapy6,17,18,24,34 (see Chapter 56). It should be undertaken References for this chapter are found on the companion
website www.expertconsult.com.
only after active periodontal disease has been controlled. If nonsurgical
 CHAPTER 69 Preparation of the Periodontium for Restorative Dentistry 698.e1

Preprosthetic Surgery Preservation of Ridge Morphology After Tooth

Management of Mucogingival Problems Extraction
Periodontal plastic surgical procedures may be undertaken for a Alveolar ridge resorption is a common consequence of tooth loss.1,2
variety of reasons.7 The most common techniques include those that Ridge preservation procedures have been shown to be useful in
increase the gingival dimensions and achieve root coverage. These anticipation of the future placement of a dental implant or for pontics
procedures are often indicated before restoration for prosthetic reasons used for ixed bridges, as well as in cases where unaided healing
(eFig. 69.1) and in conjunction with orthodontic tooth movement.34 would result in an unaesthetic deformity16,26,27,33,36,42 (eFig. 69.3).
Root coverage procedures may also be undertaken for purposes of
comfort and aesthetics (eFig. 69.2).7 At least 2 months of healing is Crown-Lengthening Procedures
recommended after soft tissue grafting procedures before initiating Surgical crown-lengthening procedures are performed to provide
restorative dentistry55 (see Chapter 65). retention form to allow for proper tooth preparation, impression

A B
eFig. 69.1 In preparation for a removable partial denture, this canine has received a gingival graft to increase
attached gingiva and deepen the vestibule. (A) Before therapy. Note minimal attached gingiva. (B) After therapy,
there is abundant attached gingiva and vestibular depth.

A B

C D
eFig. 69.2 Connective tissue graft placed under a double-papilla flap has been used to provide root coverage
for a maxillary right canine. (A) Maxillary canine before therapy. (B) Connective tissue graft placed over denuded
root surface. (C) Papilla placed over connective tissue. (D) Final result.
698.e2 PART 3 CLINICAL PERIODONTICS

B C D

E F G
eFig. 69.3 (A) The maxillary right lateral incisor has failed endodontically, with a fistulous tract noted exiting
from the attached gingiva. (B) The tooth is atraumatically removed and the socket debrided while maintaining
the surrounding anatomic integrity. (C) In an effort to reduce ridge collapse, the socket is grafted with a combination
of deproteinized bovine bone and calcium sulfate. (D) Provisional fixed partial denture is placed, with an ovate
pontic extending 2 mm into the socket and supporting the surrounding tissues. (E–F) After 8 weeks, the socket
has healed, preserving the gingival and papillary architecture, in preparation for an aesthetic final prosthesis.
(G) Final restoration.

procedures,23 and placement of restorative margins (eFig. 69.4),23 attached gingiva and less than 3 mm of soft tissue require a lap procedure
and to adjust gingival levels for aesthetics.35,50 It is important that and bone recontouring (eFig. 69.9). In the case of caries or tooth fracture,
crown-lengthening surgery is done in such a manner that the biologic to ensure margin placement on sound tooth structure and retention
width is preserved. The biologic width is deined as the physiologic form, the surgery should provide at least 4 mm from the apical extent
dimension of the junctional epithelium and connective tissue attach- of the caries or fracture to the bone crest (eFig. 69.10).
ment (see Chapter 70). This measurement has been found to be With the advent of predictable implant dentistry, it is important
relatively constant at approximately 2 mm (±30%).11 The healthy to carefully evaluate the value of crown lengthening for restorative
gingival sulcus has an average depth of 0.69 mm (eFig. 69.5).21 It therapy as opposed to tooth removal and replacement with a dental
has been theorized that infringement on the biologic width by the implant (eBox 69.1).
placement of a margin of a restoration within its zone may result in
gingival inlammation,21 pocket formation, and alveolar bone loss38 Alveolar Ridge Reconstruction
(eFig. 69.6). Consequently, it is recommended that there be at least Patients are frequently seen with alveolar ridge resorption after tooth
3 mm between the gingival margin and bone crest.13,41,44,47 This allows loss (see Chapter 75). To provide for adequate anatomic dimensions
for adequate biologic width when the restoration is placed 0.5 mm for the construction of an aesthetic pontic (see Chapter 70, or for a
within the gingival sulcus44,47 (eFig. 69.7). discussion on the placement of dental implants see Chapter 75),
Surgical crown lengthening may include the removal of soft tissue alveolar ridge reconstruction is undertaken.42,43,45 In the case of
or both soft tissue and alveolar bone. Reduction of soft tissue alone is aesthetic pontic construction, small defects may be treated with soft
indicated if there is adequate attached gingiva and more than 3 mm of tissue ridge augmentation (eFig. 69.11). For larger defects and in
tissue coronal to the bone crest (eFig. 69.8). This may be accomplished those sites receiving dental implants, hard tissue modalities are used43,45
by either gingivectomy or lap technique (see Chapter 60). Inadequate (eFig. 69.12).
 CHAPTER 69 Preparation of the Periodontium for Restorative Dentistry 698.e3

A B

C D
eFig. 69.4 Surgical crown lengthening has provided these otherwise unrestorable mandibular molars with
improved retention and restorative access for successful restorations. (A) Before crown lengthening. (B) Crown-
lengthening surgery completed. Note increased clinical crown. (C) Buccal view after surgery. (D) Final
restorations.

Gingival sulcus
0.69 mm
Biologic Junctional
width epithelium
2.04 mm 0.97 mm
Connective tissue
attachment
1.07 mm eFig. 69.6 Although gingival inflammation around crowns may have a
variety of causes, infringement of biologic width must be considered.

Bone
Periodontal
ligament

Cementum

eFig. 69.5 The biologic width has been estimated to be about 2 mm.
Efforts should be made to preserve its integrity.
698.e4 PART 3 CLINICAL PERIODONTICS

2 mm
3 mm

Gingival sulcus Bone Bone

0.69 mm
eFig. 69.9 With less than 3 mm of soft tissue between the bone and
Junctional gingival margin, or less-than-adequate attached gingiva, a flap procedure
Biologic epithelium
width and osseous recontouring are required for crown lengthening.
0.97 mm
2.04 mm
Connective tissue
attachment
1.07 mm
At least 1 mm of tooth
structure for margin
placement and retention
Bone
Periodontal
ligament 1 mm
4 mm
Cementum 3 mm

eFig. 69.7 Placement of the restorative margin 0.5 mm into the sulcus
allows for the maintenance of the biologic width.
Bone
eFig. 69.10 In the case of caries or fracture, at least 1 mm of sound
tooth structure should be provided above the gingival margin for proper
restoration.

eBOX 69.1 Surgical Crown Lengthening

5 mm
3 mm Indications
Subgingival caries or fracture.
Inadequate clinical crown length for retention.
Unequal or unaesthetic gingival heights.
Contraindications
Surgery would create an unaesthetic outcome.
Bone Bone
Deep caries or fracture would require excessive bone removal on
eFig. 69.8 Greater than 3 mm of soft tissue between the bone and gingival contiguous teeth.
margin, with adequate attached gingiva, allows crown lengthening by The tooth is a poor restorative risk.
gingivectomy.
 CHAPTER 69 Preparation of the Periodontium for Restorative Dentistry 698.e5

A B

C D

E F

G H
eFig. 69.11 (A) Loss of the maxillary left central incisor has resulted in an unaesthetic alveolar ridge defect.
(B–E) An incision is made at the ridge crest, a pouch is created, and a soft tissue graft harvested from the
palate is placed into the pouch. (F–H) A removable appliance with an ovate pontic is placed in light contact
with the grafted site. Swelling around the pontic apex results in a tissue concavity from which the more natural-
appearing final restoration emerges.
698.e6 PART 3 CLINICAL PERIODONTICS

A B

C D

E F

G H
eFig. 69.12 Postextraction ridge defect is grafted with a combination of autogenous and deproteinized
bovine bone and contained by nonresorbable barrier membrane.53 After 8 months, the site is reopened and the
membrane removed. A comparison of parts B and G shows significant reconstitution of hard tissue, in this case
used for the installation of a dental implant. (A) Edentulous ridge before surgery. (B) Flap reflection to visualize
defect. (C) Graft material placed over resorbed ridge. (D) Nonresorbable titanium-reinforced membrane placed
over graft material. (E) Graft site sutured. (F) Surgical site reopened 8 months after surgery. (G) New bone over
ridge. (H) Implant placed into augmented ridge.
 CHAPTER 69 Preparation of the Periodontium for Restorative Dentistry 698.e7

CASE SCENARIO 69.1

Patient: 31-year-old female
Background Information
The patient has a fractured crown on tooth #7. She is healthy and has no
known drug allergies.

CASE-BASED QUESTION SOLUTION AND EXPLANATION

1. To provide a full crown restoration in this case, a surgical crown Answer: D
lengthening should be performed. Why? Explanation: Teeth damaged by caries or fracture once certiied as
A. To provide for retention, tooth preparation, and impressions restorable can often be retained by performing a surgical crown-
B. To preserve “biologic width” lengthening procedure. Teeth in the aesthetic zone require special
C. To maintain aesthetic gingival levels consideration. Care should be taken not to increase the crown length at
D. All of the above the expense of aesthetics. Efforts should be made to maintain a gingival
level that is symmetrical to the contiguous teeth and the contralateral
side. If it appears that a crown-lengthening surgery will result in an
unaesthetic gingival level, an alternative treatment, such as orthodontic
extrusion, should be considered.

CASE SCENARIO 69.2

Patient: 44-year-old female
Chief Complaint: My gums have receded and I am unhappy with my
appearance.
Background Information
The patient is healthy and has no known drug allergies.

CASE-BASED QUESTION SOLUTION AND EXPLANATION

1. This patient is preparing for orthodontics and restorative dentistry. Answer: E
Why should soft-tissue grafting be considered? Explanation: Gingival recession is the result of a combination of an
A. To prevent future gingival recession underlying bone dehiscence and gingival inlammation. The root
B. To protect the exposed root exposure can result in dental sensitivity, root damage, and an unesthetic
C. To reduce dentinal sensitivity appearance. The treatment is soft tissue grafting.
D. To provide for an aesthetic tooth length
E. All of the above
698.e8 PART 3 CLINICAL PERIODONTICS

CASE SCENARIO 69.3

Patient: 64-year-old male
Chief Complaint: “My gums are swollen.”
Background Information
The patient has a history of infrequent dental care and developed
asymptomatic gingival enlargement over several years. He also has
hypertension and takes the antihypertensive medication amlodipine, a
calcium channel blocker.

CASE-BASED QUESTION SOLUTION AND EXPLANATION

1. What should this patient do to prepare for orthodontic treatment and Answer: F
restorative dentistry? Explanation: It is important to complete periodontal treatment aimed at
A. Consult with his medical doctor before treatment to discuss a controlling an active disease before the commencement of orthodontics
possible medication change, which may be in part responsible and restorative dentistry. This patient takes medication, which has led to
for the gingival overgrowth drug-induced gingival overgrowth. This gingival enlargement is often
B. Complete scaling and root planing and oral hygiene education related to a combination of plaque-associated inlammation and the
C. Reevaluate after a suitable period for the resolution of gingival effect of the calcium channel blocker, amlodipine. Resolution of the
enlargement problem requires treating both the plaque-associated inlammation and
D. Consider surgical treatment to reduce enlarged gingival tissues the response to the medication. Once the medication has been
E. Enter into a well-planned prevention program discontinued, in conjunction with nonsurgical periodontal therapy, the
F. All of the above result may be complete resolution of the hyperplasia. If not, surgical
reduction may be indicated.

CASE SCENARIO 69.4

Patient: 55-year-old male Background Information
Chief Complaint: “I fractured my tooth, but I would really like to The patient recently fractured tooth #29, close to bone crest. He has had
retain it.” previous endodontic treatment and is asymptomatic. The patient is
healthy and has no known drug allergies.

CASE-BASED QUESTION SOLUTION AND EXPLANATION

1. Based on the photos presented, what treatment option is available to Answer: B
meet the patient’s desire for tooth retention? Explanation: Tooth fracture is a common dental malady. Surgical crown
A. Preparation of the tooth for a crown with the inish line lengthening provides the opportunity to retain structurally damaged
approximating the bone crest. teeth, once they have been judged to be salvageable. It allows access
B. Surgical crown lengthening followed by a crown restoration. for restorative procedures and retention form. Care must be taken
C. The tooth cannot be restored; extraction and replacement is the preserve space for supracrestal soft tissue growth to a physiologic
only option. dimension (“biologic width”). Failure to do so can result in chronic
gingival inlammation and possible bone loss.
 CHAPTER 69 Preparation of the Periodontium for Restorative Dentistry 698.e9

27. Lekovic V, Kenney EB, Weinlaender M, et al: A bone regenerative

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22. Kois JC: The restorative-periodontal interface: biological parameters, cal crown extension: a rational basis for treatment, Int J Periodontics
Periodontol 2000 11:29, 1996. Restorative Dent 17:465, 1997.
23. Kois JC: Clinical techniques in prosthodontics: relationship of the 48. Spear FM, Kokich VG: A multidisciplinary approach to esthetic dentistry,
periodontium to impression procedures, Compend Contin Educ Dent Dent Clin North Am 51:487, 2007.
21:684, 2000. 49. Stambaugh RV, Dragoo M, Smith DM, et al: The limits of subgingival
24. Kokich VG: Esthetics: the orthodontic-periodontic restorative connection, scaling, Int J Periodontics Restorative Dent 1:31, 1981.
Semin Orthodont 2:21, 1996. 50. Studer S, Zellweger U, Schärer P: The aesthetic guidelines of the
25. Kramer JM, Nevins M: Int J Periodontics Restorative Dent 1:4, 1981. mucogingival complex for ixed prosthodontics, Pract Periodontics
(editorial). Aesthet Dent 4:333, 1996.
26. Lekovic V, Camargo PM, Klokkevold PR, et al: Alterations of the 51. Tagge DL, O’Leary TJ, El-Kafrawy AH: The clinical and histological
position of the marginal soft tissue following periodontal surgery, J response of periodontal pockets to root planing and oral hygiene, J
Clin Periodontol 7:525, 1980. Periodontol 46:527, 1975.
698.e10 PART 3 CLINICAL PERIODONTICS

52. Takei HH, Azzi RR, Han TJ: Preparation of the periodontium for 54. Waerhaug J: The furcation problem: etiology, pathogenesis, diagnosis,
restorative dentistry. In Newman MG, Takei HH, Carranza FA, therapy and prognosis, J Clin Periodontol 7:73, 1980.
editors: Carranza’s clinical periodontology, ed 9, Philadelphia, 2002, 55. Wennström JL: Mucogingival therapy. In Proceedings of the 1996
Saunders. World Workshop in Periodontics. Lansdowne, Virginia, July 13-17,
53. Urban IA, Nagursky H, Lozada JL, et al: Horizontal ridge augmentation Ann Periodontol 1:671, 1996.
with a collagen membrane and a combination of particulated autogenous
bone and anorganic bovine bone derived mineral: a prospective case
series, Int J Periodontics Restorative Dent 33:299, 2013.
 CHAPTER 70

Restorative Interrelationships
Frank M. Spear | Todd R. Schoenbaum | Joseph P. Cooney

CHAPTER OUTLINE
Biologic Considerations
Aesthetic Tissue Management
Occlusal Considerations in Restorative Therapy
Special Restorative Considerations (e-only)

For expanded discussions on margin placement, biologic width, and aesthetic tissue management as well as online-only
content on special restorative considerations, please visit the companion website at www.expertconsult.com.

restorations should be chosen not only for their aesthetic advantages

Editors’ note: An animation (slide show) has been added by the editors
but also for their favorable periodontal impact.
as a supplement to the chapter. It was produced by My Dental Hub as
The use of equigingival margins traditionally was not desirable
a patient education tool and covers the basic elements in a conceptual
because they were thought to retain more plaque than supragingival
manner. It is not intended to be a procedural guide for dental
or subgingival margins and therefore resulted in greater gingival
professionals.
inlammation. There was also the concern that any minor gingival
recession would create an unsightly margin display. These concerns
The relationship between periodontal health and the restoration of are not valid today, not only because the restoration margins can be
teeth is intimate and inseparable. For restorations to survive long aesthetically blended with the tooth, but also because restorations
term, the periodontium must remain healthy so that the teeth are can be inished easily to provide a smooth, polished interface at the
maintained. For the periodontium to remain healthy, restorations gingival margin. From a periodontal viewpoint, both supragingival
must be critically managed in several areas so that they are in harmony and equigingival margins are well tolerated.
with their surrounding periodontal tissues. To maintain or enhance The greatest biologic risk occurs when placing subgingival
the patient’s aesthetic appearance, the tooth–tissue interface must margins.42 These margins are not as accessible as supragingival or
present a healthy natural appearance, with gingival tissues framing equigingival margins for inishing procedures. In addition, if the
the restored teeth in a harmonious manner. This chapter reviews the margin is placed too far below the gingival tissue crest, it violates
key areas of restorative management necessary to optimize periodontal the gingival attachment apparatus.
health, with a focus on the aesthetics and function of restorations. As described in Chapter 3, the dimension of space that the healthy
gingival tissues occupy between the base of the sulcus and the
underlying alveolar bone is composed of the junctional epithelial
Biologic Considerations attachment and the connective tissue attachment. The combined
Margin Placement and Biologic Width attachment width is now identiied as the biologic width. Most authors
One of the most important aspects of understanding the periodontal– credit Gargiulo, Wentz, and Orban’s 1961 study18 on cadavers with
restorative relationship is the location of the restorative margin to the initial research establishing the dimensions of space required by
the adjacent gingival tissue. Restorative clinicians must understand the gingival tissues. They found that, in the average human, the
the role of biologic width in preserving healthy gingival tissues and connective tissue attachment occupies 1.07 mm of space above the
controlling the gingival form around restorations. They must also crest of the alveolar bone and that the junctional epithelial attachment
apply this information in the positioning of restoration margins, below the base of the gingival sulcus occupies another 0.97 mm of
especially in the aesthetic zone, where a primary treatment goal is space above the connective tissue attachment. The combination of
to mask the junction of the margin with the tooth. these two measurements, averaging approximately 1 mm each,
A clinician is presented with three options for margin placement: constitutes the biologic width (Fig. 70.3). Clinically, this information
supragingival, equigingival (even with the tissue), and subgingival.69 is applied to diagnose biologic width violations when the restoration
The supragingival margin has the least impact on the periodontium. margin is placed 2 mm or less away from the alveolar bone and the
Classically, this margin location has been applied in unaesthetic gingival tissues are inlamed with no other etiologic factors evident.
areas because of the marked contrast in color and opacity of traditional Restorative considerations frequently dictate the placement of
restorative materials against the tooth. With the advent of more restoration margins beneath the gingival tissue crest. Restorations
translucent restorative materials, adhesive dentistry, and resin cements, may need to be extended gingivally (1) to create adequate resistance
the ability to place supragingival margins in aesthetic areas is now and retentive form in the preparation, (2) to make signiicant contour
a reality (Figs. 70.1 and 70.2). Therefore whenever possible, these alterations because of caries or other tooth deiciencies, (3) to mask

699
 CHAPTER 70 Restorative Interrelationships 699.e1

Abstract
Periodontal health is intimately tied to most aspects of restorative
dentistry. The location and integrity of the restorative margins must
be designed to respect the integrity of the periodontal biologic width.
The contours of the restorations and any pontics can and will affect
the health and aesthetics of the periodontal tissues. Successful
restorative therapy is a key component of creating and maintaining
a healthy oral environment.

Keywords
restorative margin
restoration design
pontic
biologic width
papilla
occlusion
restoration contour
impression
700 PART 3 CLINICAL PERIODONTICS

Biologic Connective tissue 1.0 mm

width
2.0 mm Junctional epithelium 1.0 mm

Sulcus 1.0 mm

Fig. 70.1 With the advent of adhesive dentistry and ultrathin ceramic
veneers, it now is possible to prepare restorations equigingival without
visible margins. The preparations for six porcelain veneers with the margins
placed at the level of tissue are shown.
Fig. 70.3 Average human biologic width: connective tissue attachment
1 mm in height; junctional epithelial attachment 1 mm in height; sulcus
depth of approximately 1 mm. The combined connective tissue attachment
and junctional epithelial attachment, or biologic width, equals 2 mm.

Bone loss

Inflammation

Fig. 70.2 The completed veneers from Fig. 70.1. Note the invisible gingival
finish line, even though the margin has not been carried below tissue.
Fig. 70.4 Ramifications of a biologic width violation if a restorative margin
is placed within the zone of the attachment. On the mesial surface of the
left central incisor, bone has not been lost, but gingival inflammation occurs.
the tooth–restoration interface by locating it subgingivally, or (4) to On the distal surface of the left central incisor, bone loss has occurred, and
lengthen the tooth for aesthetic reasons. When the restoration margin a normal biologic width has been reestablished.
is placed too far below the gingival tissue crest, it impinges on the
gingival attachment apparatus and creates a violation of biologic
width.49 Two different responses can be observed from the involved
gingival tissues (Fig. 70.4). The more common inding with deep margin placement is that
One possibility is that bone loss of an unpredictable nature and the bone level appears to remain unchanged, but gingival inlammation
gingival tissue recession occurs as the body attempts to re-create develops and persists. To restore gingival tissue health, it is necessary
room between the alveolar bone and the margin to allow space for to establish space clinically between the alveolar bone and the margin.
tissue reattachment. This is more likely to occur in areas in which This can be accomplished either by surgery to alter the bone level
the alveolar bone surrounding the tooth is very thin in width. Trauma or by orthodontic extrusion to move the restoration margin farther
from restorative procedures can play a major role in causing this away from the bone level.
fragile tissue to recede. Other factors that may impact the likelihood
of recession include (1) whether the gingiva is thick and ibrotic or Biologic Width Evaluation
thin and fragile and (2) whether the periodontium is highly scalloped Radiographic interpretation can identify interproximal violations of
or lat in its gingival form. It has been found that highly scalloped, biologic width. However, with the more common locations on the
thin gingiva is more prone to recession than a lat periodontium with mesiofacial and distofacial line angles of teeth, radiographs are not
thick ibrous tissue.47 diagnostic because of tooth superimposition. 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
KEY FACT extends into the attachment and that a biologic width violation has
Thin gingiva and highly scalloped papilla are more highly prone to recession occurred.
after normal restorative procedures. A more positive assessment can be made clinically by measuring
the distance between the bone and the restoration margin using a
 CHAPTER 70 Restorative Interrelationships 701

sulcular probing depth are then used to predict how deep the margin
can safely be placed below the gingival crest. With shallow probing
depths (1 to 1.5 mm), extending the preparation more than 0.5 mm
subgingivally risks violating the attachment. This assumes that the
periodontal probe will penetrate into the junctional epithelial attach-
ment in healthy gingiva an average of 0.5 mm. With shallow probing
Biologic Connective depths, future recession is unlikely because the free gingival margin
width tissue 2.0 mm
is located close to the top of the attachment. Deeper sulcular probing
3.0 mm Junctional
depths provide more freedom in locating restoration margins farther
epithelium 1.0 mm
below the gingival crest. In most circumstances, however, the deeper
Sulcus 1.0 mm
the gingival sulcus, the greater is the risk of gingival recession.
Locating the restorative margin deep subgingivally should be avoided,
as it increases the dificulty in making an accurate impression, inishing
the restoration margins, and increases the likelihood of inlammation
and recession.

Provisional Restorations
Three critical areas must be effectively managed to produce a favorable
Fig. 70.5 Possible variations exist in biologic width. Connective tissue biologic response to provisional restorations.3,74 The marginal it,
attachments and junctional epithelial attachments may be variable. In this crown contour, and surface inish of the interim restorations must
example, the connective tissue attachment is 2 mm in height, the junctional be appropriate to maintain the health and position of the gingival
epithelial attachment 1 mm in height, and the sulcus depth 1 mm, for a tissues during the interval until the inal restorations are delivered.
combined total tissue height above bone of 4 mm. However, the biologic Provisional restorations that are poorly adapted at the margins, that
width is 3 mm. This is just one variation that can occur from the average
are overcontoured or undercontoured, and that have rough or porous
depicted in Fig. 70.3.
surfaces can cause inlammation, overgrowth, or recession of gingival
tissues. The outcome can be unpredictable, and unfavorable changes
sterile periodontal probe. The probe is pushed through the anesthetized in the tissue architecture can compromise the success of the inal
attachment tissues from the sulcus to the underlying bone. If this restoration.
distance is less than 2 mm at one or more locations, a diagnosis of
biologic width violation can be conirmed. This assessment is Marginal Fit
completed circumferentially around the tooth to evaluate the extent Marginal it has clearly been implicated in producing an inlammatory
of the problem. However, biologic width violations can occur in response in the periodontium. It has been shown that the level of
some patients in whom the margins are located more than 2 mm gingival inlammation can increase corresponding with the level of
above the alveolar bone level.22 In 1994 Vacek and colleagues70 also marginal opening.15 Margins that are signiicantly open (several tenths
investigated the biologic width phenomenon. Although their average of a millimeter) are capable of harboring large numbers of bacteria
width inding of 2 mm was the same as that previously presented and may be responsible for the inlammatory response seen. However,
by Gargiulo and associates,18 they also reported a range of different the quality of marginal inish and the margin location relative to the
biologic widths that were patient speciic. They reported biologic attachment are much more critical to the periodontium than the
widths as narrow as 0.75 mm in some individuals, whereas others difference between a 20-µm it and a 100-µm it.42,46,59
had biologic widths as tall as 4.3 mm (Fig. 70.5).
This information dictates that speciic biologic width assessment Crown Contour
should be performed for each patient to determine if the patient needs Restoration contour has been described as extremely important to
additional biologic width, in excess of 2 mm, for restorations to be the maintenance of periodontal health.26,75 Ideal contour provides
in harmony with the gingival tissues. The biologic, or attachment, access for hygiene, has the fullness to create the desired gingival
width can be identiied for the individual patient by probing to the form, and has a pleasing visual tooth contour in aesthetic areas.
bone level (referred to as “sounding to bone”) and subtracting the Evidence from human and animal studies clearly demonstrates a
sulcus depth from the resulting measurement. This measurement relationship between overcontouring and gingival inlammation,
must be done on teeth with healthy gingival tissues and should be whereas undercontouring produces no adverse periodontal effect.48,51
repeated on more than one tooth to ensure an accurate assessment. The The most frequent cause of overcontoured restorations is inadequate
technique allows the variations in sulcus depths found in individual tooth preparation by the dentist, which forces the technician to produce
patients to be assessed and factored into the diagnostic evaluation. a bulky restoration to provide room for the restorative material. In
The information obtained is then used for deinitive diagnosis of areas of the mouth in which aesthetic considerations are not critical,
biologic width violations, the extent of correction needed, and the a latter contour is always acceptable.
parameters for placement of future restorations.
Subgingival Debris
Margin Placement Guidelines Leaving debris below the tissue during restorative procedures can
When determining where to place restorative margins relative to the create an adverse periodontal response. The cause can be retraction
periodontal attachment, it is recommended that the patient’s existing cord, impression material, provisional material, or either temporary
sulcular depth be used as a guideline in assessing the biologic width or permanent cement.55 The diagnosis of debris as the cause of gingival
requirement for that patient. The base of the sulcus can be viewed inlammation can be conirmed by examining the sulcus surrounding
as the top of the attachment, and therefore the clinician accounts for the restoration with an explorer, removing any foreign bodies, and
variations in attachment height by ensuring that the margin is placed then monitoring the tissue response. It may be necessary to provide
in the sulcus and not in the attachment.4,36,37,56 The variations in tissue anesthesia for patient comfort during the procedure.
 CHAPTER 70 Restorative Interrelationships 701.e1

Rule 1: If the sulcus probes 1.5 mm or less, place the restoration

Correcting Biologic Width Violations margin no more than 0.5 mm below the gingival tissue crest.
Biologic width violations can be corrected either by surgically This is especially important on the facial aspect and will prevent
removing bone away from proximity to the restoration margin or a biologic width violation in a patient who is at high risk in that
by orthodontically extruding the tooth and thus moving the margin regard.
away from the bone. Surgery is the more rapid of the two treatment
options.57 It is also preferred if the resulting crown lengthening creates
a more pleasing tooth length. Indications and contraindications for
surgical crown lengthening are presented in Chapters 60 and 65 and
illustrated with clinical examples. In these situations, the bone should
be moved away from the margin by the measured distance of the
ideal biologic width for that patient, with an additional 0.5 mm of
bone removed as a safety zone.
There is a potential risk of gingival recession after removal of
bone.7 If interproximal bone is removed, there is a high likelihood
of papillary recession and the creation of an unaesthetic triangle
of space below the interproximal contacts. If the biologic width
violation is on the interproximal side, or if the violation is across
the facial surface and the gingival tissue level is correct, orthodontic
extrusion is indicated27 (eFigs. 70.1 to 70.4). The extrusion can be
performed in two ways. By applying low orthodontic extrusion force,
the tooth will erupt slowly, bringing the alveolar bone and gingival
tissue 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 attachment violation. The tooth
is stabilized in this new position and then is treated with surgery
to correct the bone and gingival tissue levels. Another option is to
perform rapid orthodontic extrusion where the tooth is erupted to the
desired amount over several weeks.31 During this period, a supracrestal
iberotomy is performed circumferentially around the tooth weekly in
an effort to prevent the tissue and bone from following the tooth. The
tooth is then stabilized for at least 12 weeks to conirm the position
of the tissue and bone, and any coronal creep can be corrected
surgically.
Clinical Procedures in Margin Placement
The irst step in using sulcus depth as a guide in margin placement
is to manage gingival health. It should be noted that the use of
reinforced all-ceramic restorations (i.e., layered zirconia, lithium eFig. 70.2 Radiograph reveals a biologic width violation on the mesial
disilicate) reduces the aesthetic rationale for subgingival margins. surface interproximally. Removal of interproximal bone would create an
Once the tissue is healthy, the following three rules can be used to aesthetic deformity. This patient is better treated with orthodontic extrusion
place intracrevicular margins: (see eFigs.70.1 and 7.3).

eFig. 70.3 After orthodontic eruption. The tooth has been erupted 3 mm
to move the bone and gingiva coronally 3 mm on the left central incisor. It
is now possible to reposition the bone surgically to the correct level and
eFig. 70.1 The left central incisor was fractured in an accident 12 months position the gingiva to the correct level, reestablishing normal biologic
ago and restored at that time. The patient is unhappy with the appearance width.
of the tissue surrounding the restoration (see eFigs. 70.2, 70.3, and 70.4).
701.e2 PART 3 CLINICAL PERIODONTICS

eFig. 70.6 Depth from the attachment to the level of the preparation
margin is greater than 3 mm. The patient in eFig. 70.5 had an altered eruption
eFig. 70.4 One-year recall photograph after orthodontic extrusion, osseous pattern and a sulcus depth of more than 3 mm when these restorations
surgery, and placement of a new restoration for the patient in eFig. 70.1. were placed.
Note the excellent tissue health after the reestablishment of biologic width.

eFig. 70.5 A 78-year-old woman presents with the maxillary anterior

restorations placed 6 months earlier. She is unhappy with the exposed eFig. 70.7 Two options were available to manage treatment appropriately:
margins and notes that the margins were covered the day the restorations (1) place the original margins to half the depth of the sulcus, in which case
were placed (see eFigs. 70.6 to 70.9). the recession that occurred would not have exposed them, or (2) perform
a gingivectomy, creating a 1- to 1.5-mm sulcus. The second option was
chosen when the restorations were redone. The margins were then placed
Rule 2: If the sulcus probes more than 1.5 mm, place the margin no 0.5 mm below the tissue after the gingivectomy (see eFigs. 70.6 and 70.8).
more than half the depth of the sulcus below the tissue crest.
This places the margin far enough below tissue so that it will
still be covered if the patient is at higher risk of recession.
Rule 3: If a sulcus greater than 2 mm is found, especially on the
facial aspect of the tooth, evaluate to see if a gingivectomy could
be performed to lengthen the teeth and create a 1.5-mm sulcus.
Then the patient can be treated using rule 1.
The rationale for rule 3 is that deep margin placement is more
dificult and the stability of the free gingival margin is less predictable
when a deep sulcus exists. Reducing the sulcus depth creates a more
predictable situation in which to place an intracrevicular margin.
The clinician cannot be sure that the tissue will remain at the corrected
level, however, because some gingival rebound can occur after
gingivectomy. However, sulcular depth reduction ensures that the
restorative margins will not be exposed and visible in the patient’s
mouth (eFigs. 70.5 to 70.9).
The placement of supragingival or equigingival margins is simple
eFig. 70.8 At 6 weeks after the gingivectomy and preparation of the
because it requires no tissue manipulation. With regard to overall teeth. Note the tissue level and that the tissue is rebounding coronally over
tooth preparation, the amount reduced incisally or occlusally, facially, the margins. This is a common finding when a pure gingivectomy is done.
lingually, and interproximally is dictated by the choice of restorative
materials. Before extending subgingivally, the preparation should be
completed to the free gingival margin facially and interproximally.
This allows the margin of the tooth preparation to be used as a
 CHAPTER 70 Restorative Interrelationships 701.e3

eFig. 70.9 Four-year recall photograph after placement of the final restora-
tions for the patient in eFig. 70.5. Note the tissue level has been maintained, eFig. 70.11 Second step in margin placement is to place a single layer
with a sulcus depth of 2 mm on the facial surface. of deflection cord below the previously prepared margin to the desired final
margin level. Here, a single cord has been placed 0.5 mm below the previously
prepared margin.

eFig. 70.10 To provide a reference position for margin placement after

tissue retraction, the margin of the tooth preparation is initially established eFig. 70.12 Margin of the preparation is now extended apically to the
level with the free gingival margin. top of the retraction cord; this represents the correct placement of the
margin below the previously nonreflected, free gingival margin.

reference for subgingival extension once the tissue is retracted

(eFig. 70.10).

Tissue Retraction
Once the supragingival portion of the preparation is completed, it
is necessary to extend below the tissue.6,23 The preparation margin
must now be extended to the appropriate depth in the sulcus, applying
the guidelines presented previously. In this process the tissue must
be protected from abrasion, which will cause hemorrhage and can
adversely affect the stability of the tissue level around the tooth.
Access to the margin is also required for the inal impression, with
a clean, luid-controlled environment. Tissue management is achieved
with gingival retraction cords using the appropriate size to achieve
the displacement required. Thin, fragile gingival tissues and shallow
sulcus situations usually dictate that smaller diameter cords be chosen
to achieve the desired tissue displacement. eFig. 70.13 To provide space for impression material, a second impression
For a rule 1 margin (sulcus depth 1.5 mm or less), the cord should cord is now placed on top of the first deflection cord. This impression cord
be placed so that the top of the cord is located in the sulcus at the is placed so that it is between the margin of the preparation and the gingiva
level in which the inal margin is to be established, which will be to create adequate space for impression material after removal of the cord.
0.5 mm below the previously prepared margin (eFig.70.11). On the
interproximal aspects of the tooth, the cord is usually 1 to 1.5 mm margin at the desired subgingival level. To create space and allow
below the tissue height because the interproximal sulcus is often 2.5 access for a inal impression, it is now necessary to pack a second
to 3 mm in depth. With this initial cord in place, the preparation is retraction cord. The second cord is pushed so that it displaces the
extended to the top of the cord, with the bur angled to the tooth so irst cord apically and sits between the margin and the tissue (eFig.
that it does not abrade the tissue (eFig. 70.12). This process protects 70.13). For the inal impression, only the top cord is removed, leaving
the tissue, creates the correct axial reduction, and establishes the the margins visible and accessible to be recorded with the impression
701.e4 PART 3 CLINICAL PERIODONTICS

eFig. 70.14 Ideal situation after removal of impression cord. The deflection
cord is still in place maintaining the open sulcus but has been displaced eFig. 70.16 Overhanging tissue has been removed and space created
apically another 0.5 mm by the placement of the impression cord, exposing for the impression material with electrosurgery. Note that the deflection
tooth structure apical to the margin so that it can be captured in the cord and the impression cord are still in place. The impression cord is now
impression. visible completely around the tooth, allowing easy access for the impression
material to the margin after removal of the impression cord.

eFig. 70.15 Deflection cord and impression cord are in place. The soft eFig. 70.17 Using electrosurgery, the fine-wire electrode tip is held parallel
tissue is falling over the margins of the preparation. In this situation, if the to the tooth preparation and rests on the cord as the tip is moved around
impression cord were removed, the impression would not capture the margins the tooth.
in the areas in which the tissue is overhanging.

material (eFig. 70.14). The initial cord remains in place in the sulcus
until the provisional restoration is completed.
As an alternative to additional retraction cords, electrosurgery
can be used to remove any overlying tissue in the retraction process.
A ine-wire electrode tip is held parallel to the tooth and against the
margin in the sulcus and moved through the overhanging tissue,
opening up the margin and the retraction cord to visual access (eFigs.
70.15 to 70.18). The electrosurgery tip sits on top of the retraction
cord in place in the sulcus. This controls the vertical position of the
tip and results in the removal of the least tissue needed for access.
For rule 2 situations in which the sulcus is deeper, two larger-
diameter cords are used to delect the tissue before extending the
margin apically (eFigs. 70.19 to 70.21). The top of the second cord
is placed to identify the inal margin location at the correct distance
below the previously prepared margin, which was at the gingival
tissue crest level. The margin is lowered to the top of the second
cord (eFig. 70.22), then a third cord is placed in preparation for the eFig. 70.18 After removal of the impression cord, an adequate space is
impression (eFigs. 70.23 and 70.24). In the patient with a deep sulcus created for the impression material, with no soft tissue overhanging the
in which the margin may be 1.5 to 2 mm below the tissue crest, margins to trap or tear the impression material. Note the first cord, or
deflection cord, is still in place.
electrosurgery is often required to remove overhanging tissue. To
avoid altering the gingival tissue height, it is important to hold the
electrosurgery tip parallel to the preparation (eFig. 70.25).
 CHAPTER 70 Restorative Interrelationships 701.e5

eFig. 70.19 First step in margin placement for the patient with altered eFig. 70.22 Preparation is now extended to the top of the second deflection
eruption or a deep sulcus is to prepare the existing free gingival margin, cord, finalizing margin location.
as in the “rule 1” patient (see text).

eFig. 70.23 After extension of the margin to the top of the deflection
eFig. 70.20 Second step for the patient with altered eruption is to place cord, a third layer of cord is applied that will act as the impression cord.
the deflection cord. Note that the placement of a single deflection cord This impression cord should be placed so that it fits between the free
does not provide adequate deflection of the tissue to allow the margin to gingival margin and the margin of the preparation. Its placement will also
be carried below tissue without abrading the gingiva with the bur. apically displace the two previously positioned deflection cords.

eFig. 70.21 Third step for the patient with altered eruption and a deep
sulcus is to place a second, larger-diameter deflection cord on top of the eFig. 70.24 Removal of the impression cord creates an adequate space
first deflection cord. Combined, these two cords allow adequate deflection for the impression material to capture the margin and 0.5 mm of tooth
to open up the sulcus so that the margin can be carried below tissue without structure below the margin in which the impression cord had displaced the
abrading the gingiva. first two cords.
701.e6 PART 3 CLINICAL PERIODONTICS

B
eFig. 70.25 If it is necessary to use electrosurgery, either in the normal
or altered-eruption patient, the correct inclination of the electrosurgery tip
is important. (A) Electrosurgery tip being held parallel to the preparation
and resting on the previously placed retraction cord. This removes a minimal
amount of tissue, and the presence of the retraction cord protects the
attachment from the electrosurgery. (B) Incorrect inclination of electrosurgery
tip. The tip is leaning away from the preparation. This inclination results in
excess tissue removal.
702 PART 3 CLINICAL PERIODONTICS

Van der Veldon72 completely removed healthy papillae to the bone

Hypersensitivity to Dental Materials level and found that they routinely regenerated 4 to 4.5 mm of total
Inlammatory gingival responses have been reported related to the tissue above bone, with an average sulcus depth of 2 to 2.5 mm. The
use of nonprecious alloys in dental restorations.52 Typically, the height above bone that the papilla strives to maintain was indirectly
responses have occurred to alloys containing nickel, although the conirmed by Tarnow and coworkers,67 who studied the relationship of
frequency of these occurrences is controversial.50 Hypersensitivity the papilla between the interproximal contact and the underlying bone.
responses to precious alloys are extremely rare, and these alloys When the distance from the interproximal bone to the interproximal
provide an easy solution to the problems encountered with the contact of the teeth measured 5 mm or less, 98% of these sites had
nonprecious alloys. Importantly, tissues respond more to the differ- complete papilla ill. When the distance was 6 mm, only 56% of the
ences in surface roughness of the material than they do to the composi- sites had complete papilla ill. When the distance was 7 mm, only
tion of the material.1,66 The rougher the surface of the restoration 27% of the sites had complete papilla ill (Fig. 70.7).
subgingivally, the greater are the plaque accumulation and gingival Because there is individual variability to the required biologic
inlammation. In clinical research, porcelain, highly polished gold, width, this information relative to the papilla is applied by locat-
and highly polished resin all show similar plaque accumulation. ing the lowest point of the interproximal contact in relation to the
Regardless of the restorative material selected, a smooth surface is top of the epithelial attachment. The ideal contact should be 2 to
essential on all materials subgingivally. 3 mm coronal to the attachment, which coincides with the depth
of the average interproximal sulcus. In assessing the soft tissues to
determine margin location, it is imperative that they be healthy and
Aesthetic Tissue Management mature. Performing the analysis on inlamed or immature tissues
Managing Interproximal Embrasures will result in supragingival margins when the tissues heal. If the
Current restorative and periodontal therapy must consider a good papillary sulcus measures greater than 3 mm, there is some risk of
aesthetic result, especially in the “aesthetic zone.” As discussed in recession with restorative procedures. Critical adjustments to margin
Chapters 58 and 65, the interproximal papilla is an important part in and soft tissue positions should be ultimately diagnosed with the use
creating this aesthetic result. The interproximal embrasure created by of well-designed and adapted provisional restorations. This will allow
restorations and the form of the interdental papilla have a unique and for treatment to be accurately designed based on the individual’s
intimate relationship.61,62 The ideal interproximal embrasure should unique biologic width.
house the gingival papilla without impinging on it and should also The clinician most frequently confronts a normal or shallow sulcus
extend the interproximal tooth contact to the top of the papilla so that with a papilla that appears too short rather than a tall papilla with
no excess space exists to trap food and to be aesthetically displeasing. a deep sulcus. Management of this situation is best approached by
Papillary height is established by the level of the bone, the biologic viewing the papilla as a balloon of a certain volume that sits on the
width, and the form of the gingival embrasure. Changes in the shape
of the embrasure can impact the height and form of the papilla. The tip
of the papilla behaves differently than the free gingival margin on the
Bone
facial aspect of the tooth. Whereas the free gingival margin averages scallop
3 mm above the underlying facial bone, the tip of the papilla averages 3.0 mm avg.
4.5 to 5 mm above the interproximal bone (Fig. 70.6). This means that Soft tissue
if the papilla is farther above the bone than the facial tissue but has scallop
the same biologic width, the interproximal area will have a sulcus 1 4.5 mm avg.
to 1.5 mm deeper than that found on the facial surface.

! CLINICAL CORRELATION
Fig. 70.6 Comparison of the behavior of the interproximal papilla relative
If you create restorations with no more than 5 mm from the contact to to bone and the free gingival margin relative to bone in the average human.
the bone, open gingival embrasures can be avoided. The downside to this There is a 3-mm scallop from the facial bone to the interproximal bone.
approach is that the teeth will look square and blocky. However, some However, on average, a 4.5- to 5-mm gingival scallop exists between the
patients can support a 7-mm papilla. Well-made provisional restorations facial tissue height and the interproximal papilla height. This extra scallop
allow accurate determination of actual papilla length. of 1.5 to 2 mm of gingiva compared with bone is the result of the extra
soft-tissue height above the attachment interproximally.

5mm 6mm 7mm

A B C
Fig. 70.7 The probability of complete fill of gingival embrasure by papilla. (A) With 5 mm from crest of bone
to the apical contact point, there is a 98% chance of complete fill of the space. (B) At 6 mm from crest to
contact, the chance of filled embrasure drops to 56%. (C) At 7 mm from crest to contact, the chance of complete
fill drops to 27%.
 CHAPTER 70 Restorative Interrelationships 703

attachment. This balloon of tissue has a form and height dictated by

the gingival embrasure of the teeth. With an embrasure that is too Pontic Design
wide, the balloon lattens out, assumes a blunted shape, and has a Classically, there are four options to consider in evaluating pontic
shallow sulcus (Fig. 70.8). design: hygienic, ridge lap, modiied ridge lap, and ovate designs
If the embrasure is the ideal width, the papilla assumes a pointed (Fig. 70.9). Regardless of design, the pontic should provide an
form, has a sulcus of 2.5 to 3 mm, and is healthy. If the embrasure occlusal surface that stabilizes the opposing teeth, allows for normal
is too narrow, the papilla may grow out to the facial and lingual, mastication, and does not overload the abutment teeth. The area of
form a col, and become inlamed. This information is applied when the pontic interfacing with the gingiva can be porcelain, metal,
evaluating an individual papilla with an open embrasure. The papilla zirconia, lithium disilicate, or some other material with no variation
in question is compared with the adjacent papillae. If the papillae in the biologic response of the tissue provided it has a smooth
are all on the same level, and if the other areas do not have open surface inish.25,53,63
embrasures, the problem is one of gingival embrasure form. If the The key differences between the four pontic designs relate to the
papilla in the area of concern is apical to the adjacent papillae, aesthetics and access for hygiene procedures. The primary method
however, the clinician should evaluate the interproximal bone levels. for cleaning the undersurface of pontics is to draw dental loss
If the bone under that papilla is apical to the adjacent bone levels, mesiodistally along the undersurface. The shape of this undersurface
the problem is caused by bone loss. If the bone is at the same level, determines the ease with which plaque and food debris can be removed
the open embrasure is caused by the embrasure form of the teeth in the process. The hygienic and ovate pontics have convex under-
and not a periodontal problem with the papilla. The papillae in the surfaces, which makes them easiest to clean. The ridge lap and
anterior maxilla average 4 mm long and are the same heights at the modiied ridge-lap designs have concave surfaces, which are more
mesial and distal sides of the tooth. Ultimately, deicient papillae dificult to access with the dental loss. Although the hygienic pontic
and open gingival embrasures are most predictably corrected with design provides the easiest access for hygiene procedures, it is much
restorations to close the space. less aesthetic and objectionable by some patients.
The ovate pontic is the ideal pontic form, particularly in areas
of aesthetic concern.61 It is created by forming a receptor site in the
edentulous ridge with a diamond bur, electrosurgery, pressure, or
wound healing. The site is shaped to create either a lat or a concave
contour so that when the pontic is created to adapt to the site, it will
have a lat or convex outline. The depth of the receptor site depends
on the aesthetic requirements of the pontic. In highly aesthetic areas
such as the maxillary anterior region, it is necessary to create a
receptor area that is 1 to 1.5 mm below the tissue on the facial aspect.
This creates the appearance of a free gingival margin and produces
optimal aesthetics (Fig. 70.10). This site can then be tapered to the
A B height of the palatal tissue to facilitate hygiene access from the
Fig. 70.8 Relationship between gingival embrasure volume and papillary palatal side. In the posterior areas, a deep receptor site can complicate
form. (A) Gingival embrasure of the teeth is excessively large as the result hygiene access. In these situations, the ideal site has the facial portion
of a tapered tooth form. Because of the large embrasure form, the volume of the pontic at the same level as the ridge, and then the site is
of tissue sitting on top of the attachment is not molded to the shape of a created as a straight line to the lingual side of the pontic. This
normal papilla but rather has a blunted form and a shallower sulcus. (B) removes the convexity of the ridge and produces a lat, easily cleanable
Ideal tooth form in which the same volume of tissue sits on top of the tissue surface on the pontic (Fig. 70.11).
attachment as in part A. Because of the more closed embrasure form from
the teeth in part B, however, the papilla completely fills the embrasure and
has a deeper sulcus, averaging 2.5 to 3 mm. Note that the ideal contact
position is 3 mm coronal to the attachment.

A B C D
Fig. 70.9 Four options to designing the shape of a pontic. (A) Hygienic pontic. Tissue surface of the pontic
is 3 mm from the underlying ridge. (B) Ridge-lap pontic. Tissue surface of the pontic straddles the ridge in saddle-like
fashion. The entire tissue surface of the ridge-lap pontic is convex and very difficult to clean. (C) Modified
ridge-lap pontic. Tissue surface on the facial is concave, following the ridge. However, the lingual saddle has
been removed to allow access for oral hygiene. (D) Ovate pontic. The pontic form fits into a receptor site within
the ridge. This allows the tissue surface of the pontic to be convex and also optimizes aesthetics.
 CHAPTER 70 Restorative Interrelationships 703.e1

Correcting Open Gingival Embrasures

Restoratively
There are two causes of open gingival embrasures: (1) the papilla
is inadequate in height because of bone loss or (2) the interproximal
contact is located too high coronally. If a high contact has been
diagnosed as the cause of the problem, there are two potential reasons.
If the root angulation of the teeth diverges, the interproximal contact
is moved coronally, resulting in the open embrasure. However, if
the roots are parallel, the papilla form is normal, and an open
embrasure exists, then the problem is probably related to tooth shape,
speciically an excessively tapered form. Restorative dentistry can
correct this problem by moving the contact point to the tip of the
papilla. To accomplish this, the margins of the restoration must be
carried subgingivally 1 to 1.5 mm, and the emergence proile of the
restoration is designed to move the contact point toward the papilla eFig. 70.27 This patient has parallel roots, has recently completed
while blending the contour into the tooth below the tissue (eFig.70.26). orthodontic therapy, and is unhappy with the open gingival embrasure
This can be accomplished easily with direct bonded restorations between her central incisors. An evaluation of papillary height reveals that
all are at an equal level. This can only mean that the open embrasure is
because the soft tissue can clearly be seen (eFigs. 70.27 to 70.29).
the result of an overly tapered tooth form (see eFigs. 70.28 and 70.29).
For indirect restorations, the desired restoration contours and
embrasure form should be established in the provisional restorations,
and the gingival tissues are allowed to adapt for 4 to 6 weeks before
the tissue contour information is relayed to the laboratory for use
in the inal restorations.

Managing Gingival Embrasure Form for Patients

With Gingival Recession
Management of the gingival embrasure form for patients who have
experienced gingival recession varies, depending on whether the
treatment is in the anterior or posterior regions of the mouth.30 In
aesthetic areas, it is necessary to carry the interproximal contacts
apically toward the papilla to eliminate the presence of large, open
embrasures. With multiple-unit restorations, it is also possible with
tissue-colored ceramics to bake porcelain papillae directly on the
restoration. In the posterior areas where the interroot widths are
signiicantly greater, it is often impossible to carry the proximal
contacts to contact the tissue without creating large overhangs on
eFig. 70.28 One method of correctly altering tooth form of the patient
the restorations. In these situations, the contact should be moved far in eFig. 70.27. A metal matrix band has been shaped to the desired tooth
enough apically to minimize any large food traps while still leaving form and placed 1 to 1.5 mm below the tip of the papilla. Restorative
an embrasure of a convenient size to be accessed with an interdental material then was added to the tooth against the matrix band, forming the
brush for hygiene. It should be noted that developing excessively new mesial surface of the left central incisor.

A B C
eFig. 70.26 Methods of altering gingival embrasure form. (A) Typical
open gingival embrasure caused by excessively tapered tooth form. (B)
Common method employed by restorative dentists to correct the embrasure,
in which material is added supragingivally. This closes the embrasure by
moving the contact to the tip of the papilla but results in overhangs that
cannot be cleaned using dental floss. Removing these overhangs restoratively
reopens the embrasure. (C) Correct method of closing the gingival embrasure,
in which the margins of the restoration are carried 1 to 1.5 mm below the eFig. 70.29 One-year recall photograph after restoring the mesial surfaces
tip of the papilla. Note that this does not encroach on the attachment of the right and left central incisors, moving the proximal contact to the tip
because the average interproximal sulcus probes 2.5 to 3 mm. This allows of the papilla and extending the restorations 1 to 1.5 mm below the papilla,
easy cleaning because of the convex profile. It also reshapes the papilla to blending them into the tooth and making an easily cleaned area (see eFigs.
a more pleasing profile aesthetically. 70.27 and 70.28).
703.e2 PART 3 CLINICAL PERIODONTICS

long interproximal contacts, whether on anterior or posterior teeth, The “full ridge-lap pontic” is an outdated design that straddles the
always creates rectangular, somewhat unaesthetic, tooth forms. convexity of the ridge buccolingually and creates an undersurface
that is entirely concave and cannot be cleaned. It is not recommended
Ridge Modification Procedures for Ideal Pontic for use in any situations. However, a modiied ridge-lap pontic can
Contours be an acceptable design if inadequate ridge exists to create an ovate
When the ridge is being surgically modiied, it is important to know pontic. With the modiied ridge-lap design, the pontic follows the
the thickness of soft tissue above the bone. This measurement is convexity of the ridge on the facial aspect but stops on the lingual
obtained by probing to the bone through the anesthetized tissue. If the crest of the ridge without extending down the lingual side of the ridge.
tissue is removed to less than 2 mm in thickness, signiicant rebound Although the facial aspect of the undersurface has a concave shape,
in ridge height may occur. If it is necessary to reduce the tissue height the more open lingual form allows adequate access for oral hygiene.
to less than 2 mm above the bone to create the desired pontic form,
some bone will need to be removed to achieve the desired result.
It is important when considering an ovate pontic to realize that
certain soft-tissue ridge parameters must exist to optimize the ovate
pontic form. First, the ridge height needs to match the ideal height
of the interproximal papillae where interproximal embrasures are
planned, either between pontics or next to abutment teeth. Second,
the gingival margin height must also be at the ideal level, or the
pontic will appear too long. Third, the ridge tissue must be facial to
the ideal cervical facial form of the pontic so that the pontic can
emerge from the tissue. If any of these three areas is inadequate,
some form of ridge augmentation is needed to produce a ridge that
can have an adequate receptor site created (eFig. 70.30). Any ridge
augmentation procedures should be completed before, or in conjunc-
tion with, fabricating an ovate pontic. When constructing the inal
restorations, the contours of the developed ovate pontic receptor site
can be conveyed to the laboratory by capturing a soft-tissue impression
4 to 6 weeks after the site has been created. eFig. 70.31 Patient who will have the right central incisor extracted
The ovate pontic can serve another important periodontal function because of periodontal disease. The patient is choosing to have a fixed
by maintaining the interdental papilla next to abutment teeth after partial denture rather than an implant as the method of replacement. An
ovate pontic will be used to maintain the papillary form after the removal
extraction.61 When a tooth is removed, the gingival embrasure form
of this central incisor (see eFigs. 70.32 to 70.38).
is lost. The normal response of the papilla to this loss of embrasure
form is to recede 1.5 to 2 mm, which corresponds to the additional
soft tissue that exists above bone on the interproximal versus the
facial aspect. However, this recession can be prevented. By inserting
the correct pontic form 2.5 mm into the extraction site the day the
tooth is removed, the gingival embrasure form and papilla can be
maintained. At 4 weeks, the 2.5-mm extension can be reduced to a
1- to 1.5-mm extension to facilitate hygiene. This procedure can
maintain the papilla next to the abutment teeth as long as the bone
on the abutment tooth is at a normal level (eFigs. 70.31 to 70.38).

eFig. 70.30 Ridge considerations when an ovate pontic is desired. For

an ovate pontic to be properly created, the soft-tissue ridge must be labial
to the desired cervical portion of the pontic. When the pontic is facial to
the ridge, it is not possible to create what appears to be a “free gingival eFig. 70.32 Note the radiographic appearance of a palatal well caused
margin” correctly. The shaded area represents the necessary amount of by a deep palatal groove on this right central incisor of the patient in eFig.
tissue that would be augmented to produce an ideal ovate pontic in this 70.31. Two attempted periodontal surgeries have failed to correct this, and
particular site. it still probes 10 mm with suppuration.
 CHAPTER 70 Restorative Interrelationships 703.e3

eFig. 70.33 Because the patient in eFig. 70.31 desired to alter the aesthet-
ics of her remaining anterior teeth, all the anterior teeth were prepared eFig. 70.36 Nine months after placement of the provisional restoration.
before removal of the right central incisor. (At 4 weeks after placement, the pontic was shortened to extend 1.5 mm
into the extraction site to facilitate oral hygiene.) Note maintenance of
papillary form and free gingival margin height, predictable in this patient
because she has excellent interproximal and facial bone.

eFig. 70.34 The key to maintenance of the interproximal papilla is that eFig. 70.37 Ovate pontic site after removal of the provisional restoration
the ovate pontic must extend 2.5 mm into the extraction site on the day of and before final impressions. Note that the papillary form has been maintained
extraction. This will maintain gingival embrasure form and therefore maintain because of the ovate pontic maintaining gingival embrasure volume.
interproximal papillary height.

eFig. 70.35 Note that when the provisional restoration is seated on the eFig. 70.38 Two-year recall photograph of the final fixed prosthesis of
day of the extraction, 2.5 mm of the pontic extend upward into the extraction the patient in eFig. 70.31. Note how the final ovate pontic also has maintained
socket. Also note the open gingival embrasures present to allow space for papillary form.
the papillae to rebound coronally.
704 PART 3 CLINICAL PERIODONTICS

1. There should be even, simultaneous contacts on all teeth in

maximal intercuspal position (MIP). This distributes the force
Pontic to bone
minimum of of closure over all the teeth instead of the few teeth that may
2 mm touch irst.
2. When the mandible moves from maximum intercuspal position
Receptor site (MIP), some form of canine or anterior guidance is desirable,
Receptor tapers 1 mm to 1.5 mm
to level of tissue deep in esthetic with no posterior tooth contacts. This mutually protective occlusion
on the palate for areas reduces the ability and force of the muscles of mastication, while
ease of hygiene.
it more evenly distributes the forces. It has been shown that, as
a result of the class III lever action, the anterior teeth receive
approximately one-ninth the force of a second molar.24,60
3. The anterior guidance needs to be in harmony with the patient’s
envelope of function. The harmony of this relationship is dem-
onstrated by a lack of fremitus and mobility on the anterior teeth,
Fig. 70.10 Ideal shape and form of an ovate pontic in the aesthetic area. by the ability of the patient to speak clearly and comfortably,
The receptor site has been created 1 to 1.5 mm apical to the free gingival and by the patient’s general sense of comfort with the overbite,
margin on the facial aspect. This creates the illusion of the pontic erupting
overjet, and guidance created during chewing and when holding
from the tissue. On the palatal side, the pontic is tapered so that the receptor
site is not extended below tissue; this allows easier access for oral hygiene. the head upright.
Note that when the receptor site is created, the bone must be a minimum 4. The occlusion should be created at a occlusal vertical dimension
of 2 mm from the most apical portion of the pontic. (OVD) that is stable for the patient. It is generally accepted that
the patient’s existing vertical dimension is at equilibrium between
the eruptive forces of the teeth and the repetitive contracted length
of the elevator muscles. It has been demonstrated that vertical
dimension can be altered with no sense of pain from muscles
and joints.8,10,21,29 However, if this alteration lengthens the ptery-
gomasseteric sling beyond its ability to adapt, the patient will
not maintain the vertical change and will close the occlusal vertical
dimension back down by intruding the teeth.11,33,39-41
5. When managing a pathologic occlusion or when restoring a
complete occlusion, the clinician needs to work with a repeatable
condylar reference position. Centric relation, deined as the most
superior condylar position, provides such a starting point.20 Centric
relation has been shown to be reproducible over multiple appoint-
ments, allowing the clinician to create the occlusion indirectly
Fig. 70.11 Option for creating an ovate pontic receptor site in less aesthetic
on an articulator and return it to the same reference position in
areas of the mouth. Rather than creating the receptor site so that the pontic
extends into the ridge, it is possible to create a flattened receptor site in the mouth.13,38,43,73 It is the only position that has been shown to
which the pontic sits flush with the ridge. This facilitates oral hygiene. shut off lateral pterygoid muscle contraction.19 Because it is a
border position, any mandibular movement will result in the
condyle moving inferiorly. Therefore centric relation is the most
Occlusal Considerations in predictable position from which an interference-free occlusion
Restorative Therapy can be created.
To manage the occlusion as previously described, the clinician
must be able to make accurate casts, use a facebow, and create
KEY FACT centric relation records so that the information can be transferred to
A mutually protective occlusion is created when all the teeth touch at the a suitable articulator. Although the details of these procedures are
same time in a normal closing arc, but when the mandible moves, all beyond the scope of this chapter, they are a routine part of any
contacts are on the anterior teeth. restorative treatment plan and must be mastered for the clinician to
achieve predictable, long-term restorative success. The reader is
referred to Chapter 55 for a more comprehensive overview of occlusal
Chapter 55 presents details on the biology of occlusion and related evaluation and therapy.
clinical evaluation procedures. The importance of occlusal trauma
as a factor in periodontal disease and its role in orofacial pain have Case Scenarios are found on the companion website
been deemphasized in numerous papers.8,14,34,35,44,45,54,65,71 However, www.expertconsult.com.
the role that occlusion plays in restorative dentistry has been reem-
phasized. The increased use of dental implants and nonmetallic
restorations has resulted in increased concern over force management. References
Some of these materials are more sensitive to occlusal trauma, and
resulting fracture, than are metal restorations. Consequently, for the References for this chapter are found on the companion
clinician who wants a high degree of predictability, understanding website www.expertconsult.com.
occlusion is critical. The clinician must know how to create an
occlusion, with the following guidelines as a goal:
 CHAPTER 70 Restorative Interrelationships 704.e1

teeth, with the goal of improving tooth stability. Unstable teeth may
Special Restorative Considerations be caused by a lack of periodontal support from bone loss, a lack
Root-Resected Teeth of support from tooth loss, or the need to splint abutment teeth to
Although the availability of implant therapy has greatly reduced the support pontics. Indications for splinting are (1) mobility of teeth
frequency with which root-amputated teeth are saved, restoration of that is increasing or that impairs patient comfort, (2) migration of
root-resected teeth is still a viable mode of treatment. Diagnosis and teeth, and (3) prosthetics in which multiple abutments are necessary.
management of multirooted teeth with furcation involvement including Before considering splinting, the clinician must identify the
the rationale for root resection are presented in detail in Chapter 62. etiology of the instability.2 Excessive occlusal forces from parafunc-
Structural challenges are created in restoring these teeth because of tion or delective tooth contacts are frequent causes of excessive
the amount of tooth structure lost in the resection process (eFig. mobility. Whenever the occlusion is the cause, occlusal therapy is
70.39). Conservative tooth preparation will maintain as much of the always performed irst. The mobility is then evaluated over time to
remaining tooth as possible, but the resulting supragingival or mini- determine if it resolves before splinting is considered. In addition,
mally prepared subgingival inish lines will require additional metal any inlammation of the periodontal supporting apparatus must be
display in the inal restoration. A cast post and core may be indicated controlled before making a decision on splinting because inlammation
to create an adequate foundation for the inal restoration. Because can produce mobility in the presence of normal occlusal forces and
the remaining roots are often very thin mesiodistally, it is dificult normal periodontal support. When the teeth are splinted, all the teeth
to cement premade posts and have adequate bulk to place a foundation in the splint share the occlusal load to some extent.16 The rigidity of
core on the mesial and distal surfaces of the post. This problem is the splint and the number of teeth used determine how the forces
avoided with the one-piece cast post and core restoration. are distributed.
Another area of concern when restoring root-resected teeth is the The most common indication to splint mobile teeth is to improve
development of appropriate contours for hygiene access. The primary patient comfort and to provide better control of the occlusion. If the
concern is to avoid any excessively heavy convexities of contour anterior teeth are mobile, adequate crown length on the teeth being
that would prevent access (eFig. 70.40 and 70.41). Facially and
lingually, the contours should be essentially a straight line from the
margin coronally, while interproximally, the contour emerges from
the margin as a straight line or is slightly convex as it slopes up to
the contact point. The interproximal areas of root-amputated and
hemisected teeth often present with surface concavities on the root
trunk, and these areas cannot be adequately cleaned with loss because
it will bridge across the concavity. The gingival embrasure form
created in the restoration must be luted into these areas so that the
surfaces can be accessed with an interdental brush.
Aesthetics is usually not a major concern unless the tooth in
question is a maxillary molar with a mesiobuccal root amputation
and the patient has a broad smile. The solution is to create an artiicial
mesiobuccal root with normal crown contour coronal to it and a
furcation made of restorative material that is easily cleanable with
an interdental brush.
eFig. 70.40 Photograph taken 6 weeks after the removal of the distal
Splinting buccal root on this maxillary first molar. Note that the crown contour has
Splinting therapy may be applied with bonded external appliances, not yet been altered. Also note the presence of a large overhang that easily
intracoronal appliances, or indirect cast restorations to connect multiple traps debris.

A B C
eFig. 70.39 (A) Maxillary molar with a class III furcation and bone loss
surrounding the distal buccal root. (B) Contour created when the distal
buccal root is removed, but the coronal contour has not yet been reshaped.
Note the overhang, which can trap food and plaque and create gingival
inflammation. (C) Correct contour after the restoration or reshaping of the
tooth. Note this illustration is only of the facial portion of the tooth. The
palatal portion of the crown and the palatal root do not appear. Note how eFig. 70.41 Correct modification of the crown form seen in eFig. 70.40.
the contour has been altered to allow easy access for an interdental brush The roof of the furcation of the remaining distal buccal root has been
to the gingival tissue and the tooth in the area in which the root was completely removed and the crown re-formed to allow easy access to the
removed. remaining roots and soft tissue.
704.e2 PART 3 CLINICAL PERIODONTICS

splinted is critical so that the interproximal connectors do not impinge

on the interdental papilla. Also, adequate space must exist between
the connector and the papilla for access with dental loss anteriorly
and with an interproximal brush on posterior teeth.

Anterior Aesthetic Surgery

The importance of gingiva in relation to anterior aesthetics has been
well documented.9,28,58,64 Various methods for altering gingival levels
have been described, including gingivectomy, apically positioned
laps with osseous recontouring, and the use of orthodontic therapy
to position the gingival tissue level apically or coronally by intruding
or extruding the teeth5,12,32,68 (Video 70.1).
Whenever an alteration in gingival levels is contemplated, the
expected outcome must be communicated to the patient to determine
eFig. 70.42 This patient is unhappy with the appearance of her maxillary
if the planned surgery is acceptable. Computer imaging can be used teeth and the discrepancies of tissue height and tooth form (see eFigs.
to provide the patient with a visual plan for the inal aesthetic result.17 70.43 to 70.49).
However, the imaging process does not allow the dentist or patient
to include the dynamics of lip movement in the evaluation of the
proposed changes. Computer imaging provides enough information
to depict the inal outcome accurately when the planned surgery will
alter the gingiva on one or two teeth while leaving the gingival levels
of adjacent teeth in their existing position.
However, when the surgery will involve many or all of the anterior
teeth and will result in moving gingiva several millimeters, to the
extent that a lap will be raised and bony levels altered, an additional
guide is desirable before surgery. Constructing these guides directly
on a stone cast is the easiest and least time-consuming method.
Before constructing the guide, treatment planning is completed on
the patient to determine the desired incisal edge position and the
desired gingival level of the tissues. This will establish the amount
of tooth display at rest and at full smile. The information is transferred
to a stone cast of the patient’s teeth, and the desired shape of the
gingival margins for each tooth is drawn on the cast. The existing eFig. 70.43 To create a surgical guide for the patient in eFig. 70.42, a
incisal edge position of each tooth is used as a reference in establishing stone cast is modified by drawing the desired soft-tissue profile with a red
wax pencil.
the desired gingival level. A composite or acrylic resin veneer is
then constructed on the cast, extending gingivally to the desired
tissue position. The veneer guide can also be extended incisally to
the desired incisal edge position so that this information can also
be included in the veneer. The veneer is trimmed, polished, and tried
in the patient’s mouth.
When the patient approves the gingival levels established with
the guide, the desired gingival correction can be completed using
the veneer guide as a surgical template. In addition to locating the
initial incisions at the correct level, the guide can also be employed
after lap relection to aid in the bony recontouring to ensure adequate
biologic width and sulcus depth at the new gingival position. The
surgeon replaces the lap at closure to the gingival level established
with the guide. Employing an aesthetic template in this manner
optimizes the predictability of the surgical therapy and establishes
the ideal tissue framework to complete the aesthetic restorations
(eFigs. 70.42 to 70.49). eFig. 70.44 A composite-resin surgical guide is fabricated on this stone
cast, extending to the line drawn. This guide can be taken to the mouth for
try-in and verification by the patient (see eFig. 70.42).
 CHAPTER 70 Restorative Interrelationships 704.e3

eFig. 70.45 Photograph taken the day the surgical guide was tried-in. eFig. 70.48 Soft-tissue profile as seen the day of surgery with the guide
The patient in eFig. 70.42 approved the new length of the maxillary anterior removed. Note that in this patient, the interproximal papillae were not
teeth and the form created by altering the soft-tissue profile. changed because the interproximal papillary form and height were deemed
acceptable (see eFigs. 70.42 to 70.47).

eFig. 70.46 By placing the surgical guide during the surgery, it is possible
to recognize where the bone needs to be placed. The surgical guide represents eFig. 70.49 Photograph taken 4 years after placement of the final restora-
the desired final free gingival margin position and can be used as a reference tion of the patient in eFig. 70.42. Note the excellent soft-tissue health and
for osseous recontouring. This patient had an average biologic width of the attainment of the desired free gingival margin and papillary form.
2 mm (see eFig. 70.42). Allowing an additional 1 mm for sulcus depth, the
desired distance between the bone and the free gingival margin will be
3 mm. With this knowledge, the periodontist can use the guide and remove
bone until it is 3 mm from the position of the guide on each tooth.

eFig. 70.47 Surgical guide is also useful during suturing. Because the
guide represents the desired free gingival margin position, it is possible to
suture to the level of the guide, knowing that the surgery has now recreated
biologic width and a 1-mm sulcus. This shortens the amount of time necessary
for healing and eliminates the need to wait for tissue rebound before
restorative dentistry.
704.e4 PART 3 CLINICAL PERIODONTICS

CASE SCENARIO 70.1

Patient: 41-year-old female there is no bleeding on probing, and the patient practices good oral
hygiene.
Chief Complaint: “My old crowns had a big open space between them by
the gums.” Current Findings: Preexisting PFM crowns on maxillary central incisors
had poor shade match and open gingival embrasures. Patient brushes and
Background Information The patient has an ASA 1, a high smile,
losses as directed and has hygiene visits twice per year. RCT/post on the
and a normal tissue biotype. Preexisting PFMs on central incisors had
maxillary right central incisor is intact.
open gingival embrasure. Pocket depths are within normal limits,

CASE-BASED QUESTIONS SOLUTION AND EXPLANATION

1. To predictably close the open gingival embrasure with the new Answer: B
crowns, the apical extent of the contact point should be _____ from Explanation: According to Tarnow 1992, contact points 5 mm from the
the interdental bone crest. interdental crest of bone will be completely illed in 98% of patients.
A. 4 mm
B. 5 mm
C. 6 mm
D. 7 mm
2. What is the apparent height of the papilla between the centrals most Answer: C
dependent on? Explanation: The height of the interdental bone is the largest variable in
A. Tissue biotype determining the apparent height of the papilla. Tissue biotype plays a
B. Prep design role, though less signiicant.
C. Crestal bone height
D. Deep margin placement
3. What risk does the subgingival margins as seen here create? Answer: A
A. Cement-induced periodontal inlammation Explanation: Subgingival margins increase the risk for inlammation
B. Increased plaque retention due to residual cement. This risk increases proportional to the
C. Aesthetic concerns due to the darkened root of the right central subgingival depth of the margin. Healthy, robust gingiva mitigates this
incisor risk to some extent.
 CHAPTER 70 Restorative Interrelationships 704.e5

CASE SCENARIO 70.2

Patient: 38-year-old male Current Findings: Existing veneers had black color stains under the
margins, which appeared to be well sealed. Stains are likely secondary to
Chief Complaint: “My old veneers are black by the gums.”
the use of ferric-sulfate hemostatic agents during the previous
Background Information: The patient has an ASA 1, a high smile, and a preparations, impressions, or delivery. No caries were detected, margins
normal tissue biotype. Preexisting veneers on central incisors had black were equigingival, and the gingiva is healthy.
stains underneath the margins. Pocket depths are within normal limits,
there is no bleeding on probing, and the patient practices good oral
hygiene.

CASE-BASED QUESTIONS SOLUTION AND EXPLANATION

1. Restorative margins in the aesthetic zone should be placed as deep as Answer: B
possible to avoid aesthetic issues with stained margins. Explanation: False. Modern all-porcelain materials allow margins to be
A. True placed equigingival or at most 0.5 mm subgingival. Deeper margins
B. False will increase the risk for recession and make it dificult to properly
isolate the area from moisture during bonding.
2. What does the irst cord rest on when it is placed into the bottom of Answer: B
the socket? Explanation: The junctional epithelium lies at the base of the sulcus. It
A. Connective tissue attachment is 1 mm thick on average. It must be treated with care to avoid damage
B. Junctional epithelium during cord placement, cementation, and probing.
C. Sulcular epithelium
3. Soft-tissue recession can be caused by trauma resulting from, for Answer: C
example, surgery, aggressive probing, aggressive cord placement, and Explanation: Thin biotype. Thin biotypes are more susceptible to
aggressive root instrumentation. Periodontal tissues with which of the recession due to manipulation or trauma. Extreme care must be
following characteristics are most at risk for recession? exercised.
A. Stippling of the gingiva
B. Blunted papilla
C. Thin biotype
D. Pocket depths of less than 2 mm