Periodontal health consideration for ceramic crown:

A Literature Review
Vinsensia Launardo* Indah Sulistiawaty* Elizabeth Mailoa**
* Postgraduate Programme, Department of Prosthodontic Dentistry, Hasanuddin University
** Department of Prosthodontic, Dentistry, Hasanuddin University

Abstract
Background The periodontal status has a significant role in a restoration prognosis
and the long term survival of the restoration. Periodontal disease is one of the major
causes for tooth loss, thus knowing the periodontal basics and treatment is important
for a practitioner to be able to diagnose the mouth and teeth condition before planning
a thorough crown restoration.
Review The article overviews and discusses periodontal considerations for ceramic
crown restorations.
Discussion The care of periodontal care in a ceramic crown treatment starts from the
ability to asses the status of periodontal health prior to the treatment. Biological
width as a protection system for the periodontal structures beneath it has three
different types to normal, high and low crest. With knowledge of this condition, a
proper restoration margin placement can be planned and designed. The crown
material is another factor that can cause irritation to the periodontal tissues in contact
with. So far, based on studies conducted on how periodontal tissues reacted to crown
materials, galvano-ceramic showed significantly less signs of clinical and
inflammatory responses.
Conclusion Understanding of the importance of biological width as a
protection to the vulnerable periodontal tissues underneath gives a
better approach to restoration margin placement. Choosing
materials for the crown should be done carefully as some can affect
the periodontal tissues in contact with. Having a better assessment
on the periodontal health prior to treatment can give a better
ground to practitioners to be able to choose materials that will
function and appeal esthetically.
Keywords: periodontal health, biologic width, ceramic crown
To author:
Please write the abstract follow the literature review article laid out, which are:
background, review of the literature, coherent and profound discussions, and
conclusion.

Periodontal health consideration for ceramic crown:

A Literature Review

Introduction
The relationship between periodontal health and the restoration goes hand in
hand.

Prior to any crown restoration, a practitioner must examine the periodontal

status of the teeth involved.1 The periodontal status has a significant role in a
restoration prognosis and the long term survival of the restoration. 1,2 Periodontal
disease is one of the major causes for tooth loss, thus knowing the periodontal basics
and treatment is important for a practitioner to be able to diagnose the mouth and
teeth condition before planning a thorough crown restoration. 1 The article overviews
and discusses periodontal considerations for ceramic crown restorations.

Periodontal protection and restoration margin placement

Sicher started to use the term dentogingival junction in 1959.3
Dentogingival junction located at the base of the gingival sulcus (crevice) is the
epithelium-tooth interface. This structure consists of relationship between hard and
soft tissues. The depth of the sulcus varies in healthy individuals, averaging 1.8 mm.
In general, the shallower it is, the more likely the gingiva will be in a state of health.
Sulcular depths up to 3 mm are considered maintainable.1,2
In 1961,Gargiulo et al., found out that the vertical dimension of the
dentogingival junction; which consist of sulcus depth (SD), junctional epithelium
(JE), and connective tissue attachment (CTA), is a physiologically formed and stable

dimension, subsequently called the Biologic Width, which forms at a level

depends on the location of the crest of the alveolar bone.4
The Biologic Width exists in every tooth and it shouldnt be just viewed as
a single liner plane but as a three-dimensional form. This serves as a natural barrier
or shield which protects two most vulnerable and important structure for survival and
longevity of a tooth, the periodontal ligament and alveolar bone. 5 The depth of the
sulcus varies in healthy individuals, averaging 1.8 mm. In general, the shallower it is,
the more likely the gingiva will be in a state of health. Sulcular depths up to 3 mm
are considered maintainable. Maintenance of healthy gingiva is better on tight and
shallow sulcus which gives optimal plaque control, and will ensure the success of
periodontal therapy as well as affording a good prognosis for subsequent restorative
treatment.1
Ideally, the margin of the final restoration should be place 1 to 2 mm
supragingivally whenever possible. Locating the margin to close to the bone may
cause periodontal destruction because making plaque removal in routine oral hygiene
procedures difficult. For esthetic consideration, it can be either place at the gingival
crest or, at the most, 0.25 to 0.5 mm subgingival, this to ensure the health of the
biologic width. If the tooth preparation violated the biologic width, an inflammatory
response results in alveolar bone resorption, increased pocket depths, increased loss
of periodontal support, exacerbation of accumulation of subgingival bacteria,
increased chronic inflammation, and further localized periodontal breakdown.2

Fig 1. Normal tooth-gingival interface and coronal periodontium. CEJ, Cementoenamel junction;
PDL, periodontal ligament; B, bone; C, cementum.1

The biologic width can be evaluated by using dental radiographs and

periodontal probe.

Kois suggested biologic width determined by measuring the

distance from gingival crest to the alveolar crest, termed bone sounding.6,7 This is
done by penetrate the anesthetized soft tissue by a probe in order to determine the
topography of the alveolar process. The patient is anesthetized and the periodontal
probe is placed in the sulcus and pushed through the attachment apparatus until the
tip of the probe engages alveolar bone. The measurements are made on anterior teeth
mid-facially and at the facial/interproximal line angles. The biologic width then
categorized into normal, high and low crest.8
Mid facial measurement for normal crest 3.0 mm, high crest less than 3.0 mm,
and low crest greater than 3.0 mm. Based on proximal measurement, normal crest is

3.0-4.5 mm, high crest less than 3.0 mm, and low crest greater than 4.5 mm. The
margin of a crown should generally be placed no closer than 2.5 mm from the
alveolar bone. Normal crest has the most ideal width to restoration margin placement
subgingivally which usually needs at least 0.5 mm below the gingiva level.
Placement of restoration margin on high crest will be too close to alveolar bone
which can cause interproximal papilla collapse. Low crest are most susceptible to
gingival recession after the placement of subgingival crown margin, however each
patients reacts differently.
Determination of the crest category allows practitioner to plan best margin
placement and to let the patient understands the long term effects of the crown margin
and gingival health and esthetic. 8 Lack of biologic width can be corrected by doing
surgical crown lengthening and orthodontic extrusion.2
Shenoy 2012, recommended ideal finishing line design for all ceramic crown
restorations for metal-free ceramic restorations is a 1 mm (minimum 0.8 mm)-wide
360 degrees deep (accentuated) chamfer with no sharp internal line angles. The
internal line angles should, be well-rounded. The finishing line should follow a
smooth curvature that remains relatively shallow inter-proximally.

Crown materials and periodontal reaction

Cosmetic dental materials which has antibacterial and anti-inflammatory
properties starting to be in demand, especially for patients who are identified with
systemic diseases such as those with cardiac risk. Full crowns with antibacterial
subgingival margins should be the preference for this category of patients. 9

Loe 1968 reviewed the reactions of the periodontal tissues to restorative

procedures, and the effect of these restorative materials on the periodontal tissue. He
believed and stated that any known type of dental restoration that extends into the
subgingival area causes damage to the periodontal tissue, either by providing
possibilities for bacterial retention, and/or by a direct irritation effect from the
material. Gottherer 2009 stated if there is a strong connection between periodontal
disease/inflammation and cardiac disease, then these procedures must either be
avoided wherever possible or, they should be done using a periodontal-friendly
material that reduces the bacterial load.9
Following the standard of care established by Amsterdam, all dentists should
consider using materials that will maintain good periodontal health with optimal fit,
reducing possible periodontal risks for systemic disease.
Goodson, et al used Captek (Precious Chemicals) when the need exists to
employ full-coverage crowns. This material provides one example of a cosmetic
restorative crown material available that can help satisfy the goal of excellent health.
This ceramometal crown incorporates the use of a gold composite alloy coping. They
documented a 70% reduction in the number of bacteria observed on normal dentin
surfaces in the same mouth, with almost 96% less bacterial adhesion compared to
ceramic-fused-to-noble metal restorations. (Fig 2)

Fig. 2 Goodsen clinical study results comparing surface material of tooth

versus amount of bacteria present in sulcus. 9

Al-Wahadni 2006, investigate the periodontal response to the presence of allceramic crowns with IPS Empress. The study founds that teeth with IPS Empress
Crowns had poorer periodontal health and more clinically evident plaque than
uncrowned teeth.10
Weishaupt et al, 2007 studied periodontal reaction to galvano-ceramic crown
in comparison to porcelain fused to metal (PFM) crown. The study uses crowns that
were in adequate function and rare signs of obvious clinical inflammation. After 24

months of follow-up, gingival tissues adjacent to galvano-ceramic crowns showed

significantly less signs of clinical and inflammatory responses according to plaque
index, gingival index, and gingival crevicular fluid flow rate compared to PFM
crowns. Their data suggest a stabilizing effect of galvano-ceramic crowns on
periodontal tissues over time.11

Conclusion
Periodontal health status of a restoration treatment is usually
overlooked by practitioners.

Understanding the importance of

maintaining the biologic width as a natural barrier and protection of

periodontal ligament and alveolar bone will increase prognosis and
longevity of a ceramic crown restoration. With a good assessment
of

the

periodontal

condition

especially

the

one

where

the

restoration margin sits, a better treatment planning and design can

be achieved and patients can be better informed of what to expect
for.
Another contributing factor is the choice of material of the
crown

as

some

can

either

increase

or

inhibits

bacterial

accumulation and in times will affects the periodontal health.

Weighing the risk from periodontal condition will give practitioners a
better ground to decide what materials to use to be able to give
optimum function and esthetic.

Bibliography
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Shenoy A, et al, Considerations determining the design and location of margins in restorative
dentistry. J Interdiscip Dentistry 2012;2:3-10.
3. Sicher H. Changing concepts of the supporting dental structures. Oral Surg Oral Med Oral
Pathol 1959;12:31-5.
4. Gargiulo AW, Wentz FM, Orban B. Dimensions and relations of the dentogingival junction in
humans. J Periodontol 1961;32:261-7.
5. lngber IS, Rose LF, Coslet JG. The biologic width a concept in periodontics and restorative
dentistry. Alpha Omegan1977;70:62-5.
6. Kois JC. Altering Gingival Levels: The Restorative Connection Part I: Biologic Variables. J
EsthetRestor Dent 1994;6:3-7.
7. Kois JC. The restorative-periodontal interface: Biological parameters. Periodontol 2000.
1996;11:29-38.
8. Robbins JW. Tissue Management in Restorative Dentistry. FunctEsthetRestorDent Series 1,
Number 3
9. Gottehrer, The periodontal crown: creating healthy tissue. Dentistry today, May 2009
10. Al-Wahadni AM1, Mansour Y, Khader Y. Periodontal response to all-ceramic crowns (IPS
Empress) in general practice. Int J Dent Hyg. 2006 Feb;41:41-6.
11. Weishaupt , Clinical and inflammatory effects of galvano-ceramic and metal-ceramic crowns
on periodontal tissues. J Oral Rehabil. 2007 Dec;34(12):941-7.
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