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Master of Medical Science

with a major in Odontology


Institute of Odontology
Stockholm 2008

Effect of crown margin position on


periodontal tissue conditions.
A systematic review and clinical interpretations.

Farid Akhlaghi

Tutor: Professor Jan Wennstrm


Department of Periodontology
University of Gothenburg
1

Effect of crown margin position on periodontal


tissue conditions.
A systematic review and clinical interpretations.
Abstract:
The present study aimed at determining the effect of crown margin position on surrounding
periodontal tissues. Searches in PubMed and Cochrane libraries from 1965 up to September
2008 were conducted. Additionally, reference lists of selected papers were hand searched for
further relevant articles. All types of studies were included, but priority was given to
randomized controlled trials (RCT). The search was limited to articles in English and
Swedish language. The search identified a total of 392 titles. Titles and abstracts were
independently screened by two reviewers (FA & JD) to identify publications that met the
inclusion criteria. The kappa score for agreement was 77,8%. Twenty-one studies were
included in the review. Study quality was assessed according to the SBU criteria[1]. Studies
varied markedly in the selection of patients and methodology. Intracrevicular depth of crown
margin position was frequently not reported. The results from included studies showed that
placement of crown margins subgingivally increase gingival inflammation (Evidence grade
3). However, relationship between depth of crown margin position and severity of
inflammation could not be confirmed. The scientific evidence for potential effect of
subgingival crown margins on periodontal attachment and bone levels was insufficient for
any conclusion.

Clinical relevance: Based on the reviewed literature, crown margins should preferably be
placed in a supragingival position in order to favour maintenance of periodontal health.

Key words; crowns; gingivitis; alveolar bone loss; periodontal attachment loss;
periodontium; prosthodontics; systematic review.

Effekten av kronskarvens placering p de


parodontala vvnaderna.
En systematisk versiktsartikel med kliniska vervganden.
Sammanfattning:
Syftet med denna systematiska versiktsartikel var att studera effekten av kronskarvens
placering p angrnsande parodontala vvnader. Skningar i PubMed och Cochranebiblioteken frn 1965 fram till september 2008 genomfrdes. Dessutom genomsktes de
bestllda artiklarnas referenslistor fr att identifiera ytterligare relevanta artiklar. Alla typer
av studier var inkluderade i granskningen, men randomiserade kontrollerade studier (RCT)
prioriterades. Skningen var begrnsad till artiklar p engelska och svenska. Sammanlagt
identifierades 392 artiklar. Titlar och abstrakt var oberoende granskade av tv tandlkare (FA
& JD) fr att identifiera publikationer som uppfyllde inklusionskriterierna. Kappa-vrdet fr
verensstmmelse var 77,8%. 21 artiklar inkluderades i studien. Studiernas kvalitet
bedmdes enligt SBUs kriterier. Studierna skiljde sig markant t i urvalet av patienter och
metodik. Ofta rapporterades inte djupet av kronskarvens lge i frhllande till den marginala
gingivan. Resultaten frn inkluderade studier visade att subgingivalt placerade kronor ger
upphov till kad gingival inflammation (Evidensstyrka 3) men frhllandet mellan graden av
inflammation till djupet av kronskarvens placering kunde inte bekrftas. Det vetenskapliga
underlaget avseende potentiell effekt av subgingivalt placerade kronskarvar p parodontal
fsteniv och benniv var otillrckligt fr att konstatera ngra definitiva slutsatser.

Klinisk relevans: Baserat p genomgngen litteratur, br kronskarvar fretrdesvis placeras


supragingivalt fr att kunna optimera upprtthllandet av parodontal hlsa.

1.Introduction:
The goal of all prosthetic treatment is to obtain a satisfying functional and esthetical oral
status. Successful treatment outcome following prosthetic treatment relies on healthy hard
tissues but also on healthy soft tissues. Side effects as a result of the treatment may arise
during the prosthetic rehabilitation, for example because of the preparation and its location[2].
Preparation types may differ in a number of ways, due to factors related to type of tooth,
clinical crown height and position, tooth vitality, the degree of remaining tooth substance and
specific aesthetic needs. Positioning of restorative margins, with relation to both the gingival
and the osseous tissues, has long been a source of controversy in periodontics, and in dentistry
as a whole. Two different principles have been discussed in the literature. The first one
recommended that the preparation should be placed subgingivally [3], and the second one
proposed location of the preparation at or above the gingival crest[4]. G.V.Black [3]
advocated a scientific approach regarding cavity preparation and design. The concept of
"extention for prevention" was one of the principles recommended. As long ago as 1930 this
concept was attacked by Gottlieb & Orban[4]. They argued that the concept of "extention for
prevention" was harmful to the periodontal tissues. This argument was further investigated by
Le et al[2], who also stated that "the concept of extention for prevention" was wrong and
outdated. In recent years the biological aspects of fixed reconstructions have received a lot of
attention. The concept of biological width was first put forward by Ingber et al.[5], who
defined it as the minimum width at the gingival sulcus required to maintain a normal gingival
attachment. This definition was based on Garguilos study [6] of post-mortem specimens.
Their research documented that there is a proportional dimensional relationship within a small
range, 0.5 mm, between the dentogingival junction and the other supporting tissues of the
tooth; namely, between the crest of the alveolar bone, the connective tissue attachment, the
junctional epithelium, and sulcus depth. In their study, a total of 325 measurements were

taken from clinically normal specimens. The authors noted a great consistency in the
dimensions of the various components: (1) the sulcus depth was 0.69 mm, (2) the junctional
epithelium was 0.97 mm, and (3) the connective tissue attachment averaged 1.07 mm. The
combined dimension of the connective tissue attachment and the junctional epithelium,
therefore, averages 2.04 mm and has been considered as the biological width. These two
zones form a biologic seal around the neck of the tooth, that acts as a barrier to help prevent
migration of microorganisms and their products into the underlying gingival connective tissue
and supporting alveolar bone. Eissman et al. [7] recommended that restorations should not be
placed at or near the alveolar crest and that there must be 2 mm of root surface between the
alveolar crest and the restoration to provide for the biologic width. Wilson and Maynard [8]
stated that some distance of unprepared tooth structure should remain between the finish
line of the prepared tooth and the junctional epithelium .. this distance ideally should be 0.5
mm. .
It has been suggested that extension of tooth preparation apical to the base of the histological
crevice will violate the biologic width, and will disrupt the biologic seal. This extension might
allow bacteria and their products to penetrate the underlying connective tissue and alveolar
bone. The purpose of this systematic review was to study the effect of crown margin
positioning on surrounding periodontal tissues. In addition, some clinical cases illustrating the
issues discussed are presented.

2- Material and methods:


A literature search for relevant articles was performed, using the PubMed and Cochrane
libraries. Additionally, reference lists of relevant articles were hand searched. All types of
studies were included, but priority was given to randomized controlled trials (RCT). Review
articles were not included, but were used to find further relevant studies. For articles that
explored the same material, the most recent report was used. The results of a study had to be
applicable to the question posed, i.e., appropriate outcome measures, follow-up period and
study design. The outcome measures for various methods reflected changes in the degree of
inflammation, clinical attachment loss and bone loss. Conclusions were based on studies that
were judged to be of moderate or of high value, as described by SBUs guidelines [1].

2.1. Search strategy and study selection;


A literature search was conducted in MEDLINE (PubMed) and the Cochrane Central Register
of Controlled Trials (CENTERAL) from 1965 up to September 2008. The search was limited
to articles in English and Swedish language. Different combinations of relevant keywords
were used to identify articles. The detailed search strategy with the keywords used was as
follows;

"Crowns"[MeSH] AND "Gingivitis"[MeSH], 160 articles, (97 articles were in English, 1


article in Swedish).

"Crowns"[MeSH] AND "Alveolar Bone Loss"[MeSH], 161 articles, (151 articles were in
English, none were in Swedish).

"Crowns"[MeSH] AND "Periodontal Attachment Loss"[MeSH], 20 articles, (all in English,


no articles in Swedish).

"Crowns"[MeSH] AND "Periodontium"[MeSH] AND "Periodontal Diseases"[MeSH], 222


articles, (163 articles were in English, none were in Swedish).

"Crowns"[MeSH] AND "Dental Prosthesis"[MeSH] AND "Periodontium"[MeSH] AND


"Tooth Preparation, Prosthodontic"[MeSH] AND "Prosthodontics"[MeSH], 24 articles, (23
articles were in English, none were in Swedish).

The Cochrane Central Register was searched, using the following combinations: crowns and
periodontal attachment loss, crowns and gingivitis, crowns and bone loss, periodontal
and prosthetic, periodontium and crowns, (34 articles were found, all in English).

Figure 1 describes the process of identifying the included studies from an initial yield of 392
titles. Titles and abstracts were independently screened by two reviewers (Farid Akhlaghi &
Jan Derks) to identify publications that met the inclusion criteria. A total of 45 articles were
identified. Kappa score on agreement was 77.8%. All disagreements were resolved by
consensus discussion after examining the abstracts. The final sample included 38 articles
which were evaluated in full text by one reviewer (FA). Additional searches of reference lists
resulted in 14 articles. These articles were also ordered in full text and were studied, rendering
a total of 52 articles, from which 21 articles were included in the study.

Figure 1; Search strategy

Electronic search
392 articles with titles and abstracts

Independent evaluation by 2 screeners


45 articles identified
(Kappa score 77.8%)

7 articles discarded after consensus discussion

Included for full text,


38 articles

Further handsearching,
14 articles

Total full text,


52 articles

31 articles excluded
(Table 3)

Final number of studies included 21


(Table 1 and 2)

2.2. Reviewing and Assessing a Studys Quality:


For assessing the quality of articles, an assessment protocol was used as described in table 4.
Quality assessment of the studies was done using criteria according to SBU [1]. The protocol
formed the basis of compiling data on a studys design and findings, to assess its quality. The
reviewer (FA) judged the quality of each study as high, moderate or low. The results were
presented in different tables (Table 1 and 2).

A study was considered to be of high value if:


RCT with a well-defined study population.
Adequate outcome measures.
Adequate statistical analysis.
Performed and presented test for the reliability of the survey methodology, and evaluators
agreement.
Power calculation.
Adjusted for / discussed confounders.
The outcomes were assessed by blinded evaluators.
Explained / analyzed drop outs.

Moderate value:
A study was considered to have a moderate value if it did not meet all the requirements for a
study of high value but neither had the characteristics of studies with low value.

Low value:
The intervention and control group were not comparable.
Lack of adequate analysis in regard to study aim.
The population was not well defined.
Large number of, or unexplained drop outs.
Further important confounders, other than those reported, were suspected.
Systematic distortion of the results could be suspected.

2.3. Rating the Reports Conclusions According to Evidence Grade:


The scientific evidence (evidence grade) for each conclusion was rated as strong (1),
moderately strong (2), limited (3) or insufficient depending on the quality of the studies
assessed.
Strong scientific basis (Evidence grade 1).
At least two studies of high value among the total scientific evidence. If some studies are at
variance with the conclusion, the evidence grade may be lower.

Moderately strong scientific basis (Evidence grade 2).


One study with high value and at least two studies with moderate value among the total
scientific evidence. If some studies are at variance with the conclusion, the evidence grade
may be lower.

Limited scientific basis (Evidence grade 3).


At least two studies with moderate value among the total scientific evidence. If some studies
are at variance with the conclusion, the evidence grade may be lower.

Insufficient scientific basis (Other evidence).

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3- Results:

3.1. Subgingival crown margins increase gingival inflammation (Evidence grade 3).

The literature search resulted in 19 selected studies in which increased gingival inflammation
could be related to the subgingival placement of the crown margin. Four studies were
considered to be of moderate value [9-12] (Table 1) and fifteen studies of low value [13-27]
(Table 2). Sixteen studies showed that there was a greater degree of inflammation around
crowns with subgingival margins [9-12, 14-18, 20-25, 27]. Two studies of low value did not
demonstrate any clear relationship between subgingival placement of the crown margin and
the degree of inflammation [19, 26]. In the first of these two [26] (Table 2), the relationship
between the location of crown margins and gingival inflammation was examined on 12
molars with one half of the facial margin being supragingival and the other half subgingival.
No difference in gingival health was found using Les Gingival Index to assess gingival
tissue reaction. The authors reported no differences in terms of sulcus depth, gingival contour,
or plaque accumulation. It was concluded that fit and finish of full crown restorations may be
more important to gingival health than the location of the finish line. However, the
intracrevicular depth of the preparation was not reported in this study. In the second article of
the two mentioned above [19] (Table 2), forty-six full crown restorations in 28 patients were
evaluated according to gingival margin placement, to determine if there was a difference in
gingival inflammation. In this study, highly motivated patients from a private practice were
selected and the results did not show any difference between supragingival and subgingival
crown margins. Furthermore, in an additional study of low value, crown margins located just
at the gingiva had more inflammation compared to both supra- and subgingival crown
margins [13] (Table 2).

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The scientific evidence grade 3 for the statement Subgingival crown margins increase
gingival inflammation is based on four studies of moderate value, according to the previous
description. A short summary of these four studies is as follows:

Studies of moderate value. (Table 1)


Four studies of moderate value [9-12] indicated a greater degree of inflammation around
crowns with subgingival margins. In a randomized 1-year clinical trial by Reitemeier [12]
(Table 1), the impact of posterior crown margin placement on gingival health was
investigated. 10 dentists examined 240 patients with 480 metal ceramic crowns. Results from
this study indicated that supragingival placement significantly lowered, and subgingival
placement significantly increased the probability of bleeding compared with control teeth.
The authors were able to demonstrate that the risk of bleeding around subgingival crown
margins was approximately twice as high compared to similar crowns with supragingival
crown margins (Odds ration 2,2). In a prospective 2-year clinical investigation by Gunay et
al.[11] (Table 1), 116 teeth were followed after crown therapy. Results from this study
showed that PBI (papillary bleeding index) was higher in the group of patients that had crown
margins placed subgingivally, and the authors concluded that the location of the restoration
margins within the zone of biologic width may impair periodontal health. In a 1-year
prospective clinical study by Flores-de-Jacoby et al. [9] (Table 1), the effects of crown margin
location on periodontal health were studied 68 weeks and 1 year post insertion. In this study
a total of 693 surfaces of crowned teeth were examined, out of which 135 had the crown
margin at the gingival crest, 415 showed a supragingival and 143 a subgingival margin. The
results from this study showed that subgingival location of crown margins provided the
highest scores of Gingival Index. In a 15-year longitudinal study by Valderhaug et al [10]
(Table 1), a total of 102 patients with 108 fixed bridges were followed over 15 years. Gingival
Index scores 2 and 3 were more frequent in the group that had received crowns. This was

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even more pronounced around crowns with subgingival placement. Valderhaug [28, 29]
reported similar results in previous studies from 1976 and 1980.

3.2. The scientific evidence is insufficient to support the statement the deeper the
placement of the crown margin, the higher the degree of inflammation.

Three studies were identified that addressed the question of whether the depth of subgingival
margin placement relates to the degree of gingival inflammation. One study was of moderate
value [11] (Table 1) and two of low value [14, 17] (Table 2). All these three studies indicated
that the deeper the placement of the crown margin, the higher the degree of inflammation.
The only study that could be considered for evidence assessment was an investigation by
Gunay [11]. It was a prospective 2-year clinical trial, in which PBI (Papillary Bleeding Index)
was analyzed before, and 3, 6, 12 and 24 months after crown therapy on 116 teeth. After
preparation, the distance between the restoration margins and the alveolar crest was
registered. Teeth were divided into 3 groups: Group 1, less than 1 mm between crown margin
and alveolar bone, Group 2, 1-2 mm and Group 3, more than 2 mm. The highest PBI increase
was noted in Group 1. The most significant increase in Group 1 was observed between 3 to 6
months after preparation.
The scientific evidence for the statement The deeper the placement of the crown margin, the
higher the degree of inflammation is therefore graded as insufficient, because no more than
one study with moderate value was identified.

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3.3. The scientific evidence of the effect of crown margin placement on periodontal
attachment and bone levels is insufficient for any conclusion.

Five studies were identified that described the relationship between crown margin location
and changes in attachment level. Two of these studies were of moderate value [11, 30] (Table
1) and three of low value [21, 25, 31] (Table 2). In one study of moderate value [11] (Table 1)
marked loss of attachment did not occur during a 2-year examination period. A second study
of moderate value [30] (Table 1) showed that intracrevicular crown placement resulted in
attachment loss despite careful supportive therapy. In this study, crowned teeth had an
average of 0.71 mm more attachment loss than control teeth during a 12-month period.
However, the author pointed out that the observed attachment loss at crowned teeth was
probably not of clinical relevance.
In a 26-year longitudinal study by Schatzle [32], the relationship between dental restorations
and periodontal health was investigated in 160 patients. This study suggested that the
increased loss of attachment found in teeth with subgingival restorations started slowly, and
could be detected clinically 1 to 3 years after the fabrication and placement of the restorations.
Since this study included only fillings and not crowns, it was excluded, and could not be
considered for evidence assessment.
Attachment loss in connection with subgingival crown margins was also reported in two
studies by Valderhaug [28, 29]. Both of these studies showed slightly higher attachment loss
around subgingival crown margins after five and ten years when compared to teeth with
margins at or above the gingival crest. Mean differences in clinical attachment levels were
found to be 0.7 mm after ten years [29]. However, the author did not provide significance
testing. In a 15-year follow-up of the same material [10] (Table 1), no analysis was found
regarding changes in attachment level. Because of the inadequate analysis, the studies [28, 29]

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were excluded and could not be considered for evidence assessment of attachment level
changes.
When evaluating changes in bone level, three studies were identified which discussed the
relationship between subgingival crown margins and bone loss [10, 11, 31]. Two studies were
found to be of moderate value [10, 11] (Table 1) and one of low value [31] (Table 2). Based
on histological observations, Tarnow et al. [31] (Table 2) showed a correlation between
subgingival crown margins and bone loss. The two remaining studies failed to show any
relationship using intraoral radiographs [10, 11]. One of them was a 15-year longitudinal
study by Valderhaug [10] (Table 1), in which the bone loss could not be related to the location
of the crown margin at the time of placement. In another study by Gunay [11] (Table 1), no
alterations of bone levels could be diagnosed on radiographs during the 2 years of
investigation. It is important to note that standardized techniques are necessary to guarantee
comparable radiographs, and due to the fact that these studies had different designs, it was
impossible to draw any conclusions regarding the changes in bone level.

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4- Discussion:

The limited number of studies in the analysis, and the diversity of the approach in determining
the influence of crown margins on periodontal tissue health, have made meaningful synthesis
of the evidence difficult. No study of high value could be found. Only a few studies of
moderate value were identified and most studies that could be related to the issue were of low
value (Table 1 and 2). However, several of the selected studies concluded that subgingival
crown margin could contribute to gingival inflammation [9-12, 14-18, 20-25, 27]. Statistically
significant differences in regard to mean Le and Silness Gingival Index (GI) values between
crowned and control teeth were observed in several patient populations. It is important to note
that GI values are an ordinal value, which means that a greater index value is correlated with
increased inflammation. Since the data is not continuous, a score of 2 does not mean that the
periodontal tissue was twice as inflamed as a score of 1. This must be taken into account in
order to reduce the risk of "bias". In a 15-year longitudinal study by Valderhaug et al. [10]
(Table 1), the authors described the relationship between gingival inflammation and the crown
margin placement by reporting the results in terms of frequencies of index score, and thus
reduced the risk of "bias".
Another consideration is that the term subgingival refers to the placement of a restoration
margin between the free gingival margin and the alveolar crest. Wilson and Maynard [8]
created the term intracrevicular restorative dentistry. It is defined as placement of
restorative margins within the gingival sulcus and above the junctional epithelium or
epithelial attachment. Because the term subgingival often refers to margins extending
beyond the gingival crevice, the term intracrevicular is more suitable to use. However, in
most studies factors such as intracrevicular depth of crown margins were frequently not
reported. Only three studies could be identified that investigated the effect of crown margin
depth on periodontal health [11, 14, 17]. In a study by Newcomb [17], 59 patients with 66

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anterior veneer crowns, with subgingival labial margins, were examined. The results from this
study showed that the degree of inflammation was related to the location of the crown margin.
There was a clear negative correlation between gingival inflammation and the distance of the
crown margin from the base of the crevice, and a strong positive correlation between gingival
inflammation and the distance of the crown margin below the gingival crest. Deeper
placement of the crown margin resulted in more gingival inflammation. Since this study was
cross-sectional, it was excluded, and could not be considered for evidence assessment.
When evaluating gingival inflammation and changes in attachment and bone levels, variables
such as initial health of the periodontium, intracrevicular depth of the restoration and
adaptation of the restoration margin are important factors for accurate assessment of the
outcome. Frequently, studies failed to report the exact techniques how these were assessed. In
addition, side effects of the prosthetic treatment per se might have significant influence.
Periodontal tissues may be affected by the preparation of the tooth, impressions,
provisionalization and cementation. It is also important to note that teeth generally have
received extensive direct restorative therapy that may have included intracrevicular
restorations before crown therapy. It is therefore suggested that future clinical investigations
document the tooths restorative history and initial periodontal status, so that each crowned
tooth serves as its own control. A further consideration is that a small but statistically
significant difference in terms of clinical attachment and bone levels may be of minor or no
clinical relevance. Some studies [10, 11] have evaluated bone levels based on radiographic
findings. Standardized radiographic methods are a prerequisite to properly assess these, but
were not always used. This may question the validity of the reported results.
The aim of the present study was to evaluate the effect of crown margin positioning on
surrounding periodontal tissues. The situation around implants might be considered as
somewhat similar to crowned teeth. The dimension of the peri-implant mucosa has been

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demonstrated to resemble that of the gingiva around teeth and includes a junctional epithelium
and a connective tissue compartment [33, 34] In so-called 2-part implants, the
abutment/fixture borderline is located in the connective tissue portion, and several studies
have shown that the gap between the intraosseous and transmucosal components have a
detrimental effect on the surrounding connective tissue and marginal bone level [35-39]. The
smaller the gap, the closer the position of the marginal bone to the abutment-implant
interface[40-43]. This condition does not exist around natural teeth and therefore a
comparison is not possible from this point of view between teeth and implants. The conditions
around subgingival crown margins are more comparable to submucosally placed implant
crown margins, because most likely both interface the epithelium. Little is known about the
effect of implant crown margin positioning on surrounding peri-implant tissues. Some studies
have shown that in patients with appropriate oral hygiene, the intracrevicular position of the
restoration margin did not appear to adversely affect peri-implant health [44, 45], while SBI
score (sulcus bleeding index) decreased as the location of a crown margin went from sub- to
supragingival position [46]. In addition, cement-retained crowns revealed a consistently
higher degree of sulcus bleeding than screw-retained crowns [46]. Further research is
necessary to understand the effect of implant crown margins on peri-implant tissues.

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5- Conclusion:

Evidence suggests that subgingival crown margins increase gingival inflammation


(Evidence grade 3).

The scientific evidence is insufficient to support the statement the deeper the placement of
the crown margin, the higher the degree of inflammation.

The scientific evidence of the effect of crown margin placement on periodontal attachment
and bone levels is insufficient for any conclusion.

Based on the reviewed literature, crown margins should preferably be placed in a


supragingival position in order to favour maintenance of periodontal health. Subgingival
margin placement, however, may not always be avoided. If this is the case, care must be taken
to involve as little of the periodontium as possible.

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Table 1: Articles of strong and moderate value

Authors

Type,

Year

Duration

Flores-de-

Prospective

Jacoby et

1-year clinical

al.[9]

study

Sample

Outcome

Results

Evidence

variables
19 pat.
693 teeth

PI

Subgingival crown margins resulted in highest

Moderate

scores of GI.

GI

GI at margins ending subgingivally > at the gingival

PD

margin> supragingivally

PI

GI scores 2 and 3 more frequent in crowned

1989
Valderhaug
et al.[10]

Longitudinal
study, 15 years

102 pat.
108 bridges

1993

teeth, mainly when the crown margins are located

GI
PD

subgingivally.
No statistical differences in bone loss between
control and crowned teeth.

Bone level

Moderate
Changes in
attachment levels
reported in previous
studies in 1976 and
1980.

Gunay
et al.[11]
2000

Prospective

41 pat.

2-year clinical

116 prepared

study

teeth

HI

PBI higher at subgingival crown margins, the

Moderate

deeper the placement the higher the increase of

PBI
PD

PBI (mainly during first 6 months).


Attachment loss did not occur in any group.
No radiographic alterations of bone levels.

PAL
Bone level
Reitemeier
et al.[12]

RCT,
1 year

240 pat.
480 metal ceramic

PI

Moderate

probability of gingival inflammation.

SBI

crowns

2002

Subgingival crown margins increase the

SBI twice as high as at intrasulcular posterior


crown margins compared with supragingival
margins.

Koke

Prospective

11 pat.

CAL

et al.[30]

1-year clinical

44 teeth,

Ging.

study

Uncrowned

recession

2003

controls

Crown placement was identified as a major factor


for attachment loss and development of gingival
recession.

Moderate

Observed attachment loss probably not of clinical


relevance.

( PI= Plaque Index, HI=Hygiene Index, GI= Gingival Index, PD= Probing Depth, CAL= Clinical Attachment Level, PBI= Papillary
Bleeding Index, GCF= Gingival Crevicular Fluid)

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Table 2: Articles of low value


Authors

Type,

Sample

Duration
Larato[27]

Cross-sectional

1969
Marcum

Outcome

Results

Evidence

variables
Gingivitis

More gingivitis around subgingival margins.

Low

66 gold crowns in

Gingival

Highest rate of inflammation with margins

Low

6 dogs

inflammation

located above and below the gingival crest. Least

(Different

inflammation with margins located at the gingival

histological

crest.

268 pat.
546 teeth

Histological

[13]

animal study,

1967

3 months

parameters)

Karlsen

Histological

[14]

animal study,

1970

2-12 months

2 dogs and

Gingival

Decrease of gingival integrity with subgingival

3 monkeys

inflammation

placement.

Low

More risk for inflammation with deeper


preparation and less accurate fit of crowns.
Similar gingival conditions around supragingval
restorations and unoperated teeth.

Silness[15]

Cross-sectional

1970

385 teeth/
contralateral

PI
GI

GI more frequent in crowned teeth with

Low

subgingival margins.

PD
Bergman

Longitudinal

et al.[16]

2-year clinical

1971

trial.

Richter &

Prospective

30 pat.

PI

GI tended to be higher when crown margins were

61 crowns

GI

subgingival.

Low

PD

12 crowns

PI

Ueno[26]

study,

GI

1973

3 years

PD

No differences in gingival health, sulcus-depth,

Low

plaque accumulation between supra- and


subgingival margin placement.
The fit and finish of full crown restorations may
be more significant than the location of crown
margins.

Newcomb

Cross-sectional

[17]

59 pat.
66 crowns with

PI

of 8,23 months/

Low

the gingival crevice, more severe gingival

GI

average age

1974

When subgingival margins approached the base of

PD

Uncrowned

inflammation.

Least inflammation when subgingival crown


margins at gingival crest or just into the gingival
crevice.

controls

Strong negative correlation between gingival


inflammation and distance of crown margin to the
base of crevice.

Janenko &
Smales[18]
1979

Cross-sectional

126 pat.
101 PJC crown
88 PBM crown

PI

Gingivitis higher around crowns than at controls.

GI

Association between gingivitis and subgingival

Low

marginal placement.

( PI= Plaque Index, HI=Hygiene Index, GI= Gingival Index, PD= Probing Depth, CAL= Clinical Attachment Level, PBI= Papillary
Bleeding Index, GCF= Gingival Crevicular Fluid)

21

Table 2 continued
Authors

Type,

Sample

Duration
Koth[19]

Cross-sectional

1982

Outcome

Results

Evidence

variables
A-38 full crown

Crevicular

Same degree of gingival inflammation around

restorations in 26

Fluid,

restored and non-restored teeth.

patients.

Gingival

No differences between supra- and subgingival

inflammation

placement.

PI

Crowned and unrestored teeth showed major

Low
only highly
motivated patients

B-46 full crown


restorations in 28
patients

Grasso

Cross-sectional

291 pat.

et al[20]

GI

1985
Muller[21]

Cross-sectional

1986

Tarnow
et al.[31]

Low

differences in PI, GI and PD. The major adverse

5 pat.
79 teeth

Histological
examination.

2 pat.
13 teeth

1986

effects on the periodontium resulted from the

PD

placement of a crown.

PI

GI slightly higher at teeth with crown margins at

GI

the gingival margin.


Minor or no clinical signs of inflammation at

PD

supragingival crown margins.

CAL

No significant alteration of attachment level.

Histological

Reformation of new supracrestal attachment within 1

observations,

week after insertion of temporary crowns with finish

changes in

line below the base of crevice.

bone and

Clinical gingival recession (0,9 mm average with

attachment

0,4-1,2 mm range) was observed within 2 weeks, and

level.

Low
No subgingivally
located margins

Low

an average recession of 1,2 mm was recorded within


8 weeks.
Recession mechanisms were activated within the
first 7 days. Reformation of intracrevicular and
junctional epithelium occurred. The reformed
junctional epithelium was located apical to the finish
line bevel and there was crestal bone resorption.

Orkin

Cross-sectional

PI

355 subgingival

et al.[22]
1987

Bader

423 pat.

Cross-sectional

Gingival tissues bleed 2.42 times more frequently

68 supragingival

GI

higher chance of gingival recession. Crowns with

Untreated controls

Gingival

supragingival margins did not differ significantly

recession

compared with contralateral teeth.

PI

Increased GI when subgingival placement of

831 pat.

Low

with subgingival margins and have a 2.65 times

Low

crown margins.

et al.[23]

GI

1991

PD

( PI= Plaque Index, HI=Hygiene Index, GI= Gingival Index, PD= Probing Depth, CAL= Clinical Attachment Level, PBI= Papillary
Bleeding Index, GCF= Gingival Crevicular Fluid)

22

Table 2 continued
Authors

Type,

Sample

Duration
Pippin

Cross-sectional

60 pat.

GI

Evidence

PFMs.

Gingival bleeding index values increased as the

Low

margin index scores increased, with the highest

GCF

60 veneers and 60

1995

Results

variables

120 restorations

et al.[24]

Outcome

PD

values recorded for subgingival margin


placement.
(Increased GCF when margins placed closer to
and below the gingiva. Higher GCF scores for the
PFMs than the corresponding values at veneers).

Giollo
et al.[25]
2007

Retrospective

40 pat.

clinical trial,

40 ceramic

3-5 years

crowns
Uncrowned
controls

PI

BI significantly higher at crowned teeth, specially

Low

with subgingival placement of margins.

BI
PPD

Statistically significant differences were not


observed in CAL between crowned and control
teeth, however more risk for attachment loss with

CAL

subgingival crowns.

( PI= Plaque Index, HI=Hygiene Index, GI= Gingival Index, PD= Probing Depth, CAL= Clinical Attachment Level, PBI= Papillary
Bleeding Index, GCF= Gingival Crevicular Fluid)

23

Table 3, Excluded articles

Authors

Year

Reason

Silness[47, 48]

1970

See later study by Silness[15] 1970 part III.

Renggli & Regolati[49]

1972

Only fillings.

Renggli[50]

1974

Only fillings.

Bellos[51]

1974

General aspects, insufficient analysis.

Silness[52]

1974

Observations on pontics.

Valderhaug & Birkeland

1976

See later study by Valderhaug[10] 1993.

Valderhaug & Heloe [53]

1977

See later study by Valderhaug[10] 1993.

Valderhaug[29]

1980

See later study by Valderhaug[10] 1993.

Romanelli[54]

1980

General aspects, no individual analysis.

Silness[55]

1980

General aspects, insufficient analysis.

Jenkins[56]

1981

General aspects, no individual analysis.

Dragoo & Williams[57]

1981

Discussion about crown preparation procedure.

Dragoo & Williams[58]

1982

Discussion about temporary crowns.

Rohner et al.[59]

1983

Only radiographic analysis without any information about

[28]

restorations type or margin placement.


Carnevale et al.[60]

1983

Discussion about tooth preparation without crown placement.

Behrend[61]

1984

General aspects, no individual analysis.

Nevins & Skurow[62]

1984

General aspects, no individual analysis.

Lesan[63]

1987

Does not address the question, no comparison between


sub/supragingival margins.

Brandau et al.[64]

1988

Does not address the question. Insufficient analysis

Bader et al.[65]

1991

No comparison between subgingival and supragingival margins.

Tiwarri et al.[66]

1992

No comparison between subgingival and supragingival margins.

Wang et al.[67]

1993

No comparison between subgingival and supragingival margins.

Sherif et al.[68]

1993

Does not address the question. Discussion about surface materials.


No comparison between sub/supragingival.

Shavell[69]

1994

Does not address the question. General aspects about preparations


and impression techniques.

24

Table 3 continued

Authors

Year

Reason

Mojon et al.[70]

1995

No information about crown margin placement.

Kois[71]

1996

General aspects.

Swartz et al[72]

1996

No information about crown margin placement.

Schatzle et al.[32]

2001

Only fillings.

Broadbent et al.[73]

2006

Does not address the question. No information about margin


placement.

De Backer et al.[74]

2007

Does not address the question. No comparison between supra- and


subgingival margins.

25

Clinical considerations and own experience;


1. Working subgingivally means a traumatisation of soft tissues which may be temporary or
permanent. The use of special instruments to protect / keep away the gingiva during preparation
(Zekrya Gingival Protector) can reduce these risks.
2. Working subgingivally means increased difficulty of the preparation procedure, and therefore
automatically a risk of an inadequate fit of the restoration. This, in turn, may lead to increased
possibility of plaque retention around the crown margin, and increased risk of mechanical irritation of
the gingiva.
3. To place crown margins subgingivally means it is more difficult to control the fit of the crown and
detect possible caries lesions.
4. Deeper placement of crown margins with traditional cementation (Phosphate cement/glasionomer
cement) gives a higher degree of inflammation.
5. Very subjectively, I would like to point out the following. Because traditionally cemented crowns
stop the incident light, the area closest to the apical part of the crown margin appears darker. This is
caused by the absence of incident light, which is blocked by the crown. In normal conditions, and
during our daily clinical work, our assessment of a "healthy" gingiva is usually based on the colour of
the gingiva. Brighter gingiva is often considered "healthy" and darker gingiva considered "diseased".
This dark zone can be detrimental not only from an aesthetic but also from a diagnostic point of
view, and should be considered during the examination. In the 80`s, several studies showed that Dicorcrowns had better gingival "health" compared with the traditional crowns. Dicor-crowns were the first
ceramic crowns which were translucent. When translucent cement was used the cervical part of the
crown had a brighter appearance. Was it perhaps this that led to a healthier looking gingiva?

Case 1:
The patient is practising good oral hygiene but still the gingiva around the subgingivally placed crown
on 11 shows gingivitis. Soft tissues around the non-treated tooth 21 are perfectly healthy. It is a quite
common clinical finding that soft tissues around subgingivally placed crowns show more gingivitis
than around non-prepared teeth under the same oral hygiene conditions.

Before probing.
Note the colour on 11 cervically.

26

After gentle probing.


Note the bleeding around 11.

Case 2:
Inadequate oral hygiene in combination with bad
fit and deep subgingival placement of the
finishing line results in pronounced gingivitis.

Case 3:

Crowned tooth 21 shows more


gingival inflammation than noncrowned,

neighbouring

teeth

even though the finishing line is


supragingival at the time of the
picture. The reason for this is
probably the increased risk for plaque retention
apically to the finishing line.

27

Case 4:
The originally cemented crown was placed subgingivally showing the typical inflammation of
subgingival margin. After an esthetic gingivectomy had been performed a bonded crown was placed
with the finishing line at the gingival level. Healthy gingiva and better esthetics are the result.

The crown on 11 has been treated five times by different


dentists. The colour is acceptable but the crown appears
too short and the gingiva is inflamed.
The crown was lengthened surgically (by Prof. Jan
Wennstrm). A new 'bonded porcelain crown' was made.
Dr. S. Toreskog

The colour, the length of the crown and gingival health


are improved. The finishing line is at the level of the
gingival crest.

Dr. S. Toreskog

Case 5:
The cemented crown 11, where the gingiva has
receeded, illustrates the darkening effect of the root
surface by the crowns blocking of incident light. This
also affects the colour of the gingiva since light is not
transmitted through the crown. As a result, the gingiva
looks slightly inflamed. Note that tooth 11 is vital.

This crown was cemented with phosphate cement and the cement has now been washed away in the
margin with a more pronounced plaque accumulation as a result.

Note the healthy gingival and the adequate colour of the


restored tooth after a bonded translucent crown has been
placed slightly supragingivally. The gingiva around 11
looks similar to the gingiva around 21 after the new
restoration was inserted.

28

Case 6:

28-year

old

woman

with

discolourations in the upper and


lower front, namely on 11, 21, 31
and 41. According to the patient, the
damage on the tooth surfaces was
due to too high consumption of
citric fruits during long periods of
time.

Previous treatment: 11 and 21 were treated with composite. 31 and 41 were treated with metal-ceramic
crowns. The sole reason for crown therapy on 31 and 41 was the discolouration of these teeth. The
patient was not satisfied with the esthetical result and wanted new restorations. She has a very good
oral hygiene. Visually, the gingiva seems healthy but examination by probing revealed gingivitis
around 31 and 41.

Porcelain veneers on 11 and 21 have been placed slightly


supragingivally. New porcelain crowns have been bonded
on 31 and 41 with subgingival finishing lines due to the
previous treatment.

This case illustrates that the gingiva around subgingivally placed cemented crowns may look
acceptable but there might still be signs of inflammation when the pockets are probed. However, the
bonded porcelain veneers placed deep subgingivally showed no signs of gingivitis after probing.

29

Case 7:
Teased at school because of the yellow colour of 21, which is
seriously affected by 'enamel hypoplasia'. 22, which has been treated
with composite, has also been affected, but not as much.
Note the inflamed gingiva caused by the absence of glossy enamel
and the accumulation of plaque at the rough dentine surface.

Dr. S. Toreskog

Tooth surface prepared subginivally so that the


anatomy of the tooth could be restored with the
bonded porcelain.

Dr. S. Toreskog

The bonded glossy porcelain has repositioned the


gingival to its natural position and the finishing
line is now at the gingival level even if it was
placed subgingivally (the gingiva has intentionally
been repositioned)

Dr. S. Toreskog

This case shows that a rough tooth surface often will result in more plaque accumulation than a
smooth ceramic surface and will thus cause more inflammation. When the surface is restored with
bonded veneers, even though they might be subgingivally placed, the inflammation will recede. This
case also illustrates beautifully that the right anatomy of the buccal veneer will reposition the marginal
gingival to its right place.

30

Case 8:
An interesting aesthetic case, from the standpoint
that the patient lost her centrals when she was 10
years old and the entire quadrant 1 and 2 was moved
orthodontically one step forward.

Dr. S. Toreskog

Before treatment.

Gingivectomy of teeth in position 13 and 23 (teeth


14 and 24) by Prof. Jan Wennstrm

After treatment.

From the standpoint of the present discussion it is


interesting to compare the colour and texture of the
gingiva around the 6 anterior teeth four years after
bonding. All teeth have been bonded but the bonded
restorations in position 13, 12, 22 and 23 (teeth 14,
13, 23 and 24) have been bonded at the gingival
level and the translucent cervical porcelain is about
0.2 mm thick letting the background colour of the
tooth shine through. The metal ceramic crowns on
the teeth in position 11 and 21 (teeth 12 and 22)
have been bonded subgingivally and the result four

Dr. S. Toreskog

years later is quite dramatic.


This case illustrates that bonded veneers/crowns placed supragingivally or at the gingival level are
superior to subgingivally placed and bonded traditional metal/ceramic crowns when it comes to
gingival response. (A 4-year clinical follow up)

31

General comments on crown margin placement:


What is the reason that we sometimes place the crown margin subgingivally?
The answer to this question is pertinent because the whole above-mentioned discussion would be
unnecessary, if we had been able to place the crown margin supragingivally with all kinds of crown
treatment. So why subgingivally?
1. Traditional crowns (Metal/Ceramic, Procera, Inceram, Lava), which are retained with traditional
cement (phosphate cement, glasionomer cement), stop the incident light so dramatically that the area
apical to the crown margin becomes very dark. Therefore, the margins of these crowns are usually
placed subgingivally for aesthetic reasons. Even if these types of crowns are cemented/bonded with a
translucent composite cement, they will stop incoming light to various degrees due to the different
opacities of their respective cores. Unfortunately, the crown margin becomes visible after a period of
time due to gingival recession, or because of continued tooth eruption which means that the cervical
area will be very unaesthetic.
2. Risk for caries? Yes, this was a big argument 50 years ago, but with today's caries prevention and
increased dental care, this is an outdated argument.
3. Problems with retention? Yes, this was a relevant factor when the crown was manufactured and
cemented traditionally. Today, this argument is not as relevant any more, due to the development of
different bonding agents.
The conclusion is therefore that, if possible, the crown margin should be placed supragingivally (using
a bonded translucent porcelain technique and a translucent cement).

Acknowledgement
I would like to thank Dr. Jan Derks for the assistance regarding the database screening and Dr. Sverker
Toreskog for the clinical pictures.

32

Table 4. Data Extraction Form.


Frsta frfattare:

Titel:

Tidskrift:

r/volym/sidor

Beskrivning av studien:

Typ av studie/studiedesign:

Primr frgestllning av studien:


-

parodontit

protetik

Material

Estetik

Annat (namnge)

Underliggande population och vrdmilj:


-

Vrdmilj

Typ av vrdgivare

rtal fr studiens genomfrande

Land/vrldsdel

Kommentarer

Patientkarakteristiska:
-

Antal individer/tnder (lder, mean/range)

Antal kvinnor (lder, mean/range)

Antal mn (lder, mean/range)

Kontrollgrupp

Bortfall frn ursprungpopulationen

Bortfall av data under studien

Kommentarer

33

Finns uppgift om:


-

Allmn hlsa

Tobaksbruk

vrigt, Kommentarer

Uppfljningstid:

Intervention;

Frbehandling/typ:

Protetisk behandling/ typ:

Material/ typ:

Kommentarer:

Effektmtt;

Frndringar i plackfrekomst

Gingival inflammation

Frndring i fickdjup

Frndring i fsteniv

34

Frndring av benvvnad

Frndring av mjukvvnadens lge

Tandmobilitet

Frlust av tnder

Inklusionskriterier:

Exklusionskriterier:

Skstrategi, skord:

35

Resultat enligt frfattarna:

Konklusion enligt frfattarna:

Sammanfattande bevisvrde:

Hgt
Medelhgt
Lgt

Sammanfattande kvalitetsomdme:

Ytterligare kommentarer:

Granskare:

Datum:

36

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