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Interdisciplinary interface
between fixed prosthodontics
and periodontics
J A A F A R A B D U O & K A R L M. L Y O N S
Prosthodontic treatment should enhance patient is an increase in biological complications (26). The
comfort, function, health and esthetics. Of equal contemporary literature pertaining to fixed
importance is that treatment should not induce dam- prosthodontic treatment reflects the close relation-
age to the periodontal structures. It is imperative that ship with periodontal parameters and promotes the
periodontal tissues are healthy before prosthodontic concept of a biologically driven prosthodontic prac-
treatment commences, and additional periodontal tice (30, 65, 74).
treatment is commonly indicated to facilitate To ensure patient satisfaction, multidisciplinary
improved prosthodontic treatment outcomes. Pre- treatment is essential. This includes simultaneous
dictable prosthesis longevity is dependent on the and coordinated periodontal and prosthodontic care
cleansability of the restored tooth or teeth and on the to ensure a favorable outcome for patients with com-
relationship between prosthodontics and periodon- plex prosthodontic and/or periodontal presentations.
tics when planning and performing the prosthodontic It is the purpose of this article to outline the areas of
treatment. overlap between prosthodontics and periodontics
Nowadays, patients are esthetically conscious and that dictate the interdisciplinary treatment. Six peri-
have high dental expectations. Furthermore, clinical odontal–prosthodontic interfaces will be discussed in
procedures in dentistry appear to be increasingly detail as they relate to conventional fixed
market-driven. When these factors are combined with prosthodontic treatment:
the regular release of new dental materials and fabri- gingival level and contour.
cation techniques, clinicians are confronted with a edentulous area.
plethora of treatment options to address a specific magnitude of periodontal support.
dental problem. As the mean age of the population is abutment tooth preparation.
increasing and the tendency is for teeth to be prosthesis morphology.
retained, it is now common to encounter difficult prosthesis material.
clinical presentations, such as severe tooth-tissue
loss, advanced periodontal disease, tooth loss and sig-
nificant esthetic problems. Prosthodontic treatment Gingival level and contour
must provide a solution to the dental problems with
acceptable longevity. Gingival morphology is critical in prosthodontics
Historically, major emphasis has been placed on because it determines the outlines and extensions of
the mechanical features of prostheses. Although sev- the dental prosthesis (30) and can contribute signifi-
eral laboratory studies have shown such features to cantly to the final dental and facial esthetics (68, 132).
be important, a large proportion of the clinical com- Several authors have referred to the gingival morpho-
plications in fixed prosthodontics have been biologi- logical variables that can influence all phases of
cal in nature, such as caries and periodontal disease prosthodontic treatment (72, 92, 132) (Table 1). Nev-
(38, 48, 62, 134). Furthermore, it appears that as the ertheless, there is controversy regarding the impor-
complexity of the prosthodontic work increases, there tance of these variables in relation to oral health and
40
Prosthodontic and periodontic interface
Table 1. Gingival morphological variables Although the exact dimensions have been disputed
(94), for the last few decades the biologic width has
Variable Description and ideal criteria
been used as a guide for clinicians. During margin
Attached gingiva Continuous and with an even width placement for fixed prostheses, prosthodontists
of at least 2 mm should ideally follow the gingival contour and not
Gingival display Varies between individuals extend more than 0.5 mm into the sulcus (13, 69, 73).
Dependent on the lip line during Likewise, periodontists use the dimensions of the bio-
function: logic width when recontouring the gingival level (30).
High lip line: most challenging to As a biologic width of 2 mm has been widely
manage clinically
accepted, it has been recommended that at least
Average lip line: considered to be
the most esthetic 3 mm of sound tooth structure should be preserved
Low lip line: the least demanding between the prosthesis margin and alveolar bone. In
Color and Pink and firmly bound down to the situations where such dimensions cannot be
surface texture necks of the teeth achieved, increases in gingival inflammation, attach-
The surface texture of the gingival ment loss (19, 96, 106, 151) and gingival recession (39,
tissues is stippled, with an 129, 146) are frequently observed.
orange-peel appearance There are several periodontal procedures that can
Interdental Firm and knife-edged modify the gingival contour. They can be classified
papilla into two categories: subtractive; and additive. To
Occupies the interdental space made
by a contact point and the interdental select the most suitable approach for any situation, a
embrasure comprehensive extra-oral and intra-oral examination,
Contour Symmetrical supplemented with radiographic analysis, is neces-
sary. It is critical to evaluate the evenness of the gingi-
Follows the contour of the upper lip
val margin and the extent of the planned gingival
The gingival height should match on the modifications. If periodontal disease is present, any
central incisors and canines
necessary treatment can be included with the gingival
The gingival height on the lateral incisor contour modifications. The initial tooth anatomy
should be slightly more incisal
should be evaluated to determine the impact of treat-
(about 1.5 mm) than on the central
incisors
ment on esthetic, hygiene and biomechanical
requirements. Furthermore, the presence of skeletal
The peak of gingival margin convexity
abnormalities can affect the treatment selection. For
should be positioned distal to the long
axis of the tooth on the labial surface complex cases, clinicians should consider additional
of the maxillary anterior teeth diagnostic tools that can provide the patient with an
insight into the expected outcome (79–81).
41
Jaafar Abduo & Karl Lyons
elimination of periodontal pockets (43). Esthetically, enlargement, and the teeth are intact, it is possible to
subtractive methods can increase tooth display and confine the surgery to the soft tissues without altering
resolve uneven gingival contour. the alveolar bone crests. In such cases, the cemento–
Nevertheless, these procedures can result in loss of enamel junction will be used as a landmark for the
hard and soft tissues, as well as an increase in root contour modifications (18). As long as the root surface
sensitivity and in the crown-to-root ratio. When sev- is not exposed, additional prosthodontic procedures
eral teeth are involved, there will be a risk of loss of are not likely to be necessary.
interdental papillae and development of black trian- A clinical dilemma arises when simultaneous crown
gles. Alteration of the tooth-emergence profile and lengthening is indicated in conjunction with
narrowing of the cervical tooth portion will accentu- prosthodontic treatment. In terms of treatment
ate this. Crown-lengthened teeth have also been sequencing, which treatment should be completed
found to be more susceptible to recession and furca- first? In cases of confined and minimal biologic width
tion involvement compared with control teeth (28). violation in less esthetically demanding situations, a
An increase in the crown-to-root ratio might induce tooth can be prepared to the final extension and
tooth mobility; however, there is a lack of compelling restored with a provisional prosthesis. Subsequently,
evidence to support this assumption (88). If subtrac- the preparation extension will guide the periodontist
tive methods are indicated to manage gingival hyper- when recontouring the soft and hard tissues (131).
plasia without osseous modification, it is likely that a This will ensure that the crown-lengthening proce-
fixed prosthesis will not be required if the teeth are dure is driven by the tooth preparation. Conservative
intact (18, 65). However, after generalized crown surgery confined to the area of defect is possible.
lengthening with osseous reduction, the root surface Unnecessary root or furcation exposure may be
of the involved teeth will be exposed. Subsequently, avoided. This treatment sequence is more applicable
full coverage prostheses become necessary to for posterior teeth in which the evenness of the gingi-
improve esthetics and patient comfort. val contour is less critical.
To overcome these problems, modifications to the Where multiple teeth are involved in the esthetic
surgery have been proposed. For example, esthetic area, or where a more invasive surgical procedure is
crown-lengthening surgery aims to minimize bone needed, crown lengthening should be completed
reduction interproximally (65). This can be advanta- before the tooth preparation. This situation may
geous when a distance of 4–5 mm remains between arise, for example, when crown lengthening of several
the bone crest and the contact point. Such a distance teeth is necessary before restoring a worn dentition
is more likely to allow an intact interdental papilla to (Fig. 1). The teeth can be prepared following soft-tis-
be maintained than if the distance is greater than sue maturation, re-establishment of the biologic
5 mm (21, 141). Likewise, removal of excessive inter- width and attainment of anatomic architecture,
proximal bone between tapering roots will increase which can take up to 6 months (14, 31, 76, 157). Com-
the horizontal separation. Distances of up to 1.5 mm pletion of crown lengthening before tooth prepara-
between the adjacent roots are sufficient to ensure an tion will allow improved visualization during the
adequate interdental papilla (21). Some authors have tooth-preparation procedure. However, the extent of
discussed multistage crown-lengthening surgery as a crown lengthening should be determined before sur-
method to localize osseous recontouring and to mini- gery. This is accomplished with a diagnostic wax-up,
mize alterations to interdental papilla (81, 132). bone sounding or a combination of both. These tech-
The etiology of the dental problem will dictate the niques will ensure that crown lengthening is
approach to the crown-lengthening procedure in prosthodontically driven. Consequently, the potential
terms of extension, invasiveness and sequence. The implications of crown lengthening can be estimated
first question to be answered is whether combined before any irreversible treatment, and revision surgi-
periodontal and prosthodontic procedures will man- cal procedures may also be avoided (2, 84).
age the patient’s concerns. Significant gingival expo-
The diagnostic wax-up
sure as a result of face height or lip length, for
example, might not be manageable by periodontal or A diagnostic wax-up aims to simulate the planned
prosthodontic procedures alone. Instead, orthog- prosthodontic treatment on articulated dental mod-
nathic and/or plastic-surgery procedures would need els. In general, this process will validate the feasibility,
to be considered. Alternatively, the patient may practicality and esthetics of the final treatment (69,
accept a compromised outcome. If the indication for 70, 79). Prosthodontic, periodontic and orthodontic
crown lengthening is management of gingival treatment can be incorporated into the diagnostic
42
Prosthodontic and periodontic interface
A B
Fig. 1. Clinical images of crown-lengthening surgery that The surgery was completed before the prosthodontic treat-
facilitated the prosthodontic treatment of a worn dentition. ment. (A) Worn anterior dentition. (B) Completed treatment.
43
Jaafar Abduo & Karl Lyons
Alternatively, longer teeth can also be achieved by gingival margin. Therefore, teeth with a small taper at
increasing the vertical tooth length (Fig. 3). This can the coronal third of the root are better candidates for
be accomplished prosthodontically by increasing the extrusion than are those with more pronounced
vertical dimension of the occlusion or by retruding tapering.
the mandible to the centric relation position (1). The
latter approach will increase the overjet between the
Additive methods
anterior teeth that facilitates restoration of the maxil-
lary teeth at a greater length. These approaches have Additive methods correct gingival level and contour
the advantages of increasing tooth display, reorganiz- by augmenting the gingival tissues and reducing the
ing the occlusion, avoiding surgical procedures and height of the clinical crown (17). In general, these
reducing tooth-structure loss as no incisal reduction methods are indicated to improve the dentogingival
is needed. Because surgical procedures may be esthetics by increasing the width of attached gingiva.
avoided, loss of interdental papillae is unlikely. Fur- In addition, they are indicated to alleviate dentine
thermore, they can be suitable options for the worn sensitivity. The available techniques are a free gingi-
dentition, where all the teeth in at least one arch need val graft, a connective tissue graft or a coronally posi-
to be restored. Confining management to the tioned flap. All aim to achieve an even band of
prosthodontic option might also provide patients attached gingiva and maintain coverage of roots.
with an immediate solution and esthetic improve- They should be completed well before the
ments. Because the root surface is not exposed, par- prosthodontic treatment.
tial coverage or bonded restorations are still an Clinically, it is desirable to have an even, thick band
option. In many cases, however, a combination of of attached gingiva about 5 mm wide. It is believed
surgical and restorative options can be considered, that attached gingiva provides an effective barrier to
and crown lengthening is likely to be necessary if the resist damage from physical, chemical, thermal and
tooth vertical height is 3 mm or less (1). bacterial stimuli. However, the role of the attached
Some patients might present with localized anterior gingiva remains controversial (17, 92) and it has been
subgingival defects. Surgical crown lengthening alone postulated that as long as the patient maintains a
might not provide an acceptable result because gingi- good level of plaque control, more recession is unli-
val evenness is affected. In such cases, forced erup- kely, even with the absence of attached gingiva (155).
tion combined with localized fibrotomy and Nevertheless, the presence of attached gingiva
thorough root planing or limited crown lengthening around teeth may improve patient comfort, facilitate
may be indicated (60, 61, 112). A surgical intervention cleaning, reduce dentine sensitivity, improve esthet-
will also be needed to prevent disharmony of the gin- ics and facilitate prosthodontic treatment (92).
gival margins associated with over-eruption of a tooth The use of additive techniques should be restricted
or teeth. Because tooth roots are tapered to varying to confined recession lesions, where an adequate
degrees, a tooth that has been extruded will have a blood supply is available (17). Prosthodontic treat-
decreased root diameter at the level of the gingival ment can, however, be completed without gingival
margin of adjacent teeth. As a result, extruded teeth augmentation procedures by modifying tooth mor-
exhibit greater taper from the incisal edge to the phology without altering the gingival contour. As a
A B
44
Prosthodontic and periodontic interface
result, the overall clinical crown length cannot be inflammation was oral-hygiene practice. Similarly, it
decreased but the emergence profile can be modified has been found that pontic design does not predict
to create a perception of correct dental proportion. tissue inflammation. Instead, regular plaque and
Other authors have discussed the application of gingi- calculus removal has been shown to ensure tissue
val-colored ceramic to conceal gingival deficiencies, health (130, 144). Following mucosal biopsy under
(Fig. 4) which, although useful, is limited in its ability pontics with minimal tissue pressure, Zitzmann
to obtain ideal esthetics (150). The patient should be et al. (163) reported histological changes with
fully aware of the esthetic outcome anticipated increased inflammatory cells and thinning of the
following placement of gingival-colored ceramic. keratinized layer; however, clinically, this was not
found to be significant. Their conclusion was that
minimal pressure was not associated with negative
Edentulous area clinical sequelae as long as good plaque control was
maintained. In another study, the impact of the
Assessing the edentulous area where a fixed prosthe- type of material used to create the pontic was found
sis is to be placed is important to minimize potential to be insignificant on compressed tissues, as long as
problems that may otherwise occur during fabrica- the pontic was highly polished with a convex tissue
tion or placement of the fixed dental prosthesis. This surface (104). Therefore, prosthesis cleansibility and
includes assessment of the location, height, width patient home care appear to be more critical for tis-
and contour of the residual ridge and the span of the sue health than type of material and tissue contact.
edentulous area. When a fixed dental prosthesis is This endorses the importance of open and rounded
planned, the prosthesis components to be considered embrasure contours as a way of facilitating cleaning
are the pontics and the connectors because they of the fixed dental prosthesis by the patient (Fig. 5).
influence the esthetics and durability of the prosthe- From a mechanical perspective, it is accepted that
sis, as well as the health of the soft tissue. the pontic and connector should be rigid enough to
Biologically, a pontic must have a design that withstand occlusal forces. This is primarily achieved
minimizes inflammation and permits oral hygiene by selection of appropriate material and an optimal
procedures to be performed easily. It has been pro- framework design. The need for a rigid framework is
posed that pontics should exhibit pressure-free con- especially important for long-span fixed dental pros-
tact on keratinized attached tissue and should not theses that are more susceptible to deflection from
allow accumulation of food or prevent plaque con- occlusal forces. Accordingly, the minimal cross-sec-
trol. This was assumed to prevent tissue inflamma- tion recommended for metal fixed dental prosthesis
tion and ulceration (6). However, more recent frameworks is 3 mm 9 3 mm, and for ceramic
studies have indicated that controlled pressure frameworks is 4 mm 9 4 mm (114).
might be beneficial by providing a seal and prevent- Historically, reducing the buccolingual width of the
ing saliva leakage and food impaction. One study pontic has been suggested as a way of reducing the
showed that there were no negative consequences load on the abutment teeth; however, there is very lit-
clinically or histologically as long as soft-tissue pres- tle evidence to support this claim. In fact, narrowing
sure did not prevent seating of the fixed dental the width of the pontic may make it more difficult to
prosthesis and the pontic fitting surface was convex achieve good esthetics and a functional occlusal rela-
and smooth (145). The same study showed that the tionship. Furthermore, it can increase the possibility
most common factor contributing to soft-tissue of food impaction around the pontics (Fig. 6) (6).
A B
Fig. 4. Clinical example of the application of gingival col- very clear, for this patient, the average smile line (B)
ored ceramic. (A) Although the color discrepancy between masked this discrepancy. The interdental papillae were
the gingival margin and the gingival-colored ceramic is predictably restored.
45
Jaafar Abduo & Karl Lyons
A B
Fig. 5. Clinical presentation of modified ridge lap pontics to replace a missing second premolar and a missing first molar
(A). (B) The embrasures were well cleared to facilitate patient home care.
A B
Fig. 6. Impact of altering the buccolingual pontic dimensions. (A) Optimal pontic dimensions should follow the contour of
the adjacent teeth. In addition to the esthetic appearance, this facilitates deflection of food from the proximal aspect. (B) A
narrow abutment will contribute to food impaction at the proximal aspect and reduce the self-cleaning abilities.
In order to provide the best esthetic outcome, the which could result in a prominent black triangle (66).
pontic dimensions should be similar to the space This problem can be reduced by widening the contact
vacated by the missing tooth. This is, however, dic- areas of the adjacent unprepared teeth. Overall, this
tated by the gingival contour and the pontic space camouflaging design can produce an acceptable out-
shape. Ideally, the residual ridge contour should be come if the patient does not have high esthetic expec-
regular and smooth, covered with attached gingiva tations, if the pontic location is not in a visible area
and at a level similar to the gingival margin of the and if the patient has a low smile line. Where there is
adjacent teeth. Such a presentation will allow a fixed excessive bone loss, a satisfactory esthetic outcome
dental prosthesis pontic to mimic the natural tooth may be better achieved with a removable prosthesis.
emerging from the gingiva and maintain the inter- In some cases, adjacent teeth might move, leading
dental papillae (33). It is not uncommon, however, to a reduction in width of the pontic space and loss of
that following tooth loss, a morphological ridge defi- dental symmetry. Such presentations might result in
ciency, such as severe resorption, may develop. In the need for orthodontic repositioning. Minor space
such instances, surgical modification with hard- and discrepancies can be managed by prosthodontic
soft-tissue grafts may be necessary (75, 116, 123, 124). treatment alone. To do this, the pontic can be pro-
These procedures, when performed correctly, can portioned to minimize the size discrepancy, and the
produce excellent results, although are potentially space difference can be corrected for by altering the
unnecessary if ridge-preservation techniques are uti- shape of the proximal areas.
lized. An alternative to surgical treatment involves To provide optimal restoration of the edentulous
prosthetic camouflaging. This involves the inclusion of space, several pontic designs have been proposed.
a root form at the cemento–enamel junction or use of Although none addresses all of the requirements,
a gingival-colored ceramic to recreate gingival con- knowing the rationale of each design allows the
tours. The aim of the gingival-colored ceramic is to clinician to select the ideal pontic for a given sce-
obtain a harmonious gingival contour; however, this nario. In the anterior region, esthetics is a primary
frequently results in pontics that have increased tissue consideration and the pontic should be well
contact (23, 46). When the gingival-colored ceramic is adapted to the tissues to give the appearance of a
applied, the cervical extension of ceramic toward the tooth emerging from the gingiva. In the posterior
gingival embrasure spaces may be limited by the path regions, the design may be modified to facilitate
of insertion of the retainer and the adjacent tooth, better oral-hygiene control.
46
Prosthodontic and periodontic interface
Fig. 7. Pontic designs for replacement of an anterior tooth. tooth emergence. (E) Modified ovate pontic for narrow
(A) Natural tooth. (B) Ridge lap pontic will produce a sur- ridge. (F) Pontic with gingival-colored ceramic can be con-
face that cannot be cleaned by the patient. (C) Modified sidered in situations where the ridge deficiencies are
ridge lap pontic can be an esthetic and cleansable option. prominent. (G) Removable partial denture provides reli-
(D) Ovate pontic has the advantage of mimicking natural able management of severely compromised ridge.
47
Jaafar Abduo & Karl Lyons
Fig. 9. Pontic designs for posterior tooth replacement. (A) pontic. (D) Modified ridge lap pontic is a suitable option
Natural tooth. (B) Ridge lap pontic can restore the natural for the wide ridge. (E) Conical pontic is more suitable for
tooth contour but cannot be reliably cleaned. (C) Sanitary the narrow ridge. (F) Ridge lap pontic with root form.
48
Prosthodontic and periodontic interface
configuration of the root and the periodontal the sustainability of abutment teeth to withstand
health (82, 98, 102, 117). occlusal forces applied to wide fixed dental prosthesis
Another factor contributing to periodontal sup- are yet to be determined.
port is the number of abutment teeth, which is par- Clinical studies have consistently shown that there
ticularly relevant when considering a multi-unit is little relationship between Ante’s Law and the long-
fixed dental prosthesis. In this regard, the literature evity and the function of fixed dental prostheses (88).
commonly discusses Ante’s Law, which mandates A series of long-term studies in Scandinavia revealed
that the combined peri-cemental area of all abut- that abutment teeth with a periodontal ligament area
ment teeth supporting a fixed dental prosthesis far less than the periodontal ligament area of the
should be equal to or greater in peri-cemental area teeth being replaced still provided adequate support
than the tooth or teeth to be replaced (3). The ratio- for long span and cross-arch fixed dental prostheses
nale of this law has seen its implementation as a (98–101). In these studies, only 8% of fixed dental
guide to safe prosthodontic design for the multi- prostheses fulfilled the requirements of Ante’s Law,
unit fixed dental prosthesis (88). Consequently, a and 57% of the fixed dental prostheses had an abut-
recommendation was developed that in situations ment-tooth periodontal ligament area that was less
in which the area of the edentulous span was than 50% of the periodontal ligament area of the
greater than the adjacent abutment teeth, additional teeth being replaced. Despite this, the studies found
precautions should be considered, such as splinting no loss in clinical attachment or periodontal bone
adjacent abutment teeth. Splinting multiple abut- support, widening of the periodontal ligament space
ment teeth controls mobility and enhances stability or increased mobility after 11 years. Although a his-
by transferring the horizontal forces to multiple tory of periodontal disease was common for their
teeth (36). Wylie and Caputo (158) established that patients, the outcome can be attributed to an absence
splinting two adjacent periodontally involved abut- of periodontitis, a rigorous maintenance protocol and
ment teeth was also beneficial in reducing alveolar patients’ oral-hygiene practices, hygienic prosthesis
bone stresses. This was confirmed by Yang et al. designs and preservation of strategic abutment teeth
(159) who used a finite element study to show that (4, 88). In another cross-sectional study, 41% of the
splinting multiple abutment teeth for long span fixed dental prostheses did not meet the require-
fixed dental prostheses reduced the stress in the ments of Ante’s Law and around 4% of the fixed den-
teeth and alveolar bone. However, both of these tal prostheses failures were attributed to periodontal
studies found that increasing the number of overloading and mobility (37).
splinted abutment teeth did not result in a propor- From a functional perspective, as no correlation
tional reduction in stress in the supporting struc- has been found between the number of abutment
tures (158, 159). Translating such findings clinically teeth and the magnitude of the occlusal forces during
is also challenging because splinting abutment teeth chewing or maximal biting, fixed dental prostheses
results in other problems such as hindering efficient that do not meet the requirements of Ante’s Law can
cleaning and predisposing the abutment teeth to withstand physiological occlusal forces without alter-
biological deterioration (40). Ensuring parallelism of ing chewing patterns (77, 78). This is true for fully
all the prepared abutment teeth can also be inva- supported cross-arch prostheses (77) and can-
sive and may explain the higher proportion of tilevered unilateral prostheses (78).
endodontic complications in splinted abutment Biologically, although violation of Ante’s Law has
teeth (7). not been shown to cause deterioration of the abut-
Although Ante’s Law constitutes a reasonable ment support, long-term clinical studies investigating
guideline, it has been challenged from two perspec- fixed dental prostheses have confirmed that the
tives: the lack of a clinical method to quantify the longer the span, the greater the number of complica-
peri-cemental area; and the lack of clinical evidence tions, particularly when compared with shorter span
(5, 37, 88). Ante’s Law emphasizes the importance of fixed dental prostheses. Leempoel et al. (83) found
the peri-cemental area, the number of teeth to be that fixed dental prostheses which did not comply
replaced and the number of abutment teeth, but with Ante’s Law exhibited a higher rate of fracture
there is lack of emphasis on the importance of the than did those fulfilling Ante’s Law, and De Backer
remaining periodontal tissues supporting the abut- et al. (26) reported that the survival rate of short span
ment teeth (77). For example, multi-rooted teeth are fixed dental prostheses (three to four units) was sig-
less affected by bone resorption than are single- nificantly higher than the survival rate of long span
rooted teeth (82). Furthermore, prognostic criteria on fixed dental prostheses (five units or more). The main
49
Jaafar Abduo & Karl Lyons
reasons for failure were caries, prosthesis fracture and acceptable, the definitive prostheses will be fabri-
loss of retention; few failures for periodontal reasons cated to resemble the diagnostic wax-up (57, 89).
were reported. It appears therefore that implement- However, the most critical feature of the periodon-
ing Ante’s Law is not fully justified in the literature tic and prosthodontic relationship is the preparation
and is not necessarily beneficial to periodontal sup- margin. In general, margin quality is considered a
port; however, it should be appreciated that long critical feature for determining the acceptability of a
span prostheses are more demanding to construct fixed prosthesis. Having a minimal marginal opening
and have a higher level of complications. is important to reduce the exposed cement line and
It can therefore be concluded that as long as subsequent leakage (62) that will result in penetration
prosthodontic treatment is preceded by appropriate and adherence of bacteria and, eventually, the devel-
periodontal therapy, and that periodontal health is opment of caries and gingival inflammation (16, 64,
well maintained, it is unlikely that periodontal sup- 105).
port will deteriorate with function when periodontal Although crown margin accuracy has been the sub-
pockets are less than 4 mm. The clinician should be ject of extensive research, the clinical parameters of
aware, however, that increasing the span of the fixed what constitutes an acceptable margin have not been
dental prosthesis will increase the risk of nonperi- established (69). Two questions remain to be
odontal complications. answered: what constitutes an acceptable margin;
and what is the implication of a marginal opening.
Microscopically, all margins are open by about
Abutment tooth preparation 100 lm, which is sufficient for penetration of bacteria
(42, 95). Despite this, many of these margins can be
Whenever a tooth is prepared, the aim is to achieve considered as clinically successful. The lack of a direct
sufficient clearance to accommodate a durable and relationship between the development of disease and
physiological restoration, without over-sacrificing marginal opening (12, 156) suggests that a marginal
natural tooth structure. Optimal tooth preparation is opening that is not clinically detected is not necessar-
achieved by controlled tooth-surface reduction, ily associated with caries or periodontal complica-
maintaining occlusal surface morphology, obtaining tions. Nevertheless, a dentist must aim for the
minimal preparation taper and preserving vertical smallest possible marginal discrepancy to minimize
preparation height (54). Adhering to these principles the risk of disease development.
safeguards mechanical durability by ensuring ade- In terms of crown margin design, the three deter-
quate material thickness and adequate retention and mining features are vertical location, horizontal width
resistance form in the abutment tooth preparation. and shape.
Adequate thickness also allows for optimal esthetics
of the prosthesis while minimizing unnecessary tooth
Vertical placement
reduction.
Whenever alteration to the tooth morphology is The severity of gingival inflammation is related to the
planned, it is recommended that a diagnostic wax- vertical location of the crown margin (74). Whenever
up is utilized. The need for a diagnostic wax-up possible, margins should be supragingival because
increases as the complexity of the treatment this is the most accessible location for assessment
increases (25, 89). The prime objective of the diag- and hygiene maintenance. Supragingival margins are
nostic wax-up is to assist with planning the most also advantageous in being easier to prepare, atrau-
feasible, achievable, conservative and practical treat- matic (74) and simple to record in an impression
ment option. The outcome of this ‘trial’ treatment (103), to evaluate the fit of the prosthesis and to
can be shown to the patient for approval or for sug- maintain by the patient and clinician (22). Supragin-
gested modifications so that the patient is informed gival margins have been found to be associated with
of the treatment options and the proposed final the lowest gingival index scores (8, 126, 129), while
outcome. Subsequently, the diagnostic wax-up facil- subgingival margins had the highest gingival index
itates an outcome-based treatment, which implies scores (126). Furthermore, subgingival crown margins
that the tooth preparation is dictated by the aims of have also been found to be associated with loss of
the final outcome rather than by the initial tooth periodontal support, pocket development and gingi-
morphology (57, 89). Provisional prostheses can be val recession (39, 67, 126–128, 148, 149). This could be
fabricated following the diagnostic wax-up and, because of preparation trauma, constant irritation,
should the patient find the provisional outcome microbial biofilm formation and difficulties in
50
Prosthodontic and periodontic interface
maintaining a good level of hygiene at the margin. used. For example, a metal margin requires a minimal
The junction between the prosthesis and the tooth reduction in the range of 0.3–0.5 mm, whereas
can be rough, facilitating microbial adhesion and ceramic requires reduction of 1–1.5 mm and metal–
enhancing the risk of caries development. For exam- ceramic requires reduction of 1.2 mm (Fig. 10). The
ple, Valderhaug & Heloe (147) found significantly clinician might therefore opt to place thinner margins
more caries around subgingival preparation margins in nonesthetic regions and reserve the wider margin
(30%) than around supragingival margins (15%) after for the esthetic regions. For the labial aspect of ante-
5 years. rior teeth, a more bulky contour may be acceptable
The advantages of supragingival margins are offset (138) because it is easier to clean than less-accessible
by their unesthetic appearance. This unesthetic areas. To facilitate an esthetic outcome without over-
appearance is a result of exposure of the tooth–pros- preparing the abutment tooth, a labial ceramic mar-
thesis junction and an incomplete tooth profile gin can be considered (Fig. 11). This applies to the
alteration. Several authors have proposed solutions to all-ceramic crown and the collarless metal–ceramic
the exposed tooth–prosthesis junction, such as use of crown margin, where the metal core is relieved 1 mm
collarless metal ceramic retainers (53). This is a viable from the margin and the entire margin is composed
option if the existing tooth structure is intact and it is of ceramic.
possible to shade match the restoration with the A clinical dilemma can arise in situations in which
remaining tooth. Subgingival margin placement can the teeth are elongated as a result of gingival reces-
be considered where deficiencies exist subgingivally, sion. This can manifest clinically as narrower teeth
where additional retention and resistance form is cervically. In this situation, standard margin prepara-
needed, where the whole contour of the tooth needs tion, although feasible, will result in significant loss of
to be modified and for esthetic reasons. To minimize dentine, rendering the tooth preparation narrow and
the risk of trauma to the gingival attachment, some mechanically compromised. In this situation, the
authors have recommended completion of the prepa- clinician should consider a more conservative prepa-
ration when the gingival margins are retracted. A ration or, in some cases, where emergence profile
slightly subgingival margin (0.5 mm) will not interfere alteration is indicated, a bulky crown contour can be
with the supracrestal fiber attachment or the biologic achieved with a conservative tooth preparation. A
width and is very likely to be accessible by the patient similar problem could arise in situations in which the
for cleaning (96). As long as the restoration margin furcation area is exposed. In this situation, a narrow
exhibits minimal opening, its location is minimally metal margin could be a suitable option to avoid cre-
subgingival (0.5 mm) and it is fabricated with a ating plaque-retentive features (6).
biocompatible material, clinical problems are very
unlikely to occur (52).
Margin design
The available margin designs are chamfer, shoulder
Horizontal width
and feather-edge (Fig. 12). There is debate about the
The width of the prepared margin will influence the best margin design in terms of accuracy and fit. In
material bulk, which dictates mechanical durability, general, the claims have anecdotal support and there
contour and esthetics. In general, the wider the mar- is no strong evidence that any specific design is better
gin, the more esthetic and the better contoured the in terms of improving the fit of the prosthesis (16,
prosthesis can be. It is easier to achieve a natural 118, 140).
appearance where the ceramic layer is thick enough Overall, the chamfer and shoulder margins share
to mask the metal and develop color without over- similar features. Both involve the establishment of a
contouring the prosthesis. An under-prepared margin 90° cavosurface margin horizontal preparation sur-
is much more likely to render the final prosthesis face. The chamfer margin is more conservative
unesthetic and unhygienic because of being over- because of the curvature between the axial (vertical)
contoured. and marginal (horizontal) preparation surfaces. They
In general, the prepared margin tends to be the are easy to prepare, even if a thin margin is planned
thinnest portion of the tooth preparation. An invasive (0.5 mm), and are readable on the preparation,
margin preparation implies that the rest of the prepa- impression and master model. For metal–ceramic
ration will be over-prepared, increasing the risk of prostheses, both the chamfer and the shoulder exhi-
iatrogenic damage. The clinician can manipulate the bit a similar level of accuracy of fit for the metal
thickness of the margin by altering the materials framework after ceramic application (58, 118, 140).
51
Jaafar Abduo & Karl Lyons
There is evidence that a shoulder margin increases at the gingival margin where the tooth is relatively
the accuracy of fit for ceramic prostheses produced narrow. Other margin designs would require the
by computer-aided design/computer-aided manufac- removal of a substantial amount of tooth structure,
turing. Bindl and Mormann (11) found that the shoul- possibly compromising the long-term prognosis of
der preparation yielded a smaller marginal gap the tooth. Problems with the feather-edge margin
(32 lm) than the chamfer preparation (71 lm). In the include difficulties in reading margins, an increased
same study, however, both margin designs produced risk of over-contouring the cervical portion of the
prostheses that exhibited clinically acceptable fit. prosthesis and a risk of distorting the thin metal sec-
Another study found that a shoulder preparation pro- tions of the margin during fabrication. There is also
duced a smaller marginal discrepancy (28 lm) than no clinical evidence showing a negative biological
the deep chamfer (65 lm) and the narrow chamfer consequence from well-fitting prostheses with
(100 lm) (135). Likewise, a different investigation feather-edge margins (9, 19, 74).
found that a shoulder margin had a better fit than a In general, a feather-edge margin has been consid-
beveled shoulder (49). On the contrary, Komine et al. ered only when a metal margin is planned (48).
(71) found that the shoulder (73 lm) and the chamfer Recently, however, the advent of high-strength zirco-
(61 lm) preparations had a minimal effect on mar- nia ceramic has resulted in further investigations into
ginal fit, and Comlekoglu et al. (24) confirmed a simi- the use of the feather-edge preparation (24). Early
lar level of fit with the two margin designs (114 lm studies have found that feather-edge margins do not
for shoulder and 144 lm for chamfer). As it was appear to affect the durability of a zirconia coping (9,
established that a marginal opening of between 100 115), and some clinical studies have suggested that
and 150 lm is clinically acceptable (42, 95), the statis- zirconia crowns with a feather-edge preparation have
tical difference reported in various studies is probably an acceptable performance in comparison with
of little clinical significance. crowns with other margin designs (107, 111, 122).
The feather-edge margin is the least destructive Some authors have therefore suggested the provi-
margin preparation because it involves only axial sion of a smooth preparation margin, without irregu-
reduction. This design could therefore be recom- larities and unsupported enamel, rather than
mended if the preparation is to extend to the root sur- recommending a specific margin geometry. Irregular-
face. The feather-edge margin is also ideal for ities compromise the subsequent clinical and labora-
periodontally involved teeth with gingival recession tory steps, increasing the likelihood of discrepancies
(29). In these cases, it is common to observe recession (10, 161).
52
Prosthodontic and periodontic interface
Furcation considerations
Furcation involvement is challenging because of the
potential for plaque accumulation and its conse-
D quences, particularly if the gingival third of the axial
surface of the prosthesis is over-contoured. A num-
ber of treatment options may be considered with
the periodontist to manage a tooth with furcation
involvement, including resection, tissue regenera-
tion, a combination of both or extraction of the
tooth (20). When preparing teeth with furcation
involvement, consideration needs to be given to the
root anatomy and the coronal tooth structure. In
particular, the furcation undercut needs to be con-
Fig. 11. Construction of metal–ceramic crowns for conser- sidered when preparing these teeth so that the
vatively prepared teeth. (A) Labially, collarless metal core
preparation will facilitate gingival health by not col-
is applied. (B, C) Palatally, metal margins can be preserved
without compromising the esthetics. (D) The completed
lecting plaque or making hygiene access difficult. In
crowns entirely mask the metal cores. the furcation area, the root trunk has an anatomical
concavity that increases in an apical direction until
there is separation of the roots. Because of this, the
Prosthesis morphology curvature of the teeth is not effective at directing
food away from the cervical area following gingival
recession that exposes the furcation. The crown
Contour
contours must therefore be re-established to mini-
The contour and profile of a prosthesis contribute mize plaque collection. A maxillary or mandibular
to whether the prosthesis will blend harmoniously molar with a Class I furcation requires a margin
with the adjacent teeth (Fig. 13). The emergence preparation that includes the furcation, or is far
profile, which is the axial contour of the prosthesis enough coronal to the furcation that it is not
from the base of the gingival sulcus and through involved with the crown preparation (6). The
53
Jaafar Abduo & Karl Lyons
Fig. 12. (A–H) Margin designs for teeth with a normal level recession require special consideration. Shoulder margin
of gingiva and teeth with gingival recession. Shoulder mar- and chamfer margin preparations will be very invasive for
gin (B) and chamfer margin preparations (C) are generally the elongated teeth. (H) A feather-edge margin will be a
suitable options for teeth without gingival recession. (D) A conservative option for such teeth by preventing signifi-
feather-edge margin for teeth without gingival recession cant axial reduction.
can, however, over-taper the preparation. (E) Teeth with
Fig. 13. Each tooth should fit in harmony with the adjacent Fig. 14. (A) A straight profile in the gingival third facilitates
teeth. (A) The labial surfaces of all the teeth exhibit a paral- establishment of a properly contoured prosthesis. (B)
lel orientation. The long axis of the incisors ideally should Widening the profile gingivally is associated with over-con-
be angled mesially. (B) The occlusal surfaces and cuspal toured prostheses.
inclination of posterior teeth have similar parallelism.
fabricated crown form should have a flat emergence create the contours of the furcation, to merge or
profile coronally so that there is no undercut to trap blend with the coronal aspects of the crown to min-
food or plaque (6, 160), and the crown should re- imize cleaning difficulty in these areas.
54
Prosthodontic and periodontic interface
Fig. 15. (A) Properly contoured interproximal contact in interproximal contact will prevent food deflection and
the occlusal third. (B) Very high interproximal contact can contribute to gingival inflammation.
cause food impaction. (C) Wide and gingivally located
55
Jaafar Abduo & Karl Lyons
Glass ceramic
56
Prosthodontic and periodontic interface
Table 2. (Continued)
or adjacent, tooth color better than other options (27, which must be avoided in patients with a nickel
55). Ceramics are brittle materials, however, and at allergy.
risk of fracture, particularly when functioning on Although rare, the majority of the documented
molar teeth. Feldspathic, leucite-reinforced and hypersensitivity reactions to dental materials are
lithium disilicate ceramics are suitable for crowning delayed hypersensitivity reactions. Clinically, these
anterior teeth and have excellent esthetics (41, 142). commonly present as a contact dermatitis or a
Lithium disilicates are also suitable for crowning mucositis. For cases that present with an allergic
premolars and for short-span anterior fixed dental reaction, it is mandatory to document the clinical
prostheses (142). Ceramics with high-strength cores, reaction and identify and remove the source of aller-
such as alumina or zirconia, are suitable for crowning gen. In documented cases of allergy, reactions often
posterior teeth (110). In addition, zirconia is suitable subside in a few weeks. However, in patients with
for short-span posterior fixed dental prostheses (121). lichenoid or erosive lesions topographically related to
To date, the limited available literature suggests that the prosthesis, replacement of the prosthesis should
zirconia is the most suitable all-ceramic option for be considered. Before undertaking any extensive
restoring molars and for short-span fixed dental replacement of prostheses, careful evaluation should
prostheses that include molar teeth (27). Crown be carried out in collaboration with a specialist in the
preparations for bilayered ceramics are not conserva- field, such as a dermatologist (69).
tive, however, because of the need for space for the
ceramic core (approximately 0.4 mm) and the overly-
ing veneering ceramic (up to 1 mm) materials. Conclusion
Ceramics for high-strength cores are opaque and
should have a veneering layer to provide a tooth- A healthy periodontium is a prerequisite for success
colored appearance (59). More recently, zirconia has with fixed prosthodontic treatment. Without a strong
been used to manufacture monolithic crowns (162). interdisciplinary relationship between periodontics
Furthermore, translucent zirconia that accepts and prosthodontics, the esthetic, functional and/or
staining has been proposed to overcome the esthetic biological outcome may be compromised and neces-
limitations (119). sitate extensive and expensive retreatment. When
planning prosthodontic treatment, consideration
should be given to factors such as the design of the
Allergy and biocompatibility
prosthesis, the preparation and the pontic, the num-
All materials used in the oral cavity must be bio- ber and quality of the abutment teeth and choice of
compatible. The materials should also be able to be material, while also considering the patient’s con-
handled safely in the clinical and laboratory envi- cerns and expectations. Abutment selection, tooth
ronments. There are unlikely to be health issues position, residual ridge form and occlusion should
with high-gold or high-palladium alloys used in also be evaluated before treatment. The location of
metal and metal–ceramic prostheses or with cera- the margin and the contour and emergence profile
mic materials (153, 154). However, there are possi- of the prosthesis will influence the response of the
ble health hazards with alloys containing nickel, gingival tissues to the prosthesis. Although
57
Jaafar Abduo & Karl Lyons
periodontal factors do not usually have a direct 12. Bjorn AL, Bjorn H, Grkovic B. Marginal fit of restorations
effect on the survival of a fixed prosthesis, harmony and its relation to peridontal bone level. I. Metal fillings.
Odontol Revy 1969: 20: 311–321.
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