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Fig 2 (a to d) Classic
signs of inflammation
(flushing, heat, tumor,
exudate, and pain).
a b
c d
However, it can be assumed that, as this is a surement should not be used to define
transition tissue, it will present much vari- how far the probe can penetrate into the
ability among different individuals and gingival sulcus under pressure, since this
should be considered the anatomical and action will likely invade the JE.
histological limit for the intracrevicular level 3. The restorative materials currently avail-
of a restorative margin preparation. able for restorative adhesive dentistry are
A second epithelial layer – the JE – lies biotolerable but not biocompatible. This
underneath the SE and presents distinct his- means that they should not remain in
tological characteristics compared with the contact with the JE because an anti-
OE and the gingival epithelium. The JE is gen-antibody reaction may occur.6,7 Ideal-
not keratinized and is therefore permeable, ly, these materials should be bioactive,
allowing for fluid exchange between the in- stimulating cellular proliferation and ad-
ternal and external environments. The JE hesion, which is similar to what happens
only presents two layers of cells – the exter- in oral and orthopedic implantology18
nal lamina (EL) and the internal basal lamina with materials such as titanium and zirco-
(IBL) – with only the former providing tissue nia as well as polymers such as polyether
stability and sealing by adhering weakly to etherketone (PEEK).19 Even implant-sup-
the surface of the enamel through hemides- ported restorations, being transmucosal
mosomes.16 It is through the JE that the hu- in nature, have been considered by some
moral and cellular defenses come into con- authors to invade the biological space.20
tact with external agents, as in cases of
tissue inflammation. Additionally, the JE is From the approximate level of the cemento-
responsible for the secretion of the gingival enamel junction (CEJ), the JE gives way api-
crevicular fluid. cally to a CT insertion. The CT forms a union
In cases of lesioning (common during through connective fibers with the root ce-
periodontal probing and/or procedures such mentum. This connection is real, since the
as prophylaxis and the insertion of a retrac- tooth end of these fibers is mineralized and
tion cord for impression, amongst others), anchors in the cement surface (the Sharpey’s
the JE is able to regenerate quickly (in 48 h) fibers). From this mineralized origin they di-
unlike the other epithelial tissues.17 rect toward the CT of the gingival margin,
The following are some critical clinical being part of its structure. From a sealing
aspects regarding the JE: perspective, an important function of the
1. Being a permeable tissue, no restorative CT is to prevent apical migration of the JE,
material or debris resulting from clinical keeping the level of the gingival margin in
procedures should remain in contact position.15
with the JE due to the risk of inducing
transient or permanent gingival inflam- Rule 2: The excellence of the
mation. clinical execution is more determi-
2. The conventional periodontal probing nant than the selected restorative
performed with a Williams or North material
Carolina millimeter probe should be per-
formed with a slight digital pressure, Several factors should be observed to
since the depth of the clinical sulcus dif- achieve periodontal health in the vicinity of
fers from that of the gingival sulcus that a dental restoration, regardless of its extent
often encompasses a small or medium and the material used. The primary factor
portion of the JE. Thus, this clinical mea- relates to the vertical location of the tooth
Fig 5 (a to g)
Subgingival prepara
tions are justified in
situations of substrate
discoloration that
require total
coverage of the
tooth by the
a b restoration. Figure (e)
shows that some-
times it is important
to restore the
discolored substrate
with direct opaque
composite resin prior
to cementation.
c d
e f
Fig 6 (a to e)
Subgingival prepara
tions are also justified
to replace restor-
ations that already
present with
subgingival prepara
tions or restorations.
a b
c d
present with SubG preparations or res- In the above cases, there is a justifiable need
torations (Fig 6). to extend the preparation within the sulcus.
3. For SubG caries. However, the position of the JE must be fully
4. For diastemas that require a suitable respected, and direct contact of the restora-
proximal emergence profile to optimize tive material should be limited to the SE,
the position of the interdental papilla which is keratinized and impermeable. Since
(Fig 7). the SE is a tissue with unique characteristics
a b
Fig 8 (a and b) In thin/festooned periodontal biotypes, the teeth usually present a more pronounced vestibular convexity, located between
the middle and cervical thirds of the crown. This seems to alleviate the direct impact of food on the periodontium. Clinicians should be
careful not to cause overcontouring in cases of no-prep as this could lead to periodontal damage.
Rule 3: The periodontal biotype is tibular surface. This biotype is less sensitive
fundamental to define the vestibu- to dental procedures and may allow for cer-
lar convexity of the restoration tain clinical indelicacies without resulting in
permanent periodontal damage.28 On the
The periodontal biotype is a factor of para- other hand, this biotype appears more
mount importance for the esthetic risk as- prone to developing periodontal pockets in
sessment in restorative dentistry and its ob- the presence of inflammation, which may
servance is fundamental to selecting the mask the evolution of irreversible tissue
adequate treatment sequence and proto- loss.15
cols, including preparation, impression pro-
cedures, temporization, and cementation. Rule 4: A respectful transition
The periodontal biotype is directly related to between the periodontium and
the convexity of the vestibular surface of restoration increases the consis-
natural teeth, which plays an important role tency of the clinical results
in directing bolus trajectory during mastica-
tion and promoting proper stimulation and The tooth-restoration-periodontium inter-
toning of the gingival margins.27 face should be optimized, with the aim of
When the periodontium is thin/fes- achieving harmony between tissues that are
tooned, the teeth usually present a more very different from an anatomical and bio-
pronoun ced vestibular convexity, located logical standpoint. The position, preparation
between the middle and cervical thirds of limit, emergence profile in combination
the crown, which seems to alleviate the di- with the vestibular contour of the ceramic
rect impact of food on the periodontium. restoration, and establishment of an “area of
Clinicians should be careful not to cause adhesive continuity” (AAC)29 allow for an ad-
overcontouring in cases of no-prep as this equate perio-restorative integration, facili-
could lead to periodontal damage (Fig 8). tating plaque control in the cervical region
The flat and thick periodontium is typically (Fig 9). The AAC, forming a hybrid interface
more mechanically resistant and is generally of different structures that have been bond-
associated with teeth that have a flatter ves- ed together, results from the correct adap-
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