Altering Gingival Levels: The Restorative Connection

Part I: Biologic Variables

J O H N C . KOIS, D M D , M S D '

A chieving periodontal harmony

commensurate with the
requirements of restorative dentistry
and esthetics at times seems diamet-
rically opposed. Blending in the
gingival esthetic components of
symmetrical levels, form /a degree of
scallop, and the amount of gingival
display (see Part 11) with the restora-
tive mechanical prerequisites of
incisaVocclusa1reduction, prepara-
tion length, and adequate sound
tooth structure (see Part 111) provides
key guidelines for therapy. However,
in order to provide predictable
esthetic results, two essential biolog-
ic issues must be fully understood.

First, where is the base of the sulcus?
This will define the cervical limita-
tions of tooth preparation and
ensure intracrevicular margin loca-
tion. This is the single most impor-
tant factor determining the gingival
response to restorative dentistry.'-3
Second, w h e r e is the osseous crest?
This is a necessary foundation for
determining gingival levels and
must be managed precisely in order
to develop predictability for altering
gingival levels and to provide a
reference for margin location.
Figure I . Total facial dentogingival unit 3 mm (measured from osseous crest t o free
gingival margin).
DENTOGINGIVAL COMPLEX ( D G C )
Our knowledge of the dentogingival
complex has been oversimplified.
It reportedly comprises three defini-
tive components:
1. the connective tissue fibrous
attachment,
2. the junctional epithelium or
epithelial attachment, and
3 . the sulcus.
The original research intimates a
vertical measurement of 2.04 mm
for biologic width.4 The same
research has popularized 0.69 mm
as a vertical measurement for the
depth of the sulcus yet clinically we
have all experienced vastly different
depths. How else could we hide a
1.5 mm metal margin in the con-
fines of this 0.69-mm sulcus. Later
publications'J have indicated cau-
tion when utilizing this average
measurement; these biologic dimen-
sions vary and are unique for each
clinical situation. Biologic width is
not a contrived illusion of mathe-
matical precision.

'Private practice, Tacoma, Washington

Associate Professor, University o f Washington,
Seattle, Washington

VOlUkiF 6 . SUMBFR I
 \.
J O U R N A L OF ESTHETIC DENTISTRY
Alterin Ginviva1
B.
Levels: The Restorativt. (:oririec.tion
Part I: iologic Variables

(FGM) is easily visualized while the

osseous crest is readily probed,
yielding a single dimension for the
complete DGC. The basis for this
approach is clinical research on 100
healthy patients with the FGM at
or coronal to the cementoenamel
junction (CEJ) of unrestored anteri-
or teeth. Measurements were made
on the direct facial and mesial sur-
face of tooth NO. 8. The data
Figure 2. Total interproximal dentogingival unit 3 to 4.5 mm (measured revealed a 3-mm linear measure-
from osseous crest to interproximal papilla).
ment on the facial aspect (Figure 1)
and a range of 3 to 4.5 mm inter-
Due to human variability the pre- amount of probing force, and the proximal depth (Figure 2). This
cise clinical delineation of the indi- location on the tooth. How then variation depends on the amount of
vidual components of the dentogin- can a clinician embark on a surgical the gingival scallop relative to the
gival complex is illusive. How then procedure to fulfil these parameters interproximal osseous scallop.
does the restorative dentist clinical- with any predictable success when These measurements represent the
ly determine the base of the sulcus they are in fact not well defined? total dentogingival complex and are
for intracrevicular margin location? Do we have a set of clinically rele- more clinically significant to ensure
Histologic sulcus depth is only vant well-defined guidelines? predictable results.
0.5 mm, whereas the clinical sulcus
depth measures from 1 to 4 mm in This can be accomplished by work- The level of the gingival tissue nor-
health. This apparent difference is ing with the total dentogingival mally mimicks or follows the archi-
due to the penetration of the complex (DGC) dimension, instead tecture of the underlying osseous
supracrestal fiber attachment by the of the individual components. crest on the facial aspect. When the
periodontal probe. The resultant Measurement can be made from the gingival tissue follows an asymmet-
vertical measurement or sulcus free gingival margin to the osseous ric pattern (Figure 3), we are not
depth is being clinically influenced crest with a periodontal probe. The sure if the osseous crest follows this
by the degree of inflammation, the level of the free gingival margin same asymmetric pattern (Figure 4)

Figure 3. Asymmetric facial gingival level. Figure 4. Asymmetric facial osseous level.
 KOlS

or if it is normal (Figure 5).How

then do we determine whether a
simple gingival resective procedure
is necessary to restore esthetic har-
mony as opposed to a full thickness
flap and osseous surgery?

If you probe to the osseous crest on

the facial aspect of the tooth with
coronally positioned gingivae and it Figure 6. “Sounding”to osseous crest measures 5 mm
measures 5 mm (Figure 6), it repre- to total DGC.
sents a 2-mm excess of the total
3-mm DGC measured everywhere
else. If there is an adequate zone of
attached tissue, resect 2 mm on the
facial aspect t o level the gingiva
(Figure 7),then sever all the supra-
crestal fibers to bone on the facial
aspect, thereby altering the gingival
level without reflecting a flap
(Figure 8). However, if the osseous
crest to FGM measured 3 mm, the
same as elsewhere despite the differ- Figure 7. Two millimeters o f gin ival tissue resected
and all su racrestal fibers severeito bone on the facial
ent gingival form (see Figure 4), a
mucoperiosteal flap would have been
P
aspect on y.

necessary to resect the osseous crest

to move the entire DGC complex to
a more apical level and develop the
same dentofacial symmetry.

Figure 8. At 1 -year recall, facial tissue level is stable.

Figure 5. Normal (symmetric) facial osseous level.

VOLUME 6. NUMBER 1 5
JOURNAL OF ESTHETIC DENTISTRY

Alterin Gingival Levels: The Restorative c'lotllle('t ion

fi
Part I: iologic Variables

The osseous scallop follows the form

of the CEJ circumferentially.This
scallop is thus greatest for the mad-
lary anterior teeth averaging 3.5
and flattens out as we move posteri-
~ r l yThe
. ~ biologic width also follows
this scallop. Utilizing more hori-
zontal tooth preparation margins
instead of more scalloped tooth
preparation margins is inappropriate
Figure 9. Biologic variation is possible with excessive for anterior teeth, due to the viola-
ingival levels. (Adapted from Coslet GI, Vanursdall R,
keisgold A.)I0 tion of the biologic width in the
interproximal area. Some latitude
exists as the gingival tissue has a
This patient represents a biologic What seems to be the most critical slightly greater scallop. This anatom-
variation of excessive gingiva with a factor is the relationship between the ic difference is due to the proximal
normal osseous crest and adequate supracrestal fiber attachment and contours of adjacent teeth and their
zone of attached tissue (Figure 9). margin location. Once we prepare a ability to support an additional
tooth apical to the base of the sulcus height of gingival tissue in the inter-
RESTORATIVE INTERFACE and place margins into the zone of proximal area. When preparing
The effect of crown margin location the biologic width, specifically the teeth it is important to know the
on plaque and gingival health is well connective tissue attachment, we total complex measurement.
documented.6 hcreases occur in gin- have violated important biologic Assuming the 3-mm dimension
gival health parameters with margin principles regarding the long-term (Figures 10 to 12) margins would be
location apical to gingival tissue. gingival health. Therefore, the most located 0.5 mm apical to the FGM
important parameter for intracrevic- and should follow the normal scal-
ular dentistry is locating the base of lop of the base of the sulcus as we
the ~ulcus.2~~ prepare interproximally (Figure 13).
On the facial aspect, the distance of

Fignre 10. Initial-note gingival scallo su ported by Figure 11. Total DGC 3 mm on facial aspect-this
proximal contact on mesial; flatter on a!sta!due to represents normal crest FGM relationship.
missing laterals.
 KOlS

margin to bone would be 2.5 mm.

In the interproximal, you should
also be at least 2.5 mm away if
you follow the gingival scallop,
because there is a longer total DGC
interproximally.

If the total complex is less than

3 111117, extreme caution should be
utilized when attempting intra- Figure 12. Total DGC 4 mm interproximal aspect-this
crevicular margins because the
patient may have a “high osseous
d a
represents the greater scallop o gin ‘Valtissue relative to
the osseous crest. I t is not pre ictab e to maintain.

crest” (Figure 15). Margin location

would be closer to the bone with a
greater liability of violating biologic
width. If the total complex is greater
than 3 mm, the “low osseous crest”
type, a more apical margin location
below the FGM can be established
without a violation of biologic
width. This also represents an
anatomic pitfall because thls patient
would be predisposed to recession
following normal retraction proce- Figure 13. Margin location 0.5 mm apical to FGM on facial following
dures because the DGC will usually scallop interproximally. Margin location 2.5 mm coronal to bone.
Note pontic receptor site established in gingival tissue to accept ovate
reestablish a normal crest-FGM pontic form.
relationship. Margin location rela-
tive to bone is more critical than
distance below the FGM.

Figure 14. Final result-metal ceramic FPD 7-1 0. (Metal framework b y

Michael Miller, CDT; ceramics by Arne Larsen, CDT).

VOLUME 6 . NUMBER I 7
 JOURNAL OF ESTHETIC DENTISTRY
Figure 15. Biologic variation possible with
normal locution of gingival levels. (Adapted
from Gxkt GI,Vanarsdall R, Weisgold AJ'O
INTERVENTION
Petf0-g suppodve periodontal
therapy, regenerative techniques,
mucopeiosfeal flaps, and
even ma&on cord affect
the entire DGC.Can we decide
what may be reversible or how
much healing time is necessary
prior to intracrevicular tooth prepa-
ration? Literature has popularized
the concept that the relative tissue
athiclcncss" would provide a guide.
It does appear that the thickness of
the underlying bone influences the
stabllny of thc faaal OSBeous -w
which could affect the location of
the facial gingival tissue level.
Additionally, surgical intervention
creates confusion for the restorative
dentist, because the base of the sul-
cus must again also be determind.
8 1-94
Alterin Gingival Levels: The Restorative Connection
part I: biologic Variables
Three months following surgery,
the tissue may appear healthy but
will not have normal gingival archi-
tecture (Figure 16). The gingival
scallop is flatter with more open
gingival embrasures. The restora-
tive dentist can then inadvertently
create margins that are impinging
on the supracrestal fibers by
preparing to close to the osseous
crest and creating a horizontal rnw
gin that does not mimic the dissimi-
lar underlying osseous scallop
(Figures 17 and 18).
The healing time necessary follow-
ing periodontal surgery prior to
tooth preparation is therefore also
It could take up to 3 years following based on the development of the
for gingival tissue to estab- total DGC. To provide a better
lish their final level and scallop. guideline for the restorative dentist,
The amount of time is determined it is advisable to position the FGM
by flap management relative to 3 mm coronal to the osseous crest
positioning with the osseous crest. at the completion of surgery. The
Figure 16. Followin sur ery the gingival architecture as flatter and c h n
to the bone-total 8GCfess than 3 mm.

Figure 17. One year later, gingival tissue is attempt-
ing to establish total DGC, but now horizontal mar-
gins have violated the biologic width.
restorative dentist must reevaluate
these dimensions prior to tooth
preparation by probing from the
FGM to the osseous crest. Ideally
3 mm should be present on the
facial aspect of anterior teeth and
3 to 4.5 mm in the interproximal
aspect when adjacent teeth are pre-
sent. Posterior teeth, tissue levels
apical to the CEJ, and delayed pas-
sive eruption are notable excep-
tions. By placing the margin loca-
tion 2.5 mm from the osseous crest,
it will be apical to the free gingival
margin and still be intracrevicular.
SUMMARY
Utilizing the total DGC can simplify
our periodontal procedures and
enhance our ability to provide intra-
crevicular margin location. An
understanding of the biologic vari-
ables will provide a more enlightened
clinical approach that will enhance
our level of predictability while
creating periodontal harmony in
the presence of restorative dentistry.
Figure 18. Surgical re-entry illustrates that margin
location does not follow scallo created at osseous
crest; interproximal aspect vio ates connective tissue
attachment.
REFERENCES
1. Maynard JG, Wilson RD. Physiologic
dimensions of the periodontium significant
to the restorative dentist. J Periodontol
1979; S0:170-174.
2. Nevins M , Skurow HM. The intracrevicu-
lar restorative margin, the biologic width,
and the maintenance ofthe gingival mar-
gin. Int J Periodont Rest Dent 1984:
4(3):31 4 9 .
3. Kois J. "The gingiva is red around my
crowns "-a differential diagnosis. Dent
Econ 1993: Apri1:lOl-lOS.
4. Gargiulo A W,Wentz FM, Orban 5.
Dimensions and relations of the dento -
gingival junction in humans. J Periodontol
1961; 32:261-267.
5. lngber IS, Rose LF, Coslet JG. The "bio-
logic width "-a concept in periodontics
and restorative dentistry. Alpha Omegan
1977: December:62.
6. de-Jacoby Lavina F, Ziafiropoulos GG,
Ciancio S. The effect of crown margin
location on plaque and periodontal health.
lnt J Periodont Rest Dent 1989;
9(3):197-205.
KOIS
P
Ash M M . Wheeler's denrol anatomy,
physiology and occlusion. 7th Ed.
Philadelphia: WB Saunders, 1993:130.
Pharma-Benfenati S, Fugazzotto PA,
Ruben MP. The effect of restorative mar-
gins on the postsurgical development and
nature ofthe periodontium: Part I. Int]
Periodont Rest Dent 1985; 5(6):31-52.
Pharma-Benfenati S, Fugazzotto PA,
Ferrira P M , et al. The effect o f restorative
margins on the postsurgical development
and nature ofthe periodontiurn. Part 11.
AMtOmica/ considerations. lnt ] Periodont
Rest Dent 1986; 6(1):6475.
10. Coslet G], Vanarsdall R, Weisgold A.
Diagnosis and classification o f delayed
passive eruption o f the dentogingival junc-
tion in the adult. Alpha Omegan 1977:
Decembec24-28.
Reprint requests:]ohn C. Kois, DMD,
561 5 Valley Avenue Enst, Tacoma, WA 98424
0 1994 Decker Periodicals
VOLUME 6, NUMBER I 9