Periodontology 2000, Vol. 74, 2017, 74–101 © 2017 John Wiley & Sons A/S.
& Sons A/S. Published by John Wiley & Sons Ltd
Printed in Singapore. All rights reserved
The periodontal restorative
interface: esthetic considerations
V I N C E N T B E N N A N I , H A D E E L I B R A H I M , L A T F I Y A A L -H A R T H I & K A R L M. L Y O N S
As esthetic expectations of patients are increasing,
patients who present with complex restorative needs
almost always require a multidisciplinary approach to
treatment. Prosthodontic/restorative and periodontic
disciplines are often involved in esthetic cases. This
cross-discipline endeavor requires both parties to
have a mutual understanding of the possibilities and
limitations of different treatments on short- and long-
term outcomes.
An appreciation of the relationship between peri-
odontal health and restoration longevity is a key fac-
tor in ensuring good function, form and esthetics of
the dentition (104, 124), and consequently achieving
a successful restorative outcome necessitates that the
final restoration is planned ahead so that it integrates
with the surrounding periodontium and the rest of
the dentition. Prerequisites to obtaining a good
esthetic outcome are: scrupulous attention to detail;
establishing an accurate diagnosis; subsequent devel-
opment of a comprehensive treatment plan; and
effective implementation of the current knowledge
on new materials and techniques. This article sum-
marizes the current knowledge on treatment plan-
ning considerations and clinical procedures that help
achieve a biologically integrated and esthetically
pleasing restoration.
Treatment planning considerations
A comprehensive periodontal examination involves
assessment of soft- and hard-tissue parameters or
what is referred to as the dentoalveolar gingival unit
(168). It is important to note that, while a number of
guidelines are presented in this paper, deviations
from the ideal do not necessarily lessen the beauty of
one’s smile, and that in nature, there is no perfect
symmetry between the two halves of the face. As
such, minor deviances from idealism may personalize
74
PERIODONTOLOGY 2000
one’s smile and would result in a more natural
appearance (146). It has also been suggested that the
cumulative visual impact of the anterior dentition
often takes over the sum of the individual parts (136).
From an esthetic perspective, the intra-oral assess-
ment involves evaluating the periodontal structures
of the bone, the gingiva, the interdental papillae or
the pink esthetic component, the teeth or the white
component, and the biologic space (168).
Soft-tissue considerations
Gingival phenotypes
Gingival biotypes were suggested as a factor that
influences restorative treatment outcomes (158).
Clinically, assessing gingival biotypes translates into
observing gingival thickness. Accordingly, two
biotypes can be identified: ‘a thick-flat’ type; and a
‘thin-scalloped’ type. Research into outcomes of root-
coverage surgery indicated predictable results after
root-coverage procedures in the case of the thick-flat
biotype (18, 96) and regrowth of gingival height after
resective osseous surgery (158). In contrast, in cases
associated with gingival inflammation, a higher risk
for soft-tissue recession was reported with the ‘thin-
scalloped’ type (71) and lower probability of complete
root coverage after root coverage surgery (18) (Figs 1
and 2).
Gingival contours
Harmony and symmetry are key factors that need to
be assessed when planning esthetic restorations. An
uneven contour of the gingivae may give rise to an
asymmetric appearance, which gives an unesthetic
smile. A healthy periodontium should be established
before embarking on any restorative esthetic proce-
dures. The gingiva shrinks when the inflamed peri-
odontium is treated and the tooth–restoration
interface may become exposed. A gingival topography

Fig. 1. Example of a thick-flat biotype (courtesy of Dr V.
Bennani).
Fig. 2. Example of a thin-scalloped biotype (courtesy of Dr
V. Bennani).
that is conducive to the final esthetic outcome is
another aim that should be planned for in advance.
From an esthetic standpoint, the relative gingival
zenith and the height of the contour of the gingival
margin are important parameters. An irregular gingi-
val contour can significantly affect the appearance of
natural and prosthetic teeth.
The zenith point orientation is distal of the long
axis of the central incisors and cuspids, and is coinci-
dent with the long axis of the lateral incisors (167). As
a general guideline, the height of the gingival margins
of central incisors and canines should be at the same
level. It is desirable to have the gingival tissue heights
of the lateral incisor teeth 1 mm incisal to the gingival
margins of the adjacent central incisors and canines
Esthetic and periodontics interface
Fig. 3. Ideal gingival frame – natural dentition (courtesy of
Dr V. Bennani).
Fig. 4. Patient with a considerable attached gingiva (cour-
tesy of Dr V. Bennani).
(167) (Fig. 3). Correct orientation of the zenith and
gingival height contour following therapeutic manip-
ulation is important as it helps avoid gingival level
disharmony and aids in establishing correct tooth
proportions. The gingival zenith can also be of assis-
tance in forming the desired axial inclination of the
teeth if the line angle position of the long axis of the
tooth is modified (82).
Importance of attached gingiva
Providing a zone of attached gingiva was once consid-
ered paramount to periodontal health (Fig. 4). Histor-
ically, gingival augmentation was recommended to
create a band of attached gingiva where this was
judged as ‘inadequate’. Lang & Lo € e (113) claimed that
gingival inflammation accompanied cases in which
less than 2 mm of attached gingiva was present. It
was believed that this band of attached gingiva is
important to dissipate the muscular pull forces (41,
113) and that it is capable of withstanding trauma
from mastication and toothbrushing (53). However,
this conception has been challenged by many
authors. Miyasato et al. (135) reported that, even in
areas of minimal attached gingiva, periodontal health
can be preserved provided that good plaque control
is practiced. Wennstro € m et al. (204–206) demon-
strated, in a series of studies, that the attached gingiva
had little influence on maintaining periodontal
75
Bennani et al.

health. The current consensus is that the width of the A

attached gingiva is inconsequential for periodontal
health in the presence of good oral-hygiene practices.
In other words, there is no evidence that a narrow
zone of attached gingiva is more prone to inflamma-
tion than a wide zone (102, 135).
Attached gingiva around teeth is important to mini-
mize the risk of gingival recession when preparing
esthetic margins and to increase patient comfort
when performing oral-hygiene procedures (80). Gin-
gival recession has been reported to occur over time
following placement of subgingival margins (184, B
192). The pathogenesis for recession in thin biotypes,
put forward by Baker & Seymour (17) who suggest
that gingival recession involves a localized inflamma-
tory process that causes breakdown of the connective
tissue, is interesting. In areas of thin gingiva, the
entire volume of gingival tissue is inflamed, which
consequently leads to rapid recession of the gingiva
(17). Although this is not necessarily accompanied by
a loss in attachment, it does mean that gingival Fig. 5. Patient complained of ‘short teeth and black
biotype is a factor that must be considered when spaces’ (courtesy of Dr V. Bennani). (A) Loss of interproxi-
planning restorative treatment in the anterior maxil- mal contacts and papillary deficiencies. (B) Matching view
1 year after rehabilitation. Proximal contacts restored with
lary region. Consequently, extra care must be taken porcelain-fused-to-metal crowns and papilla restored (no
not to traumatize the gingiva when intrasulcular periodontal surgery).
restoration margins are prepared in a site with a thin
gingival biotype.
the crest of the bone and related it to the presence or
Papillae contours
absence of interdental papilla. They found that when
Cho et al. (49) evaluated factors that may be associ- this distance is 5 mm or less, the papilla is present
ated with the papillary contours in the maxillary ante- almost 100% of the time. A distance of 6 or 7 mm cor-
rior dentition. They associated age, tooth shape, responded to the presence of the papilla 56% or 27%
interdental contact length, gingival thickness and the of the time, respectively (189).
distance from the contact point to the alveolar crest
with papilla dimensions. They found that long narrow
Hard-tissue considerations
teeth and incisally positioned interproximal contacts
may contribute to papillary deficiency. The same Several parameters are important when considering
study found that square-shaped teeth favored the the relationship of the crown shape to the supporting
occurrence of a competent papilla more than did gingival form. While it seems most logical that a pros-
triangular teeth (49). From an esthetic stance, the thetic crown contour should approximate that of the
three-dimensional relationship of the gingival margin natural tooth in shape, it is sometimes necessary, for
to the crest of the alveolar bone, and to the interprox- several reasons, to change the original dimensions of
imal contact point, are important parameters. The these contours. One such reason is to close open gin-
distance from the gingival margin to the alveolar gival embrasures and diastemas. In a faciolingual
bone varies at different tooth sites. For example, the direction, however, the prosthetic crown contour
free gingival margin is located 3 mm coronal to the should not be increased more than 0.5 mm from the
bone crest on the facial side whereas interproximally, gingival margin as then it may induce plaque reten-
the papilla between the teeth is located 4.5–5 mm tion (109).
coronal to the alveolar bone crest (108, 180). The The relationship between the proximal surfaces of
position of the contact point relative to the alveolar adjacent teeth is another factor that influences both
crest is of importance in maintaining and recon- gingival health and esthetics. When adjacent roots are
structing the interdental papilla (Fig. 5). Tarnow et al. in close approximation, there is less flexibility in alter-
(189) measured the distance from the contact area to ing crown contours, as this may compromise the

76

intricate relationship between interproximal gingival
tissues. On the other hand, when the roots are further
apart, deviations from the original contour are less
likely to compromise gingival health (108, 109).
The location of the interproximal contact areas also
seems to be a critical factor in the esthetic evaluation
as they define incisal and gingival embrasures and
the height of the interdental papillae (127, 138). Con-
sequently, both the locations and dimensions of
interproximal contact areas should be taken into con-
sideration when restoring teeth in the laboratory or in
the clinical setting. The interproximal contact area of
the central incisor is located in the incisal third,
whereas the contact areas of the lateral incisors, cani-
nes and premolars are situated more apically (138).
This, in turn, affects the location of the gingival
embrasures. The heights of the interdental papilla
and the incisal embrasures move in an apical direc-
tion from anterior teeth toward posterior teeth. This
reduction in the distal contact area height relative to
its mesial counterpart results in an increased depth of
incisal embrasures from central incisors to canines
(178).
Biologic space and the need for crown
lengthening
Crown lengthening involves surgically increasing the
clinical crown height. This procedure is indicated for
facilitating restorations in teeth with structurally
inadequate clinical crowns or for exposing subgingi-
val tooth margins that may hamper restorative access.
It is also indicated for esthetic reasons, or in the case
of the ‘gummy smile’, which may require surgical cor-
rection to decrease the gingival display.
When the restoration margin is extended into the
biologic width, gingival inflammation develops within
the attachment apparatus and persists in the area
(198). The biologic width is the vertical dimension of
the dentogingival complex, which comprises the sul-
cular depth, the junctional epithelium and the con-
nective tissue attachment (77). Ingber (98) defined
the biologic width as the measurement between the
depth of the gingival sulcus and the crest of alveolar
bone, and suggested that preserving this distance is
necessary for a healthy periodontal attachment.
Although most clinicians are familiar with the con-
cept of biologic width, some confusion exists regard-
ing its relevance to clinical procedures (98). Gargiulo
et al. (77), who calculated the biologic width mea-
surements of 287 individual teeth from 30 autopsy
specimens, established that there is a definite propor-
tional relationship between the alveolar crest, the
Esthetic and periodontics interface
connective tissue attachment, the epithelial attach-
ment and the sulcus depth. They reported the follow-
ing mean dimensions: a sulcus depth of 0.69 mm; an
epithelial attachment of 0.97 mm; and a connective
tissue attachment of 1.07 mm. Based on their work,
the biologic width is commonly stated to be the
sum of the epithelial and connective tissue measure-
ments, namely a value of 2.04 mm it is important to
realize, however, that significant variations of dimen-
sions were observed, particularly of the epithelial
attachment that ranged from 1.0 to 9.0 mm (77)
(Fig. 6).
When the biologic width is encroached upon by
caries or restorations, the periodontium reacts by re-
creating room between the alveolar bone and the
restorative margin to allow space for tissue reattach-
ment. This can result in gingival inflammation,
increased probing depths and gingival recession
(Fig. 7). To avoid these consequences, the dentist
measures probing depths before embarking on tooth
preparation to decide whether or not crown length-
ening is needed. Crown lengthening should only be
performed on a healthy periodontium free of inflam-
mation. An accurate assessment of the relationship
between the preparation margins to the healthy gin-
gival sulcus can then be made before performing
crown-lengthening surgery.
Understanding the interplay between the position
of the gingival margin, the cemento–enamel junction
and that of the alveolar crest is important. When
determining the ideal position for placing the margin
of an esthetic restoration, it is important that the total
dimension of the attachment and the sulcus depth,
are taken into account. This allows the clinician to
establish the long-term restorative effects on gingival
health and esthetics. A minimum distance of 3 mm
should be planned between the restorative margin
and the alveolar bone to avoid the deleterious effects
of biologic width violation (150). It has also been sug-
gested that, when the sulcus probing depth measures
1.5 mm or less, the margin could be placed 0.5 mm
below the gingival tissue crest. If the sulcus probing
depth is more than 1.5 mm, the restorative margin
can be placed in half the depth of the sulcus. If the
sulcus probing depth is greater than 2 mm, gingivec-
tomy could be performed to lengthen the tooth and
create a 1.5 mm sulcus (108, 141).
Prosthetic considerations
Restoration contours
The relationship between the coronal contours of an
artificial crown and the gingival tissue has been well
77
Bennani et al.
A B
D E
Fig. 7. Patient complained of ‘bleeding gums and
unpleasant appearance’ (courtesy of Dr V. Bennani). (A)
Pocketing > 7 mm, inflammation of gingival tissue, gin-
gival recession and unesthetic crowns. Note that the opa-
que layer is showing at the gingival third of the
porcelain-fused-to-metal crowns. (B) Occlusal views after
removal of the crowns. Note the lack of reduction on the
finishing lines and iatrogenic interproximal preparations,
and invasion of the biological width requiring a peri-
odontal crown-lengthening procedure. (C) Matching view
78
Fig. 6. Schematic representation of
biologic width (in mm). Reproduced
with permission from Elsevier. From
Bennani et al. (28).
C
F
12 weeks after periodontal crown lengthening with the
first set of provisional restorations in place. (D) Same
view, provisionals removed. Note the gain of vertical
height, allowing proper space for the attachment and for
the future restorations. (E) Placement of new finishing
lines; note that these are kept slightly supragingivally. (F)
Second set of provisionals in place allowing for further
maturation of the supporting tissue. These provisionals
are also used to evaluate esthetics, phonetics and func-
tion.

A B
Fig. 8. Restoration contours (courtesy of Dr V. Bennani).
(A) Tooth preparation should allow enough space to per-
mit the technician to create a mechanically sound and
esthetically acceptable prosthesis. (B, C) The fixed
documented (69, 203, 213). Two aspects of coronal
contour, key to good tissue integration, are the cervi-
cal contour and the interproximal contour (108)
(Fig. 8).
Cervical contour. Coronal contour requirements are
that they should resemble the natural teeth but also
in doing so provide an environment that promotes
optimal gingival health (81, 108). These contours are
normally determined by tooth anatomy, periodontal
condition, margin placement and access to oral
hygiene (Fig. 9). Sometimes compromises have to be
made to satisfy both esthetics and proper access for
oral hygiene (80). The most common error made in
re-creating contours of an artificial crown is over-
contouring of the facial and the lingual surfaces (152).
Poor preparation of the abutment can lead to over-
contouring because if there is a lack of space it forces
the dental technician to over-contour the restoration
(40) (Fig. 10). Properly contoured facial, lingual and
interproximal surfaces will avoid any impingement
on the soft tissue and prevent plaque accumulation
(107, 172, 182), which could result in gingival inflam-
mation (152). When the coronal contour of the
restoration prevents access for oral hygiene and/or
creates pressure on the soft tissue, the gingival heath
is liable to be compromised (108).
A B
Esthetic and periodontics interface
C
prosthesis should be fabricated with the proper contours
and emergence profile, to allow a long-lasting esthetic
result and patient access to all areas to maintain periodon-
tal health.
The profile of the restoration as it emerges from the
gingival sulcus is also an important factor to consider
(99, 199). This profile, described by Stein & Kuwata
(183) in 1977 as the emergence profile of a restora-
tion, should be straight for the first 0.5 mm of the
restoration to maintain healthy gingival tissues
(Fig. 11). Another parameter that needs consideration
in this area is the emergence angle. The emergence
angle is formed by the junction of a line though the
long axis of the tooth and a tangent drawn to the
coronal of the tooth as it emerges from the sulcus
(164). Du et al. (66), in a recent study, recommend
that the maxillary anterior artificial crown should fol-
low an emergence angle of 15°. These authors also
recommend a straight emergence profile of 0.5 mm
to maintain healthy gingival tissues. In the esthetic
zone this profile includes a subgingival component
and a supragingival component. The subgingival por-
tion should follow the contours of the cemento–
enamel junction to support the gingival tissue. The
final restoration should follow the contour estab-
lished by the root anatomy (80). Becker & Kaldahl (22)
and Padbury et al. (150) state that buccal and lingual
contours should be flat, usually < 0.5 mm wider than
the cemento–enamel junction, and that furcation
areas should be barrelled out to allow for easier oral
hygiene access. Over-contouring tends to increase
Fig. 9. Cervical contour (courtesy of
Dr V. Bennani). The furcation area
should be barreled out (A) as this
allows sufficient room to fabricate a
properly contoured crown (B).
79
Bennani et al.
B
C
Fig. 10. An overcontoured restoration is often the result of
an underprepared abutment (courtesy of Dr V. Bennani).
(A) Note the inflamed gingiva and the opaque appearance
of the porcelain-fused-to-metal crowns. (B) IPS empress
crowns after final cementation with resin cement. Note the
supragingival margins. (C) Twelve months after delivery,
showing good integration of the crowns with the gingival
tissues. In this case no periodontal surgery was performed.
After revisiting the tooth preparation, the over-contoured
restorations were simply replaced with well-contoured
provisionals to allow the gingival tissue to heal.
plaque retention and can lead to inflammation of the
gingival tissue. Inversely, under-contoured teeth
rarely show signs of gingival inflammation (152). In
conclusion, cervical contours should not be overbuilt
and should always allow easy access for oral hygiene
(Fig. 12).
Interproximal contours. Interproximal contours are
considered by some authors to be even more impor-
tant than the facial and lingual contours (137). Inter-
proximal contours are critical as they have an
80
Fig. 11. The emergence profile of a restoration should be
straight for the first 0.5 mm to maintain healthy gingival
tissues (courtesy of Dr V. Bennani).
immense impact on the shape and health of the
papilla, especially when the roots of the adjacent teeth
are close together (109). Overbuilding the interproxi-
mal contours will impinge on the interpapilla space
and considerably reduce access to oral hygiene, result-
ing in inflamed and hypertrophied papilla (73). How-
ever, Hirshberg (93) concluded that good oral hygiene
had more effect on the papilla health and contour
than did the height of the embrasure. Another cause
of papillary inflammation is iatrogenic preparation of
proximal surfaces of the tooth impinging on the inter-
proximal epithelial collar (73). This violation of the
biological width can only be resolved with a surgical
crown-lengthening procedure (109).
On the other hand, proximal surfaces should not be
under-contoured. Loose interproximal contacts lead
to food impaction and are often uncomfortable for
the patient (150). Even if there is conflicting opinion
on the effect of an open interproximal contact and
pocketing (103, 115), it is generally accepted that firm
interproximal contacts are important for gingival
health (150). Furthermore, proximal surfaces should
not be under-contoured as opening them excessively
can result in poor esthetics, poor phonetics and lat-
eral food impaction (73). To conclude, the ideal size
of the interproximal surface is one that permits good
access to oral hygiene, does not compress the papilla,
allows proper phonetics, is in harmony with the adja-
cent teeth and provides effective, and properly
located and shaped proximal contacts (26, 73, 161,
172).
Margin design
Adequate tooth reduction is essential to provide
enough space for an esthetic thickness of material

A B C D
Fig. 12. Accurate registration of the prepared tooth struc-
ture and part of the unprepared surface beyond the mar-
gin (courtesy of Dr V. Bennani). (A) Capture of the tooth-
emergence profile and its transfer onto the die (step 1). (B,
C) This profile is then elongated using a #15 blade in the
dental laboratory (step 2) to ease its transfer on the future
and to avoid over-contoured restorations. When teeth
are prepared for fixed prostheses, care must be exer-
cised not to traumatize gingival tissues, especially in
areas of thin or minimally attached gingiva, as reces-
sion may consequently follow (161), leading to a com-
promise in the esthetic outcome. The authors
recommend the use of silicone keys made from a
wax-up as a guide, thus ensuring that enough room is
created for the final restoration.
The type of finish line chosen can increase the
potential for trauma to the epithelial attachment. A
shoulder finish line can be formed subgingivally while
keeping the rotary instrument totally embedded in
the peripheral tooth contours, therefore avoiding tis-
sue trauma. Extra care is warranted when a chamfer
or bevelled shoulder type of finish line is established,
as part of the rotary instrument is located outside
peripheral tooth contours with a greater likelihood
for gingival tissue damage (83). To minimise the likeli-
hood of adverse effects on the soft tissue, Sous et al.
(179) recommend using ultrasonic tips when creating
the subgingival finish.
Margin placement
Supragingival margins are the ideal standard when it
comes to restoration margin location. Studies on both
animals (198) and humans (176, 177) have demon-
strated that a favorable periodontal response is asso-
ciated with restorative margins which are placed
coronal to, or at, the level of the gingival margin. Plac-
ing a restoration in the gingival crevice should always
be considered a compromise. Clinical studies have
reported more attachment loss with subgingival
crown margins than with equi- or subgingival mar-
gins (192). Restoration margins for full crowns or
veneers must frequently be extended into the gingival
Esthetic and periodontics interface
E
crown (step 3). (D) A shoulder preparation with no sharp
angles is excellent for metal–ceramic crowns with porce-
lain butt margins. (E) The porcelain-fused-to-metal crown
has a proper emergence profile that supports the soft tis-
sues and allows soft-tissue integration of the restoration.
crevice for a number of reasons, such as in the case of
subgingival caries, to increase retention and resis-
tance forms for a short clinical crown, or for esthetics.
Nevertheless, certain precautions can be taken to
minimize colonization with bacterial biofilm. It is
important to reproduce the original tooth contours as
closely as possible and avoid creating restorations
with marginal overhangs.
Marginal integrity
Conventional wisdom suggests that restorations with
open margins lead to clinical problems (14, 84). Pla-
que accumulation may lead to clinical consequences,
such as gingival inflammation and recession, which
may have an impact on the final esthetic result (173).
However, establishing the consequences of ill-fitting
margins has not been straightforward. There is still
controversy around what defines a clinically accept-
able margin. Published data on what constitutes an
‘acceptable’ marginal discrepancy varies between 30
and 200 lm (50, 60, 120, 132, 148, 193).
Although the marginal adaptation is likely to carry
undesirable periodontal effects, more deleterious
effects seem to be related to overhanging subgingival
margins than they are to open-prostheses margins.
Lang et al. (112) demonstrated that the placement of
subgingival overhangs resulted in changes to the
microflora to that which resembles microflora har-
vested from adult chronic periodontitis. Therefore,
not only do overhangs result in increased plaque
retention but also in an increase in periodontal patho-
gens in the area and in periodontitis of greater severity
(87, 149). Stetler & Bissada (184) also reported that
there is a higher likelihood of gingival recession when
placing subgingival restorations in sites with a narrow
band of gingiva than in sites with a thick band.
81
Bennani et al.
Optimizing esthetic outcomes
Preprosthetic surgery
The gingival apparatus plays an important role in
the overall beauty of an individual’s smile. Esthetic
periodontal plastic surgery is becoming an insepara-
ble part of dental treatment as patients become
increasingly more conscious of dental esthetics.
Therefore, it is important for clinicians to be aware
of the different options, the reliability of these treat-
ment modalities, the consistency of results and the
long-term prognosis. This requires scientific
approaches to therapeutic procedures. The different
plastic-surgery procedures range from those that
involve correcting short crowns to those which cor-
rect defects such as recession and interdental papil-
lary loss. In the next section these surgical
procedures will be discussed.
Correction of the short crown
Short crowns and/or excessive gingival display are
considered as unpleasant by many patients (125).
Tjan et al. (191) described the position of the upper
lip line in relation to the teeth and gingiva as an
important factor in the esthetics of a smile. They
reported an anterior crown height display of less than
75% in a low smile and of 75–100% in an average
smile. A high or ‘gummy’ smile, on the other hand,
shows the full length of the anterior crown heights, in
addition to a band of gingival tissue.
These conditions can be attributed to skeletal or
tooth factors. The skeletal factors may be vertical
excess of maxillary tissue, short upper lip or a combi-
nation of both (76). Tooth factors may be a result of
normal variation in length, incisal edge wear or exces-
sive gingival display. Incisal edge wear is seen in
patients with parafunctional habits causing attrition
of teeth, in patients with dental trauma or in patients
with caries. On the other hand, short crowns as a
result of excess gingival coverage can be caused by
gingival hyperplasia or altered passive eruption (62).
In altered passive eruption, the gingival margin fails
to migrate apically to 1–2 mm of the cemento–
enamel junction. In gingival hyperplasia, the gingiva
usually appears abnormal (Fig. 13). However, in the
case of tooth wear and altered passive eruption, the
gingiva is of normal texture and contour. The differ-
ence between these two appearances can be diag-
nosed by inserting a probe into the gingival margin:
the cemento–enamel junction can be detected in the
case of tooth wear but cannot be located in the case
82
Fig. 13. The gingival appearance in phenytoin-induced
gingival hyperplasia (courtesy of Dr L. Al Harthi).
of altered passive eruption (76). Altered passive erup-
tion is classified into two types: type I and type II. In
type I there is an increased gingival band, and if the
cemento–enamel junction–bone distance is more
than 2 mm, it is called subgroup A; subgroup B is
when bone is at the level of, or less than 2 mm from,
the cemento–enamel junction. Both subgroups are
also seen in type II altered passive eruption, in which
the gingival band is normal (58). The choice of surgi-
cal procedure will depend on the type and subgroup.
Pre-prosthetic planning. Before the decision is made
regarding the type of surgical procedure, pre-prosthe-
tic planning of the desired esthetic outcome should
be performed. An assessment of the smile line and
periodontal parameters is paramount in determining
the most suitable treatment plan and surgical
approach to correct the excessive gingival display.
Current standards in the average smile suggest locat-
ing the gingival contour at canines at a level similar,
or slightly apical, to that at central incisors, but more
coronal at lateral incisors (30). An understanding of
the interplay between the position of the gingival
margin, the cemento–enamel junction and the alveo-
lar crest is important when deciding on the treatment
plan. Ingber (98) defined the biologic width as the
measurement between the depth of the gingival sul-
cus and the crest of alveolar bone, and suggested that
preserving this distance is necessary for a healthy
periodontal attachment (98). Therefore, clinicians
have been using this distance as a guideline to pre-
serve the biologic width when performing crown-
lengthening surgery. To plan with this concept, both
the distance from the gingival margin to the
cemento–enamel junction, and from the gingival
margin to the bone crest, are measured utilizing bone
sounding of the cemento–enamel junction and the
alveolar bone crest. Measuring this distance helps
dictate the most suitable surgical technique to estab-
lish a more harmonious dentogingival ratio. This

information could be transferred to a diagnostic wax-
up and can be shown to the patient whose opinion is
important in the decision-making process (185). Once
the clinician and the patient are satisfied with the
esthetic outlook appearance on the model, this infor-
mation is transferred to a surgical template (100). The
surgical template will serve as a guide for the choice
of surgical procedure and thus will help achieve pre-
dictable results and improve the esthetic outcome.
Another important consideration of esthetic crown
lengthening is the harmony of anterior and posterior
segments. Tjan et al. (191) have reported that second
premolars are displayed in 80% of adults while smil-
ing. Therefore, in some cases the crown-lengthening
procedure may be extended up to the first molar.
Surgical procedures. The surgical management of
short crowns by crown lengthening may include gin-
givectomy or apically repositioned flap, with or with-
out ostectomy. Gingivectomy is indicated in type I
altered passive eruption. In the clinical situation illu-
strated in Figure 14, the initial incisions are made at
the buccal aspect following the outline of the surgical
template, while the interproximal incisions are intra-
sulcular, thus preserving the papilla. In subgroup A
the excess tissue is excised, and in subgroup B a full-
thickness flap is elevated buccally and an ostectomy
A D
E (A) A diagnosis of altered passive
B the clinical examination is drawn on
F ensures proper support and stability
C for the stent. The palatal window
G
Esthetic and periodontics interface
is performed only at the buccal side, leaving a dis-
tance of 2.5–3 mm between the stent and the bone
(8). In type II altered passive eruption, apically reposi-
tioned flap, with or without ostectomy, is indicated.
Here, intrasulcular incisions are made, then the surgi-
cal stent is applied to guide the ostectomy in the case
of subgroup B. This is followed by suturing the buccal
flap to the level of the osseous crest to minimize the
chance of future tissue regrowth (34). However, it is
important to note that some tissue regrowth should
be expected, especially in patients with a thick peri-
odontal biotype (34, 158). Therefore, secondary sur-
gery may be needed to refine esthetic outcomes, as
illustrated by a case of esthetic crown lengthening
(Fig. 14).
A minimally invasive surgical technique for crown
lengthening has been described in the literature (42).
Here, sulcular incisions are performed, followed by
removal of bone with microchisels without flap eleva-
tion. A comparison study between the traditional
crown-lengthening technique and this minimally
invasive technique has reported similar clinical
results (162). However, this is very technique sensitive
and the amount of bone removed cannot be accu-
rately visualized. Another disadvantage of this tech-
nique is its limitation to those cases with thin bone
(162).
Fig. 14. Patient complained of
‘showing too much gum’ (courtesy of
Dr H. Ibrahim and Dr S. Praema).
eruption was made. (B) A line indi-
cating probing depths obtained from
the cast. A clear rigid stent following
this contour is fabricated. The buccal
window acts as a guide and allows
access during surgery. (C) Occlusal
view of the stent on the cast. The
palatal and occlusal coverage
facilitates access during surgery
when needed. (D) The stent is tried
in the mouth before surgery. (E) The
stent used at the time of surgery. The
incision made represents the pre-
scribed line on the diagnostic cast.
(F) Result 6 months after surgery.
(G) Result 6 months after surgery
(closer view). Tooth 21 will require a
secondary surgery to correct the gin-
gival level.
83
Bennani et al.
Other surgical treatment modalities include elec-
trosurgery and diode or neodymium-doped yttrium
aluminium garnet (Nd:YAG) lasers for the removal of
gingival tissue. These should only be performed to
remove the excess keratinized tissue. As lasers are
‘end cutting’ and side safe, they can be used in a
novel approach to osseous crown lengthening. Flap-
less osseous crown lengthening can be performed by
recontouring the osseous crest apically using the
superpulsed CO2 laser, or diode or Nd:YAG lasers
(121). However, a disadvantage of electrosurgery or
laser surgery is the production of collateral tissue
damage compared with no collateral tissue damage
following surgery with a scalpel.
Correction of recession
Recession has been defined as ‘the displacement of
the marginal tissue apical to the cemento–enamel
junction’ (9). Gingival recession results from the api-
cal migration of gingival tissues. Periodontal surgery
to provide root coverage has been reported since the
beginning of the 20th century (15). A variety of surgi-
cal techniques are available. These are pedicle grafts,
free grafts, grafts combining the two modalities and
guided tissue regeneration, which uses artificial
membrane beneath the flap.
The predictability of root coverage with surgery is
influenced by many factors, including whether the
gingival margin is apical to the mucogingival junc-
tion, whether there is loss of interproximal peri-
odontium and the extent of tooth malposition (134).
Moreover, the predictability of root coverage can be
enhanced by the use of a microsurgical approach
(36). Burkhardt & Lang (37) reported that 98% of
sites in the microsurgery group remained stable
during the first year compared with 90% in the con-
ventional macrosurgery group. Whatever procedure
used, the basic principles in periodontal surgery
have to be observed preoperatively, during the
intervention and postoperatively (37).
Free grafts. Free grafts are divided into free gingival
graft (94, 134, 186), which is an epithelialized free
A B
84
gingival graft, and connective tissue graft (114), which
is a subepithelial free graft. With free grafts a partial-
thickness flap is raised over the tooth using sulcular
incisions and oblique, mesial and distal releasing inci-
sions. Then the exposed root surface and the sur-
rounding recipient bed are covered with donor tissue,
of similar size, from the palate. The graft can either be
placed over the surface of the recipient area (nonsub-
merged) or under the flap (submerged). Surgical suc-
cess will depend on the thickness of the graft
harvested, which should be at least 2 mm (118). A
thick free-gingival graft will be more likely than a thin
graft to revascularize and survive on an avascular root
surface. Flap tension is also important for the success
of the grafting procedure. This needs to be minimized
when suturing to allow passive adaptation to the root
surface (156).
The flap is usually repositioned in the case of a con-
nective tissue graft. A modification of this technique
has been proposed in which a tunnel is prepared
instead of the envelope flap (5, 6). In this technique,
partially epithelialized connective tissue grafts were
used; the epithelial border of the graft was not
excised, but was left coronal to the border of the flap.
Bouchard et al. (32) suggested removing the epithelial
collar and completely immersing the graft under the
flap; the rationale of this is to enhance the esthetic
results. The connective tissue graft has an advantage
over a free gingival graft as the risk of discomfort and
the potential for postoperative bleeding from the
donor area is reduced because of the large palatal
wound that results from a free gingival graft. More-
over, the color match in connective tissue grafts is
better than that in free gingival grafts (134) making it
a preferable procedure for esthetic reasons (Fig. 15).
Pedicle grafts. Pedicle graft procedures are usually
recommended if there is sufficient width, length and
thickness of keratinized tissue adjacent to the area of
gingival recession and if the vestibule is not shallow.
The pedicle flap might be released from adjacent
teeth, known as rotational flaps (laterally repositioned
flap, double papilla flap), or from above the same
Fig. 15. The unpredictable color
match is apparent after placement of
the free gingival graft (courtesy of Dr
L. Al Harthi). (A) Before surgery. (B)
After surgery.

tooth, known as advanced flap procedures (coronally
positioned flap, semilunar coronally repositioned
flap). The surgical techniques are similar except for
the flap design. After adequate anesthesia is obtained,
the exposed root surface is root planed to eliminate
calculus, plaque and caries. Additionally, any root
prominence that could be reduced without removal
of excessive tooth structure is eliminated. The
exposed root surface can be conditioned with, for
example, citric acid or tetracycline hydrochloride;
however, controlled studies comparing laterally repo-
sitioned flap (144) and free gingival graft (33), with
and without root conditioning (citric acid), show no
statistically significant benefit. The flap is then raised
according to the chosen design.
The advantages of pedicle grafts are that there is
only one surgical site and the blood supply of the
pedicle flap covering the root surface is preserved.
However, these procedures are only applicable for
relatively minor gingival recession (narrow and
shallow) or for recession limited to one tooth (208). In
laterally repositioned flap, a full-thickness (86) or a
partial-thickness (181) flap from an adjacent donor
area is dissected and laterally repositioned to cover
the defect, thus maintaining the connection with the
donor site and preserving blood supply. Whether a
full- or a split-thickness laterally repositioned flap is
used depends on the surgeon’s preference as no dif-
ference has been shown between the two procedures
(72), although a review by Wennstro € m (207) found
that the use of laterally repositioned flap on teeth
with an initial recession depth of < 3 mm had better
results than when used on teeth with defects of
> 3 mm.
The double papillary repositioned flap involves the
lateral movement of both mesial and distal flaps to
the defect (52). This procedure has limited usefulness
because of its poor predictability and the high surgi-
cal skill required to perform the procedure (92). High
success rates were, however, achieved when a free
connective-tissue graft was combined with full-thick-
ness double pedicle flaps. Complete root coverage
was observed in 80–90% of defects (91).
Coronally positioned (7) and semilunar coronally
repositioned (190) flaps are only used if more than
3 mm of keratinized tissue apical to the recession
defect is present and the gingiva has a thickness of at
least 1 mm (7). A modification of the coronally posi-
tioned flap, in which no release incisions are made,
has been proposed (215). The use of Emdogain@
under a coronally positioned flap has shown better
results than coronally positioned flap alone, or of
acellular dermal matrix is used. However, this adds
Esthetic and periodontics interface
cost and there appears to be no difference compared
with connective tissue graft with a coronally posi-
tioned flap (39).
Guided tissue regeneration. Guided tissue regenera-
tion describes surgical procedures that attempt to
regenerate lost periodontal structures through dif-
ferential tissue responses (9). The technique for
guided tissue regeneration was originally developed
for the treatment of infrabony defects (142). Later, it
was used for the treatment of marginal tissue reces-
sion defects to substitute for autogenous grafts, with
promising results obtained by histology (54). The
advantages of guided tissue regeneration over the
other procedures are: lack of donor-site morbidity;
less chair time; unlimited availability of the product;
and uniform thickness of the product (201). Clinical
trials comparing guided tissue regeneration-based
procedures with free gingival grafts and subepithe-
lial connective tissue grafts have reported similar
results (155, 200). Nonetheless, guided tissue regen-
eration-based procedures often result in less root
coverage and less predictability than free and pedi-
cle grafts, with flap thickness being the main factor
influencing outcome. Exposure of the membrane is
one of the complications that could occur after the
guided tissue regeneration surgery but it is not the
only reason for the lower root coverage. The main
influential factor is flap thickness. A flap thickness
of ≥ 0.8 mm in the defect area is adequate and will
improve the percentage of root coverage (26.7% root
coverage in thin tissues vs. 95.9% root coverage in
thick tissues) (90, 129). Nonresorbable (157) and
bioabsorbable (155) barrier membranes have been
used. Similar results were obtained for both (163)
but the advantage of the bioabsorbable membranes
is the single surgical procedure (Fig. 16).
Decision making for choice of technique. The choice
of surgical technique will depend on the anatomical
characteristics of the area, that is: the tooth location;
multiple or single recession defects; the interdental
attachment level (Miller Class); the amount and thick-
ness of keratinized tissue apical and/or lateral to the
recession; the vestibular depth; and the height and
width of the recession defect (59) (Table 1).
Complete root coverage should be a prerequisite
for success; however, this is not always possible. A
study investigating patient satisfaction reported that
patients considered the esthetic results as ‘very good
to excellent’ when root coverage was ≥ 80.2% (106).
Another important factor is color match of the tissue
and soft-tissue appearance. The free gingival graft is
85
Bennani et al.

A B

C D Fig. 16. Patient referred for correc-

tion of the recession defect on tooth
23 (courtesy of Dr L. Al Harthi). (A)
Moderate-to-wide recession defect
on tooth 23 (Miller Class I). The
patient’s concern is esthetics. After
preparing the recipient site by rais-
ing an envelope flap and scaling the
denuded root surface (B) a biore-
sorbable graft is sutured in place (C).
(D) Eighteen months after surgery.

Table 1. Decision aid model for root coverage surgery (single recession)*

Procedure Miller Miller Miller Wide Deep Thick keratinized Thin keratinized
Class I† Class II Class III defect defect tissue‡ tissue

Coronally positioned flap or semilunar + +

coronally repositioned flap

Connective tissue graft+coronally + + + + + + +

positioned flap

Enamel matrix derivative+coronally + + + + + +

positioned flap

Barrier membranes+coronally + + + + + +
positioned flap

Laterally repositioned flap + +

Guided tissue regeneration + + + + +

*Miller Class IV not included, evidence still weak (46).
†Depending on the thickness of the keratinized tissue: the simpler, more cost-effective surgical procedures are coronally positioned flap and connective tissue
graft+coronally positioned flap.
‡The simpler, cost-effective surgery will be coronally positioned flap.

considered unesthetic as a result of poor color match
and is therefore no longer recommended in the
esthetic zone. The double-papilla flap is also out-
dated because of its technique sensitivity and its
unpredictability as a result of the risk of cleft forma-
tion, resulting from suturing above a denuded root.
Long-term stability is also important, although most
randomized controlled studies comparing different
techniques are of short duration (45). Long-term
studies of 5 years’ duration have concluded that con-
nective tissue graft and coronally positioned flap have
better gingival margin stability in single recession
defects than does coronally positioned flap alone in
single recession defects. Moreover, the connective
tissue graft and coronally positioned flap have shown
creeping attachment or coronal improvement of the
gingival margin over time (111, 154). In these studies,
Miller Class I defects showed no differences in results
between the two surgical procedures for the entire
observation period. However, in Miller Class II defects
a difference in stability was noted after 12 months,
favoring connective tissue graft and coronally posi-
tioned flap. A systematic review by Buti et al. (38),
looking at the ranking of treatments according to
effectiveness for complete root coverage, showed
superior results of enamel matrix derivative plus
coronally positioned flap in comparison with connec-
tive tissue graft plus coronally positioned flap,

86

although the difference was not statistically signifi-
cant. Another systematic review, in which connective
tissue graft was replaced with guided tissue regenera-
tion, enamel matrix derivative or barrier membranes,
showed less complete root coverage, although this
was only significant in the case of guided tissue
regeneration (39). Moreover, this systematic review
showed that multiple combinations of more than one
graft and/or biomaterial under the flap did not add
any benefits to the simpler procedures. A meta-analy-
sis of different procedures also confirmed that con-
nective tissue graft and coronally positioned flap is
the most predictable cost-effective technique to
obtain complete root coverage (44). Therefore,
enamel matrix derivative or barrier membranes could
be used in cases in which there is insufficient connec-
tive tissue graft or if the patient prefers a single surgi-
cal site, and these should be given to patients as
options.
The clinician’s preference between these proce-
dures is likely to drive the decision-making process.
In Table 1, we propose the most predictable proce-
dures for the different scenarios around the single
recession defect, taking into account the available
evidence. In comparison, for multiple recession
defects the studies available are scarce, making it dif-
ficult to recommend a particular procedure (43). A
recent systematic review proposed that connective
tissue graft or barrier membranes is recommended
with coronally positioned flap, modification of the
coronally positioned flap or tunnel preparation (85).
This systematic review also found that the outcomes
with coronally positioned flap were not as favorable,
suggesting that modified coronally positioned flap or
use of a tunnel preparation might be superior to coro-
nally positioned flap in multiple recession defects.
Correction of lost interdental papilla
The loss of interdental papilla can lead to many prob-
lems, such as esthetic problems (so-called ‘black tri-
angles’), phonetic problems (space allowing passage
for the air or saliva) and food impaction. Restoration
of lost interdental papilla is one of the more challeng-
ing problems in esthetic dentistry. Therefore, preserv-
ing the interdental papilla in different procedures
should be of paramount importance. In anterior
teeth, the interdental papilla has a pyramidal shape,
with the tip located immediately beneath the contact
point. Posteriorly, it is broader and has been
described as having a concave col or bridge shape
(51). However, this disappears when a contact point
is absent or when interdental papilla migrate apically
(187).
Esthetic and periodontics interface
The distance between the interdental bone to the
contact point has been described as a major factor for
predicting complete papilla fill (189). When the dis-
tance from the contact point to the alveolar bone is
≤ 5 mm, complete papilla fill occurs in 98% of cases,
while papilla fill decreases to 56% and 27% when the
contact point to the alveolar bone is 6 and 7 mm,
respectively (189). This fill can also be affected by the
interproximal distance between roots (49). A number
of other factors affecting the presence of interdental
papilla have been described and these include tooth
morphology, periodontal biotype and periodontal
bioform (2). It is important to understand these fac-
tors when restoring teeth in order to preserve the
interdental papilla.
Papilla loss is classified into four categories (140).
The interdental papilla is classified as normal when it
fills the embrasure space to the apical extent of con-
tact area. When the interdental papilla does not fill
the embrasure space but is coronal to the interproxi-
mal cemento–enamel junction, papilla loss is classi-
fied as class I. Class II papilla loss is considered as
occurring when the interdental papilla lies apical to
the interproximal cemento–enamel junction, while in
class III papilla loss, the interdental papilla lies apical
to the facial cemento–enamel junction.
Correction of lost interdental papilla can be carried
out surgically or nonsurgically, depending on the
amount of loss (31). Nonsurgically, the loss can be
corrected through restorative camouflage or an
orthodontic approach. Restoratively, the contact
point can be lengthened and located more apically,
allowing coronal displacement of the interdental gin-
giva. Orthodontic closure of the interdental space and
coronal movement of the tooth can both cause some
degree of coronal ‘creeping’ of the papilla (88).
Papilla reconstruction surgery has been described
in the literature. Some of the techniques used include
a pedicle flap with or without a connective tissue graft
(21, 88), and a connective tissue graft with or without
autogenous bone (10, 11). In the pedicle flap tech-
nique, semilunar and intrasulcular incision are made
to release the connective tissue of the root surface
and the papilla is coronally placed. The connective
tissue graft is then harvested from the palate, placed
in the space created by the displacement and
sutured. This procedure may be repeated after
3 months of healing, until the desired outcome is
achieved (88). With the connective tissue graft tech-
nique, a partial thickness flap is raised on the labial
and palatal surfaces of the tuberosity area, the graft is
harvested with or without autogenous bone and then
it is trimmed to shape and size. The palatal and labial
87
Bennani et al.

flaps are sutured in place covering the graft. This area A

is very small and the blood supply is minimal and can
easily be jeopardized, leading to necrosis of grafted
tissue. Consequently, the procedure is not predictable
and long-term stability is not guaranteed (131). More-
over, multiple authors have suggested that the sur-
gery may need to be repeated several times to achieve
an optimal result.
At the time of writing, no evidence was available to
show statistically which method is best; however, all
studies stress the importance of careful tissue manip-
B
ulation to increase the chance of success. In one
study, the use of microsurgery was recommended to
improve surgical outcomes (139) and, in other stud-
ies, the use of injectable autogenous material has
been proposed to overcome the need to raise a flap
(61, 131). Despite this, the reconstruction of lost inter-
dental papilla remains challenging and unpre-
dictable, and further studies are needed to determine
the best technique (145).
From the evidence available, it is clear that presur- C
gical planning to preserve the papilla, rather than
reconstruction, is important. Different flap tech-
niques have been described to preserve the papilla
and minimize its loss as much as possible (47, 55,
188). All of these techniques aim to preserve the
papilla by eliminating any incision through it;
depending on technique, the incisions are made to
the palatal or buccal surfaces and a full-thickness flap
is reflected to preserve the papilla (Fig. 17). If the
interproximal area is very narrow, however, preserv- D
ing the papilla may be difficult. To overcome this lim-
itation, Cortellini and his group (56) proposed
another flap design – ‘the simplified papilla preserva-
tion flap’ – in which an oblique incision is made
across the papilla, from the gingival margin at the
buccal line angle of the involved tooth to the mid-
interproximal portion of the papilla under the contact
point of the adjacent tooth. A full-thickness palatal
flap, including the papilla, and a split-thickness buc-
cal flap are then elevated together. This technique is
best used when the interdental space is ≤ 2mm. Cor- Fig. 17. Patient undergoing periodontal treatment
tellini & Tonetti (57) also emphasize the importance required flap access surgery on teeth 11 and 12 (courtesy
of using a microsurgical approach to reduce trauma of Dr L. Al Harthi). (A) Preoperative photograph showing
to the papilla. interdental papilla between teeth 11 and 12. (B) Papilla
preservation flap raised by placing the incision palatally.
Increasing the zone of attached gingiva in prosthetic (C) Papilla kept intact to buccal flap. (D) Five months after
dentistry surgery.

The importance of a zone of attached gingiva for

maintaining periodontal health is controversial; of keratinized tissue and ≥ 1 mm of attached
however, its importance for esthetics and in gingiva is necessary around teeth’ (105). In
selected clinical situations have been reported prosthodontics, gingival augmentation is required
(169). The current consensus states that: ‘≥ 2 mm in cases in which there is an inadequate zone of

88

keratinized tissue around a prosthesis, especially if
the margins are subgingival, and in cases in which
a removable prosthesis is needed and there is a
shallow vestibule (9). It has been suggested that
5 mm of keratinized tissue is desirable to prevent
recession in areas in which a restoration with sub-
gingival margins is planned (130). Moreover, kera-
tinized tissue thickness and width are important
around implants (214).
The two procedures most frequently used to
increase the width of keratinized tissue are free
gingival graft (186) and connective tissue graft (68).
Both techniques are of similar predictability but
connective tissue grafts have better esthetic results
(147). One important factor to note is that connec-
tive tissue grafts have a higher shrinkage rate in
comparison with free gingival grafts (105). To avoid
the morbidity of two surgical sites, the use of allo-
graft (97, 151) and xenograft (169) materials have
been proposed. Both show good results; however,
allograft materials (being derived from cadavers)
possess the disadvantage of an increased risk of
disease transmission. A systematic review compared
these procedures and proposed a decision tree to
increase the zone of attached gingiva according to
the availability of tissue in the donor site (105)
(Fig. 18).
Respecting the periodontal structures
through prosthodontic procedures
Close attention to both soft and hard tissues around
the teeth, before, during and after restorative proce-
dures, will greatly increase the probability of a suc-
cessful esthetic outcome (80). Donovan et al. (65)
Esthetic and periodontics interface
proposed five strategies for ensuring proper nontrau-
matic tissue management when working in the
esthetic zone. They proposed that optimal soft-tissue
health may be attained before impression making by
minimizing iatrogenic soft-tissue trauma during mar-
gin placement and gingival displacement procedures
and waiting an appropriate amount of time after
periodontal surgical therapy to allow tissue healing.
They also recommended providing provisional
restorations of excellent quality and ensuring the
elimination of any excess temporary cement. Proper
cementation of provisional restorations is also an
important factor to achieve gingival health. After
cementation, all traces of provisional cement should
be removed to prevent unfavorable gingival healing
(79, 171).
An esthetic restoration must also be biologically
integrated, and a key factor to achieving this is
the proper management of the gingival frame.
Fixed prosthodontic procedures can lead to gingi-
val inflammation, recession or pocketing. Trauma
can be caused to the periodontal apparatus by
tooth preparation, provisional restorations, gingival
retraction and impression procedures, and the
design of the restoration and its marginal adapta-
tion (108). Some insult to the periodontium is
almost inevitable; however, to avoid irreversible
adverse effects this should be kept to a minimum.
All practitioners working in the esthetic zone have
experienced the adversities of working with sup-
porting tissue and know that the real challenge is
its ‘nontraumatic’ management. The anatomy and
biology of the periodontal structures must be per-
fectly understood and periodontal health must be
achieved before treatment (40).
Fig. 18. Decision tree for the treat-
ment of inadequate attached tissue.
Adapted from Kim & Neiva (106).
CTG: connective tissue graft; FGG:
free gingival graft.
89
Bennani et al.

Respecting biologic integrity during margin A

placement

Subgingival margins should be considered a compro-

mise and therefore supragingival margins are pre-
ferred (73, 80). A durable, esthetic and functional
result is only possible if a smooth and precise margin
preparation and high-quality impression are B
achieved, which then facilitates the fabrication of an
accurately fitting restoration. If an abutment is not
discolored and has no previous subgingival restora-
tions, an all-ceramic crown allows an esthetic result
while allowing the prosthesis to be kept supragingival
(83) (Fig. 19). Unfortunately, this cannot always be
achieved and sometimes the margin must be subgin-
gival. In such cases the margin should be placed no
more than 0.5 mm apically to the free gingival margin
to avoid the risk of violating the biological width
(109). Several authors advocate delaying the final C
margin location until the gingival tissues are fully
healed (65, 73). Regardless of the margin situation
and design, a precise and well-defined margin should
always be achieved (83) (Fig. 20).
Many techniques have been proposed to minimize
trauma to the periodontal tissues whilst finalizing the
margins of a preparation. The development of electri-
cally driven, high-speed, slower-speed/high-torque
Fig. 19. If an abutment is not discolored and has no previ-
handpieces and microscopes has made optimal ous subgingival restorations, an all-ceramic crown allows
preparations easier to obtain (122, 124). To prevent an esthetic result while keeping the prosthesis supragingi-
damage of the sulcus, and to improve visibility when val (courtesy of Dr V. Bennani). (A) Patient complained of
positioning the margins, a very fine, wet cord can be ‘short centrals and black space’. (B) Two IPS empress
placed at the base of the sulcus (83, 124). This tech- crowns. (C) These crowns allow a high degree of light
transmission, making the supragingival restorative margin
nique is helpful to allow for some degree of error dur- virtually invisible.
ing high-speed instrumentation in deep sulci (48, 210).
To reduce trauma further when dropping the cervi- Another advance in margin preparation was made
cal finish line to its final intracrevicular position, the with the introduction of sonic oscillating preparation
tissue guard end-cutting bur was introduced in the instruments (122) and more recently with ultrasonic
1990s. These tissue protection burs have a diamond oscillating instruments (179). Both operate in the
coating only on their tip and are specially designed same way but the ultrasonic tips are significantly
han the tip of the bur to minimize tissue damage dur- more efficient than the sonic instruments (35). Owing
ing margin placement (Two Striper Multi-use Dia- to their nonrotary action, oscillating tips allow rapid
monds; Premier Dental Products Co., Norristown, PA, and minimally invasive preparation of margins. Mar-
USA). These burs have a polished shank of a larger gin definition is significantly enhanced and poses lit-
diameter than their diamond coated tip allowing to tle risk to intact neighboring tooth surfaces (122, 196).
retract the gingival margin while finalizing the mar- Such tools are very useful in cases of excessive crowd-
gins; they are available in different diamond grit sizes ing, especially when used on overlapping interdental
and diameters (65). These burs are a definite surfaces. Another indication for use of oscillating
improvement to the use of conventional chamfer or preparation instruments is the need for subgingival
shoulder burs to finalize margins; however, the rota- margins, which can be finished precisely with little
tional action of these instruments and their small risk of damaging the soft tissue (179). This is a partic-
working surface create shallow circular indentations ular advantage when treating individuals with a thin
on the margin’s surface, making achievement of biotype, as damage can result in unsightly gingival
smooth finishing lines quite challenging (95) (Fig. 21). recession (117).

90

A B
Fig. 20. Patient complaint of ‘bleeding gums and unpleas-
ant appearance’ (courtesy of Dr V. Bennani). (A) Inflam-
mation of gingival tissue, gingival suppuration and
unesthetic crowns. Note the uneven gingival frame on
teeth 13, 12, 22 and 23. (B) Occlusal views. Note the
inflammation of the interdental papilla, the overcon-
toured buccal surfaces of teeth 11 and 21 and the expo-
sure of opaque ceramic on the palatal surface. These
over-contoured restorations are the result of inadequate
tooth reduction. (C) After placement of adequate
Ultrasonic instruments create a better-defined and
smoother margin than do conventional rotary instru-
ments with tissue guard end-cutting burs (95). The
margins are smoother and wider than those prepared
with tissue guard end-cutting burs. Ultrasonic instru-
ments also allow the production of extremely precise
finishing lines, which are up to three times smoother
than margins produced with a tissue guard end-cut-
ting bur (70, 95). A key advantage is their lack of rota-
tion, thereby permitting improved control during
delicate preparations (122). This is done by adjusting
the frequency of oscillation to change the abrasive
activity of the instrument, providing a smooth subgin-
gival finish line and allowing greater control when
preparing areas with difficult access (128). Further-
more, ultrasonically abraded enamel/dentine surfaces
have been shown to have less smear layer compared
with surfaces abraded with a rotary instrument fitted
with a diamond tip (70, 195) (Fig. 22). A thinner smear
layer at the margin of the preparation is an advantage
because it is difficult to clean this area effectively with-
out causing bleeding of gingival tissue, which might
compromise the cementation and/or bonding of the
restoration. Furthermore, if the smear layer is not
removed, it will plug the dentinal tubules, preventing
Esthetic and periodontics interface
provisional restorations and suitable preparation of teeth,
the soft tissue was allowed to heal partially. Then, peri-
odontal crown lengthening was performed to re-create
adequate biological width. The gingival frame on the
adjacent teeth was addressed with a full-thickness flap
from tooth 13 to tooth 23. (D) Three months after surgery.
(E). IPS empress crowns after placement. Note the
improved contour of the gingival frame, the health of the
gingival tissues and the maturation underway of the
interdental papillae.
the formation of resin tags that are crucial for bonding
(70). Ultrasonic preparation is therefore indicated for
marginal placement because it allows a smooth, clean
and accurate preparation, resulting in less marginal
microleakage (122) and the provision of a successful
long-term prosthesis.
Respecting biologic integrity during tissue retraction
for impression
When making impressions of subgingival crown
margins, it is often necessary to displace the gingiva
to gain access to the prepared margin. Methods
for displacing the gingiva include mechanical,
chemomechanical (chemicals embedded in cords or
in an injectable matrix) and surgical (lasers, electro-
surgery and rotary curettage). It is important that the
technique employed is not traumatic to the periodon-
tal tissues (24, 133). If not properly carried out, gingi-
val retraction can have a negative effect on the soft
tissues around the abutments, sometimes causing
irreversible damage. Depending on the type of soft
tissue (thick vs. thin), the amount of keratinized
attached tissue and the position of the preparation
margin (at the gingival margin vs. intracrevicular), dif-
ferent tissue-management procedures are indicated
91
Bennani et al.
Fig. 22. Scanning electron microscopy image of dentin
surfaces prepared with tissue guard end-cutting bur and
an ultrasonic tip (courtesy of Dr Horne and Dr Bennani).
(A) Dentin surface prepared with an ultrasonic tip (32,000
(83). The objective of gingival retraction is to expose
all the prepared tooth structure and part of the
unprepared surface beyond the margin, allowing the
clinician to capture the tooth-emergence profile (20,
26, 80) (Fig. 23). To achieve optimal gingival displace-
ment, two factors should be considered. First, there
should be a minimum of 0.2 mm exposure of the sul-
cular grooves to ensure flow and bulk of impression
material around the finish line (16, 116). Second, care
should be taken that the pressure generated during
this process is nontraumatic to the epithelium attach-
ment (16, 27, 28, 119, 123). Optimal gingival
92
Fig. 21. Scanning electron micro-
scopy image of a shoulder margin
finished with the tissue guard end-
cutting bur (3250 magnification).
Note the circular indentations on the
margin’s surface created as a result
of the small working surface and the
rotational action of the bur (courtesy
of Dr Horne and Dr Bennani).
magnification). Note the thinner smear layer with more
tubules exposed. (B) Dentin surface prepared with the tis-
sue guard end-cutting bur (33,000 magnification). Note a
thick smear layer with no visible tubules.
displacement should not be carried out at the
expense of the epithelial attachment. If the epithelial
attachment is exposed to pressure that is greater than
it can withstand, then it will be compromised. Unfor-
tunately, no in vivo research data are available on the
pressures generated by tissue-retraction techniques.
The only data available are related to periodontal
probing pressures and to the maximum pressure that
the gingival epithelium attachment can tolerate (19,
194). van der Velden (194) advised that a probing
force of 0.75 N is required to allow the probe tip to
reach the base of the sulcus while maintaining an

A B
Fig. 23. Accurate registration of the prepared tooth struc-
ture and part of the unprepared surface beyond the mar-
gin (courtesy of Dr V. Bennani). (A) There should be a
minimum of 0.2 mm exposure of the sulcular grooves to
intact coronal connective tissue attachment. A 0.63-
mm-diameter probe would generate a pressure of
2,400 kPa.
Other options available are surgical methods, but
these are not recommended in the esthetic zone. Sur-
gical techniques (lasers, electrosurgery and rotary
curettage) involve the removal of tissue to form a
trough around the preparation to expose the margins
to the impression material, thus failing to meet the
objective of a truly conservative technique (28). While
recognized as an effective method of retraction, inju-
dicious use of either of these techniques can cause
necrosis of the gingiva and, in extreme cases, of the
underlying bone (80, 209). These procedures should
be avoided in areas where gingival architecture is thin
or over prominent teeth, such as in anterior segments
of the mouth (80). Retraction techniques have been
often debated and controversy remains around the
use of mechanical or chemomechanical techniques.
Displacement cords have, for many years, been the
most popular method for gingival displacement in
fixed prosthodontics (29). A 1999 survey of 1,246
prosthodontists revealed that 98% of respondents
used retraction cord and, of these, 44% used a plain
single-cord technique (89). The mechanical technique
using nonimpregnated retraction cord has been
reported to induce less damage to the periodontal tis-
sues compared with cord impregnated with hemo-
static agents (12, 122).
Cordless displacement materials have been devel-
oped because of the inherent disadvantages of con-
ventional cord systems and could possibly replace
cord as the standard (101). Cordless retraction mate-
rials are available in different consistencies: as a paste
injected into the sulcus or as a foam packed with a
retraction cap (13). The paste and the foam operate
differently and generate dissimilar pressures (24, 27).
Cordless displacement materials remove the need for
clinicians to pack the material into the crevicular
Esthetic and periodontics interface
ensure flow and bulk of impression material around the
finish line. (B) Accurate registration of part of the unpre-
pared surface beyond the margin to capture the tooth-
emergence profile.
sulcus. Furthermore, inclusion of the hemostatic
agent in a matrix, rather than in a liquid, may gener-
ate fewer adverse effects than when it is used directly
in contact with the sulcus (3, 174, 212). Another
advantage of paste materials is that none of them
contain ferric sulfate as a vasoconstrictor, which,
owing to its iron content, will stain tissues a yellow-
brown to black color for several days after its use
(202) (Figs 24 and 25).
The placement of cord and cotton strings into the
gingival sulcus may injure the sulcular epithelium
(119). The damage depends on the force used in
packing the cord, the chemical with which the cord
has been impregnated and the length of time that the
cord is left in place within the sulcus (73). This could
be problematic as the pressure generated by placing
cords was recently evaluated in an in vitro study and
found to be much higher than the pressure that the
epithelial attachment could tolerate (24, 194). Loe €&
Silness (119) showed that heavy forces during posi-
tioning of displacement cords could destroy the
uppermost Sharpey fibres and, as a result, gingival
recession may occur and occasionally loss of attach-
ment. Cordless materials (paste and foam) are less
traumatic to the gingival tissue, less painful to the
Fig. 24. Use of the double cord technique. The first cord is
an ultrathin cord, which will stay in place throughout
impression taking, while the second cord is one size larger
and will be removed just before injection of impression
material (courtesy of Dr V. Bennani).
93
Bennani et al.
Fig. 25. Use of a cordless retraction paste. The paste is injected
into the gingival sulcus, left for 2 min, then rinsed away before
the impression is taken. (Courtesy of Dr Law).
patient and quicker to deliver than displacement
cords (4, 126, 153, 212). Studies have shown that gin-
gival tissues recover within a week after an impres-
sion has been taken using cordless displacement
material (paste and foam) (153).
Yang et al. (212) compared epinephrine-impreg-
nated cords and cordless displacement materials
(paste and foam) and found that they demonstrate
clinically insignificant tissue recession. Furthermore,
this was recently confirmed in a double-blind ran-
domized clinical trial in which gingival cord with 25%
aluminium chloride astringent gel and a 15% alu-
minium chloride astringent-based paste cordless
displacement material were compared. Neither
technique resulted in worse periodontal indices at
10 days after retraction; however, lower post-treat-
ment levels of inflammatory cytokines were present
after the use of the paste cordless displacement mate-
rial compared with the cord (170). Further research in
this area is needed.
Injection matrices are a promising option for gin-
gival retraction, but there is little research on their
effectiveness. Some authors have recommended
them for when margins are not too subgingival (74,
211). In contrast, Acar et al. (1) compared impres-
sions in which gingival retraction had been carried
out using aluminium chloride-impregnated cord
and paste gingival retraction materials and they
concluded that when taking an impression of a
standardized subgingival margin preparation, both
groups produced perfect or acceptable impressions.
One of the limitations of Acar’s research was that
the subgingival positioning of margins varied
greatly from one sample to another: ‘A subgingival
preparation finish line of between 1 and 2 mm was
ensured’. This important variation in margin posi-
tioning could have a significant impact on the
results. Beier et al. (23) found that a cordless dis-
placement foam material was less effective in teeth
94
with intrasulcular preparation, and further research
is needed in this area.
An in vitro study investigated the pressures exerted
by four different cordless gingival displacement mate-
rials (paste and foam). It was found that there were
statistically significant differences between the pres-
sures generated by two of the cordless materials. The
foam produced two to four times less pressure than
the paste materials (27). Of the three pastes tested,
one produced half the pressure, raising the question
of their clinical effectiveness. Further clinical research
testing is required to quantify the effectiveness of
cordless systems and to quantify better the minimum
effective pressures.
Whichever mechanical technique is used, it is
important to inspect the sulcus after the impression
to ensure that no foreign material remains, as this
would further traumatize the periodontal structures.
Several cases of swelling, pain and periodontal
inflammation have been reported following the
retention of impression materials in the sulcus (13,
78, 143, 160, 175).
Promoting and maintaining gingival health with
provisional restorations
Provisional restorations may be used to improve peri-
odontal health before making the final preparation
and final impression when replacing iatrogenic
restorations that have damaged the soft tissues. Pro-
visional restorations may also be used to maintain
gingival health by preserving the position, contour
and color of the gingiva while the definitive restora-
tion is constructed (67, 81). To achieve these goals the
gingiva should rest on a properly contoured, smooth
and well-fitting provisional (63, 172) (Fig. 26). Several
authors agree that this can be more reliably com-
pleted when the provisional restorations are fabri-
cated in a dental laboratory. Indirect techniques can
deliver an ideally contoured provisional, which is key
to achieving good esthetics and proper access for oral
hygiene (75, 110, 159, 165, 213). Poor provisionals are
often linked to periodontal inflammation and gingival
recession (40, 64). Problems with provisional restora-
tions, such as rough surfaces and incorrect contours,
promote plaque accumulation (63, 161, 197). Several
authors advocate delaying the final margin location
until the gingival tissues are fully healed (65, 73).
Leaving margins supragingival or at the gingival crest
in the first instance improves the soft-tissue status.
Supragingival margins are easier to capture accu-
rately and they facilitate fabrication of well-fitting
provisional restorations, which are vital for optimal
gingival health (83). Two aspects of coronal contours

A this distance was 5 mm or less, the papilla was pre-
B with the patient, should select the most appropriate
C D
Fig. 26. Patient complaint of a black line on old porcelain-
fused-to-metal crowns (courtesy of Dr V. Bennani). (A)
Overcontoured porcelain-fused-to-metal crowns are asso-
ciated with gingival recession. (B) Provisional restorations
in place to improve periodontal health before the final
preparation and final impression. Note the healthy con-
tour of the gingiva. (C) Profile view of the previous porce-
lain-fused-to-metal crown. Note the overcontoured
cervical profile. (D) Matching view with provisionals in
place. Note the proper emergence profile, allowing good
support of the gingival margin.
– the cervical contour and the interproximal contour
– are key for good tissue integration (108). The gingi-
val contour is most often flat; and the interproximal
embrasures should be precisely shaped as they influ-
ence the ability of the tissue to resume its normal
architecture (73). Particular attention should be paid
to the shape and position of the proximal contact.
Tarnow et al. (189) determined that one of the vari-
ables affecting the shape of the interproximal papilla
was the distance from the base of the contact point to
the crest of the bone. Their results showed that when
Esthetic and periodontics interface
sent almost 100% of the time. The volume of the
embrasure space is dictated by several factors: the
distance between adjacent teeth; the location of the
base of the proximal contact in relation to the crestal
bone; and the accessibility to oral hygiene (189). At
the provisional stage the interproximal embrasure
should apply a very minimal pressure on the papilla
and allow access for hygiene. The clinician, together
cleansing tools, such as interproximal brushes, or
orthodontic or regular floss, to achieve perfect clean-
ing of the area without damaging the papilla (73). To
maintain optimal periodontal health it is crucial that
the patient is shown how to clean their provisional
restoration properly and that maintenance of oral
hygiene is monitored at every clinical visit (81). It is
important to achieve optimal periodontal health
before proceeding to the final restoration; and the
contour, occlusion, surface texture and cervical shape
of the provisional may be modified to ensure this
(40). In this way the provisional serves as ‘a trial and
error’ step, guiding the contour of the final restora-
tion. This is a key step to creating a successful and
long-lasting final restoration (80), and it is therefore
important not to think of a provisional restoration
just as a mere short-term gap filler. Provisional
restorations allow the clinician to assess any negative
effects on the periodontium before committing to the
final restoration (40).
Summary
Dentists and dental specialists are regularly asked to
design an attractive smile. Creating esthetically pleas-
ing results at the restorative periodontal interface con-
tinues to be a challenge. A predictable successful
outcome cannot be achieved without a comprehensive
examination and accurate diagnoses that are subse-
quently used to generate an appropriate treatment
plan. Predictability and success in esthetic dentistry
are largely dependent on the health and stability of the
periodontal tissues. Similarly, periodontal health is
reliant on the continued integrity of the restoration. To
ensure longevity and esthetics, an understanding of
the intricate relationship between periodontal tissues
and restorative dentistry is paramount.
Restorations should be planned for and constructed
in line with the principles that ensure ongoing, opti-
mal, soft-tissue health, otherwise the esthetic outcome
may be compromised. Emphasis should be placed on
diagnosis of gingival contour aberrations and
95
Bennani et al.
respecting the biologic space requirements. Of equal
importance are the marginal quality of the prosthesis,
the margin location of the restoration and atraumatic
tooth preparation and impression procedures.
Once the desired outcome is achieved, scrupulous
post-treatment maintenance is certainly a major pre-
requisite for long-term success. Effective plaque con-
trol by the patient, and regular examinations and
hygiene visits are key factors in preserving gingival
stability over long periods of time.
References
€ Erkut S, Ozc
1. Acar O, € ßelik T, Ozdemır E, Akcßil M. A clinical
comparison of cordless and conventional displacement
systems regarding clinical performance and impression
quality. J Prosthet Dent 2014: 111: 388–394.
2. Ahmad I. Anterior dental aesthetics: gingival perspective.
Br Dent J 2005: 199: 195–202.
3. Akca EA, Yildirim E, Dalkiz M, Yavuzyilmaz H, Beydemir B.
Effects of different retraction medicaments on gingival tis-
sue. Quintessence Int 2006: 37: 53–59.
4. Al-Ani A, Bennani V, Chandler N, Lyons K, Thomson M. New
Zealand dentists use of gingival retraction techniques for fixed
prosthodontics and implants. NZ Dent J 2010: 106: 92–96.
5. Allen AL. Use of the supraperiosteal envelope in soft tissue
grafting for root coverage I. Rationale and technique. Int J
Periodontics Restorative Dent 1994: 14: 216–227.
6. Allen AL. Use of the supraperiosteal envelope in soft tissue
grafting for root coverage II. Clinical results. Int J Peri-
odontics Restorative Dent 1994: 14: 302–315.
7. Allen E, Miller PDJ. Coronal positioning of existing gingiva:
short term results in the treatment of shallow marginal tis-
sue recession. J Periodontol 1989: 60: 316–319.
8. Alpiste-Illueca F. Morphology and dimensions of the den-
togingival unit in the altered passive eruption. Med Oral
Patol Oral Cir Bucal 2012: 17: e814–e820.
9. American Academy of Periodontology. Glossary of peri-
odontal terms, 4th edn. Chicago, IL: AAP, 2001.
10. Azzi R, Etienne D, Carranza F. Surgical reconstruction of
the interdental papilla. Int J Periodontics Restorative Dent
1998: 18: 467–474.
11. Azzi R, Takei H, Etienne D, Carranza F. Root coverage and
papilla reconstruction using autogenous osseous and con-
nective tissue grafts. Int J Periodontics Restorative Dent
2001: 21: 141–147.
12. Azzi R, Tsao T, Carranza F, Kenney E. Comparative study
of gingival retraction methods. J Prosthet Dent 1983: 50:
561–565.
13. Baba N, Goodacre C, Jekki R, Won J. Gingival displacement
for impression making in fixed prosthodontics contempo-
rary principles, materials, and techniques. Dent Clin North
Am 2014: 58: 45–68.
14. Bader J, Rozier R, McFall W Jr, Ramsey D. Effect of crown
margins on periodontal conditions in regularly attending
patients. J Prosthet Dent 1991: 65: 75–79.
15. Baer P, Benjamin SD. Gingival grafts: a historical note. J
Periodontol 1981: 52: 206–207.
96
16. Baharav H, Kupershmidt I, Laufer B, Cardash H. The effect
of sulcular width on the linear accuracy of impression
materials in the presence of an undercut. Int J Prosthodont
2004: 17: 585–589.
17. Baker D, Seymour GJ. The possible pathogenesis of gingi-
val recession. J Clin Periodontol 1976: 3: 208–219.
18. Baldi C, Pini-Prato G, Pagliaro U, Nieri M, Saletta D, Muzzi
L, Cortellini P. Coronally advanced flap procedure for root
coverage Is flap thickness a relevant predictor to achieve
root coverage? A 19-case series. J Periodontol 1999: 70:
1077–1084.
19. Barendregt D, Van der Velden U, Reiker J, Loos BG.
Clinical evaluation of tine shape of periodontal probes
using probing forces. J Clin Periodontol 1996: 23: 397–
402.
20. Baudoin A, Bennani V. Réussir un projet prothétique en
implantologie. [Success in oral rehabilitation with
implant-supported prosthesis]. Quintessence Interna-
tional Publishing, Paris: Quintessence International Pub-
lishing, 2003. 133 pp.
21. Beagle JR. Surgical reconstruction of the interdental
papilla: case report. Int J Periodontics Restorative Dent
1992: 12: 145–151.
22. Becker C, Kaldahl WB. Current theories of crown contour
margin placement and pontic design. J Prosthet Dent 1981:
45: 268–277.
23. Beier U, Kranewitter R, Dumfahrt H. Quality of impres-
sions after use of the Magic FoamCord gingival retraction
system-a clinical study of abutment teeth. Int J Prostho-
dont 2009: 22: 143–147.
24. Bennani V, Aarts J, He LH. A comparison of pressure gen-
erated by cordless gingival displacement techniques. J
Prosthet Dent 2012: 107: 388–392.
25. Bennani V, Aarts JM, Schumayer D. Correlation of pressure
and displacement during gingival displacement: an
in vitro study. J Prosthet Dent 2016: 115: 296–300.
26. Bennani V, Baudoin A. Esthétique et profile d’émergence en
implantologie [Aesthetic and emergence profile in implan-
tology]. Editions CdP, Paris: Editions CDP, 2000. 116 pp.
27. Bennani V, Inger M, Aarts JM. Comparison of pressure
generated by cordless gingival displacement techniques. J
Prosthet Dent 2014: 112: 163–167.
28. Bennani V, Schwass D, Chandler N. Gingival retraction
techniques for implant versus teeth. Current status. J Am
Dent Assoc 2008: 139: 1354–1363.
29. Benson B, Bomberg TJ, Hatch RA, Hoffman W Jr. Tissue
displacement methods in fixed prosthodontics. J Prosthet
Dent 1986: 55: 157–292.
30. Besler U. Esthetics checklist for the fixed prosthesis. Part
II: Biscuit-bake try-in. In: Scha€rer P, Rinn LA, Kopp FR,
editors. Esthetic guidelines for restorative dentistry. Chi-
cago, IL: Quintessence, 1982: 188–192.
31. Blatz M, Hu € rzeler MB, Strub JR. Reconstruction of the lost
interproximal papilla Presentation of surgical and nonsur-
gical approaches. Int J Periodontics Restorative Dent 1999:
19: 395–406.
32. Bouchard P, Etienne D, Ouhayoun JP, Nilveus R. Subep-
ithelial connective tissue grafts in the treatment of gingival
recessions. A comparative study of procedures. J Periodon-
tol 1994: 65: 929–936.
33. Bouchard P, Nilveus R, Etienne D. Clinical evaluation of
tetracycline HCl conditioning in the treatment of gingival

recessions. A comparative study. J Periodontol 1997: 68:
262–269.
34. Bragger U, Lauchenauer D, Lang NP. Surgical lengthening
of the clinical crown. J Clin Periodontol 1992: 19: 58–63.
35. Buoncristiani J, Seto BG, Caputo AA. Evaluation of ultra-
sonic and sonic instruments for intra-radicular post
removal. J Endod 2010: 20: 486–489.
36. Burkhardt R, Lang NP. Coverage of localized gingival
recessions comparison of micro-and macrosurgical tech-
niques. J Clin Periodontol 2005: 32: 287–293.
37. Burkhardt R, Lang NP. Fundamental principles in
periodontal plastic surgery and mucosal augmentation - a
narrative review. J Clin Periodontol 2014: 41(S15): S98–
S107.
38. Buti J, Baccini M, Nieri M, La Marca M, Pini-Prato G. Baye-
sian network meta-analysis of root coverage procedures:
ranking efficacy and identification of best treatment. J Clin
Periodontol 2013: 40: 372–386.
39. Cairo F, Nieri M, Pagliaro U. Efficacy of periodontal plastic
surgery procedures in the treatment of localized gingival
recessions. A systematic review. J Clin Periodontol 2014: 41
(S15): S44–S62.
40. Carranza F. Carranza’s clinical periodontology, 11th edn.
St. Louis: Elsevier Saunders, 2012.
41. Carranza F Jr, Carraro JJ. Mucogingival techniques in
periodontal surgery. J Clin Periodontol 1970: 41: 294–
299.
42. Carvalho P, Silva RC, Joly JC. Aesthetic crown lengthening.
A flapless new approach (in Portuguese). Rev Assoc Paul
Cir Dent 2009: 1: 26–33.
43. Chambrone L, Lima LA, Pustiglioni FE, Chambrone LA.
Systematic review of periodontal plastic surgery in the
treatment of multiple recession-type defects c. J Can Dent
Assoc 2009: 75: 203a–203f.
44. Chambrone L, Pannuti CM, Tu YK, Chambrone LA. Evi-
dence-based periodontal plastic surgery II. An individual data
meta-analysis for evaluating factors in achieving complete
root coverage. J Periodontol 2012: 83: 477–490.
45. Chambrone L, Sukekava F, Arau  jo MG, Pustiglioni FE,
Chambrone LA, Lima LA. Root-coverage procedures for
the treatment of localized recession-type defects. A
Cochrane systematic review. J Periodontol 2010: 81: 452–
478.
46. Chambrone L, Tatakis DN. Periodontal soft tissue root
coverage procedures. A systematic review from the AAP
regeneration workshop. J Periodontol 2015: 86(2S): S8–S51.
47. Checchi L, Schonfeld SE. A technique for esthetic treat-
ment of maxillary anterior infrabony lesions. Quintessence
Int 1988: 19: 209–213.
48. Chiche G, Pinault A. Esthetics of anterior fixed prosthodon-
tics. Chicago, IL: Quintessence Publishing, 1994.
49. Cho H, Jang HS, Kim DK, Park JC, Kim HJ, Choi SH, Kim
CK, Kim BO. The effects of interproximal distance between
roots on the existence of interdental papillae according to
the distance from the contact point to the alveolar crest. J
Periodontol 2006: 77: 1651–1657.
50. Christensen GJ. Marginal fit of gold inlay castings. J Pros-
thet Dent 1966: 6: 296–305.
51. Cohen B. Morphological Factors in the pathogenesis of the
periodontal disease. Br Dent J 1959: 107: 31–39.
52. Cohen D, Ross SE. The double papillae repositioned flap
in periodontal therapy. J Periodontol 1968: 39: 65–70.
Esthetic and periodontics interface
53. Corn H. Periosteal separation-its clinical significance. J
Periodontol 1962: 33: 140–153.
54. Cortellini P, Clauser C, Prato GP. Histologic assessment of
new attachment following the treatment of a human buc-
cal recession by means of a guided tissue regeneration
procedure. J Periodontol 1993: 64: 387–391.
55. Cortellini P, Pini Prato G, Tonetti M. The modified papilla
preservation technique. A new surgical approach for inter-
proximal regenerative procedures. J Periodontol 1995: 66:
261–266.
56. Cortellini P, Pini Prato G, Tonetti M. The simplified
papilla preservation flap. A novel surgical approach for
the management of soft tissues in regenerative proce-
dures. Int J Periodontics Restorative Dent 1999: 19: 589–
599.
57. Cortellini P, Tonetti MS. Microsurgical approach to peri-
odontal regeneration Initial evaluation in a case cohort. J
Periodontol 2001: 72: 559–569.
58. Coslet G, Vanarsdall R, Weisgold A. Diagnosis and clas-
sification of delayed passive eruption of the dentogingi-
val junction in the adult. Alpha Omegan 1977: 10: 24–
28.
59. de Sanctis M, Clementini M. Flap approaches in plastic
periodontal and implant, surgery: critical elements in
design and execution. J Clin Periodontol 2014: 41(S15):
S108–S122.
60. Dedmon HW. Disparity in expert opinions on size of
acceptable margin openings. Oper Dent 1981: 7: 97–
101.
61. DeVore D, Kelman CD, Fagien S, Casion P. Autologen
autologous injectable dermal collagen. In: Bosnick S, edi-
tor. Principles and practices of ophthalmic, plastic and
reconstructive surgery. Philadelphia, PA: W. B. Saunders,
1996: 670–675.
62. Dolt AH 3rd, Robinns JW. Altered passive eruption: an eti-
ology of short clinical crowns. Quintessence Int 1997: 28:
363–372.
63. Donaldson D. The etiology of gingival recession associ-
ated with temporary crowns. J Periodontol 1974: 45: 468–
471.
64. Donaldson D. Gingival recession associated with tempo-
rary crowns. J Periodontol 1973: 44: 691–696.
65. Donovan T, Cho GC. Predictable aesthetics with metal-
ceramic and all-ceramic crowns: the critical importance of
soft-tissue management. Periodontol 2000 2001: 27: 121–
130.
66. Du JK, Li HY, Wu JH, Lee HE, Wang CH. Emergence angles
of the cementoenamel junction in natural maxillary ante-
rior teeth. J Esthet Restor Dent 2011: 23: 362–369.
67. Dykema R, Goodacre CJ, Phillips RW. Modern practice in
fixed prosthodontics. Philadelphia, PA: W. B. Saunders Co,
1986.
68. Edel A. Clinical evaluation of free connective tissue grafts
used to increase the width of keratinised gingiva. 1974.
Periodontal Clin Investig 1998: 20: 12–20.
69. Ehrlich J, Hochman N. Alterations on crown contour –
effect on gingival health in man. J Prosthet Dent 1980: 44:
523–525.
70. Ellis R, Bennani V, Purton D, Chandler N, Lowe B. The
effect of ultrasonic instruments on the quality of prepara-
tion margins and bonding to dentin. J Esthet Restor Dent
2012: 24: 278–285.
97
Bennani et al.
71. Ericsson I, Lindhe J. Recession in sites with inadequate
width of the keratinized gingival An experimental study in
the dog. J Clin Periodontol 1984: 11: 95–103.
72. Espinel M, Caffesse RG. Comparison of the results
obtained with the lateral positioned pedicle sliding flap-
revised technique and the lateral sliding flap with a free
gingival graft technique in the treatment of localised gingi-
val recession. Int J Periodontics Restorative Dent 1981: 1:
30–37.
73. Ferencz J. Maintaining and enhancing gingival architecture
in fixed prosthodontics. J Prosthet Dent 1991: 65: 650–657.
74. Ferrari M, Cagidiaco MC, Ercoli C. Tissue management
with a new gingival retraction material a preliminary clini-
cal report. J Prosthet Dent 1996: 75: 242–247.
75. Fisher D, Shillingburg HT, Dewhirst RB. Indirect tempo-
rary restorations. J Am Dent Assoc 1971: 82: 160–163.
76. Garber D, Salama MA. The aesthetic smile: diagnosis and
treatment. Periodontol 2000 1996: 11: 18–28.
77. Gargiulo A, Wentz FM, Orban B. Dimensions and relations
of the dentogingival junction in humans. J Periodontol
1961: 32: 261–267.
78. Glenwright HD. Bone regeneration following damage by
polysulphide impression material. A case report. J Clin
Periodontol 1975: 2: 250–252.
79. Goldberg P. Iatrogenic factors in periodontal disease.
McGill Dent Rev 1973: 34: 2–7.
80. Goldberg P, Higginbottom FL, Wilson TG. Periodontal con-
siderations in restorative and implant therapy. Periodontol
2000 2001: 25: 100–109.
81. Goodacre CJ. Gingival esthetics. J Prosthet Dent 1990: 64:
1–12.
82. Goodlin R. Gingival aesthetics: a critical factor in smile
design. Oral Health 2003: 93: 10–28.
83. Gracis S, Fradeani M, Celletti R. Biological integration of
aesthetic restorations: factors influencing appearance and
long-term success. Periodontol 2000 2001: 27: 29–44.
84. Grasso J, Nalbandian J, Sanford C, Bailit H. Effect of
restoration quality on periodontal health. J Prosthet Dent
1985: 53: 14–19.
85. Graziani F, Gennai S, Rolda n S, Discepoli N, Buti J, Madi-
anos P, Herrera D. Efficacy of periodontal plastic proce-
dures in the treatment of multiple gingival recessions. J
Clin Periodontol 2014: 41(S15): S63–S76.
86. Grupe HE. Modified technique for the sliding flap opera-
tion. J Periodontol 1966: 37: 491–495.
87. Hakkarainen K, Ainamo J. Influence of overhanging poste-
rior tooth restorations on alveolar bone height in adults. J
Clin Periodontol 1980: 7: 114–120.
88. Han T, Takei HH. Progress in gingival papilla reconstruc-
tion. Periodontol 2000 1996: 11: 65–68.
89. Hansen P, Tira DE, Barlow J. Current methods of finish-
line exposure by practicing prosthodontists. J Prosthodont
1999: 8: 163–170.
90. Harris RJ. A comparison of 2 root coverage techniques
Guided tissue regeneration with a bioabsorbable matrix
style membrane versus a connective tissue graft combined
with a coronally positioned pedicle graft without vertical
incisions. Results of a series of consecutive cases. J Peri-
odontol 1998: 69: 1426–1434.
91. Harris RJ. The connective tissue with partial thickness
double pedicle graft the results of consecutively-treated
defects. J Periodontol 1994: 65: 448–461.
98
92. Harris RJ. Double pedicle flap-predictability and aesthetics
using connective tissue. Periodontol 2000 1994: 65: 448–461.
93. Hirshberg SM. The relationship of oral hygiene to embra-
sure and pontic design - a preliminary study. J Prosthet
Dent 1972: 27: 26–38.
94. Holbrook T, Ochsenbein C. Complete coverage of the
denuded root surface with a one-stage gingival graft. Int J
Periodontics Restorative Dent 1983: 3: 8–27.
95. Horne P, Bennani V, Purton D, Chandler N. Ultrasonic
margin preparation for fixed prosthodontics: a pilot study.
J Esthet Restor Dent 2012: 24: 201–209.
96. Hwang D, Wang HL. Flap thickness as a predictor of root
coverage a systematic review. J Periodontol 2006: 77: 1625–
1634.
97. Imberman M. Gingival augmentation with an acellular
dermal matrix revisited: surgical technique for gingival
grafting. Pract Proced Aesthet Dent 2007: 19: 123–128.
98. Ingber J, Rose LF, Coslet JG. “The Biologic Width”: a con-
cept in periodontics and restorative dentistry. Alpha Ome-
gan 1977: 70: 62–65.
99. Jameson L, Malone WFP. Crown contours and gingival
response. J Prosthet Dent 1982: 47: 620–624.
100. Jorgensen M, Nowzari H. Aesthetic crown lengthening.
Periodontol 2000 2001: 27: 45–58.
101. Kazemi M, Memarian M, Loran V. Comparing the effec-
tiveness of two gingival retraction procedures on gingival
recession and tissue displacement: clinical study. Res J Biol
Sci 2009: 4: 335–339.
102. Kennedy J, Bird WC, Palcanis KG, Dorfman HS. A longitu-
dinal evaluation of varying widths of attached gingiva. J
Clin Periodontol 1985: 12: 667–675.
103. Kepic T, O’Leary TJ. Role of marginal ridge relationships as
an etiologic factor in periodontal disease. J Periodontol
1978: 49: 570–575.
104. Khuller N, Sharma N. Biologic width Evaluation and cor-
rection of its violation. J Oral Health Comm Dent 2009: 3:
20–25.
105. Kim D, Neiva R. Periodontal soft tissue non-root coverage
procedures: a systematic review from the AAP regenera-
tion workshop. J Periodontol 2015: 86(2S): S56–S72.
106. Kim S, Choi YH, Kim YG, Park JW, Lee JM, Suh JY. Analysis
of the esthetic outcome after root coverage procedures
using a comprehensive approach. J Esthet Dent 2014: 26:
107–118.
107. Koidis P, Burch JG, Melfi RC. Clinical crown contours con-
temporary view. J Am Dent Assoc 1987: 114: 792–795.
108. Kois JC. Altering gingival levels the restorative connec-
tion part I: biologic variables. J Esthet Restor Dent
1994: 6: 3–7.
109. Kois JC. The restorative-periodontal interface biological
parameters. Periodontol 2000 1996: 11: 29–38.
110. Krug RS. Temporary crowns and bridges. Dent Clin North
Am 1975: 19: 313–320.
111. Kuis D, Sciran I, Lajnert V, Snjaric D, Prpic J, Pezelj-Ribaric
S, Bosnjak A. Coronally advanced flap alone or with con-
nective tissue graft in the treatment of single gingival
recession defects: a long-term randomized clinical trial. J
Periodontol 2013: 84: 1576–1585.
112. Lang N, Kiel RA, Anderhalden K. Clinical and microbiolog-
ical effects of subgingival restorations with overhanging or
clinically perfect margins. J Clin Periodontol 1983: 10: 563–
578.

113. Lang N, Loe H. The relationship between the width of ker-
atinized gingivae and gingival health. J Periodontol 1972:
43: 623–627.
114. Langer B, Langer L. Subepithelial connective tissue graft tech-
nique for root coverage. J Periodontol 1985: 56: 715–720.
115. Larato D. Relationship of food impaction to interproximal
intrabony lesions. J Periodontol 1971: 42: 237–238.
116. Laufer B, Baharav H, Cardash HS. The linear accuracy
of impressions and stone dies as affected by the thickness
of the impression margin. Int J Prosthodont 1994: 7: 247–
252.
117. Leblebicioglu B, Rawal S, Mariotti A. A review of the func-
tional and esthetic requirements for dental implants. J Am
Dent Assoc 2007: 138: 321–329.
118. Livingston HL. Total coverage of multiple and adjacent
denuded root surfaces with a free gingival autograft. A case
report. J Periodontol 1975: 46: 209–216.
119. Loe€ H, Silness J. Tissue reactions to string packs used in
fixed restorations. J Prosthet Dent 1963: 13: 318–323.
120. Lofstrom L, Barakat MM. Scanning electron microscopic
evaluation of clinically cemented cast gold restorations. J
Prosthet Dent 1989: 61: 664–669.
121. Magid K, Robert AS. Laser use for esthetic soft tissue modi-
fication. Dent Clin North Am 2007: 51: 525–545.
122. Magne P, Besler U. Bonded porcelain restorations in the
anterior dentition a biomimetic approach. Carol Stream,
IL: Quintessence Publishing, 2002.
123. Magne P, Magne M, Besler U. Impressions and aesthetic
rehabilitation: the preparatory work, clinical procedures
and materials. Schweiz Monatsschr Zahnmed 1995: 105:
1302–1316.
124. Malament KA. Prosthodontics achieving quality aesthetic
dentistry. J Am Dent Assoc 2000: 131: 1742–1749.
125. Malkinson S, Waldrop TC, Gunsolley JC, Lanning SK,
Sabatini R. The effect of esthetic crown lengthening on
perceptions of a patient: attractiveness, friendliness, trust-
worthiness, intelligence, and self-confidence. J Periodontol
2013: 84: 1126–1133.
126. Manolakis A, Bartsch N, Hahn P. Clinical comparison of a
gingiva retraction paste and impregnated cords (abstract
1837). International Association for Dental Research/
American Association for Dental Research/Canadian Asso-
ciation for Dental Research 82nd General Session; Hono-
lulu, 2004.
127. Martegani P, Silvestri M, Mascarello F, Scipioni T, Ghezzi
C, Rota C, Cattaneo V. Morphometric study of the inter-
proximal unit in the esthetic region to correlate anatomic
variables affecting the aspect of soft tissue embrasure
space. J Periodontol 2007: 78: 2260–2265.
128. Massironi D, Pascetta R, Romeo G. Precision in dental
esthetics: clinical and laboratory procedures. Milan: Quin-
tessenza Edizioni, 2007.
129. Matarasso S, Cafiero C, Coraggio F, Vaia E, de Paoli S.
Guided tissue regeneration versus coronally repositioned
flap in the treatment of recession with double papillae. Int
J Periodontics Restorative Dent 1989: 18: 444–453.
130. Maynard J, Wilson RD. Physiologic dimensions of the peri-
odontium significant to the restorative dentist. J Periodon-
tol 1979: 50: 170–174.
131. McGuire MK, Scheyer ET. A randomized double-blind pla-
cebo-controlled study to determine the safety and efficacy
of cultured and expanded autologous fibroblast injections
Esthetic and periodontics interface
for the treatment of interdental papillary insufficiency
associated with the papilla priming procedure. J Periodon-
tol 2007: 78: 4–17.
132. McLean J, Von Fraunhofer JA. The estimation of cement
film thickness by an in vivo technique. Br Dent J 1971: 131:
107–111.
133. Meraner M. Soft tissue management for difficult cervical
restorations. Gen Dent 2006: 54: 117–120.
134. Miller PD Jr. Root coverage using the free soft tissue auto-
graft following citric acid application. III. A successful and
predictable procedure in areas of deep-wide recession. Int
J Periodontics Restorative Dent 1985: 5: 14–37.
135. Miyasato M, Crigger M, Egelberg J. Gingival condition in
areas of minimal and appreciable width of keratinized gin-
giva. J Clin Periodontol 1977: 4: 200–209.
136. Morley J, Eubank J. Macroesthetic elements of smile
design. J Am Dent Assoc 2001: 132: 39–45.
137. Morris ML. Artificial crown contours and gingival health.
J Prosthet Dent 1962: 12: 1146–1156.
138. Nelson S. Wheeler’s dental anatomy, physiology and occlu-
sion. Chicago: Elsevier Health Sciences, 2015.
139. Nordland W, Sandhu HS, Perio C. Microsurgical technique
for augmentation of the interdental papilla. Three case
reports. Int J Periodontics Restorative Dent 2008: 28: 543–
549.
140. Nordland WP, Tarnow DP. A classification system for loss
of papillary height. J Periodontol 1998: 69: 1124–1126.
141. Nugala B, Kumar BS, Sahitya S, Krishna PM. Biologic width
and its importance in, periodontal and restorative den-
tistry. J Conserv Dent 2012: 15: 12–17.
142. Nyman S, Lindhe J, Karring T, Rylander H. New attach-
ment following surgical treatment of human periodontal
disease. J Clin Periodontol 1982: 9: 290–296.
143. O’Leary T, Standish SM, Coomer RS. Severe periodontal
destruction following impression procedures. J Periodon-
tol 1973: 44: 43–48.
144. Oles R, Ibbott CG, Laverty WH. Effects of citric acid treat-
ment on pedicle flap coverage of localized recession. J
Periodontol 1985: 56: 259–261.
145. Oliveira J, Storrer CM, Sousa AM, Lopes TR, Vieira JD,
Deliberador TM. Papillary regeneration:anatomical
aspects and treatment approaches. RSBO 2012: 9: 448–456.
146. Ong E, Brown RA, Richmond S. Peer assessment of dental
attractiveness. Am J Orthod Dentofacial Orthop 2006: 130:
163–169.
147. Orsini M, Orsini G, Benlloch D, Aranda JJ, La zaro P, Sanz
M. Esthetic and dimensional evaluation of free connective
tissue grafts in prosthetically treated patients: a 1-year
clinical study. J Periodontal 2004: 75: 470–477.
148. Ostlund LE. Cavity design and mathematics: their effect
on gaps at the margins of cast restorations. Oper Dent
1985: 10: 122–137.
149. Pack A, Coxhead LJ, McDonald BW. The prevalence of
overhanging margins in posterior amalgam restorations
and periodontal consequences. J Clin Periodontol 1990:
17: 145–152.
150. Padbury A, Eber R, Wang HL. Interactions between the
gingiva and the margin of restorations. J Clin Periodontol
2003: 30: 379–385.
151. Park JB. Increasing the width of keratinized mucosa
around endosseous implant using acellular dermal matrix
allograft. Implant Dent 2006: 15: 275–281.
99
Bennani et al.
152. Perel ML. Axial crown contours. J Prosthet Dent 1971: 25:
642–649.
153. Phatale S, Marawar PP, Byakod G, Lagdive SB, Kalburge JV.
Effect of retraction materials on gingival health: a histopatho-
logical study. J Indian Soc Periodontol 2010: 14: 35–39.
154. Pini Prato G, Cairo F, Nieri M, Franceschi D, Rotundo R,
Cortellini P. Coronally advanced flap versus connective
tissue graft in the treatment of multiple gingival reces-
sions. A split-mouth study with a year follow-up. J Clin
Periodontol 2010: 37: 644–650.
155. Pini Prato G, Clauser C, Cortellini P, Tinti C, Vincenzi G,
Pagliaro U. Guided tissue regeneration versus mucogingi-
val surgery in the treatment of human buccal recessions. A
year follow-up study. J Periodontol 1996: 67: 1216–1223.
156. Pini Prato G, Pagliaro U, Baldi C, Nieri M, Saletta D, Cairo
F, Cortellini P. Coronally advanced flap procedure for root
coverage. Flap with tension versus flap without tension:a
randomized controlled clinical study. J Periodontol 2000:
71: 188–201.
157. Pini Prato G, Tinti C, Vincenzi G, Magnani C, Cortellini P,
Clauser C. Guided tissue regeneration versus mucogingival
surgery in the treatment of human buccal recession. J
Periodontol 1992: 63: 919–928.
158. Pontoriero R, Carnevale G. Surgical crown lengthening a
12-month clinical wound healing study. J Periodontol
2001: 72: 841–848.
159. Preston JD. A systematic approach to the control of
esthetic form. J Prosthet Dent 1976: 35: 393–402.
160. Price C, Whitehead FI. Impression materials as foreign
bodies. Br Dent J 1972: 133: 9–14.
161. Ramfjord S, Ash MM. Periodontology and periodontics:
modern theory and practice. Philadelphia and St Louis:
Ishiyaku, EuroAmerica, 1989.
162. Ribeiro FV, Hirata DY, Reis AF, Santos VR, Miranda TS,
Faveri M, Duarte PM. Open-flap versus flapless esthetic
crown lengthening: 12-month clinical outcomes of a ran-
domized controlled clinical trial. J Periodontol 2014: 85:
536–544.
163. Roccuzo M, Lungo M, Corrente G, Gandolfo S. Compari-
tive study of a bioresorbable and a non-resorbable mem-
brane in the treatment of human buccal gingival
recessions. J Periodontol 1996: 67: 7–14.
164. Rosenberg M, Kay HB, Keough BE, Holt RL. Periodontal
and prosthetic management for advanced cases. Chicago,
IL: Quintessence, 1988.
165. Rosenstiel F, Land MF, Fujimoto J. Contemporary
fixed prosthodontics, 4th edn. Chicago: Elsevier Health
Sciences, 2006.
166. Rotella R, Ercoli C, Funkenbusch PD, Russell S, Feng C.
Performance of single-use and multiuse diamond rotary
cutting instruments with, turbine and electric handpieces.
J Prosthet Dent 2014: 3: 56–63.
167. Rufenacht C, Berger RP. Fundamentals of esthetics. Chi-
cago, IL: Quintessence, 1990.
168. Saadoun AP. The dentoalveolar gingival unit. Esthetic soft
tissue management of teeth and implants. Chichester, West
Sussex, UK: A John Wiley & Sons Ltd., 2012: 20–65.
169. Sanz M, Lorenzo R, Aranda JJ, Martin C, Orsini M. Clini-
cal evaluation of a new collagen matrix (mucograft proto-
type) to enhance the width of keratinized tissue in patients
with fixed prosthetic restorations: a randomized prospective
clinical trial. J Clin Periodontol 2009: 36: 868–876.
100
170. Sarmento H, Leite FR, Dantas RV, Ogliari FA, Demarco FF,
Faot F. A double-blind randomised clinical trial of two
techniques for gingival displacement. J Oral Rehabil 2014:
41: 306–313.
171. Satinover R. Review of the literature of tissue reaction to
subgingival restorations. Pa Dent J 1970: 37: 34–41.
172. Schluger S, Yuodelis RA, Page RC. Periodontal disease.
Philadelphia, PA: Lea & Febiger, 1977.
173. Schwartz N, Whitsett LD, Berry TG, Stewart JL. Unserviceable
crowns and fixed partial dentures: life-span and causes for
loss of serviceability. J Am Dent Assoc 1970: 81: 1395–1401.
174. Shannon A. Expanded clinical uses of a novel tissue-
retraction material. Compend Contin Educ Dent Suppl
2002: 23: S3–S6.
175. Shapiro N. Severe gingival damage after polysiloxane
impression procedures: a case report. J Periodontol 1988:
59: 769–770.
176. Silness J. Periodontal conditions in patients treated with
dental bridges. J Periodontal Res 1970: 5: 60–68.
177. Silness J. Periodontal conditions in patients treated with
dental bridges. II. The influence of full and partial crowns
on plaque accumulations, development of gingivitis and
pocket formation. J Periodontal Res 1970: 5: 219–224.
178. Snow SR. Strategies for successful esthetic dental treat-
ment. J Calif Dent Assoc 2007: 35: 475–484.
179. Sous M, Lepetitcorps Y, Lasserre JF, Six N. Ultrasonic sul-
cus preparation a new approach for full crown prepara-
tions. Int J Periodontics Restorative Dent 2009: 29: 277–287.
180. Spear FM. Maintenance of the interdental papilla follow-
ing anterior tooth removal. Pract Periodontics Aesthet Dent
1998: 11: 21–28.
181. Staffileno H, Levy S, Gargiulo A. A Histologic study of cel-
lular mobilization and repair following a periosteal reten-
tion operation via split thickness mucogingival flap
surgery. J Periodontol 1966: 37: 117–131.
182. Stein R, Glickman I. Prosthetic considerations essential for
gingival health. Dent Clin North Am 1960: 4: 177–188.
183. Stein R, Kuwata M. A dentist and a dental technologist
analyze current ceramo-metal procedures. Dent Clin
North Am 1977: 21: 729–749.
184. Stetler KJ, Bissada NF. Significance of the width of Keratinized
Gingiva on the periodontal status of teeth with submarginal
restorations. J Periodontol 1987: 58: 696–700.
185. Studer S, Zellweger U, Scha €rer P. The aesthetic guidelines
of the mucogingival complex for fixed prosthodontics.
Pract Periodontics Aesthet Dent 1996: 8: 333–341.
186. Sullivan H, Atkins JH. Free autogenous gingival grafts. I.
principles of successful grafting. Periodontics 1968: 6: 121–
129.
187. Takei HH. The interdental space. Dent Clin North Am
1980: 24: 169–176.
188. Takei HH, Han TJ, Carranza FA Jr, Kenney EB, Lekovic V.
Flap technique for periodontal bone implants. J Periodon-
tol 1985: 56: 204–210.
189. Tarnow D, Magner AW, Fletcher P. The effect of the dis-
tance from the contact point to the crest of bone on the
presence or absence of the interproximal dental papilla. J
Periodontol 1992: 63: 995–996.
190. Tarnow DP. Semilunar coronally repositioned flap. J Clin
Periodontol 1986: 13: 182–185.
191. Tjan AH, Miller GD, The JG. Some esthetic factors in a
smile. J Prosthet Dent 1984: 51: 24–28.

192. Valderhaug J. Periodontal conditions and carious lesions
following the insertion of fixed prostheses: a 10-year fol-
low-up study. Int Dent J 1980: 30: 269–304.
193. Valderrama S, Van Roekel N, Andersson M, Goodacre
CJ, Munoz CA. A comparison of the marginal and
internal adaptation of titanium and gold-platinum-pal-
ladium metal ceramic crowns. Int J Prosthodont 1994:
8: 29–37.
194. van der Velden U. Probing force and the relationship of
the probe tip to the periodontal tissues. J Clin Periodontol
1979: 6: 106–114.
195. van Meerbeek B, Van Landuyt K, De Munck J. Bonding to
enamel and dentin. In: Summit J, Robins J, Schwartz R,
dos Santo J, eds Fundamentals of operative dentistry A con-
temporary approach. Chicago, IL: Quintessence Publish-
ing, 2006: 183–260.
196. Vanderlei A, Borges AL, Cavalcanti BN, Rode SM. Ultra-
sonic versus high-speed cavity preparation: analysis of
increases in pulpal temperature and time to complete
preparation. J Prosthet Dent 2008: 100: 107–109.
197. Waerhaug J. Effect of rough surfaces upon gingival tissue. J
Dent Res 1956: 15: 323–325.
198. Waerhaug J. Healing of the dento-epithelial junction fol-
lowing subgingival plaque control. II: as observed on
extracted teeth. J Periodontol 1978: 49: 119–134.
199. Wagman SS. The role of coronal contour in gingival health.
J Prosthet Dent 1977: 37: 280–307.
200. Wang H, Bunyaratavej P, Labadie M, Shyr Y, MacNeil
RL. Comparison of clinical techniques for treatment
of gingival recession. J Periodontol 2001: 72: 1301–
1311.
201. Wang H, Modarressi M, Fu JH. Utilizing collagen mem-
branes for guided tissue regeneration-based root coverage.
Periodontol 2000 2012: 59: 40–157.
202. Wassell R, Barker D, Walls AWG. Crowns and other extra-
coronal restorations: impression, materials and technique.
Br Dent J 2002: 192: 679–684, 687–690.
203. Weisgold AS. Contours of the full crown restoration. Alpha
Omegan 1977: 12: 77–79.
Esthetic and periodontics interface
204. Wennstro € m J, Lindhe J. Plaque-induced gingival inflam-
mation in the absence of attached gingiva in dogs. J Clin
Periodontol 1983: 10: 266–276.
205. Wennstro € m J, Lindhe J. Role of attached gingiva for main-
tenance of periodontal health. Healing following exci-
sional and grafting procedures in dogs. J Clin Periodontol
1983: 10: 206–221.
206. Wennstro € m J, Lindhe J, Nyman S. Role of keratinized gin-
giva for gingival health Clinical and histologic study of,
normal and regenerated gingival tissue in dogs. J Clin Peri-
odontol 1981: 8: 311–328.
207. Wennstro € m JL. Mucogingival therapy. Ann Periodontol
1996: 1: 671–701.
208. Wennstro € m JL, Pini Prato GP. Mucogingival therapy Peri-
odontal plastic surgery. In: Lindhe J, Karring T, Lang NP,
editors. Clinical periodontology and implant dentistry.
Copenhagen: Blackwell Munksgaard, 2003: 576–649.
209. Wilhelmsen N, Ramfjord S, Blankenship J. Effects of elec-
trosurgery on the gingival attachment in rhesus monkeys.
J Periodontol 1976: 47: 160–170.
210. Wilson R, Maynard G. Intracrevicular restorative dentistry.
Int J Periodontics Restorative Dent 1981: 1: 34–49.
211. Wostmann B, Haderlein D, Balkenhol M, Ferger P. Influence
of different retraction techniques on the sulcus exudate flow.
IADR/AADR/CADR 82nd General Session; Hawaii, 2004.
212. Yang J, Tsai CM, Chen MS, Wei JY, Lee SY, Lin CT. Clinical
study of a newly developed injection-type gingival retrac-
tion material. Chin Dent J 2005: 24: 147–152.
213. Youdelis R, Faucher R. Provisional restorations an inte-
grated approach to periodontics and restorative dentistry.
Dent Clin North Am 1980: 24: 285–303.
214. Zigdon H, Machtei EE. The dimensions of keratinized
mucosa around implants affect clinical and immunologi-
cal parameters. Clin Oral Implants Res 2008: 19: 387–392.
215. Zucchelli G, De Sanctis M. Treatment of multiple reces-
sion-type defects in patients with esthetic demands. J Peri-
odontol 2000: 71: 1506–1514.
101