1. periodont. Res. 5: 225-229.

1970

Periodontal conditions in patients

treated with dental bridges
III. The relationship between the location of the crown margin
and the periodontaJ condition

JOHN SILNESS
Department of Crown and Bridge Prosthodontics, School of Dentistry,
University of Bergen, Bergen, Norway

The periodontal condition of 385 linguai abutment tooth areas with varying location of the re-
tainer margins was compared with that of 3S5 contralateral tooth surfaces which were caries-free
and devoid of fillings. The periodontal condition was assessed by recording the Plaque Index
(Silness and Loe 1964), Gingival Index (Loe and Sitaess 1963) and by measuring pocket depth
by the method of Glavind and Loe (1967). The location of the retainer margins was recorded
according to the Margin Index (Siiness 1970a). A supragingival position of the crown margins
seemed to be the most favourable location, whereas retainer margins at and below the giogival
crest interfered significantly with gingival health. The most harmful letfects upon the gingival
condition seemed to be produced by retainer margins located subgingivally.

effect of bridge fabrication upon the peri-

Introduction
In the two first papers of this series it was
shown that subgingival hridge retainer mar-
gins have an adverse effect upon the perio-
dontal condition of abutment teeth. It was
also shown that limited coverage of the re-
tainers is more advantageous than full cover-
age as far accumulation bf plaque^ develop-
ment of gingivitis, and the formation of
pockets are concerned (Silness 1970a,
1970b). In both reports, the, periodontal
condition of the abutment teeth was com-
pared with that of contralateral teeth (con-
trols) carrying amalgam and silicate fillings.
This paired-sample design has the advantage
that the periodontal condition of a relatively
great number of homologous teeth can be
compared with that of the abutments. One
of the limitations of the design is that the
treatment given contralateral teeth may
have, and no doubt frequently has, an
adverse effect upon the periodontal con-
dition of the controls. Obviously, on com-
parison this would tend to mask tbe true
odontal condition of the abutments. For
this reason, it was not feasible in the two
earlier reports to elaborate on the contro-
versial question: What is, from a periodontal
point of view, the most favourable position
of the retainer margins? The purpose of the
present report was to throw light on this
question by comparing the periodontal con-
dition of abutment tooth areas with that of
contralateral tooth surfaces devoid of resto-
rations and clinically detectable carious
lesions.
Material and Methods
The data for the present report were drawn
from the material described in the second
article in this series to which the reader is
referred (Silness 1970b). The periodontal
condition was assessed by recording the
Plaque Index (Silness and Loe 1964), Gin-
gival Index (Loe and Silness 1963) and by
measuring pocket depth according to Gla-
vind and Loe (1967). The position of the
226 SILNESS

Table I ses showed that on the lingual aspects of

Number of lingual abutment (A) and control
(C) tooth surfaces grouped according
to the Margin Index scores (0. 1, 2 and 3)
Number of surfaces
Group A C
Ml 0 36
iMI 1 108
Ml 2 96
Ml 3 95
retainer margins was recorded as explained
by Silness (1970a). In addition to assessing
the periodontal condition of the controls,
the incidence of caries and fillings was
recorded. The present study was based on a
comparison between abutment tooth areas
with varying location of the retainer mar-
gins and contralateral intact surfaces. On
these criteria, comparison could only be
made between lingual tooth areas. The ma-
terial consisted of 385 lingual abutment
tooth areas together with 385 controls and
was grouped according to tbe Margin Index
scores as shown in Table I.
A further sub-grouping by discriminating
between bridge-work recipients who had
been instructed in methods to improve the
oral hygiene and those who had not (Silness
1970b) was attempted. However, the analy-
the teeth the difference in periodontal
condition between instructed and non-in-
structed individuals was small and not
significant. In addition, the relationship be-
tween retainer margin location and perio-
dontal condition was no different in instruc-
B6 ted and non-instructed patients. For these
108
96 reasons, and since no advantage would be
95 gained and degrees of freedom lost through
a further sub-grouping, the data from the
instructed and non-instructed groups were
combined in the present analysis.
Mean Plaque Index and Gingival Index
as well as the mean pocket depth were
calculated. The significance of differences
within the groups was tested by Student's
t-test for paired comparisons. The signifi-
cance of differences between the groups was
estimated by the t-test for group compari-
sons.
Results
The results are presented iti Table II and
Fig. 1.
Oral hygiene
The mean Plaque Index of the four groups
varied between 1.35 and 1.82 for the abut-
ment tooth areas and between 1.30 and 1.38
for the control tooth areas.

Table II
Mean Plaque Index, Gingival Index and pocket depth of the lingual abutment tooth
areas (A) and lingual control tooth areas (C) for the different groups
(Mi 0, Ml 1, Ml 2 and M! 3)

A C
Plaque Gingival Pocket Plaque GingivaS Pocket
Index Index Depth Index Index Depth
Groups Mean SE Mean SE Mean SE Mean SE Mean SE Mean SE

Ml 0 1.36 0,07 1.1B 0.O6 2.40 0,06 1.30 0.07 1.20 0.06 2,39 0.06
Ml 1 1.33 B.dt, 1,19 n.OS 2.41 0.05 1.3S 0.06 1.23 0.05 2.43 0.06
MIS- 1.69 0.0€ 1.38 0.06 2.55 O.Oe 1,38 0.07 1.22 0.06 2,4S 0.06
MI 3 1.82 0.05 1,53 0.05 2.66 0.05 1,37 0.06 1.25 O.05 2,44 0.06
 C R O W N M A R G I N S A N D P E R I O D O N T A L C O N D I T I O N S 227

For the MI 3 group the t-test of the
means showed a statistically significant
difference in mean Plaque Index between
the abutments and the controls (p < 0.001).
The difference between abutments and con-
trols was significant also in group MI 2
(p < 0.005). The difference in mean Plaque
Index recorded within each of the groups
MI 1 and MI 0 was not significant.
The comparisons between the different
groups showed that the mean Plaque Index
for the abutments of group MI 3 was signi-
ficantly higher than that of the abutments
belonging to group MI 2. Further, the mean
PI I-value of group MI 2 was significantly
different from that of the groups MI 1 and
MI 0 (p < 0.025). No statistically signi-
ficant differences in mean Plaque Index
were found between the different groups of
control tooth areas.
Gingivai heuiih
The mean Gingival Index for the different
groups of abutment tooth areas varied be-
tween 1.18 and 1.53 and between 1.20 and
1.25 for the control areas.
The difference in mean Gingival Index
between the abutments and the controls was
significant both in group MI 3 (p < 0.001)
and in group MI 2 (p < 0.05). The dif-
ference within each of the groups MI 1 and
MI 0 was not significant.
The comparisons between the groups
revealed that the mean Gingival Index for
abutments belonging to MI 3 was signifi-
cantly higher than the mean Gl-value of
MI 2 (p < 0.05) which again was different
from that of MI 1 and MI 0 (p < 0.025),
The small differences in Gingival Index
between the group means of the controls
were not significant.
Pocket depth
The mean pocket depth on the lingual
aspect of the abutments varied between 2.40
mm and 2.66 m and between 2.39 mm and
2.45 mm for the controls.
In grotip MI 3 the mean pocket depth

HI Gl
D A B U T M E N T lEETH
SCORES SCORES
• CONTROL TEETH

2.0 2.0

1,5 1.5

1,0 t.O

05 as

Ml
U 1 Z 3 u \ I 3
GROUPS
Fig. t. Diagiirammatic representation of the mean Plaque and Gingival Index scores of abutments and con-
trols in the four Margin Index (Ml) groups (0, 1. 2 and 3).
228 SILNESS
of the abutmetits was significantly deeper
than that of the controls (p < 0.001). For
the remaining three groups the paired com-
parisons showed no significant mean pocket
depth differences.
The comparisons between the groups
showed that the mean pocket depth of MI 3
was not significantly deeper than that of MI
2. However, the difference in pocket depth
between MI 3 and MI 1 as weD as MI 0
was statistically significant (p < 0.001). The
remaining group comparisons for abutments
and controls showed no significant dif-
ferences between the means.
Discussion
The present epidemiological results confirm
and elaborate the trends previously reported
(Silness 1970a, b). A relationship exists
between the gingival condition of abutment
teeth and the location of the bridge retainer
margins.
In the present study, it was possible to
establish a correlation between the perio-
dontal state and the location of the retainer
margins by using detailed systems of record-
ing the position of crown margins and of
assessing the clinical changes in periodontal
condition for an individual tooth surface
(Loe and Silness 1963, Silness and Loe
1964, Glavind and Loe 1967, Silness 1970a).
Clinically, it was possible to distinguish
three different states of periodontal health
on the lingual aspects of the abutment teeth.
The differences were apparently related to
the differences in the location of .the re-
tainer margins, since the intact, hoiriorogous
control tooth surfaces showed no corres-
ponding differences in periodontal condi-
tion.
As characterized by the amounts of
plaque, severity of the gingivitis and pocket
depth, the deterioration in periodontal condi-
tion was most pronounced in areas with the
retainer margins in a subgingival position.
In areas with the crown margiti level with
the gingival crest the alteration in perio-
dontal state was less marked. However, the
periodontal condition was inferior both to
that of the controls and to that of the areas
with crown margins above the gingival crest.
This latter location of the margins did
not seem to interfere with the periodon-
tal state since the condition of the abut-
ment areas was no different from that of
the control surfaces with which it was
compared. The results of the present study,
therefore, stiggest that, from a periodontal
point of view, a supragingival position of
the crown margin is the most favourable
one. In accordance with previous histologi-
cal and epidemiological work (Wsrhatjg
1953, Silness 1970a, h) it was also found
that subgingival margins produce the most
unfavourable peeriodontal condition. In
this respect, crown margins level with
the gingival margin took an interme-
diate position. This finding is at variance
with the results of histological investigations
reported by Marcum (1967) who found that
crowns with margins located even with the
gingival crest caused the least inflammatory
response in dog.
It is clear that the cervical junction be-
tween the artificial crown, the luting mate-
rial and the tooth is a 'Weak link, since it
has been shown that bacteria as well as
degenerate and necrotic tissue tend to ag-
gregate in this region (W,Krhatig 1953).
When the cervical margins of the crown
are located subgingivally the harmful effects
of the soft debris accumulation cannot be
obviated because the junctional region.-is
inaccessible to cleansing (Silness 1970b). It
is noteworthy that the same diffictilty,
though less pronounced, may be encoun-
tered when the cervical crown margins are
located even with the gingival crest. At least,
this seems to be so as far as mechanical
cleansing of lingual abutment tooth areas is
concerned.
 CROWN MARGINS A N D P E R I O D O N T A L C O N D I T i; 0 N 3
References
Glavind, L. and H. Loe.. 1967. Errors in the
clinical assessment of periodontal destruction.
} . periodont. Res. 2: 180-184.
Loe, H. and J. Silness. 1963. Periodontal dis-
ease in pregnancy. I. Prevalence and severity.
Acta odont. scand. 21: 533-551.
Marcom, J. S. 1967. The effect of crown
marginal depth upon gingival tisstje. /. prosth.
Dent. 17: 479-487.
Silness, J. and H. Loe. 1964. Periodontal dis-
ease in pregnancy IL Correlation between
oral hygiene and periodontal condition. Acta
odont. scand. 11: 121-135,
229
Silness, J. 1970a. Periodontal conditions in
patients treated with dental bridges. /. peri-
odont. Res. Sr 60-68.
Silness, J. 1970b. Periodontal conditions in
patients with dental bridges. II. The in-
fluence of full an partial crowns on plaque
accumulation, development of gingivitis and
pocket formation. /. periodont. Res.
Waerhaug, J. 1953. Tissue reactions around
,artificial crowns 3. Periodont. 24: 172-185.
Address,:
School of Denlislry,
Universily of Bergen,
5000 Bergen, Norway.