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Review Article The perio-restorative interrelationship-

expanding the horizons in esthetic dentistry
Priya John, Majo Ambooken, Anu Kuriakose, Jayan Jacob Mathew
Department of Periodontics, Mar Baselios Dental College, Thankalam, Kothamangalam, Kerala, India

Address for correspondence: Dr. Priya John, E-mail: priyajoseph226@gmail.com

ABSTRACT
The astute clinician strives to create a beautiful smile paying due heed not only to the gleaming white teeth, but also to the
health of the surrounding tissues. A sound periodontium provides a firm foundation for an esthetic and functional prosthesis.
Conversely, when restorations are designed to be self-cleansing and promote gingival health, the tissues present a harmonious
esthetic blend at the restorative -gingival interface. This review paper aims at exploring the potential of an interdisciplinary
approach to achieve this end. This involves incorporating a comprehensive treatment plan, paying close attention to both soft and
hard tissues around teeth and implants before, during, and after restorative procedure. Key aspects of the restoration and partial
denture design that have a direct effect on the periodontium include restoration contour, margin adaptation, margin placement,
prosthetic and restorative materials, design of fixed and removable partial dentures, restorative procedures and occlusal function.
Special emphasis is paid to the consequences of violation of biologic width, that leads to incessant inflammation, possible
recession and unsightly exposure of crown margin. Periodontal considerations include control of periodontal inflammation,
correction of the gingival architecture, and periodontal maintenance. A search of articles from “Pubmed” and “Medline” with
the keywords restorative-alveolar interface, methods of gingival retraction and biologic width was conducted. A total of 430
abstracts were collected, of which most relevant articles were included in this paper.

CLINICAL RELEVANCE TO INTERDISCIPLINARY DENTISTRY

• To promote restoration and pontic designs that promote favorable tissue response.
• To stress the importance of preserving biologic width to all dental practitioners
• To shed light on iatrogenic damage to the periodontium from certain materials and procedures.
• To unveil the potential of periodontal plastic surgery techniques like augmenting attached gingiva and esthetic crown
lengthening prior to restorative procedures when indicated.
• To emphasize the need for recall and maintenance therapy.
All the above concepts can be successfully implemented into clinical practice.

Key words: Methods of gingival retraction, biologic width, restorative-alvelolar interface

INTRODUCTION restorative treatment may have adverse effects

on the periodontium by increasing accumulation

A beautiful smile can be crafted only against

a backdrop of healthy gingiva. A sound
periodontium provides a firm foundation for an
esthetic and functional prosthesis. The practice of
restorative dentistry has a reciprocal relationship
with the maintenance of periodontal health. Poor
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of plaque while untreated periodontal disease will
compromise the success of restorative dentistry.[1]
When restorations are designed to be self‑cleansing
and promote gingival health, the tissues present a
harmonious esthetic blend at the restorative‑gingival
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DOI: How to cite this article: John P, Ambooken M, Kuriakose A, Mathew JJ. The
10.4103/2229-5194.162745 perio-restorative interrelationship-expanding the horizons in esthetic
dentistry. J Interdiscip Dentistry 2015;5:46-53.

46 © 2015 Journal of Interdisciplinary Dentistry | Published by Wolters Kluwer - Medknow

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John, et al.: The perio-restorative interrelationship
interface. The purpose of this review is to explore the
effects of contemporary restorative procedures and
materials on the periodontium. On the other hand, the
clinical relevance of some periodontal plastic surgery
procedures for a healthier restorative‑alveolar interface
is outlined.
RESTORATIVE CONSIDERATIONS
THAT IMPACT THE PERIODONTIUM
• Restoration contour and contact areas
• Margin adaptation and defects
• Location of margin
• Role of provisional restorations
• Design of fixed and removable partial dentures (RPDs)
• Occlusal function
• Prosthetic and restorative materials and alloy
hypersensitivity
• Iatrogenic damage from restorative procedures.
Contour and contact areas
Clinical longevity of any prosthesis is directly related to
achieving proper restorative contours.[2] It is the function of
the axial form of teeth to afford protection and stimulation
to the marginal periodontium.[3,4]
Physiologic tooth contouring
• Allows for self‑cleansing mechanisms of cheek,
tongue, etc. For instance, the bucco‑lingual bulge
should be <0.5 mm wider than the cemento‑enamel
junction[3,5,6]
• There must be sufficient space: Cervically to create
the correct contour that facilitates plaque removal,
occlusally to allow the restoration of a proper
occlusion, and axially to provide a proper thickness
of veneering material to achieve an esthetically
acceptable prosthesis.
Insufficient preparation of abutment teeth is often done
to preserve sound tooth structure, but often results in
over contouring.
Problems with over contouring
• “Food traps” from open contacts, overhangs, or
plunger cusps may occur
• Poor occlusal design, and poor esthetics[5,6]
• When the coronal contour of a restoration prevents
access for oral hygiene or creates mechanical pressure
on the gingival tissue, gingival health is likely to be
compromised[7]
• Plaque accumulation, inflammation, bleeding, and
potential bone loss. Plaque is the primary factor in
gingivitis[8]
Journal of Interdisciplinary Dentistry / Jan-Apr 2015 / Vol-5 / Issue-1
• An unesthetic emergence profile of a restoration is
created. The emergence profile is the shape of the
restoration in relation to the gingival tissues. Stein and
Kuwata described the part of the axial contour that
extends from the base of the gingival sulcus past the
free margin of the gingiva as the emergence profile
that was straight in the gingival third.[9]
Schluger et al. felt the cervical bulge overprotects the
microbial plaque. Schluger et al. have advocated “flat”
not “fat” contours.[8] Over contouring is potentially more
detrimental to the periodontium than under contouring.[10]
Contact areas
• Should be in the coronal third of the crown and buccal
in relation to the central fossa
• Proximal contact points are buccal to the central
fossa line, except for maxillary molars founds at the
middle third. This creates a large lingual embrasure
for optimum health of the lingual papilla.[2,5]
Problems with misplaced contacts
• Horizontal food impaction is produced by the action
of the tongue, lips, cheeks and results from poorly
contoured interproximal surfaces. Lower fixed
partial dentures usually collect more food than upper
dentures, particularly in the molar region
• Lifting and rotating forces on dentures
• Deflective occlusal contacts.[11]
Marginal adaptation and defects
• Scientific data indicate that even clinically successful
crowns have margins that are open. The average
opening is about 100 nm, which tends to harbor
bacterial plaque even around the best fitting margins
of a restoration causing inflammation[4,5]
• Roughness of the tooth‑restoration interface from
scratches in the surface of carefully polished acrylic
and ceramic crowns, inadequate marginal fit of the
restoration, dissolution and disintegration of the
luting material causing crater formation between the
preparation and the restoration and inflammation of
gingiva[12]
• Sharp edges or corners in the preparation not
reproduced accurately on the stone die can create
marginal discrepancies. Dentists must ensure that the
crowns completely seat on the tooth.
Preparation margin designs for metal ceramic
crowns
• The chamfer: The thin metal collar may distort during
the firing of porcelain, thus producing inaccurate
margins
47
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John, et al.: The perio-restorative interrelationship
• Feather‑edge margin: Used for cast crowns and
veneers. But finish line is hard to read and not
amenable to thorough finishing and polishing
• A shoulder with bevel is more conservative than a full
shoulder preparation, but the presence of the metal
collar necessitates an intra‑crevicular preparation in
esthetic areas
• A shoulder preparation allows for sufficient bulk
for porcelain to produce esthetically pleasing
restorations.[11,13]
Location of margin: The clinical significance
of margin placement
Eissman et al.’s design criteria for fixed partial dentures
state that crown margins should be placed on tooth
surfaces that are fully exposed to cleansing action,
preferably supragingival or slightly into the sulcus. [3]
Vigorous tooth brushing was effective up to 0.7 mm below
the gingival margin, suggesting that the submarginal
extension of restorations should be limited to no more
than this distance.[7] Restorative requirements frequently
necessitate subgingival margin placement in order to gain
resistance or retention form to alter tooth contour, for
caries for subgingival tooth fracture removal, in furcation
involvement and to hide the tooth‑restorative interface
or have contacts that need to be lengthened apically to
avoid black triangles.[8] In such cases, subgingival margin
placement is necessary, marginal fit should be optimal
because rough restorations or grossly open margins lead
to an accumulation of bacterial plaque.[12]
Advantages of supragingival margins over
subgingival margins
• Supragingival margins improved periodontal health[14]
• Subgingival margins demonstrated increased plaque,
gingival index score, and probing depths[15]
• Furthermore, more spirochetes, fusiforms, rods and
filamentous bacteria were found to be associated with
subgingival margins[16‑18]
• Violation of the connective tissue attachment; and
greater pathogenicity of the subgingival plaque are
documented with subgingival margins[17]
• Supragingival margins stay away from the periodontal
tissues, and thus, they are easier to prepare, record
and maintain.[13,19]
Current trends favor equigingival margins over older
concepts of subgingival margins for crowns, which are
kinder to the periodontium. Furthermore, advances with
emerging translucent restorative materials adhesive
dentistry, and r esin cements, pr omote polished
margins that esthetically blend with the tooth for a
healthy tooth‑restorative interface even when placed
equigingival.[20]
48
The concept of biologic width, and its applications
in placement of gingival margins
Understanding and clinically managing the concept of
biological width is the key to creating gingival harmony
with dental restorations. The biologic width is defined
as the dimension of space occupied by the soft tissues
above the level of the alveolar crest. The connective
tissue attachment occupied 1.07 mm above the level of
the crestal bone, junctional epithelium attachment below
the base of the gingival sulcus to be 0.97 mm, and an
average sulcus depth of 0.69 mm. In the average human,
this 2–3‑mm distance remains constant in health and
disease.[21,22] Encroachment on the biological width by
tooth preparation, caries, fracture, restorative materials
or orthodontic devices can lead to bacterial accumulation,
persistent gingival inflammation eventually resulting in
increased probing depths, gingival recession or pocket
formation.
Assessment of biologic width
Wilson and Maynard have described the concept of
intra‑crevicular restorative dentistry. Intra‑crevicular
margins are defined as those confined within the
gingival crevice.[23] The restorative dentist must be able
to determine the base of the sulcus for intra‑crevicular
margin location. Kois suggested that the restorative
dentist must determine the total distance from the
gingival crest to the alveolar crest.[4] This procedure is
termed bone sounding. The tissues are anesthetized,
and the periodontal probe is placed in the sulcus and
pushed through the attachment apparatus until the
tip of the probe engages alveolar bone. Based on this
measurement, the three categories of biologic width
described are:[24]
• Normal crest: A biologic width of 3 mm on the
labial aspect allows for a crown margin that is placed
0.5 mm subgingivally
• High crest: Measurement lesser than 3 mm does not
allow for subgingival margins without bone removal
• Low crest: Measurement of more than 3.0 mm. It
is most susceptible to recession secondary to the
placement of an intra‑crevicular crown margin in the
presence of a thin periodontium.
This is an attempt of the body to recreate room above the
alveolar crest for tissue reattachment.
Correction of violation of biologic width
To restore gingival health, it is necessary to reestablish the
space clinically between alveolar bone and the gingival
margin. For this purpose, either surgery to alter bone
level[25,26] or orthodontic extrusion of the tooth to move
the restoration margin away from the bone level.
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John, et al.: The perio-restorative interrelationship

Margin placement guidelines construction. The undersurface of pontics in fixed bridges

should barely touch the mucosa. When the contact is
• Rule I: If the sulcus probes 1.5 mm or less, place the
excessive, it prevents cleaning. The “modified ridge‑lap”
restoration margin 0.5 mm below the gingival tissue
pontic has pinpoint, pressure‑free contact on the facial
crest
slope of the ridge, and all surfaces should be convex,
• Rule II: If the sulcus probes more than 1.5 mm, place
smooth, and highly polished or glazed.[11,32,33] The sanitary
the margin one‑half the depth of the sulcus below
pontic is most hygienic, but ovate pontic combines both
the tissue crest. This places the margin enough below
esthetics and hygiene.
tissue so that it is still covered if the patient is at higher
risk of recession
Crowns for root‑resected teeth
• Rule III: If the sulcus >2 mm is found, especially on the
facial aspect of the tooth, then evaluate to see whether Root resection may be indicated in multirooted teeth with
a gingivectomy could be performed to lengthen the advanced Grade II to III furcation involvements.[26] Crowns
teeth and create a 1.5 mm sulcus. Then the patient that are placed on upper molars that have undergone root
can be treated as mentioned in rule I.[25] resection must be contoured in a specific way to ensure
that the patient has access for oral hygiene measures. The
Gingival retraction preparation eliminates residual ledges, roots, furcation
lips or horizontal components or the furcation.[33,34] The
It can be achieved mechanically using retraction cords,
gingival embrasure form created in the restoration must be
copper bands or cords.
fluted into these areas so that the surfaces can be accessed
an interdental brush, a knife edge or chamfer margin is
• A single‑cord technique is the least traumatic option
indicated[9] [Figure 1].
than two cord technique and is normally employed
when the sulcus, is shallow, and the margin is
A cast post and core may be indicated to create an
placed only minimally in the crevice in areas of root
adequate foundation for the final restoration.[33] When
proximity.[25,27]
palatal root has been resected, re‑contouring of the crown
results in a much thinner crown buccopalatally. After root
Chemicals used for the treatment of chords diffuse in
separation, close proximity of the roots should be relieved
blood circulation through crevicular epithelium, help to
using one of the following options.
control seepage of blood or gingival fluid but Can cause
• Partial instead of full‑coverage restorations to avoid
damage to gingiva if used injudiciously.[20,25] Newer and
preparing and restoring the side of the tooth with the
safer materials like biocompatible polymer – hydroxylate
proximity problem
polyvinyl acetate (Merocel) absorbs intraoral fluids and
• More apical placement of the restorative margin if the
is soft and adaptable. Expasyl is a paste that not only
root trunk tapers apically or an odontoplasty with a
opens the sulcus but also leaves the field dry. It is mainly
flame‑shaped bur to increase the separation
composed of micronized kaolin, aluminum chloride and
• Orthodontic movement to separate the teeth; and
water.[28]
strategic extractions.[20]
Role of provisional restorations Lateral forces are controlled by minimizing cuspal inclines
Provisional restorations are needed to protect the on the resected molar and the teeth stabilizing it. Bergman
prepared teeth, to reduce the sensitivity of the vital
abutments, and to prevent tooth migration. They are
used to correct esthetics, phonetics and occlusal scheme
before fabrication of the definitive restoration. Provisionals
should have good marginal fit and polish. This prevents
plaque accumulation and related inflammatory gingival
overgrowth or recession.[1,29,30]

Design of fixed and partial dentures and

crowns for root‑resected teeth
A bridge should be designed to minimize accumulation
of dental plaque and food debris and to maximize access
for cleansing by the patient. It should also provide
embrasures for the passage of food and protection of Figure 1: Treatment of Grade II furcation involvement with root
gingival crevices.[31] Stein concluded that the pontic design resection. Contour of crown modified to prevent ledge formation.
was more important than the material used in the pontic Occlusal platform reduced

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John, et al.: The perio-restorative interrelationship
et al. (1982) also reported that RPDs did not compromise
long‑ter m dental health. Conventional RPDs were
designed and fabricated to keep denture bases, clasps,
and bars as far from the gingiva as possible.[35]
Occlusion
Occlusal discrepancies in a restoration appear to be
a significant risk factor that contributes to more rapid
periodontal destruction and that treatment of occlusal
discrepancies seemed to slow periodontal destruction.[36]
Cantilever designs often result in fractures of casting and
roots and periodontal inflammation around abutment
tooth. Occlusal evaluation is to be done after inflammation
due to periodontitis has subsided due to changes in
tooth‑tissue relationship. Occlusal appliance therapy may
be used before occlusal adjustment for acute issues. Use
cantilevers sparingly and with light occlusal contact if
needed with multiple abutments.[33]
Restorative materials and alloy sensitivity
Self‑curing acrylics are less tissue friendly. Improperly
finished composites may become rough. Phosphate
cements and silicates are irritant. Lab cast and high
polish of restorations is important in preventing plaque
accumulation.[37] Unfavorable gingival reactions to alloys
used in the oral environment have been documented.[38]
The fine marginal fit of glass ceramics and porcelain veneers
have least gingival irritation.
Iatrogenic damage from procedures
Special care should be directed to minimize mechanical
and chemical trauma to the natural dentition and to the
periodontium during restorative procedures. Injudicious
use of electrosurgery, cryosurgery and laser can cause
excessive necrosis of the gingiva and in extreme cases,
the underlying bone. Excessive pressure while trimming
and fitting bands may sever or traumatize the gingival
attachment and lead to irreversible gingival recession.[27]
The residual material of retraction cords left in the crevice
can lead to periodontal abscess later. Injury from rubber
dam clamp and disks can lead to gingival inflammation.
CURRENT TRENDS IN PERIODONTAL
ASPECTS OF RESTORATIVE
DENTISTRY
• Supragingival placement of margins of restorations
• Avoidance of over contoured restoration, and minimal
concern with lack of contour
• Occlusal stability through precise occlusal adjustment
and accurate reconstruction of occlusal anatomy in
single restorations
• Restricted indications for splinting of mobile teeth
50
• Hemisection with fixed bridges in cases of extensive
bifurcation involvement.[27]
The purpose of restorative dentistry is to restore and
maintain health and functional comfort of the natural
dentition combined with satisfactory esthetics. Thus,
all dental restorations should comply with established
requirements for periodontal physiology and health, both
with regard to surface and functional characteristics.[39]
PERIODONTAL CONSIDERATIONS
Periodontal therapy to resolve inflammation must be
completed before restorative dentistry.
Importance of a healthy periodontium:
A firm foundation for precise and lasting
restorations
• Healthy gingival margins do not shrink after tooth
preparation and enable accurate impressions[40,41]
• There are less chances of bleeding after preparation,
which aids visibility and making impressions[42]
• Stable tissues, free of inflammation ensures predictable
restorations[43]
• Trauma from occlusion on teeth with untreated
periodontitis may increase tooth mobility and rate of
attachment loss[44]
• Quality and topography of the periodontium should
be improved to prevent negative changes once the
restorations have been placed.[2] For instance, a wider
zone of attached gingiva is needed around abutment
teeth and in those with subgingival restorations
as less inflammation is reported than in teeth with
narrow zones.[45] It is useful in areas of esthetic margin
placement, to facilitate impressions, and in some cases,
to increase patient comfort. Thicker tissues have been
found to provide adequate protection against recession.
Periodontal therapy
• A thorough periodontal evaluation is indicated in the
planning stages prior to fabrication of the prosthesis.
Selection of abutment teeth is based on prosthodontic
and periodontal considerations, including bone
support and architecture, width of attached gingiva,
tooth mobility, root anatomy, and tooth position
• Controlling or eliminating periodontal disease
with cause‑related therapy and surgical therapy to
eliminate pockets
• Correction of the gingival architecture that may favor
disease, impair esthetics, or impede placement of
prosthesis with preprosthetic surgery
• Periodontal maintenance and motivation for oral
hygiene should be given during treatment and interim
periods.[27]
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John, et al.: The perio-restorative interrelationship

Cause‑related therapy eliminates tension on marginal gingiva in the area of

a frenum
Plaque control, calculus removal, and the removal of any
• Removal of gingival excess and maintaining biologic
inadequate dental restorations in the gingival environment,
width: In situations in which a tooth has a short
treatment of food impaction, correction of trauma from
clinical crown deemed inadequate for retention of a
occlusion, and orthodontic tooth movement, motivation
required cast restoration, it is necessary to increase
for oral hygiene, as well as extraction of hopeless teeth
the size of the clinical crown using periodontal surgical
can be done.
procedures [Figure 5].
Surgical therapy This can be done surgically or orthodontically while
• Periodontal flap surgery may be necessary to gain maintaining the biologic width. To select the proper
access for debridement, to reduce pockets and treatment approach for crown lengthening, an analysis
for periodontal regenerative therapy with bone of the individual case with regard to crown‑root alveolar
grafts [Figure 2] bone relationships should be done.
• Preprosthetic surgery: Gingival augmentation: It can
be done using a free gingival graft or connective tissue • External bevel gingivectomy: This can be done when
graft or acellular dermal matrix[16] there is more than adequate attached gingiva and at
• A vestibuloplasty may be required in areas where least 5 mm excessive suprabony gingival tissue is
a shallow vestibule complicates oral hygiene. present and no bone involvement [Figure 6]
Correction of shallow vestibule also facilitates gain
in attached gingiva. Vestibuloplasty by periosteal
fenestration [Figure 3], and vestibuloplasty with free
gingival graft [Figure 4]. Removal of aberrant frena
improves vestibular depth, attached gingiva and

Figure 3: Vestibuloplasty with periosteal fenestration for treatment of

shallow vestibule and insufficient width of attached gingiva

Figure 2: Flap surgery with bone grafting

Figure 5: Crown lengthening with osteoplasty done for unesthetic

Figure 4: Vestibuloplasty with free gingival graft. Incision given, gingival margins and reduced height of clinical crown. Vertical and
recipient bed, and template for graft prepared. Free gingival graft internal bevel incisions are given. Flap raised and bone recontoured
harvested and sutured in place to prevent violation of biologic width

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John, et al.: The perio-restorative interrelationship
Figure 6: Esthetic gingival recontouring with external bevel incision
for unesthetic gingival margins. Gingival margins established in golden
proportions
• Internal bevel gingivectomy: Reduction of excessive
pocket depth and exposure of additional coronal
tooth structure in the absence of a sufficient zone
of attached gingiva with or without the need for
correction of osseous abnormalities requires a
surgical procedure, wherein the flap must always be
internally beveled so as to expose the supporting
alveolar bone [Figure 7]
• Apically positioned flap with bone re‑contouring: It
is used to expose sound tooth structure in cases of
tooth fracture or caries. As a general rule, at least
4 mm of sound tooth structure must be exposed at
the time of surgery. It is indicated for multiple teeth in
the nonesthetic zone.[25,26] Esthetic crown lengthening
can be done using flap surgery with bone removal
using a surgical guide. The golden proportion has
been recommended as a guide for an esthetic tooth/
restoration: The mesial‑distal width of a tooth is
approximately 75% of its height. Allen recommended
having the gingival margins on incisors peak slightly
distal to the midline of the teeth. Central incisors, with
an average length of 11–12 mm, should be 1.5 mm
longer than laterals[46]
• Pontic ‑ soft tissue relationships: If soft tissue form
and surface characteristics are deemed unacceptable,
corrections should precede fabrication of the
restoration. Pontics should preferably be placed
over keratinized tissue rather than alveolar mucosa.
Ridge augmentation may be accomplished by
internal connective tissue grafts, free soft tissue
onlay‑autografts, or ridge transposition. When
the ridge is covered by excessive amounts of
soft tissue, ridge reduction can be accomplished
by gingivoplasty or internal soft tissue wedge
reduction (e.g., tuberosity reductions).[47] Osseous
respective surgery may be indicated when a bony
portion of the ridge is covered by a thin layer of soft
52
Figure 7: Internal bevel gingivectomy with osseous contouring for
prosthetic restoration of fractured tooth. Core buildup done and crown
is in place
tissue. Ridge reduction surgery may be required to
increase the vertical clearance between the residual
ridge and opposing occlusion.
SUPPORTIVE PERIODONTAL
THERAPY
Maintenance recalls are essential to the long‑term success
of fixed and removable prosthesis especially overdenture
abutments. Hygiene adjuncts using end‑tufted brushes and
daily application of fluoride are beneficial.
CONCLUSION
An interdisciplinary approach requiring coordinated efforts
by the restorative dentist and periodontist is the need
of the hour. Close attention paid to both soft and hard
tissues around teeth and implants before, during, and after
restorative produces a successful outcome. It also gives
the patient the benefit of comprehensive treatment with
precise and lasting and restorations.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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