RestorativeDentistry

Nikhil Puri

Komal Puri, Sujata Surendra Masamatti and Vidya Dodwad

Restorative Aspects of Periodontal

Disease: An Update Part 2
Abstract: Along with the biologic considerations regarding crown placement, restorative margin location and implications for soft tissue
stability, as explained in the first part of this two part series, there are various restorative dentistry procedures and restorations which,
if neglected, may aggravate periodontal disease. This second article describes the surgical techniques for correction of biologic width,
correction of interproximal embrasure form, crown preparation and pontic design, and thereafter covers the restorative aspects that may
damage the periodontal tissues. Some of the special cases, like splinting, restoration of root resected or bicuspidized tooth, root caries or
external resorption cases leading to periodontal tissue damage have also been explained.
Clinical Relevance: Knowledge of the maintenance of the periodontium and how it can be affected by restorative procedures is important
for both the clinician and the patient in order to preserve the aesthetics and health of the dentition as a whole.
Dent Update 2014; 41: 638–652

The preservation of a healthy periodontium
is critical for the long-term success of a
restored tooth. General dental practitioners
(GDPs) must constantly balance the
restorative and aesthetic needs of their
patients with periodontal health.1 One
factor that is of particular importance is
the potential damage to the periodontium
when the restorative margins are placed
subgingivally.
According to Garguilo et al,2
‘biologic width’ is the zone of the root
Nikhil Puri, MDS, Senior Lecturer,
Department of Conservative Dentistry
and Endodontics, Komal Puri,
MDS, Senior Lecturer, Department
of Periodontics, Institute of Dental
Studies and Technologies, Modinagar,
Ghaziabad, Uttar Pradesh, India, Sujata
Surendra Masamatti, MDS, Reader and
Vidya Dodwad, MDS, Professor and
Head, Department of Periodontics, ITS
Dental College, Murad Nagar, Ghaziabad,
Uttar Pradesh, India.
638 DentalUpdate September 2014
surface coronal to the alveolar crest, to
which the junctional epithelium and
connective tissue are attached that
averages 2.04 mm in depth; but this may
vary from tooth to tooth and is present in
all healthy dentition.3 It has been stated
in the first part of this series that crown
margins, when positioned subgingivally,
may be associated with gingival
inflammation when in violation of the
biologic width, whereas supragingivally
located crown margins are associated with
the least gingival inflammation. Although
supragingival placement of restorative
and crown margins may compromise
aesthetics to some extent, it allows for
ease of impression-taking, cleansing,
detection of secondary caries, and is
associated with maintainable probing
depths.4,5 Subgingival margins, on the
other hand, can have damaging effects on
the neighbouring hard and soft tissues,
especially when they encroach on the
junctional epithelium and supracrestal
connective tissue,6 and may lead to
gingival inflammation, loss of connective
tissue attachment and bone resorption.3,7,8
It would therefore seem to be
advantageous to increase the dimension
of the clinical crown through surgical
crown lengthening rather than violating
the biologic width by injudicious
subgingival tooth preparations.9,10 To
avoid these potential problems to the
supporting structures of teeth, surgical
crown lengthening can provide adequate
clinical crown structure.
Surgical crown lengthening
Surgical crown lengthening
is designed to increase the length of
the clinical crown. Crown lengthening
techniques have been traditionally
used as an adjunct to restorative
procedures, particularly in cases where
subgingival caries or fractures require the
exposure of sound tooth structure and
re-establishment of the biologic width
space. Also cases of chronic gingivitis that
result from the placement of restorations
violating the biologic width may also
be treated with crown lengthening
procedures.11
With patients becoming
more concerned for aesthetic-oriented

treatment, an understanding of an
interdisciplinary treatment approach
has now developed. As a result, crown
lengthening procedures have become an
integral component of aesthetic treatment
and are utilized with increasing frequency
to enhance the appearance of restorations
placed within the aesthetic zone.
Surgical crown lengthening is a
procedure used to expose a greater height
of tooth structure in order to allow proper
restoration of the tooth prosthetically.
Periodontal crown lengthening is a
procedure that recontours the gingival
tissue surrounding one or more teeth so
that an adequate amount of healthy tooth is
exposed.12 Crown lengthening is often used
as part of a treatment plan for a tooth that is
to be restored with a crown. This procedure
provides the necessary space between the
supporting bone and margins of the crown,
preventing the new crown from damaging
the periodontal tissues. Crown lengthening
is recommended to make a restorative
procedure possible. For example, if a tooth
is badly worn, decayed, or fractured, below
the gingival line, crown lengthening adjusts
the gingival and bone levels to gain access to
more of the tooth so that it can be restored.13
Indications 14
 Inadequate clinical crown for retention
(extensive caries, root caries/tooth fracture,
root perforation, root resorption within
the cervical third of the root in teeth with
adequate periodontal attachment);
 Short clinical crowns;
 Placement of restorative margins
subgingivally;
 Unaesthetic gingival levels or margins;
 Teeth with excessive occlusal/incisal wear;
 Restorations which violate biologic width.
Contra-indications14
 Deep caries or fracture requiring
excessive bone removal;
 Post surgery creating unaesthetic
outcomes;
 Tooth with inadequate crown:root ratio
(ideal ratio 2:1);
 Non restorable tooth;
 Tooth with increased risk of furcation
involvement;
 Unreasonable compromise of aesthetics;
 Unreasonable compromise on adjacent
alveolar bone support.
September 2014 DentalUpdate 639
External bevel gingivectomy technique
This technique is generally
used to improve aesthetics and takes
the form of a gingivectomy to excise the
soft tissue.15 Gingivectomy is a successful
procedure for reconstruction of biologic
width; but can only be used in cases where
gingival hyperplasia or pseudopockets are
present (>3 mm of biologic width) and in
the presence of an adequate amount of
keratinized tissue14 (Figure 1).
Apically repositioned flap surgery
When there is a thick tissue
biotype, especially with a ledge on the
crestal bone, an apically repositioned flap
and bone recontouring may be preferable.15
An apically repositioned flap is used when
the objective is to preserve the present
attached gingiva or increase the width
of attached gingiva, where it is narrow or
absent.14,16
Classification and treatment sequence11
Following an assessment of the
alveolar crest position, four distinct clinical
scenarios may be identified (Table 1).
Correction of interproximal
embrasure form
A positive contact relation
of one tooth with another, mesially and
distally in each dental arch, must be
present. Contact areas prevent the food
from being trapped between the teeth and
help to stabilize the dental arches by the
combined anchorage of all teeth in either
arch in positive contact with each other.
In order to maintain the healthy gingiva in
the interdental areas, the contact points
should be located incisally or occlusally
and buccally.17 Proper contact points and
alignment of adjoining teeth allows proper b
spacing between them for the normal bulk
of gingival tissue attached to the bone and
teeth. On the facial aspect of the tooth,
the tip of the papilla behaves differently
as compared to the free gingival margin,
with the free gingival margin being, on
average, 3 mm above the underlying facial
bone, and the tip of the papilla being, on
average, 4.5–5 mm above the interproximal
bone. This means that, if the papilla is
farther above the bone than the facial
tissue but has the same biologic width, the
RestorativeDentistry
interproximal area will have 1.0–1.5 mm
deeper sulcus than is found on the facial
area.18
The open gingival embrasures
could be found in two cases, when either
the papilla is inadequate in height due
to bone loss or the interproximal contact
is located too high coronally. Restorative
dentistry can correct this problem by
moving the contact point to the tip
of the papilla. To accomplish this, the
margins of the restoration must be carried
subgingivally 1–1.5 mm and the emergence
profile of the restoration is designed to
move the contact point toward the papilla,
while blending the contour into the tooth
below the tissue.18
The challenge for the restorative
dentist who has to restore these teeth
is always present, so as to leave open
embrasures and establish the appearance
of a natural-looking tooth, or close the
embrasures but create square-looking
restorations with long contacts. As long as
the tooth contacts are equal in length and
the papillary heights relatively level, the
square tooth form with closed embrasures
is aesthetically preferable to the open
embrasures, while restoring the teeth.19
The height of the papilla is
determined by three factors:
a
Figure 1. Crown lengthening by external bevel
gingivectomy in UL2: (a) pre-operative view; (b)
after external bevel gingivectomy incision in UL2.
RestorativeDentistry

Classification Characteristics Technique Advantages Disadvantages

Type I Sufficient soft tissue Gingivectomy/gingivoplasty May be performed by the

allows gingival excision procedure (Figure 1). restorative dentist.
without exposure of the Provisional restorations
alveolar crest or violation of the desired length
of the biologic width. may be placed immediately.

Type II Sufficient soft tissue Surgical repositioning of the Will tolerate a temporary Requires osseous
allows gingival excision gingival margin without exposure violation of the biologic contouring. May
without exposure of the of the alveolar crest, but width. Allows staging of require a surgical
alveolar crest but in nevertheless in violation of the the gingivectomy and referral.
violation of the biologic biologic width. Soft tissues will osseous contouring
width. attempt to re-establish this procedures. Provisional
dimension upon impingement. restorations of the
In thin periodontal biotypes, desired length may be
this may result in crestal placed immediately.
resorption and subsequent
recession, while in thick
periodontal biotypes it may
manifest as chronic gingival
inflammation. Osseous
recontouring surgery may be
staged separately.

Type III Gingival excision to the Providing a surgical template Staging of the procedures Requires osseous
desired clinical crown derived from a relevant aesthetic and alternative treatment contouring. May
length will expose the blueprint. This template will serve sequence may minimize require a surgical
alveolar crest. as a guide during surgery so that, display of exposed referral; limited
following flap reflection, a subgingival structures. flexibility.
constant relationship between the Provisional restorations of
anticipated clinical crown and desired length may be
the osseous crest levels can be placed by second-stage
established and maintained gingivectomy.
through the bone contouring
process. The periodontist should
also be instructed to reposition
the flaps coronally, rather than
apically, in order to maximize
tissue preservation and allow the
anticipated revisions to the
gingival margin that will follow
once healing from the osseous
surgery has been completed
(Figure 2).

Type IV Gingival excision will Apically positioned Limited surgical

result in inadequate band mucoperiosteal flap. options, no flexibility,
of attached gingiva. a staged approach is
not advantageous,
may require a surgical
referral.

Table 1. Proposed classification system for aesthetic crown lengthening procedures.

640 DentalUpdate September 2014

 RestorativeDentistry

1. The level of the interproximal bone;
2. The patient’s biologic width; and
3. The size and shape of the gingival
embrasure of the teeth.
Tarnow et al evaluated the heights
of the contact above the interproximal bone
and level of papilla fill and stated that, when
the contact was 5 mm from the bone, the
papilla always filled the space; when the
contact was 6 mm from the bone, the papilla
filled the embrasure 56% of the time and,
when the embrasure was 7 mm long, only 27%
of the time did the papilla fill it. In general, then,
a contact above the bone of 4.5 mm to 5 mm
should always be filled by the papillae.20
Crown preparation
The following underlying factors
should be considered before selection of
the restorative material and the relative
tooth preparation design:21
 Tissue type;
 Corono-apical position of the crown a Pontics should aesthetically
margin relative to the gingival margin and to
the need of maintaining the tooth’s vitality;
 Tooth vitality;
 Abutment integrity;
 Abutment height;
 Occlusal clearance for proper strength;
 Aesthetic needs of the patient;
 Parafunctional habits.
Crown preparation designs for
full-coverage restorations are classified into b
four categories:
1. Feather-edge;
2. Chamfer;
3. Shoulder with bevel;
4. Shoulder.
Shoulder with bevel (vertical preparation)
The shoulder with bevel can
be used for ceramometal crowns, full gold
crowns and gold crowns with resin facings.
It is more conservative than a full shoulder
preparation, but the presence of the
metal collar necessitates an intracrevicular
preparation in aesthetic areas.21,23
Shoulder (horizontal preparation)
The shoulder is probably the
most popular design because it is easily
read by the technician, and it allows
sufficient bulk for porcelain to produce
aesthetically pleasing restorations (Figure
3). It can be used for all-ceramic or metal-
ceramic crowns with either a metal collar
or a porcelain butt margin.21,24
Whenever possible, crown
margins should be placed supragingivally
a
for ease of impression taking, margin
finishing and overall periodontal health.
Subgingival margin placement may be
required when the root resected area
needs to be covered. The crown margin
should be apical to the pulpal chamber
floor or root canal that was exposed by
resection, especially if these structures
have not been sealed with amalgam, but to
prevent violation of the biologic width; the
subgingival crown margins should not be
closer than 3 mm to the alveolar crest. This
may require additional lengthening of the
crown. To preserve remaining tooth structure
and encourage a better-fitting restoration,
a knife-edge finish line or a chamfer design
is recommended, which eliminates residual
ledges, roots, furcation lips or horizontal
components. In maxillary molars it eliminates
the remaining internal furcation invasions
(IFI).25,26
Pontic design
and functionally replace missing teeth and,
at the same time, be non-irritating to the
mucosa and allow effective plaque control.27

Feather-edge (vertical preparation) b

Frequently used for gold cast
crowns and porcelain or resin-veneered
crowns in periodontally involved cases, the c
feather-edge preparation design requires
the least amount of tooth structure removal.
However, finishing and polishing can be
difficult and finish line may be difficult to
read in this type of preparation.21

Figure 3. Tooth preparation should allow enough

Chamfer (‘hybrid’ preparation)
Widely used for cast restorations
or for ceramometal crowns with a minimal
metal collar. The visibility of the metal does
not allow these crowns to be used in areas
where the aesthetic demands are high.21,22
Figure 2. Crown lengthening using osseous
recontouring in maxillary anteriors from UR3 to
UL3: (a) pre-operative; (b) flap reflection and
bone recontouring; (c) post-operative.
space cervically, occlusally and axially to give the
technician the ability to create a mechanically
sound and aesthetically acceptable prosthesis.
(a, b) Shoulder preparation with no sharp angles
is excellent for metal-ceramic crowns with butt
porcelain margins.

September 2014 DentalUpdate 643

 RestorativeDentistry
While evaluating pontic design,
four designs should be considered:
1. Sanitary;
2. Ovate;
3. Ridge lap;
4. Modified ridge lap.
The restorative material for
all four designs can be either glazed
porcelain, polished gold or polished resin
and, as long as the smooth surface finish is
present, there is no difference in biologic
response of the tissue on contact with the
restoration.28 The sanitary and ovate pontics
have convex undersurfaces that facilitate
cleaning and allow for effective plaque
control. The ridge lap and modified ridge
lap designs have concave surfaces that
are more difficult to access and clean with
dental floss. A modified ridge lap design can
be given where there is inadequate ridge to
place an ovate pontic. In this type, the facial
aspect of the undersurface has a concave
shape; adequate access for oral hygiene is
allowed by the more open lingual form.18,25
Along with the biologic
considerations during crown placement,
restorative margin location and implications
for soft tissue stability, as explained in the
first article and initial part of this article,
there are various restorative dentistry
procedures and restorations which, if
neglected, may aggravate periodontal
disease.
Restorative dentistry
procedures
The GDP may be guilty of
perpetuating periodontal disease as a result
of injudicious dental therapy, which may
further aggravate periodontal disease. This
damage to the periodontal structures is
called iatrogenic damage and the factors
causing it are called iatrogenic factors.29
Restorations, endodontic therapy, fixed
and removable prosthesis and orthodontic
therapy all have the potential to become
iatrogenic to periodontal structures if not
carried out properly (Figures 4 and 5).
General dental practitioners
should also be careful during certain
procedures, such as the placement
of interdental wedges, matrix bands,
rubber dam, rubber dam clamps and
temporary restorations. The presence
of caries, fractured/faulty restorations,
restorative overhangs or undercontoured
644 DentalUpdate September 2014
restorations and open or light contacts demands of the highly concerned patients.
may lead to altered chewing patterns due Additionally, these anatomical root surface
to food impaction or an unstable occlusal presentations can impair the mechanical
relationship. Repair of the defect may be root planing that may be carried out prior
all that is required to re-establish occlusal to surgical procedure for root coverage
harmony.30 procedures. In such cases, combined
It is also important for the GDP/ restorative and periodontal surgical
specialist to understand that, in order procedures should be undertaken.36
to prevent periodontal tissue damage, Clinicians in the past have used resin-
the properties of the various restorative modified glass ionomer (RMGI) restorations
materials available must be considered, or fluoride-releasing resin materials with
as well as the hypersensitivity reaction pre-reacted glass (PRG) in subgingival
that some patients may encounter with locations with predictable success.37 It has
restorative materials. been demonstrated histologically that
both epithelium and connective tissue can
adhere to the RMGIs in the subgingival
Restorative materials environment.38 Lucchesi et al,39 evaluated
A great variety of dental
materials are now available for use in
restorative dentistry that differ in their
capacity to retain plaque, owing to
differences in their surface texture, but all
can be adequately maintained if they are
polished and accessible to patient care,31
but can lead to plaque accumulation and
gingival inflammation if left unpolished
with rough surface and margins (Figure 6).
Willershausen et al32 studied the influence
of resin-based restorations, amalgams
and gold alloys, as restorative materials
in immediate contact with the gingival
tissues, and observed a high prevalence Figure 4. Faulty prosthesis severely traumatizing
of gingival irritation in association with the gingiva in relation to mandibular anteriors.
resin-based materials. The authors stated
the reasons for such irritation as: non-
indicated applications, failure of technique,
or simply the chemical properties of the
materials. Ababnaeh et al33 evaluated Class
II, III and V restorations with amalgam,
tooth-coloured materials (resin composite
and glass ionomer), non-precious alloys,
porcelain and acrylic, in addition to crowns
and bridge abutments. They concluded
that crowns, bridge abutments (especially Figure 5. Orthodontic therapy leading to
acrylic and non-precious metals) and Class inflammatory gingival enlargement.
II amalgam restorations were associated
with highest risk of periodontal breakdown.
Similarly, Paolantonio et al34 compared
and evaluated amalgam, glass ionomer
cement, and composite resin subgingival
restorations and concluded that these
restorations do not significantly affect the
clinical parameters recorded.
A close association between
gingival recession and cervical lesions has
Figure 6. Rough restoration leading to plaque
been noted.35 Conventional restorative
accumulation in LL6.
techniques may not meet the aesthetic

RMGIs or microfilled resin composite
(MRC) and coronally positioned flaps (CPF)
in the treatment of non carious cervical
lesions associated with gingival recession,
at 6 months following surgery. Root
coverage improvement without damage
to periodontal tissues was observed,
supporting the use of a coronally
positioned flap for the treatment of root
surfaces restored with RMGI or MRC as
being effective over the 6-month period.
Comparing the
biocompatibility of the materials used for
the restoration, gold, acrylic and porcelain
caused adverse tissue reactions, especially
when the surfaces were rough and
unpolished.40 Glass ceramic restorations
showed markedly reduced bacterial
colonization compared with natural
contralateral teeth.41
Hypersensitivity to dental
materials
Hypersensitivity with the
use of some dental materials has been
observed. Patients with a known nickel
allergy develop a reaction to an intra-oral
nickelchromium dental alloy. Acrylic may
be irritant to tissues, although the material,
when fully polymerized, is not irritating
to tissues. Similarly, phosphate cements
and silicates are slight irritants. Gingival
tissues adjacent to composite resin
restorations extended subgingivally may
develop gingivitis, even in the presence
of good oral hygiene. More importantly,
tissues respond more to the differences in
surface roughness of the material rather
than its composition. The rougher the
surface of the restoration subgingivally,
the greater the plaque accumulation and
gingival inflammation. The permeability
of the gingival epithelium enhances the
penetration of leachable components and
thus the potential for toxic and allergic
reactions.42 The pulp devitalizers used in
endodontic therapy, like formocresol if
used injudiciously, may cause gingival
tissue damage (Figure 7).
Restoration overhangs
Overhanging dental
restorations have long been viewed as
a contributing factor to gingivitis and
possible periodontal attachment loss. It
September 2014 DentalUpdate 647
RestorativeDentistry
is generally accepted that overhanging Restoration of special cases
restorations contribute to gingival Splinting
inflammation owing to their retentive Splinting therapy may be carried
capacity for bacterial plaque, an increase out with the aim of connecting multiple
of the specific periodontal pathogens teeth in order to improve stability of teeth.
in the plaque, and inhibiting the Unstable teeth may be the result of a lack of
patient’s access to remove accumulated periodontal support due to bone loss, lack
plaque.43,44 Subgingival restorative of support from tooth loss, trauma, and to
margins are associated with the support pontics by splinting the abutment
development of plaque-associated teeth. Indications for splinting are as follows:
inflammatory periodontal disease, with a  Increasing or progressive mobility of
shift in the subgingival flora from health teeth, that impairs patient comfort;
to one associated with disease.43,45  Migration of teeth; or
Evidence exists that any  Prosthetics where multiple abutments are
restoration with a subgingival margin necessary.
is associated with some degree of Before considering splinting,
inflammation, both clinically and the aetiology of unstable teeth must
histologically,46 and with increased be identified,52 and the presence of
gingival fluid flow.47 inflammation of the periodontal supporting
An overhanging Class II apparatus must be controlled because
restoration may prevent access to inflammation can produce mobility in the
interdental cleaning, even for patients presence of normal occlusal forces and
with good oral hygiene (Figure 8). normal periodontal support. As all the teeth
In addition to their effect on the in the splint share the occlusal load to some
inflammatory process, overhangs may extent, rigidity of the splint and number of
also cause damage by impinging on teeth used should be determined for the
the interdental embrasure and the appropriate distribution of forces.18
biologic width.48 Mokeem49 has shown
that removal of an overhang results in
improved plaque control and restoration Root resection/hemisection/bicuspidization
of gingival health, and therefore should Patients with advanced
be a part of initial periodontal therapy.
A significant reduction in pocket depth
was also observed after removal of the
overhanging restoration.
Roughness in the subgingival
area is also considered to be a
major contributing factor to plaque
accumulation and retention, leading to
gingival inflammation, which could be
the result of one or more factors:
 Grooves in the surface of carefully
polished restorations;
 Separation of the restoration margin Figure 7. Gingival desquamation due to spill of
and luting material from the cervical formocresol during root canal treatment in LR7.
finish line, that exposes the rough
surface of the prepared tooth;
 Dissolution of luting material between
the tooth preparation and restoration;
 Inadequate marginal fit of the
restoration.50
A gap of 20–40 microns, on average,
is present between the margin of the
restoration and unprepared tooth
surface in the subgingival environment,
leading to colonization by bacterial
Figure 8. Restorative overhang in UL6.
plaque.51
 RestorativeDentistry
periodontal disease may place clinicians
in a challenging situation. One such
condition is multi-rooted teeth with
furcation involvement, as most of the cases
end up with extraction as the only option
in advanced condition. The alternative
treatment may involve combining restorative
dentistry, endodontics and periodontics in
order to retain the tooth in whole or in part.53
The term ‘tooth resection’
denotes the excision and removal of any
segment of the tooth or a root with or
without its accompanying crown portion.
Various resection procedures described are:
 Root amputation which involves the
removal of one or more roots of a multi-
rooted tooth, at the same time permitting
retention of the remaining tooth portion;
 Hemisection which is defined as
removal or separation of the root with its
accompanying crown portion; and
 Bisection or bicuspidization which is the
separation of mesial and distal roots of
mandibular molars along with their coronal
portion, where both segments are then
retained individually54,55 (Figure 9).
According to Newell,56 the
advantage of the amputation, hemisection
or bisection is the retention of some or the
entire tooth. Farshchian and Kaiser57 have
reported the success of a molar bisection
with subsequent bicuspidization. However,
there are a few associated disadvantages as
follows:
 Root surfaces that are reshaped by
grinding in the furcation or at the site of
hemisection are more susceptible to caries;
 Failure of endodontic therapy for any
reason will cause failure of the procedure;
 An improperly shaped occlusal contact
area may convert acceptable forces into
destructive forces and predispose the tooth
to trauma from occlusion and ultimate
failure of root separation and resection
(Garrett et al).58
The clinician also faces
challenges while restoring these teeth
because of the amount of tooth structure
lost in the resection process. Conservative
tooth preparation preserves as much
of the remaining tooth as possible, but
the resultant supragingival or minimally
prepared subgingival finish lines lead to
metal display in the final restoration.18
Another factor to be taken into
consideration when restoring these teeth is
the development of appropriate contours
648 DentalUpdate September 2014
for proper oral hygiene access. The
gingival embrasure form created in the
restoration must be easily accessible with
an interdental brush.18
External resorption
External root resorption can be divided
into three categories:
1. Progressive inflammatory resorption;
2. Cervical resorption; and
3. Replacement resorption.
Cervical root resorption is not a
very common type of progressive external
inflammatory resorption.59 This is usually
painless, and goes unnoticed by the patient
unless pulpal or periodontal infection is
present.60 In some cases, a deep lesion/
defect can result in sensitivity to thermal
changes because of pulpal proximity and
can also lead to damage to periodontal
attachment apparatus (Figure 10).
The treatment of external
resorption is directed towards the
complete removal of the resorptive tissue
to obtain a sound dentinal margin.61 It
must be decided if endodontic treatment
is necessary and the defect restored with
an appropriate restorative material.
A surgical approach
generally involves reflection of the flap,
debridement, curettage, restoration of
the defect with restorative materials
like amalgam, composite resin, or glass-
ionomer cement, and repositioning of the
flap to its original position. Periodontal
reattachment with amalgam62 or
composite resin63 is usually not seen, and
is unlikely with glass-ionomer resin. There
is experimental evidence to suggest that
re-attachment may occur when ProRoot®
MTA is used in this situation.64
Figure 9. Bicuspidization and restoration with
two separate metal crowns in LL6 region.
Summary
The preservation and
maintenance of a healthy natural dentition
is the ultimate goal of all phases of clinical
dentistry. In an integrated multidisciplinary
approach to dental care, periodontal
treatment should logically precede the final
restorative procedures, and both restoration
and periodontium should be in harmony
for the long term maintenance and survival
of teeth. Tissue management is of utmost
importance and the real basis on which to
determine whether prosthesis has been
properly fabricated and integrated in the
mouth of a patient. This can be achieved
only through attention to detail and the
allowance of an appropriate amount of time
to carry out every single procedure.
These articles have reviewed
some of the more significant concepts and
clinical considerations relating to restorative
procedures in order to maintain periodontal
health. The aim has been to focus the
attention of clinicians on the perio-
restorative interdisciplinary aspects, that
should always be kept in mind when trying
to replace missing tooth structure.
References
1. Lanning SK, Waldrop TC, Gunsolley JC, Maynard
JG. Surgical crown lengthening; evaluation of the
biological width. J Periodontol 2003; 74: 468–474.
2. Garguilo AW, Wentz FM, Orban B. Dimensions of
dentogingival junctions in humans. J Periodontol
1961; 32: 261–267.
3 Maynand JG, Wilson RD. Physiological dimensions
of the periodontium significant to restorative
dentistry. J Periodontol 1979; 50: 170–174.
4. Silness J. Periodontal conditions in patients
treated with dental bridges II. The influence of
full and partial crowns on plaque accumulation
development of gingivitis and pocket formation.
J Periodontol Res 1970; 5: 219–224.
5. Bader JD, Rozier RG, McFall WJ, Ramsey DL. Effect
of crown margins on periodontal conditions in
regularly attending patients. J Prosthet Dent 1991;
65: 75–79.
6. Newcomb G. The relationship between the
location of subgingival crown margins and
gingival inflammations. J Periodontol 1974; 45:
151–154.
7. Black PL. Restorative margins and periodontal
health; a new look at an old perspective. J Prosthet
Dent 1987; 57: 683–689.
8. Nevins M, Skurow HM. The intracrevicular

restorative margins, the biological width and 11. Lee EA. Aesthetic crown lengthening:
maintenance of the gingival margin. Int J classification, biologic rationale, and treatment
Periodont Rest Dent 1984; 4(3): 30–49. planning considerations. Pract Proced Aesthet
9. Kohavi D, Stern N. Crown lengthening Dent 2004; 16(10): 769–778.
procedure. Part I. Clinical aspects. Compend 12. Ravi Kiran V. Multidisciplinary rehabilitation of
Contin Educ Dent 1983; 4: 347–354. a patient with altered passive eruption and
10. Ingber JS, Rose LF, Coslet JG. The biological width hypodontia – case report. Annls Essences Dent
– a concept in periodontics and restorative 2010; 2: 55–60.
dentistry. Alpha Omegan 1977; 10: 62–65. 13. Prabhakar Rao KV, Narendranath Reddy, Anitha B.
Aesthetic crown lengthening. Annls Essences Dent
2010; 2(3): 124–128.
14. Nugala B, Santosh Kumar BB, Sahitya S, Krishna
a PM. Biologic width and its importance in
periodontal and restorative dentistry. J Conserv
Dent 2012; 15: 12–17.
15. Cunliffe J, Grey N. Crown lengthening surgery –
indications and techniques. Dent Update 2008;
35: 29–35.
16. Martins TM, Fernandes LA, Mestrener SR, Saito
CTMH, De Oliveira Nóbrega FJ, Bosco AF. Apically
positioned flap: reestablishment of esthetics and
integrity of the dento gingival unit. Perspect Oral
Sci 2010; 2(1): 43–47.
17. Ash MM. Wheeler’s Dental Anatomy, Physiology
b and Occlusion 7th edn. Philadelphia: WB
Saunders Co, 1993: pp102–127.
18. Spear FM, Cooney JP. Periodontal-restorative
interrelationships. In: Carranza’s Clinical
Periodontology 9th edn. Newman MG, Takei HH,
Carranza FA (eds). Philadelphia: Saunders, 2002:
pp949–964.
19. Spear FM. Interdisciplinary esthetic management
of anterior gingival embrasures. Adv Esthet
Interdisc Dent 2006; 2(2): 20–28.
20. Tarnow DP, Magner AW, Fletcher P. The effect
c of the distance from the contact point to the
crest of bone on the presence or absence of the
interproximal dental papilla. J Periodontol 1992;
63(12): 995–996.
21. Gracis S, Fradeani M, Celletti R, Bracchetti G.
Biological integration of aesthetic restorations:
factors influencing appearance and long-term
success. Periodontology 2000 2001; 27: 29–44.
22. Shillingburg HT, Hobo S, Fisher DW. Preparation
design and marginal distortion in porcelain-
fused-to-metal restorations. J Prosthet Dent 1973;
29(3): 276–284.
23. Rosner D. Function, placement and reproduction
of bevels for gold castings. J Prosthet Dent 1963;
13: 1161–1166.
24. Prince J, Donovan T. The esthetic metal-ceramic
margin: a comparison of techniques. J Prosthet
Dent 1983; 50: 185–192.
25. Sood S, Gupta S. Periodontal-restorative
Figure 10. (a) Periodontal pocket in UL1; (b) interactions: a review. Ind J Multidisc Dent 2011;
external resorption seen after flap reflection in 1(4): 208–215.
UL1; (c) IOPA revealing external resorption in UL1. 26. Malone WFP et al. Tylman’s Theory and Practice
September 2014 DentalUpdate 651
RestorativeDentistry
of Fixed Prosthodontics 8th edn. St Louis: Ishiyaku
Euro-America, Inc USA 1989: pp71–112.
27. Ramfjord SP, Ash MM. Periodontal considerations
in restorative and other aspects of dentistry. In
Periodontology and Periodontics: Modern Theory
and Practice 1st edn. Shiyako Euro-America, Inc
USA, 1996: pp339–352.
28. Podshadley AG. Gingival response to pontics.
J Prosthet Dent 1968; 19(1): 51–57.
29. Shenoy VK, Rodrigues S. Iatrogenic dentistry and
the periodontium. J Ind Prosthodont Soc 2007;
7(1): 17–20.
30. Patel S. The inter-relationship between restorative
dentistry and periodontology. Saudi Dent J 1999;
11(3): 124–133.
31. Sotres LS, Van Huysen G, Gilmore HW. A histologic
study of gingival tissue response to amalgam,
silicate and resin restorations. J Periodontol 1969;
40(9): 543–546.
32. Willershausen B, Kottgen C, Ernst CP. The influence
of restorative materials on marginal gingiva. Eur J
Med Res 2001; 6(10): 433–439.
33. Ababnaeh KT, Al-Omari M, Alawneh TN. The
effect of dental restoration type and material on
periodontal health. Oral Health Prev Dent 2011;
9(4): 395–403.
34. Paolantonio M, D’ercole S, Perinetti G, Tripodi D,
Catamo G, Serra E, Bruè C, Piccolomini R. Clinical
and microbiological effects of different restorative
materials on the periodontal tissues adjacent to
subgingival class V restorations. J Clin Periodontol
2004; 31(3): 200–207.
35. Terry DA, Mc Guire MK, Mc Laren E, Fulton R,
Swift EJ, Barnes P. Perioesthetic approach to the
diagnosis and treatment of carious and non
carious cervical lesions. Part I. J Esthet Restor Dent
2003; 15(4): 217–232.
36. Terry DA, McGuire MK, McLaren E, Fulton R, Swift
EJ. Perioesthetic approach to the diagnosis and
treatment of carious and non carious cervical
lesions. Part II. J Esthet Restor Dent 2003; 15(5):
284–296.
37. Scherer W, Dragoo MR. New subgingival
restorative procedures with Geristore resin
ionomer. Pract Periodont Aesthet Dent 1995; 7
(Suppl 1): 1–4.
38. Dragoo MR. Resin-ionomer and hybrid-ionomer
cements: Part II, human clinical and histologic
wound healing responses in specific periodontal
lesions. Int J Periodont Rest Dent 1997; 17(1): 75–87.
39. Lucchesi JA, Santos VR, Amaral CM, Peruzzo
DC, Duarte PM. Coronally positioned flap for
treatment of restored root surfaces: a 6-month
clinical evaluation. J Periodontol 2007; 78(4):
615–623.
40. Waerhaug J. Effect of rough surfaces upon
gingival tissue. J Dent Res 1956; 35(2): 323–325.
 RestorativeDentistry
41. Savitt ED, Malament KA, Socransky SS, Melcer
AJ, Backman KJ. Effects of colonization of oral
microbiota by a cast glass-ceramic restoration.
Int J Periodont Rest Dent 1987; 7(2): 22–35.
42. Anvasavice KJ (ed). Phillip’s Science of Dental
Materials 11th edn. St Louis Missouri: Saunders
Publishing: pp196–197.
43. Lang NP, Kiel RA, Anderhalden K. Clinical
and microbiological effects of subgingival
restorations with overhanging or clinically
perfect margins. J Clin Periodontol 1983;
10(6): 563–578.
44. Leon A. Amalgam restorations and periodontal
disease. Br Dent J 1976; 140(11): 377–382.
45. Reeves WG. Restorative margins placement and
periodontal health. J Prosthet Dent 1991; 66(6):
733–736.
46. Karlsen K. Gingival reactions to dental restorations.
Acta Odontol Scand 1970; 28(6): 895–904.
47. Mormann W, Regolati B, Renggli HH. Gingival
reaction to well-fitted subgingival proximal gold
inlays. J Clin Periodontol 1974; 1(2): 120–125.
48. Matthews DC, Tabesh M. Detection of localized
tooth-related factors that presdispose to
periodontal infections. Periodontology 2000 2004;
34: 136–150.
652 DentalUpdate September 2014
49. Mokeem SA. The impacts of amalgam overhang
removal on periodontal parameters and gingival
crevicular fluid volume. Pak Oral Dent J 2007; 27(1):
17–22.
50. Silness J. Fixed prosthodontics and periodontal
health. Dent Clin North Am 1980; 24(2): 317–329.
51. Setz J, Diehl J. Gingival reaction on crowns with
cast and sintered metal margins: a progressive
report. J Prosthet Dent 1994; 71(5): 442–446.
52. Amsterdam M. Periodontal prosthesis: twenty five
years in retrospect. Alpha Omegan 1974; 67(3):
8–52.
53. Gupta D, Sharma P, Khandelwal S. Salvage
periodontally compromised teeth through
bicuspidization. Int J Res Dent (IRJID) 2011; 1(2):
19–29.
54. Tarnow D, Fletcher P. Classification of the vertical
component of furcation involvement. J Periodontol
1984; 55: 283–284.
55. Waerhaug J. The furcation problem: etiology,
pathogenesis, diagnosis, therapy and prognosis.
J Clin Periodontol 1980; 7: 73–95.
56. Newell DH. The role of the prosthodontist in
restoring rootresected molars: a study of 70 molar
root resections. J Prosthet Dent 1991; 65: 7–15.
57. Farshchian F, Kaiser DA. Restoration of the split
molar: bicuspidization. Am J Dent 1988; 1: 21–22.
58. Garrett S, Gantes B, Zimmerman G, Egelberg J.
Treatment of mandibular Class III periodontal
furcation defects: coronally positioned flaps with
and without expanded polytetrafluoroethylene
membranes. J Periodontol 1994; 65: 592–597.
59. Gonzales JR, Rodekirchen H. Endodontic and
periodontal treatment of an external cervical
resorption. Oral Surg Oral Med Oral Pathol Oral
Radiol Endod 2007; 104(1): e70–77.
60. Frank AL, Torabinejad M. Diagnosis and treatment
of extracanal invasive resorption. J Endod 1998;
24(7): 500–504.
61. Frank AL, Bakland LK. Nonendodontic therapy for
supraosseous extracanal invasive resorption.
J Endod 1987; 13(7): 348–355.
62. Frank AL. External-internal progressive resorption
and its nonsurgical correction. J Endod 1981; 7(10):
473–476.
63. Goodman JR, Wolffe GN. The treatment of cervical
external resorption in adolescents. Preliminary
findings. Br Dent J 1980; 149(8): 234–236.
64. Koh ET, Torabinejad M, Pitt Ford TR, Brady K,
McDonald F. Mineral trioxide aggregate stimulates
a biological response in human osteoblasts.
J Biomed Mater Res 1997; 37(3): 432–439.