RestorativeDentistry

Komal Puri

Nikhil Puri, Vidya Dodwad and Sujata Surendra Masamatti

Restorative Aspects of Periodontal

Disease: An Update Part 1
Abstract: Today’s dentistry is dominated by restorative procedures which are carried out to meet the demands of not only function but
also aesthetics. Prosthetic and restorative therapies generally require a healthy periodontium as a prerequisite for successful treatment
outcome. A mouth with a healthy periodontium may be affected by restorations of poor quality, and restorations of the highest quality
may fail in a mouth with periodontal disease. This is the first of two articles that attempt to explain the concept of the complex question
of biologic width and the problems that occur after improper margin placement in the periodontium. Initially, the dimensions of biologic
width are considered and then margin placement and reasons for restorative procedures are discussed. This article also addresses the
interactions between periodontal tissues and restorative procedures.
Clinical Relevance: Understanding the impact of restorative procedures on periodontal health in regular dental examination by dentists
can help in early diagnosis and treatment of periodontal diseases. This could prevent further progression of disease and reduce the
frequency of tooth loss.
Dent Update 2014; 41: 545–552

Periodontal tissues form a strong basis for both
aesthetics and comfort of the dentition as
well as the functioning of dental tissues.1 The
interrelationship of restorative dentistry and
periodontics is a dynamic one.2 The periodontal
health at the restorative gingival interface
represents a big challenge for the restorative
dentist, as the tooth and its surrounding
structures are continuously being affected by
microbial flora, and restorative dentistry may
aggravate this condition.3
Prosthetic and restorative
treatments generally require a healthy
Komal Puri, MDS, Senior Lecturer,
Department of Periodontics, Nikhil Puri,
MDS, Senior Lecturer, Department of
Conservative Dentistry and Endodontics,
Institute of Dental Studies and
Technologies, Modinagar, Ghaziabad,
Uttar Pradesh, India, Vidya Dodwad,
MDS, Professor and Head and Sujata
Surendra Masamatti, MDS, Reader,
Department of Periodontics, ITS Dental
College, Murad Nagar, Ghaziabad, Uttar
Pradesh, India.
July/August 2014 DentalUpdate 545
periodontium as a prerequisite for successful
outcome, and this interaction between two
important fields of dentistry is present on many
fronts, including placement of restorative and
crown margins, and contours of the crown,
and the response of the gingival tissues to
restorative preparations.1
Periodontal attachment loss
begins when the epithelial integrity of the
dentogingival unit is breached by microbial
flora, trauma, or both. The progression of
the periodontal destruction appears to be
related to host susceptibiity, competence of
the surrounding tissues, and virulence factors
of bacterial pathogens,4,5 which in turn may
be influenced by the three main aspects of a
dental restoration: morphology, margin quality
and margin location.3
Glickman6 has rightly stated that
every restoration has a periodontal dimension.
A mouth with a healthy periodontium may
be affected by restorations of poor quality,
and restorations of the highest quality may
fail in a mouth with periodontal disease. It
is important that the restorative phase of
dental treatment is commenced keeping
in mind the periodontal health status of
the patient and only when the patient has
learned to maintain that health.7 The practice
of restorative dentistry has a reciprocating
interrelationship with the maintenance
of periodontal health. Undiagnosed
and untreated periodontal disease may
compromise the success of restorative
dentistry, and poor restorative treatment may
have adverse effects on the periodontium by
increasing the accumulation of plaque and
inducing changes in the composition of the
microbial flora. The successful integration of
periodontal and restorative dentistry for both
natural teeth and implants requires knowledge
and the application of both mechanical and
biological principles.8 The proper location of
the restorative and crown margins relative
to the alveolar bone height may be one of
the most important parameters to ensure
long-term gingival health, as the restorations
that interfere with host defences will create
sites where micro-organisms thrive and cause
destruction.9
Successful restorative dentistry can
be best accomplished when healthy and stable
tissues surround the teeth or their implant
replacements and, by evaluating both soft and
hard tissues around teeth and implants before,
during and after restorative procedures, the
 RestorativeDentistry
probability of a successful outcome will be
greatly increased.8
This is the first of two articles that
emphasizes the restorative considerations
of periodontal disease, and covers the
factors important in operative dentistry and
prosthetics for the maintenance of periodontal
health. In this part, the biologic considerations
during crown placement and the way these
may damage the periodontal tissues are
described and the various other restorative
aspects that may damage the periodontal
tissues are also covered.
The second part of the article will
include the surgical techniques for correction
of biologic width, correction of interproximal
embrasure form, crown preparation, pontic
design, splinting and some of the special
cases, like the restoration of a root resected or
a bicuspidized tooth, root caries or external
resorption cases leading to periodontal tissue
damage.
Importance of preparation of
the periodontium for restorative
dentistry
Periodontal disease is a
multifactorial, polymicrobial and polygenic
disease with variable clinical features, with the
primary aetiological agent being the specific
bacterial pathogens. Supragingivally, local
factors like crowding, calculus and rough
unpolished restorations act as plaque retentive
areas leading to host response in the form of
gingival inflammation and/or gingivitis.
When allowed to progress, the
Gram-negative anaerobes flourish and any
irregularities like root anatomy, subgingival
restorative margins and overhanging dental
restorations will enhance bacterial adhesion to
the pocket epithelium and the tooth surface,
thus allowing the growth of subgingival
plaque.10
The reasons why periodontal
disease should to be eliminated prior to
restorative dentistry are:11,12
 To locate and determine the gingival
margins of restorations properly; the position
of the healthy and stable gingival margin must
be established prior to tooth preparation.
Margins of restorations covered by inflamed
gingiva shrinks after periodontal treatment.
 The position of the tooth may be altered
in periodontal disease. Resolution of
inflammation after treatment causes the
tooth to move again, often back to its original
546 DentalUpdate July/August 2014
position. Biologic considerations during
 Restorations designed for teeth before crown placement, restorative
the periodontium is treated may produce margin location and implications
injurious tensions and pressures on the for soft tissue stability
treated periodontium.
Concept of biologic width
 Inflammation of the periodontium impairs
In the human body, an ectodermal
the capacity of abutment teeth to meet the
tissue serves to protect against invasion
functional demands made on them.
from bacteria and other foreign materials.
 Discomfort from tooth mobility may
However, both teeth and dental implants must
interfere with mastication and function.
penetrate this defensive barrier.17 The natural
 It is easier to obtain accurate impressions
seal that develops around both, protecting
and make more precise preparations on
the alveolar bone from infection and disease,
healthy gingivae than inflamed ones.
is known as the biologic width.18 The biologic
 To minimize the risk of trauma to the
width is defined as the dimension of the soft
gingival tissues during preparation and
tissue which is attached to the portion of the
impression procedures.
tooth coronal to the crest of the alveolar bone
Restorative dentistry has an effect
(Figure 1). This term was based on the work of
on the periodontal health in many ways,
Gargiulo et al,19 who described the dimensions
which include the type of restorative material,
and relationship of the dentogingival junction
the way in which it is placed, and the contour
in humans. Measurements made from the
of the restoration.3,13 The degree of retention
dentogingival components of 287 individual
of plaque is an important factor; for example,
teeth from 30 autopsy specimens established
the subgingival margins of the restorations
that there is a definite proportional relationship
and crowns, the fit of dentures and bridges,
the contour and materials of the restorative
between the alveolar crest, the connective
material.14 Also, if subgingival restorations
tissue attachment, the epithelial attachment,
are placed, they should be smooth finished
and the sulcus depth. Gargiulo et al19 reported
the following mean dimensions: a sulcus depth
if possible, formed in materials unlikely to
of 0.69 mm, an epithelial attachment of 0.97
deteriorate under plaque and, ideally, retard
mm, and a connective tissue attachment of
plaque formation.14 Efforts should be made to
1.07 mm. Based on this work, the biologic
gain access to subgingival lesions by the use
width is commonly stated to be 2.04 mm,
of small localized flaps,15 to provide access,
which represents the sum of the epithelial
vision and proper adaptation and finish to the
and connective tissue measurements.1 In
restoration.16
1977, Ingber et al20 described ‘Biologic width’
Extra care is required for
and credited D Walter Cohen for first coining
various procedures on the tissues, like the
the term. The basis for the biologic width is
placement of matrix bands, interdental
the so-called ‘radius of inflammatory effect’ in
wedges, rubber dam, rubber dam clamps and
which there is a finite distance of approximately
temporary restorations. Clinicians also need
1−2 mm over which the tissue lytic properties
to consider the length of time a restoration
of localized inflammation operate.21,22
has been defective, and be mindful of a
The biologic width is essential for
gingival inflammation suddenly becoming a
preservation of periodontal health and removal
destructive periodontal lesion.3
of injurious factors that might damage the
Many attempts have been made
periodontium. The dimension of biologic width
to improve both techniques and materials
is not constant. It depends upon the location
to meet the ever-increasing aesthetic
of the tooth in the alveolus, varies from tooth
requirements of patients. However, too often
to tooth, and also from the aspect of the
the emphasis is placed on these factors as
tooth. It has been shown that 3 mm between
the only keys to success. It is instead the
the preparation margin and alveolar bone
integration of a natural-looking prosthesis
maintains periodontal health for 4−6 months.23
within a healthy periodontium that should
This 3 mm constitutes 1 mm supracrestal
represent the ultimate goal of the treatment,
connective tissue attachment, 1 mm junctional
emphasizing the restorative materials and
epithelium and 1 mm gingival sulcus, on
clinical procedures that play a role in any
average. This allows for adequate biologic
clinician’s attempt to create biologically
width even when the restorations margins are
acceptable and aesthetically pleasing long-
placed 0.5 mm within the gingival sulcus.24
lasting restorations.
 RestorativeDentistry

Nevins and Skurow stated that

biologic width should be maintained during
tooth preparation and impression taking,
and also the subgingival margin extension
should be limited to 0.5−1 mm, because it is
impossible for the clinician to detect where
the sulcular epithelium ends and where the
junctional epithelium begins.25

Margin placement and biologic width

Placing restorative margins
within the biologic width frequently leads to
gingival inflammation, clinical attachment
loss and alveolar bone loss (Figures 2 and 3).
This is thought to be due to the destructive
inflammatory response to microbial plaque
located at deeply placed restorative margins
encroaching on the biologic width. This may
further progress and lead to formation of
pockets and also recession.1,26,27
In a 2-year study, Gunay et
al28 compared 116 prepared teeth to 82
unrestored healthy teeth in 41 patients and
concluded that restorative margin placement
within the biologic width was detrimental to
periodontal health with maximum increase in
papillary bleeding score and probing depth
measurements at sites where the restorative
margin was <1 mm from the alveolar crest.1
While many clinicians prefer to
place restorative margins subgingivally, the
detrimental effects of margins below the free
gingival margin is well documented. While
most periodontists prefer restorative margins
to remain coronal to the sulcus, it is understood
that certain conditions necessitate placement
of subgingival margins. These may include
aesthetic concerns, the need for increased
retention form, refinement of pre-existing
margins, root caries, cervical abrasion and root
sensitivity. However, if none of these factors
is of concern, it appears prudent to place
restorative margins supragingivally1 (Figure 4).
In addition, the location of
restorative margins is determined by many
factors, including aesthetics, retentive factors,
susceptibility to root caries, and degree of
gingival recession.
When determining where to
place restorative margins relative to the
periodontal attachment, it is recommended
that the patient’s existing sulcus depth is
used as a guideline in assessing the biologic
width requirement for that patient.2 The
base of the sulcus can be viewed as the top
of the attachment and therefore variations
Figure 1. Biologic width composed of junctional epithelium and connective tissue attachment.
a
in attachment height are accounted for by
ensuring that the margin is placed in the
sulcus and not in the attachment. The first step
in using sulcus depth as a guide in margin
placement is to manage gingival health.2
Regardless of the preparation design and its
position (supra or subgingival), a precise and
well-defined margin should always be the aim.
According to Richter and Ueno,29 marginal fit b
and finish may be more significant to gingival
health than the location of the margin. Ideally,
the margin of a prosthetic restoration should
be easily accessible for the following reasons:
 To facilitate fabrication of the provisional
restoration;
 To facilitate impression taking, to allow
assessment of the fit of the restoration;
 To allow margin finishing and burnishing;
 To facilitate plaque removal.30 Figure 2. (Case 1) Subgingival restorative
Once the tissue is healthy, the margin within biologic width leading to gingival
following three rules can be used to place intra- inflammation in relation to UL1. (a) Fractured
UL1. (b) Gingival inflammation and discoloration
crevicular margins.2,31
in UL1 after crown placement.
Rule I
If the sulcus probes 1.5 mm or less,
place the restoration margin 0.5 mm below the
gingival tissue crest. This is especially important
on the facial aspect and prevents a biologic
width violation in a patient who is at high risk
in that regard.
Rule II
If the sulcus probes more than 1.5 Figure 3. (Case 2) Subgingival restorative
mm, place the margin one-half the depth of margin within biologic width leading to gingival
the sulcus below the tissue crest. This places inflammation in relation to UL1.

July/August 2014 DentalUpdate 547

 RestorativeDentistry
the margin far enough below tissue so that it
is still covered if the patient is at higher risk of
recession.
Rule III
If a sulcus greater than 2 mm
is found, especially on the facial aspect of
the tooth, then evaluate to see whether a
gingivectomy could be performed to lengthen
the teeth and create a 1.5 mm sulcus. Then the
patient can be treated as mentioned in Rule I.
Depending on the thickness
of the underlying bone and the dimension
of keratinized gingiva, different clinical and
histological responses can result from a
supracrestal biological width violation. Usually,
with a thick periodontium (fairly flat cement-
enamel junction and gingival scallops, thick
cortical plates and increased thickness of
keratinized gingiva), little apical migration
of the dentogingival unit and intrabony
pocket formation are observed.32 Whereas in
the presence of a thin periodontium (high
gingival scallop, thin cortical plates and
limited thickness of keratinized gingiva),
gingival recession and apical migration of the
dentogingival unit may instead be observed.
This migration is sometimes self-limiting,
as observed by Tarnow et al.33 Prominent
roots need to be evaluated to identify any
fenestrations or dehiscences. These conditions
associated with a thin periodontium contra-
indicate the placement of a restorative margin
subgingivally.30
Biologic width evaluation17,31
1. Clinical method
If the patient experiences tissue
discomfort when the margins are being
assessed with a periodontal probe, it may be
considered that a violation of biologic width
has occurred with the potential to lead to
gingival hyperplasia, bleeding on probing,
recession, bone loss and pocket formation
(Figure 2).
2. Bone sounding
Biologic width can be assessed by
measurement with periodontal probe to the
bone level and subtracting the sulcus depth
from it. If the distance from base of sulcus to
bone is less than 2 mm, it is considered to be a
violation of biologic width. This assessment is
completed circumferentially around the tooth
to evaluate the extent of the problem.
548 DentalUpdate July/August 2014
3. Radiographic measurement apparatus and to allow for some degree of
Radiographic interpretation can error during the high-speed instrumentation.35
identify interproximal violations of biologic For a Rule 1 margin, the cord
width (Figure 5). However, with the more should be placed in such a way that the top
common locations on the mesiofacial and of the cord is located in the sulcus at the level
distofacial line angles of teeth, radiographs where the final margin will be established,
are not diagnostic because of tooth which will be 0.5 mm below the previously
superimposition. A parallel profile radiographic prepared margin. On the interproximal
technique has been recently described as a aspects of the tooth, the cord will usually be
non-invasive, concise, reproducible and simple 1−1.5 mm below the tissue height because
technique used to measure the length and the interproximal sulcus is often 2.5−3 mm
thickness of a dentogingival unit.34 in depth. With this initial cord in place, the
preparation is extended to the top of the cord,
Tissue retraction2,30 with the bur angled to the tooth so that it will
To enhance access, so that damage not abrade the tissue. This process protects
to the soft tissues is prevented during crown the tissue, creates the correct axial reduction
or cavity preparation and impression taking, and establishes the margin at the desired
it may be desirable to carry out some degree subgingival level. A second retraction cord is
of gingival retraction.2 The objective of tissue required to create space for final impression.
retraction is to expose all of the prepared The second cord is pushed so that it displaces
tooth structure and, possibly, a portion of the the first cord apically and is sited between the
unprepared root beyond the margin by causing margin and the tissue. For the final impression,
a horizontal and vertical displacement of the
marginal gingiva. This can be achieved by the
use of gingival retraction cords. A single-cord
technique is the least traumatic option and is
normally employed when the sulcus is shallow
and the margin is placed only minimally in the
crevice. A double-cord technique is used when
the sulcus is deeper. The first cord is ultrathin
(000) cord, which will stay in place throughout
impression taking, while the second cord is one
size bigger and will be removed just before
injection of impression material. From the point
of view of prosthetic convenience, it may be Figure 4. Supragingival restorative margin in UL5
desirable to employ this technique because it and UL6.
yields more extensive displacement. However,
the soft tissue anatomy on the buccal aspect
of the anterior teeth rarely permits two cords
to be placed. In the presence of a limited facial
crevice, a selective double-string technique
is better, the second cord being placed only
interproximally and lingually. The second cord
is usually one size bigger than the first, and it is
soaked to control fluid seepage and any slight
bleeding. The first cord, which stays in place
throughout the impression procedure, is left
untreated.30
This maneouvre has two
advantages: it highlights the base of the
sulcus and therefore the ultimate limit of
the preparation before causing irreversible
damage; and it pushes the gingival margin
outward and apically to expose the unprepared
Figure 5. IOPA showing root canal treated UR1
tooth structure to be removed better. Margin
and UL1 in which subgingival crown margins will
placement has to respect the attachment lie within the biologic width.

the top cord is removed, leaving the margins
visible and accessible to be recorded with the
impression material. The initial cord remains
in place in the sulcus, until the provisional
restoration is completed. For Rule 2 situations,
where the sulcus is deeper, two larger diameter
cords are used to deflect the tissue prior to
extending the margin apically. The top of the
second cord is placed to identify the final
margin location at the correct distance below
the previously prepared margin, which was
at the gingival tissue crest level. The margin is
lowered to the top of the second cord and then
a third cord is placed in preparation for the
impression.2
Various chemicals used for the
treatment of cords include:2
 0.1% and 8% recemic epinephrine;
 100% alum solution (potassium aluminum
sulphate);
 5% and 25% aluminum chloride solution;
 Ferric subsulphate (Monsel’s solution);
 13.3% ferric sulphate solution;
 8% and 40% zinc chloride solution;
 20% and 100% tannic acid solution;
 45% negatol solution.
These drugs diffuse in blood
circulation through crevicular epithelium,
which is non-keratinized and semi-permeable,
and cause vasoconstriction, which results in
transient gingival shrinkage. This can cause
transient ischaemia and helps to control
seepage of blood or gingival fluid.36
Recent advances
Merocel: Merocel retraction
strips are made of a synthetic material that
is specifically chemically extracted from a
biocompatible polymer (hydroxylate polyvinyl
acetate) that creates a net-like strip (2 mm
thick). This material is chemically pure, easily
shaped, effective for absorption of intra-
oral fluids, soft and adaptable and free of
fragments.37
Expasyl: This is a paste for gingival
retraction that not only opens the sulcus but
also leaves the field dry, ready for impression-
taking or cementation. It is mainly composed
of micronized kaolin, aluminum chloride
and water. The material is simple, rapid, safe,
painless, haemostatic, economical and reliable.2
Impression techniques
The impression technique can have
a negative impact on the soft tissues around
the abutments, even causing irreversible
July/August 2014 DentalUpdate 551
RestorativeDentistry
damage if the technique is not properly carried a much greater hazard to periodontal health
out. Severe and painful periodontal reactions than is lack of contour, since both supra- and
will occur if rubber-based impression material subgingival plaque accumulation may be
is introduced into the gingival tissues during enhanced by overcontoured margins. The
impression-taking procedures.11 Careful greater the convexity, the more difficult it is
visual inspection of the impression for torn to remove the plaque.39 The facial or lingual
areas is needed and, if evidence of tearing is surface of a restoration should not have more
detected, the clinician should immediately than 0.5 mm bulge adjacent to the gingival
check the tissue to remove any remnant of margin because this may interfere with
the impression. Otherwise a foreign body of adequate plaque removal.9
impression material can cause severe gingival
inflammation and may be misdiagnosed at a
Interproximal contacts and embrasure space
subsequent appointment.2
Hirschfeld40 stated that improperly
constructed restorations are one of the factors
Provisional restorations leading to food impaction. Open proximal
Provisional restorations must contacts are considered to be contributing
provide an environment conducive for factors to periodontal pocket formation.
the maintenance of periodontal health.38 Whereas deficient interproximal integrity
Provisional restorations that are poorly may be unclear, open contacts leading to
adapted at the margins are overcontoured food impaction are often uncomfortable to
or undercontoured and have rough or the patient, and prevent the self-cleaning
porous surfaces that can cause inflammation, mechanisms of the adjacent cheek, lips and
overgrowth or recession of gingival tissues. tongue, and it is still generally accepted that
The outcome can be unpredictable and lead to tight interproximal contacts are important
unfavourable changes in the tissue architecture for gingival health1 (Figure 7). Normally, there
that can compromise the success of the final must be a positive contact relation, mesially
restoration (Figure 6). and distally, of one tooth with another in each
dental arch. The areas of contact are small
and are surfaces, not mere points of contact.
Crown contour and emergence profile
Contact areas keep food from being trapped
Crown contours are normally
between the teeth and help to stabilize the
determined by tooth anatomy, periodontal
dental arches by the combined anchorage of
condition, margin placement, and access for
all teeth in either arch in positive contact with
oral hygiene. Conflicting results have been
each other. In order to maintain the healthy
given by different authors regarding contour
gingiva in the interdental areas, the contact
of crowns. Yuodelis et al39 demonstrated that
points should be located incisally or occlusally
the greater the amount of facial and lingual
and buccally.41 Proper contact and alignment
bulge of an artificial crown, the more the
of adjoining teeth will allow proper spacing
plaque was retained at the cervical margin.
between them for the normal bulk of gingival
Proper restorative contours require adequate
tissue attached to the bone and teeth.2 A
tooth reduction to allow proper thickness
significant relationship was seen between
of restorative materials, while allowing
food impaction and contact type (greater food
easy access for personal oral hygiene. The
impaction at sites with open or loose contacts),
emergence profile of a restoration in aesthetic
and between food impaction and probing
areas has two aspects: subgingival form and
supragingival form. The subgingival form
should follow the contours of the cement-
enamel junction and support the gingival
tissues. Within limits, increased thickness of
interproximal subgingival contours leads to
increased papillary height, while increased
facial contours lead to apical positioning of the
gingival tissues.8
When the gingiva contacts a flat
tooth surface, there is a tendency to develop a
thick free gingival margin. Overcontouring of
Figure 6. Poorly adapted provisional restorations.
restorations or faulty placement of contour is
 RestorativeDentistry
depth and loss of clinical attachment.1
Cementation and polishing of restorations
After cementation of the
restorations, all retained excess cement must
be removed. When restorations extend below
the gingival margin, particles of cement within
the sulcus may be overlooked and can cause
damage to the periodontal tissues.42 Although
surface textures of restorative materials differ
in their capacity to retain plaque, all can be
adequately cleaned and maintained if they are
polished.43,44
Summary
A healthy coexistence between
dental restorations and their surrounding
structures should be the goal of the
conscientious dentist and the expectation of
the informed patient. The successful integration
of periodontal and restorative dentistry for
both natural teeth and implants requires
knowledge and application of both mechanical
and biological principles as discussed in
this first article. The second part describes
the surgical techniques available for the
maintenance of periodontal health.
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