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SARANRAJ JPS PUBLICATION DR. SYED WALi PEERAI

Bl. IAITHIIEYAI IAMAL/lliAM
Essentials Of
PERIODONTICS & ORAL IMPLANTOLOGY
Published by Dr. Syed Wali Peeran and Dr. Karthikeyan Ramalingam @
Saranraj JPS Publication,
Mylapore, Chennai, Tamil Nadu, India

© Dr. Syed Wali Peeran

Dr. Karthikeyan Ramalingam
1st Edition 2021
ISBN: 978-81-950475-4-3
All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or
mechanical, including photocopy, recording or any information storage and retrieval system without the permission in writing from the
publisher.
Note: As new information becomes available, changes become necessary. The editors/author/contributors and the publishers have,
as far as it is possible, taken care to ensure that the information given in this book is accurate and up to date. In veiw of the possibility
of human error or advances in medical science neither the editor nor the publisher nor any other party who has been involved in the
preparation or publication of this work warrants that the information contained herein is in every respect accurate or complete. Readers
are strongly advised to conirm. This book is for sale in India only and cannot be exported without the permission of the publisher in
writing. Any disputes and legal matters to be settled under Chennai jurisdiction only.

Published in India
 CHAPTER

63 Restorative – Periodontic
Inter-relations
Syed Wali Peeran &
Karthikeyan Ramalingam

Chapter Outline:
• Introduction • Ferrule length.
• Definitions and terminology. • Biological Width Requirements.
• Clinical studies on biologic width • Biologic width evaluation.
• Location of the restoration margin. • Surgical Techniques for Crown Lengthening.
– Supragingival margins. – External bevel gingivectomy.
– Equi-gingival margins. – Apically positioned flap with bone recontouring
– Subgingival margins. • Forced tooth eruption.
• Restoration overhangs. • Forced tooth eruption with fibrotomy.
• Artificial crown contour. • Conclusion.
• Proximal contact relationships. • Review Questions.
• Influence of material. • Principal references and suggested further reading

The long-term success of a restored tooth depends on

the preservation of a healthy periodontium. There is a
significant relationship between restorative dentistry and
periodontal health. The increase in aesthetic demand has
shifted the focus to create ideal soft tissue contour around
the prosthesis or implants.
There has been a difficulty in placement of restorative
margins and prosthetic replacement of periodontally
compromised patients. There are situations when teeth
with extensive caries or subgingival fractures, the decision
should be made whether to extract or restore it with
endodontic and periodontal therapy.
Many treatment failures were attributed to poor handling
of periodontal tissues but blamed on poor oral hygiene/
cooperation by the patient. However, the actual reason for
these incidents is the violation of biologic width due to
improper margins.

Fig 63-1: Restorative – Periodontic Inter-relations

Periodontics & Oral Implantology 1

 Inter-disciplinary relations Section - X

DEFINITIONS AND TERMINOLOGY: dimensions were found to be similar among different

implant systems and remained stable over time.
BIOLOGIC WIDTH is defined as the physiologic
dimension of the junctional epithelium and connective
tissue attachment. (Glossary of Periodontal Terms, 2001)
Biologic width is the total of supracrestal fibers, junctional
epithelium, and sulcus. (Nevins and Skurow)
Biologic width is the zone of the root surface coronal to
the alveolar crest, to which the junctional epithelium
and connective tissue are attached. (Garguiloet al.)
The biologic width is defined as the dimension of the soft
tissue, which is attached to the portion of the tooth
coronal to the crest of the alveolar bone. (Padbury et al.).
The biologic width is defined as the junctional epithelium
and supracrestal connective tissue attachment
surrounding every tooth (Ingber et al., Amiri-Jezeh et al.).
Fig. 63.2 Dento gingival unit (Courtesy – Dr.P.C.Anila)
Gingival aesthetics is based on the constant vertical
dimension of periodontal tissues called the biologic width. CLINICAL STUDIES ON BIOLOGIC WIDTH:
It refers to the physiological dento-gingival junction of
natural teeth. It acts as a biologic seal surrounding the teeth Garguilo, Wentz & Orban studied dento-gingival
to protect the subgingival connective tissue from microbes components of 287 individual teeth from 30 autopsy
and simultaneously support the alveolar bone. specimens. They reported a certain uniformity of the
dimension of some components of biologic width:
The width of free gingiva and junctional epithelium keep
♦ Mean depth of the histologic sulcus is 0.69mm,
changing during active tooth eruption and passive eruption.
However, the width of connective tissue fibres above the ♦ Mean junctional epithelium measures 0.97mm (0.71
alveolar crest does not undergo any alterations. to 1.35 mm),
The measurement has been found in some studies to ♦ Mean supra-alveolar connective tissue attachment is
be relatively constant at approximately 2mm (±30%). 1.07 mm (1.06 to 1.08 mm).
Proximally, when the interdental papilla fills the gingival As sulcular depth is variable, authors usually refer biologic
embrasure, about 5mm of soft tissue is present between width only as the sum of epithelial and connective tissue
the alveolar crest and tip of interdental papilla. This 5mm attachment, is therefore 2.04 millimetres (1.77 to 2.43
corresponds to 1mm of connective tissue, 1mm of epithelial mm).
attachment and 3mm of sulcular depth.
Vacek et al evaluated 171 cadaver tooth surfaces and
The dimension of biologic width can vary based on tooth reported a mean measurement of 1.34mm for sulcus
position, from tooth to tooth or surface to surface on the depth, 1.14mm for epithelial attachment and 0.77mm for
same tooth, but it is present in all healthy dentition.It varies connective tissue attachment.
in different individuals.
Eissman et al concluded that biologic width to be about 2mm.
The biologic width follows the architecture of the bone Alpistie-Illueca reported biologic width to be 2 0.72mm.
crest which follows the scalloped shape of CEJ. Similarly, Ghahroudi et al reported a biologic width of 2.46mm for
biologic width is also established around implants based anterior teeth and 2.63mm for posterior teeth, 2.7mm for
on the location of alveolar crest. The mean width around thick and 2.4mm for thin tissue biotypes.
implants is 3-4mm corresponding to 2mm of junctional
Stenly reported that length of junctional epithelium to be
epithelium and 1.3-1.8mm of connective tissue. These
0.l to 1.4mm. The variations of epithelial attachment range
2 Periodontics & Oral Implantology
Chapter 63 Restorative – Periodontic Inter-relations

from 1mm to 9mm. However, most authors recommended Moreover, inindividuals with a history of periodontal
measurement of connective tissue attachment for disease, they found the mean dimensions of the biologic
consistent results. width ranged from 1.25±0.19 mm to 3.95±1.04 mm. They
Rasouli Ghahroudi et al reported that the biologic width also found that the smallest biologic width measurement
was not only different in individuals but also could be was 0.5 mm, and the greatest amounted 6.40 mm.
dissimilar in different teeth.They suggested that itshould be Attachment loss and increased probing depths influenced
calculated independently prior to restorative treatments. the dimensions of the biologic width There was significant
intra- and inter-individual variability in the dimensions of
Schmidt et al in a recent review summarised the available the biologic width.
studies on the biologic width and found that in humans
without a reported history of periodontal disease the
mean dimensions of the biologic width ranged from 1.5 to
2.7 mm. The smallest biologic width measurement was 0.2
mm. Tooth type and tooth site influenced the dimensions
of the biologic width.

Fig. 63.3: Biologic width around teeth and implants.

The underlying bone morphology determines the ♦ Thin biotype has increased risk for facial recession and
horizontal component of biologic width especially interproximal loss of gingival tissue with periodontal
horizontal component of bone loss. disease and after any surgery.

The vertical component of biologic width is dependent on The rule of biologic width is that there is a zone of
gingival biotype. connective tissue separating the epithelium from the
underlying osseous structures. Bone cannot be maintained
♦ Thick biotype is more resistant to recession and below the epithelium without a connective tissue
shows pocket formation after apical migration of interface.
junctional epithelium.
Periodontics & Oral Implantology 3
 Inter-disciplinary relations Section - X

Schmidt etalin his review inferred that a‘magic number

The factors to be looked for in maintenance of biologic
for the biologic width as a treatment objective cannot be
width include:
recommended, as the use of mean values could mask the
♦ Location of restorative margins – especially actual clinical situation. It was also inferred that the biologic
subgingival margins. width seems to be affected by periodontal disease.
♦ Restoration overhangs. Location of restorative margins:
♦ Artificial crown contour. Biologic width is essential for preservation of periodontal
♦ Proximal contact relationships. health, and any irritation or disturbance of the biologic
width by the restorative margins might damage the
Fig. 63.4 Maintenance of biologic width
periodontium.

Fig. 63.5 Physiological function of biologic width Fig. 63.6: Biologic width

Fig. 63.7: Factors that determine the location of restoration margin

4 Periodontics & Oral Implantology

Chapter 63 Restorative – Periodontic Inter-relations

The clinician can place supragingival, equi-gingival (even with ♦ They facilitate increased plaque accumulation
the tissue) and subgingival margins. It is always advisable to subgingivally which leads to accelerated periodontal
place supragingival margins. breakdown and recurrent caries.
Supragingival margins: ♦ In thin gingival biotypes, the inflammatory response
to plaque accumulation results in gingival recession.
Supragingival margins of the restoration or crowns were ♦ In thick gingival biotypes, crestal bone loss, loss of
associated with least gingival inflammation. It was classically connective tissue attachment and deep pocket
recommended for non-aesthetic areas due to marked formation can be seen.
contrast in colour and opacity of traditional restorative
materials against the tooth. But with the advent of adhesive ♦ Gingival hyperplasia and minimal bone loss or a
dentistry and resin cements, it can also be used in aesthetic combination of these presentations can also be seen
areas. at times.
♦ In general, the culprit is the plaque accumulation
Orkin et al reported a lesser chance of bleeding and gingival
consequent to the subgingival margins rather than
recession in supragingival restorations. Silness found that
the mere placement of margin subgingivally.
supragingival crown margin was most favourable and did
not compromise gingival health. New comb analysed 66 anterior crowns with subgingival
margins. He reported that nearer a subgingival crown
Kosyfaki et al reviewing the interactions between dental
margin to the epithelial attachment, more severe was the
crowns and periodontal tissues indicated that a crown
gingival inflammation.
margin with a supragingival location was the most beneficial
restoration type in terms of periodontal health. Parma-Benfenati et al observed 5mm of osseous resorption
when restorative margins were placed at alveolar crest
Advantages of supragingival restorations:
in beagle dogs. Minimal resorption was noted when
♦ Ease of impression making restorations were placed 4mm coronal to the alveolar
♦ Ease of cleansing crest. Severe bone resorption was noted in areas with thin
cortical bone and interdental septa.
♦ Least gingival inflammation
Tal et al reported that violation of biologic width resulted
♦ Detection of secondary caries
in loss of periodontal support. They reported gingival
♦ Maintenance of probing depths. recession and bone loss in association with Class V cavities
Equi-gingival margins: on canines of beagle dogs.
Equi-gingival margins were not preferred due to increased Gunay et al reported that sites with restorative margins
plaque accumulation and gingival inflammation. However, <1mm to the alveolar crest showed higher papillary
with superior finishing techniques, it can be used to get bleeding scores and probing depths.
a smooth polished interface at gingival margin. It is also Regardless of the depth of penetration, the mere presence
well-tolerated by the periodontium, provided it is above of subgingival restoration can induce unwanted tissue
the crest. If it violates the biologic width, it can result in effects. Renggli and Regolati showed that even well-
periodontal disease. adapted subgingival amalgam fillings showed greater plaque
Subgingival margins: accumulation and gingivitis than normal tooth structure.
Waerhaug reported that subgingival restorations were
There is a potential risk of periodontal damage, especially
plaque-retentive areas inaccessible to scaling instruments.
if the margins are places sub-gingivally. Subgingival margins
can lead to gingival inflammation and destruction of biologic
These areas continued to accumulate plaque even
width. Subgingival margins with adequate supra gingival plaque control. He also
demonstrated gingivitis and attachment loss with
♦ They can at instances cause direct operative trauma
submarginal restorations in monkeys and dogs.
to the tissues.

Periodontics & Oral Implantology 5

 Inter-disciplinary relations Section - X

Wang et al proposed that posterior teeth with crowns or overhangs and left a smoother restoration than sonic
proximal restorations showed more furcation involvement scalers and curettes.
and attachment loss than teeth without proximal Brunsvold & Lane reported a prevalence of 25-76% of
restorations. overhanging restorations for all restored surfaces.
Settler and Bissada showed that subgingival restorations on Gilmore & Sheiham showed radiographic bone loss in the
teeth with narrow zone of keratinized gingiva showed higher interproximal areas of posterior teeth with overhanging
gingival index scores than those teeth with wider zones. restorations.
Hence, clinicians should consider gingival augmentation in
such cases before placement of subgingival restorations. Highfield & Powell showed that removal of overhangs and
professional plaque control improved gingival indices and
Dragoo and Williams showed compromised healing with bone scores.
gingival bevel crown margins than shoulder preparations
on human teeth. Jeffcoat & Howell correlated severity of overhang with
periodontal destruction. They classified overhangs into
Flores-de-Jacoby et al reported that subgingival margins had 3 categories based on their space occupied,
increased plaque, gingival index scores, and probing depths.
There was also an increase in spirochetes, fusiforms, rods ♦ Small - <20% of interproximal space
and filamentous bacteria in subgingival margins. ♦ Medium – 20 to 50% of interproximal space
Valderhaug & Birkeland reported that 27% of crown ♦ Large- >51% of the interproximal space
margins placed subgingivally became supragingival margins They reported greater bone loss around teeth with
after 5 years. They also showed greater mean attachment large overhangs. Small and medium overhangs were not
loss with subgingival restorations. associated with bone loss.
Use of sulcular depth as a guide: Lang et al reported that placement of subgingival margins
altered the associated microflora similar to adult chronic
1. If the sulcus depth is 1.5mm or less, the restoration periodontitis. They showed higher proportions of
margin should be 0.5mm below the gingival crest. It is bacteroides and gram-negative anaerobic rods.
important on the facial aspect to maintain the biologic
width if the patient is at high risk for recession. Chen et al reported greater attachment loss in teeth with
overhang surfaces.
2. If the sulcus depth is more than 1.5mm, place the
margin approximately 0.75mm/ half the sulcus depth, Pack et al reported 62% of all restorations had overhangs
so that it is still under the tissue if the patient is at and were associated with severe periodontal disease.
high risk for recession. Overhangs are usually noted with swaged crowns, and the
3. If sulcus depth is >2mm especially on the facial aspect, margins are placed subgingivally for swaged crowns. Many
evaluate whether gingivectomy could be performed have been replaced with metal ceramic crowns with precise
to create a 1.5mm sulcus and treat the patient using margins to reduce gingival inflammation.
first rule.
Artificial crown contour:
Restoration overhangs:
There are conflicting reports regarding the proper contour
Overhanging restorations are considered to be a needed to maintain gingival health. Some reports show
contributing factor for gingivitis and attachment loss, due to that original anatomic tooth contour permits functional
retention of bacterial plaque and increase in periodontal stimulation and maintains gingival health. Others advise that
pathogens within the bacterial plaque. under-contoured crown is better for periodontal health.
Most restorations could be recontoured without replacing,
Yuodelis et al reported that crowns with greater facial and
and it should be a standard component of non-surgical
lingual bulge showed more plaque retention at the cervical
therapy. A motor-driven diamond tip was faster in removing
margins.
6 Periodontics & Oral Implantology
Chapter 63 Restorative – Periodontic Inter-relations

Ehrlich & Hochman reported that factors other than Ferrule length:
variations in crown contour determined the gingival A ferrule is a metal ring or cap intended for
response. strengthening.
Becker & Kaldahl reported that buccal and lingual crown Ferrule is defined as metal band or ring used to fit the
contours should be flat and not fat. It should be <0.5mm root or crown of a tooth (Glossary of Prosthodontic
wider than the CEJ. The furcation areas should be fluted or Terms, 2005).
barrelled out to accommodate oral hygiene maintenance.
Ferrule effect is a 360-degree metal collar of the crown
Proximal contact relationships: surrounding the parallel walls of the dentine extending
Tight interproximal contacts are important for gingival coronal to the shoulder of the preparation (Sorensen &
health. Open contacts can lead to food impaction and Engelman).
increase patient discomfort. Thus, loose or open proximal A foundation restoration is used to increase the crown
contacts contribute to pocket formation. height, width or both to increase the retention of full-
Kepic & O’Leary demonstrated no difference in periodontal crown restoration. In these situations, supragingival
breakdown, if adequate oral hygiene was maintained. margins may be partially or entirely placed on
foundation restorative material. However, prosthetically,
Larato reported that 18% of intrabony lesions were this restoration in the apical one-third of preparation
associated with factors that cause food impaction. would be subjected to maximum occlusal load.
Hancock et al reported a significant relationship between Similarly, when a post is placed, occlusal stress will
food impaction and contact type. They showed greater concentrate on the cement used for retention.
food impaction at sites with open or loose contacts. The ferrule is formed by circumferentially extending
These sites showed increased probing depth. the restorative margin 1-2mm apical to the most apical
Influence of material: extent of foundation restoration or core build-up. This
ferrule will disperse the occlusal forces onto periodontal
Restorations are in contact with gingival surfaces. ligament rather on the post and core.
Best biocompatible materials should be used to
create an optimal biologic response. Rough surfaces of Hence, while planning to maintain biologic width,
restorations will promote plaque formation and 3mm with additional 1.5mm should be allotted towards
maturation. High energy surfaces are known to collect ferrule design.
more plaque. The materials can be ranked based on Biological Width Requirements:
plaque accumulation and biocompatibility as glass-
ceramics, zirconium oxide, titanium, dental porcelain, The recommendation is that a minimum of 3mm of space
metal alloys and composite resin. is needed between restorative margins and alveolar bone.
This width should be maintained while planning for any
Paolantonio et al assessed amalgam, glass-ionomer restoration.
cement and composite resin subgingival restorations.
They reported that though there were no significant Ingber et al suggested a minimum of 3mm from the
differences, composite resin had negative effects on restorative margin to the alveolar crest.
quantity and quality of subgingival plaque. The patients Maynard and Wilson divided the periodontium
should be highly motivated towards oral hygiene and by into 3 dimensions and claimed that all these
accurate contouring, finishing and polishing of subgingival dimensions influenced decision of restorative
restorations. treatment.
Quirynen & Bollen explained that surface roughness and ♦ Superficial physiologic represents free and attached
surface-free energy influence supragingival and subgingival gingiva surrounding the tooth.
plaque formation. ♦ Crevicular physiologic represents the gingival
crevice extending from the free gingival margin
to the junctional epithelium
Periodontics & Oral Implantology 7
 Inter-disciplinary relations Section - X

♦ Subcrevicular physiologic is analogous to Mankoo also stressed the importance of biologic width in
biologic width, consisting of junctional implants on edentulous ridges.
epithelium and connective tissue attachment. Crown margins which extend apically beyond the junctional
They reported that margin placement into the subcrevicular epithelium can violate the requirements for periodontal
physiologic space should be avoided. health and cause loss of periodontium. An inappropriate
Nevins and Skurow stated that when subgingival margins crown margin increases plaque accumulation in close
are placed, it should not disrupt the junctional epithelium proximity to bone crest. When a subgingival crown margin
or connective tissue attachment during preparation and is to be placed, it may be necessary to surgically move the
impression taking.The subgingival extension should be only crestal bone margin apically, so that there is at least 3 mm
0.5-1mm, as the clinician cannot detect where the sulcular space between the margin and the bone.
epithelium ends and junctional epithelium begins.They also
proposed that minimum of 3mm distance from crown
margin to alveolar crest.
Block suggested the use of free gingival margin as reference
point for measurements, as biologic width was difficult to
judge by the clinician. If the restorative margins end at or
near the alveolar crest, surgical crown lengthening was
necessary.

Fig. 63.8 Consequences of violation of biological width

Biologic width evaluation:
It can be evaluated with radiographs and clinical
assessment.
Radiographic interpretation:
Studies with Bitewing radiographs reported an average
of 0.4mm to 2mm distance between the CEJ and alveolar
crest. Radiographic interpretation can identify gross
interproximal violations of biologic width.
However, with common locations on the mesiofacial
and distofacial line angles of teeth, radiographs are not
diagnostic because of tooth superimposition.
8 Periodontics & Oral Implantology
Clinical assessment:
♦ Biologic width:
* Transgingival probing or bone sounding with a
manual probe is recommended to determine
an individual’s biologic width. It checks for thick
connective tissue attachment and junctional
epithelium. The probe is pushed through the
anaesthetized attachment tissues from the sulcus
to the underlying bone. The sulcus depth is
subtracted the probing depth to get the biologic
width.
* It should be performed on healthy gingival tissues,
i.e. after the periodontal health is established and
should be repeated on more than one tooth to
confirm the accuracy.
Chapter 63 Restorative – Periodontic Inter-relations

* The biologic width is assessed for the adjacent
teeth not subscribed for any dental procedure,
and an average is calculated. This will give the
biologic width for the particular individual.
♦ For violation of biologic width:
* A more accurate assessment can be made clinically
by measuring the distance between the bone and
the restoration margin using a sterile periodontal
probe.
* If a patient experiences tissue discomfort when
restoration margin levels are assessed with a
periodontal probe, it is a good indicator that This surgery can provide additional clinical tooth structure
biologic width violation has occurred.
* Bone sounding - If this resultant width is less than
2mm at one or more locations, a diagnosis of
biologic width violation can be confirmed.
Etiology of the violation of the biologic width
♦ Tooth preparation-damage to the JE.
♦ Soft tissue retration procedures.
♦ Impression techniques.
♦ Electrosurgery
♦ Temporary restoration.
Fig. 63.9 Etiology of the violation of the biological width
CLINICAL CROWN: The portion of a tooth that
extends occlusally or incisally from the margin of the
investing soft tissue, usually gingiva. (American Academy of
Periodontology 1992).
LENGTHENING OF CLINICAL CROWN: A
surgical procedure designed to increase the extent of
supragingival tooth structure for restorative or esthetic
purposes by apically positioning the gingival margin,
removing supporting bone, or both. May be accomplished
by orthodontic tooth movement.(American Academy of
Periodontology 1992).
to give a coronal or equi-gingival margin to the restoration.
Failure to do surgery prior to margin placement can lead
to violation of biologic width. Hence, surgery should be
recommended if the final restoration will be 3 mm from
alveolar crest.
Crown lengthening procedures include:
♦ Gingivectomy
♦ Apically positioned flap surgery
♦ Apically positioned flap with osseous reduction
♦ Orthodontic forced eruption: It is a conservative but
time-consuming process. It is useful for isolated teeth
requiring crown lengthening.
♦ Combination

Surgical Techniques for Crown Lengthening; * Forced eruption with surgery

* Forced eruption combined with fiberotomy
Allen reported that violation of biologic width leads
to reaction by periodontium. Alveolar bone will resorb Surgical crown lengthening may include the removal of soft
inconsistently to provide space for a new connective tissue tissue and alveolar bone. Reduction of soft tissue alone is
attachment resulting in increased probing depth. Hence, it indicated if there is adequate attached gingiva and more
is advisable to increase the dimension of clinical crown by than 3mm of tissue coronal to the bone crest.
This may be accomplished by either gingivectomy or
surgical crown lengthening than violating the biologic width
with a subgingival restoration. apically positioned flap technique. Both of these techniques
CROWN: The part of a tooth that is covered with enamel have limited applications, as bone removal is needed to
or a dental restoration and normally projects beyond the make the distance between alveolar crest and anticipated
gingival margin.(American Academy of Periodontology restoration margins.
1992). Inadequate attached gingiva and less than 3mm of soft tissue
ANATOMIC CROWN: The portion of a natural tooth indicates surgical flap procedure and osteoplasty/ osseous
that extends from its cemento-enamel junction to the resection. Apically positioned flap with osseous surgery is
occlusal surface or incisal edge.(American Academy of the most common technique for crown lengthening.
Periodontology 1992).

Periodontics & Oral Implantology 9

 Inter-disciplinary relations Section - X

Smukler and Chaibi described supracrestal gingival fibers,
their variations between sites and reformation after surgical
excision. The regrowth of these fibres are dictated by the
underlying anatomy of the dental and osseous units.
Surgical lengthening gives immediate results, as the tooth
structure is exposed after surgery.
Literature suggests a minimum distance of 3-4mm from the
restorative margin to alveolar crest.
Indications for Crown Lengthening:
♦ Development of Adequate Crown Structure:
* Subgingival caries.
* Shortened by extensive caries
♦ Periodontally hopeless teeth.
♦ Non-restorable teeth.
♦ Endodontically unstable teeth.
♦ Teeth that may require excessive bone removal on
contiguous teeth. eg., Deep caries or deep fracture.
♦ Teeth with short root trunks.
♦ Teeth with inadequate root length.
Rationale and Planning:
Before a decision is made for restoration of teeth with
subgingival caries or fracture below gingival margin, the
prognosis of saving such teeth should be re-evaluated with
caution.

* Short clinical crowns with or without aesthetic The parameters to be considered include bone loss
deficiencies percentage, probing depth, furcation involvements,
mobility, and crown: root ratio, pulpal involvement, and
* Fracture in the coronal third of the root. strategic value. Crown lengthening procedure can be
* Perforation in the coronal third of the root. recommended only if the prognosis is favourable.
* Inadequate clinical crown structure for retention. Most authors suggest a minimum distance of 3mm from
♦ Aesthetics: the final restorative margin to the alveolar crest, to get a
supragingival margin. This includes 1mm for supra-crestal
* Incomplete passive eruption when unequal or
connective tissue attachment, 1mm for junctional epithelium
unaesthetic gingival heights are present (Gummy
and 1mm for sulcus depth. This 3mm also approximates to
smile).
2.04mm biologic width proposed by Gargiulo et al.
* Teeth shortened by incomplete exposure of
Wagenberg et al suggested that at least 5 to 5.25 mm of
anatomical crown
hard tooth substance above the bone margins/ alveolar
* Aesthetic enhancement crest is necessary for teeth requiring post and core. It is
• Exposure of subgingival caries needed to establish the biologic width and achieve ferrule
• Exposure of fractures effect. They also advocated 8-12 weeks of waiting period
before final prosthodontic treatment.
However, Crown lengthening is often underutilized
due to, Ghahroudi et al reported at least 3.5mm clearance is
needed to avoid violation of biologic width.
♦ Post-and-core restorations (Risks root fracture)
Others also suggest 5mm clearance to allow individual
♦ Subgingival margin placement – (Risks violating variations in biological width and prevent the clinician from
biologic width) removing too little bone, as under-reduction has been
The failures out of these procedures complicate treatment, reported by Herrero et al. Minimal osseous reduction
raise expenses and cause further patient frustration. can lead to reduced gain in clinical crown post-treatment.
Contraindications: Additional 0.5mm of bone could be removed as a safety
zone.
♦ Systemic factors which do not allow surgery to be
carried out. The surgeon should discuss the final treatment plan with the
restorative dentist, so that osseous reduction can be planned
♦ Teeth with minimal bone support. accordingly. For amalgam or composite restorations, 4mm

10 Periodontics & Oral Implantology

Chapter 63 Restorative – Periodontic Inter-relations

is needed. For post-and-core restorations, at least 6mm of

exposed tooth surface is needed above the alveolar crest.
This accounts for 4mm from alveolar crest and 1.5mm
ferrule length.

Fig. 63.10 Pre-Operative

Fig. 63.10 Indications for Apically positioned flap with

bone recontouring-Crown lengthening.
Pre-operative view

Fig:1-Intra-Operative

Fig: 2-week post-operative

Fig 63.11 Crown lengthening with Gingivectomy Fig. 63.12 Crown lengthening with internal bevel
(External bevel gingivectomy) incision (courtesy Dr.Neha)

Periodontics & Oral Implantology 11

 Inter-disciplinary relations Section - X

Apically positioned flap with bone
recontouring:
It is often necessary to remove the supporting bone from
around a tooth to achieve adequate distance between the
alveolar crest and restoration margins. If the post-operative
width of gingiva is less than 3mm, then apically positioned
flap should be planned.
Garber et al stated that “The tissue is the issue, but the
bone sets the tone.” It should be considered occluso-
apical dimension, mesio distal dimension and buccolingual
dimension. Ostectomy refers to removal of supporting
bone and osteoplasty refers to removal of non-supporting
bone.
Osseous reduction can compromise periodontal support
and damage neighbouring teeth. It may lead to furcation
involvement and poor crown: root ratio. After establishing
prognosis, flap surgery can be done before or after post
and core or core build-up with initial crown preparation.
It is contraindicated for crown lengthening of a single tooth
in aesthetic zone. It is indicated for crown lengthening of
multiple teeth in a quadrant or sextant of dentition.
f. Palatally, a scalloped subsulcular incision is placed
anticipating the final position. The palatal flap is
thinned so that it conforms with the osseous
contours on suturing.
g. A distal wedge procedure is performed if in
case the last tooth to be crown lengthened is
the terminal tooth.
♦ Osseous contouring if necessary.
a. It is done with rotary handpiece, chisels, and
curettes or piezo-electric cutting device.
b. It should follow the desired contour of overlying
gingiva
c. End-cutting burs can be used to remove bone
with minimal damage to root surface.
♦ Place resorbable internal vertical mattress sutures.
[Interrupted sutures work well with mucoperiosteal
flaps.]
♦ Remove the sutures after a week.
♦ Periapical Radiographs are needed to ensure sufficient
root length is available.

The steps include, ♦ Allow 3 months for thick gingival biotypes and 6
months for thin gingival biotypes for the bone and
♦ Internal bevel incision or Reverse bevel incision is soft tissue to stabilize.
used to raise a flap. This initial incision should mimic
the contours of ideal scallop of the buccal bone. After surgery, a provisional restoration should be
readapted. Bragger et al reported that probing depths
a. If gingival width is narrow, intra-sulcular incisions did not change after 6 weeks of healing. It should be
can be used. remembered that bone resorption usually follows osseous
b. Care should be taken to preserve at least 3mm resective surgery. Additional 0.6-0.8mm of resorption
of keratinized tissue between the incision and the occurs up to 1 year following surgery.
mucogingival junction. Most authors quote a period of 1 to 3 months or up to 6
c. Adjacent teeth on either side are included to months of waiting for ensuring stability after surgical crown
attain proper gingival and bone contour. lengthening, to begin final restoration. The completion of
remodeling after surgical crown lengthening procedures
d. Bevelled vertical releasing incisions are made to
may require at least 6 months.
allow better access and apical positioning of the
flap. Forced tooth eruption:
e. Full thickness mucoperiosteal flap is elevated
Other option for crown lengthening is orthodontic
except for the apical few millimetres of the
extrusion with or without surgery/supracrestal fibrotomy.
buccal flap which is elevated as a split thickness
flap.This apical retention of periosteum will aid in It requires fixed orthodontic appliance, an activation
the apical positioning of the flap and suturing in period of 4-6 weeks and 6-8 week retention period for
the new position. the tooth to be stabilized in the new position. The tooth

12 Periodontics & Oral Implantology

Chapter 63 Restorative – Periodontic Inter-relations

must be extruded to a distant equal or slightly longer than the supracrestal connective tissue fibers and prevent the
the sound tooth structure that will be exposed by future crestal bone from migrating in coronal direction.
surgery. After extrusion, surgical crown lengthening may It is done for crown lengthening in sites where gingival
be needed to remove the gingiva and bone that follows margin of adjacent teeth should be maintained.
the tooth in its coronal path. For aesthetic reasons, the
bone and soft tissue levels of adjacent teeth should remain It is contraindicated for teeth with angular bony defects
unaltered. and ectopically erupting tooth.
A malpositioned tooth or tooth with sustained recession Factors responsible for maintenance of gain in crown height
is erupted to level of normally positioned teeth.The crown after surgical crown lengthening include the following:
to root ratio could be improved when compared to flap ♦ Individual patient healing characteristics.
surgery with osseous reduction, where gingival margins of
♦ Reformation of biologic width.
unaffected normal teeth are moved apically to the level of
receded or malposed tooth. ♦ Adequacy of positive osseous architecture created
during surgery.
The rationale is that it stretches the gingival and periodontal
fibres producing a coronal shift in gingiva and bone. The ♦ Timing of restorations.
supracrestal fibres and periodontal ligament adapts to ♦ Post-operative plaque control.
tooth movement by alveolar bone growth and plays an Clinical reviews:
active role in shortening the extended fibres.
VanderVelden observed coronal regrowth of interproximal
Indications: gingival tissue after surgical crown lengthening. He reported
Failure to consider orthodontic extrusion can lead to that this coronal regrowth occurred during 6-12 months
♦ Poor cosmetic outcome in anterior teeth – gingival of healing and remained unchanged during 5-7 years of
recession maintenance.

♦ Poorer crown: root ratio Bragger et al reported a minimal change in levels of gingival
margins after surgery till the end of their study.
♦ Loss of bone support on adjacent teeth.
Other clinical studies have studied positional changes of
♦ For treating isolated teeth as it minimizes gingival
free gingival margins immediately after surgery and during
recession and loss of bone support on adjacent
healing but have not focused on biologic width.
teeth
Few histological studies on animal models showed
♦ For teeth with horizontal fractures below the gingival
postoperative crestal resorption after denudation. The
attachment or alveolar crest.
connective tissue attachment was re-established with
♦ Used to reduce pocket depth at sites with angular scaling and root planing. However, these results were not
bone defects. confirmedwith human clinical trials.
♦ Used to level and align gingival margins and crowns of Lanning et al reported that biologic width of treated sites
teeth to get aesthetic harmony. was re-established to its vertical dimension in 6 months.
Forced tooth eruption with fibrotomy: A consistent 3mm gain was observed at 3rd and 6th week
examination.
If fibrotomy is performed during forced tooth eruption, Oakley et al and Carnevale et al reported bone resorption
the gingival margin, and alveolar crest are maintained infollowing crown lengthening provides supracrestal tooth
their pre-treatment position, and gingiva-tooth interface of
structure for connective tissue attachment, leading to
adjacent teeth remains unchanged. reestablishment of biologic width. Irrespective of the
It requires fixed orthodontic therapy and fibrotomy is surgical procedure for crown lengthening, the biologic
performed with a scalpel at 7-10 days intervals to sever width would be re-established in treated sites after 12
weeks.
Periodontics & Oral Implantology 13
 Inter-disciplinary relations
Some clinical studies have reported changes in position of Principal references and suggested further
free gingival margin, attachment and bone levels whereas reading:
others reported stability after crown lengthening. Caton
et al reported a reduction in the distance between the
gingival margin and apical extent of junctional epithelium
after surgery.
Kiran et al reported that biologic width was significantly
smaller after ostectomy than gingivectomy, on post-surgical
assessment. They also showed that a tendency for growth
in coronal direction was evident after gingivectomy and
not present after flap surgery with ostectomy.
Lindhe and Nymann proposed that during active
periodontal treatment, the gingival margin shifted in apical
direction. This displacement was compensated by coronal
regrowth during post-operative maintenance period. This
coronal displacement was influenced by the tissue biotype.
Patients with thick tissue biotype showed more coronal
soft tissue regrowth than thin tissue biotype.
Oakley et al reported in their histometric analysis that
after crown lengthening, biologic width was re-established.
The junctional epithelium was established at the apical
extent of root planing. Space for supracrestal connective
tissue attachment was created by crestal resorption of
alveolar bone. This contradicts the view that supracrestal
connective tissue attachment would reform coronal to the
apical extent of root planing, and this greater exposure of
tooth structure would be needed during surgery.
Conclusion:
Periodontal health is dependent on the integrity of the
restoration given. A minimum of 3mm space is needed
between restorative margin and alveolar crest to allow
2mm for biologic width and 1mm for sulcus depth.
Overhanging restorations and open inter-proximal contacts
should be removed during disease control phase of therapy.
It is preferable to place supragingival margins. If subgingival
margins are indicated, then crown-lengthening should be
performed either surgically or orthodontically to provide
adequate biologic width.
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