"The Intemotional Jaurnol ol Penodanlics ond Restarotive Denlisiry' 3/1984

31

The Intracrevicular Restorative The singular most challenging ospect

Margin, the Biologic Width, and of the full coverage restoration is the
the Maintenance of the Gingival placement of the intracrevicular mar-
Margin
gin. The complexity of the basic steps
necessory to routinely construct and
deliver this restoration without
damoging a healthy periodantium
gives credence to its detractors who
proclaim the wisdom of the supra-
gingival margin for the full crown.
All clinicians and academio com-
prehend that it would be preferable
to avoid the gingivol suicus with any
Myran Nevins. D.D.S'
HowordM. Skurow, D.D.S.' restorative endeavor.'""^
There ore, however, daily clinical
situations that tend to transform this
debate from the esoteric to the prog-
matic. The following ore considera-
tions:

1. Cosmetics. Patients ore cognizont

of the potential to achieve o more re-
fined esthetic result when neither the
restorative morgin nor the root struc-
ture is in evidence.^'^This is particu-
larly true in the maxillary anterior
area [Fig. 1).
2. The exposure and refinement of a
preexisting tooth preporotion when
replacing existing restorative dentist-
ry. It frequently is necessary to per-
form periodontal surgery to create
sound tooth structure upon which to
finish the new tooth preparotion. This
is porticularly important when treat-
ing the interproximol surface where
"extension for prevention" principles
of operative dentistry have resulted
in the subgingival placement of al-
loys on interproximal surfaces (Figs.
2 and 3¡. It is also necessary when a
previous crown preporotion extends
beyond the gingivol sulcus, ond can-
not be captured with routine impres-
sion techniques (Fig. 4). Periodontal
surgical procedures tend to result in
additionol clinicol crown length but
90 Humphrey Street do not always preclude the extension
Swompscott, Mossachusett5 01907

'The InternotÈonoi Journol o( Periodontics and Restorotive Dentislry" 3/1984

32

Fig I The c'own on the maxillary leit central incisor is considered Ott
esthetic liability by the patient^ who quickly designates the morginol fit
as the problem.

Fig 2 The previous Class II alloy restoration on the mandibular

bicuspid extended beyond the crest of the mterdentol papilla and re-
.sulted in a lock of sound supragingival taoth structure for the morgir
of the provisional crown (nate arrow}

Fig. 3 Periodontol surgery aimed at the resolution of 'he mucoainai-

val prooiems nos resulten m o s¡gniiicanl ¡ncrease rn supraginqival
tooth structure farrow} Note that the alveolar bone '5 covered by
periosteum This demonstrotes that hone structure wos not lemoved
to accomplish this result.

"The International Journof of Periodonlics and Restararive Dentislrv" 3/198'!

 33

of fhe preparation into the sulcus.

This is especiolly true when consider-
ing a molar where the separation of
the roots (furcation) is only 3-5 mm
from the cemento-enamel junction.^
The possibilities of surgicol crown fig. 4 The previo tooth preparation extended
subgingivalfy. The w dentist has no choice but
lengthening ore limited and every to encounter the
h previous problems ond to accept
possible advantage is necessary for the present tooth preporotion ¡orrowj unless
periodontal surgery is utilized ta provide new
retention of the retoiner (Figs. 5 ond looth structure lor Ihe margin of the new crown.
6). It is of paromount importance
when there is o long edentulous spon
extending to a single obutment.
3. Mechanical ond technical reten-
tion. There are times when the clini-
cian strives for eoch millimeter of
tooth structure because of preexist-
ing damoge to the tooth, such as a
cusp thot has fractured to or below
the gingivol margin.
4. Root cories. Even with the advent
and recognition of the beneficial use
of fluoride, root caries remain o con-
cern. This problem con be devastot-
ing when it involves a strategic abut-
ment tooth and may be justification
to extend the restoration to the gin-
givoi sulcus in a dentition showing
prior evidence of root caries (Fig. 7).
5. Teeth with severe cervicol abra-
sion. It is necessary to end the resto-
ration on sound tooth structure api-
cal fo the domaged area. Tooth
preparation must be preceded by a Fig. 5 This molor is strotegic as o potential abut- Fig 6 The same tooth as ir 1 Fig 5,after
crown exposure procedure (Figs. 8 - ment OS it is the only posterior taotii in this quod- periadi ntol SLtrgery, now hers suHic
ront Crown lengthening procedures will be chol- ; to pr<yceed with the restara ion. tt will b,
10). tenging becouse al the limited loalh structure rrytap rovide o post f jnd cor • ta ougmer.
available from the cervical line ol a maxillary nlion c1Í this retainer.
Ó. Root sensitivity. All clinicions re- malor to the opening ol the iurcations.
cognize this difficulty. Fortunotely, it
represents a minority of teeth.
The clinical definition of ¡ntrocrevicu-
lar, when referring to the gingival
margin of a dentol restorotion, de-
signates its placement in that space
bounded by the tooth and the sulcu-
iar epithelium. It should not infringe
upon the junctionol epithelium.'"'^ Fig 7 Note the cories at the gingivol margins ol
This is not to be confused with the these restorations (orrowsl. It is necessary >o es-
tablish new laoth structure before proceeding with
"subgingivol" placement of the re- new restorations

"The Internotionol Journol oi Periodontics ond Reslorotive Dantis

 34

Fig. 8a Cervical abrasion has resulted in no place to finish Ihe rnandibulor abutment tooth prcporotic
on the buccal surface (arrows} Crown lengthening periodontai surgery should be performed before p
ceeding with the necessory restorations.

rig

"The Internaliorol Journol ol Periodontics and Restorolive Dennstry' 3/1984

 35

. P An anterior view ol the cose in Fig. 8 belore restorative dentisliy was performed.

Fig 10 An onlerior view ol ihe patient in Fig. 9 atler periadontal surgery ond lull caveroge restorations.
The maxillary and mandibular incisors hove been replaced by panties to oHord a more cosmetic result.
Note the hannany oi restoration and periadontium thai existí on the maxillory and mandibular cuspids.

"The InlernaHonal Journol ol Periadontics and Restorotive DentiEtiy' 3/19B4

 36

h UNATTACHED
ATTACHED
GINGIVA

AHACHED
AHACHED
GINGIVA
GINGIVAL SULCUS

EPJTHE. AHACH.

FIBER A n A C H .

MCG

fig. i I This diagram illustrotes those entities that must be considered when evaluating the bioloaic width ior a particular surfoce of a tooth. II denotes the dii-
ierence between kerotinized tissues thai can he considered attached and »hose that ore not attached to the tooth ond are thus less iormidoble borders to insults
irom restorotive dentistry. It would be voluable to place the probe on the outer suriace oí the tissues when considering the dimension of tissue desired ior a theon
icol or practical healthy periodontium ¡Fig. 2j.

"The IntemolionolJournol ol Periodoriics ond Restorative Denlistry" 3/1984


starative margin which frequently is
defined only as disappeoring from
sight below the gingivol crest. The
sulcus is very limited in depth in a
heoltfiy non-treated or heolthy
treoted periodontium. It probobly will
be only 1—3 mm in depth and, as one
considers posterior dentistry, it is very
difficult to moneuver in this limited
space.
An examinotion of the clinical entities
of the periodontium shows that the
crest of the alveolar bone is covered
by the supra-olveolar fiber complex.
These fibers insert into the cementum
of the root by means of Sharpey's
fibers and occupy approximately the
next millimeter occlusally,'^'^ The
gingival sulcus as conceptualized
clinically begins at the occlusal-most
extension af the ¡unctionol
epithelium. The depth af a heolthy
sulcus can vary relotive to the posi-
tion of o tooth in its alveolar housing,
the quality of the soft tissue ap-
paratus, etc, but it is not likely to be
less than 1 mm in depth. This then es-
timates the potential minimum com-
bined sum of tfie suprocrestal fibers,
the junctional epithelium, and the sul-
cus ot an approximate minimum af 3
mm supracrestal, with the potential
to increase. This dimension for a par-
ticulor surface of a single tooth will
henceforth be described as the
"biologic width" (Fig, 11),
-The Int ;rnationol Journal oi Periodonrics and Resloiative Dentislrv' 3/1984
37
Previously it has been hypothesized
thot it is necessary to disrupt the
epithelium of the sulcus and/or the
junctional epithelium to establish an
inflommotory lesion in the gingival
fiber apparatus '* It olsa has been
stated that it is necessory to disrupt
the gingival corium and fiber ap-
poratus ta actively disrupt the alveo-
lar crest ond permanently lose
bone,"''^ If one considers this
hypothesis in reverse, it would not be
possible to conceptualize the gingi-
val morgin moving apically in a
properly treated periodontium with a
"biologic widtfi" established for a
particular taath by placing the flap
margin at the crest af bone, and ol-
lowing the formation af the three en-
titles as befits the individuol taoth,
unless the crest af bone moved api-
cally. This thought obviously pre-
cludes the placement af the flop at
any paint occlusal to the crest of
bone.
Consider the potential to insult the
periodontium when performing o full
crown restorotion. First it is necessory
to prepare the toath with a rotary in-
strument revolving at greater than
200,000 rpm. There is an obvious
possibility of damaging the soft tis-
sues, but the restorative dentist must
minimize damage to the saft tissues,'
Underpreparation af the tooth
should be avoided, as an underpre-
pared tooth inevitably results in an
overcontaured crown,' The tech-
nician has no alternative it he sub-
scribes ta the manufacturer's recom-
mendation for the restorotive mate-
riols. This is not meant to pravide a
license far the indiscriminate viola-
tion of the dental pulp, os it is not
necessary to encounter prophylactic
endadontics in order to create the
proper roam for the restoration. The
38
Fig. f2 Thesante diligence fnusfbe e;
ínG cfGofion Of thç fnofoins fof fhe ptov.
Storotion as 's directed toward the pern
StOrat'On. The provisional resforalfon st
g^ide fo consfrud fhe finof result
'The Intemotionol Journol ot Periodontics ond Restorotive Dentistry' 3/1984
provisionol restoration is then ex-
tended to the margin of the gin-
giva.''• ^^ This margin should be
created with the same diligence used
in constructing the margin of a per-
manent crown (Fig. 12).^'' An impres-
sion must be secured with access to
the introcrevicular finish line. It may
be that there is no best way to take
isedin Fig. 13 Alt impressioning techniques hove the an impression. Copper tubes with
¡ot re- potenfiot to disturb fhe periodonftum This enoirt^ compound impressions, electricol
int re- pte of copper tube and compound impressions is
s OS fhe an illustration of the care necessary to ochieve the current to provide a trough for the
desired result.
impression at the marginal level, and
the placement of retraction cord in
the sulcus, alt have the potential to
be traumatic to the (unctional
epithelium and the suprocrestal gin-
gival fiber camplexes (Fig. 13).^^^^
Therefore, every effort should be
made to minimize disruption of the
soft tissues.
In summory, if the clinicion does not
disrupt the junctionol epithelium or
the gingival fiber apparatus, he will
not chonge the level of the alveolor
crest and the gingival margin will not
migrate optcally (recede). The more
probable result of minor irritotions
during mechanical endeavors will be
gingival hyperplasia, which can be
managed clinically. If recession con
be eliminated during and following
the restorative procedure, a mojor
problem in the construction of o cos-
metically acceptable restorotion con
be ovoided.
It is, therefore, of integral importance
 39

to fhe maintenance of a fieal!hy

periodonüum !ha! no restorative ef-
forf violate the junctional epiffielium
of connective tissue fiber apparatus.
This priority es!oblishes !he most api-
cal extent of tfie full coverage resto-
rations not exceeding the depth of
tfie sulcus, even though i! is nol pos-
sible for tfie clinician to identify the
most coronol exten! of the ¡uncüonol
epithelium when preparing o !oath.
The goal of establisfiing the finish line
for a !oo!h preparation is based
upon tfie retention of fhe retainer^'
ond !he provision of odequa!e space
for tfie restorative cosmetic mote-
riols. • Therefore, it is necessory to
be able !o select !he proper method
of !ooth preparation as required by
!he challenge af hand ¡Fig. 14). Al- Fig l^a The rtioiar preparation ends in a feath- Fig. 14b Note the chamfer linish line ond the
ered edge, as casmetic demands far this tooth ditching of the die.
though shoulder and/ar cfiamfer ore diHerent from thase for the maxillary incisor
that utilizes a chamfer finish line. Note the ditching
preparafions are necessary to pro- ol the dies to demorcate the mast apical extension
vide fhe room for the cosmeüc ma!e- of the iinish lines (arrows!.

rial of a restorafion, fhere is usually

no opparent reoson for more tfian
minimal extension of perhops Vs !o f
mm below the gingival eres! (Figs, f 5 Fig. 15 The tooth preparotian ends in a chomler
to allow room for the esthetic material in the con-
and 1Ó). This, tfien, con serve as a struction ot this lull crown hr the moxillory centrat otty with oin-
first guide in !ooth preparoüon tha! will
be helpful in respecting the bound-
aries of tfie crevice. When restoring
elongated posterior teeth, the
cosmeüc moteriat is not as critical,
and the space for it can be provided
for in the design of the cosüng, rather
ffian in !he !oo!h preparaüon (Figs.
17-19). Therefore, o full shoulder or

'T>ie irternalianal Journol ol Periodontics and Restorotive Dentislry" 3/1984

 40
fig Ua The íooíh preparolton hi elongated
posterior feeth allows ¡he tinish line lo be in fhe
¡oim ol o ieothered edge.
deep chamfer taoth preparation is
usually not necessory for elongated
posterior teeth
Marginol deformotlon has been re-
peatedly shown when o 1 mm collar
is placed on o feathered edge prep-
aration,^°' ^' This is not a tactor tor a
molor full-gold east erown or ony
posterior restoration with o 2-3 mm
gold collar (Fig. 18].
There is frequently o disparity be-
tween the opicol extent ot o restoro-
tion interproxlmolly and radicularly.^''
The parabolic architecture ot the on-
terior oreo with its narrow alveolar
pracess is more severe thon the pos-
terior where the alveolor process
widens to occommodote the larger
root surfoces. Interestingly, this on-
tertor dispority approaches the same
3 mm OS the minimol "biologic
width." Inexperienced elinielons may
mistakenly extend the tooth prepara-
tion on all surfaces to one eireumter-
enttal depth, ond this is likely to vio-
late the interproximal soft tissue at-
"The International Journol al Periadontics and Restorative Dentistry" 3/1984
Fig. 17b The motor costings end in a Ieothered
edge.
tachments of the periodontium. It Is
imperative nat to eommit this error,
as if results in the extension of the in-
terproximal margin too tar subgingi-
vally.
It is not important which impression
technique is utilized. It is impartant to
respect the fragility of the junctlonal
epithelium ond the ottaehment of the
supraerestol tibers, and to be eoreful
not to disrupt them (Fig. 13). It is
necessary to be cognizant of the ad-
vontoges and disadvontages of
eoch technique and to be oble to
select and apply that methodology
best suited to the problem at hand.
Fig 18 Posterior crowns can end with a gold cal-
lar and thus avoid the necessity ol o chamier or
shoulder to make room lor the restarotive mate-
rial The room iar the cosmetic material (porcelain)
is created m the casting.
After the impression is secured and
the die constructed, the next critical
step is the demorcation of the finish
line ¡Fig. 20]. This is referred ta gen-
erally as "ditching the die," and can
be mast precise only when ae-
eomplished by the same persan who
prepared the tooth. It is not possible
to extend o costing too for opicolly it
the die is properly ditched. This, then,
precludes domage to the soft tissue
ottaehment apparatus when trying
on a costing or the framework ior o
fixed bridge (Figs. 21o—21d). It
should also establish the finish line in
an area that is occessible to allaw
the removal ot excess cement after
the permanent restoration is
eemented into place. When the re-
storative margin extends too far sub-
gingivally, it may retain exeess ce-
ment on its margin (Fig. 22). This con
be a plaque problem, and ean result
in an inflammatory response, os it
may not be possible to remove the
excess cement.

fig. 19a A full chamier pre This prep-
Oratian fs indicated where m depth oí the
preparotion af the gingival third is to be utili •dio
a ceromametal restoration This deep chamfer
serves Ihe purpose af being able to develop
contour. This preporation is excellent to use with
small gold collar for maximum esthetics.
Fig Í9b A full shoulder preporot'on This is the
preporation ot choice for the indivduol full porce-
lain jacket crown This preporofion oliov/s ¡or uni-
at the gingival third where no underlying metal is
being used. Hawever^ the parcelain butt fit is more
difficult to achieve than using a gald coilor
"The Inlernolionoi Journal of Periodoriics a r d Restorative Dentisln^" 3/I9S4
41
fig. 19c A full chomier with bevel ihis prepara-
tian can be vsed for a ceramometal restoration
where the ffnish Une can ine placeo in an ¡ntra-
crevcular area with the chamfer at a higher level.
It has the same advantages os the f\jU chamfer
and 'S mosf readily adaptable to fhe posferior
dentition where o display oi gold would not be
obiectionoble Hov/ever^ fhe gold coilor must be
wide enough to prevent distortion during the
porceloin (¡ring cycle.
 42
Fig, 2 la A fixed bridge is being reviewed lor
compliance with periodontol health belare being
cemented. The gmgivo has been injured by the
tooth preporotion, provisionol bridge, impression
technique, and costing adjustment procedures.
The technician was not oble to read the dies occu-
rately, but was obligated to demarcate the linish
line He, therefore, erred on Ihe side ol extending
lurther below Ihe gingival crest so as nat to be
short. This tissue is detoched and probably will nol
remain stable in height or offer soft tissue protec-
Fig. 21c The costing is further sealed so thai it:
buccol margin is in contact with the gingival mar-
gin. This places the interproximal margin af the
restaratian lurlher subgingivolly.
"The Inlernolionol Journal of PerrodonUcs and Restoralive Deniistry" 3/1984
Fig 20 The costinas can only extend apically to
the area of the die that is ditched to demarcate the
finish line ol the preparation 'arrowj. The clinician
who has prepored the tooth should ossume the
obligation of estoblishing this end point, as this is
the inaividua' most aware ot its proper placement.
Fig. 21b The lured bridge is seated so Ihot the in-
ierproKimal morgin extends I 'h mm below the tis-
sue morgin The buccal margin has nol yet
reached^the qinaivii
Fig. 21d The lixed bridge is now completely
seated. The buccal gold collar is no longer visible,
but the interproximol morgin extends 4—5 mm
below the gingival crest interproximally. It is dif-
ficult lo imogine complete removal oi cement, let
ohne on intact soft tissue ottachment to the tooth.
This is the wrong depth to contemplóte when per-
torrning intracreviculor morgin placement t\o
.houid be this lor subqinaivallv

1 arr -.wl
Figure 23a
Fig 23a A soft tissue modi•I Olds th:! technologist
in his understonding of the iritrocrevii •utor finish of
Ihe restorath 'hen desigr mg the iTostings.
The authars wish to express Ihe
Fig 22 The reflect 3/Î of th\ P eriodont Iliop
elm inat interproxi •no! pod ef. ig demo nstroti
rete ined cem ent yeors offer h perman ent
cen enta 'ion of lull coverage restorolio sino
Fiq. 23b The sati tissue model öfter the addition
olceromics to the castings
atian to Donold Martin for slides 23a and 23b.
"The InternationclJournol of Periodontics and Restorotive Dentistry" 3/1984
43
Soft tissue models are of benefit to
the technician as they emulate the
gingiva and allow oil to visuolize the
theoretic placement of the restorative
margin (Figs 23a and 23b). They are
only relative and must be checked
clinicolly to be of value.^^
The validity of the intracrevicular
placement of fhe gingival margin re-
quires the tracking af cases for an ex-
tended period of time, and the ob-
servation of two factors. First and
easiest to ossay is the level of the
gingivol margin. The premise of the
"biologic width" allows for little orno
opical migratian, as it would be
necessary for the level of the alveolar
crest to move apicolly to accommo-
date recession. This can be observed
clinicolly (Figs. 24h-24m). The sec-
ond factor is the level of the alvealor
crest (Figs. 24i and 24n). It is always
important to protect and preserve
the remaining alveolar housing. The
level of alveolar support can be
measured rodiographically relative
to the apical extent of the restorotive
morgin.
 Fig. 24o The original ladiogrophic suivey T/n-' goal oi 'he penodanti^t ¡5 lo piotoct tiic ícvd ol suppoitmij h.

Fig. 24b It is necessary lo examine ond Icack a

dentition for a lang period af lime befoie consid- Fig 2-tc The mondibulai
ering that the regime ot therapy is successful. This .iiono/ bridgei, aie m plací nd ihe patient I
photograph was taken in Octobei 1968 The ready lo¡ fjeiiodontol swa^ thot will accom,
mondibulor provisionol bridge is m place.

"The I nie motion a i Joiimol ol Periodonlics und Re^loradve Dentislry" 3/198'!

 ol the linat tooth picp- Fig. 24g The peiiodonta, ' lissues continue to ,
sott ¡issues The case mam in a stale ol heollh I3/ j/.e 'me the costin
fid Qo'o 'csfOfottorfi rn ore lit la Ihe toeith piepor olions This recogntz
too^h prcporfjfion'i ITC the coie that hers beer. e.erased during Ihe
lety. lestoiotive proir eduiet.

Fin 2Jh The linol pimliKM is cenicnlcd into

f'li.:c- Note ii>€ harmony rhat i'iisis bctwoc-n i

Fig 241 The lull moulh rodiogrophic sert

in ¡969 oilers ÍI guideline OS to Ihe origin!.,.
giapi^ic rclnlianship ol Ihc restorolive morí
the inleipravmol eieslsol bone. It is import'..!^' .^
lecognire that this is a two-diinenitanal reduction
ola thiee-dimensianal obisct, and that one entity
con be piotecled onto another hee Fig 251

"The Internclionol Journal al Periodondcsoiid ReslarolLve Dentisliv" 3/1984

Fig 241. An opportunity lo examine the resull !.1 Fig 741 The peiiodontot pfohe demonstróles fig 24m Thcluilcintc
yeois öfter trcatmeni. The visit wos piecipitatedby that the gingival morgin is intact spotiolly ond iiiaigins continue tobe
I . I — ^ 1 1 ^ .- Tí,— . ^ — J r It TL . .' J kj- -J the precision partial de
a losi locing on o monoiouiai inasor. me mai- uioiogKaiiy me poiieni s cooperotion wiin oe-
g p
ginol iciotionship is app'ofimolely 'JIÉ' some OS it tjridement procedures hos contributed signiii.
wos when l/if filed budges woie d deli\eied This l h l
reflects Ihe suigicnl monagemeni. Ihe care ol
manipulation af >hc piniofionlium during the con-
sliuciion oí the piosthesiSf and the core cxeicised
by ihe patient

The moit recent full mouth lodiogiophic suivcy íl°83¡ reveols the same bony piotilc y.'hcri Hu- icsloiotivc morgnK ore- u;.cd

suits in the iupei imposition olone entity i

apron af o ciown generolly entends lurther apicolly Ihon the interprommot moig edlodiogiophii-olly. theipsult¡.iiesents II
gin Ibuccol apiori¡ contacting bone. This offers an exacting mail.ei lo tiiid II

The internütionüi Journal oi Penodontics and Reslorolive Denlisl/y" 3/198-1


The rodiograph is a two-dimensional
reduction of the three-dimensional
periodontium (Fig, 25), The buccol
apron, therefore, is projected as
being ot tfie some height as the inter-
proximol bone, olthaugh it projects
further apicolly. This serves as a vol-
uable trocer for the level of the crest
of bone.
The following case report dem-
onstrotes the improvisotion of the in-
tracrevicular extension of the restora-
tive margin when a chamfer toolh
preporotion is used for a time. It is necessary to reline the pro-
ceromometal restoration,^ Presurgi-
cal tooth preporation does nat ex-
tend beyond where the provisionol
restoration can be adapted (Figs,
Gingival Crevice
Junctional Epithelium
Transseptal Fibers
26G ond 2óbl, This alleviotes undue
postsurgicol thermal sensitivity ond
ollows the patient to maintain the
necessary plaque cantrol to obviate
inflammotion during the pastsurgical
development of the "biologic width"
[Fig, 2ócl. The pastsurgical tooth
preparation is augmented at obout
the 8-12 week postsurgicol time
frame, depending upon individual
consideration. It will not extend
beyand the crevice. Finol impres-
sions are generally not taken at this
visional bridge to the gingival margin
ond establish the emergence profile,
height of contour, and the embrasure
design far each crown (Fig, 26dj.
Interproximal
Crest of Bone
'The International Journal ol Periadontics ond Reslorali'/e Dentislrv' 3/19B4
47
Only when the crown contours of the
trial restorotion and the health of the
periadontium are synchronized is the
tinol impression taken and the cose
carried ta completion (Figs, 2óe—
26g|, If aberrations accur, it is neces-
sary to intervene and alter the soft
tissues ond/or crown contours be-
fore finishing.
In conclusion, it is necessary to em-
phasize that the periodontium would
fare betterifna restorotive margin ap-
proached the gingiva. However, that
sometimes can't be avoided, for rea-
sons explained previously. Therefore,
it is mandotory fa adhere fa the prin-
ciples stated in fhis article to avoid
insulf fo the supporting structures.
 48

Fig. 26o The original clinical photogroph de-
notes o denlifion fhaf has experienced debnde
merii iheropy. The maxillary right lateral incisor M
be extracfed for periodontal ond cosmetic
reasons.
Fig. 26b The moxillory righf cuspid and both Fig 26c The provisional restorotion hos been
central incisors hove been prepared to receive the place lor 10
10 weeks. The entroction wound has
provisionat restoratian. The taoth preparation heoted ond the panlic has been corrected.
does not extend beyond a point where il con be
captured with the morgins al the provisional
bridges This eliminates extreme thermal reactions
olter periadantal surgery and attaws the extension
ol the rnorgin ta the gingiva at a time when the
periodontol tissues have reached their full dimen-
sion.

Fig. 26d Feriodantal surgery has enhonced the
dimension ol attoched gingiva on the cuspid, cor-
rected the edentulous orea for the placement al
the lateral incisor panlic, and resulted in packet
elimination.
Fig. 26e The finished dies are ditched by the re-
storative dentist. They cleorly reflect the use olta-
biol chamfers lar the Itnish line of the taoth prep-
Fig. 261 The castings for the ceromametal resto-
ratian are tried in ploce before the ceramic mate-
rial is placed on Ihe Irome. This enables the clini-
cian to test Ihe fit ol the costings and wake any
necessary adjustments.

Fig. 26g The linal bridge is in ptace. Themargms

olthe restoration extend inta the gingivol crevice
ta satisfy the esthetic needs of Ihe potient.

"The Inteinotional Journol ot Periodontics ond Restorotive Dentistry" 3/1984


References
1. Goldstein, R, Esthetics in Dentistry.
Philadelphio: J. B. Lippincott Co., 1976, p.
33a.
2. Newcomb, G. M The relationship be-
tween the location of sublingual crawn mor-
gins and gingival inflarnmotion. J. Penodon-
tol. 45:151, 1974.
3. Silness, J. Periodontol conditions in po-
tients treoted with dental bndges, II. The in-
fluence of full and partial crowns on plaque
accumulation, development of gingivitis
and pocket formofion. J. Periodont. Res.
5:219, 1970.
4. Silness, J. Fixed prosthodontics ond
periodontai heolth. Dent. Gin. North Am.,
Vol. 24, No. 2, 1980,
5. Woerhaug, J. Tissue reoctions around
ortificiol crowns. J. Periodontol. 54:172,
1983.
6. <oy, H B. Esthetic considerations in the
definitive periodontol prosthetic monage-
menf of the maxillary onterior segment. Int.
J. Periodontol. Rest. Dent. 3:45, 1982.
7. Miller, L. A clinicion's interpretotion of
tooth preparation ond the design of metal
substructures for metal-ceramic restora-
tions, pp. I53-20Ó, In McLeon, J. W. (ed.i
Denfof Ceromics Proceedings of the First
International Sympasium of Ceramics.
Chicago: Quintessence Publ. Co., 1983
a. Wheeler, R. C. Dental Anatomy, Physiol-
ogy ond Occlusion. Philodelphia: W. B
Saunders Co., 1974, p. 237,
9. Dragoo, M. R., and Willioms, G. B.
Periodontai tissue reactions to restorative
procedures. Int. J. Peridontol. Rest. Dent,
1:9, 1981.
10. yVilson, R D., ond Moynard, J. G. The
relationship of resto rotive dentistry to
periodontics. In Prichord, J. F. The Diag-
nosis ond Treotment af Periodontol Diseose
in General Dentol Proctice. Chapter 28.
Philodelphia: W. 6. Saunders Co , 1979.
11. Wilsan, R. D., ond Moynard, G. Intro-
creviculor restorative dentistry, int. J
Penadonfol. Rest. Dent. 4:35, 1981.
12. Ross, S. E., and Gorguilo, A. The surgi-
cal management of the restorative alveolar
interface. Int. J. Periodont. Rest. Dent. 3:9,
1982.
13. Garguib, A. W., Went7, F. M., and
Orbon, B. J. Dimensions ond relations of
the dentogingivol [unction in humans. J.
Peridontol. 32.261, 19Ó!
14. Moynord, J G., and Wilson, R. D.
Physiologic dimensions of ihe periodontium
fundomental to successful restorotive den-
tistry. J. Penodonfal. April, 1979.
15. Goldman, H. M., and Cahen, D. W.
Periodontol Therapy St. Louis: C. V. Mosby
Co., 1968, pp. 110-165.
16 Aisenberg, M. S., and Aisenberg, A. D.
A new concept of pockei formotion. Oral
Surg. 1:1047, 1948.
17. Goldman, H. M. The relotionshipof the
epithelial ottachment ta the adiocent fibers
of fhe periadontal membrone. J Dent Res.
23:177, 1944.
18. Goldmon, H. M. The topogrophy and
rale of the gingival fibers. J. Dent. Res.
30.331, 195!.
19. Schluger, S.,Vuodelis, R A., and Page,
15. C. Periodontai Disease. Philodelphio: Leo
ond Febiger, 1977, p. 662.
20. Tylman, S. Theory and Proctice of
Crown ond Fi^ed Portial Prosthodontics
(Bridge), 6th ed. St. Louis: Tfie C. V. Mosby
Co., 1970, pp. 225-229.
21. Preston, J. Rotional approach to tooth
preparation for ceramometol restorotions.
Dent. Clin. North Am. 21 683, 1977.
22. Drogoo, M. fi., ond Willioms, G. B.
Periodontai tissue reactions to restorotive
procedures. Port II. Int. J. Penodontol. Rest,
Denf. 2:35, 1982.
"The internotiorol Joumal ol Periodontics ond Restorolive Dentisirv' 3/1984
49
23. Lytle, J. D., and Skurow, H. M The in-
terproximal embrosure. Dent. Clin. North
Am. 15:641, 1971.
24. Nevins, M Interproximol periodontai
diseose - The embrasure as on etialogic
foctor. Ini. J. Penodonfol. Rest. Dent. Ó9,
1982.
25. Horrison, J, D. Effect of retraction mote-
rials on the gingival sulcus epithelium, J.
Prosthet. Dent. n'514, 1961.
26. Loe, H., and Silness, J. Tissue reactions
fo string pocks used in fixed restorofions. J.
Prostfiet. Dent. 13:318, 1963.
27. Nixon, K. C , Adkins, K F , and Keys, D.
W. Hlstoloqical evoluotion of effects pro-
duced in oTveolor bone following gingivol
incision with on electrosurgical scolpel. J.
Periodontol 46:40, 1975.
28. Wilhelmsen, N. R., Romfjord, S. D., and
Blankenship, J. R. Effects of electrosurgery
on the gingi>/ol attachment in rhesus mon-
keys. J. Periodontol. 47160, 1976.
29. Gilboe, D. B., and Teteruck, W. F. Fun-
damentals of extracoronol taoth preporo-
tion. Part I. Retention ond resistance farm. J,
Prosthet. Dent. 32:651, 1974.
30. Homaguchi, H,, Cocciotore, A., ond
Tuellei, V. M. Morginol distortion of tfie
porcelain-tjonded-to-metol complete
crown. J. Prosthet. Dent. 47:146, 1982
31. Kuwoto, M Gingival morgin designs af
obutments for ceromometal restorotions.
Ouint. Dent Technol. 37-43, 1980.
32. Mortin, D Soft tissue, master cast. Int.
J. Periodontol Rest. Dent. 4:35, 1982.
33. McLeon, J. W. The Science and Art of
Dental Ceramics, Vol. II. Chicago: Quintes-
sence Publ. Co , 1980,