Interactions between the gingiva and the margin of restorationsDocument Transcript
J Clin Periodontol 2003; 30: 379–385 Copyright r Blackwell Munksgaard 2003
Printed in Denmark. All rights reserved
Interactions between the gingiva Allan Padbury, Jr, Robert Eber
and Hom-Lay Wang
Department of Periodontics/Prevention/
and the margin of restorations
Geriatrics, School of Dentistry, University of
Michigan, Ann Arbor, MI, USA
Padbury Jr A, Eber R, Wang H-L. Interactions between the gingiva and the margin of
restorations. J Clin Periodontol 2003; 30: 379–385. r Blackwell Munksgaard, 2003.
An adequate understanding of the relationship between periodontal tissues and
restorative dentistry is paramount to ensure adequate form, function, esthetics, and
comfort of the dentition. While most clinicians are aware of this important
relationship, uncertainty remains regarding speciﬁc concepts such as the biologic
width and indications and applications for surgical crown lengthening. This review
discusses the concept of the biologic width and its relationship to periodontal health Key words: restorations; crown margins;
and restorative dentistry. The importance of restorative margin location, materials, and biological width; periodontal and gingival
contours related to periodontal health is also addressed. The rationale and indications health
for surgical crown lengthening are elaborated. Particular surgical principles of crown
lengthening are examined in detail. Accepted for publication 27 May 2002
Periodontal tissues form the foundation and relationship of the dentogingival There is general agreement that
for proper esthetics, function, and com- junction in humans. Measurements made placing restorative margins within the
fort of the dentition. All prosthetic and from the dentogingival components of biologic width frequently leads to gin-
restorative therapies generally require a 287 individual teeth from 30 autopsy gival inﬂammation, clinical attachment
healthy periodontium as a prerequisite specimens established that there is a loss, and bone loss. This is thought to be
for successful outcome. The interplay deﬁnite proportional relationship be- due to the destructive inﬂammatory
between periodontics and restorative tween the alveolar crest, the connective response to microbial plaque located at
dentistry is present at many fronts, tissue attachment, the epithelial attach- deeply placed restorative margins.
including location of restorative mar- ment, and the sulcus depth. Gargiulo et Clinically, these changes are manifested
gins, crown contours, and response of al. (1961) reported the following mean as deepened periodontal pockets or
the gingival tissues to restorative pre- dimensions: a sulcus depth of 0.69 mm, gingival recession. These changes have
parations. The purpose of this review an epithelial attachment of 0.97 mm, and been substantiated by studies that have
paper is to summarize both past and a connective tissue attachment of assessed the histological and clinical
present literature regarding basic con- 1.07 mm. Based on this work, the responses of periodontal tissues to
cepts of periodontal–restorative inter- biologic width is commonly stated to be restorative margins placed within the
actions, particularly with regard to 2.04 mm, which represents the sum of the biologic width. Newcomb (1974) ana-
interactions at the gingival margin, epithelial and connective tissue measure- lyzed 66 anterior crowns with subgingi-
including the dentogingival attachment ments. One must realize however that val margins of varying depths and
and the impact of restorations, which signiﬁcant variations of dimensions were compared them to uncrowned contral-
encroach upon these tissues. observed, particularly the epithelial at- ateral controls. The results showed that
tachment, which ranged from 1.0 to the nearer a subgingival crown margin
9.0 mm. The connective tissue attach- was to the epithelial attachment (hence
Biologic Width ment, on the other hand, was relatively nearer the biologic width), the more
The term biologic width is familiar to constant. Recently, similar biologic likely that severe gingival inﬂammation
most clinicians, yet there still exists width dimensions were also reported occurred. Parma-Benfenati et al. (1986)
confusion regarding its meaning and (Vacek et al. 1994). Evaluating 171 observed approximately 5 mm of oss-
relevance to clinical procedures. The cadaver tooth surfaces, they observed eous resorption when restorative mar-
biologic width is deﬁned as the dimen- mean measurements of 1.34 mm for gins were placed at the alveolar crest
sion of the soft tissue, which is attached sulcus depth, 1.14 for epithelial attach- in beagle dogs. Minimal resorption
to the portion of the tooth coronal to the ment, and 0.77 mm for connective tissue was observed where restorations were
crest of the alveolar bone. This term was attachment. This group also found that placed 4 mm coronal to the alveolar
based on the work of Gargiulo et al. the connective tissue attachment was the crest. Bone resorption was particularly
(1961), who described the dimensions most consistent measurement (Fig. 1). severe in areas with thin cortical bone
380 Padbury Jr et al.
not disrupt the junctional epithelium or
connective tissue apparatus during pre-
paration and impression taking. The
authors recommended limiting subgin-
gival margin extension to 0.5–1.0 mm
because it is impossible for the clinician
to detect where the sulcular epithelium
ends and the junctional epithelium
begins. They also emphasized allowing
a minimum 3.0 mm distance from the
alveolar crest to the crown margin.
Block (1987) also claimed that the
biologic width was difﬁcult for clini-
cians to visualize and suggested the free
gingival margin as the reference point
for measurements for margin place-
ment. Block stated that when restorative
margins end at or near the alveolar crest
level, surgical crown-lengthening pro-
cedures are necessary.
It is important to note that recom-
mendations regarding placement of re-
storations in relation to the biologic
Fig. 1. Biologic width. width are based on opinion articles.
They have evolved due to clinical
experiences and interpretations of var-
ious experimental studies. Nonetheless,
it appears that a minimum of 3.0 mm of
and interdental septa. Tal et al. (1989) margins must be from the bone crest to space between restorative margins and
further demonstrated that biologic width avoid deleterious effects. Ingber et al. alveolar bone is a dimension that is
violation results in loss of periodontal (1977) suggested that a minimum of prudent to adhere to in restorative
support. Class V cavities were prepared 3 mm was required from the restorative treatment planning.
in canine teeth of 43 beagle dogs so that margin to the alveolar crest to permit
the apical border rested on the alveolar adequate healing and restoration of
crest. Control teeth had Class V notches the tooth. Maynard & Wilson (1979) Restorative Margin Location
placed at the cemento-enamel junction. divided the periodontium into three Not only do restorative margins placed
All cavities were restored with amal- dimensions: superﬁcial physiologic, subgingivally risk invading the attach-
gam, and 1 year following surgery, crevicular physiologic, and subcrevicu- ment apparatus, but also unwanted
gingival recession and bone loss were lar physiologic. The superﬁcial physio- tissue effects appear to result merely
signiﬁcantly greater at test sites com- logic dimension represents the free and due to their subgingival location, re-
pared to control teeth (3.16 and attached gingiva surrounding the tooth, gardless of depth of sulcus penetration.
1.17 mm versus 0.5 and 0.15 mm, re- while the crevicular physiologic dimen- Orkin et al. (1987) demonstrated that
spectively). Recently, Gunay et al. sion represents the gingival crevice – subgingival restorations had a greater
(2000) demonstrated that restorative extending from the free gingival margin chance of bleeding and exhibiting
margin placement within the biologic to the junctional epithelium. The sub- gingival recession than supragingival
width was detrimental to periodontal crevicular physiologic space is analo- restorations. Silness (1980) evaluated
health. In a 2-year study, they evaluated gous to the biologic width described by the periodontal condition of the lingual
116 prepared teeth compared to 82 Gargiulo et al. (1961), consisting of the surfaces of 385 ﬁxed partial denture
unrestored teeth in 41 patients. Papillary junctional epithelium and connective abutment teeth. He found that a supra-
bleeding score and probing depths tissue attachment. Maynard & Wilson gingival position of the crown margin
increased at sites where the restorative claimed that all three of these dimen- was the most favorable, whereas mar-
margin was o1 mm from the alveolar sions affect restorative treatment deci- gins below the gingival margin signiﬁ-
crest. sions and the clinician should cantly compromised gingival health.
Encroachment of the biologic width ‘conceptualize’ all three areas and the Renggli & Regolati (1972) demon-
becomes of particular concern when interplay between them and restorative strated that gingivitis and plaque accu-
considering the restoration of a tooth margins. In particular, the authors mulation were more pronounced in
that has fractured or been destroyed by claimed that margin placement into the interdental areas with well-adapted sub-
caries near the alveolar crest level. Also, subcrevicular physiologic space should gingival amalgam ﬁllings compared to
esthetic demands often require ‘‘bury- be avoided to prevent the placement of sound tooth structure Waerhaug (1978)
ing’’ of restorative margins subgingiv- ‘permanent calculus’ beyond the cre- stated that subgingival restorations are
ally, which can lead to violation of this vice. Nevins & Skurow (1984) stated plaque-retentive areas that are inacces-
space. Various authors have recom- that when subgingival margins are sible to scaling instruments. These
mended minimal distances restorative indicated, the restorative dentist must retentive areas continue to accumulate
Interactions between gingiva and margin of restorations 381
plaque even in the presence of adequate although crown margins may be placed changes in the associated microﬂora to
supragingival plaque control. subgingivally, it is highly likely that that of one resembling the ﬂora ob-
In a cross-sectional study of 134 over time the margins will eventually be served in adult chronic periodontitis.
periodontitis patients, Wang et al. located supragingivally. Valderhaug & Increased proportions of Gram-negative
(1993) demonstrated that posterior teeth Birkeland (1976) evaluated 114 patients anaerobic rods, in particular black
with crowns or proximal restorations with 329 total crown restorations. Most pigmented Bacteroides, were observed.
were associated with more furcation of the crowns (59%) were located Chen et al. (1987) evaluated human
involvement and greater attachment loss subgingivally at the beginning of the extracted teeth with overhanging re-
than teeth without proximal restora- study period. After 5 years, only 32% of storations compared to nonrestored
tions. Stetler & Bissada (1987) evalu- the crown margins remained below the teeth and reported greater attachment
ated the effects of width of keratinized gingival margin. They also demon- loss associated with overhang surfaces.
gingiva and subgingival restorations on strated that greater mean attachment Pack et al. (1990) assessed the preva-
periodontal health. Teeth with subgin- loss was associated with subgingival lence of restoration overhangs and
gival restorations and narrow zones of restorations compared to supragingival associated periodontal disease of 100
keratinized gingiva showed signiﬁcantly margins (1.2 versus 0.6 mm). patients who had recently completed
higher gingival index scores than teeth treatment. Sixty-two percent of all
with submarginal restorations with wide proximal restorations had overhanging
zones of keratinized gingiva. Thus, margins, and periodontal disease was
clinicians should consider gingival Restoration Overhangs more severe when overhangs were
augmentation for teeth with minimal Overhanging dental restorations have present. When adjacent to neighboring
keratinized gingiva before placing long been viewed as a contributing teeth, overhanging margins also signiﬁ-
subgingival restorations. factor to gingivitis and possible period- cantly affected the periodontal status of
Waerhaug (1980) demonstrated gin- ontal attachment loss. They pose a those teeth.
givitis and attachment loss associated signiﬁcant concern as their prevalence Thus, overhangs not only increase
with submarginal restorations in mon- has been estimated at 25–76% for all plaque mass but also increase the
keys and dogs. Clinical and histological restored surfaces (Brunsvold & Lane speciﬁc periodontal pathogens in the
observations of human teeth by Dragoo 1990). It is generally accepted that plaque. Most overhanging restorations
& Williams (1981, 1982) demonstrated overhanging restorations contribute to can be recontoured without replacing
compromised healing associated with gingival inﬂammation due to their the restoration, and this should be
gingival bevel crown margins compared retentive capacity for bacterial plaque. considered a standard component of
to shoulder preparations. Flores-de-Ja- Gilmore & Sheiham (1971) illustrated nonsurgical treatment. A variety of
coby et al. (1989) studied the effects of interproximal radiographic bone loss devices have been suggested for over-
crown margin location on periodontal adjacent to posterior teeth with over- hang removal, most based on clinical
health and bacterial morphotypes in hanging restorations. Highﬁeld & Po- opinions. One study demonstrated that a
humans 6–8 weeks and 1 year post- well (1978) demonstrated that overhang motor-driven diamond tip is faster for
insertion. Subgingival margins demon- removal plus professional plaque con- removing overhangs and led to smooth-
strated increased plaque, gingival index trol improved gingival indices and bone er restorations compared to sonic scalers
scores, and probing depths. Further- scores. Jeffcoat and Howell (1980) and curettes, respectively (Spinks et al.
more, more spirochetes, fusiforms, rods, demonstrated a link to the severity of 1986).
and ﬁlamentous bacteria were found to the overhang and the amount of period-
be associated with subgingival margins. ontal destruction. Based upon radio-
The location of restorative margins is graphic evaluations of 100 teeth with
determined by many factors, including overhangs and 100 without, they re- Artiﬁcial Crown Contour
esthetics, retentive factors, susceptibil- ported greater bone loss around teeth Regarding crown contour, conﬂicting
ity to root caries, and degree of gingival with large overhangs. The severity of reports exist regarding the proper con-
recession. While many clinicians place bone loss was directly proportional to tours necessary for maintaining gingival
restorative margins subgingivally, the the severity of the overhang. Overhangs health. Some report that an artiﬁcial
detrimental effects of margins below the were designated as large if they occu- crown should follow the original anat-
free gingival margin is obviously well pied 451% of the interproximal space. omy of tooth contour to permit func-
documented. While most periodontists Small and medium overhangs (o20% tional stimulation and to maintain
would prefer restorative margins to and 20–50% of the interproximal space, gingival health. Others advise that
remain coronal to the sulcus, it is respectively) were not associated with crowns should be undercontoured for
understood that certain conditions ne- bone loss. Lang et al. (1983) investi- better periodontal health. Yuodelis et al.
cessitate placement of subgingival mar- gated the speciﬁc aspects of the local (1973) demonstrated that the greater the
gins. These may include esthetic bacterial accumulation associated with amount of facial and lingual bulge of an
concerns, need for increased retention overhanging restorations. Five gold artiﬁcial crown, the more the plaque
form, reﬁnement of preexisting margins, MOD onlays with 1 mm overhangs were retained at the cervical margin. Ehrlich
root caries, cervical abrasion, and root placed in mandibular molars of period- & Hochman (1980) evaluated differ-
sensitivity. However, if none of these ontally healthy dental students for 9–27 ences in subgingival crown contours in
factors is of concern, it appears prudent weeks. They were replaced in a cross- four periodontally healthy patients and
to place restorative margins supragin- over design by onlays with clinically determined that factors other than var-
givally. It is also important for clin- perfect margins. The placement of iations in crown contour of 71 mm
icians and patients to understand that subgingival overhangs resulted in determined gingival response. In a
382 Padbury Jr et al.
review of periodontal–prosthetic inter- esthetic deﬁciencies, and teeth shor- reduction are limited because bone
actions, Becker & Kaldahl (1981) tened by incomplete exposure of the removal is often necessary to provide
opined that buccal and lingual crown anatomic crown are all candidates for adequate distance from the osseous crest
contours should be ‘‘ﬂat’’, not ‘‘fat’’, surgical lengthening. Oftentimes, failure to the anticipated restoration margin,
usually o0.5 mm wider than the CEJ, to perform surgery prior to margin allowing for biologic width. Therefore,
and that furcation areas should be placement in these situations leads to APF with osseous surgery is the most
‘‘ﬂuted’’ or ‘‘barreled out’’ to accom- margins placed too near the alveolar common technique for crown-lengthen-
modate oral hygiene in these areas. crest, thus invading the biologic width ing surgery. APF with osseous surgery
space. Therefore, in the early stages of consists of a reverse bevel incision and
restorative treatment planning, if the subsequent mucoperiosteal ﬂap reﬂec-
Proximal Contact Relationships clinician believes that the margin of the tion. Vertical releasing incisions are
ﬁnal restoration will be r3 mm from often made to allow better access and
Clinical impressions suggest loose or
the alveolar bone crest, crown lengthen- apical positioning of the ﬂap. Initial
open proximal contacts to be contri-
ing should be recommended. This can incisions may be intrasulcular if gingi-
buting factors to periodontal pocket
not only be accomplished by surgery but val width is narrow, or scalloped when
formation. Nonetheless, the literature
also by orthodontic forced eruption, or a gingival width is wide. Generally, an
proposes conﬂicting views on the sub-
combination of both. Numerous factors adjacent tooth on each side of the tooth
ject. This may be due to different oral
may determine if crown lengthening is to be lengthened is included in the
hygiene levels of the different study
needed and often, more important, if a surgical procedure to allow for proper
populations. Kepic & O’Leary (1978),
particular tooth (or teeth) is indeed a contour of the gingiva and underlying
for example, demonstrated no differ-
candidate for crown-lengthening sur- bone. Initial osseous recontouring is
ence in periodontal breakdown at sites
gery. Before proceeding with surgery, completed with the use of rotary
with deﬁcient proximal contacts com-
the clinician should always ﬁrst con- handpieces and then completed with
pared to satisfactory sites, provided
sider whether orthodontic extrusion is chisels and curettes to achieve the
adequate oral hygiene was maintained.
appropriate. Failure to consider ortho- desired reduction while maintaining a
Larato (1971) evaluated 121 dry adult
dontic extrusion can lead to poor scalloped, parabolic bony contour to
human skulls and found that only 38 of
cosmetic outcomes (i.e. gingival reces- follow the desired contour of the over-
206 intrabony lesions (18%) were
sion, particularly in anterior teeth), lying gingiva. In addition, end cutting
associated with factors able to cause
poorer crown:root ratios, and loss of burs are currently available that are
food impaction. While the role of
bone support on adjacent teeth (Ingber designed for removing bone with mini-
deﬁcient interproximal integrity may
et al. 1977). mal risk of damaging the root.
be unclear, open contacts leading to
Often, caries or lack of tooth struc- Most authors agree that a minimum
food impaction are often uncomfortable
ture necessitates bone removal to a distance of 3 mm is required from the
to the patient, and it is still generally
point where the periodontal support of osseous crest to the ﬁnal restorative
accepted that tight interproximal con-
the tooth is compromised, a furcation is margin following a crown-lengthening
tacts are important for gingival health.
exposed, or an inadequate crown:root procedure to allow the margin to ﬁnish
Hancock et al. (1980) evaluated 40
ratio results. If these situations are ¨
supragingivally (Bragger et al. 1992).
naval recruits to determine the relation-
anticipated, the treatment plan must be Thus, 3 mm allows for 1 mm of supra-
ship of interdental contacts on period-
reevaluated and the strategic value of crestal connective tissue attachment,
ontal status. Results revealed no
the tooth considered. Also, esthetic 1 mm of junctional epithelium, and
signiﬁcant relationship between contact
issues must be evaluated presurgically, 1 mm for sulcus depth. It should be
type and gingival index or probing
particularly if crown lengthening is noted again, however, that 3 mm as-
depth. However, a signiﬁcant relation-
needed for the anterior teeth. sumes a biologic width of approxi-
ship was seen between food impaction
While many situations require it, mately 2.04 mm, based on Gargiulo’s
and contact type (greater food impac-
crown-lengthening surgery is often un- ﬁndings. It is important to remember
tion at sites with open or loose con-
derutilized. Because of this, too much that there was signiﬁcant individual
tacts), and between food impaction and
reliability is placed on post and core variation in Gargiulo’s study, especially
probing depth. These ﬁndings help
restorations and deep subgingival mar- at the epithelial attachment. Therefore,
support the notion that food impaction
gin placement to gain adequate reten- it may be more reasonable to allow
contributes to periodontal disease.
tion for restorative purposes (Allen more than 3 mm between the restorative
1993). This often leads to root fractures margin and the crestal bone to allow for
in the case of post and core restorations, individual variation. Wagenberg et al.
Surgical Crown Lengthening and violation of the biologic width in (1989), in fact, suggested a 5 mm
Crown-lengthening surgery is designed the case of deep subgingival margins. distance from bone to the restorative
to increase clinical crown length for These factors contribute to greater margin. They clariﬁed that the length of
various reasons. The clinical crown is expense and frustration for the patient, the clinical crown, furcation locations,
that portion of the tooth that extends hence further complicating restorative and esthetic considerations limit sur-
occlusally or incisally from the invest- and periodontal therapy. gery. They also advocated waiting 8–12
ing soft tissue, usually the gingiva Surgical methods for crown length- weeks before ﬁnal prosthetic treatment.
(American Academy of Periodontology ening include (a) gingivectomy, (b) This group noted that bone removal is
1992). Teeth with subgingival caries or apically positioned ﬂap surgery (APF), inherently unnatural to the periodontist
shortened by extensive caries, fractures, and (c) APF with osseous reduction. and thus clinicians have a tendency to
short clinical crowns with or without Gingivectomy and APF without osseous remove too little bone during crown
Interactions between gingiva and margin of restorations 383
lengthening procedures. Others have distance will account for individual Some investigators have questioned
also advocated allowing 5 mm from biologic width variations and most whether the biologic width dimensions
bone to restoration to ensure adequate likely ‘‘assure’’ that enough space will return following crown-lengthening
osseous reduction. It is felt that 5 mm exist between the bone crest and the procedures. Caton’s group observed that
will allow for individual variations in eventual restorative margin. For teeth following osseous surgery and apically
biologic width dimensions and will that are planned for post and core positioned ﬂap, there was a reduced
prevent the clinician from removing restorations, the surgeon should provide distance between the gingival margin
too little bone. The phenomenon of at least 5–6 mm of exposed tooth above and the apical extent of the junctional
underreduction was recently demon- the osseous crest. This again allows for epithelium (Caton & Nyman 1981).
strated by Herrero et al. (1995). They 4 mm from the alveolar crest to the Also, since it is widely known that
evaluated the amount of actual surgical restorative margin while also account- osseous surgery results in crestal bone
crown lengthening achieved during ing for a 1.5 mm ferrule length. The resorption (Wilderman et al. 1970),
surgery in relation to the desired 3 mm ferrule effect refers to the idea that a questions have arisen as to the exact
goal. Clinicians of different experience 3601 metal collar of crown surrounding nature of the dento-gingival unit follow-
levels performed the lengthening proce- the parallel walls of the dentin should ing osseous resective surgery. Oakley et
dures, and a separate examiner com- extend at least 1.5 mm apical to the al. (1999) investigated the formation of
pleted the measurements before, during, shoulder of the preparation (Libman & the dento-gingival unit following
and 8 weeks after surgery. Results Nicholls 1995). crown-lengthening surgery in nonhu-
demonstrated a mean reduction of For teeth planned for crown restora- man primates. Crown lengthening was
2.4 mm, 0.6 mm less than that required tions, generally these cases present with performed in the incisor region of three
to achieve the 3 mm goal. Also, experi- the tooth or portions of the tooth adult monkeys. Histometric analysis
enced clinicians achieved greater oss- fractured or decayed at the gingival revealed that the biologic width is
eous reduction. The authors concluded margin. The clinician should provide reestablished following the procedure.
that clinicians might need to be more enough coronal tooth exposure to allow The junctional epithelium is established
aggressive and take measurements dur- for adequate retention of the crown at the apical extent of root planing.
ing surgery to achieve their desired goal along with planing for a 4 mm distance Space for the supracrestal connective
of osseous reduction. Pontoriero & from the restorative margin to the tissue attachment is created by crestal
Carnevale (2001) demonstrated the un- alveolar crest. The clinician should also resorption of alveolar bone. This contra-
wanted effects of minimal osseous bear in mind that bone resorption dicts the views of some authors who
reduction during crown-lengthening usually follows osseous resective sur- opined that the supracrestal connective
surgery. Eighty-four teeth underwent gery. It has been estimated that an tissue would reform coronal to the
crown-lengthening procedures and were additional 0.6–0.8 mm of bone resorp- apical extent of root planing, thus
followed for 1 year postoperatively. tion occurs up to 1 year following necessitating a greater exposure of tooth
While initially a mean of 3.9 mm of osseous surgery (Wilderman et al. structure during surgery.
new tooth structure was exposed, 1 year 1970, Selipsky 1976).
later a mean of 3.05 mm of coronal ¨
Bragger et al. (1992) completed one
displacement of the gingival occurred, of the few controlled studies evaluating
thus resulting in an overall mean gain of periodontal changes in the healing Conclusions
crown length of 0.85 mm. In all these phase after surgical crown lengthening. The health of the periodontal tissues is
surgical procedures, while the gingival Twenty-ﬁve patients who received sur- dependent on properly designed restora-
margin was repositioned apically fol- gery were monitored for 6 months. tive materials. Overhanging restorations
lowing surgery, minimal osseous reduc- Clinical parameters of 43 test and 42 and open interproximal contacts should
tion was completed (approximately control teeth were evaluated using an be addressed and remedied during the
1 mm). This study demonstrates the acrylic splint as a reference. The results disease control phase of periodontal
importance of adequate alveolar crest demonstrated alveolar crest reduction of therapy. Regarding restorative margins,
reduction in order to allow for a 1–2 mm following surgery in 53% of undoubtedly it is preferable if margins
desirable ﬁnal gingival margin location. cases. 3–4 mm of bone removal was can remain coronal to the free gingival
A common problem during crown- carried out in 4% of cases. Mean tissue margin. Obviously, subgingival margin
lengthening surgery is that the surgeon recession following surgery was placement is often unavoidable. How-
cannot precisely determine where the 1.32 mm, while 29% of sites demon- ever, care must be taken to involve as
restorative dentist will place the ﬁnal strated 1–4 mm gingival recession be- little of the sulcus as possible. Evidence
restorative margin. Hence, it is impera- tween 6 weeks and 6 months suggests that even minimal encroach-
tive that the surgeon and the restorative postoperatively. Attachment levels or ment on the subgingival tissue can lead
dentist communicate prior to treatment. probing depths did not change after 6 to deleterious effects on the period-
When uncertainty remains, a successful ¨
weeks of healing (Bragger et al. 1992). ontium. Furthermore, deep margin pla-
outcome can usually be achieved if the This study lends support to the concept cement risks invading the soft tissue
surgeon follows certain basic principles. of refraining from restorative treatment attachment of the gingiva to the tooth,
When an amalgam or composite re- for at least 6 weeks following crown- often leading to a more pronounced
storation is planned for a particular lengthening surgery. Furthermore, due plaque-induced inﬂammatory response.
tooth, the clinician must allow for to the possibility of recession, delaying If restorative margins need to be placed
approximately 4 mm distance between margin placement for 6 months follow- near the alveolar crest, crown-lengthen-
the apical extent of the planned restora- ing surgery in areas of esthetic concerns ing surgery or orthodontic extrusion
tive margin and the alveolar crest. This may be indicated. should be considered to provide ade-
384 Padbury Jr et al.
quate tooth structure while simulta- ´
chirurgicale sont analyses. Des principes chir- tional Journal of Periodontics and Restora-
neously assuring the integrity of the ´
urgicaux particuliers de l’elongation coronaire tive Dentistry 20, 171–181.
biologic width. Although individual ´ ´
sont examines en detail. Hancock, E. B., Mayo, C. V., Schwab, R. R. &
variations exist in the soft tissue attach- Wirthlin, M. R. (1980) Inﬂuence of inter-
dental contacts on periodontal status. Journal
ment around teeth, there is general
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any ﬁnancial interests, either directly or
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Stetler, K. & Bissada, N. (1987) Signiﬁcance of Wang, H-L., Burgett, F. G. & Shyr, Y. (1993) Fax: (734) 936-0374
the width of keratinized gingival on the The relationship between restoration and e-mail: email@example.com