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Ksenija Jorgi-Srdjak1

Periodontal and Prosthetic Aspect Darije Planak1


Tomislav Marievi1
of Biological Width Mick R. Dragoo2
Andrija Bonjak1

Part I: Violation of Biologic Width 1Department of Periodontology


School of Dental Medicine
University of Zagreb, Croatia
2Department of Fixed
Prosthodontics
School of Dental Medicine
University of Zagreb, Croatia
3Private practice, Escondido,
USA

Summary Acta Stomatol Croat


2000; 195-197
This review gives the wide aspect of the complex question of biologic
width and represents an attempt to answer some of the demands in
relation to it. First of all, it debates the problems that occur after REVIEW
improper margin placement in the periodontium. Initially, the dimen- Received: July 4, 2000
sions of biologic width are contemplated and then margin placement,
is discussed and the success of restorative procedures and reasons for Address for correspondence:
failure. Andrija Bonjak
Key words: biologic width, margin placement. Department of Periodontology
School of Dental Medicine
Gundulieva 5, 10000 Zagreb
Croatia

Introduction periodontal health and removal of irritation that


might damage the periodontium (prosthetic restora-
A great part of periodontal literature deals with tions, for example). The millimeter that is needed
the checking, reconstruction and maintenance of from the bottom of the junctional epithelium to the
biologic width. This, in Croatian literature, rel- tip of the alveolar bone is held responsible for the
atively unknown term, deserves to be closely lack of inflammation and bone resorption, and as
explained. Gargiulo et al (1) reported in 1961 a such the development of periodontitis. The dimen-
certain uniformity of the dimension of some com- sion of biologic width is not constant, it depends on
ponents of biologic width: the location of the tooth in the alveola, varies from
mean depth of the histologic sulcus is 0.69 mm, tooth to tooth, and also from the aspect of the tooth.
mean junctional epithelium measures 0.97 mm Its constancy (is only one - it) can only be found in
(0.71 to 1.35 mm), healthy dentition (4,5,6).
mean supraalveolar connective tissue attachment There is a problem in determining biologic
is 1.07 mm (1.06 to 1.08 mm). width. It does exist, but clinically, it is impossible
The total of the attachment is therefore 2.04 to define. If the gingiva looks healthy, and does not
millimeters (1.77 to 2.43 mm) and is called the bleed on probing, one can suspect that the histologic
biologic width (2,3), essential for preservation of sulcus (which has been destroyed while probed) of

Acta Stomatol Croat, Vol. 34, br. 2, 2000. ASC 195


Ksenija Jorgi-Srdjak et al. Violation of Biological Width

such a healthy or treated tooth was approximately Preparation


0.5 mm deep. This means that the margin of a
It is desirable to place the margin in a location
restoration may not be put more than 0.5 mm
that will facilitate the following (4):
subgingivally. With this in mind, all requirements
1. Preparation of the tooth and finishing of the
for the maintenance of periodontal health can be
margin (easiest supragingivally)
established.
2. Duplication or the margins with impressions that
There are literature reports of unfavorable effects can be removed past the finish line without
of restorative therapy on periodontal tissue tearing or deformation (easiest supragingivally)
(7,8,9,10). Prosthetics can lead to greater plaque 3. Fit and finish of the restoration and removal of
accumulation; they can incite inflammation as well excess material (easiest supragingivally)
as add to the progression of periodontal disease. It 4. Verification of the marginal integrity of the
has been proved that even marginally adapted restoration (easiest supragingivally)
prosthetic structure can have negative effects on the
periodontium, had it been placed subgingivally. The ultimate success of the restoration
Subgingival placement of the crown and preparation
A number of factors hold some importance for
margins potentially endanger biologic width and
the success of a prosthetic restoration.
lead to periodontal reaction. If the biologic width is
1. Brushing, flossing, and maintaining the restora-
violated during the preparation of the tooth, some
tion on a daily basis (easiest supragingivally)
authors (11-20) claim that there will be no place left
2. Removing plaque, calculus and performing
for the attachment and the result in the development
periodic inspection of the marginal integrity of
of attachment loss and pocketing can be observed.
the restoration without damaging the marginal fit
Violated biologic width can result in uncontrolled
or scratching the restorative material (easiest
bone resorption and might grow over the quantity
supragingivally)
of the bone necessary for the supralimbal insertions
3. Avoiding changes in gingival contour (easiest
of the connective tissue attachment on the tooth
supragingivally)
root. The result is advanced periodontitis.
4. Improving the esthetics. Esthetic requirements
Nevins and Skurow (21) have defined the of the patients often call for intracrevicular
biologic width as the total of supracrestal fibers, placement of margins. However, a study pub-
junctional epithelium and sulcus. Wagenberg (22) lished by Watson and Crispin (28) showed that
concluded that at least 5 to 5.25 mm of hard tooth many patients did choose the optimum gingival
substance above the bone margins is necessary for health offered by supragingival margin place-
a correctly prepared restoration placement. Such ment, over the less healthy, improved esthetic
claims have also been substantiated by other attempt of a subgingival margin, if the patients
authors (6,9,10,20,23,24,25), who proved that 3 mm understood the circumstances and were given a
between the preparation margin and alveolar bone choice. The study also showed that 83% of
maintains periodontal health for 4 to six months. dentists do not analyze tooth visibility when
deciding on margin placement for esthetic
appearance, and only 64% of dentists actually
Margin placement and biologic width assess the patients desires before deciding
where to place the margin (28).
Most dentists daily answer a question of great 5. Root sensitivity. Subgingival margin placement
importance: where to place the preparation margin, is only a temporary solution if the gingival
supragingivally, at the beginning of the gingival recession progresses. Good oral hygiene and
sulcus or subgingivally? Two basic factors should be local fluoride treatment resolve most root sen-
taken into account. First are the shape and the method sitivities.
of preparation, which depends upon the therapist. The 6. Subgingival extension of caries, restorations, or
second factor is the ultimate success of the restora- fractures. In the past, subgingival margin place-
tion, which is influenced by a number of items. ment was advocated for teeth in which insuf-

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Ksenija Jorgi-Srdjak et al. Violation of Biological Width

ficient or questionable retention could be gained deeper the margins lie, the greater is the possibility
from supragingival margins. This was to give that it is unpolished (42).
greater length and surface area, and sometimes It is precisely these places which represent ideal
more parallelism, for increased retention. Today, bacteria colonizing areas at which, the moment it
the best way to achieve this is preprosthetic becomes too tight, result in localized inflammation
surgical crownlengh tening procedure, which and gingivitis. Oral hygiene maintenance in such
establishes an adequate biologic width and places is impossible, clinical signs being chronic
allows correct margin placement. inflammatory response and progress of attachment
Research in animals and humans (24,29-34) loss. These problems can be met halfway by proper
showed that marginal infection is most commonly casting techniques and polishing of the margins of
connected with subgingivally placed margins, and restorations. It is important to mention that every
that supragingival placement has a substantial pos- restoration whose margin lies supragingivally is less
itive effect on gingival health. Teeth with sub- potential to be ideal, compared to a restoration
gingival margins show higher inflammation index whose margin lies supragingivally.
values than sound teeth. There is a clear connection If the biologic width is violated, it is impossible
between plaque accumulation, caused by inadequate to maintain periodontal health. One or more of the
restorations, and periodontal disease (4). following develops (4):
1. Bone loss under the preparation margin that
Reasons for failure violated the biologic width. Pocket and pro-
A problem arises in cases where subgingival gressive periodontal tissue loss (periodontal
placement is absolute necessary. Different parts of ligament and bone) develop.
this complex (tooth, cementum and crown) can 2. Gingival recession and localized bone loss
easily become the location of plaque accumulation. develop. This happens in cases where the
There is a special stress on metal-ceramic crowns, labiobuccal bone is thin (43).
whose thin metal margin is usually oxidazed, air 3. Localized gingival hyperplasia with minimal
abraded, but can never be polished, and therefore is bone loss. Although this represents the best
rough. Opaque ceramic parts, which are coarse, also prognosis for the tooth, this course of action
become exposed. These factors play a great role in maximally compromises the esthetic component
plaque accumulation and periodontal health of a and is as such unacceptable for the patient.
patient (35-41). Hyperplasia is most frequently found in altered
passive eruption and subgingivally placed
Gingival inflammation, as well as periodontitis,
restoration margins.
can be, caused by improperly finished prosthetic
restorations. Such margins, whether they are pro- Patients with these findings always end up at a
duced directly or indirectly, are frequent, often periodontologist. After comprehensive examination,
everyday findings, especially if it is known that it case history and periodontal charting, the peri-
is almost impossible to ideally finish the margins of odontologist will start with an intensive oral hygiene
crowns and veneers (22). The most frequent reason programme, and, depending on re-evaluation
for incorrect margins is the impossibility to perform results, decide on surgical periodontal treatment.
proper casting and/or margin finishing when the Surgical procedures are described in the second
margin is already located subgingivally (26). The part.

Acta Stomatol Croat, Vol. 34, br. 2, 2000. ASC 197

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