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 For restoration to survive long term the periodontium must

remain healthy so that teeth are maintained.
 For the periodontium to remain healthy restoration must be
critically maintained in several area so that they are in
harmony with their surrounding periodontal tissue.
 To maintain and enhance the patient esthetic appearance
the tooth-tissue interface must present a healthy natural
appearance with gingival tissue framing a restored teeth in
a harmonious manner.
 Defective dental restorations and anatomical aberration of
the teeth often favour plaque accumulation leading to
gingival inflammation.
Biological consideration
- Restorative margins
- Biological width
- Overhanging restoration
- Marginal Fit
- Crown contour
- Hypersensitivity to restorative material
- Sub gingival debris
- Interproximal Embrasure form.
- Restorative correction of open gingival Embrasure
- Location, fit and finish of restorative margins are critical
factor in the maintenance of peridontal health.
- According to the concept of “ extension for prevention”
Postulated by G.V. Black, margins of restoration have to be
placed on self cleancing regions of teeth.
- Restoration with supragingival margin gave the most
favourable gingival response.
- Restoration with margin placed subgingivally appeared to be
most harmful to the periodontium.
- Gingival inflammation and loss of attachment with pocket
formation have been observed.
- Surface roughness of the restoration and tooth- restoration
interface favour plaque retention.
- Restorative margin should preferably be placed
- In case when placement of restorative margin subgingivally
is unavoidable due to caries, tooth fracture, previous
restoration or aesthetics, it should placed not more then 0.5
mm into the sulcus so that plaque should be achieved.
The dimension of space that the healthy gingiva tissue
occupy above the alveolar bone is identified as Biological
An average length of 1.07mm of connective tissue
attachment and 0.97mm of epithelial attachment.
 So on an average the biological width measures 2.04mm.
 Invasion of this space result in inflammation and crestal
resorption of alveolar bone.
 Invasion of the biological width should avoided during
restoration, in order to prevent attachment loss and
persist gingival inflammation.
 The more common finding with deep marginal placement is
that the bone bevel appears is remain unchanged but
gingival inflammation develops and persist.
Evaluation of biological width:
- Radiographic interpretation can identify interproximal violation of
biological width.
- If patient having discomfort when restorative margins level being
assessed with a periodontal probe it is a good indication that the margin
extends into the attachment and that a biological width violation
- more positive assessment can be made clinically by measuring the
distance between the bone and margin.
- The probe is pushed through the anaesthetized attachment tissue from
the sulcus to the underlying bones.
- If the distance is less than 2mm at one or more
location, a diagnosis of biological width violation
can be confirmed.
 Assessment is completed circumferentially around the

 The biological or attachment , width can be identified for

each individual patient by probing under anesthesia to the
bone level and subtracting the sulcus depth from the
resulting measurement.
 this measurement must be performed on teeth with healthy
gingiva tissue and should be reapeted more than one tooth
for accurate measurement.
 The information is obtained is then used to definitive
diagnose biological width violation.
Correction of Biologic-Width Voilation:

1.SURGICALLY: By removing bone away from proximity to

the restorative margins.
Drawback: High risk of inter papillary recession.

2. ORTHODONTICALLY: By extruding the tooth out of the



•By applying low extrusive forces

•By rapid orthodontic extrusion
Why the restoration extended sub-gingivally???

 For adequate resistance& retention

 To make significant contact & contour
 To mask the tooth-restoration interface gingivally.
Too Sub-Gingivally located margins may results…..
Unpredicted bone loss
Gingival tissue recession

Other factors inducing Gingival recesion:

 Trauma from restorative procedures
 Thickness of gingiva
 Gingival Form- scalloped\Flat
 Overhanging restoration most commonly encountered with
amalgam restoration.
 Improper placement of matrix band and wedge result in over
hanging restoration.
 This area are most frequently area of plaque retention.
 It also create an enviornment favourable for the growth of
pathogenic organism.
 Removal of overhangns followed by professional tooth
cleaning result in improvement of periodontal tissue.
Marginal fit :
 Marginal fit has clearly been implicated in producing an
inflammatory response in the peridontium.
 The level of gingival inflammation can increase corresponding
with the level of marginal opening.
 Margins that are significantly open are capable of harboring
large number of bacteria and may be responsible for the
inflammatory response .
 Restoration contour extremely importance of the
periodontal health.
 Contour provides access for hygiene.
 Baker and Wayne described three theories of crown
contour, they are
(1) Gingival protection theory
(2) Muscle action theory
(3) Theory of access for oral hygiene.
 According to gingival protection theory the contour of the
restoration should be designed to protect the marginal
gingiva from mechanical injury during mastication.
 Over contour of crown leads to plaque retention and
marginal gingivitis.
 According to muscle action theory believe that the
functional movement of lips, cheeks and tongue has cleansing
action of teeth.
 The crown contour should be designed to facilitate this
cleaning action during mastication.
 According of access for oral hygiene is based on the
concept that periodontal disease is plaque associated.
 Over contouring of crown decrease access for oral hygiene.
 Inflammatory gingival response have been reported related
to the use of non precious alloy in dental restoration.
 Rough dental surface favour plaque accumulation and
contribute to periodontal disease.
 In class II amalgam restoration polishing of the proximal
surface is difficult and surface appear rough as compared to
enamel surface.
 Three to four year old composite restoration showed
greater deterioration with higher plaque.
 Composite resins and glass ionomer cement are the material
of choice for restoration, where the aesthetics are
 Porcelain seems to retain plaque than other restorative
 The highly polished surface of porcelain inhibit plaque
formation and permits its rapid removal too.
 Plaque retentive properties of the restorative materials
appear to be most important factor responsible for
initiation of periodontal disease.

Leaving debris below the tissue during the restorative

procedure can cause adverse periodontal ligament
•Retraction cords
•Impression material
•Provisional material
•Cements - Temporary \ permanent
Inter-proximal Embrasure Form

Any change in shape or form of embrassure

Change in height & form of the papilla

Food impaction, Accumulation of micro-organisms &

Plaque accumulation
 Too Wide Embrasure – Flattened & Blunt Papilla
 Too Narrow Embrasure – Inflammed Papilla
 Ideal Embrasure – Healthy & pointed Papilla
Proper proximal contact is essential to prevent food
Forceful wedging of food into interproximal spaces occur due
to the funneling effect of adjacent tooth surface directing
food interproximally and into open contact areas.
Opposing cusp which force into the proximal area is called
plunger cusp.
The mechanical pressure on the interdental tissue can cause
ischemia, inflammation, and necrosis of the interdental
It favours plaque growth and pocket formation.
The contact point should be placed occlusally and buccally to
facilitate access for interdental plaque control.
Ideal interproximal embrasure should house the gingival
papilla without impinging on it and also extend the
interproximal tooth contact to the top of the papilla so that
no excess space exist to trap food .
 Mainly there are two cause of open gingival embrasure :
either the papilla is inadequate in height due to bone loss or
interproximal contact is located to high coronally.
 If high contact has been dignosed as the cause of the
problem ther are two potential reasons either root
angulation of tooth diverge or interproximally contact is
moved coronally resultig in the open embrasure.
 If the root angulation of the tooth diverges -> the
interproximal contact is moved coronally -> open embrasure.
 If the root are parallel, the papilla form is normal, and open
embrasure exists than the problem is related to tooth
 Restorative procedure can correct this problem by moving
the contact point to the tip of the papilla.
 The margins of the restoration must be carried
subgingivally 1 to 1.5mm.
 And emergence profile of the restoration is designed to
move the contact point toward the papilla while blending the
contour below the tissue.
 The increases in the utilization of the dental implant and nonmetalic
cosmetic restoration has resulted with the increases concern with the
force management.
 The restoration is the more sensitive with occlusal trauma.
 For create good occlusion following point should be follow:
(1) There should be even simultaneous contact on all teeth during centric
closure. This distributed the force of closure over all teeth instead
of few teeth.
(2) When the mandible moves from centric closure some form of canine or
anterior guidance is desirable with on posterior tooth contacts.
(3) The anterior guidance needs to be harmony with the patients
neuromuscular envelop of function. Relationship is demonstrated by a
lack of framitus and lack of mobility of anterior teeth, patient can
speak clearly and comfortably.
(4) The occlusion should be created at a verticle dimension that is stable
for the patient.
 It is generally accepted that the patient existing vertical dimension is
an equilibrium between the eruptive force of their teeth and the
repetitive contracted length of their elevator muscle.
(5) When managing a pathological occlusion or when restoring a complete
occlusion a repeatable condoler reference position is needed.
 Removal partial dentures prepared without occlusal lag
tends to shink into edentulous area causing gingival
recession of adjacent tooth .
 This can be prevented by providing occlusal lag to the clasp.
 Fixed prosthesis should be designed to facilitate
mechanical plaque control .
For type of pontic design :
1. Modified ridge lap pontic with concave gingival surface and
open interproximal space. Cleaning the undersurface of
pontic is difficult in this case, as the pontic makes a
surface contact with gingival tissue buccally and lingually.
2. Lap facing pinpoint contact pontic with open interproximal
The pontic makes only a pinpoint contact with ridge and
interproximal space are open so the cleansing is easy.
3. Lap facing pinpoint contact pontic with closed interproximal
4. Sanitary pontic
Contact between the pontic and alveolar mucosa should be
restricted to pinpoint as far as possible plaque control.
Restoration of Root – Resected Tooth

 One piece cast or core

is indicated.
 Development of
appropriate contour
for hygienic access.
 Avoid any excess
Applied to:
onded External Appliances
ntra Coronal Appliances
ndirect Cast Restorations
Indication: To prevent mobility

 Any inflammation of the periodontal Supporting tissues

must be controlled before making a decision for
splinting because Inflammation may cause mobility in
presence of normal occlusal forces & PDL. Support.
Anterior Aesthetic Surgery
 More Imp. in Anterior Region
 Gingivectomy, Apically displaced flaps with osseous
recontouring & Use of Orthodontics in positioning the
gingiva apically or coronally by Extruding or Intruding
the teeth.
 Computer Imaging for Visual preview
 A Stone cast of patient`s own teeth may be used –
Composite or Acrylic veneer is constructed on the
cast extending gingivally in a correct position.

 A defective dental restoration and anatomical

aberrations of the teeth often favour plaque
accumulation leading to gingival inflammation.
 A good knowledge of such factor is essential for
prevention of periodontal disease by adapting suitable
restorative procedure or correcting the anatomical

Clinical periodontology - Michael G.Newman

- Henry H. Takei
- Ferrmin A. Carranza

Clinical periodontology and

Implant Dentistry -Jan Lindhe