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Physiologie Dimensions of the Periodontium Significant to

the Restorative Dentist*


J. Gary Maynard, Jr., d.d.s.| Richard Daniel K. Wilson, d.d.s4
of successful restorative that require daily consideration by the theradentistry pist.1 The preservation of a healthy periodontal attachment is the most significant factor in the long-term prognosis of a restored tooth. In order to assist the restorative dentist in accomplishing the objective of a healthy periodontium in the presence of restorative dentistry, the authors have divided the dentogingival unit and its epithelial and connective tissue covering into three separate components; these three components all blend together, and distinct lines of separation do not exist. However, if these components are considered daily by the dentist, and an attempt is made to visualize them during intracrevicular restorative procedures, the predictability of successful restorative dentistry will be
There
are many components

by

limiting and descriptive than the phrase "subgingival margin". Subgingival margins often extend beyond the gingival crevice into the junctional epithelium and connective tissue. This causes marginal and papillary gingivitis, which may progress to Periodontitis.4"6 Some of the reasons for intracrevicular placement of margins are as follows: removal of caries or faulty restorations, development of adequate retention, prevention of root sensitivity, and satisfaction of the esthetic demands of the patient. The theory that dental caries can be prevented by extending the margin of the
ice. The term is
more

restoration into the

gingival crevice has not been proven.

Superficial Physiologic Dimension The choice of the word superficial was made because this dimension is obvious to the clinician when he examines the tooth and its surrounding tissue. The superficial physiologic dimension extends from the mucogingival junction to the gingival margin (Fig. 1). It is composed of the attached gingiva and the free gingiva. The keratinized epithelial covering and the underlying dense connective tissue fibers of the attached gingiva dissipate the tensional stress created by the frenulum and muscle fibers and protect the mobile free gingival margin from tension. If there is insufficient attached gingiva for intracrevicular restorative procedures, increasing this superficial physiologic dimension by a surgical procedure should be considered before restorative treatment begins. If restorative procedures extend into a crevice and the external covering of that crevice is alveolar mucosa or an insufficient amount of gingiva, the result may be apical migration of the marginal tissue, the attachment apparatus, or both (Figs. 2 and 3). If sufficient attached gingiva is present, the soft tissue abuse may be reversible or may not reach the level of clinical significance (Fig. 4 and 5). An adequate band of keratinized tissue is fundamental to successful restorative dentistry if the margins of the restorations are extended under the free

These components have been termed the physiologic dimensions of the periodontium that are fundamental to successful restorative dentistry.2 The word "physiologic" was chosen because it means "consistent with the normal functioning of an organism."3 Preservation of an intact dentogingival unit with the gingival margin slightly coronal to the cementoenamel junction in a state of optimum health is consistent with the normal functioning of a tooth. The physiologic dimensions of the periodontium for the successful maintenance of a healthy periodontium have been classified as follows: I. Superficial Physiologic Dimension, II. Crevicular Physiologic Dimension, III. Subcrevicular Physiologic Dimension (Fig. 1). This classification serves as a guide and teaching aid to the practitioner. It encompasses previously recognized landmarks and structures of the periodontium and attempts to organize them in a fashion that is meaningful to the restorative dentist. Intracrevicular Restorative Margins

markedly improved.

gingival margin. How Much Gingiva is Adequatefor Restorative


Procedures?
enter the

Intracrevicular restorative margins are defined as those placed into and confined within the gingival crev* Send reprint requests to: J. Gary Maynard, Jr., D.D.S., 4909 Grove Ave., Richmond, Va. 23226. t Clinical Professor, Department of Periodontics, Medical College of Virginia, Virginia Commonwealth University, Richmond, Va. X Clinical Professor and Director, Periodontal Prosthesis Department of Periodontics, Medical College of Virginia, Virginia Commonwealth University.

plans restorative procedures that will gingival crevice, approximately 5 mm of keratinized tissue, composed of 2 mm of free gingiva and 3 mm of attached gingiva, is necessary to meet the restorative objectives. Occasionally restorations may be placed successfully with less, but success is far more predictable
If the clinician

with the above dimensions. A second dimension of keratinized tissue to be evaluated is the thickness. As with all tissue, this varies from patient to patient, and in the same patient from tooth to tooth. The clinician should not take for granted that sufficient tissue in the vertical dimension necessarily indicates that the tissue is thick enough to tolerate intracrevicular restorative procedures. If a periodontal probe

170

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Physiologic Dimensions of Periodontium


ENAMEL**-

171

BOTTOM OF CREVICE* JUNCTIONAL EPITHELIUMCEMENTOENAMEL***JUNCTION CONNECTIVE* TISSUE FIBERS

CREVICULAR EPITHELIUM

FREE GINGIVAE

KERATINIZED
TISSUE

ATTACHED GINGIVAE

PERIODONTAL LIGAMENT**

*MUCOGINGIVAL JUNCTION

ALVEOLAR

PROCESS

Figure 1. Diagram illustrating the concept of the three physiologic dimensions of the periodontium which are significant to the restorative dentist. Superficial physiologic dimension, shaded medium grey. Crevicular physiologic dimension, shaded dark grey. Subcrevicular physiologic dimension, shaded light grey.

Figure 2. Mandibular right canine serving as a retainer for a fixed prosthesis. The marginal tissue is inflamed and has moved apicallyfrom its prerestorative location.

FlGURE 3. The periodontal probe demonstrates reduced resistto probing and indicates a depth that probes 6 mm. The end of the probe passes beyond the mucogingival junction.
ance

through the free gingival margin, even though the superficial aspect of that margin is clinically diagnosed as keratinized tissue, the ability of that keracan

be

seen

tinized tissue to support intracrevicular restorative pro-

cedures is doubtful. The surgical placement of a thicker and more substantial segment of keratinized tissue should be considered.

172

Maynard,

Wilson

J. Periodontol.

April,

1979

tissue is present.

Figure 4. Six maxillary anterior teeth to be restored with complete coronal coverage. A sufficient dimension of keratinized

Figure 5. A 3-year postinsertion view of the teeth restored with porcelain fused to metal crowns with metal intracrevicular margins. The tissue appears clinically healthy.

procedures.

Marginal Tissue Recession When there is recession and the soft tissue margin is alveolar mucosa, it is incorrect to call it "gingival recession". At the time of examination, one cannot be certain whether the tissue margin was alveolar mucosa when the tooth erupted or whether it had been gingiva (free) which had been lost through recession and is presently alveolar mucosa. "Marginal tissue recession" is a more accurate description of the process that has occurred. If marginal tissue recession is present prior to beginning restorative procedures, the two-step technique previously described7 should be considered. This includes first placing the free graft and, after healing, using a second procedure to position the grafted marginal tissue coronally as a pedicle graft. This sequence has a high rate of success, offers a more symmetrical and esthetic alignment of marginal tissue, and creates an environment more capable of withstanding intracrevicular restorative Crevicular Physiologic Dimension

is in contact with the surface of the tooth. These two parts of the crevice (the depth and its circumference) have been termed the depth and breadth aspects of the crevicular physiologic dimension. Depth of the crevice can be described as being either excessive or adequate for restorative dentistry. Excessive crevicular depth is characteristic of periodontal disease. inDiagnosis of periodontal disease is made by spection, palpation, and probing. The periodontal pocket is pathognomonic of periodontal disease; it is present in no other disease."8 Successful long-term restorative dentistry depends on a healthy periodontium around the tooth being restored; restorative procedures should not be done in the presence of disease. Without adequate "inspection, palpation, and probing," periodontal disease may be overlooked, and a crown may be fabricated for a tooth with excessive crevicular depth. To prepare a tooth for an intracrevicular margin, a minimum depth of 1.5 to 2 mm is suggested by the authors if the margin is to be covered by the free gingiva. If crevice depth is less, the patient and the therapist must be content with supragingival margins (Fig. 6). Immediately following periodontal surgical procedures, the restorative dentist is often faced with a crevice less than 1.5 mm deep. In an attempt to place casting margins beneath the gingiva, he "creates" a crevice during tooth preparation. This is done at the expense of an intact dentogingival unit, and there is permanent damage to the junctional epithelium and underlying supra-alveolar connective tissue fibers. The significance of this damage is explained in the discussion of the subcrevicular physiologic dimension. Restorative procedures must be delayed until a new gingival crevice develops after periodontal surgery. This waiting period may be 6 weeks, but it is usually much longer. To proceed with the intracrevicular margin preparation before the development of a new gingival crevice

fragile epithelium

"

..

The gingival crevice extends from the free gingival margin to the junctional epithelium (Fig. I). Normally it has depth that measures from 0 to 3 to 4 mm, and it is lined with thin crevicular epithelium. In health this thin,

Figure 6. A
unit fixed

7-year, postinsertion view of a maxillary leftfourprosthesis with gold collars partially visible. Where the crevicular depth is less than 1.5 mm, it becomes necessary to allow some of the collar of the crown to be visible.

Volume 50 Number 4

Physiologic Dimensions of Periodontium

173

of adequate depth, will cause prolonged marginal inflammation and usually pocket formation. The breadth or circumferential aspect of a crevice also must be understood. In health, the epithelial lining of the crevice is in direct contact with the tooth surface. There is no significant space separating this crevicular epithelial lining from the tooth surface. In restoring a tooth with a full coverage restoration with intracrevicular margins, care must be taken to avoid injury of the crevicular epithelial lining. This injury may occur by quantitative and qualitative violation of the circumferential aspect of the crevice. Quantitative violation is defined as excessive material being placed within the crevice. For example, the crown that restores the tooth is larger than the natural tooth that was previously present. This chronically distends the crevicular lining and probably the junctional epithelium (Fig. 7). The crevicular lining usually has been injured during tooth preparation, impression taking, and placement of a temporary restoration. When a crown that is too large is cemented, there is permanent distention and injury to the crevicular lining. The result of overcrowded embrasure spaces is inflammation of marginal tissue. This is a common finding after placement of such a restoration.9 The qualitative violation of the circumferential aspect of a crevice is defined as poor adaptation and roughness of the margin of the restoration (Fig. 8). Such a violation results in both mechanical irritation of the crevicular epithelium and a harbor for microbial flora. Clinically this is demonstrated by chronic inflammation of the marginal tissue and bleeding from the crevicular area, which with time will result in dissolution of the supra-

Figure 8. Rough and ill-fitting intracrevicular crown margins. The inflamed and edematous marginal tissues are the result of a qualitative violation of the crevicular physiologic dimension.

alveolar connective tissue fibers, apical proliferation of the junctional epithelium, and pocket formation. subcrevicular physiologic dimension This dimension is defined as the distance from the base of the gingival crevice to the alveolar crest and includes the junctional epithelium and the supra-alveolar connective tissue fibers (Fig. 1). Gargiulo, Wentz and Orban10 described this dimension. It varies in width because of variation in width of the supra-alveolar connective tissue fibers. The connective tissue component appears to remain constant through the stage of passive eruption. These authors found the average measurement of the epithelial attachment to be 0.97 mm with a range of averages of 0.71 to 1.35 mm. The connective tissue fiber attachment had an average measurement of 1.07 mm with a range of averages of 1.06 to 1.08 mm. Measurements of this subcrevicular physiologic dimension may vary from tooth to tooth and from surface to surface on the same tooth. However, this dimension is constant in one respect, that is, its presence on all teeth. Encroachment into this dimension is prevalent among restorative dentists as they attempt to place a margin "subgingivally" rather than intracrevicularly. Such violation severs the junctional epithelium and the supra-alveolar connective tissue fibers. The subsequent retraction procedures, impression technique, and placement of a temporary restoration maintain the injury to the periodontium. A progressive inflammatory process
ensues.

FlGURE 7. Restorative dentistry inserted 18 months prior to the taking of this picture. A maxillary rightfour-unitfixedprosthesis is accompanied by a single crown on the maxillary right canine. There is no solder joint between the canine and the premolar. The inflammation and aberrant contour of the interdental tissue is a result of too much restorative material in the crevice on the mesial of the premolar and the distal of the canine. This is a quantitative violation of the crevicular physiologic dimension.

When the final restoration is placed into this previously injured and inflamed area, continuation of the inflammatory process results. The dentist, in effect, has, inserted permanent calculus beyond the crevice. Interproximally, the result is usually loss of eresiai bone. Apical migration of the junctional epithelium occurs, and a periodontal pocket is soon present. Periodontal disease has been created by restoration of the tooth without proper consideration for subcrevicular physiologic dimension.
Occlusion The role of trauma from occlusion in continues to be studied. Recent

investigations11'12 appear

Periodontitis

174
to

Maynard,

Wilson
to

1. Periodontol. Aprii. 1979

support the contention that, in a healthy periodontium and in the absence of inflammation, repeated occlusal trauma will not increase depth that can be measured with a probe. Poison11 comments that although the "subcrestal periodontal tissues" undergo "resorptive, reparation and adaptive reactions" to occlusal trauma, there is no evidence that trauma from occlusion will produce

reach his objective, the restorative dentist must remember the fundamental precept of the health professions, which is: Do no harm. Daily observation of the three physiologic dimensions permits the therapist to restore teeth with minimal injury to the periodontium.
References

periodontal pocketing. In the healthy periodontium, occlusal trauma can render teeth mobile. As long as the crevicular and subcrevicular physiologic dimensions remain unaffected by inflammation, this mobility is reversible if the source of

the trauma is removed. Violation of the crevicular or subcrevicular physiologic dimension by restorative dentistry will cause inflammation which, in the presence of occlusal trauma, will result in more rapid periodontal destruction. Preservation of an intact crevicular and subcrevicular physiologic dimension by the restorative dentist will allow traumatic occlusal forces to be corrected without permanent damage to the periodontium. Conclusion

Amsterdam, M.: Periodontal prosthesistwenty-five Alpha Omegan 13, December 1974. 2. Prichard, J. F.: The diagnosis and treatment of periodontal disease. Wilson, R. D., and Maynard, J. G., Jr. (eds), General Dental Practice, Chapter 19, to be published. Philadelphia, W. B. Saunders Co., 1978. 3. Stein, J. (ed) 77e Random House Dictionary of the English Language, p. 1087. New York, Random House, 1967. 4. Silness, J.: Periodontal conditions in patients treated with dental bridges I, II and III. J Periodont Res 5: 60, 219, and 225, 1970. 5. Renggli, H. H., and Regolati, .: Gingival inflammation
1.

years in retrospect.

the objectives of restorative be clear. The first and most basic objective therapy is preservation of the teeth. The attainment of this objective would be far less complex if it could be considered independent of restoration of function, comfort and esthetics, but such is not the case. The latter objectives usually require sophisticated restorative dentistry and often include restorations with intracrevicular margins. Although it is widely accepted that the best restorative margin is one that is placed coronal to marginal tissue, most restorations have margins in the gingival crevice, and permanent tissue damage is common. In attempting When
must

treating patients,

Periodontol 45: 3, 1974. 7. Maynard, J. G, Jr.: Coronal positioning of a previously placed autogenous gingival graft. J Periodontol 48: 3, 1977. 8. Prichard, J. F.: Advanced Periodontal Disease, Surgical and Prosthetic Management, 2nd ed., p. 132. Philadelphia, W. B. Saunders Co., 1972. 9. Skurow, H. M., and Lytle, J. D.: The interproximal embrasure. Dent Clin North Am 15: 641, 1971. 10. Gargiulo, A. W., Wentz, F. M., and Orban, B.: Dimensions and relations of the dentogingival junction in humans. J Periodontol 32: 261, 1961. 11. Poison, A. M., Meitner, S. W., and Zander, . .: Trauma and progression of marginal Periodontitis in squirrel monkeys. J Periodont Res 11: 279, 1976. 12. Lindhe, J., and Svanberg, G: Influence of trauma from occlusion in progression of experimental Periodontitis in the beagle dog. J Clin Periodont 1: 3, 1974.

plaque accumulation by well-adapted supra-gingival and sub-gingival proximal restorations. Acta Odontol Oct. 1972. 6. Newcomb, G. M.: The relationship between the location of subgingival crown margins and gingival inflammation. /
and

Announcements
POSTGRADUATE DENTAL PROGRAM ALBERT EINSTEIN COLLEGE OF MEDICINE Postgraduate Extension Program (Off Campus Courses): Faculty members of the Postgraduate Dental Program, who are specialists in their fields, are available for short, intensive courses that can be given in various cities if a sufficient number of practitioners evince interest. If clinical facilities are available, these courses can be a combination of lectures and demonstrations. For further information and application, write to: Dr. Irving Yudkoff, Director, Postgraduate Dental Program, Albert Einstein College of Medicine, 1165 Morris Park Ave., Bronx, New York 10461. GEORGETOWN UNIVERSITY SCHOOL OF DENTISTRY
Academic

sity School of Dentistry is inviting applications for a full-time faculty position in Periodontics at the level of assistant professor, effective August 1979. The appointment is available for participation in clinical and didactic instruction for undergraduate students and for research. Time will be allowed for clinical practice. Graduation from an accredited post doctoral degree or certification program in Periodontics is required and training and/or experience in teaching is preferred.
Interested individuals should send their curriculum vitae to Peter D. Ferrigno, D.D.S., M.S., Chairman, Department of Periodontics and Endodontics, Georgetown University School of Dentistry, 4000 Reservoir Rd. NW, Washington, DC 20007.

Opportunity.

District of ColumbiaGeorgetown Univer-

Georgetown University is an equal opportunity, employer.

affirmative action

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