"The Inlemalionol Journal ol Periodonlics and ResloroMve Denlistry" 4/1983

The Surgical Management of the

Restorative Alveolar Interface (II)

Stanley E. Poss, D.D.S'

Anthony Gorguilo, D.D S '
Henry W C'oaem, D.D.S.^
Douglasl Philips. D.D.S.'

Clinical Associale Professor, Department

of Penodonlics, Loyola University, 240
West Palmello Park Road, Boca Raton,
Florida 33432
Professor and Cfiairman, Department ol
Periodontics. Loyola Universily, 2160 S.
First Avenue, Moywood, Illinois 60153
1701 EosI Woodfield Rood, Schaumburg,
Illinois 0I72
125 Worth Avenue, Palm Bench, Florida
33480

In Ihe preceding partof ihis series relaljng to the reslorotive alveolar inlerfoce, II: 3, 1981, Ihe analomical
position of the restorative olveolar interface R.AJ.) was described as
being that portion of the root surface
extending from the alveolar crest
opically to ihe restorative margin
coronally. The advantages of tooth
preporation of the R.A.I, al the time
of periodontal surgery as related to
the reattochment of ihe gingival fiber
apparatus and to Ihe placement of
the restorative
margins were
documented with clinical coses.
Since publication, it has been
brought to our attention that other
clinicians are concerned about the
placement of the restorative margin
in the gingival sulcus, and subsequent problems with periodontal
health on this R.A.I, as c result of
under- or over-preparotion.
Here we will describe a human histologie section that was taken after
surgicol preparation af the restorative alveolar interface. We believe
that the lower position of the surgical
preparation near the alveolar base
was not well demarcated in this section, and thus we plan another study
with additianal human histologie
material to enhance the information
avouable relative to surgical intervention and its long-standing implications for the health of the adjacent
tissue.
Surgical intervention in the periodontal structures of the oral cavity is
evaluated with both human ond histologie material to confirm clinical information
and
to
enhance
techniques. The human histologie
material presented here parallels
mony of the clinical observations already reported.
As an introduction to the anatomic

"The Inteinoiional Journal of Periodontics and Restarotive Dentilry" 4/1963

10

Fig. la A mssiodis/al histologie section ihowing o nortnal psnaaontiun} ot tiis iinte oferupiiofi and sxotiafion. The enamel is slit! completely t rtvelopea in the ortativs epithelium ona will cotilinue to be so
unlil the lip o he erupting laoth pierce! the orai epitheLim. Noie the almost complete tor/notion of the
root. The QFFOW points to o normal aiveiitar crest-to-tooth letotionship.

I'Q. to Ths arrow notes ihe nommai onaiomy

ond histology ol on interproximai popiiia belweer
two manoitruiar incisors The cuspid is in on activt
state o eruption and wiii likely carry the aiveola
process acclusalty as it erupts.

configuralion of the looth tissue surface under consideration, il is best lo

begin with the normal hislologic seclion of the denlogingival junction
(Fig. 1]. This area will be discussed
later with respect to the proposed
tooth preparation and its relationship
to the soft tissue attachments at the
dentogingival junction.
In order to understand the alterations
better, we will describe the normal
relationships of those structures that
comprise the dentogingival unit as
seen in histologie sections [Fig. la).
The sulcular epithelium is continuous
with the junctional epithelium thot
abuts on the tooth surface. The basal
cells of these two epithelia lie side by

the same with only glandular orifices

and the teeth passing through the
epithelium. The cells of the gland
ducts lie along the cells of the oral
epithelium and are joined to them.
The teeth differ from hair and nails in
that they are mineralized. Accordingly, we might anticipate that the
cells of the junctional epithelium
would have a special mode of attachment to the teeth. Actually, the
dentogingival attachment is a functional unit consisting of 1) the fibrous
attachment of the lamina propria to
the cementum and |2) the unctionol
epithelium. Each has a different function Fig. lb).

side on a basal lamina common to

both.
The attachment, or junctJonal
epithelium,
like
the
sulcular
epithelium, is thin, unkeratinized and
lacks epithelial ridges. Capillaries
course close to the attachment
epithelium and may form connective
tissue invaginations, which bring the
blood supply into more intimate contact with it.
Ordinarily, the skin forms a continuum broken only by the hair, nails,
glandular orifices and body openings. With the exception of the body
openings, the integrity of fhe skin is
maintained and constitutes a defensive barrier. The oral mucosa is much

"The Irlemolioral Jojmol of Periodonlics and Besloralive Dentislry" '1/1983

The connective tissue is able to wilhstand mechanical stresses. The dentogingival fibers extend from the
cementum and fan aut into the gingiva. This attochment is reinforced by
the other fibers of the gingiva, which
provide firmness and strengfh. The
connective tissue also contains fhe
circulatory supply.
The unctional epithelium, in a braad
sense, pravides a seal at the base of
the sulcus ogoinst the penetration of
chemical and bacferiol substances.
The ultra structural nature of the
epithelial attachment of the tooth
surface has been demonstrated by
Stern.^"^ Both reduced omeloblasts
and gingival epithelial cells have
been shown to form a basal lamina
on enamel and cementum. Hemidesmosomes of these cells ottach to the
bosal lomina in the same manner as
a basal cell. The epithelial attachment is submicroscopic, approximately 400 A.*
To understand the attochment of fhe
gingivo lo the tooth more fully, we
must appreciate the mechanism of
the changing position of the gingiva
to the tooth during eruption. After the
tooth is formed and calcified, it is
covered
by
reduced
enamel
epithelium. During the eruption of the
tooth,
fhe
reduced
enamel
epithelium comes into contact with
the gingival epithelium, and these
two tissues join. When the tip of the
tooth emerges from the mucous
membrane, the reduced epithelium is
ottached to almost the entire enamel
surface. However, the epithelium
separates from the surface of the
enamel, gradually exposing more of
the crown.
The unctional epithelium is initially
composed of omeloblosts. After
eruption, the relationship of the unc-

tional (attachment) epithelium to the

toath may remain unchanged for a
few years. It is no\ unusual to find
ameloblasts af fhe bose af the col.
The unctional epithelium is long at
first but becomes progressively
shorter. Before secondary junctional
epithelium can form on the tooth, the
primary junctional epithelium must
degenerate. As the connective tissue
fibers immediately subjacent to this
atlochment
degenerate,
the
epithelium can proliferate along the
surface of the enamel to the cementum. The downgrowth of the
epithelium alang the cementum
would be impassible in the presence
of the intact connective tissue. The
events that provoke the loss at the
connective tissue fibers in incipient
disease are not yet cleor. The fibers
may disappear because of toxic influences from the gingival sulcus, enzymatic action of the epithelium,
loss of cementum vitality,' collagenolysis by fibroblasts,'" or possibly because of the presence of tissue
collagenoses^^ or the activity of lymphocytes.'^' '^

As the epithelium separotes from the

tooth surface during packet formation or in recession, the apical end of
the ottachment epithelium gradually
moves onto the cementum. The bottom of the sulcus, which was first lacated on enamel, moves progressively toward the cementoenamel
unction and apically beyand that
paint. Thus, the ottachment may
move from the enamel to the cementum. Passive exposure is defined as
the first part of this process, during
which time (after the tooth has
erupted into occlusion) a gradual recession of the gingival margin with
an increased exposure of the clinical

'The Internolional Journal of Penodontics and Restoralive Dentistry" 4/1983

12

crown occurs until the cementoenamel unction is reoched.

In the classical concept there ore two
cuticles, the primary and the secondory. Before the tooth s fully
erupted, the attochment of ameloblosts to the enamel is mediated by
the primary enamel cuticle. This cuticle is believed to be the last substance formed by the ameloblasts.
When the ameloblasts are replaced
by oral epithelium, a second cuticle is
formed. On enomel, it covers the
primary enomel cuticle and is called
the secondary enamel cuticle. On
cementum, it is the only cuticle and it
is referred to as the cmentai cuticle.
The secondary enamel cuticle and
the cmentai cuticle together constitute the dental cuticle (cutcula dentis). The presence of mucopolysaccharjdes has been demonstrated in
the cuticle, however, the composition
of the cuticle is controversial. Some
authors claim that the cuticle s a
cementum-like substance;'''''^others
claim that it is derived from denatured hemoglobin'* or from salivary
mucins.'''
Perhaps the most significont fact
about the epithelial ottachment is
that it resembles an electron microscopic basal lamina; the cells of the
ottachment are joined to this structure by hemidesmosomes. Hemidesmosomes are organelles that are
found in viable basal cells.
The microscopic section of the
human tissue reveals the mesiol root
of a hemisected molar in which the
clinical crown hos been prepared by
elimination of all enamel or cementum. The tooth preparation has been
advanced to the level of the crestal
bone Fig. 2a]. In addition, all connective tissue attachments have
been eliminated by the rotary instru"Tlie Interrafionol Journal o( Periodontics ond Resloralive Dentislry" 4/1983

Fig 2o The exftocted mesial fool o a mandibtilai molar in black, t is the experimental model io
gain hnher knowledge al the R.A I.

Fig. 2b The histologie sediun al the extiocted

root in Fig. 2a. It wo entrocled 30 days alter the
al The clinical crown is devoid of enomel ond

cetnenhiw.
bj The epitheliol aHochment.
c) lymphocyte iulilttalion.
df The ispofrsd connsclivs U551JG ottochmenl oppofafus snowing the periodonfat ligomenf to be
perp&ndicutor to Ihs sunacs 01 fns root ond ol'
veolar crest Note the Sharpey liber attochmenl.

13

ment. This removal of periodontal ligament fibers from the root surface is
unintentional. Despile Ihe troumafic
insult to these tissues, we can see a
rather acceptoble tissue response at
the 30-doy interval (Fig. 2b). The microscopic preparation shows the
complete removal of enamel and
cemenium n the area of tooth preparation. The dentin surface of the
tooth preparation has a basophilic
stained layer similar to cementum.
The sulcus has well-developed sulcular and unclional epithelium with the
epithelial attachment evident at the
level of the remoining cementum at
the most apical extent of the crown
spoce (Fig. 2), the stratified squamous epithelium is porakeralotic ond
is supported by loosely arranged
connective tissue fibers that ore infiltrated by small lymphocytes and
plasma cells. The gingiva is attached
to the tooth via gingival fibers connecting into cementum at the most
coronal margin of the remoining
cementum. The tooth side shows attachment by supracrestal fibers and
the horizontal fibers of the periodontoi ligament.

The crestal orea of the alveolar bone

exhibits rsorption reversal lines that
cantain Sharpey's fiber attachments.
We observe a well-repaired sulculor
ipithelium, epithelial attachment ond
the re-establishment of o connective
tissue attachment along with osseous repair, i.e., a re-establishment of
the "normal" attochments of the
dentogingival unction. This biologic
observation gives credence to the
technique of tooth preparotion at the
time of surgical exposure. These observations have been mode an only
ane human specimen and serve as
the impetus for o carefully planned
series af animal studies with
parameters that can utilize actual
measurements in establishing a "recanstituted" dentogingival junction.
When ane seeks a clinical model of
an ocute insult to the gingival tissues
similar to tooth preparotion, the apprapriate exomple moy be found in
the reoction observed experimentally
when elastic bands are introduced
into the gingivol sulcus.^^ They encourage the occumulation of bacterial plaque ond the compressian and
necrosis af surface epithelium and
the subjacent lamino propria. The
teeth become extruded and moke
premoture contact with their antagonists. An inflammatory reoction
is noted within the first 72 hours and
periodontol packets of opproximotely 4-6 mm are found within the
first week. They will remain as long
OS the impacted elastic remains in
the gingival sulcus. Removal of the
elastic results in apparently prompt
clinical repair within three weeks.
Such repair moy be by an epithelial
attachment rather thon by correct
fibrous reattachment to the surfoce
of the root and may not be capable
of offering the same resistance lo fu-

"The Irlernolionai Journal of PeriodonlicB and Reilorative Dentistry" '1/1983

14

Fig. 3 Jhe hislohgic revieyv ot expefunenlol

penodonfai disease induced by the impacfion of
an elasiic in the gingivai sulcus. There s on ocule
inHammafory response Ihaf noy be ikened to ihe
insult ol subgingival dentistry.

Fig 4 A demonstrotion o taolh preparation

from both o hbiof ond on masa! view without violotsng the inteiproximai tissues and their otlachmenl to the tooth. The orrow shows the rotary
instrurr^ent to just barely extend into the gingival
sulcus

fig 5 A demonsffotion ot disregard lor the

onotomical intsrproximal structures during tooth
preparation trotn oain a iaDial uno on nciSOi
viev/. The arrow paints to the rotary nstrurnsnt extending the tooth preporation subgingivotty. tt is
on error to routinely prepore the tooth al the some
level circutnferentially.

ture insults. This then may be likened

to what occurs when o tooth is prepared subgingivolly beyond the gingival crevice and results in the destruction of the attachment of the
connective tissue fibers to the cemental surface of the tooth.

In conclusion, there is positive clinical evidence that the method of

tooth preparation presented in this
series of articles can be accomplished with a predictable
periodontal result. It would appear
to curtail the necessity of subgingival

tooth preparation beyond the crevice as this already would have been
accomplished at the time of surgery.
It will be necessary to use an animal
model research project to test this
hypothesis further.

'The Internolional Journal of Periodonlics and Resforohve Dentislry" 4/1983

15

Fig. This diaprom shoves o tooth with on inceosed dinicaf crown foliovving pocket elimination theiopy. There 15 an incteosed rise rom the iabiol surface to the interproximoi surioce as noted
by the orrow. The tooth preporotion ends in the
gsngivot crevice Note fhe chonge in onn of the
tooth preparation inci$aly from the triangular form
found in Figures 4 ond 5. Thi$ occurs because of
thefopenng morphofogy o( the rootos it proceeds
opicoHy

Fig 7 The ncisa! V&V O ihe tooth preporaf'on

coniinorng to bscon^s more roi/nded 05 the oii^fcal crtJ*vn incGOses ond Ihe tooth ptsporotion
proceeds further apicolty.

Fig 8 The vanotion of root morphology ond the proximai relationship ofodjoirjing teeth is of prime importance to the dinican '^en considering tooth preparotion. Proximal fOOt concavities ore of particular
importonce

The Interna lion al iournoi of Periodonfics and Restorolive Denlislrv" 4/1983

16

fig 9 The arrowy no's the nse ^rom fhe buccol furcaUon between the
ouccO' ^oots to the fOU'CLfiOf Q'rrgivo' iriofQin oficf ths onotoiny of Ins interpioxtraoi inoiof ftjTCot'O^ on the tnsfo! sunocG of ths TioxiUoiy first motor
The periodontal probe on ths mesiol $urface of the first bicuspid depicts

Fig. 0 A fofory instfums t is used to eiiminalB the overhanging tooth

slructtjfe exposed at ihe Irr of surgery to the point of fhe olveohr crest.

Fig. i 1 The iopered d'ontond stone extended

below the gingivof morgin doesf^'f provide
odequafe room for the phcement of re$lorolfve

Fig. J2 The arrows show fhe creation of more

space to accept fhe prosthetic restoration by increased reduction of the abutment tooth.

The Inlemotioral Journal of Penodonlics and Restaralive Denfislry"

Fig. 13 The presentation al a ctmcat cose oiler

the completion ol the initial debrrdemerii phose of
therapy. Note the diastema between the moxiihry

Fig. It An elastic S used to dose Ihc diastema

between the centralinasors so ihat the space between the mesial surlaces of the moxiiiary lateral
incisors will not be greater than the sum ol the
mesiodislal dimension of the central incisors to be
ettroded

r/- 5 Th exirocte fnoxiltofy incisors on ihs

son^s ooy thof HG uioxiHoiy pfovtsiono! bfioge i
lo be deiivered They wilf be used as a guide o
bothiorm and iunctiorun the f'nol porceh'n fe$to

\ .

Fig i8 The rnasittary Used bridges belo

torn coloring

Fig. 16 The provisionat restarationi ore in pioi.tr

prior to periodontalsurgery. The finat tooth preporations hove not been done ol this time. The teeth
will be prepared ta the R.A.I, ot the lime ol
periodanlal suigery.

Fig. 19
in place.

Thelultladah

the lixed bridges

Fig 20 The moxillary and mandibular Used

bridges ore inserted in place. Note the camplementary retotianship ol the resiorative margins
ta the soft tissues.

Fia. 31 A cteor weiv ol the subgmgivot morgin

plocement provided with the restorotions on Ihe
lateral incisor and the cuspid.

"The Intemationol Journal ot Penodontics and Restorarive Dentisin," 4/1983

18

Fig. 22 Note Ihe compaliMity of Ihe rsslorations

la the gingivol issues Aho noie the rehl'onship
of the centiol inoso! onlK to Ihe hierol :ncior
ohtilment looth ond relomer.

fig 23 A pololol view ol Ihe maiifciy lixed

bridge m place

Fig. 24 A rodiogrophic

"The International Joumol of Periodortics o r d Restorotive Denlistiy" 4/1983

e cemented in place

19

References
1. Stetn, I B..
The fine structure of the omelobloslenamel iunction in rol incisors; epithelial attachment and cuticular membrane. In Brese, S. S., editor: Electron
Microscopy. New York: Academic
Press, Inc. 1962.
2. Slern, I 6.:
Electron microscopic observations of
the dento-gingivol attachrrenl m rot incisors Abstract. I.A.D.R. 41.96, 1963
3. Grant, D., Stern, I B and Everett, F.G.'
Otban's Periodontics, ed. 2. Si. Louis:
The CV, Mosby Company, 1963.
4 Lisfgorten, M. A..
Phase-contrasI and electron microscopic study of the junction between reduced enamel epithelium and enamel
in unerupted human teeth. Arch Oral
Bid. 11:999, 1966.
5. Schroeder, H. E. and Listgarten, M A.:
The fine structure of the developing
epithelial altochment of human teeth. In
Wolsky, A., editor: Development Biology, vol. 2 Basel: A. KorgerAG, 1971
6. Schulfe-Houdt, S, D., Woerhaug, J.,
From S. H ond Altromodal, A..
On the nature of contact betvueen the
qingivol epithelium and the tooth surface. Periodontics 1103, 1963.
7. Gorgiulo, A. W , Wentz, F. M. and
Orban, B, J.:
Dimensions ond relations of the dentogingival junclion in humans J.
Periodontol, 32:261, 1961.
8 Weinmonn, J. P, Svobodo, J. F. and
Woods, P. W..
Hereditary disturbonces of enamel formation and calcification. JADA 32.397,
1945.
9. Gottlieb, B,:
Biology of the cementum. J. Periodontol. 13:13, 19'12.
10. Rose, G. G. and Robertson, P. B.:
Collogenolysis by human gingival fibroblast cell lines. J. Dent Res. 56'416,
1977
11. Fullmer, H M. ond Gibson, W j
Collagenolyfic activity in gingivo of
man Nature 209:728, 1966.
12. Schroeder, H. E.:
Quantitative parameters of early
human gingival inflommalion. Arch
OralBiol. 15:383, 1970.
13. Schroeder, H. E. end Poge, R. C :
Lymphocyte-fibioblast interaction in the
pathaqenesis of inflammatory gingival
disease. Experientio 28:1228, 1972.

14. listgarten, M. A.:

Phase-contrast and electron microscopic study o the unction between reduced enamel epithelium and enomel
in unerupted humon teeth. Arch. Oral
Biol. 11.999, I960.
15. Levine, P. T., Glimcher, M J. and
Bonar, L. C :
Collagenous loyer covering the crown
enamel of unerupted permanent
human teeth Science 46:1676, 196'!.
16 Hodson, J. J :
Origin and noture of the cutcula dentis.
Nature 209:990, 1966.
17. Armstrong, W G.:
Ammo-acid composition of the acquired pellicle of human looth enamel.
Nature 210:197, 1966.
18. Toto, P. D., Kollar, J. A., Gorgiulo, A.
W.:
Gingivitis induced by gingival impaction in monkeys. Oral Surg. 52:3,1981.
19. Ross, S., Gargiub, A
inl J Periodant Restorative Dent. 11:3,
1982.
20. Amsterdam, M,:
Postgroduate and Graduate Notes.
University of Pennsylvania, School of
Dental Medicine, 1957.
21. Amsterdam, M.:
Periodontal Con side rotions in the
Selection ond Treatment of Abutment
Teeth. Presented to the Centennial
Meeting of the A.D.A., New York 1959.
22. Amsterdam, M.'
The Distal Extension Problem Presented to the Northeastern Society of
Period ontology. New York, 191
23. Amsterdam, M., and Fon, L.:
Provisional splinting - principles and
techniques. Dent. Clin. N. Am., March,
1959, p. 73.
24. Amsterdam, M., and Rossman, S. R.:
Technique and hemisection of multirooteJ teeth. Alpha Omegan, 53:4,
1960.
25. Coslet, J. G., Vonorsdall, R. L., and
y^eisgold. A.:
Diagnosis and dossificotion of delayed
passive eruption of the dento-gingivcl
iunction in the adult. Alpho Omegan
70: Dec. 1977.
26 Ochsenbein, C , and Ross, S. E.:
A re-evcluation of osseous surgery.
Dent. Clin. N. Am. 23: 87-102, 1969.

Intemotiorol Journal of Periodontics ond Restorolive Denlislry" 4/1983