See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/281631814

Clinical considerations in restorative dentistry — A narrative review

Article · September 2015

DOI: 10.4103/2231-0754.164377

CITATIONS READS
0 3,903

3 authors:

Ashwini Tumkur Shivakumar Dr Sowmya H K

JSS Dental College and Hospital JSS Dental College and Hospital
22 PUBLICATIONS   24 CITATIONS    9 PUBLICATIONS   15 CITATIONS   

SEE PROFILE SEE PROFILE

Sangeeta Dhir
Max Healthcare
73 PUBLICATIONS   49 CITATIONS   

SEE PROFILE

Some of the authors of this publication are also working on these related projects:

periodontitis and metabolic conditions View project

All content following this page was uploaded by Dr Sowmya H K on 10 September 2015.

The user has requested enhancement of the downloaded file.

[Downloaded free from http://www.jicdro.org on Thursday, September 10, 2015, IP: 14.139.156.146]

Review Article

Clinical considerations in restorative dentistry —

A narrative review
Ashwini Tumkur Shivakumar, Sowmya Halasabalu Kalgeri, Sangeeta Dhir1
Department of Conservative Dentistry and Endodontics, Jagadguru Sri Shivarathreeshwara Dental College and Hospital, Mysore, Karnataka,
1
Department of Periodontology and Implantology, Dr. Bhimrao Ramji Ambedkar Institute of Dental Sciences, Patna, Bihar, India

Access this article online

ABSTRACT
Website: www.jicdro.org
The relationship between periodontal health and the restoration of teeth is intimate and inseparable. Human DOI: 10.4103/2231-0754.164377
teeth are designed in such a way that the individual tooth contributes significantly to their own support as well as Quick Response Code:
collectively the teeth in the arch. Decay on the proximal surfaces occurs mainly due to the faulty interrelationship
between the contact area, marginal ridge, the embrasures and the gingiva. An adequate understanding of
the relationship between periodontal tissues and restorative dentistry is paramount to ensure an adequate
form, function, aesthetics and comfort of the dentition. For long-term survival of restoration, both functionally
and esthetically, certain biological considerations are very critical to preserve the health of the periodontium
and thus must be given due importance in clinical practice. While most clinicians are aware of this important
relationship, uncertainly remains regarding specific concept such as biologic width and its maintainces.

Key words: Biologic width, contact and contours, marginal ridge, occlusal forces

INTRODUCTION dental care the patient so as to establish a good oral health.

Optimizing tooth form has always been the “holy grail” of
restorative dentistry. Recreating the missing tooth anatomy
is important not only to replace the lost tooth structure but
also to re-establish ideal form and function.[1]
Successful restorative dentistry can be accomplished when
there is a healthy and stable supporting tissue surrounding
the tooth; close attention to both hard tissue and soft tissue
during and after restorative procedures will greatly increases
the probability of successful outcome.[2]
Restoring the proper anatomy of the tooth and maintaining
the health of the soft tissue should be a prime consideration
during the restorative procedure. This article reviews the
clinical considerations that need to be adopted while
restoring a natural tooth and or implant restoration.
A review of general medical status and past dental history is
necessary as it influences the treatment plan.
Review of general health helps to identify systemic health
problem that may modify the dental treatment that is
necessary. Common communicable diseases such as herpes
simplex, chicken pox, mumps, etc. should be diagnosed and
special infection control measures or delaying the treatment
may be required.
Drug allergies and systemic health should be elicited from
the patient prophylactic antibiotic coverage must be provided
prior to the treatment. Conditions like uncontrolled diabetics
and hypertensive or those on immunosuppressive therapy
(transplant patients) should be referred to physician consult
before dental treatment.[3]

PATIENT EVALUATION Clinical examination

Hard tissue and soft tissue examination intraorally is a must
General health for proper treatment planning. Table 1 explains the overview
A through examination is necessary to provide comprehensive of the clinical examination.[4]

Address for correspondence: Material options for restoring a teeth

Dr. T. S. Ashwini, Department of Conservative Dentistry and
Endodontics, Jagadguru Sri Shivarathreeshwara Dental College and
Hospital, Mysore - 570 015, Karnataka, India.
E-mail: drashts2000@yahoo.co.in
Generally, choice of dental filling material should be based
on the patient’s case history, clinical, radiographic and other
relevant findings. The dentist must decide whether or not

122 Journal of the International Clinical Dental Research Organization | July-December 2015 | Vol 7 | Issue 2
[Downloaded free from http://www.jicdro.org on Thursday, September 10, 2015, IP: 14.139.156.146]

Ashwini, et al.: Clinical considerations in restorative dentistry

to restore the tooth and, if restoration is required, which the restoration. Table 3 lists the commonly used direct and
restorative material to employ for the anticipated situation. indirect restorative material.[6]

Deciding factors for restorative treatment[5]
• Extent of caries.
• Strength of remaining tooth structure.
• Specific characteristics of the patient’s dentition and
periodontal health.
• Patient’s oral hygiene and dental caries history.
• Financial costs of the procedure to the patient.
• Risks and benefits of the procedure to the patient.
• Ability of the dentist to perform the procedure.
• Preferences of the dentist and the prevailing standard of
care.
• Acceptance by the patient.
Although caries is the predominant reason for restoration of
teeth, several other clinical conditions, such as tooth fracture,
restoration failure, and trauma, also may require restoration.
The most common clinical conditions, treatment options,
and restorative material options are summarized in Table 2.[5]
DIRECT AND INDIRECT RESTORATIVE MATERIALS
Direct materials are those that can be placed directly in the
tooth cavity during a single appointment. Indirect materials
are used to fabricate restorations in the dental laboratory
that then are placed in or on the teeth; placement of indirect
materials generally requires two or more visits to complete
Table 1: Clinical examination
Extra-oral examination.
The mouth in general.
Examination of teeth and restorations.
Clinical examination for caries.
Clinical examination for existing restorations.
Clinical examination for other defects.
Radiographic examination of teeth and restorations.
Adjunctive aids.
Evaluation of the periodontium.
Evaluation of occlusion.
The life of dental restoration depends on material and
procedure, size and location of the restoration, chewing
habits, oral hygiene and its maintenance, and systemic
conditions. Material related factors include strength;
wear resistance, tolerance to water, dimensional stability
and colour stability. Because each restoration has unique
circumstances that profoundly affect its lifetime. This article
does not attempt to discuss or predict longevity of service
for any of these materials but it discus about restabilising a
single tooth in proper form and function.
Re-establishing the anatomy of the tooth
Contact and contours
Contacts
Establishing the interproximal contact is the primary
objective of restorative procedures.[7] Ideal Proximal contact
acts as a barrier against food impaction and thus contributes
to underlying periodontal health.[8] By providing food spillway
and facilitating hygienic cleaning.
Contact point has been defined as the point when teeth
erupt and acquire proximal contact with adjacent tooth
proximal attrition leads to the conversion of contact point
to contact area.
The proximal contact or the contact area refers to the surface
area where the proximal surfaces of neighboring teeth come
in contact. Contact area is usually located in upper one third
of the crown of most of the tooth.[1]
Creates a natural embrasure providing a opportunity for good
maintenance of the interproximal area.
An ideal contact serves by:
• Maintaining the dental arch stability by transmitting the
force along the long axis of the teeth.[9]

Table 2: Indications, treatment, and restorative material options for the restoration of posterior teeth
Clinical condition
Questionable caries -smooth surface
“white sport,” deep pit or fissure
Incipient (early) caries
Moderate to extensive caries
Defective or failed restoration
Tooth fracture
Post-endodontic restoration
Preferred treatment options Dental material options
Fluoride treatment; oral hygiene instruction; Sealant
seal pits and fissures and/or observe and
re-evaluate
Preventive resin/sealant Preventive resin/sealant, composite, glass
ionomer
Restore or extract if tooth destruction is Amalgam, cast metal, ceramic, metal - ceramic
extensive
Repair or replacement Will depend on whether restoration is being
repaired or replaced, but may include any
restorative material
Restore or extract depending upon severity Amalgam, composite, cast alloys, metal - ceramic,
ceramics (depends on severity of fracture)
Restore and protect with Cast alloy, metal ceramic, ceramic — onlay or
onlay or crown crown

Journal of the International Clinical Dental Research Organization | July-December 2015 | Vol 7 | Issue 2 123
[Downloaded free from http://www.jicdro.org on Thursday, September 10, 2015, IP: 14.139.156.146]
Ashwini, et al.: Clinical considerations in restorative dentistry
• The correct relationship with the adjacent tooth allows
a good support against masticatory forces and promotes
the deflection of the food through the embrasure.[10]
• Influences speech and cosmetics especially in the anterior
region.[9]
Improper restoration in the contact area will cause displacement
of the teeth, lifting forces of the teeth, rotation of the teeth,
deflecting occlusal contact and food impaction.[11]
Disadvantages of improper contact areas
Faulty contacts leads to restorative defects which hampers
the health of the periodontium:
• Too broad contact bucco-lingually or occlusal-gingivally
causes change in the tooth anatomy, improper shunting
of food in bucco-lingual direction because of narrow
embrasure this leads to food impingement in the contact
area and contact area which is more concave (or flat)
can be broad which will result in improper physiological
movement of the tooth.[10,12]
• Too narrow contact bucco-lingually or occluso-gingivally
causes food impaction vertically and horizontally which leads
to wide embrasure in which lead to greater food retention
and plaque accumulation and contact area which is more
convex will diminish the extent of the contact area.[10,12]
• Contact area placed too occlusally, bucally or lingually
will result in flattened marginal ridge of the restoration,
Contact point too gingivally will lead to increased depth
of occlusal embrasure, loose contact creates continuity
between embrasure leading to food impaction.[10]
It is not uncommon to observe good proximal contact but in
adequate contour in proximal restoration. Similarly a good
contour with the poor proximal contact exits can be possible.[8]
Contours
Each tooth exhibits contour in the form of concavity and
convexity. Facial and lingual convexities of the tooth holds the
gingival under tension and also protects the gingival margin by
deflecting the food away.[12] The over convexities can create a
favourable environment for the growth of microorganisms.[10]
A facial and lingual concavity helps in occlusal static
and dynamic relation, as they determine the pathway of
mandibular teeth into and out of centric occlusal. Deficiency
of this concavity will inhibit the physiological movements.[10,12]
Table 3: Commonly used direct and indirect materials
Direct Indirect
Amalgam All-Ceramic (Porcelain)
Resin-based Composites Metal-Ceramic
(Direct and Indirect)
Glass Ionomers Cast-Gold (High Noble) Alloys
Resin-Modified Ionomers Resin-Modified Ionomers
124 Journal of the International Clinical Dental Research Organization | July-December 2015 | Vol 7 | Issue 2
In addition to creating a contact area of proper size, location
and configuration, it is also essential to restore the proximal
surface to a proper contour. Fabricating a restoration that
does not reproduce the concavities and convexities which
occur here naturally will lead to overhanging or under
hanging restorations which leads to periodontal damage.[12]
Clinical impression suggests loose or open proximal contact to
be the contributing factors to periodontal pocket formation.
It is still generally accepted that a good contour and a tight
proximal contact are important for gingival health.[13]
Marginal ridges
Marginal ridges of the posterior tooth are considered to be
of a primary importance in providing structural strength to
crown.[14] It has a greater thickness of enamel than other
areas. Loss of one or more marginal ridge weakens the
tooth.[15]
It is imperative to have a marginal ridge of proper dimension,
compatible to the occlusal anatomy creating a pronounced
adjacent triangular fosse and occlusal embrasure. Marginal
ridge should always form in two planes bucco-lingually
meeting at a very obtuse angle. This feature is essential
when an opposing functional cusp occludes with the marginal
ridge. These essential features are necessary to prevent food
lodgement which causes damage to the periodontium.
There are two forces acting on two marginal ridges, force 1
and 2 which have their horizontal components, 1H and 2H
drive the two teeth towards each other, thus preventing any
proximal impaction of food.[12] The vertical forces 1V and
2V which are acting vertically are resolved normally by the
underlying tissue [Figure 1].[10] Marginal ridge portion of the
restoration should be compatible with the adjacent marginal
ridge, both the ridges should be approximating at the same
level and display correct occlusal embrasure for the passage
of the food to facial and lingual surface.[3]
Figure 1: Horizontal and Vertical forces on the tooth
[Downloaded free from http://www.jicdro.org on Thursday, September 10, 2015, IP: 14.139.156.146]
Ashwini, et al.: Clinical considerations in restorative dentistry
Criteria’s for restorations of marginal ridge:
1. In the absence of marginal ridge:
The forces 1will be directed towards the proximal ridge of
the adjacent tooth and force 2 is directed on to the same
tooth, so the horizontal forces 1H and 2H will act on the
same tooth, which will tend to drive the two teeth away
from each other. The vertical component 1V and 2V can
impact the food intraorally [Figure 2].
2. Adjacent marginal ridge not compatible with height:
Restoring the marginal ridge higher than the adjacent
one will allow force1 (A) on the proximal surface of the
restoration, the horizontal component 1H (AH) will drive
the restored tooth away from the contacting tooth and
the vertical component will push debris interproximally
even in the presence of force 2 (B) with its horizontal
component (BH) acting on the adjacent marginal ridge
there is some separation of the teeth as force 2(B) is too
small as compared to force 1 (A). By restoring the marginal
ridge lower than the adjacent one we can expect the same
movement of the tooth but the major movement will be
non restored tooth [Figure 3a and b].
3. Marginal ridge with no triangular fossae:
In this situation there are no occlusal plans in the marginal
ridges, so there are no occlusal forces acting 1 and 2, so
Figure 2: Absence of marginal ridge
Figure 4: Absences of adjacent triangular fossa
Journal of the International Clinical Dental Research Organization | July-December 2015 | Vol 7 | Issue 2
there are no horizontal component 1H and 2H to drive
the tooth toward each other and vertical force 1V and 2V
will impact the food interproximally [Figure 4].
4. Single planed marginal ridge in bucco-lingual direction
This can create the premature contact during both
function and static occlusion, one plan marginal ridge
increases the depth of adjacent triangular fossa by
increasing the stress in this area and also increases the
height of the marginal ridge at the centre, and this will
deflect the food away from the spillway [Figure 5].
5. Thin marginal ridge in mesio-distal bulk:
Will be susceptible to fracture or deformation leading
to the problems of previously mentioned faulty marginal
ridge (discussed in point 1, 2, 3 and 4) [Figure 6].
Studies have shown that regardless of loading directions and
location, the marginal ridges and proximal contact area were
sites of low strain.[14] Thickness of enamel at the marginal ridge
is high and loss of tooth structure in this area weakens the
tooth structure. Both clinical and experimental studies have
highlighted the importance of preserving the marginal ridge.[16-18]
b
Figure 3: (a) Improper marginal ridge (b) Improper marginal ridge
Figure 5: One planned marginal ridge
125
[Downloaded free from http://www.jicdro.org on Thursday, September 10, 2015, IP: 14.139.156.146]
Ashwini, et al.: Clinical considerations in restorative dentistry
Effective dentine thickness
The depth of the cavity is most detrimental irritating factor
to the pulp. The most important factor is the thickness of
the dentine between the floor of the cavity and the floor of
the pulp chamber called effective depth. Clinical judgement
about the need for specific liners and bases are linked to the
amount of the remaining dentine thickness (RDT) which is
shown in Table 4.[3]
Affected and infected dentine
Fusyama has reported two distinct layer of carious dentin,
an outer and an inner layer, which is termed as infected
dentine and affected dentine. In tooth preparation it is
desirable that only infected dentine to be removed leaving
the affected dentine. Infected dentine is an outer layer
contains micro-organisms and the collagen is irreversibly
denatured and it cannot be remineralized, soft in nature,
can be stained easily and should be excavated. Affected
dentine is an inner layer has no bacteria, reversibly
denatured, remineralizable, hard in nature and does not
stain and should be preserved.[3,19]
Figure 6: Thin marginal ridge
Table 4: Pulpal protection depending on the remaining dentine thickness (RDT)
RDT >2 mm
Amalgam Only Sealer
Composite Dentine bonding system
Gold inlays and onlays Cement
Ceramics Dentine bonding system/Resin
cements
Table 5: Biological considerations in restorative treatments
Deleterious affects of restorative procedures on dentin
Heat generated by cutting actions of the burs or during polishing of
the restorations
Undue dehydration during cutting
Heat transfer through metallic restorations which are thermal
conductors
Applications of any restorative material that provides a toxic
environment of cut surface
126 Journal of the International Clinical Dental Research Organization | July-December 2015 | Vol 7 | Issue 2
Biological considerations in restorative treatments
Dentine forms the bulk of the tooth and a protective
encasement for the pulp. As the vital tissue without vascular
supply and innervation it is nevertheless able to respond to
thermal, chemical, or tactile external stimuli. Of the various
forms of treatment, operative procedures are the most
frequent cause of pulpal injury. Trauma to the pulp can’t
always be avoided, particularly with extensive restorations.
A competent clinician, recognizing the hazards associated
with each step of the restorative process, can often minimize
if not prevent, trauma to preserve the vitality of the tooth.
The deleterious affect and its effective management are
mentioned in Table 5.
Embrasures
It’s a “V” shaped space that originate from proximal contact,[3]
the interdental space is a physical space between two adjacent
teeth, its form and volume are determined by the morphology
of the teeth which is composed of cervical, occlusal, buccal
and lingual pyramidal embrasures. The apex of the pyramid
ends at the contact point of the aproximal teeth.[21]
The correct relationship of embrasure, cusp to sulci, marginal
ridge and grooves of adjacent and opposing teeth provide
opportunity for escape of food from the occlusal surface
during mastication.[3]
An exaggerated occlusal embrasure because of faulty marginal
ridge will direct force 1 and 2 towards adjacent proximal
surfaces with the horizontal component driving the tooth
away and the vertical component 1V and 2V pushing the
debris into proximally [Figure 7].
Absence of occlusal embrasure because of faulty marginal
ridge will act like a pair of tweezers grasping the food.
RDT 0.5 to 2 mm RDT <0.5 mm
Base/Sealer Sub- base/Base/ Sealer
Dentine bonding system Sub- base/Dentine bonding
system
Base/cement Sub- base/Base/ Cement
Dentine bonding system/ Sub- base/Dentine bonding
Resin cements system/Resin cements
Effective management
Prolong applications of air through three way syringe
Use of a suitable coolant while cutting the tooth especially while
using high speed handpiece
Placement of proper insulators and medicaments or liners beneath the
restorations to maintain the normal biological conditions of dentin.[20]
[Downloaded free from http://www.jicdro.org on Thursday, September 10, 2015, IP: 14.139.156.146]

Ashwini, et al.: Clinical considerations in restorative dentistry

Although debris won’t be pushed interproximally it will be

very difficult to remove [Figure 8].

Integrity of the dental papilla is the main concern while

restoring the tooth. The absence and loss of interdental
papilla which intern leads to absences or loss of embrasure
may cause aesthetic impairment, phonetic problems, and
food impaction.

Biological width and restorations

It’s defined as dimension of soft tissue which is attached to
the portion of the tooth coronal to the crest of the alveolar
bone. The term was based on work of Gargiulo et al.,[13] it
provides the natural seal that develops around the tooth
protecting the alveolar bone from the infection and the Figure 7: Exaggerated occlusal embrasure

disease.[22]

Gargiulo et al., reported that marginal width is commonly

about 2.4 mm, which represents the some of epithieal and
connective tissue measurements that is sulcus of 0.69 mm,
epithelial attachment of 0.97 mm and a connective tissue
width of 1.07 mm.[13] The width is not constant it varies
according to the location of the tooth [Figure 9].

Biological width impingement is of concern when considering

the restoration of the tooth with a subgingival fracture or has
been destroyed by subgingival caries approaching the alveolar
crest. Often aesthetic restoration makes sub gingival margins
leads the violation of these space. Jorgic- Srdjak K et al., have Figure 8: No occlusal embrasure
stated that when sub gingival margins are indicated, the
restorative dentist must not disrupt the junctional epithelium
or connective tissue apparatus.[23]

Supragingival margins provides easy preparation of the tooth,

finishing of the margins, impression making, fit and finish of
the restoration, verification of the restoration, less irritating
to the periodontal tissues.[23]

Equigingival margins
Traditionally this type of margins were not desirable,
as it favors to lot of food accumulation which leads to
increased gingival inflammation and also concern was
the minor gingival recession would create an unsightly
margin display.
Figure 9: Biologic width

These drawbacks are not valid today, not only because

margins can be aesthetically blended with the tooth and also
the restoration can be finished easily. From the periodontal
view both supragingival and equigingival margins are well
to be tolerated.[24]
Subgingival margins
Restorative consideration will frequently detect the
placement of restoration margins beneath the gingival
crest; invasion of biological periodontal ligament space for
additional retention space will cause iatrogenic periodontal
ligament disease with the premature loss of restoration.[25]
Subgingival restorations have demonstrated more quantative
and qualitative changes in micro flora, increased plaque index,
gingival index, recession, pocket depth and gingival fluid.[26,27]

Journal of the International Clinical Dental Research Organization | July-December 2015 | Vol 7 | Issue 2 127
[Downloaded free from http://www.jicdro.org on Thursday, September 10, 2015, IP: 14.139.156.146]
Ashwini, et al.: Clinical considerations in restorative dentistry
Biologic width violation leads to chronic progressive gingival
inflammation, Clinical attachment loss and alveolar bone
loss. Gingival hyperplasia is also most frequently found in
subgingivally placed restorative margins.
Evaluation of biologic width violation
The most important diagnostic method is bone sounding,
which is done by probing under local anaesthesia to bone
level. Biologic width is assessed by subtracting the sulcular
depth from the resulting bone sounding measurement. If
this distance is less than 2 mm, then a violation of biologic
width can be diagnosed. Radiographic evaluation can assess
interproximal violation of biologic width. But it is not
diagnostic because of tooth superimposition.[28]
Evaluation of biologic width
The techniques employed in dental practice for the evaluation
of biologic width.[29]
By Radiographs.
By Periodontal probe.
Correction of biologic width violation
Biologic width violation can be corrected surgically or
orthodontically.[30]
• Surgical correction is aimed at removing the bone away
from the restorative margin done by gingivectomy,
apically repositioned flap with or without ostectomy.
• Orthodontic correction, the tooth is moved coronally
away from the bone is done either by slow eruption or
forced eruption with supracrestal fiberotomy.
Biologic considerations during implant restoration
The ultimate long term success of implants is largely relied
upon the interphase between implants and their surrounding
tissues, both hard and soft tissues. Dental implant have two
distntic interface with oral tissues.
• The soft tissue- implant interface is where the peri-implant
mucosa meets the implant creating a biological seal to
prevent future disease invasion. Due to the natural of the
tissue component, soft tissues surrounding the dental
implants are called peri- implant mucosa instead of gingival.
• The hard tissue- implant interface where the alveolar bone
contact with implant surface. This integration provides
stability and rigidity that implant needs.[31]
The successful integration of periodontal and restorative
dentistry for both natural teeth and implant requires
knowledge and application of both biological and mechanical
principles.
Subgingival margins should be considered as a compromise
and supragingival margins are preferred.
128 Journal of the International Clinical Dental Research Organization | July-December 2015 | Vol 7 | Issue 2
Where the aesthetic is not a concern and adequate tooth
structure exists, supra gingival margins are recommended. In
areas with the inadequate tooth structure crown lengthening
or orthodontic extrusion can be used to increase clinical
crown lengthening.
For subgingival placement of the dental implant several
principles should be considered.
• The marginal fit should be optimal because of the rough
surface or open margin leads to bacterial accumulation
that are associated with inflammatory periodontal
disease.
• The margins of the implant should extend only slightly
into the gingival sulcus, to avoid violation of biologic
width.
• Materials used in the restorations should be compatible
with the soft tissue and lend themselves to the precise
interface to minimize marginal discrepancies that
encourages retention of bacterial plaque.
In areas of aesthetic concern, to minimize the effect of
bacterial trap at the implant and restorative junction the
clinician should consider selection of the implant system that:
• Has the interphase coronal to facial and lingual bone.
• Provides the closest possible implant/abdument interface.
• Allows screw- retained restorations.[2]
Considerations for complex restorations
An operator should have a through knowledge of restorative
design, materials and technique when examining the badly
mutilated teeth following steps should be taken before
finalizing that design and executing it.
• Evaluate the P-D organ and the periodontium of the tooth
to be restored, preferably before the patient is anesthetized.
• Remove all the undermined enamel. There is no place for
such enamel in all permanently restored posterior teeth.
• Clean all surrounding walls from dentin that is infected.
• Through knowledge of biologic concept is a must (as
discussed above).[12]
Restorative margin and periodontium
The gingival peripheral destructions should be recorded
and the margins of the restorations should be planned
accordingly:
• If the tooth destruction is located supragingivally, no need
for the any change in the periodontium.
• If the tooth destruction is located apically to gingival
cervice but suprabony, gingivectomy is performed to
expose the apical limit of defect.
• If apical limit of defect is infrabony:
a. Full thickness mucoperiosteal flap is raised with
osteotomy to correct the defect.
b. Intentional extrusion of the tooth is done.
[Downloaded free from http://www.jicdro.org on Thursday, September 10, 2015, IP: 14.139.156.146]
Ashwini, et al.: Clinical considerations in restorative dentistry
CONCLUSION
The relationship between restoration and periodontal health
of the teeth is intimate and inseparable; maintenance of
gingival health constitutes one of the keys for tooth and
dental restoration longevity. An adequate understanding
of relationship between periodontal tissues and restorative
dentistry is paramount to ensure adequate form, function
and aesthetics and comfort of the dentition.
The clinician should have an adequate knowledge about
anatomy and the functional aspects of contacts and contour
so as to reproduce using proper restorative material. Recent
updates with extensive knowledge about the matrix system
will help to reproduce the normal anatomy and contacts
between the teeth which will help in maintaining the healthy
oral cavity.
In spite of the increase emphasis on the perio-restorative
interphase in restorative dentistry, many dentists have
been unable to utilize the concept of biological width in a
practical manner, so this article is briefed about the clinical
considerations during restoration.
REFERENCES
1. Ramya R, Raghu S. Optimizing tooth form with direct posterior
composite restorations. J Conserv Dent 2011;14:330-6.
2. Goldberg PV, Higginbottom FL, Wilson TG. Periodontal
considerations in restorative and implant therapy. Periodontol
2000 2001;25:100-9.
3. Roberson TM, Heymann H, Swiff EJ. Sturdevent’s Art and
Science of Operative Dentistry. 4th ed. Maryland Heights; Mosby
Publications; 2002,389-99, 410,174-7 & 33-5.
4. Ramya R, Raghu S. Clinical Operative Dentistry Principles
and Practices. 2nd ed. Bangalore: EMMESS Medical Publishers;
2011, 190.
5. Appendix I — The Benefits of Dental Amalgam. Ad Hoc
Subcommittee on the Benefits of Dental Amalgam — materials,
methods and indications for the restorations of posterior teeth.
6. ADA Council on Scientific Affairs. Direct and indirect restorative
materials. J Am Dent Assoc 2003;134:463-72.
7. Chuang SF, Su KC, Wang CH, Chang CH. Morphological analysis
of proximal contacts in class II direct restorations with 3D image
reconstruction. J Dent 2011;39:448-56.
8. Khan FR, Umer F, Rahman M. Comparison of proximal contact and
contours of premolars restored with composite restoration using
circumferential matrix band with and without separation ring: A
randomized clinical trial. Int J Prosthodont Restor Dent 2013;3:7-13.
9. Eissmann HF, Radke RA, Noble WH. Physiologic design criteria
for fixed dental restorations. Dent Clin North Am 1971;15:543-68.
10. Vimal KS. Textbook of Operative Dentistry. 2nd ed. New Delhi:
CBS Publishers and Distributors; 2008:71-7.
11. Linkow L. Contact areas in natural dentition and fixed
prosthodontics. J Prostho Dent 1962;12:132-7.
Journal of the International Clinical Dental Research Organization | July-December 2015 | Vol 7 | Issue 2
View publication stats
12. Marzouk MA, Simonton AL, Gross RD. Operative Dentistry-
Modern Theory and Practice. 1st ed. Tokyo: Ishiyaku EuroAmerica,
Inc. Publishers; 1989: 240-5.
13. Padbury A Jr, Eber R, Wang HL. Interactions between the gingiva
and the margin of restorations. J Clin Periodontol 2003;30:379-85.
14. Palamara JE, Palamara D, Messer HH. Strains in the marginal ridge
during occlusal loading. Aust Dent J 2002;47:218-22.
15. Eshleman JR, Janus CE, Jones CR. Tooth preparation designs for
resin-bonded fixed partial dentures related to enamel thickness.
J Prosthet Dent 1988;60:18-22.
16. Hansen AR, Asmussen E, Christiansen NC. In vivo fracture of
endodontically treated posterior teeth restored with amalgam.
Endod Dent Traumatol 1990;6:49-55.
17. Mondelli J, Steagall L, Ishikiriama A, de Lima Navarro MF,
Soares FB. Fracture strength of human teeth with cavity
preparation. J Prosthet Dent 1980;43:419-22.
18. Reeh ES, Messer HH, Douglas WH. Reduction in tooth stiffness
as a result of endodontic and restorative procedures. J Endod
1989;15:512-6.
19. Tandon S. Textbook Book of Pedodontics. 2nd ed. New Delhi: Paras
Medical Publishers; 2008:401.
20. Baum L, Phillips RW, Lund MR. Textbook of Operative Dentistry.
2nd ed. Philadelphia: WB Saunders Company; 1985:81.
21. Prato GP, Rotundo R, Cortellini P, Tinti C, Azzi R. Interdental
papilla management: A review and classification of the
therapeutic approaches. Int J Periodontics Restorative Dent
2004;24:246-55.
22. Nugala B, Kumar BS, Sahitya S, Krishna PM. Biologic width and
its importance in periodontal and restorative dentistry. J Conserv
Dent 2012;15:12-7.
23. Jorgic-Srdjak K, Plancak D, Maricevic T, Dragoo MR, Bosnjak A.
Periodontal and prosthetic aspect of biological width part I:
Violation of biologic width. Acta Stomatol Croat 2000;34:195-7.
24. Khuller N, Sharma N. Biologic width: Evaluation and correction
of its violation. J Oral Health Comm Dent 2009;3:20-5.
25. Waerhaug J. Healing of the dento-epithelial junction following
subgingival plaque control. II: As observed on extracted teeth.
J Periodontol 1978;49:119-34.
26. Valderhug J, Birkeland JM. Periodontal conditions in patients
5 years following insertion of fixed prostheses. Pocket depth and
loss of attachment. J Oral Rehabil 1976;3:237-43.
27. Newman MG, Takie H, Klokkevold PR. Carranza’s Clinical Periodontol.
10th ed. Philadelphia: Saunders; Elsevier Publishing; 2006:134.
28. Shenoy A, Shenoy N, Babannavar R. Periodontal considerations
determining the design and location of margins in restorative
dentistry. J Interdiscip Dent 2012;2:3-10.
29. Maheaswari R, Golla UR, Logarani, Sudagaran M, Rohan SB.
Biologic width - critical zone for a healthy restoration. IOSR-JDMS
2014;13:93-8.
30. Tsao YP, Wang HL. Periodontal considerations in implant therapy.
Int Chin J Dent 2003;3:13-30.
31. Chandra S, Chandra S, Girish C. Textbook of Operative Dentistry.
1st ed. Delhi: Jaypee Brothers Medical Publishers Ltd.; 2007:337.
Cite this article as: Shivakumar AT, Kalgeri SH, Dhir S. Clinical considerations
in restorative dentistry - A narrative review. J Int Clin Dent Res Organ
2015;7:122-9.
Source of Support: Nil. Conflict of Interest: None declared.
129