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Review Article
Key words: Biologic width, contact and contours, marginal ridge, occlusal forces
122 Journal of the International Clinical Dental Research Organization | July-December 2015 | Vol 7 | Issue 2
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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] The life of dental restoration depends on material and
• Extent of caries. procedure, size and location of the restoration, chewing
• Strength of remaining tooth structure. habits, oral hygiene and its maintenance, and systemic
• Specific characteristics of the patient’s dentition and conditions. Material related factors include strength;
periodontal health. wear resistance, tolerance to water, dimensional stability
• Patient’s oral hygiene and dental caries history. and colour stability. Because each restoration has unique
• Financial costs of the procedure to the patient. circumstances that profoundly affect its lifetime. This article
• Risks and benefits of the procedure to the patient. does not attempt to discuss or predict longevity of service
• Ability of the dentist to perform the procedure. for any of these materials but it discus about restabilising a
• Preferences of the dentist and the prevailing standard of single tooth in proper form and function.
care.
• Acceptance by the patient.
Re-establishing the anatomy of the tooth
Contact and contours
Although caries is the predominant reason for restoration of Contacts
teeth, several other clinical conditions, such as tooth fracture, Establishing the interproximal contact is the primary
restoration failure, and trauma, also may require restoration. objective of restorative procedures.[7] Ideal Proximal contact
The most common clinical conditions, treatment options, acts as a barrier against food impaction and thus contributes
and restorative material options are summarized in Table 2.[5] to underlying periodontal health.[8] By providing food spillway
and facilitating hygienic cleaning.
DIRECT AND INDIRECT RESTORATIVE MATERIALS
Contact point has been defined as the point when teeth
Direct materials are those that can be placed directly in the
erupt and acquire proximal contact with adjacent tooth
tooth cavity during a single appointment. Indirect materials
proximal attrition leads to the conversion of contact point
are used to fabricate restorations in the dental laboratory
to contact area.
that then are placed in or on the teeth; placement of indirect
materials generally requires two or more visits to complete The proximal contact or the contact area refers to the surface
area where the proximal surfaces of neighboring teeth come
Table 1: Clinical examination in contact. Contact area is usually located in upper one third
Extra-oral examination. of the crown of most of the tooth.[1]
The mouth in general.
Examination of teeth and restorations.
Clinical examination for caries. Creates a natural embrasure providing a opportunity for good
Clinical examination for existing restorations. maintenance of the interproximal area.
Clinical examination for other defects.
Radiographic examination of teeth and restorations.
Adjunctive aids. An ideal contact serves by:
Evaluation of the periodontium. • Maintaining the dental arch stability by transmitting the
Evaluation of occlusion.
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 Preferred treatment options Dental material options
Questionable caries -smooth surface Fluoride treatment; oral hygiene instruction; Sealant
“white sport,” deep pit or fissure seal pits and fissures and/or observe and
re-evaluate
Incipient (early) caries Preventive resin/sealant Preventive resin/sealant, composite, glass
ionomer
Moderate to extensive caries Restore or extract if tooth destruction is Amalgam, cast metal, ceramic, metal - ceramic
extensive
Defective or failed restoration Repair or replacement Will depend on whether restoration is being
repaired or replaced, but may include any
restorative material
Tooth fracture Restore or extract depending upon severity Amalgam, composite, cast alloys, metal - ceramic,
ceramics (depends on severity of fracture)
Post-endodontic restoration Restore and protect with Cast alloy, metal ceramic, ceramic — onlay or
onlay or crown crown
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• The correct relationship with the adjacent tooth allows In addition to creating a contact area of proper size, location
a good support against masticatory forces and promotes and configuration, it is also essential to restore the proximal
the deflection of the food through the embrasure.[10] surface to a proper contour. Fabricating a restoration that
• Influences speech and cosmetics especially in the anterior does not reproduce the concavities and convexities which
region.[9] occur here naturally will lead to overhanging or under
hanging restorations which leads to periodontal damage.[12]
Improper restoration in the contact area will cause displacement
of the teeth, lifting forces of the teeth, rotation of the teeth, Clinical impression suggests loose or open proximal contact to
deflecting occlusal contact and food impaction.[11] be the contributing factors to periodontal pocket formation.
It is still generally accepted that a good contour and a tight
Disadvantages of improper contact areas proximal contact are important for gingival health.[13]
Faulty contacts leads to restorative defects which hampers
the health of the periodontium: Marginal ridges
• Too broad contact bucco-lingually or occlusal-gingivally Marginal ridges of the posterior tooth are considered to be
causes change in the tooth anatomy, improper shunting of a primary importance in providing structural strength to
of food in bucco-lingual direction because of narrow crown.[14] It has a greater thickness of enamel than other
embrasure this leads to food impingement in the contact areas. Loss of one or more marginal ridge weakens the
area and contact area which is more concave (or flat) tooth.[15]
can be broad which will result in improper physiological
movement of the tooth.[10,12] It is imperative to have a marginal ridge of proper dimension,
• Too narrow contact bucco-lingually or occluso-gingivally compatible to the occlusal anatomy creating a pronounced
causes food impaction vertically and horizontally which leads adjacent triangular fosse and occlusal embrasure. Marginal
to wide embrasure in which lead to greater food retention ridge should always form in two planes bucco-lingually
and plaque accumulation and contact area which is more meeting at a very obtuse angle. This feature is essential
convex will diminish the extent of the contact area.[10,12] when an opposing functional cusp occludes with the marginal
• Contact area placed too occlusally, bucally or lingually ridge. These essential features are necessary to prevent food
will result in flattened marginal ridge of the restoration, lodgement which causes damage to the periodontium.
Contact point too gingivally will lead to increased depth
There are two forces acting on two marginal ridges, force 1
of occlusal embrasure, loose contact creates continuity
and 2 which have their horizontal components, 1H and 2H
between embrasure leading to food impaction.[10]
drive the two teeth towards each other, thus preventing any
It is not uncommon to observe good proximal contact but in proximal impaction of food.[12] The vertical forces 1V and
adequate contour in proximal restoration. Similarly a good 2V which are acting vertically are resolved normally by the
contour with the poor proximal contact exits can be possible.[8] underlying tissue [Figure 1].[10] Marginal ridge portion of the
restoration should be compatible with the adjacent marginal
Contours ridge, both the ridges should be approximating at the same
Each tooth exhibits contour in the form of concavity and level and display correct occlusal embrasure for the passage
convexity. Facial and lingual convexities of the tooth holds the of the food to facial and lingual surface.[3]
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]
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Criteria’s for restorations of marginal ridge: there are no horizontal component 1H and 2H to drive
1. In the absence of marginal ridge: the tooth toward each other and vertical force 1V and 2V
The forces 1will be directed towards the proximal ridge of will impact the food interproximally [Figure 4].
the adjacent tooth and force 2 is directed on to the same 4. Single planed marginal ridge in bucco-lingual direction
tooth, so the horizontal forces 1H and 2H will act on the This can create the premature contact during both
same tooth, which will tend to drive the two teeth away function and static occlusion, one plan marginal ridge
from each other. The vertical component 1V and 2V can increases the depth of adjacent triangular fossa by
impact the food intraorally [Figure 2]. increasing the stress in this area and also increases the
2. Adjacent marginal ridge not compatible with height: height of the marginal ridge at the centre, and this will
Restoring the marginal ridge higher than the adjacent deflect the food away from the spillway [Figure 5].
one will allow force1 (A) on the proximal surface of the 5. Thin marginal ridge in mesio-distal bulk:
restoration, the horizontal component 1H (AH) will drive Will be susceptible to fracture or deformation leading
the restored tooth away from the contacting tooth and to the problems of previously mentioned faulty marginal
the vertical component will push debris interproximally ridge (discussed in point 1, 2, 3 and 4) [Figure 6].
even in the presence of force 2 (B) with its horizontal
component (BH) acting on the adjacent marginal ridge Studies have shown that regardless of loading directions and
there is some separation of the teeth as force 2(B) is too location, the marginal ridges and proximal contact area were
small as compared to force 1 (A). By restoring the marginal sites of low strain.[14] Thickness of enamel at the marginal ridge
ridge lower than the adjacent one we can expect the same is high and loss of tooth structure in this area weakens the
movement of the tooth but the major movement will be tooth structure. Both clinical and experimental studies have
non restored tooth [Figure 3a and b]. highlighted the importance of preserving the marginal ridge.[16-18]
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
b
Figure 3: (a) Improper marginal ridge (b) Improper marginal ridge
Figure 4: Absences of adjacent triangular fossa Figure 5: One planned marginal ridge
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126 Journal of the International Clinical Dental Research Organization | July-December 2015 | Vol 7 | Issue 2
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disease.[22]
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
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Biologic width violation leads to chronic progressive gingival Where the aesthetic is not a concern and adequate tooth
inflammation, Clinical attachment loss and alveolar bone structure exists, supra gingival margins are recommended. In
loss. Gingival hyperplasia is also most frequently found in areas with the inadequate tooth structure crown lengthening
subgingivally placed restorative margins. or orthodontic extrusion can be used to increase clinical
crown lengthening.
Evaluation of biologic width violation
The most important diagnostic method is bone sounding, For subgingival placement of the dental implant several
which is done by probing under local anaesthesia to bone principles should be considered.
level. Biologic width is assessed by subtracting the sulcular • The marginal fit should be optimal because of the rough
depth from the resulting bone sounding measurement. If surface or open margin leads to bacterial accumulation
this distance is less than 2 mm, then a violation of biologic that are associated with inflammatory periodontal
width can be diagnosed. Radiographic evaluation can assess disease.
interproximal violation of biologic width. But it is not • The margins of the implant should extend only slightly
diagnostic because of tooth superimposition.[28] into the gingival sulcus, to avoid violation of biologic
width.
Evaluation of biologic width • Materials used in the restorations should be compatible
The techniques employed in dental practice for the evaluation with the soft tissue and lend themselves to the precise
of biologic width.[29] interface to minimize marginal discrepancies that
encourages retention of bacterial plaque.
By Radiographs.
By Periodontal probe. In areas of aesthetic concern, to minimize the effect of
bacterial trap at the implant and restorative junction the
Correction of biologic width violation clinician should consider selection of the implant system that:
Biologic width violation can be corrected surgically or • Has the interphase coronal to facial and lingual bone.
orthodontically.[30] • Provides the closest possible implant/abdument interface.
• Surgical correction is aimed at removing the bone away • Allows screw- retained restorations.[2]
from the restorative margin done by gingivectomy,
apically repositioned flap with or without ostectomy. Considerations for complex restorations
• Orthodontic correction, the tooth is moved coronally An operator should have a through knowledge of restorative
away from the bone is done either by slow eruption or design, materials and technique when examining the badly
forced eruption with supracrestal fiberotomy. mutilated teeth following steps should be taken before
finalizing that design and executing it.
Biologic considerations during implant restoration • Evaluate the P-D organ and the periodontium of the tooth
The ultimate long term success of implants is largely relied to be restored, preferably before the patient is anesthetized.
upon the interphase between implants and their surrounding • Remove all the undermined enamel. There is no place for
tissues, both hard and soft tissues. Dental implant have two such enamel in all permanently restored posterior teeth.
distntic interface with oral tissues. • Clean all surrounding walls from dentin that is infected.
• The soft tissue- implant interface is where the peri-implant • Through knowledge of biologic concept is a must (as
mucosa meets the implant creating a biological seal to discussed above).[12]
prevent future disease invasion. Due to the natural of the
Restorative margin and periodontium
tissue component, soft tissues surrounding the dental
The gingival peripheral destructions should be recorded
implants are called peri- implant mucosa instead of gingival.
and the margins of the restorations should be planned
• The hard tissue- implant interface where the alveolar bone
accordingly:
contact with implant surface. This integration provides
• If the tooth destruction is located supragingivally, no need
stability and rigidity that implant needs.[31]
for the any change in the periodontium.
The successful integration of periodontal and restorative • If the tooth destruction is located apically to gingival
dentistry for both natural teeth and implant requires cervice but suprabony, gingivectomy is performed to
knowledge and application of both biological and mechanical expose the apical limit of defect.
principles. • If apical limit of defect is infrabony:
a. Full thickness mucoperiosteal flap is raised with
Subgingival margins should be considered as a compromise osteotomy to correct the defect.
and supragingival margins are preferred. b. Intentional extrusion of the tooth is done.
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