SECTION VI

Periodontal-
Restorative
Interrelationships
OUTLINE

Chapter 69 Preparation of the Periodontium for Restorative

Dentistry
Chapter 70 Restorative Interrelationships
Chapter 71 Multidisciplinary Versus Interdisciplinary
Approaches to Dental and Periodontal Problems

3847
CHAPTER 69

Preparation of the
Periodontium for
Restorative Dentistry
Philip R. Melnick, Henry H. Takei

CHAPTER OUTLINE

Rationale for Therapy

Sequence of Treatment
Control of Active Disease
Preprosthetic Surgery (e-only)
Conclusion

Editors' note: An animation (slide show) has been added by the

editors as a supplement to the chapter. It was produced by My
Dental Hub as a patient education tool and covers the basic
elements in a conceptual manner. It is not intended to be a
procedural guide for dental professionals.

3848
Periodontal health is the sine qua non, a prerequisite, of successful
comprehensive dentistry.25 To achieve the long-term therapeutic
targets of comfort, good function, treatment predictability,
longevity, and ease of restorative and maintenance care, active
periodontal infection must be treated and controlled before the
initiation of restorative, aesthetic, and implant dentistry. In
addition, the residual effects of periodontal disease or anatomic
aberrations inconsistent with realizing and maintaining long-term
stability must be addressed. This phase of treatment includes
techniques performed in anticipation of aesthetic or implant
dentistry, such as clinical crown lengthening, covering denuded
roots, alveolar ridge retention or augmentation, and implant site
development (Video 69.1: Effects of Single Tooth Loss ).

Rationale for Therapy

The many reasons for establishing periodontal health before
performing restorative dentistry include the following52:

1. Periodontal treatment is undertaken to ensure the

establishment of stable gingival margins before tooth
preparation. Noninflamed, healthy tissues are less likely to
change (e.g., shrink) as a result of subgingival restorative
treatment or postrestoration periodontal care.28,29 In
addition, tissues that do not bleed during restorative
manipulation allow for a more predictable restorative and
aesthetic result.22,23
2. Certain periodontal procedures are designed to provide for
adequate tooth length for retention, access for tooth
preparation, impression making, tooth preparation, and
finishing of restorative margins in anticipation of restorative
dentistry.22,47 Failure to complete these procedures before
restorative care can add to the complexity of treatment and
introduce unnecessary risk for failure.22
3. Periodontal therapy should antecede restorative care
because the resolution of inflammation may result in the
repositioning of teeth46 or in soft tissue and mucosal
changes.20,48 Failure to anticipate these changes may interfere

3849
 with prosthetic designs planned or constructed before
periodontal treatment.
4. Traumatic forces placed on teeth with ongoing periodontitis
may increase tooth mobility, discomfort, and possibly the
rate of attachment loss.9 Restorations constructed on teeth
free of periodontal inflammation, synchronous with a
functionally appropriate occlusion, are more compatible
with long-term periodontal stability and comfort (see
Chapters 18 and 55).
5. Quality, quantity, and topography of the periodontium may
play important roles as structural defense factors in
maintaining periodontal health. Orthodontic tooth
movement and restorations completed without the benefit
of periodontal treatment designed for this purpose may be
subject to negative changes that complicate construction and
future maintenance.55
6. Successful aesthetic and implant procedures may be difficult
or impossible without the specialized periodontal
procedures developed for this purpose.

Learning Box 69.1

Periodontal treatment is undertaken to ensure the establishment of
stable gingival margins before tooth preparation. Noninflamed,
healthy tissues are less likely to change (e.g., shrink) as a result of
subgingival restorative treatment or postrestoration periodontal
care. In addition, tissues that do not bleed during restorative
manipulation allow for a more predictable restorative and aesthetic
result.

Sequence of Treatment
Treatment sequencing should be based on logical and evidence-
based methodologies, taking into account not only the disease state
encountered but also the psychological and aesthetic concerns of
the patient. Because periodontal and restorative therapy is
situational and specific to each patient, a plan must be adaptable to

3850
change depending on the variables encountered during the course
of treatment. For example, teeth initially determined to be
salvageable may be judged “hopeless,” thus altering the established
treatment scheme.20,48
Generally, the preparation of the periodontium for restorative
dentistry can be divided into two phases: (1) control of periodontal
inflammation with nonsurgical and surgical approaches and (2)
preprosthetic periodontal surgery (Box 69.1).

Box 69.1
Sequence of Treatment in Preparing
Periodontium for Restorative Dentistry
Control of Active Disease

Emergency treatment
Extraction of hopeless teeth
Oral hygiene instructions
Scaling and root planing
Reevaluation
Periodontal surgery
Adjunctive orthodontic therapy

Preprosthetic Surgery

Management of mucogingival problems

Preservation of ridge morphology after tooth extraction
Crown-lengthening procedures
Alveolar ridge reconstruction

Control of Active Disease

When the clinician is presented with a patient with different stages
of periodontal involvement, this condition must be treated before
one can contemplate any restorative dentistry. This step is the most
important part of preparing the periodontium for restorative

3851
dentistry. The inflammatory state of the supporting tissues must be
eliminated or controlled with biofilm removal, scaling, root
planing, and, if necessary, periodontal surgery.
The periodontal therapy is intended to control the active disease
(see Chapters 47 to 57). In addition to the removal of biofilm and
root surface accretions that are the primary etiologic agents,
secondary local factors, such as plaque-retentive overhanging
margins and untreated caries, must be addressed.14,19

Emergency Treatment
Emergency treatment is undertaken to alleviate symptoms and
stabilize acute infection. This includes endodontic as well as
periodontal conditions (see Chapters 45 and 46). To the patient, the
control of acute pain, especially endodontic, is the most important
reason for seeking dental therapy. Therefore this aspect of therapy
must be properly addressed before any other therapy is instituted.

Extraction of Hopeless Teeth

Extraction of hopeless teeth is followed by provisionalization with
fixed or removable prosthetics. Retention of hopeless teeth without
periodontal treatment may result in bone loss around the adjacent
teeth.32 It is also important to consider the extraction of teeth with a
poor prognosis when implant replacement has become a
predictable alternative to keeping and attempting periodontal
therapy.

Oral Hygiene Measures

As indicated earlier, oral hygiene measures, when properly applied,
will reduce plaque biofilm scores and gingival inflammation30,51 (see
Chapter 48). However, in patients with deep periodontal pockets
(>5 mm), plaque biofilm control measures alone are insufficient for
resolving subgingival infection and inflammation.5,30 Hygiene alone
does not allow the brush to reach into the deep pocket area to
remove nor disturb the plaque biofilm.

3852
Scaling and Root Planing
Scaling and root planing combined with oral hygiene measures
have been demonstrated to significantly reduce gingival
inflammation and the rate of the progression of periodontitis3,4,31
(see Chapter 50). This applies even to patients with deep
periodontal pockets5,15 (Fig. 69.1).

FIG. 69.1 Root planing has resolved the gingival

inflammation of this patient.

Learning Box 69.2

When the clinician is presented with a patient with any stage of
periodontal involvement, this condition must be treated before one
can contemplate any restorative dentistry.

Reevaluation
After 4 weeks the gingival tissues are evaluated to determine oral
hygiene adequacy, soft tissue response, and pocket depth (see
Chapter 47). This permits sufficient time for healing, reduction in
inflammation and pocket depths, and gain in clinical attachment
levels. However, in deeper pockets (>5 mm), plaque biofilm and
calculus removal are often incomplete2,54 with risk of future
breakdown8,49 (Fig. 69.2). As a result, periodontal surgery to access
the root surfaces for instrumentation and to reduce periodontal
pocket depths must be considered before restorative care proceeds.

3853
 FIG. 69.2 (A) Before treatment. (B) After 4 weeks, oral
hygiene instructions and scaling and root planing have
improved this patient's periodontal status. However,
inflammation associated with pockets deeper than 5
mm suggests a need for periodontal surgery.

Periodontal Surgery
Periodontal surgery may be required for some patients (see
Chapters 60, 62, and 63). This should be undertaken with future
restorative and implant dentistry in mind. Some procedures are
intended to treat active periodontal disease successfully,12,37 and
others are aimed at preparing the mouth for restorative or
prosthetic care.55 Crown lengthening is an example of such surgery.
Both types of surgery are for preparing the periodontium for
restorative dentistry.

3854
Adjunctive Orthodontic Therapy
Orthodontic treatment has been shown to be a useful adjunct to
periodontal therapy6,17,18,24,34 (see Chapter 56). It should be
undertaken only after active periodontal disease has been
controlled. If nonsurgical treatment is sufficient, definitive
periodontal pocket therapy may be postponed until after the
completion of orthodontic tooth movement. This allows for the
advantage of the positive bone changes that orthodontic therapy
can provide. However, deep pockets and furcation invasions may
require surgical access for root instrumentation in advance of
orthodontic tooth movement. Failure to control active periodontitis
can result in acute exacerbations and bone loss during tooth
movement.10 As long as the periodontium is periodontally healthy,
teeth with preexisting bone loss may be moved orthodontically
without incurring additional attachment loss.39,40
If teeth that are to be orthdontically moved lack keratinized
attached gingiva, soft tissue–grafting procedures are often indicated
in anticipation of orthodontic therapy. The procedure is necessary
to increase the dimension of attached tissue to prevent the
possibility of gingival margin recession.34,55

Learning Box 69.3

Periodontal surgery is performed for the treatment of active
periodontal disease as well as for the preprosthetic preparation of
the periodontium. Some procedures are intended to treat active
disease successfully, and others are aimed at preparing the mouth
for restorative or prosthetic care.

Preprosthetic Surgery
Management of Mucogingival Problems
Periodontal plastic surgical procedures may be undertaken for a
variety of reasons.7 The most common techniques include those that
increase the gingival dimensions and achieve root coverage. These
procedures are often indicated before restoration for prosthetic

3855
reasons (eFig. 69.1) and in conjunction with orthodontic tooth
movement.34 Root coverage procedures may also be undertaken for
purposes of comfort and aesthetics (eFig. 69.2).7 At least 2 months of
healing is recommended after soft tissue grafting procedures before
initiating restorative dentistry55 (see Chapter 65).

EFIG. 69.1 In preparation for a removable partial

denture, this canine has received a gingival graft to
increase attached gingiva and deepen the vestibule.
(A) Before therapy. Note minimal attached gingiva. (B)
After therapy, there is abundant attached gingiva and
vestibular depth.

3856
 EFIG. 69.2 Connective tissue graft placed under a
double-papilla flap has been used to provide root
coverage for a maxillary right canine. (A) Maxillary
canine before therapy. (B) Connective tissue graft
placed over denuded root surface. (C) Papilla placed
over connective tissue. (D) Final result.

Preservation of Ridge Morphology After

Tooth Extraction
Alveolar ridge resorption is a common consequence of tooth loss.1,2
Ridge preservation procedures have been shown to be useful in
anticipation of the future placement of a dental implant or for
pontics used for fixed bridges, as well as in cases where unaided
healing would result in an unaesthetic deformity16,26,27,33,36,42 (eFig.
69.3).

3857
 EFIG. 69.3 (A) The maxillary right lateral incisor has
failed endodontically, with a fistulous tract noted exiting
from the attached gingiva. (B) The tooth is
atraumatically removed and the socket debrided while
maintaining the surrounding anatomic integrity. (C) In
an effort to reduce ridge collapse, the socket is grafted
with a combination of deproteinized bovine bone and
calcium sulfate. (D) Provisional fixed partial denture is
placed, with an ovate pontic extending 2 mm into the
socket and supporting the surrounding tissues. (E–F)
After 8 weeks, the socket has healed, preserving the
gingival and papillary architecture, in preparation for an
aesthetic final prosthesis. (G) Final restoration.

Crown-Lengthening Procedures
Surgical crown-lengthening procedures are performed to provide
retention form to allow for proper tooth preparation, impression
procedures,23 and placement of restorative margins (eFig. 69.4),23

3858
and to adjust gingival levels for aesthetics.35,50 It is important that
crown-lengthening surgery is done in such a manner that the
biologic width is preserved. The biologic width is defined as the
physiologic dimension of the junctional epithelium and connective
tissue attachment (see Chapter 70). This measurement has been
found to be relatively constant at approximately 2 mm (±30%).11 The
healthy gingival sulcus has an average depth of 0.69 mm (eFig.
69.5).21 It has been theorized that infringement on the biologic width
by the placement of a margin of a restoration within its zone may
result in gingival inflammation,21 pocket formation, and alveolar
bone loss38 (eFig. 69.6). Consequently, it is recommended that there
be at least 3 mm between the gingival margin and bone crest.13,41,44,47
This allows for adequate biologic width when the restoration is
placed 0.5 mm within the gingival sulcus44,47 (eFig. 69.7).

EFIG. 69.4 Surgical crown lengthening has provided

these otherwise unrestorable mandibular molars with
improved retention and restorative access for
successful restorations. (A) Before crown lengthening.
(B) Crown-lengthening surgery completed. Note
increased clinical crown. (C) Buccal view after surgery.
(D) Final restorations.

3859
 EFIG. 69.5 The biologic width has been estimated to
be about 2 mm. Efforts should be made to preserve its
integrity.

EFIG. 69.6 Although gingival inflammation around

crowns may have a variety of causes, infringement of
biologic width must be considered.

3860
 EFIG. 69.7 Placement of the restorative margin 0.5
mm into the sulcus allows for the maintenance of the
biologic width.

Surgical crown lengthening may include the removal of soft

tissue or both soft tissue and alveolar bone. Reduction of soft tissue
alone is indicated if there is adequate attached gingiva and more
than 3 mm of tissue coronal to the bone crest (eFig. 69.8). This may
be accomplished by either gingivectomy or flap technique (see
Chapter 60). Inadequate attached gingiva and less than 3 mm of soft
tissue require a flap procedure and bone recontouring (eFig. 69.9).
In the case of caries or tooth fracture, to ensure margin placement
on sound tooth structure and retention form, the surgery should
provide at least 4 mm from the apical extent of the caries or fracture
to the bone crest (eFig. 69.10).

3861
EFIG. 69.8 Greater than 3 mm of soft tissue between
the bone and gingival margin, with adequate attached
gingiva, allows crown lengthening by gingivectomy.

EFIG. 69.9 With less than 3 mm of soft tissue between

the bone and gingival margin, or less-than-adequate
attached gingiva, a flap procedure and osseous
recontouring are required for crown lengthening.

3862
 EFIG. 69.10 In the case of caries or fracture, at least 1
mm of sound tooth structure should be provided above
the gingival margin for proper restoration.

With the advent of predictable implant dentistry, it is important

to carefully evaluate the value of crown lengthening for restorative
therapy as opposed to tooth removal and replacement with a dental
implant (eBox 69.1).

eBox 69.1
Surgical Crown Lengthening
Indications

Subgingival caries or fracture.

Inadequate clinical crown length for retention.
Unequal or unaesthetic gingival heights.

Contraindications

Surgery would create an unaesthetic outcome.

Deep caries or fracture would require excessive bone removal
on contiguous teeth.
The tooth is a poor restorative risk.

Alveolar Ridge Reconstruction

3863
Patients are frequently seen with alveolar ridge resorption after
tooth loss (see Chapter 75). To provide for adequate anatomic
dimensions for the construction of an aesthetic pontic (see Chapter
70, or for a discussion on the placement of dental implants see
Chapter 75), alveolar ridge reconstruction is undertaken.42,43,45 In the
case of aesthetic pontic construction, small defects may be treated
with soft tissue ridge augmentation (eFig. 69.11). For larger defects
and in those sites receiving dental implants, hard tissue modalities
are used43,45 (eFig. 69.12).

3864
EFIG. 69.11 (A) Loss of the maxillary left central incisor
has resulted in an unaesthetic alveolar ridge defect.
(B–E) An incision is made at the ridge crest, a pouch is
created, and a soft tissue graft harvested from the
palate is placed into the pouch. (F–H) A removable
appliance with an ovate pontic is placed in light contact
with the grafted site. Swelling around the pontic apex
results in a tissue concavity from which the more

3865
 natural-appearing final restoration emerges.

EFIG. 69.12 Postextraction ridge defect is grafted with

a combination of autogenous and deproteinized bovine
bone and contained by nonresorbable barrier

3866
 membrane.53 After 8 months, the site is reopened and
the membrane removed. A comparison of parts B and
G shows significant reconstitution of hard tissue, in this
case used for the installation of a dental implant. (A)
Edentulous ridge before surgery. (B) Flap reflection to
visualize defect. (C) Graft material placed over
resorbed ridge. (D) Nonresorbable titanium-reinforced
membrane placed over graft material. (E) Graft site
sutured. (F) Surgical site reopened 8 months after
surgery. (G) New bone over ridge. (H) Implant placed
into augmented ridge.

Conclusion
As described in this and other sections of this textbook, the
therapeutic goals of patient comfort, function, aesthetics,
predictability, longevity, and ease of restorative and maintenance
care are attainable only by a carefully constructed interdisciplinary
approach with accurate diagnosis and comprehensive treatment
planning serving as the cornerstones. The complex interaction
between periodontal therapy and successful restorative dentistry
only serves to underscore this premise.

Case Scenario 69.1

Patient:
31-year-old female
Background Information
The patient has a fractured crown on tooth #7. She is healthy and
has no known drug allergies.

3867
CASE-BASED
SOLUTION AND EXPLANATION
QUESTION
1. To provide a full Answer: D
crown restoration Explanation: Teeth damaged by caries or fracture once certified as
in this case, a restorable can often be retained by performing a surgical crown-
surgical crown lengthening procedure. Teeth in the aesthetic zone require special
lengthening consideration. Care should be taken not to increase the crown length
should be at the expense of aesthetics. Efforts should be made to maintain a
performed. Why? gingival level that is symmetrical to the contiguous teeth and the
A. To provide contralateral side. If it appears that a crown-lengthening surgery will
for result in an unaesthetic gingival level, an alternative treatment, such
retention, as orthodontic extrusion, should be considered.
tooth
preparation,
and
impressions
B. To
preserve
“biologic
width”
C. To
maintain
aesthetic
gingival
levels
D. All of the
above

3868
Case Scenario 69.2

Patient:
44-year-old female
Chief Complaint:
My gums have receded and I am unhappy with my appearance.
Background Information
The patient is healthy and has no known drug allergies.

CASE-BASED
SOLUTION AND EXPLANATION
QUESTION
1. This patient is preparing Answer: E
for orthodontics and Explanation: Gingival recession is the result of a
restorative dentistry. Why combination of an underlying bone dehiscence and gingival
should soft-tissue grafting inflammation. The root exposure can result in dental
be considered? sensitivity, root damage, and an unesthetic appearance. The
A. To prevent future treatment is soft tissue grafting.
gingival recession
B. To protect the
exposed root
C. To reduce dentinal
sensitivity
D. To provide for an
aesthetic tooth
length
E. All of the above

Case Scenario 69.3

Patient:

3869
64-year-old male
Chief Complaint:
“My gums are swollen.”
Background Information
The patient has a history of infrequent dental care and developed
asymptomatic gingival enlargement over several years. He also has
hypertension and takes the antihypertensive medication
amlodipine, a calcium channel blocker.

CASE-BASED
SOLUTION AND EXPLANATION
QUESTION
1. What should this Answer: F
patient do to Explanation: It is important to complete periodontal treatment aimed
prepare for at controlling an active disease before the commencement of
orthodontic orthodontics and restorative dentistry. This patient takes medication,
treatment and which has led to drug-induced gingival overgrowth. This gingival
restorative enlargement is often related to a combination of plaque-associated
dentistry? inflammation and the effect of the calcium channel blocker,
A. Consult amlodipine. Resolution of the problem requires treating both the
with his plaque-associated inflammation and the response to the medication.
medical Once the medication has been discontinued, in conjunction with
doctor nonsurgical periodontal therapy, the result may be complete
before resolution of the hyperplasia. If not, surgical reduction may be
treatment to indicated.
discuss a
possible
medication
change,
which may
be in part
responsible
for the
gingival
overgrowth

3870
 B. Complete
scaling and
root planing
and oral
hygiene
education
C. Reevaluate
after a
suitable
period for
the
resolution
of gingival
enlargement
D. Consider
surgical
treatment to
reduce
enlarged
gingival
tissues
E. Enter into a
well-
planned
prevention
program
F. All of the
above

Case Scenario 69.4

Patient:
55-year-old male
Chief Complaint:
“I fractured my tooth, but I would really like to retain it.”
Background Information
The patient recently fractured tooth #29, close to bone crest. He has
had previous endodontic treatment and is asymptomatic. The
patient is healthy and has no known drug allergies.

3871
CASE-BASED
SOLUTION AND EXPLANATION
QUESTION
1. Based on the photos Answer: B
presented, what Explanation: Tooth fracture is a common dental malady. Surgical
treatment option is crown lengthening provides the opportunity to retain structurally
available to meet the damaged teeth, once they have been judged to be salvageable. It
patient's desire for allows access for restorative procedures and retention form. Care
tooth retention? must be taken preserve space for supracrestal soft tissue growth to
A. Preparation a physiologic dimension (“biologic width”). Failure to do so can
of the tooth for result in chronic gingival inflammation and possible bone loss.
a crown with
the finish line
approximating
the bone crest.
B. Surgical
crown
lengthening
followed by a
crown
restoration.
C. The tooth
cannot be
restored;
extraction and
replacement is
the only
option.

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3872
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Payne AG, et al: Interventions for replacing missing teeth:
alveolar ridge preservation techniques for dental site
development. Cochrane Database Syst Rev. 2015 [CD010176].
43. Rios HF, Vignoletti F, Giannobile WV, et al. Ridge
augmentation procedures. Lang N, Lindhe J. Clinical
periodontics and implant dentistry. 2015 [Wiley-Blackwell].
44. Rosenberg ES, Cho SC, Garber DA. Crown lengthening
revisited. Compend Contin Educ Dent. 1999;20:527.
45. Sanz-Sanchez IL, Ortiz-Vigon AL, Sanz-Martin I, et al.
Effectiveness of lateral bone augmentation on the alveolar
crest dimension: a systematic review and meta-analysis. J
Dent Res. 2015;94(9 Suppl):128S–142S.
46. Sato S, Ujiie H, Ito K. Spontaneous correction of pathologic
tooth migration and reduced infrabony pockets following
nonsurgical periodontal therapy: a case report. Int J
Periodontics Restorative Dent. 2004;24:456.
47. Smukler H, Chaibi M. Periodontal and dental considerations
in clinical crown extension: a rational basis for treatment.
Int J Periodontics Restorative Dent. 1997;17:465.
48. Spear FM, Kokich VG. A multidisciplinary approach to
esthetic dentistry. Dent Clin North Am. 2007;51:487.
49. Stambaugh RV, Dragoo M, Smith DM, et al. The limits of
subgingival scaling. Int J Periodontics Restorative Dent.
1981;1:31.
50. Studer S, Zellweger U, Schärer P. The aesthetic guidelines of
the mucogingival complex for fixed prosthodontics. Pract
Periodontics Aesthet Dent. 1996;4:333.
51. Tagge DL, O'Leary TJ, El-Kafrawy AH. The clinical and
histological response of periodontal pockets to root planing

3876
 and oral hygiene. J Periodontol. 1975;46:527.
52. Takei HH, Azzi RR, Han TJ. Preparation of the
periodontium for restorative dentistry. Newman MG, Takei
HH, Carranza FA. Carranza's clinical periodontology. ed 9.
Saunders: Philadelphia; 2002.
53. Urban IA, Nagursky H, Lozada JL, et al. Horizontal ridge
augmentation with a collagen membrane and a
combination of particulated autogenous bone and
anorganic bovine bone derived mineral: a prospective case
series. Int J Periodontics Restorative Dent. 2013;33:299.
54. Waerhaug J. The furcation problem: etiology, pathogenesis,
diagnosis, therapy and prognosis. J Clin Periodontol.
1980;7:73.
55. Wennström JL. Mucogingival therapy. In Proceedings of the
1996 World Workshop in Periodontics. Lansdowne,
Virginia, July 13-17. Ann Periodontol. 1996;1:671.

3877
CHAPTER 70

Restorative
Interrelationships
Frank M. Spear, Todd R. Schoenbaum, Joseph P. Cooney

CHAPTER OUTLINE

Biologic Considerations
Aesthetic Tissue Management
Occlusal Considerations in Restorative Therapy
Special Restorative Considerations (e-only)

Editors' note: An animation (slide show) has been added by the

editors as a supplement to the chapter. It was produced by My
Dental Hub as a patient education tool and covers the basic
elements in a conceptual manner. It is not intended to be a
procedural guide for dental professionals.

The relationship between periodontal health and the restoration of

teeth is intimate and inseparable. For restorations to survive long
term, the periodontium must remain healthy so that the teeth are

3878
maintained. For the periodontium to remain healthy, restorations
must be critically managed in several areas so that they are in
harmony with their surrounding periodontal tissues. To maintain
or enhance the patient's aesthetic appearance, the tooth–tissue
interface must present a healthy natural appearance, with gingival
tissues framing the restored teeth in a harmonious manner. This
chapter reviews the key areas of restorative management necessary
to optimize periodontal health, with a focus on the aesthetics and
function of restorations.

Biologic Considerations
Margin Placement and Biologic Width
One of the most important aspects of understanding the
periodontal–restorative relationship is the location of the restorative
margin to the adjacent gingival tissue. Restorative clinicians must
understand the role of biologic width in preserving healthy gingival
tissues and controlling the gingival form around restorations. They
must also apply this information in the positioning of restoration
margins, especially in the aesthetic zone, where a primary
treatment goal is to mask the junction of the margin with the tooth.
A clinician is presented with three options for margin placement:
supragingival, equigingival (even with the tissue), and
subgingival.69 The supragingival margin has the least impact on the
periodontium. Classically, this margin location has been applied in
unaesthetic areas because of the marked contrast in color and
opacity of traditional restorative materials against the tooth. With
the advent of more translucent restorative materials, adhesive
dentistry, and resin cements, the ability to place supragingival
margins in aesthetic areas is now a reality (Figs. 70.1 and 70.2).
Therefore whenever possible, these restorations should be chosen
not only for their aesthetic advantages but also for their favorable
periodontal impact.

3879
 FIG. 70.1 With the advent of adhesive dentistry and
ultrathin ceramic veneers, it now is possible to prepare
restorations equigingival without visible margins. The
preparations for six porcelain veneers with the margins
placed at the level of tissue are shown.

FIG. 70.2 The completed veneers from Fig. 70.1. Note

the invisible gingival finish line, even though the margin
has not been carried below tissue.

The use of equigingival margins traditionally was not desirable

because they were thought to retain more plaque than
supragingival or subgingival margins and therefore resulted in
greater gingival inflammation. There was also the concern that any
minor gingival recession would create an unsightly margin display.
These concerns are not valid today, not only because the restoration

3880
margins can be aesthetically blended with the tooth, but also
because restorations can be finished easily to provide a smooth,
polished interface at the gingival margin. From a periodontal
viewpoint, both supragingival and equigingival margins are well
tolerated.
The greatest biologic risk occurs when placing subgingival
margins.42 These margins are not as accessible as supragingival or
equigingival margins for finishing procedures. In addition, if the
margin is placed too far below the gingival tissue crest, it violates
the gingival attachment apparatus.
As described in Chapter 3, the dimension of space that the
healthy gingival tissues occupy between the base of the sulcus and
the underlying alveolar bone is composed of the junctional
epithelial attachment and the connective tissue attachment. The
combined attachment width is now identified as the biologic width.
Most authors credit Gargiulo, Wentz, and Orban's 1961 study18 on
cadavers with the initial research establishing the dimensions of
space required by the gingival tissues. They found that, in the
average human, the connective tissue attachment occupies 1.07 mm
of space above the crest of the alveolar bone and that the junctional
epithelial attachment below the base of the gingival sulcus occupies
another 0.97 mm of space above the connective tissue attachment.
The combination of these two measurements, averaging
approximately 1 mm each, constitutes the biologic width (Fig. 70.3).
Clinically, this information is applied to diagnose biologic width
violations when the restoration margin is placed 2 mm or less away
from the alveolar bone and the gingival tissues are inflamed with
no other etiologic factors evident.

3881
 FIG. 70.3 Average human biologic width: connective
tissue attachment 1 mm in height; junctional epithelial
attachment 1 mm in height; sulcus depth of
approximately 1 mm. The combined connective tissue
attachment and junctional epithelial attachment, or
biologic width, equals 2 mm.

Restorative considerations frequently dictate the placement of

restoration margins beneath the gingival tissue crest. Restorations
may need to be extended gingivally (1) to create adequate
resistance and retentive form in the preparation, (2) to make
significant contour alterations because of caries or other tooth
deficiencies, (3) to mask the tooth–restoration interface by locating
it subgingivally, or (4) to lengthen the tooth for aesthetic reasons.
When the restoration margin is placed too far below the gingival
tissue crest, it impinges on the gingival attachment apparatus and
creates a violation of biologic width.49 Two different responses can
be observed from the involved gingival tissues (Fig. 70.4).

3882
 FIG. 70.4 Ramifications of a biologic width violation if a
restorative margin is placed within the zone of the
attachment. On the mesial surface of the left central
incisor, bone has not been lost, but gingival
inflammation occurs. On the distal surface of the left
central incisor, bone loss has occurred, and a normal
biologic width has been reestablished.

One possibility is that bone loss of an unpredictable nature and

gingival tissue recession occurs as the body attempts to re-create
room between the alveolar bone and the margin to allow space for
tissue reattachment. This is more likely to occur in areas in which
the alveolar bone surrounding the tooth is very thin in width.
Trauma from restorative procedures can play a major role in
causing this fragile tissue to recede. Other factors that may impact
the likelihood of recession include (1) whether the gingiva is thick
and fibrotic or thin and fragile and (2) whether the periodontium is
highly scalloped or flat in its gingival form. It has been found that
highly scalloped, thin gingiva is more prone to recession than a flat
periodontium with thick fibrous tissue.47

Key Fact
Thin gingiva and highly scalloped papilla are more highly prone to
recession after normal restorative procedures.

The more common finding with deep margin placement is that

the bone level appears to remain unchanged, but gingival
inflammation develops and persists. To restore gingival tissue

3883
health, it is necessary to establish space clinically between the
alveolar bone and the margin. This can be accomplished either by
surgery to alter the bone level or by orthodontic extrusion to move
the restoration margin farther away from the bone level.

Biologic Width Evaluation

Radiographic interpretation can identify interproximal violations of
biologic width. However, with the more common locations on the
mesiofacial and distofacial line angles of teeth, radiographs are not
diagnostic because of tooth superimposition. If a patient
experiences tissue discomfort when the restoration margin levels
are being assessed with a periodontal probe, it is a good indication
that the margin extends into the attachment and that a biologic
width violation has occurred.
A more positive assessment can be made clinically by measuring
the distance between the bone and the restoration margin using a
sterile periodontal probe. The probe is pushed through the
anesthetized attachment tissues from the sulcus to the underlying
bone. If this distance is less than 2 mm at one or more locations, a
diagnosis of biologic width violation can be confirmed. This
assessment is completed circumferentially around the tooth to
evaluate the extent of the problem. However, biologic width
violations can occur in some patients in whom the margins are
located more than 2 mm above the alveolar bone level.22 In 1994
Vacek and colleagues70 also investigated the biologic width
phenomenon. Although their average width finding of 2 mm was
the same as that previously presented by Gargiulo and associates,18
they also reported a range of different biologic widths that were
patient specific. They reported biologic widths as narrow as 0.75
mm in some individuals, whereas others had biologic widths as tall
as 4.3 mm (Fig. 70.5).

3884
 FIG. 70.5 Possible variations exist in biologic width.
Connective tissue attachments and junctional epithelial
attachments may be variable. In this example, the
connective tissue attachment is 2 mm in height, the
junctional epithelial attachment 1 mm in height, and the
sulcus depth 1 mm, for a combined total tissue height
above bone of 4 mm. However, the biologic width is 3
mm. This is just one variation that can occur from the
average depicted in Fig. 70.3.

This information dictates that specific biologic width assessment

should be performed for each patient to determine if the patient
needs additional biologic width, in excess of 2 mm, for restorations
to be in harmony with the gingival tissues. The biologic, or
attachment, width can be identified for the individual patient by
probing to the bone level (referred to as “sounding to bone”) and
subtracting the sulcus depth from the resulting measurement. This
measurement must be done on teeth with healthy gingival tissues
and should be repeated on more than one tooth to ensure an
accurate assessment. The technique allows the variations in sulcus
depths found in individual patients to be assessed and factored into
the diagnostic evaluation. The information obtained is then used for
definitive diagnosis of biologic width violations, the extent of
correction needed, and the parameters for placement of future
restorations.

3885
Correcting Biologic Width Violations
Biologic width violations can be corrected either by surgically
removing bone away from proximity to the restoration margin or
by orthodontically extruding the tooth and thus moving the margin
away from the bone. Surgery is the more rapid of the two treatment
options.57 It is also preferred if the resulting crown lengthening
creates a more pleasing tooth length. Indications and
contraindications for surgical crown lengthening are presented in
Chapters 60 and 65 and illustrated with clinical examples. In these
situations, the bone should be moved away from the margin by the
measured distance of the ideal biologic width for that patient, with
an additional 0.5 mm of bone removed as a safety zone.
There is a potential risk of gingival recession after removal of
bone.7 If interproximal bone is removed, there is a high likelihood
of papillary recession and the creation of an unaesthetic triangle of
space below the interproximal contacts. If the biologic width
violation is on the interproximal side, or if the violation is across the
facial surface and the gingival tissue level is correct, orthodontic
extrusion is indicated27 (eFigs. 70.1 to 70.4). The extrusion can be
performed in two ways. By applying low orthodontic extrusion
force, the tooth will erupt slowly, bringing the alveolar bone and
gingival tissue with it. The tooth is extruded until the bone level has
been carried coronal to the ideal level by the amount that needs to
be removed surgically to correct the attachment violation. The tooth
is stabilized in this new position and then is treated with surgery to
correct the bone and gingival tissue levels. Another option is to
perform rapid orthodontic extrusion where the tooth is erupted to
the desired amount over several weeks.31 During this period, a
supracrestal fiberotomy is performed circumferentially around the
tooth weekly in an effort to prevent the tissue and bone from
following the tooth. The tooth is then stabilized for at least 12 weeks
to confirm the position of the tissue and bone, and any coronal
creep can be corrected surgically.

3886
EFIG. 70.1 The left central incisor was fractured in an
accident 12 months ago and restored at that time. The
patient is unhappy with the appearance of the tissue
surrounding the restoration (see eFigs. 70.2, 70.3, and
70.4).

3887
 EFIG. 70.2 Radiograph reveals a biologic width
violation on the mesial surface interproximally.
Removal of interproximal bone would create an
aesthetic deformity. This patient is better treated with
orthodontic extrusion (see eFigs.70.1 and 7.3).

3888
 EFIG. 70.3 After orthodontic eruption. The tooth has
been erupted 3 mm to move the bone and gingiva
coronally 3 mm on the left central incisor. It is now
possible to reposition the bone surgically to the correct
level and position the gingiva to the correct level,
reestablishing normal biologic width.

EFIG. 70.4 One-year recall photograph after

orthodontic extrusion, osseous surgery, and placement
of a new restoration for the patient in eFig. 70.1. Note
the excellent tissue health after the reestablishment of
biologic width.

Margin Placement Guidelines

3889
When determining where to place restorative margins relative to
the periodontal attachment, it is recommended that the patient's
existing sulcular depth be used as a guideline in assessing the
biologic width requirement for that patient. The base of the sulcus
can be viewed as the top of the attachment, and therefore the
clinician accounts for variations in attachment height by ensuring
that the margin is placed in the sulcus and not in the
attachment.4,36,37,56 The variations in sulcular probing depth are then
used to predict how deep the margin can safely be placed below the
gingival crest. With shallow probing depths (1 to 1.5 mm),
extending the preparation more than 0.5 mm subgingivally risks
violating the attachment. This assumes that the periodontal probe
will penetrate into the junctional epithelial attachment in healthy
gingiva an average of 0.5 mm. With shallow probing depths, future
recession is unlikely because the free gingival margin is located
close to the top of the attachment. Deeper sulcular probing depths
provide more freedom in locating restoration margins farther below
the gingival crest. In most circumstances, however, the deeper the
gingival sulcus, the greater is the risk of gingival recession.
Locating the restorative margin deep subgingivally should be
avoided, as it increases the difficulty in making an accurate
impression, finishing the restoration margins, and increases the
likelihood of inflammation and recession.

Clinical Procedures in Margin Placement

The first step in using sulcus depth as a guide in margin placement
is to manage gingival health. It should be noted that the use of
reinforced all-ceramic restorations (i.e., layered zirconia, lithium
disilicate) reduces the aesthetic rationale for subgingival margins.
Once the tissue is healthy, the following three rules can be used to
place intracrevicular margins:

Rule 1: If the sulcus probes 1.5 mm or less, place the restoration

margin no more than 0.5 mm below the gingival tissue crest.
This is especially important on the facial aspect and will
prevent a biologic width violation in a patient who is at high
risk in that regard.

3890
 Rule 2: If the sulcus probes more than 1.5 mm, place the margin
no more than half the depth of the sulcus below the tissue
crest. This places the margin far enough below tissue so that
it will still be covered if the patient is at higher risk of
recession.
Rule 3: If a sulcus greater than 2 mm is found, especially on the
facial aspect of the tooth, evaluate to see if a gingivectomy
could be performed to lengthen the teeth and create a 1.5-
mm sulcus. Then the patient can be treated using rule 1.

The rationale for rule 3 is that deep margin placement is more

difficult and the stability of the free gingival margin is less
predictable when a deep sulcus exists. Reducing the sulcus depth
creates a more predictable situation in which to place an
intracrevicular margin. The clinician cannot be sure that the tissue
will remain at the corrected level, however, because some gingival
rebound can occur after gingivectomy. However, sulcular depth
reduction ensures that the restorative margins will not be exposed
and visible in the patient's mouth (eFigs. 70.5 to 70.9).

EFIG. 70.5 A 78-year-old woman presents with the

maxillary anterior restorations placed 6 months earlier.
She is unhappy with the exposed margins and notes
that the margins were covered the day the restorations
were placed (see eFigs. 70.6 to 70.9).

3891
 EFIG. 70.6 Depth from the attachment to the level of
the preparation margin is greater than 3 mm. The
patient in eFig. 70.5 had an altered eruption pattern
and a sulcus depth of more than 3 mm when these
restorations were placed.

EFIG. 70.7 Two options were available to manage

treatment appropriately: (1) place the original margins
to half the depth of the sulcus, in which case the
recession that occurred would not have exposed them,
or (2) perform a gingivectomy, creating a 1- to 1.5-mm
sulcus. The second option was chosen when the
restorations were redone. The margins were then
placed 0.5 mm below the tissue after the gingivectomy
(see eFigs. 70.6 and 70.8).

3892
 EFIG. 70.8 At 6 weeks after the gingivectomy and
preparation of the teeth. Note the tissue level and that
the tissue is rebounding coronally over the margins.
This is a common finding when a pure gingivectomy is
done.

EFIG. 70.9 Four-year recall photograph after

placement of the final restorations for the patient in
eFig. 70.5. Note the tissue level has been maintained,
with a sulcus depth of 2 mm on the facial surface.

The placement of supragingival or equigingival margins is simple

because it requires no tissue manipulation. With regard to overall
tooth preparation, the amount reduced incisally or occlusally,
facially, lingually, and interproximally is dictated by the choice of
restorative materials. Before extending subgingivally, the

3893
preparation should be completed to the free gingival margin
facially and interproximally. This allows the margin of the tooth
preparation to be used as a reference for subgingival extension once
the tissue is retracted (eFig. 70.10).

EFIG. 70.10 To provide a reference position for margin

placement after tissue retraction, the margin of the
tooth preparation is initially established level with the
free gingival margin.

Tissue Retraction
Once the supragingival portion of the preparation is completed, it is
necessary to extend below the tissue.6,23 The preparation margin
must now be extended to the appropriate depth in the sulcus,
applying the guidelines presented previously. In this process the
tissue must be protected from abrasion, which will cause
hemorrhage and can adversely affect the stability of the tissue level
around the tooth. Access to the margin is also required for the final
impression, with a clean, fluid-controlled environment. Tissue
management is achieved with gingival retraction cords using the
appropriate size to achieve the displacement required. Thin, fragile
gingival tissues and shallow sulcus situations usually dictate that
smaller diameter cords be chosen to achieve the desired tissue
displacement.
For a rule 1 margin (sulcus depth 1.5 mm or less), the cord should

3894
be placed so that the top of the cord is located in the sulcus at the
level in which the final margin is to be established, which will be 0.5
mm below the previously prepared margin (eFig.70.11). On the
interproximal aspects of the tooth, the cord is usually 1 to 1.5 mm
below the tissue height because the interproximal sulcus is often 2.5
to 3 mm in depth. With this initial cord in place, the preparation is
extended to the top of the cord, with the bur angled to the tooth so
that it does not abrade the tissue (eFig. 70.12). This process protects
the tissue, creates the correct axial reduction, and establishes the
margin at the desired subgingival level. To create space and allow
access for a final impression, it is now necessary to pack a second
retraction cord. The second cord is pushed so that it displaces the
first cord apically and sits between the margin and the tissue (eFig.
70.13). For the final impression, only the top cord is removed,
leaving the margins visible and accessible to be recorded with the
impression material (eFig. 70.14). The initial cord remains in place
in the sulcus until the provisional restoration is completed.

EFIG. 70.11 Second step in margin placement is to

place a single layer of deflection cord below the
previously prepared margin to the desired final margin
level. Here, a single cord has been placed 0.5 mm
below the previously prepared margin.

3895
EFIG. 70.12 Margin of the preparation is now extended
apically to the top of the retraction cord; this represents
the correct placement of the margin below the
previously nonreflected, free gingival margin.

EFIG. 70.13 To provide space for impression material,

a second impression cord is now placed on top of the
first deflection cord. This impression cord is placed so
that it is between the margin of the preparation and the
gingiva to create adequate space for impression
material after removal of the cord.

3896
 EFIG. 70.14 Ideal situation after removal of impression
cord. The deflection cord is still in place maintaining
the open sulcus but has been displaced apically
another 0.5 mm by the placement of the impression
cord, exposing tooth structure apical to the margin so
that it can be captured in the impression.

As an alternative to additional retraction cords, electrosurgery

can be used to remove any overlying tissue in the retraction
process. A fine-wire electrode tip is held parallel to the tooth and
against the margin in the sulcus and moved through the
overhanging tissue, opening up the margin and the retraction cord
to visual access (eFigs. 70.15 to 70.18). The electrosurgery tip sits on
top of the retraction cord in place in the sulcus. This controls the
vertical position of the tip and results in the removal of the least
tissue needed for access.

3897
EFIG. 70.15 Deflection cord and impression cord are in
place. The soft tissue is falling over the margins of the
preparation. In this situation, if the impression cord
were removed, the impression would not capture the
margins in the areas in which the tissue is
overhanging.

EFIG. 70.16 Overhanging tissue has been removed

and space created for the impression material with
electrosurgery. Note that the deflection cord and the
impression cord are still in place. The impression cord
is now visible completely around the tooth, allowing
easy access for the impression material to the margin
after removal of the impression cord.

3898
 EFIG. 70.17 Using electrosurgery, the fine-wire
electrode tip is held parallel to the tooth preparation
and rests on the cord as the tip is moved around the
tooth.

EFIG. 70.18 After removal of the impression cord, an

adequate space is created for the impression material,
with no soft tissue overhanging the margins to trap or
tear the impression material. Note the first cord, or
deflection cord, is still in place.

For rule 2 situations in which the sulcus is deeper, two larger-

diameter cords are used to deflect the tissue before extending the
margin apically (eFigs. 70.19 to 70.21). The top of the second cord is

3899
placed to identify the final margin location at the correct distance
below the previously prepared margin, which was at the gingival
tissue crest level. The margin is lowered to the top of the second
cord (eFig. 70.22), then a third cord is placed in preparation for the
impression (eFigs. 70.23 and 70.24). In the patient with a deep
sulcus in which the margin may be 1.5 to 2 mm below the tissue
crest, electrosurgery is often required to remove overhanging
tissue. To avoid altering the gingival tissue height, it is important to
hold the electrosurgery tip parallel to the preparation (eFig. 70.25).

EFIG. 70.19 First step in margin placement for the

patient with altered eruption or a deep sulcus is to
prepare the existing free gingival margin, as in the “rule
1” patient (see text).

3900
 EFIG. 70.20 Second step for the patient with altered
eruption is to place the deflection cord. Note that the
placement of a single deflection cord does not provide
adequate deflection of the tissue to allow the margin to
be carried below tissue without abrading the gingiva
with the bur.

EFIG. 70.21 Third step for the patient with altered

eruption and a deep sulcus is to place a second,
larger-diameter deflection cord on top of the first
deflection cord. Combined, these two cords allow
adequate deflection to open up the sulcus so that the
margin can be carried below tissue without abrading
the gingiva.

3901
EFIG. 70.22 Preparation is now extended to the top of
the second deflection cord, finalizing margin location.

EFIG. 70.23 After extension of the margin to the top of

the deflection cord, a third layer of cord is applied that
will act as the impression cord. This impression cord
should be placed so that it fits between the free
gingival margin and the margin of the preparation. Its
placement will also apically displace the two previously
positioned deflection cords.

3902
EFIG. 70.24 Removal of the impression cord creates
an adequate space for the impression material to
capture the margin and 0.5 mm of tooth structure
below the margin in which the impression cord had
displaced the first two cords.

EFIG. 70.25 If it is necessary to use electrosurgery,

3903
 either in the normal or altered-eruption patient, the
correct inclination of the electrosurgery tip is important.
(A) Electrosurgery tip being held parallel to the
preparation and resting on the previously placed
retraction cord. This removes a minimal amount of
tissue, and the presence of the retraction cord protects
the attachment from the electrosurgery. (B) Incorrect
inclination of electrosurgery tip. The tip is leaning away
from the preparation. This inclination results in excess
tissue removal.

Provisional Restorations
Three critical areas must be effectively managed to produce a
favorable biologic response to provisional restorations.3,74 The
marginal fit, crown contour, and surface finish of the interim
restorations must be appropriate to maintain the health and
position of the gingival tissues during the interval until the final
restorations are delivered. Provisional restorations that are poorly
adapted at the margins, that are overcontoured or undercontoured,
and that have rough or porous surfaces can cause inflammation,
overgrowth, or recession of gingival tissues. The outcome can be
unpredictable, and unfavorable changes in the tissue architecture
can compromise the success of the final restoration.

Marginal Fit
Marginal fit has clearly been implicated in producing an
inflammatory response in the periodontium. It has been shown that
the level of gingival inflammation can increase corresponding with
the level of marginal opening.15 Margins that are significantly open
(several tenths of a millimeter) are capable of harboring large
numbers of bacteria and may be responsible for the inflammatory
response seen. However, the quality of marginal finish and the
margin location relative to the attachment are much more critical to
the periodontium than the difference between a 20-µm fit and a
100-µm fit.42,46,59

3904
Crown Contour
Restoration contour has been described as extremely important to
the maintenance of periodontal health.26,75 Ideal contour provides
access for hygiene, has the fullness to create the desired gingival
form, and has a pleasing visual tooth contour in aesthetic areas.
Evidence from human and animal studies clearly demonstrates a
relationship between overcontouring and gingival inflammation,
whereas undercontouring produces no adverse periodontal
effect.48,51 The most frequent cause of overcontoured restorations is
inadequate tooth preparation by the dentist, which forces the
technician to produce a bulky restoration to provide room for the
restorative material. In areas of the mouth in which aesthetic
considerations are not critical, a flatter contour is always acceptable.

Subgingival Debris
Leaving debris below the tissue during restorative procedures can
create an adverse periodontal response. The cause can be retraction
cord, impression material, provisional material, or either temporary
or permanent cement.55 The diagnosis of debris as the cause of
gingival inflammation can be confirmed by examining the sulcus
surrounding the restoration with an explorer, removing any foreign
bodies, and then monitoring the tissue response. It may be
necessary to provide tissue anesthesia for patient comfort during
the procedure.

Hypersensitivity to Dental Materials

Inflammatory gingival responses have been reported related to the
use of nonprecious alloys in dental restorations.52 Typically, the
responses have occurred to alloys containing nickel, although the
frequency of these occurrences is controversial.50 Hypersensitivity
responses to precious alloys are extremely rare, and these alloys
provide an easy solution to the problems encountered with the
nonprecious alloys. Importantly, tissues respond more to the
differences in surface roughness of the material than they do to the
composition of the material.1,66 The rougher the surface of the
restoration subgingivally, the greater are the plaque accumulation

3905
and gingival inflammation. In clinical research, porcelain, highly
polished gold, and highly polished resin all show similar plaque
accumulation. Regardless of the restorative material selected, a
smooth surface is essential on all materials subgingivally.

Aesthetic Tissue Management

Managing Interproximal Embrasures
Current restorative and periodontal therapy must consider a good
aesthetic result, especially in the “aesthetic zone.” As discussed in
Chapters 58 and 65, the interproximal papilla is an important part
in creating this aesthetic result. The interproximal embrasure
created by restorations and the form of the interdental papilla have
a unique and intimate relationship.61,62 The ideal interproximal
embrasure should house the gingival papilla without impinging on
it and should also extend the interproximal tooth contact to the top
of the papilla so that no excess space exists to trap food and to be
aesthetically displeasing.
Papillary height is established by the level of the bone, the
biologic width, and the form of the gingival embrasure. Changes in
the shape of the embrasure can impact the height and form of the
papilla. The tip of the papilla behaves differently than the free
gingival margin on the facial aspect of the tooth. Whereas the free
gingival margin averages 3 mm above the underlying facial bone,
the tip of the papilla averages 4.5 to 5 mm above the interproximal
bone (Fig. 70.6). This means that if the papilla is farther above the
bone than the facial tissue but has the same biologic width, the
interproximal area will have a sulcus 1 to 1.5 mm deeper than that
found on the facial surface.

3906
 FIG. 70.6 Comparison of the behavior of the
interproximal papilla relative to bone and the free
gingival margin relative to bone in the average human.
There is a 3-mm scallop from the facial bone to the
interproximal bone. However, on average, a 4.5- to 5-
mm gingival scallop exists between the facial tissue
height and the interproximal papilla height. This extra
scallop of 1.5 to 2 mm of gingiva compared with bone
is the result of the extra soft-tissue height above the
attachment interproximally.

Clinical Correlation
If you create restorations with no more than 5 mm from the contact
to the bone, open gingival embrasures can be avoided. The
downside to this approach is that the teeth will look square and
blocky. However, some patients can support a 7-mm papilla. Well-
made provisional restorations allow accurate determination of
actual papilla length.

Van der Veldon72 completely removed healthy papillae to the

bone level and found that they routinely regenerated 4 to 4.5 mm of
total tissue above bone, with an average sulcus depth of 2 to 2.5
mm. The height above bone that the papilla strives to maintain was
indirectly confirmed by Tarnow and coworkers,67 who studied the
relationship of the papilla between the interproximal contact and
the underlying bone. When the distance from the interproximal
bone to the interproximal contact of the teeth measured 5 mm or
less, 98% of these sites had complete papilla fill. When the distance
was 6 mm, only 56% of the sites had complete papilla fill. When the

3907
distance was 7 mm, only 27% of the sites had complete papilla fill
(Fig. 70.7).

FIG. 70.7 The probability of complete fill of gingival

embrasure by papilla. (A) With 5 mm from crest of
bone to the apical contact point, there is a 98% chance
of complete fill of the space. (B) At 6 mm from crest to
contact, the chance of filled embrasure drops to 56%.
(C) At 7 mm from crest to contact, the chance of
complete fill drops to 27%.

Because there is individual variability to the required biologic

width, this information relative to the papilla is applied by locating
the lowest point of the interproximal contact in relation to the top of
the epithelial attachment. The ideal contact should be 2 to 3 mm
coronal to the attachment, which coincides with the depth of the
average interproximal sulcus. In assessing the soft tissues to
determine margin location, it is imperative that they be healthy and
mature. Performing the analysis on inflamed or immature tissues
will result in supragingival margins when the tissues heal. If the
papillary sulcus measures greater than 3 mm, there is some risk of
recession with restorative procedures. Critical adjustments to
margin and soft tissue positions should be ultimately diagnosed
with the use of well-designed and adapted provisional restorations.
This will allow for treatment to be accurately designed based on the
individual's unique biologic width.
The clinician most frequently confronts a normal or shallow
sulcus with a papilla that appears too short rather than a tall papilla
with a deep sulcus. Management of this situation is best
approached by viewing the papilla as a balloon of a certain volume
that sits on the attachment. This balloon of tissue has a form and
height dictated by the gingival embrasure of the teeth. With an

3908
embrasure that is too wide, the balloon flattens out, assumes a
blunted shape, and has a shallow sulcus (Fig. 70.8).

FIG. 70.8 Relationship between gingival embrasure

volume and papillary form. (A) Gingival embrasure of
the teeth is excessively large as the result of a tapered
tooth form. Because of the large embrasure form, the
volume of tissue sitting on top of the attachment is not
molded to the shape of a normal papilla but rather has
a blunted form and a shallower sulcus. (B) Ideal tooth
form in which the same volume of tissue sits on top of
the attachment as in part A. Because of the more
closed embrasure form from the teeth in part B,
however, the papilla completely fills the embrasure and
has a deeper sulcus, averaging 2.5 to 3 mm. Note that
the ideal contact position is 3 mm coronal to the
attachment.

If the embrasure is the ideal width, the papilla assumes a pointed

form, has a sulcus of 2.5 to 3 mm, and is healthy. If the embrasure is
too narrow, the papilla may grow out to the facial and lingual, form
a col, and become inflamed. This information is applied when
evaluating an individual papilla with an open embrasure. The
papilla in question is compared with the adjacent papillae. If the
papillae are all on the same level, and if the other areas do not have
open embrasures, the problem is one of gingival embrasure form. If
the papilla in the area of concern is apical to the adjacent papillae,
however, the clinician should evaluate the interproximal bone
levels. If the bone under that papilla is apical to the adjacent bone
levels, the problem is caused by bone loss. If the bone is at the same
level, the open embrasure is caused by the embrasure form of the
teeth and not a periodontal problem with the papilla. The papillae

3909
in the anterior maxilla average 4 mm long and are the same heights
at the mesial and distal sides of the tooth. Ultimately, deficient
papillae and open gingival embrasures are most predictably
corrected with restorations to close the space.

Correcting Open Gingival Embrasures

Restoratively
There are two causes of open gingival embrasures: (1) the papilla is
inadequate in height because of bone loss or (2) the interproximal
contact is located too high coronally. If a high contact has been
diagnosed as the cause of the problem, there are two potential
reasons. If the root angulation of the teeth diverges, the
interproximal contact is moved coronally, resulting in the open
embrasure. However, if the roots are parallel, the papilla form is
normal, and an open embrasure exists, then the problem is
probably related to tooth shape, specifically an excessively tapered
form. Restorative dentistry can correct this problem by moving the
contact point to the tip of the papilla. To accomplish this, the
margins of the restoration must be carried subgingivally 1 to 1.5
mm, and the emergence profile of the restoration is designed to
move the contact point toward the papilla while blending the
contour into the tooth below the tissue (eFig.70.26). This can be
accomplished easily with direct bonded restorations because the
soft tissue can clearly be seen (eFigs. 70.27 to 70.29). For indirect
restorations, the desired restoration contours and embrasure form
should be established in the provisional restorations, and the
gingival tissues are allowed to adapt for 4 to 6 weeks before the
tissue contour information is relayed to the laboratory for use in the
final restorations.

3910
 EFIG. 70.26 Methods of altering gingival embrasure
form. (A) Typical open gingival embrasure caused by
excessively tapered tooth form. (B) Common method
employed by restorative dentists to correct the
embrasure, in which material is added supragingivally.
This closes the embrasure by moving the contact to
the tip of the papilla but results in overhangs that
cannot be cleaned using dental floss. Removing these
overhangs restoratively reopens the embrasure. (C)
Correct method of closing the gingival embrasure, in
which the margins of the restoration are carried 1 to
1.5 mm below the tip of the papilla. Note that this does
not encroach on the attachment because the average
interproximal sulcus probes 2.5 to 3 mm. This allows
easy cleaning because of the convex profile. It also
reshapes the papilla to a more pleasing profile
aesthetically.

EFIG. 70.27 This patient has parallel roots, has

recently completed orthodontic therapy, and is
unhappy with the open gingival embrasure between

3911
 her central incisors. An evaluation of papillary height
reveals that all are at an equal level. This can only
mean that the open embrasure is the result of an
overly tapered tooth form (see eFigs. 70.28 and
70.29).

EFIG. 70.28 One method of correctly altering tooth

form of the patient in eFig. 70.27. A metal matrix band
has been shaped to the desired tooth form and placed
1 to 1.5 mm below the tip of the papilla. Restorative
material then was added to the tooth against the matrix
band, forming the new mesial surface of the left central
incisor.

3912
 EFIG. 70.29 One-year recall photograph after restoring
the mesial surfaces of the right and left central incisors,
moving the proximal contact to the tip of the papilla
and extending the restorations 1 to 1.5 mm below the
papilla, blending them into the tooth and making an
easily cleaned area (see eFigs. 70.27 and 70.28).

Managing Gingival Embrasure Form for

Patients With Gingival Recession
Management of the gingival embrasure form for patients who have
experienced gingival recession varies, depending on whether the
treatment is in the anterior or posterior regions of the mouth.30 In
aesthetic areas, it is necessary to carry the interproximal contacts
apically toward the papilla to eliminate the presence of large, open
embrasures. With multiple-unit restorations, it is also possible with
tissue-colored ceramics to bake porcelain papillae directly on the
restoration. In the posterior areas where the interroot widths are
significantly greater, it is often impossible to carry the proximal
contacts to contact the tissue without creating large overhangs on
the restorations. In these situations, the contact should be moved far
enough apically to minimize any large food traps while still leaving
an embrasure of a convenient size to be accessed with an
interdental brush for hygiene. It should be noted that developing
excessively long interproximal contacts, whether on anterior or
posterior teeth, always creates rectangular, somewhat unaesthetic,
tooth forms.

Pontic Design
Classically, there are four options to consider in evaluating pontic
design: hygienic, ridge lap, modified ridge lap, and ovate designs
(Fig. 70.9). Regardless of design, the pontic should provide an
occlusal surface that stabilizes the opposing teeth, allows for normal
mastication, and does not overload the abutment teeth. The area of
the pontic interfacing with the gingiva can be porcelain, metal,
zirconia, lithium disilicate, or some other material with no variation
in the biologic response of the tissue provided it has a smooth

3913
surface finish.25,53,63

FIG. 70.9 Four options to designing the shape of a

pontic. (A) Hygienic pontic. Tissue surface of the pontic
is 3 mm from the underlying ridge. (B) Ridge-lap
pontic. Tissue surface of the pontic straddles the ridge
in saddle-like fashion. The entire tissue surface of the
ridge-lap pontic is convex and very difficult to clean.
(C) Modified ridge-lap pontic. Tissue surface on the
facial is concave, following the ridge. However, the
lingual saddle has been removed to allow access for
oral hygiene. (D) Ovate pontic. The pontic form fits into
a receptor site within the ridge. This allows the tissue
surface of the pontic to be convex and also optimizes
aesthetics.

The key differences between the four pontic designs relate to the
aesthetics and access for hygiene procedures. The primary method
for cleaning the undersurface of pontics is to draw dental floss
mesiodistally along the undersurface. The shape of this
undersurface determines the ease with which plaque and food
debris can be removed in the process. The hygienic and ovate
pontics have convex undersurfaces, which makes them easiest to
clean. The ridge lap and modified ridge-lap designs have concave
surfaces, which are more difficult to access with the dental floss.
Although the hygienic pontic design provides the easiest access for
hygiene procedures, it is much less aesthetic and objectionable by
some patients.
The ovate pontic is the ideal pontic form, particularly in areas of
aesthetic concern.61 It is created by forming a receptor site in the
edentulous ridge with a diamond bur, electrosurgery, pressure, or
wound healing. The site is shaped to create either a flat or a concave

3914
contour so that when the pontic is created to adapt to the site, it will
have a flat or convex outline. The depth of the receptor site depends
on the aesthetic requirements of the pontic. In highly aesthetic areas
such as the maxillary anterior region, it is necessary to create a
receptor area that is 1 to 1.5 mm below the tissue on the facial
aspect. This creates the appearance of a free gingival margin and
produces optimal aesthetics (Fig. 70.10). This site can then be
tapered to the height of the palatal tissue to facilitate hygiene access
from the palatal side. In the posterior areas, a deep receptor site can
complicate hygiene access. In these situations, the ideal site has the
facial portion of the pontic at the same level as the ridge, and then
the site is created as a straight line to the lingual side of the pontic.
This removes the convexity of the ridge and produces a flat, easily
cleanable tissue surface on the pontic (Fig. 70.11).

FIG. 70.10 Ideal shape and form of an ovate pontic in

the aesthetic area. The receptor site has been created
1 to 1.5 mm apical to the free gingival margin on the
facial aspect. This creates the illusion of the pontic
erupting from the tissue. On the palatal side, the pontic
is tapered so that the receptor site is not extended
below tissue; this allows easier access for oral
hygiene. Note that when the receptor site is created,
the bone must be a minimum of 2 mm from the most
apical portion of the pontic.

3915
 FIG. 70.11 Option for creating an ovate pontic receptor
site in less aesthetic areas of the mouth. Rather than
creating the receptor site so that the pontic extends
into the ridge, it is possible to create a flattened
receptor site in which the pontic sits flush with the
ridge. This facilitates oral hygiene.

Ridge Modification Procedures for Ideal

Pontic Contours
When the ridge is being surgically modified, it is important to know
the thickness of soft tissue above the bone. This measurement is
obtained by probing to the bone through the anesthetized tissue. If
the tissue is removed to less than 2 mm in thickness, significant
rebound in ridge height may occur. If it is necessary to reduce the
tissue height to less than 2 mm above the bone to create the desired
pontic form, some bone will need to be removed to achieve the
desired result.
It is important when considering an ovate pontic to realize that
certain soft-tissue ridge parameters must exist to optimize the ovate
pontic form. First, the ridge height needs to match the ideal height
of the interproximal papillae where interproximal embrasures are
planned, either between pontics or next to abutment teeth. Second,
the gingival margin height must also be at the ideal level, or the
pontic will appear too long. Third, the ridge tissue must be facial to
the ideal cervical facial form of the pontic so that the pontic can
emerge from the tissue. If any of these three areas is inadequate,
some form of ridge augmentation is needed to produce a ridge that
can have an adequate receptor site created (eFig. 70.30). Any ridge

3916
augmentation procedures should be completed before, or in
conjunction with, fabricating an ovate pontic. When constructing
the final restorations, the contours of the developed ovate pontic
receptor site can be conveyed to the laboratory by capturing a soft-
tissue impression 4 to 6 weeks after the site has been created.

EFIG. 70.30 Ridge considerations when an ovate

pontic is desired. For an ovate pontic to be properly
created, the soft-tissue ridge must be labial to the
desired cervical portion of the pontic. When the pontic
is facial to the ridge, it is not possible to create what
appears to be a “free gingival margin” correctly. The
shaded area represents the necessary amount of
tissue that would be augmented to produce an ideal
ovate pontic in this particular site.

The ovate pontic can serve another important periodontal

function by maintaining the interdental papilla next to abutment
teeth after extraction.61 When a tooth is removed, the gingival
embrasure form is lost. The normal response of the papilla to this
loss of embrasure form is to recede 1.5 to 2 mm, which corresponds
to the additional soft tissue that exists above bone on the
interproximal versus the facial aspect. However, this recession can
be prevented. By inserting the correct pontic form 2.5 mm into the
extraction site the day the tooth is removed, the gingival embrasure
form and papilla can be maintained. At 4 weeks, the 2.5-mm
extension can be reduced to a 1- to 1.5-mm extension to facilitate
hygiene. This procedure can maintain the papilla next to the

3917
abutment teeth as long as the bone on the abutment tooth is at a
normal level (eFigs. 70.31 to 70.38).

EFIG. 70.31 Patient who will have the right central

incisor extracted because of periodontal disease. The
patient is choosing to have a fixed partial denture
rather than an implant as the method of replacement.
An ovate pontic will be used to maintain the papillary
form after the removal of this central incisor (see eFigs.
70.32 to 70.38).

3918
 EFIG. 70.32 Note the radiographic appearance of a
palatal well caused by a deep palatal groove on this
right central incisor of the patient in eFig. 70.31. Two
attempted periodontal surgeries have failed to correct
this, and it still probes 10 mm with suppuration.

3919
EFIG. 70.33 Because the patient in eFig. 70.31 desired
to alter the aesthetics of her remaining anterior teeth,
all the anterior teeth were prepared before removal of
the right central incisor.

EFIG. 70.34 The key to maintenance of the

interproximal papilla is that the ovate pontic must
extend 2.5 mm into the extraction site on the day of
extraction. This will maintain gingival embrasure form
and therefore maintain interproximal papillary height.

EFIG. 70.35 Note that when the provisional restoration

3920
is seated on the day of the extraction, 2.5 mm of the
pontic extend upward into the extraction socket. Also
note the open gingival embrasures present to allow
space for the papillae to rebound coronally.

EFIG. 70.36 Nine months after placement of the

provisional restoration. (At 4 weeks after placement,
the pontic was shortened to extend 1.5 mm into the
extraction site to facilitate oral hygiene.) Note
maintenance of papillary form and free gingival margin
height, predictable in this patient because she has
excellent interproximal and facial bone.

3921
 EFIG. 70.37 Ovate pontic site after removal of the
provisional restoration and before final impressions.
Note that the papillary form has been maintained
because of the ovate pontic maintaining gingival
embrasure volume.

EFIG. 70.38 Two-year recall photograph of the final

fixed prosthesis of the patient in eFig. 70.31. Note how
the final ovate pontic also has maintained papillary
form.

The “full ridge-lap pontic” is an outdated design that straddles

the convexity of the ridge buccolingually and creates an
undersurface that is entirely concave and cannot be cleaned. It is
not recommended for use in any situations. However, a modified
ridge-lap pontic can be an acceptable design if inadequate ridge
exists to create an ovate pontic. With the modified ridge-lap design,
the pontic follows the convexity of the ridge on the facial aspect but
stops on the lingual crest of the ridge without extending down the
lingual side of the ridge. Although the facial aspect of the
undersurface has a concave shape, the more open lingual form
allows adequate access for oral hygiene.

Occlusal Considerations in

3922
Restorative Therapy

Key Fact
A mutually protective occlusion is created when all the teeth touch
at the same time in a normal closing arc, but when the mandible
moves, all contacts are on the anterior teeth.

Chapter 55 presents details on the biology of occlusion and related

clinical evaluation procedures. The importance of occlusal trauma
as a factor in periodontal disease and its role in orofacial pain have
been deemphasized in numerous papers.8,14,34,35,44,45,54,65,71 However,
the role that occlusion plays in restorative dentistry has been
reemphasized. The increased use of dental implants and
nonmetallic restorations has resulted in increased concern over
force management. Some of these materials are more sensitive to
occlusal trauma, and resulting fracture, than are metal restorations.
Consequently, for the clinician who wants a high degree of
predictability, understanding occlusion is critical. The clinician
must know how to create an occlusion, with the following
guidelines as a goal:

1. There should be even, simultaneous contacts on all teeth in

maximal intercuspal position (MIP). This distributes the
force of closure over all the teeth instead of the few teeth
that may touch first.
2. When the mandible moves from maximum intercuspal
position (MIP), some form of canine or anterior guidance is
desirable, with no posterior tooth contacts. This mutually
protective occlusion reduces the ability and force of the
muscles of mastication, while it more evenly distributes the
forces. It has been shown that, as a result of the class III
lever action, the anterior teeth receive approximately one-
ninth the force of a second molar.24,60
3. The anterior guidance needs to be in harmony with the
patient's envelope of function. The harmony of this
relationship is demonstrated by a lack of fremitus and

3923
 mobility on the anterior teeth, by the ability of the patient to
speak clearly and comfortably, and by the patient's general
sense of comfort with the overbite, overjet, and guidance
created during chewing and when holding the head
upright.
4. The occlusion should be created at a occlusal vertical
dimension (OVD) that is stable for the patient. It is generally
accepted that the patient's existing vertical dimension is at
equilibrium between the eruptive forces of the teeth and the
repetitive contracted length of the elevator muscles. It has
been demonstrated that vertical dimension can be altered
with no sense of pain from muscles and joints.8,10,21,29
However, if this alteration lengthens the pterygomasseteric
sling beyond its ability to adapt, the patient will not
maintain the vertical change and will close the occlusal
vertical dimension back down by intruding the teeth.11,33,39-41
5. When managing a pathologic occlusion or when restoring a
complete occlusion, the clinician needs to work with a
repeatable condylar reference position. Centric relation,
defined as the most superior condylar position, provides
such a starting point.20 Centric relation has been shown to be
reproducible over multiple appointments, allowing the
clinician to create the occlusion indirectly on an articulator
and return it to the same reference position in the
mouth.13,38,43,73 It is the only position that has been shown to
shut off lateral pterygoid muscle contraction.19 Because it is
a border position, any mandibular movement will result in
the condyle moving inferiorly. Therefore centric relation is
the most predictable position from which an interference-
free occlusion can be created.

To manage the occlusion as previously described, the clinician

must be able to make accurate casts, use a facebow, and create
centric relation records so that the information can be transferred to
a suitable articulator. Although the details of these procedures are
beyond the scope of this chapter, they are a routine part of any
restorative treatment plan and must be mastered for the clinician to
achieve predictable, long-term restorative success. The reader is

3924
referred to Chapter 55 for a more comprehensive overview of
occlusal evaluation and therapy.

Special Restorative Considerations

Root-Resected Teeth
Although the availability of implant therapy has greatly reduced
the frequency with which root-amputated teeth are saved,
restoration of root-resected teeth is still a viable mode of treatment.
Diagnosis and management of multirooted teeth with furcation
involvement including the rationale for root resection are presented
in detail in Chapter 62. Structural challenges are created in restoring
these teeth because of the amount of tooth structure lost in the
resection process (eFig. 70.39). Conservative tooth preparation will
maintain as much of the remaining tooth as possible, but the
resulting supragingival or minimally prepared subgingival finish
lines will require additional metal display in the final restoration. A
cast post and core may be indicated to create an adequate
foundation for the final restoration. Because the remaining roots are
often very thin mesiodistally, it is difficult to cement premade posts
and have adequate bulk to place a foundation core on the mesial
and distal surfaces of the post. This problem is avoided with the
one-piece cast post and core restoration.

EFIG. 70.39 (A) Maxillary molar with a class III

furcation and bone loss surrounding the distal buccal
root. (B) Contour created when the distal buccal root is
removed, but the coronal contour has not yet been
reshaped. Note the overhang, which can trap food and

3925
 plaque and create gingival inflammation. (C) Correct
contour after the restoration or reshaping of the tooth.
Note this illustration is only of the facial portion of the
tooth. The palatal portion of the crown and the palatal
root do not appear. Note how the contour has been
altered to allow easy access for an interdental brush to
the gingival tissue and the tooth in the area in which
the root was removed.

Another area of concern when restoring root-resected teeth is the

development of appropriate contours for hygiene access. The
primary concern is to avoid any excessively heavy convexities of
contour that would prevent access (eFig. 70.40 and 70.41). Facially
and lingually, the contours should be essentially a straight line from
the margin coronally, while interproximally, the contour emerges
from the margin as a straight line or is slightly convex as it slopes
up to the contact point. The interproximal areas of root-amputated
and hemisected teeth often present with surface concavities on the
root trunk, and these areas cannot be adequately cleaned with floss
because it will bridge across the concavity. The gingival embrasure
form created in the restoration must be fluted into these areas so
that the surfaces can be accessed with an interdental brush.

EFIG. 70.40 Photograph taken 6 weeks after the

removal of the distal buccal root on this maxillary first
molar. Note that the crown contour has not yet been
altered. Also note the presence of a large overhang
that easily traps debris.

3926
 EFIG. 70.41 Correct modification of the crown form
seen in eFig. 70.40. The roof of the furcation of the
remaining distal buccal root has been completely
removed and the crown re-formed to allow easy
access to the remaining roots and soft tissue.

Aesthetics is usually not a major concern unless the tooth in

question is a maxillary molar with a mesiobuccal root amputation
and the patient has a broad smile. The solution is to create an
artificial mesiobuccal root with normal crown contour coronal to it
and a furcation made of restorative material that is easily cleanable
with an interdental brush.

Splinting
Splinting therapy may be applied with bonded external appliances,
intracoronal appliances, or indirect cast restorations to connect
multiple teeth, with the goal of improving tooth stability. Unstable
teeth may be caused by a lack of periodontal support from bone
loss, a lack of support from tooth loss, or the need to splint
abutment teeth to support pontics. Indications for splinting are (1)
mobility of teeth that is increasing or that impairs patient comfort,
(2) migration of teeth, and (3) prosthetics in which multiple
abutments are necessary.
Before considering splinting, the clinician must identify the

3927
etiology of the instability.2 Excessive occlusal forces from
parafunction or deflective tooth contacts are frequent causes of
excessive mobility. Whenever the occlusion is the cause, occlusal
therapy is always performed first. The mobility is then evaluated
over time to determine if it resolves before splinting is considered.
In addition, any inflammation of the periodontal supporting
apparatus must be controlled before making a decision on splinting
because inflammation can produce mobility in the presence of
normal occlusal forces and normal periodontal support. When the
teeth are splinted, all the teeth in the splint share the occlusal load
to some extent.16 The rigidity of the splint and the number of teeth
used determine how the forces are distributed.
The most common indication to splint mobile teeth is to improve
patient comfort and to provide better control of the occlusion. If the
anterior teeth are mobile, adequate crown length on the teeth being
splinted is critical so that the interproximal connectors do not
impinge on the interdental papilla. Also, adequate space must exist
between the connector and the papilla for access with dental floss
anteriorly and with an interproximal brush on posterior teeth.

Anterior Aesthetic Surgery

The importance of gingiva in relation to anterior aesthetics has been
well documented.9,28,58,64 Various methods for altering gingival
levels have been described, including gingivectomy, apically
positioned flaps with osseous recontouring, and the use of
orthodontic therapy to position the gingival tissue level apically or
coronally by intruding or extruding the teeth5,12,32,68 (Video 70.1 ).
Whenever an alteration in gingival levels is contemplated, the
expected outcome must be communicated to the patient to
determine if the planned surgery is acceptable. Computer imaging
can be used to provide the patient with a visual plan for the final
aesthetic result.17 However, the imaging process does not allow the
dentist or patient to include the dynamics of lip movement in the
evaluation of the proposed changes. Computer imaging provides
enough information to depict the final outcome accurately when the
planned surgery will alter the gingiva on one or two teeth while
leaving the gingival levels of adjacent teeth in their existing

3928
position.
However, when the surgery will involve many or all of the
anterior teeth and will result in moving gingiva several millimeters,
to the extent that a flap will be raised and bony levels altered, an
additional guide is desirable before surgery. Constructing these
guides directly on a stone cast is the easiest and least time-
consuming method. Before constructing the guide, treatment
planning is completed on the patient to determine the desired
incisal edge position and the desired gingival level of the tissues.
This will establish the amount of tooth display at rest and at full
smile. The information is transferred to a stone cast of the patient's
teeth, and the desired shape of the gingival margins for each tooth
is drawn on the cast. The existing incisal edge position of each tooth
is used as a reference in establishing the desired gingival level. A
composite or acrylic resin veneer is then constructed on the cast,
extending gingivally to the desired tissue position. The veneer
guide can also be extended incisally to the desired incisal edge
position so that this information can also be included in the veneer.
The veneer is trimmed, polished, and tried in the patient's mouth.
When the patient approves the gingival levels established with
the guide, the desired gingival correction can be completed using
the veneer guide as a surgical template. In addition to locating the
initial incisions at the correct level, the guide can also be employed
after flap reflection to aid in the bony recontouring to ensure
adequate biologic width and sulcus depth at the new gingival
position. The surgeon replaces the flap at closure to the gingival
level established with the guide. Employing an aesthetic template
in this manner optimizes the predictability of the surgical therapy
and establishes the ideal tissue framework to complete the aesthetic
restorations (eFigs. 70.42 to 70.49).

3929
 EFIG. 70.42 This patient is unhappy with the
appearance of her maxillary teeth and the
discrepancies of tissue height and tooth form (see
eFigs. 70.43 to 70.49).

EFIG. 70.43 To create a surgical guide for the patient

in eFig. 70.42, a stone cast is modified by drawing the
desired soft-tissue profile with a red wax pencil.

3930
 EFIG. 70.44 A composite-resin surgical guide is
fabricated on this stone cast, extending to the line
drawn. This guide can be taken to the mouth for try-in
and verification by the patient (see eFig. 70.42).

EFIG. 70.45 Photograph taken the day the surgical

guide was tried-in. The patient in eFig. 70.42 approved
the new length of the maxillary anterior teeth and the
form created by altering the soft-tissue profile.

3931
 EFIG. 70.46 By placing the surgical guide during the
surgery, it is possible to recognize where the bone
needs to be placed. The surgical guide represents the
desired final free gingival margin position and can be
used as a reference for osseous recontouring. This
patient had an average biologic width of 2 mm (see
eFig. 70.42). Allowing an additional 1 mm for sulcus
depth, the desired distance between the bone and the
free gingival margin will be 3 mm. With this knowledge,
the periodontist can use the guide and remove bone
until it is 3 mm from the position of the guide on each
tooth.

EFIG. 70.47 Surgical guide is also useful during

suturing. Because the guide represents the desired
free gingival margin position, it is possible to suture to
the level of the guide, knowing that the surgery has

3932
now recreated biologic width and a 1-mm sulcus. This
shortens the amount of time necessary for healing and
eliminates the need to wait for tissue rebound before
restorative dentistry.

EFIG. 70.48 Soft-tissue profile as seen the day of

surgery with the guide removed. Note that in this
patient, the interproximal papillae were not changed
because the interproximal papillary form and height
were deemed acceptable (see eFigs. 70.42 to 70.47).

EFIG. 70.49 Photograph taken 4 years after placement

of the final restoration of the patient in eFig. 70.42.
Note the excellent soft-tissue health and the attainment
of the desired free gingival margin and papillary form.

3933
Case Scenario 70.1

Patient:
41-year-old female
Chief Complaint:
“My old crowns had a big open space between them by the gums.”
Background Information
The patient has an ASA 1, a high smile, and a normal tissue
biotype. Preexisting PFMs on central incisors had open gingival
embrasure. Pocket depths are within normal limits, there is no
bleeding on probing, and the patient practices good oral hygiene.
Current Findings:
Preexisting PFM crowns on maxillary central incisors had poor
shade match and open gingival embrasures. Patient brushes and
flosses as directed and has hygiene visits twice per year. RCT/post
on the maxillary right central incisor is intact.

CASE-BASED QUESTIONS SOLUTION AND EXPLANATION

1. To predictably close the open Answer: B

3934
 gingival embrasure with the new
crowns, the apical extent of the
contact point should be _____ from
the interdental bone crest.
A. 4 mm
B. 5 mm
C. 6 mm
D. 7 mm
2. What is the apparent height of the
papilla between the centrals most
dependent on?
A. Tissue biotype
B. Prep design
C. Crestal bone height
D. Deep margin placement
3. What risk does the subgingival
margins as seen here create?
A. Cement-induced periodontal
inflammation
B. Increased plaque retention
C. Aesthetic concerns due to the
darkened root of the right
central incisor
Explanation: According to Tarnow 1992, contact
points 5 mm from the interdental crest of bone will
be completely filled in 98% of patients.
Answer: C
Explanation: The height of the interdental bone is
the largest variable in determining the apparent
height of the papilla. Tissue biotype plays a role,
though less significant.
Answer: A
Explanation: Subgingival margins increase the risk
for inflammation due to residual cement. This risk
increases proportional to the subgingival depth of
the margin. Healthy, robust gingiva mitigates this
risk to some extent.

Case Scenario 70.2

Patient:
38-year-old male
Chief Complaint:
“My old veneers are black by the gums.”
Background Information:
The patient has an ASA 1, a high smile, and a normal tissue
biotype. Preexisting veneers on central incisors had black stains
underneath the margins. Pocket depths are within normal limits,
there is no bleeding on probing, and the patient practices good oral
hygiene.
Current Findings:
Existing veneers had black color stains under the margins, which
appeared to be well sealed. Stains are likely secondary to the use of
ferric-sulfate hemostatic agents during the previous preparations,
impressions, or delivery. No caries were detected, margins were
equigingival, and the gingiva is healthy.

3935
CASE-BASED QUESTIONS
1. Restorative margins in the aesthetic zone
should be placed as deep as possible to avoid
aesthetic issues with stained margins.
A. True
B. False
2. What does the first cord rest on when it is
placed into the bottom of the socket?
A. Connective tissue attachment
B. Junctional epithelium
C. Sulcular epithelium
3. Soft-tissue recession can be caused by
trauma resulting from, for example, surgery,
aggressive probing, aggressive cord
placement, and aggressive root
instrumentation. Periodontal tissues with
which of the following characteristics are
most at risk for recession?
A. Stippling of the gingiva
B. Blunted papilla
C. Thin biotype
D. Pocket depths of less than 2 mm
References
1. Adamczyk E, Speichowics E. Plaque accumulation on
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1990;3:285.
2. Amsterdam M. Periodontal prosthesis: twenty-five years in
3936
SOLUTION AND EXPLANATION
Answer: B
Explanation: False. Modern all-porcelain
materials allow margins to be placed
equigingival or at most 0.5 mm
subgingival. Deeper margins will increase
the risk for recession and make it difficult
to properly isolate the area from moisture
during bonding.
Answer: B
Explanation: The junctional epithelium
lies at the base of the sulcus. It is 1 mm
thick on average. It must be treated with
care to avoid damage during cord
placement, cementation, and probing.
Answer: C
Explanation: Thin biotype. Thin biotypes
are more susceptible to recession due to
manipulation or trauma. Extreme care
must be exercised.
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3. Amsterdam M, Fox L. Provisional splinting: principles and
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6. Benson BW, Bomberg TJ, Hatch RA, et al. Tissue
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vertical dimension on the masticatory system in subjects
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15. Felton DA, Kanoy BE, Bayne SC, et al. Effect of in vivo
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of the dentogingival junction in humans. J Periodontol.
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the superior belly of the lateral pterygoid muscle in relation
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20. The glossary of prosthodontic terms. ed 8. Elsevier/Mosby:
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21. Gross MD, Ormianer Z. A preliminary study on the effect of
occlusal vertical dimension increases on mandibular
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the preparation line and periodontal health: a prospective 2-
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2000;20:173.
23. Hansen PA, Tira DE, Barlow J. Current methods of finish
line exposure by practicing prosthodontists. J Prosthodont.
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mechanical and mathematic models to study
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fixed partial dentures. J Prosthet Dent. 1966;16:937.
26. Hochman N, Yaffe A, Ehrlich J. Crown contour variation in
gingival health. Compend Contin Educ Dent. 1983;4:360.
27. Ingber JS. Forced eruption. II. A method of treating
nonrestorable teeth: periodontal and restorative
considerations. J Periodontol. 1995;47:203.
28. Kay HB. Esthetic considerations in the definitive periodontal
prosthetic management of the maxillary anterior segment.
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29. Kohno S, Bando E. Die funcktionelle anpassung der
kaumuskulatur bei starker beisshenbung [Functional
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increases in the vertical dimension]. Dtsch Zahnarztl Z.
1983;38:759.

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30. Kois JC, Spear FM. Periodontal prosthesis: creating
successful restorations. J Am Dent Assoc. 1992;123:108.
31. Kozlovsky A, Tal H, Lieberman M. Forced eruption
combined with gingival fiberotomy: a technique for clinical
crown lengthening. J Clin Periodontol. 1991;18:330.
32. Lie T. Periodontal surgery for the maxillary anterior area. Int
J Periodontics Restorative Dent. 1992;12(1):73.
33. Lindauer SJ, Gay T, Rendell J. Effect of jaw opening on
masticatory muscles: EMG-force characteristics. J Dent Res.
1993;72:51.
34. Lindhe J, Ericsson I. The influence of trauma from occlusion
on progression of experimental periodontitis in dogs. J Clin
Periodontol. 1982;53:562.
35. Lindhe J, Svanberg G. Influence of trauma from occlusion on
progression of experimental periodontitis in the beagle dog.
J Clin Periodontol. 1974;1:3.
36. Listgarten MA. Periodontal probing: what does it mean? J
Clin Periodontol. 1980;7:165.
37. Listgarten MA, Mao R, Robinson PJ. Periodontal probing
and the relationship of the probe tip to periodontal tissues. J
Periodontol. 1976;47:511.
38. Long JH. Locating centric relation with a leaf gauge. J
Prosthet Dent. 1973;29:608.
39. MacKenna BR, Türker KS. Jaw separation and maximum
incising force. J Prosthet Dent. 1983;49:726.
40. Manns A, Mirallees R, Guerrs F. The changes in electrical
activity of the postural muscles of the mandible upon
varying the vertical dimension. J Prosthet Dent. 1981;45:438.
41. Manns A, Spreng M. EMG amplitude and frequency at
different muscular elongations under constant masticatory
force or EMG activity. Acta Physiol Lat Am. 1977;27:259.
42. Marcum JS. The effect of crown margin depth upon gingival
tissue. J Prosthet Dent. 1967;17:479.
43. McKee JR. Comparing condylar position respectability for
standardized versus nonstandardized methods of achieving
centric relation. J Prosthet Dent. 1997;77:280.
44. Meitner S. Co-destructive factors of marginal periodontitis
and repetitive mechanical injury. J Dent Res. 1975;54:78.

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45. National Institutes of Health Technology. Management of
temporomandibular disorders, Assessment conference
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46. Newcomb GJ. The relationship between the location of
subgingival crown margins and gingival inflammation. J
Periodontol. 1974;45:151.
47. Olsson M, Lindhe S. Periodontol characteristics in
individuals with varying forms of the upper central
incisors. J Clin Periodontol. 1991;18:78.
48. Parkinson CF. Excessive crown contours facilitate endemic
plaque niches. J Prosthet Dent. 1976;35:424.
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3941
 tissue following denudation procedures. J Clin Periodontol.
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3942
CHAPTER 71

Multidisciplinary
Versus
Interdisciplinary
Approaches to Dental
and Periodontal
Problems
Dennis P. Tarnow, Mitchell J. Bloom

CHAPTER OUTLINE

Educational Trends Toward Multidisciplinary Specialist

Education in Implant Treatment
The Future

3943
Traditionally, periodontal treatment has been delivered using an
interdisciplinary model of therapy, with general dentists and
specialists each providing their respective aspects of care to the
same patients according to a comprehensive plan of therapy (Figs.
71.1 to 71.22). Conversely, a multidisciplinary approach is centered
on a single provider delivering care across a range of dentistry
disciplines. This practitioner can be a general dentist or a specialist,
as traditional modes of practice have evolved and in some aspects
look quite different from the classic model. The interdisciplinary
system has worked well because the patient benefits from the best
mix of talent from a “team” of dentists. Regardless of whether an
interdisciplinary or multidisciplinary approach is utilized, it is
critical for primary providers to have a thorough understanding of
the signs, symptoms, local and systemic risk factors, and
pathophysiology of disease processes as they relate to periodontal
and dental implant therapy. Additionally, they must possess a
strong working knowledge of the range of treatment options
available along with their respective indications, contraindications,
benefits, and liabilities to effectively formulate a proper treatment
plan. At this point the dentist can then decide whether he or she has
the requisite knowledge, expertise, and experience to meet the
patient's needs to proceed in a multidisciplinary fashion or should
refer the patient to a specialist for care at a more advanced level.

FIG. 71.1 Complex interdisciplinary implant care

scenario. Extraoral preoperative condition. Aesthetic
compromise is evident in this challenging treatment

3944
 scenario where there is significant gingival display.

FIG. 71.2 Intraoral preoperative condition. A concave

soft-tissue profile that contributes to a dark shadow
and aesthetic compromise is evident bilaterally
(arrows).

FIG. 71.3 Preoperative radiographs. The roots of

adjacent teeth do not converge to interfere with proper
orientation of the positions of the planned dental
implants. However, there is limited space between the
adjacent tooth roots.

3945
 FIG. 71.4 Intraoral preoperative clinical view. Soft-
tissue contours as seen with the existing restorations
removed.

FIG. 71.5 Implant surgery. Initial incisions using a

papilla-sparing technique to minimize disturbing the
healthy supracrestal attachment on the surfaces of the
adjacent teeth.

3946
FIG. 71.6 Intraoperative clinical view. Edentulous right
and left treatment areas both show concave bony
defects labially.

FIG. 71.7 Intraoperative clinical view. Implants placed

in a prosthetically guided orientation that is palatal to
the buccal depression.

FIG. 71.8 Intraoperative clinical view. Correction of

bony defects using guided bone regeneration
technique. Resorbable barrier membranes are shown
in position after being trimmed to a suitable shape and
fitted in place.

3947
 FIG. 71.9 Intraoperative clinical view. A particulate
bone graft material is placed and shaped to fill the
bony depression under the previously fitted membrane.

FIG. 71.10 Implant healing abutments, which act to

facilitate coronal and labial positioning of the soft-
tissue flap, were previously placed. This will work in
conjunction with the augmentation procedure to correct
the preoperative soft-tissue concavity.

3948
 FIG. 71.11 Convex ridge shape after augmentation is
shown after completion of the surgical procedure.

FIG. 71.12 The gingival third of the provisional

restoration has been reduced so it does not impinge on
the surgical site. The vertical position of the soft-tissue
height on completion of the surgery is favorable as
compared with that of the adjacent natural teeth.

3949
 FIG. 71.13 Postoperative radiograph. The dental
implants are in good position. Given the amount of
available space between the adjacent tooth roots, a
narrow-diameter implant was selected as part of the
treatment plan to yield a biologically and prosthetically
favorable result.

FIG. 71.14 Postoperative clinical view at 1 week after

surgery. The soft tissue is healing well. Note the
favorable soft-tissue response where the papillae were
not disturbed using a conservative incision design.

3950
FIG. 71.15 Postoperative clinical view 3 months after
surgery. The soft tissues have healed favorably with
maintenance of the free gingival margin position
situated to yield a prosthetic clinical crown of
appropriate length.

FIG. 71.16 Screw-retained single provisional crowns

inserted and connected to the dental implants to begin
nonsurgical sculpting of the peri-implant soft tissue.

3951
 FIG. 71.17 The peri-implant soft tissue is sculpted
three-dimensionally to represent the cross section of
the natural tooth being replaced to create a more
natural appearance in the final restoration than
possible with prefabricated round healing abutments.

FIG. 71.18 Peri-implant soft tissue after nonsurgical

sculpting. Notice the early stages of papillae reforming
in the spaces between the natural teeth and dental
implants.

3952
 FIG. 71.19 Custom abutments in place on the dental
implants. Gold plating of the custom abutments was
done to impart a hue to the peri-implant sulcus and soft
tissue to optimize the aesthetic outcome.

FIG. 71.20 Final crowns are seen here on the date of

insertion. The crown contours dictate the gingival
contours.

3953
 FIG. 71.21 Radiograph following final crown insertion.
Note the customized emergence profile of the
prosthetic components on the dental implants.

FIG. 71.22 Final aesthetic outcome from both an

intraoral and extraoral perspective.

Many of the early innovators in the field of implant dentistry

were general practitioners. Subsequently, their early
accomplishments were built on using rigid and narrowly defined
surgical and prosthetic protocols whose effectiveness and
predictability were supported by well-documented long-term
research studies put forth by Dr. P.I. Brånemark. His namesake
implant design, when used precisely as directed with respect to
case type and patient selection, strict surgical protocols, specialized

3954
armamentarium, and a narrow range of treatment options, made it
possible for clinicians to achieve highly predictable treatment
outcomes. The initial offering of training in the Brånemark method
was limited only to specialist prosthodontists and oral surgeons, the
former group focusing on the restorative aspect of care and the
latter group on the surgical phase of therapy. However, as implant
dentistry continued to evolve, periodontists became increasingly
more active in the field, ultimately sharing the same role and
stature as their oral surgeon colleagues in this arena. The same was
true for many general practitioners with respect to their
prosthodontist colleagues in terms of delivering implant restorative
care.
The range of indications for the use of dental implants expanded
beyond the limited mandibular full arch case type Brånemark
initially taught to include partial edentulism, single teeth, and even
orthodontic and maxillofacial applications. Regenerative techniques
have been developed as well to address hard- and soft-tissue
deficiencies that, for many patients, had previously deemed them
unsuitable candidates for dental implant therapy. Autogenous
intraoral block grafting, guided bone regeneration, maxillary sinus
grafting, transposition of the inferior alveolar nerve, ridge splitting,
distraction osteogenesis, and biologics are among the many
strategies that have emerged to overcome limitations for less-than-
optimal sites.
Early implant designs and materials were subject to limitations
and even prone to problems. Those with machined surfaces
suffered from a significantly higher failure rate in sites with poor-
quality bone, whereas those with rough surfaces, coupled with
other design flaws, were prone to late failure resulting from
inflammatory peri-implant disease or prosthetic complications.
With all of these variables in play and emerging so rapidly during
the formative years, implant dentistry was relegated largely to the
specialty care arena. Through innovative implant designs, advances
in material science, opportunities for simplified surgical techniques,
digital planning and manufacturing technologies, systematic
treatment protocols, and better data to appreciate success and risk
factors, predictable outcomes have become readily achievable. The
widespread emergence and acceptance of implant dentistry and the

3955
fact that it is both a surgical and prosthetic modality puts it at the
center of many of the trends transforming traditional practice
models.
Periodontology, like other specialties, has evolved to embrace a
more global view of patient care. It is suggested that in addition to
learning all of the standard periodontal procedures of the past, the
contemporary periodontist should also be able to restore simple
implant cases such as those located outside of the aesthetic zone
(Figs. 71.23 to 71.32). Periodontists will continue to be trained to
manage hard and soft tissues and perform all of the latest
periodontal plastic surgical procedures to preserve and reconstruct
pleasing gingival architecture in the aesthetic zone to the highest
level of sophistication and complexity. However, as the definition
of what is deemed a successful outcome continues to evolve and the
bar for the definition is raised, the surgeon must remain acutely
aware of the restorative aspects of care and abreast of related
advances. In other words, it has become essential that periodontists
not limit their knowledge and care to the treatment of periodontal
disease alone.

FIG. 71.23 Multidisciplinary simple implant care

scenario: favorable soft-tissue parameters combined
with a low smile line. Preoperative view of the maxillary
right first premolar. With the exception of a small
degree of gingival recession, all other aspects of the
surrounding periodontium are intact.

3956
 FIG. 71.24 A fracture extending in a mesiodistal
orientation is evident on the occlusal surface of the
maxillary first premolar.

FIG. 71.25 Healed ridge 3 months after tooth

extraction. Note the wide zone of keratinized tissue
present and favorable maintenance of the height of the
adjacent interdental papillae.

3957
FIG. 71.26 The healed ridge demonstrates favorable
buccolingual dimension and soft-tissue quality. Based
on preoperative clinical and radiographic evaluation,
placement of a dental implant in an uncomplicated
fashion can be expected.

FIG. 71.27 Surgical access for placement of the dental

implant using a horizontal incision that extends
intrasulcularly to the nearest buccal and palatal line
angles of the adjacent teeth.

3958
 FIG. 71.28 The endosseous implant is properly
positioned to facilitate an optimal prosthetic outcome in
the final restoration.

FIG. 71.29 After a period of healing during which the

implant was submerged, stage II surgery to expose it
was accomplished. In this scenario, a fixed provisional
restoration was secured to the implant to serve as a
matrix and begin sculpting the resultant soft-tissue
profile in lieu of using a conventional nonanatomic
round healing abutment. Note the position of the flap
margin on the prosthetic crown. It is located occlusal to
the expected cementoenamel junction (CEJ) location
to compensate for expected soft-tissue healing and
remodeling and yield a favorable aesthetic outcome.

3959
 FIG. 71.30 The healed peri-implant sulcus
demonstrates the three-dimensionally generated result
achieved using a provisional crown for soft-tissue
sculpting. Note the recreation of the interdental papilla,
the result of a favorable relationship between the
interproximal bone height of the adjacent teeth and
reestablishment of contact areas between the natural
teeth and the provisional restoration.

FIG. 71.31 Occlusal view of the anatomic peri-implant

sulcus formed by the contours of the provisional
restoration subgingivally.

3960
 FIG. 71.32 Final implant-supported restoration in
place.

Surgical specialists (i.e., periodontists) who are trained according

to a multidisciplinary approach will provide even greater benefit to
their patients from this evolved philosophy. Consider the case for
immediate dental implant placement along with simultaneous
fabrication and insertion of a provisional restoration at the time of
tooth extraction. This treatment is a series of steps that integrates
both surgical and restorative areas of dentistry. As such, suitable
depth of knowledge in all phases is needed to allow for proper
diagnosis, case selection, and clinical delivery of care for predictable
outcomes and to yield the wide range of benefits this treatment
offers to both the patient and the doctor. Even when the role of
implant surgeons is limited to the surgical phase of therapy,
achieving the best and most predictable outcomes requires that they
possess a thorough understanding of the realities and intricacies
related to the fabrication and delivery of the planned prosthesis.
This “restorative” knowledge and experience will help them to
place implants in as close to ideal orientation in all three spatial
dimensions and to avoid such common errors as excessive implant
angulation by understanding the restorative challenges that may
otherwise result. Additionally, the well-versed periodontist will be
better able to communicate effectively with restorative colleagues
and may even serve as a resource to guide and educate those who
might have less familiarity with the subject matter when an
interdisciplinary approach is utilized.

3961
Educational Trends Toward
Multidisciplinary Specialist Education
in Implant Treatment
For the multidisciplinary model of practice to be able to deliver care
at the level presently available through the interdisciplinary model,
the provider (general practitioner or specialist) needs to be
comprehensively trained with a broader scope and depth of
expertise than typical contemporary norms often deliver. This is
reflected in the many changes and opportunities in continuing and
postgraduate training, particularly those centered on the surgical
aspects of dental implant therapy.
Continuing education offerings span a broad range. Some are
limited to didactic teaching with laboratory simulation, whereas
others take the form of clinical fellowship-style programs that
encompass a patient care component lasting a year or longer. As
such, some general practitioners and traditionally trained
prosthodontists who have sought out advanced postgraduate
training might add some aspects of surgical care (commensurate
with the scope and level of their respective training) to the range of
services they personally provide. Conversely, members of the
surgical specialties (e.g., periodontists and oral surgeons) would
have received a level of training that would enable them to
recommend, guide, and, if necessary, provide a range of restorative
treatments. Indeed, rigidly defined accreditation standards for
some postgraduate specialties have already been revised and reflect
this trend toward encouraging multidisciplinary training.
Traditional nonsurgical restorative training programs now include
basic implant surgical training in their curricula. Advanced
education specialty programs in prosthodontics, among other
topics, now include an increased allocation of time in their didactic
and clinical curricula in the area of diagnosis, as well as training to
the level of competency with respect to simple single-tooth
implants in healed ridges of favorable dimension and in sites
outside the aesthetic zone.

3962
The Future
It has already become the accepted norm that not all surgery will be
done by a periodontist or oral surgeon, nor is it likely that all
restorative work will be done by a general dentist or
prosthodontist. Instead, simple cases that require surgery and
restoration will probably be performed entirely by either a well-
trained general dentist or a specialist. In fact, many periodontists
have already begun working with their restorative colleagues by
making the final impression or index of the implant at the time of
surgery and forwarding it to them. In such a scenario, the
restorative dentist may now only need to insert the final restoration
when it comes back from the laboratory, thus expediting treatment
and enhancing the experience for both the patient and the doctor.
Although it is conceivable that simple implant cases will more
likely be treated in a multidisciplinary fashion, an interdisciplinary
approach will still exist and be utilized for patients who require
advanced treatments, particularly when there is a deficiency of soft
and/or hard tissues.
Periodontists of the future will have a multidisciplinary approach
to patient care. They will continue to provide all of the specialty
services that “classically” trained periodontists have done for
decades, but they will also be well suited to better support their
restorative colleagues.

3963
SECTION VII

Supportive Care and

Results of Periodontal
Treatment
OUTLINE

Chapter 72 Supportive Periodontal Treatment

Chapter 73 Results of Periodontal Treatment

3964