MAGAZINE OF ALPHA OMEGA INTERNATIONAL DENTAL FRATERNITY

VOL. 10 0 DECEMBER 1977 @ NUMBER 3

FEATURES
ImporlanreoltheSingleTooth
Page 17 Rcstoralion.
KcnnethW.Laudenbach.D.D.5. ..

ort ton Amsterdam -Pveceptar par Excellence. AdultTooth Movemenl: Alteration

ail id ~ ~ a u d r e aD.D.S.
u, . . . . . . . . . . . . . . . . . . . . Page 19 o l theOccluralVertical Dimension
PrepatorytoTmthMovement.
Manuel H. Marks, D.D.5.
Herman Corn, D.D.S. ........................ Page54

The Use of Telescopes i n General Dentistry. The"BialogicWidth"-AConcept i n

DanielCarulio.D.D.5. Periodonlicr and Rertoralive Dentistry.
Francis Matararza.D.D.5. . . . . . . . . . . . . . . . . . . . . Page20 Jeffrey S.Ingber, D.D.S.
LauirF.Roie,D.D.S..M.D.
j.CeorgeCarlet.D.D.5. ......................
Page62

Diagnorismd Clarification o f lnlerdental PapillaeGrafU

.DelayedParrive h u p l i o n a f the PeierA.Rubelman,D.D.S. . . . . . . . . . . . . . . . . . . . Page66
Dentogingival l u n d i o n i n the Adult.
I.GcorgeCoilel.D.D.S.
RobrriVanarrdall, D.D.5.
Arnold Weiigoid,D.D.S. ..................... Page24

Reldtion~hipofthe Neutrophilto 7 The Influence of Systemic Direare

Host RerirlancelnPeriodontalDiseare. Upon PrortheticTrealment.
Robert i.Genco.D.D.5. DonI.Trachienberg.D.D.5. . . . .
Louirl. Gianciola,D.D.S. Page31

V Contoursof the Full Crown

Restoration.
Page36 ArnoldS.Weirgald,D.D.S.

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ALPHA OMEGA FRATERNITY

2 6 7 5fh Avenue, N e w York, N. Y. 10016
MEMBER PUBLICATION AMERICAN ASSOCIATION OF DENTAL EDITORS
Wagnosis and Classification of Delayed
of the
Passive Eru~tition
~entogin~iwal Junction inthe Adult.
.I. George Coslet, D.D.S.
Associate Professor of Periodontics, Director of Post Doctoral Periodontics and Director of the Division of
Advanced Dental Educationat the University of Pennsylvania.
Robert Vanarsdall, D.D.S.
~Assistant
~----
~~~ Professor of Orthodontics and Periodontics and Acting
at the university of ~ e n n s ~ l v a n i a .
-
Arnold Weiseold, D.D:S.
.U:;:T~.,:,;:nnd CI.lirx::r. ofrLe !?ep;::trner.!
Doctoral Periodontal Procthesirat the I:n~\~.rsity
Review of the Literature
It is frequently observed in adults
that a short clinical crown exists due
to gingival tissue being located in-
cisally or occlusally on the anatomical
crown (Figure 1). Descriptions of this
condition occur in the literature but
offer only clinical observations with
little understanding of the dento-
gingival junction and the anatom-
ical interrelationships between the
soft and hard tissues. Where the
gingival margin fails to recede dur-
ing tooth eruption to a level apical to
the cervical convexity of the tooth
crown, Goldman and Cohenlg have
described as altered (retarded) pas-
sive eruption. Volchansky and Cleat-
on-Joneslg 0' describe this condi-
tion as delayed passive eruption.
They defined delayed passive erup-
tion as a dentogingival relationship
whereby the margin of the gingiva
is positioned incisally/occlusally on
the anatomic crown in adulthood
and does not approximate the ce-
mento-enamel jnnction; utilizing
this criteria, 12% of patients exam-
ined demonstrated delayed passive
eruption.
Loe1 describes the normal dento-
gingival relationship for adults as
being located on the enamel ap-
proximately 0.5 to 2 mm coronal to
the cement0 enamel junction
(CEJ) in fully erupted teeth. Loe's
perception of the relationship of the
tissues involved in the dentogingi-
val junctionis illustrated in Figure 2.
The gingival margin is located on
the enamel with the junctional epi-
thelium positioned from the base of
the sulcus to the CEJ. The gingival
fiber apparatus is present with its
fibers embedded into the cemen-
tum and is located between the
CEJ coronally and thecrest of alveolar
bone apically. The mucogingival
junction is preferably located apical
to the crest of bone. Gingival fibers
34
" Chairman of the Denartment of Periodontics
u!!-:?:x :in.' Funcri:?r. o: : k t ?!::::ic;:!:::y
oi Pcnn>)I\,snia.
near the apical area of the cemen-
tum course over the alveolar crest to
insert in the periostium of the bone
and intermingle with the fibers lo-
cated in the attached gingiva be-
tween the alveolar crest and muco-
gingivaljunction.
The histologic relationships of the
dentogingival junction were de-
scribed by Sicher in 1959. He de-
fined the dentogingival junction as
a functional unit composed of two
parts (1) the connective tissue fi-
brous attachment of the gingiva and
(2) the epithelial attachment. The
firmness of the dentogingival junc-
tion is enhanced by the gingival fi-
ber apparatus embedded into the
cementum and which fan out into
the gingiva. According to Sicher, the
function of the epithelial attach-
ment is to protect the connective
tissue fiber junction to the tooth.
Schroeder and Listgarten15 demon-
strated with electron microscopy
that the epithelial attachment does
--..-.-
9Ah-r- to the enallle! by the he=.$
desmesome and basement lamina
which is identical to the epithelial
- connective tissue junction found
between epithelial cells of the
gingiva and the underlying connec-
tive tissue. They introduced a new
term for the epithelial attachment:
the junctional epithelium, which
they stated was derived from the re-
duced enamel epithelium.
Sicher originally maintained that
the attachment of the epithelium
to the tooth was not unusually
strong, however, the firmness of the
attachment of the gingiva to the
tooth is not a function of the epithel-
ium but is the function of the col-
legenous fibers which insert in the
cementum located between the
CEJ and the alveolar crest. Gargiulo,
Wentz and Orban' described the
dentogingival junction as being the
distance from the tip of the gingival
m
<"- - ..
s --:;
" ?
3%
- ~*.:.
i'T
-,
-~
.,
ii..
)~^.
Sy:ren 2nd Ei:~::-:~:'Pos;
. .
. . ..R
. .
margin to the crest of the alveolar
process. In normal healthy gingiva
they found the distance from the
CEJ to the crest of alveolar process
to be an average of 1.55 mm in
length. This was a consistent find-
ing and indicated that there is a def-
inite proportional relationship be-
tween the dentogingival junction
and the other supporting tissues of
the tooth.
As clinical crown heights vary in
the child and young adult (according
to age and the stage of tooth erup-
tion), Volchanksy and Cleaton-
Joneslg 20 had difficulty in applying
the classical dimensions of the den-
togingival relationship as described
by Loel for the normal adult. They
were interested in determing the
normal position of the gingival mar-
gin on the anatomic crown in chil-
dren between the ages of 6 and 16.
Their study and others have con-
firmed that clinical crown height in-
creases with increasing age (see Fig-
lure !1 HOWPVP~, the ni.!mber of club-
jects in their study was too small to
define a normal clinical crown
height for a given age. They obser-
ev, however, no abnormal or marked
wear patterns suggesting that wear
did not play a role in the variation
of clinical crown height.
In all of the clinical papers re-
viewed on delayed (or altered) pas-
sive eruption in adults or dentogin-
gival relationships in children dur-
ing eruption there was no attempt
to determine or correlate the rela-
tionship of the alveolar crest to the
dentogingival junction. Of interest is
the study of Boyle, Via and McFal15
on the radiographic analysis of al-
veolar crest height and age because
it introduced another parameter
related to changes that occur in the
relationships of the tissues compris-
ing the dentogingival junction in
the healthy periodontium. The pur-
pose of their study was to investi- described by Loel, as seen in Figure 2 lation, with 5.4 per cent of the pati-
gate radiographically the interprox- and diagrammatically in Figure 4. ents having both Vincent's infec-
imal bone crest levels in clinically Variations in the height of the gin- tion and delayed altered eruption.
healthy patients ranging in age from gival margin on the anatomic crown They further pointed out that de-
I I to 70 years. The measurements have been observed in adults at vari- layed altered eruption is not mere-
taken from the CEJ to the alveolar ous ages (Figure 5). In Volchansky ly an inflammatory hyperplasia
crest ranged between 0.2 mm and and Cleaton-Jones' previously men- since it is often observed in the ab-
2.15 mm with a mean distance of tioned survey, 12.1 per cent of one sence of clinical inflammation and
1.24 mm. However, there was a thousand and twenty-five patients therefore exists as an entity unto
graphic expression of regression of exhibited delayed passive eruption. itself. Since they found such a high
CEJ crest distance with age. Be- This represents a significant num- correlation between the presence
tween the ages of 10 to 20 CEJ - ber of patients clinically demon- of delayed passive eruption and Vin-
crest distance was less than 1.0 mm strating a variation of the gingival cent's infection (x test, P=0.001) they
with a statistical increase in CEJ height on the anatomic crown and believe this entity to be a predis-
- crest distance with advancing is certainly not interpreted as an posingfactor to Vincent's disease.
age to 1.5 mm. Although the authors uncommon occurrence. They report- Gingiva-~natomicCrown
state that it is doubtful that a thera- ed the presence of Vincent's infec- Relationships
pist would consider bone changes of tion in 8.6 Der cent of the totd DODU- Our observations of delaved ~ a s s i v e
this magnitude over a 59 year span
to be of any clinical significance, it is
difficult to determine whether the
alveolar crest to CEJ change of
0.017 mm per year is entirely physi-
ologic. The study does imply that the
normal CEJ-osseous crest distance
of 1.5 mm as described by Gargiulo,
Wentz and Orban' does not exist in
all ages and may frequently be as
little as 0.2 mm.
These questions arise:
1. What is the normal dentogin-
gival relationship of the gingiva,
tooth and alveolar bone in the child,
the adolescent and the adult?
2. Clinically, in the adult when de-
layed passive eruption exists, what
is the significance of the relation-
ships of the gingival tissue, the CEJ
and the CEJ - osseous crest distance?
It is the purpose of this paper to dis-
cuss the relationship of the dentogin-
gival junction at various ages and
suggest a classification of delayed
passive eiiipiioii in :hi a&!:, At.
tention is focused on the clinical
problem delayed passive eruption
creates for the restorative dentist
and periodontist, especially when
surgicalintervention is indicated.
Discussion
Clinical observations of the dento-
gingival junction in children during
the transitional dentition demon-
strate that during eruption the gin-
gival margin may be at various
heights on the anatomic crown.
Following a child during the primary,
transitional and into the perma-
nent dentition one observes the
changes as in Figure 3.
During the transitional dentition
stage it is not abnormal to expect
the gingival margin to be located at
various heights on the anatomic
crown. Normally by the age of 18 to
20 the majority of individuals have a
dentogingival relationship clinically
eruption in the adult have been that
clinically there are two general
types of gingival tissue relationships
to the anatomic crown. In many
cases, especially the dense gingival
tissue type, there appears to be an
excessive amount of gingiva (Fig-
ure 6). In these cases, clinical mea-
surenlents of the width of the at-
tached gingiva indicate that the
zone of gingiva present is greater
than the mean widths documented
by Ainamo and Loe' Bowers' and
Fehr, and Carin and Muhleman.6 In
the excessive gingiva cases, if the
base of the gingival pocket was as-
sociated with the level of the CEJ,
resection of the gingival tissue cor-
onal to the CEJ would result in a
Fig. 4. Diagrammatic representotionof
narmoldentogingivoi relationshipin the
odult.
Fig. 5. A. A 38yeoraldfemolepotieol
exhibitingdeloyedporriveeruption. 0
Notesmall clinical crownrdi~plo~ed
by
this30yeorold malewitha rimilor
<linicoiproblem.
Fig. 6. Diogrom of Type lAdelayed porrive
eiuption with retrartoblegingival margin
ond6mm of depth.
26
width of gingiva to the mucogin-
gival junction that falls within the
mean widths as described by the
former anthors. The other type of
gingival tissue often seen in adult
cases of delayed altered eruption
exhibits gingival widths which are
average and fall within the means
described by Bowers and Ainamo
and Loe. However, keratinized tis-
sue present in these cases is located
entirely on the anatomic crown
(Figure 7). In these cases with gin-
giva of average width the mucogin-
gival junction is usually present at
the !eve! of the CFJ. Resection of
the gingival pocket in these cases
(if the base of the pocket was posi-
tioned at the level of the CEJ) would
Fig.7.Diogrom otiype2Bdelayed ~ ~ ~ r i v e
eruption with theentire bond of kero-
tinired tiriue locotedon theonotomicai
crown ond the orreour crest Iorc~tedot the
CEJ.
result in the complete elimination
of all masticatory mucosa.
-
Alveolar Crest CEJ Relationships
During surgical management of de-
layed passive eruption, observations
of the alveolar crest - CEJ relation-
ship proved to be of great signifi-
cance.
Surgical treatment of the gin-
gival tissues in children and ado-
lescents for periodontal and ortho-
dontic reasons has demonstrated a
high incidence in which the alveolar
crest is located at the CEJ (Figure 8).
Although the alveolar crest is found
sligb.tly apical to the CE; in some
cases, rarely is the alveolar crest -
CEJ distance in children and ado-
lescents the 1.5 mm mean distance
described by Garigulo, Wentz and
Orban7Itappears that during the dif-
ferent stages of eruption the a1-
veolar crest - CEJ distance remains
quite small or non-existent (Figure
9). This relationship should be con-
sidered normal for these age groups.
The fact that the identical relation-
ship can be carried over in adulthood
with delayed passive eruption is of
special interest.
Many clinicians have observed
during mucogingival surgery that the
position of the alveolar crest is at the
level of the CEJ. This is contrary t o
the description by Orban,'"i~her,'~
Goldmanuand Loe, whereby the con-
nective tissue attachment serves to
maintain the functional integrity
of the underlying structures by its re-
sistance to mechanical stresses. The
alveolar crest - CEJ distance re-
ported by Gargiulo, Wentz and Or-
ban7 in the normal periodontium is
believed to be necessary for main-
tenance of gingival health. The ab-
sence of the normal alveolar crest -
C W distance as described by these
authors may account for the predis-
position of many cases of delayed
passive eruption in the adult to ex-
hibit gingival pathology. There is us-
ually a pseudopocket and lack of gin-
gival tonus associated with gingival
tissue high on the anatomic crown.
These relationships are very sig-
nificant as they relate to clinical
dentistry (Figure 10). A clear descrip-
tion of the clinical problem through
classification will lead to a correct
diagnosis.
Classification of Delayed Passive
Eruption in the Adult
I. Gingival/ Anatomic Crown
Relationships:
Type 1 is represented by the pres-
ence of the gingival margin being
incisal or occlusal to the CEJ where
 there is a noticeable wider gingival
dimension from the gingival mar-
gin to the mucogingival junction
,
than the generally accepted mean
width according to Bowers and
Ainamo and Loe. The mucogingival
junction is usually apical to the al-
veolar crest in these cases.
Type 2 is represented by a gingival
dimension from the margin to the
gingival tonus of the epithelial gin- collagen bundles of the gingival fi-
gival cuff can be maintained. The ber apparatus. The organization of
gingival tissue most frequently ob- the fibers of the gingival corium dif-
served in Type 1 cases of delayed pas-
sive eruption is a dense tissue type.
fer from those described by Gold-
man in the normal periodontium.
Adults with this type of delayed The clinical significance of this al-
passive eruption seem to be more teration in the dentogingival junc-
resistant to gingival pathology than tion cannot be completely assessed
Type 2cases. at this time; however, it may be re-
The significance of the alveolar lated to the predisposition to gingival

I
mucogingival junction which ap-
pears to fall within the normal mean
width as described by Bowers,' Ain-
amo and Loe.' In this type all of the
crest - CEJ distance is related to the
gingival fiber apparatus as previous-
ly noted. In either case, Type I or
pathology. It certainly could be a sig-
nificant relationship that could al-
ter the wound healing of the dento-
Type 2, when the alveolar crest is gingival junction when delayed pas-

I
gingiva is located on the anatomic
cro-n with the mucogingiva! junc-
tionlocated at the level of the CEJ.
located at the CEJ in the adult there
is a lack of available cementum
apical to the CEJ and coronal to the
sive eruption cases are treated sur-
gically.
In closing, it should be pointed out
I 11. Alveolar Crest - CE.1 alveolar crest for the insertion of the that the classification presented is
)
~~~~ ~

Relationships Fig. 8,A,Obrervetheedemotaus, chron

icollyinflomedgingival tirrvepre.ent in
In subgroup A, the alveolar crest - this 10 year old potient. 8. Radiograph
CEJ relationship corresponds to the with pointinplocetorhow depthof the
1.5 mm distance accepted as nor- gingival pocket. C. Gingiva woi re-
mal. This distance allows for normal tiactable, D. Bonelorotedot theCEJ.
insertion of the gingiva fiber appara-
tus into cementum (Figure 11).
In subgroup B, the alveolar crest
is at the level of the CEJ. This rela-
tionship is frequently observed dur-
ing the transitional dentition under-
going active eruption (Figure 12).
The classification is depicted in
the following chart illustrating

I morphological relationship of the

gingiva, anatomic crown, CEJ and
alveolar crest to the dentogingival
junction (Figure 13).
Summary
It becomes apparent that the com-
bination of possible tissue relation- Fig.9.A. Notegingival hyperpiorio that
dsveloped inthernoxillory archduring

I ships of delayed passive eruption of

the dentogingival junction is sig-
nificant in periodontal therapy and
arthodontictheropy forthir 16yeorold
~ r n t i ~8.~Aftei
t . oll active forces were
forseveral months priorto de-
restorative dentistry. The relation- banding, thegingivol tiiiuewor reflected.
C. Observe tho1 the bone ir locoted of the
ship ol' ihe mucogingival junction in
CEJ on all the teelh. 0.Noorseour surgery
case Type iA or 1. is not as signifi- war done to exporecementvm. Therefore
cant as in Type 2.4 or 28. In Type 2 onecan expectthe poortirrue form or
delayed passive eruption, the gin- seen heieportoperotively.Thir iirigoifi-

I giva is located on the anatomic

crown. Even though in Type 2A
there is a normal alveolar crest -
contto understand ~ h e n e v o l u o t i n gwound
healing in young potientr.

CEJ distance, all of the gingiva is un-

I
t
supported by connective tissue fi-
bers. This case type is most frequent-
ly seen in thin tissue types and ap-

I pears to be highly susceptible to peri-

odontal disease. In case Type LA the
mucogingival junction is located
apical t o the alveolar crest. Even

I though there may be excessive gin-

gival tissue high on the anatomic
crown, part of the gingiva is support-
ed by the gingival fiber apparatus --
and alveolar bone. Since there is
1 enough cementum available for the
insertion of rhc ginp\;rl fiber ap-
~ i~ ~o .. ~ . ~ ~ i~ d t~ ~h t i~ ~ z~ t ~

m o r ~ n oc q m r e C. 0~.~,60;..*e.,,
t~
y p~e~zh~ p

n.c;g r p
~i obi r~i vte~ei r~u p~t i o n a ~ofi the kerotinized tiriueir locotedon the crown.
should re5tor.t;ve~enti,trv become neceirorvthirelotionihiowould have to becorreaed first. 8. Diaqrommaticoll~,the
." . oi ,:t a-n ,nee ..C <,. :,.>v C 1- 5 3 2 year o a pa?e-!:ro-, erlel.5
'I C ' "oven 0 5 ! 0 ( 0!?0 A vn ~ ~ : .e2,v ~51,'~ F~ x'O u."e 3 r ~ < e r c c c' ,I p e 2 A 0 e 0 ) v O c..p! o? lnc 7.Coy ng " 0
pdra,us it nppeasj ,hat V O

1 .no or c ~ n ~ c n o v , ~ ~- r~ a?. E
e l .r r e ~ n ,pro,
r 1 8 r e o I s i . r o n m e c ,ups , .,,c.ppoiieo o, . r e g ng 1 3 I oar o p p c - ? - . r
 1 OSSEOUS CREST AT CEl
I CLASSIFICATION OF ALTERED PASSIVE ERUPTION
IN THE ADULT IAH.mIOAL~ nod lilsiOLO

TYPE I : AN EXCESSIVE AMOUNT OF OlNOlVA

I I
F i g . 11. Diosiom a1 thenormol orieoui CrertCEJ
topagiophy a r r s e n i n i u b g r o u p A.Cementuni5
ovoilmble tar collagenous fiber ottochment.

NORMAL OSSEOUS CREST/CEJ

, , . , ., . : ' ,
r

.. :
Fig. 12. Diagramof thearieour crest Fig. 13. ClarsificatlonChort.
located at the CEJ a r ~ e e n i nsubgroup 8.

based only on clinical observation
and is not a result of a statistical sur-
vey in a population of delayed pas-
sive eruption. No attempt is made
to present information on the fre-
quency of occurrence of the various
types of delayed passive eruption.
Such information would be of great
value because of the necessity to
treat delayed passive eruption in the
adult. It is hoped that the classifica-
tion will bring an awareness to the
clinician of the significant differ-
ences in the various types of delayed
passive eruprion in reicrctice to the
tissues of the dentogingival junction
and alveolar crest. The awareness
of these differences should result in
a better understanding of delayed
passive eruption in the adult and im-
proved management of these cases
therapeutically by the restorative
dentist and the periodontist.
BIBLIOGRAPHY
I. Ainama, J. and Loe, H.: Anatomical Char-
acteristics af Gingiva. A Clinical and micrc-
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2. Baer, P. N. and Benjamin, S. D.: Pcrio-
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3. Black, G. V.: Descriptive Anatomy of the
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4. Bowers, G. M.: A study of the width of at-
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5. Bayle, W., Via, F. and MeFall, W., JI.:
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6. Fehr, Carin and Muhlemann, H. R.: The
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..-..
1461
8. Goldman, H.: The Topography and Role
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by. 1968.
10. Listgarten, M.: Electron Microscopic
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. ~~~.
11. Manson. J. D.: Passive Eruotion. Dent.
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Grant, D.: Periodontics, D. V. Mosby Co.,
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14. Rose, T. and App, G.: A clinical study of
the development of the attached gingival
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manzibular anteribr teeth in the deeidrr-
J. Ceorg~Cor1et.D.U.S. Robert Vansmdail, D.D.S.
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Philadclphis. Pa. 19174 Villanova, Pa. 19085
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15. Schroeder, H. E. and Listgarten, M.:
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attachment of human teeth, monographs
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Karger, 1971.
16. Sicher, H.: Changing concepts of the
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1959.
17. Ten Cate, A. R.: The dento-gingival junc-
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18. Van der Linden. F., and Puterlao, H.: De-
las. Harper and Row Pub. Hagentown, Mary-
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19, Vnlchsnsky and Cleaton-Jones: Delayed
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