Romanian Journal of Oral Rehabilitation

Vol. 14, No.4 October-December 2022

IMPLICATIONS OF PERIODONTAL STATUS IN THE SUCCESS OF

DIFFERENT TYPES OF FIXED PROSTHETIC CONSTRUCTIONS
Irina Grădinaru 1, Loredana Liliana Hurjui 2, Radu Mircea Sireteanu Cucui3*, Oana
Elena Ciurcanu 1 Violina Budu1*, Adina Oana Armencia 1, Daniela Onișoru 4, Cristina
Iordache1, Magda-Ecaterina Antohe 1

1. “Grigore T.Popa’’ University of Medicine and Pharmacy, Iasi, Faculty of Dental Medicine,
Romania
2. ‘’Grigore T.Popa’’ University of Medicine and Pharmacy, Iasi, Faculty of Medicine, Romania
3.’’Dimitrie Cantemir’’ University ,Tg. Mureș, Faculty of Medicine, Romania
4. ‘’Dunarea de jos’’ University , Galați, Faculty of Medicine and Pharmacy, Romania

Corresponding authors*:
Radu Mircea Sireteanu Cucui, e-mail :medidentes@yahoo.com
Oana Elena Ciurcanu, e-mail : onutza73@gmail.com
Violina Budu , e-mail :buduviolina@yahoo.com

All authors have equal scientific contribution

Abstract: Restorative dentistry, in particular whole crown preparation is known to cause gingival recession.
Inadequate partial dentures and soft tissue support can cause severe gum recession. Incorrect use of elevators in
oral surgery procedures can destroy the alveolar bone of adjacent teeth causing recession. The aim of this study is
to evaluate the cumulative factors influencing the final therapeutic success following the lowering of periodontal
status with the type of prosthetic restoration performed.We evaluated a total of 80 prosthetic restorations, 20
veneers and 25 zirconia-supported ceramic crowns and 35 metal-ceramic crowns(CCM). The percentage of sites
showing a periodontal space depth greater than 3 mm was lower in the porcelain veneer group. The frequency of
periodontal pockets of 4 mm was 1% in the buccal surfaces of the veneers, 4% in the CCM buccal surfaces and
2% in the CCM palatal surfaces. There were no statistically significant differences between the determinations
made at the sites assessed at the CCM level and those assessed at the veneers level. 1. Subgingival placement of
prosthetic restorations has a negative impact on periodontal health and consequently on their aesthetic outcome.
Ceramic veneers, due to their preparation requirements and the advantage they offer due to their all-ceramic
structure, have the least impact on periodontal health status.

Keywords: Gingival hypergrowth, gingival diseases, restorative dentistry, bleeding index

The complexity of the aspects under
which lesions of periodontal structures are
encountered and the clinical manifestations
that occur with the application of restorative
treatments, have created serious confusion
of orientation, both in case studies and in
finding the most appropriate ways of
prevention. Periodontal diseases are
characterized from an anatomical-
pathological point of view by the
progressive destruction of tooth attachment
structures and from a clinical point of view
by the progressive mobilization of teeth
which can lead to spontaneous tooth
loss[1,2,3].
The treatment, or more correctly,
the prevention of gum recession, is not a
problem isolated to periodontology. Most
areas of dentistry are related in one way or
another to the prevention or creation of gum
recession[4,5,6].
Restorative dentistry, in particular
whole crown preparation is known to cause
gingival recession. Inadequate partial
dentures and soft tissue support can cause
severe gum recession. Incorrect use of

59
elevators in oral surgery procedures can
destroy the alveolar bone of adjacent teeth
causing recession[7,8,9].
Of course, there are conditions
beyond our control, such as inherited
dehiscence and aberrant eruption patterns
that influence gum recession. The
culmination of treatment in preventing gum
recession is changing the anatomical factors
of alveolar bone integrity and marginal
tissue quality. While it has been clarified
that untested hypotheses of the gingival
recession process exist, these anatomical
factors remain the focus of current clinical
techniques.
Prevention of alveolar dehiscence
and attachment of long gingival fibers is one
of the goals of therapy. Another goal is to
maintain an attached gingival area and its
"fiber barrier". The most stable combination
of these anatomical factors that can be
achieved in each situation should be the
therapeutic target[10,11,12].
Treatment and prevention of gum
recessions in the past often had to do with
the structural condition that led to gum
grafting procedures in areas that otherwise
would have been healthy. Usually, the
patient is unaware of the occurrence of gum
recession and does not complain of any of
the symptoms discussed above[13,14,15].
The treatment of gum recession has
to do with the initial prevention or
continuation of gum recession when there is
a lack of attached gum or when alveolar
dehiscence is present. A careful
examination can help in predicting
recession and determining which areas need
to be treated. This evaluation should include
a careful "listening" of the alveolar bone in
the area without attached gingiva[16,17,18].
Several techniques, now well
mastered, allow recessions to be covered by
60
lateral translation flap, coronally
repositioned flap, epithelial-conjunctival
free gingival graft, and free conjunctival
enclosed graft[19,20,21,22].
The aim of this study is to evaluate
the cumulative factors influencing the final
therapeutic success following the lowering
of periodontal status with the type of
prosthetic restoration
performed[23,24,25,26].
Material and method
We evaluated a total of 80 prosthetic
restorations, 20 veneers and 25 zirconia-
supported ceramic crowns and 35 metal-
ceramic crowns(CCM). Patients included in
the study (140 patients, 80 women and 60
men) based on informed consent, who
presented with prosthetic reduced partial
edentulousness and periodontal symptoms,
manifested by changes in shape, color or
texture of the gingiva, oedema; mild or
spontaneous bleeding, gingival pain and
sensitivity or gingival itching, tooth
mobility, pockets of different depths, hyper-
growths of different degrees.
Clinical attachment loss was
assessed by periodontal probing assessing
the depth of the pockets as well as the
degree of recession, the level of each test
tooth at at least 6 sites (V, O, MV, ML, DV,
DL) the reference element for the
assessment of attachment loss was the JAC
(cemento-amellar junction) expressing the
distance from the sulcus/pouch bottom in
millimeters. For periodontal registration, all
4 sides were measured.
Results and discussions
The results of the periodontal health
investigation are shown in the graphs below.
The percentage of sites showing a
periodontal space depth greater than 3 mm
was lower in the porcelain veneer group.
The frequency of periodontal pockets of 4 The bleeding index increased in
mm was 1% in the buccal surfaces of the proportion to the increase in the location
veneers, 4% in the CCM buccal surfaces index of the prosthetic restoration margins
and 2% in the CCM palatal surfaces. There (Fig.1).
were no statistically significant differences
between the determinations made at the
sites assessed at the CCM level and those
assessed at the veneers level.

3.00 face 0.90 face

2.80 ts 0.80 0.77 ts
2.50 2.48 2.48 0.70
2.24 0.64
2.00 0.60 0.60
1.73 0.50
1.63
1.50 1.46 0.40 0.40
1.38 0.39
0.30 0.25
1.00
0.20 0.22
0.17
0.50 0.10
0.00
0.00
interproximal central interproximal central
interproximal central interproximal central
VESTIBULAR PALATAL
VESTIBULAR PALATAL

Fig.1 The bleeding index according with different types of prosthetic restorations
For each index group (0-3) of In the case of CCM 28% of the
restoration margin location, the bleeding prosthetic restoration margins were placed
indices were higher for CCM than for juxta-gingivally to the buccal face while 62%
veneers. were placed subgingivally. At the palatal
faces of the CCM, 31% of the restorations
No significant differences in
were placed juxta-gingivally and 49% were
bleeding index were found between age
placed subgingivally.
subgroups or within the same age subgroup.
The evaluators rated the surface
The plaque index was generally low
quality of the prosthetic restorations and
for the buccal side and did not vary
their color as better in the veneers than in
statistically significantly between the two
the CCM for restorations included in the 0-
study groups. Its evaluation at the lingual
6 months age group (85% α vs 30% α) as
face actually contrasted the natural tooth
well as those included in the > 24 months
structure to that of the palatal faces of the
age group (75% α vs 35% α).
veneer crowns, with higher values recorded
for the latter. There were no statistically
significant differences between the two
Recording of the prosthetic
study groups in the ability to restore shape
restoration margin location index showed
and contour (restoration of dental
that 56% of the PF margins were placed
morphology), although 35% of the crowns
juxta-gingivally and 21% were placed
analyzed and 32% of the veneers were over
supra-gingivally.
contoured due to insufficient preparation.

61
 No fractures were detected in either
the veneers or the CCM group.The
marginal integrity of the restorations did not
differ statistically significantly between the
two groups.
There were no significant
differences in the degree of comfort
provided by each of the two types of
restorations, with patients rating it as
excellent and good.
In terms of aesthetic satisfaction, 80%
of the patients included in the group with
veneers older than 24 months rated the
aesthetic result as excellent, as opposed to
40% of the patients in the same subgroup
but treated with CCM.
The success/failure of different
methods of restoring the aesthetic balance
Fig.2 Risk of developing gum pathology (gum recession, gingivitis)
Placement of restoration margins deep
enough so that they cannot be cut away but
at the same time preserve the dimensions of
the periodontal biological space.
The study showed a proportional
increase in the bleeding index in correlation
with the placement index of the prosthetic
restoration margins. The closer the margins
of the prosthetic restorations were placed to
the free gingival margin, the higher the risk
of gingivitis .
62
of dento-periodontic units depends to a
large extent on the way the clinician
manages the dento-periodontic support, the
technology itself chosen (all-ceramic or
metal-ceramic) having a much smaller
impact[27,28] .
Studies show that the subgingival
placement of prosthetic restorative margins
has negative effects on periodontal health
status and therefore on aesthetic outcomes.
When deciding on the level of placement of
prosthetic restorative margins, the clinician
has to consider basically two aspects:
The ability to maintain periodontal health
with reduced risk of gingival recession with
consequent exposure of the restoration
margins or gingival inflammation (Fig. 2).
Similarly, another cause of the deterioration
of periodontal health was insufficient
preparation of the organic superstructure,
which led to over-contour in both porcelain
veneers and veneer crowns.
In the study group, significant
differences were found between the two
groups in terms of periodontal recession: 28%
in the case of CCM versus 20% in the case
of veneers (Fig 3).
 Romanian Journal of Oral Rehabilitation
Vol. 14, No.4 October-December 2022

Fig.3 Periodontal recession veneers vs CCM

Determination of the depth of The most important step in the

periodontal pockets revealed higher values
in the case of CCM. However, no depths
greater than 4mm were recorded in either
study group.
From the point of view of restoration of
shape, count, color, surface structure and
texture, the success rate for porcelain
veneers was higher than for metal-ceramic
veneer crowns (89% vs. 74%). The reasons
for these results are multiple.
In terms of shapes and contours, there
was a greater tendency for under-
preparation in veneer crowns leading to
over-contoured restorations.
fabrication of a ceramic bridge on zirconia
using CAD-CAM is the preparation of the
sill teeth, which must be impeccable, as well
as the impression of the preparations(Fig.4).
Essential preparation considerations
that influence the final aesthetics and a good
relationship with the periodontium are:
- vertical walls with a conicity of 4-6
preparation with threshold
- preparation depth 1.5 – 2 mm
(lateral and occlusal), maximum 2.5
mm, depending on tooth volume and
occlusal relationship.

63
 Fig.4 Aspects of rehabilitation by means of aesthetic restorations on zirconium support

Tooth preparation for cast ceramic requirements and the advantage they offer
veneers must meet 3 requirements: tissue due to their all-ceramic structure, have the
economy least impact on periodontal health status.
,necessary space for ceramics, maximum 2. At the same time, the closer the
preservation of the surface of the grinding edge of the CCM is to the free gingival
surface in order to obtain optimal adhesion margin, the higher the bleeding index is and
to the enamel-composite surface. the higher the bleeding index is compared
to porcelain veneers placed at the same level.
Conclusions
3. The potential for restoration of
1. Subgingival placement of
shape, size, color, surface structure and
prosthetic restorations has a negative
texture is higher for porcelain veneers,
impact on periodontal health and
especially when restoring maxillary central
consequently on their aesthetic outcome.
incisors.
Ceramic veneers, due to their preparation
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