Periodontal health is a priority in restorative procedure

A clinical case by our Community member Dr. Wasan Al Maeeni

This article and its content are published under the Author’s responsibility as an expression of the Author’s own ideas and practice. Styleitaliano denies any responsibility about the visual and written content of this work.

As we know patients are increasingly focusing on dental esthetics, we should be familiar with all the criteria to follow to get them there as their dentists. A beautiful smile is not only about brightness, but also about healthy soft tissues. A sound periodontium provides a firm foundation for an esthetic and functional final result.
A 60-year-old female patient came to my clinic asking for an esthetic rehabilitation and gingival treatment. In this clinical case we will clarify the interrelation between dental restorations and gingival tissue by explaining the factors that most affect soft tissue health.

styleitaliano style italiano close up showing old incongruous composite restorations

Fig.1
Upon clinical examination of soft and hard tissues, we could find old fillings and gingival inflammation due to overhanging restorations. Restoration margins extending subgingivally, especially if poor in terms of quality, will directly affect the periodontal tissues and enhance plaque retention in the most crucial zone. Elimination of the causative factor is the first thing to do, so we replaced the old composite fillings and we gave the gingival tissue two weeks to shrink and go back to their actual position without any affecting factors.

styleitaliano style italiano prepared and isolated abutment

Fig.2
After establishing gingival health, due to the extension of the cavities, an indirect approach was chosen. In the preparation phase, it is very important to choose a position of the finishing line not too deep – not to invade the biological width and cause chronic gingival inflammation or rescission – and not more than 0.7 mm into the sulcus, as it is virtually impossible to precisely restore a tooth to the exact coronal edge of the junctional epithelium.

styleitaliano style italiano cementing crowns on central incisors

Fig.3
Isolation is highly recommended when achievable to prevent entry of gingival fluid and blood inside the crown during cementation.

styleitaliano style italiano excess cement flowing our of lateral incisor crowns

Fig.4
A short light curing of excess cement helps eliminate most of the excess material in a semi-gel state, which makes it easier to remove. This helps prevent pushing excess cement into gingival sulcus, which may induce foreign body gingivitis.

styleitaliano style italiano cemented crowns under rubber dam isolation

Fig.5
After excess cement removal.

styleitaliano style italiano new smile with ceramic crowns and healthy gum

Fig.6
Two weeks after cementation, esthetic appearance and gingival health are established, and papillae are growing back to fill the gingival embrasures. All of that as a result of:
• Respect of the biological width.
• Correct positioning of interproximal contact points.
• Smooth area between finishing line and restoration margin (no overhangs)
• No excess cement
• Good oral hygiene instructions to the patient

Conclusions

Overhanging restorations provide a favorable environment for plaque accumulation, causing periodontal destruction. To ensure long term gingival health, one of the most important parameters is managing the proper margin location of a restoration relative to the alveolar bone. Placing the finishing line as deep as possible into the sulcus can be a grave error. If the biologic width is compromised, there is a potential for changes in the underlying osseous structure with possible gingival recession and/or pocket formation. Moreover, excess cement must be avoided at all times, especially in subgingival restorations, in order to prevent gingival irritation, recession, and in some cases, bone loss and failure of prosthesis.

Bibliography

1. Gargiulo AW, Wentz FM, Orban B. Dimensions and relations of the dentogingival junction in humans. J Periodontology . 1961;32:261–7.
2. Palmer R, Floyd P. Periodontal examination and screening in Periodontology. Springer 2021; 11.
3. Freedman G. Contemporary esthetic dentistry. Elsevier 2012; 552.

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