Periodontal considerations for adhesive ceramic dental ... · The International Journal of Esthetic...

444 | The International Journal of Esthetic Dentistry | Volume 14 | Number 4 | Winter 2019

CLINICAL RESEARCH

Periodontal considerations for

adhesive ceramic dental restorations:

key points to avoid gingival problems

Maristela Lobo, DDS, MsC, PhD

Professor of Advanced Program in Implant and Esthetic Dentistry, SENAC University,

Sao Paulo, Brazil

Oswaldo Scopin de Andrade, DDS, MSc, PhD

Director of Advanced Program in Implant and Esthetic Dentistry, SENAC University,

Sao Paulo, Brazil

João Malta Barbosa, DDS, MSc

Prosthodontist, Department of Oral Rehabilitation, Implantology Institute, Lisbon, Portugal

Volunteer Researcher, Department of Biomaterials and Biomimetics,

New York University College of Dentistry, New York, NY, USA

Ronaldo Hirata, DDS, MsC, PhD

Assistant Professor of Biomaterials, New York University College of Dentistry, New York, NY, USA

Correspondence to: Dr Maristela Maia Lobo

Rua Ministro Gabriel de Resende Passos, 500, Cj 1010, Moema São Paulo SP, Brazil;

Tel: +55 11 5051-3534/+55 11 9 9447-7436; Email: [email protected]

LOBO ET AL

445The International Journal of Esthetic Dentistry | Volume 14 | Number 4 | Winter 2019 | 445The International Journal of Esthetic Dentistry | Volume 14 | Number 4 | Winter 2019 |

Abstract

The stability and health of the periodontal tissues

should be a common goal for all dental care providers

with regard to natural or restored teeth as well as im-

plant-supported restorations or any other type of

prosthesis. The objective of this study was to address

the key aspects to be respected when executing ad-

hesive oral rehabilitations involving ceramic restora-

tions, regardless of their thickness, and to reinforce

the importance of each step to ensure the success

and longevity of the treatment from a periodontal

standpoint. This article reviews the fundamentals of

the periodontics that relate directly or indirectly to ad-

hesive ceramic dental restorations, and also addresses

their clinical relevance.

(Int J Esthet Dent 2019;14:444–457)

CLINICAL RESEARCH


Introduction

A healthy periodontium should be the ulti-

mate goal for all professionals involved with

comprehensive oral rehabilitations because

the health and stability of the periodon-

tal-restorative transition is key to treatment

success.1 Unfortunately, frequent adhesive

rehabilitation failures occur because this

clear goal for prosthetic rehabilitations is

not sufficiently respected. These failures oc-

cur as recurrent gingivitis, localized or gen-

eralized, or as irreversible periodontal at-

tachment loss through gingival recession

and/or periodontal pocket formation that,

in extreme cases, may ultimately lead to

tooth loss.2,3 The recurrence of these clinic-

al scenarios may indicate that there has not

been enough commitment to periodontal

health by some dental professionals. It

therefore seems pertinent to reinforce the

importance of the commitment to health,

function, and esthetics, in that order. These

goals are fundamental to obtain the desired

longevity and stability for any provided treat-

ment.

The term ‘contact lenses’ has been in-

creasingly used worldwide by the dental

community as a marketing term to describe

thin porcelain veneers that aim to improve

smile esthetics without dental preparation

(no-prep veneers). However, clinical reality

has shown that only very few and highly

specific situations make it possible to avoid

the need for dental preparation while pro-

viding the space required for the restorative

material. In most clinical situations, the

need for a ceramic restoration is highly

subjective, and the request for such a treat-

ment by a patient may be comparable with

the desire to acquire a fashion/trendy item.

When a patient demands a treatment that

conflicts with the clinician’s recommenda-

tion, the clinician should educate the pa-

tient and explain the indications and contra-

indications of such a treatment so that a

fully informed decision can be taken. De-

spite this ideal approach, unfortunately

some clinicians seem more interested in

performing the treatment regardless of its

clinical indications, which leads to an in-

crease in overtreatments. As a conse-

quence, the rate of retreatments of recently

performed adhesive esthetic rehabilitations

due to periodontal compromises is also on

the rise. With that, the patient enters, often

at an early age, the so called ‘restorative cy-

cle,’ which sooner or later culminates in

tooth loss.4

Most failures occur from what can only

be seen as a lack of knowledge of the inter-

action between restorative dentistry and

Fig 1 (a to c)

Recurrent gingivitis

associated with

indirect restorations.

a

b

c

LOBO ET AL

447The International Journal of Esthetic Dentistry | Volume 14 | Number 4 | Winter 2019 |

periodontics, sometimes combined with a

poor or careless technical execution (Figs 1

and 2). An important factor that seems to

potentiate these negative outcomes is the

presence of a thin/festooned periodontal

biotype, described to present an increased

risk of gingival margin instability and conse-

quent esthetic compromise.5 Patients with

delicate biotypes are more prone to devel-

oping gingival margin recession as a result

of a temporary or prolonged periodontal

aggression, often seen in adhesive rehabili-

tations with ‘contact lenses.’ Therefore, it is

important to recall patients presenting deli-

cate biotypes that require extra care when

managing soft tissues for restorative pur-

poses (ie, it can be stated that periodontal

tissues require clinical respect).

Periodontal clinical respect means to:

1. Preserve the biological space, avoiding

the direct contact of the restorative ma-

terials with the junctional epithelium (JE)

and/or the connective tissue (CT) attach-

ment.6,7

2. Optimize the emergence profile and the

cervical contour of the restoration by

avoiding overlapping or misadaptations

that may promote plaque accumulation

and/or affect the ideal food trajectory.8

3. Avoid excessive manipulation of the gin-

gival margin with retraction cords, he-

mostatic agents, clamps, impression ma-

terials, and inadequate instrumentation.9

4. Strive for excellent marginal adaptation,

with or without tooth preparation.

5. Avoid the contact of impregnated mater-

ials during cementation (retraction cords

and an excess of adhesive cement).

6. Ensure adequate sealing and adaptation

of the restoration in relation to the dental

substrate, avoiding misadaptations, voids,

and/or spaces susceptible to subsequent

plaque accumulation.10

The objective of this article is to address

the key factors or ‘rules’ to be respected

during the execution of adhesive ceramic

restorations, regardless of their thickness,

and to reinforce the importance of each

step to ensure the success and longevity of

the treatment from a periodontal stand-

point.

Fig 2 (a to d) Classic

signs of inflammation

(flushing, heat, tumor,

exudate, and pain).

a

c

b

d

CLINICAL RESEARCH


Rule 1: The biological equilibrium of prosthetic/periodontal transi-tion determines the success and longevity of the treatment

For the majority of mammals, teeth are ar-

ticulated organs. This imposes an anatomi-

cal challenge to the organism’s defense

system: one third of the tooth is exposed in

the oral cavity, in contact with the saliva

and diverse microorganisms, and the re-

maining two thirds are inserted within the

bony structure of the alveolar process.

Therefore, an efficient and reliable bio-

logical seal is essential to maintain a bio-

logical and ecological balance between

the external and internal environments so

as to prevent microorganisms from pene-

trating the systemic blood stream. This seal

exists through the combined functions of

the JE (epithelial seal) and the CT insertion

(connective seal), which in combination

form the so-called biological space11-13

(Fig 3).

The first line of periodontal defense

consists of the oral epithelium (OE), partic-

ularly the inserted gingiva. This epithelial

layer is stratified and keratinized as well as

impermeable and resistant to mechanical,

chemical, and bacterial aggressors.14 It is

considered to be part of the protective

periodontium as it plays a role in protecting

the more internal organic layer – the CT –

from coming into contact with external

agents. Like other epithelial tissues, the

periodontal epithelium exhibits little inter-

stitial space, with its constituting cells very

close to each other and with few to no

blood vessels. Therefore, the nutrition of

this outer layer is provided by the underly-

ing CT through the basal layer of the epi-

thelium. Often, with the goal of increasing

the area of nutrition, the epithelium can

project crests toward the inner CT that can

increase in number and size in the pres-

ence of inflammatory processes.15

Due to the dual environment (external

and internal) in which a tooth exists, the OE

invaginates toward the tooth surface to

form a sulcus. This sulcular epithelium (SE)

is less keratinized and has characteristics

similar to those of the OE, with a superficial

layer of keratin. This characteristic allows it

to seal the internal and external environ-

ments and therefore represents the primary

line of periodontal protection.16 On average,

it is 0.7 mm long in the vestibular surface

and 1.0 mm long in the interproximal sur-

face of the anterior teeth11 (Fig 3). It is clini-

cally important to recall that the SE can

only be evaluated histologically (eg, it is not

possible to perform a probing evaluation).

Fig 3 (a to c) A

biological seal is

provided by the

combined functions

of the junctional

epithelium and the

connective tissue

insertion, which in

combination form

the biological space.a

b

c

Connective sealing

Epithelial sealingGingival sealing

LOBO ET AL


However, it can be assumed that, as this is a

transition tissue, it will present much vari-

ability among different individuals and

should be considered the anatomical and

histological limit for the intracrevicular level

of a restorative margin preparation.

A second epithelial layer – the JE – lies

underneath the SE and presents distinct his-

tological characteristics compared with the

OE and the gingival epithelium. The JE is

not keratinized and is therefore permeable,

allowing for fluid exchange between the in-

ternal and external environments. The JE

only presents two layers of cells – the exter-

nal lamina (EL) and the internal basal lamina

(IBL) – with only the former providing tissue

stability and sealing by adhering weakly to

the surface of the enamel through hemides-

mosomes.16 It is through the JE that the hu-

moral and cellular defenses come into con-

tact with external agents, as in cases of

tissue inflammation. Additionally, the JE is

responsible for the secretion of the gingival

crevicular fluid.

In cases of lesioning (common during

periodontal probing and/or procedures such

as prophylaxis and the insertion of a retrac-

tion cord for impression, amongst others),

the JE is able to regenerate quickly (in 48 h)

unlike the other epithelial tissues.17

The following are some critical clinical

aspects regarding the JE:

1. Being a permeable tissue, no restorative

material or debris resulting from clinical

procedures should remain in contact

with the JE due to the risk of inducing

transient or permanent gingival inflam-

mation.

2. The conventional periodontal probing

performed with a Williams or North

Caro lina millimeter probe should be per-

formed with a slight digital pressure,

since the depth of the clinical sulcus dif-

fers from that of the gingival sulcus that

often encompasses a small or medium

portion of the JE. Thus, this clinical mea-

surement should not be used to define

how far the probe can penetrate into the

gingival sulcus under pressure, since this

action will likely invade the JE.

3. The restorative materials currently avail-

able for restorative adhesive dentistry are

biotolerable but not biocompatible. This

means that they should not remain in

contact with the JE because an anti-

gen-antibody reaction may occur.6,7 Ideal-

ly, these materials should be bioactive,

stimulating cellular proliferation and ad-

hesion, which is similar to what happens

in oral and orthopedic implantology18

with materials such as titanium and zirco-

nia as well as polymers such as polyether-

etherketone (PEEK).19 Even implant-sup-

ported restorations, being transmucosal

in nature, have been considered by some

authors to invade the biological space.20

From the approximate level of the cemento-

enamel junction (CEJ), the JE gives way api-

cally to a CT insertion. The CT forms a union

through connective fibers with the root ce-

mentum. This connection is real, since the

tooth end of these fibers is mineralized and

anchors in the cement surface (the Sharpey’s

fibers). From this mineralized origin they di-

rect toward the CT of the gingival margin,

being part of its structure. From a sealing

perspective, an important function of the

CT is to prevent apical migration of the JE,

keeping the level of the gingival margin in

position.15

Rule 2: The excellence of the clinical execution is more determi-nant than the selected restorative material

Several factors should be observed to

achieve periodontal health in the vicinity of

a dental restoration, regardless of its extent

and the material used. The primary factor

relates to the vertical location of the tooth

CLINICAL RESEARCH


preparation limit. In this respect, two ele-

ments should be considered: first, ensuring

an appropriate distance for an adequate re-

storative emergence profile; and second,

aiming whenever possible for a supragin-

gival (SupG) or equigingival (EqG) restorative

limit. However, if a subgingival (SubG) limit is

unavoidable, the preparation limit should re-

main in contact with the SE (an imperme-

able tissue), penetrating a maximum of

0.5 mm on the vestibular surface and

1.0 mm on the interproximal surfaces in re-

lation to the free gingival margin.21

In addition to the vertical level of the

preparation limit (SupG, EqG or SubG), the

overall excellence of the tooth preparation

and the adequate adaptation of the overlay-

ing restoration (temporary or permanent) is

paramount to achieving periodontal health.

An inadequate dental preparation may re-

sult in excessive restoration contouring, an

inadequate emergence profile, an incorrect

occlusal design, and ultimately in functional

and esthetic failure.

It is important to recall that the purpose

of any dental preparation is to provide space

for the restorative material. In rare excep-

tions, a tooth may present a deficient coro-

nal volume and therefore require no prepara-

tion (Fig 4a). However, even in the case of a

tooth with such characteristics, it is import-

ant to plan for the position of the cervical

and interproximal restorative limits of the

future restoration. It is also important to plan

for its emergence profile in such a way that

a predictable adaptation in the restoration is

achieved, avoiding possible periodontal

damage. This cervical and interproximal de-

marcation should be smooth, with an aver-

age depth of 0.2 to 0.4 mm to avoid cervical

dentin exposure (Fig 4b).

According to Richter and Ueno,22 the

definition and excellence of the preparation

limit may be even more important than its

vertical level in relation to the free gingival

margin. Preferably, dental preparations

should not be positioned within the gingival

sulcus,21 ideally being 0.2 to 0.5 mm above

the gingival margin, especially when the

color of the substrate is favorable (Fig 4c).

SupG preparations have various advantages

as they are more accessible during the exe-

cution of several clinical procedures, includ-

ing easier access and visualization during

preparation, facilitated impression or scan-

ning as well as for oral hygiene procedures

and long-term maintenance.21,23

Despite all the previous considerations,

SubG preparations are justified in certain sit-

uations:

1. Substrate discoloration (Fig 5).

2. Replacement of restorations that already

Fig 4 (a) The

purpose of any

dental preparation is

to provide space for

the restorative

material. A tooth may

present a deficient

coronal volume and

therefore not require

preparation. (b) It is

important to position

the cervical and

interproximal

demarcation with an

average depth of 0.2

to 0.4 mm to avoid

cervical dentin

exposure and ensure

an adequate

emergence profile.

(c) Dental prepara-

tions should ideally

be positioned 0.2 to

0.5 mm above the

gingival margin, espe-

cially when the color

of the substrate is

favorable.

a

b

c

LOBO ET AL


Fig 5 (a to g)

Subgingival prepara-

tions are justified in

situations of substrate

discoloration that

require total

coverage of the

tooth by the

restoration. Figure (e)

shows that some-

times it is important

to restore the

discolored substrate

with direct opaque

composite resin prior

to cementation.

a

c

e

b

d

f

g

CLINICAL RESEARCH


present with SubG preparations or res-

torations (Fig 6).

3. For SubG caries.

4. For diastemas that require a suitable

proximal emergence profile to optimize

the position of the interdental papilla

(Fig 7).

In the above cases, there is a justifiable need

to extend the preparation within the sulcus.

However, the position of the JE must be fully

respected, and direct contact of the restora-

tive material should be limited to the SE,

which is keratinized and impermeable. Since

the SE is a tissue with unique characteristics

Fig 6 (a to e)

Subgingival prepara-

tions are also justified

to replace restor-

ations that already

present with

subgingival prepara-

tions or restorations.

a b

c d

e

LOBO ET AL


that are clinically indefinable, parameters

such as probing should not be used in the

decision-making process regarding how

much a particular sulcus can be penetrated

in relation to the free gingival margin. It is im-

portant to consider that in the vast majority

of individuals, the gingival sulcus (or SE) has a

perennial distance, being a transitional epi-

thelium between the OE and the JE.11

From an evidenced-based dentistry (EBD)

standpoint, some of the previously men-

tioned clinical considerations regarding the

relational dental preparation limit and the

periodontal tissues have already gained con-

sensus with the scientific community, these

being:

1. The JE is part of the biological space and

is permeable. Therefore, any restorative

material that contacts its surface will

have an almost direct contact with the

underlying CT and will generate varying

levels of inflammation.24

2. The restorative materials available for

dental restorations are only biotolerable,

not biocompatible or bioactive.25 All re-

storative materials (direct or indirect,

temporary or final) can generate anti-

gen-antibody reactions and should not

come into direct contact with the JE,

with the exception of titanium, zirconia,

and PEEK.6,19

3. The vast majority of patients present with

thin/festooned periodontal biotypes,

which increases the risk of periodontal

harm, gingival margin stability, and a re-

sultant esthetic compromise.5 Depend-

ing on the periodontal biotype, different

clinical and histological responses may

arise from a biological space violation:

periodontal pocket formation, gingival

recession, and/or apical migration of the

dentogingival complex.26

In summary, it is important to define clinic-

al strategies, not only regarding the preser-

vation of hard dental tissues but also in

terms of respecting the periodontal in-

volvement. These clinical strategies should

translate into sufficient invasiveness, ade-

quate instrumentation, EBD clinical proto-

cols, and the employment of premium ma-

terials. Well-adjusted provisional and/or

final restorations directly affect the final re-

storative outcome as well as the health of

the adjacent tissues. An in-depth know-

ledge of the histoanatomy of the periodon-

tal tissues and an awareness of how certain

prosthetic procedures can impact perio-

dontal health are prerequisites for any clin-

ician involved in adhesive restorative den-

tistry.

Fig 7 (a to c)

Diastemas that

require a suitable

proximal emergence

profile to optimize

the position of the

interdental papilla

demand subgingival

margin preparations.a

b

c

CLINICAL RESEARCH


Rule 3: The periodontal biotype is fundamental to define the vestibu-lar convexity of the restoration

The periodontal biotype is a factor of para-

mount importance for the esthetic risk as-

sessment in restorative dentistry and its ob-

servance is fundamental to selecting the

adequate treatment sequence and proto-

cols, including preparation, impression pro-

cedures, temporization, and cementation.

The periodontal biotype is directly related to

the convexity of the vestibular surface of

natural teeth, which plays an important role

in directing bolus trajectory during mastica-

tion and promoting proper stimulation and

toning of the gingival margins.27

When the periodontium is thin/fes-

tooned, the teeth usually present a more

pronoun ced vestibular convexity, located

between the middle and cervical thirds of

the crown, which seems to alleviate the di-

rect impact of food on the periodontium.

Clinicians should be careful not to cause

overcontouring in cases of no-prep as this

could lead to periodontal damage (Fig 8).

The flat and thick periodontium is typically

more mechanically resistant and is generally

associated with teeth that have a flatter ves-

tibular surface. This biotype is less sensitive

to dental procedures and may allow for cer-

tain clinical indelicacies without resulting in

permanent periodontal damage.28 On the

other hand, this biotype appears more

prone to developing periodontal pockets in

the presence of inflammation, which may

mask the evolution of irreversible tissue

loss.15

Rule 4: A respectful transition between the periodontium and restoration increases the consis-tency of the clinical results

The tooth-restoration-periodontium inter-

face should be optimized, with the aim of

achieving harmony between tissues that are

very different from an anatomical and bio-

logical standpoint. The position, preparation

limit, emergence profile in combination

with the vestibular contour of the ceramic

restoration, and establishment of an “area of

adhesive continuity” (AAC)29 allow for an ad-

equate perio-restorative integration, facili-

tating plaque control in the cervical region

(Fig 9). The AAC, forming a hybrid interface

of different structures that have been bond-

ed together, results from the correct adap-

Fig 8 (a and b) In thin/festooned periodontal biotypes, the teeth usually present a more pronounced vestibular convexity, located between

the middle and cervical thirds of the crown. This seems to alleviate the direct impact of food on the periodontium. Clinicians should be

careful not to cause overcontouring in cases of no-prep as this could lead to periodontal damage.

a b

LOBO ET AL


tation between them, so that there are no

discrepancies that promote plaque accu-

mulation.

Not only the clinician but also the dental

technician/ceramist must be knowledge-

able about the biological implications of the

indirect restoration being produced in order

to ensure an adequate finishing and adapta-

tion of the restoration margin as well as an

appropriate emergence profile. The dental

technician must observe the position of the

soft tissues and respect the biological space

in no-prep cases, participating together with

the clinician in the material selection pro-

cess for each particular situation.

Finally, care during the bonding of ce-

ramic dental restorations is fundamental to

attaining a successful perio-restorative in-

terface connection. Attention should be

paid to the choice of the composite resin

cement viscosity and the adhesive protocol,

which must be respected and followed me-

ticulously. The use of gingival retraction

cords should be restricted to cases where

complete hemostasis is not attainable in the

JE, allowing for the passage of crevicular

fluid from the internal to the external envi-

ronment. In these cases, a thinner retraction

cord (No. 000), impregnated with an alumi-

num-based hemostatic solution (to avoid

subsequent spotting) should be selected

and positioned at the level of the JE (ie, it

should not be apparent). Retraction cords

should also be used in cases of SubG prep-

arations, since mechanical separation is re-

quired. The shorter the time the retraction

cord is kept in position, the better for the

health of the periodontium. On the other

hand, there is no need to use gingival re-

traction cords in the case of a SupG prepara-

tion with healthy periodontal tissues.

While absolute isolation (with rubber

dam) is fundamental to control humidity, it

may be deleterious to the gingival margin

during cementation.30 Alternatively, this

control could be achieved with relative iso-

Fig 9 (a to c) The position, preparation limit, and emergence profile in combina-

tion with the vestibular contour of the ceramic restoration as well as the

establishment of an area of adhesive continuity (AAC) allow for an adequate

perio-restorative integration, facilitating plaque control in the cervical region.

a

b

c

CLINICAL RESEARCH


lation through the use of saliva absorbents

and lip retractors or by utilizing modified ab-

solute isolation.

Another important aspect is the sealing

of the restoration and the flow of the ce-

ment. During this procedure, the clinician

should be careful to prevent the formation

of voids that occur when air is trapped be-

tween the restoration and the tooth surface.

Once the restoration is fully seated, the ex-

cessive cement should be carefully re-

moved using appropriate instrumentation,

brushes, and floss, ideally under magnifica-

tion. Light curing only the central area of the

restoration through the use of collimating

tips on the photopolymerization device fa-

cilitates the complete removal of the resin

cement. This helps to ensure that there is

no excess material before the final polymer-

ization of the resin cement at the AAC.

In cases of multiple restorations, the gin-

gival retraction cords (if indicated) should be

removed only after complete photopoly-

merization of all the elements. After this has

been completed, marginal finishing should

take place, for which No. 12 and/or No. 12D

scalpel blades, prophylactic strips, dental

floss, and in some cases rubber cups with

fine polishing pastes may be used.

A follow-up appointment should be

scheduled to assure that the periodontium

in the vicinity of the new restoration pres-

ents a healthy appearance, with no signs of

inflammation, pain, heat, redness, tumor,

and/or exudate.

Final considerations

Many factors can be related to the perio-

dontal success of an adhesive dental reha-

bilitation. Although techniques and mater-

ials will change and evolve over the years

and new tools will emerge, the biology will

not change. The clinician and dental techni-

cian/ceramist are obliged to keep abreast of

the latest developments and constantly ex-

pand their knowledge of the biological be-

havior of the periodontal and dental tissues

in relation to the techniques and materials

used for oral rehabilitation, so that by res-

pecting these tissues the success and long-

evity of the restoration may be fully achieved.

The stability and health of the periodontal

tissues should be a common goal for all

dental care providers with regard to natural

or restored teeth as well as implant-support-

ed restorations or any other type of pros-

thesis.

LOBO ET AL


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