BRACItETTANDJOHNSTON

2. Repair of an existing glass ionomer restoration with contours on nonprepared teeth using glass ionomer cement: a 4.5-year
report. J Am Dent Assoc 1984@4:782-3.
new material can probably be accomplished, especially 6. Ngo H, Earl A, Mount GJ. Glass ionomer cements: a la-month evalu-
when retention of the repair would be enhanced by adhe- ation. J PIWTHET DENT 1986;55:203-5.
sion of the new material to tooth structure. 7. Reisbick MH, Brodsky JF. Strength parameters of composite resins. J
PROSTHET DENT 1971;26:178-85.
8. McLean JW, Powis DR, Prosser HJ, Wilson AD. The use of glass ion-
REFERENCES omer cements in bonding composite resins to dentin. Br Dent J
1. Wilson AD, Kent BE. A new translucent cement for dentistry. Br Dent 1984;158:410-4.
J 1972;132:133-5. 9. Grizzle JE, Starmer CF, Koch GG. Analysis of categorical data by lin-
2. Swartz ML, Phillips RW, Clark HE. Long-term F release from glass ear models. Biometrics 1969;25:489-504.
ionomer cements. J Dent Res 1984;63:158-60.
3. Mount GJ. Longevity of glass ionomer cements. J PROSTHEF DENT Reprint requests to:
1986;55:682-5. DR. WILLIAM W. BRACKEZT
4. Tyas MJ, Beech DR. Clinical performance of three restorative materi- THE OHIO STATE UNIVEMITV
als for non-undercut cervical abrasion lesions. Aust Dent J 1985;30: COLLJIGE OF DENTISTRY
260-4. COLUMBUS, OH 43210
5. Brandau HE, Ziemiecki TL, Charbeneau CT. Restoration of cervical

A rationale for comparison of plaque-retaining properties of

crown systems
John A. Sorensen, D.M.D.*
University of California, Los Angeles, School of Dentistry, Los Angeles, Calif.

The sequence of the initiation, formation, development, and maturation of dental

plaque was reviewed. The gingival response to plaque formation was identified to
control plaque growth for prolonged gingival health. A strong implication has been
established between rough, overcontoured metal ceramic restorations and period-
ontal disease. Unsightly soft tissue around crowns result from increased plaque
accumulation. In comparing esthetic crowns, three critical variables are consid-
ered. The factors that mediate plaque accumulation and influence gingival health at
the tissue-restoration interface are (1) surface roughness, (2) marginal fit, and (3)
contour. Minimizing plaque accumulation is crucial for gingival health. (J PROSTAET
DENT 1989$32:264-Q.)

T here are various reasons for the existence of
iatrogenic periodontal disease.‘-4 Traumatic preparation
and impression procedures and poor provisional restora-
tions with unsuitable laboratory support may insult the
gingival tissues. Subgingival margins greatly increase the
frequency of periodontal disease.2*5-8Although indications
for subgingival margins exist, there are biologic liabilities:
(1) difficult tooth preparation and impressions, (2) limited
detectability of marginal fit and contour, (3) intrusion of
plaque-retaining materials such as cement into the sulcus,
and (4) limited access for plaque removal.
Minimizing plaque accumulation is essential to pro-
longed gingival health. Manufacturers have claimed that
specific crowns resist plaque adhesion. With the rapid in-
Presented at the Academy of Denture Prosthetics meeting, Mon-
terey, Calif.
*Assistant Professor, Director, Graduate Proathodontics.
10/l/13689
troduction of new all-ceramic crown systems, it is difficult
for the dentist to decide the most appropriate restoration.
There are numerous criteria that should be evaluated: es-
thetics, ease of tooth preparation, difliculty of crown fab-
rication, marginal integrity, strength, and biologic re-
sponse.
This review describes the process of plaque formation
and the gingival response. By defining the factors mediat-
ing plaque accumulation on crown surfaces, a comparison
of the gingival response to different crown systems may be
possible.
PLAQUE FORMATION
Plaque formation follows a consistent series of events.
After a tooth is cleaned, the enamel surface is rapidly cov-
ered with an organic film, the acquired pellicle.9 Adsorption
of salivary glycoproteins to apatite surfaces is respdnsible
for pellicle formation. lo-l2 This bioflm rapidly becomes a
constituent of plaque in two important stages.

264 SEPTEMBER1989 VOLUME62 NUMBER3

PLAQUE-RETAINING PROPERTIES
Bacterial colonization occurs when individual bacteria
adhere to minute surface irregularities that shelter the or-
ganisms from oral cleansing forces.13 Bacterial adherence
occurs by a chemical or physiological interaction between
components on the bacterial cell surface and the enamel
pellicle.‘*, l5 From an initial nidus of colonization, a single
layer of cells proliferate over the surface and coalesce with
neighboring bacteria. l3 The multiplying bacteria must
have retention mechanisms to accumulate on tooth sur-
faces and adherence to each other.16 A matrix of bacterial
glycocalyces and salivary glycoproteins retains the micro-
bial mass to the tooth surface with cohesion of bacteria.17
The volume of plaque increases by appositional growth
through microbial multiplication and selective adherence
of salivary microorganisms. The ecology of plaque is
dynamic, allowing a sequential colonization with organisms
altering the environment t,o establish new organisms with
greater pathogenicity.ls
If the microbial plaque are prevented from maturing,
gingival health is possible. However, if allowed to mature
with elevated pathogenicity, the characteristic inflamma-
tory changes of gingivitis will pervail.lg
Supragingival plaque maturation is responsible for
gingivitis.Zo-22 With the inflammatory changes, the mar-
ginal gingiva are enlarged by edema, increasing the sub-
gingival sulcus where bacteria are protected from cleans-
ing. Crevicular fluid flow and epithelial cell growth is ele-
vated in an altered ecologic environment.18 These changes
increase the complexity of plaque flora and encourage the
establishment of subgingival microorganisms of which
many are unable to be first colonizers.18 With time, accu-
mulation of inorganic salts ensues with conversion of
plaque to calculus.
The extension of plaque is affected by the anatomy, po-
sition, and surface characteristics of the teeth, the archi-
tecture of gingival tissue and its relationship to the tooth.
It is also influenced by friction at the tooth surface by diet,
lips, and tongue.2sl 24Plaque retention is enhanced by cal-
culus, defective restorations, carious lesions, and other
rough surfaces.25
SEQUELAE OF PLAQUE
ACCUMULATION
The role of dental plaque in the etiology of gingivitis has
been overwhelmingly demonstrated.20, 26-2gAs supragingi-
val plaque accumulates, the effects of bacterial byproducts
are limited to the gingival margin. With the growth of
plaque subgingivally, inflammation spreads apically with
deterioration of connective tissues, loss of epithelial at-
tachment and eventual destruction of crestal bone. Clini-
cally, these tissues change in color, surface texture, consis-
tency, and the gingival crevice.* Initially, these tissue
changes may be undetectable. However, with time the se-
verity of the soft tissue pathology becomes obvious with
unesthetic appearance. The long-term periodontal re-
THE JOURNAL OF PROSTHETIC DENTISTRY
sponse to plaque irritants occurs in either of two ways: (1)
apical recession of the tissues or (2) chronic gingival
inflammation with increased pocket depth. Both of these
marginal gingival reactions are unacceptable.
Subgingival restorations rapidly become covered with
plaque, and the toxic irritation causes inflammation and
loss of attachment.30-35Animal studies were substantiated
by human epidemiologic investigations showing more in-
flammation on teeth with restorations and that crowns ac-
cumulate greater plaque.2p35,36Glantz36 demonstrated that
dental plaque adheres to the surfaces of restorative mate-
rials longer than enamel or dentin surfaces. A study of ex-,
tracted teeth revealed that most restorations placed sub-
gingivally were covered with plaque within a short period.34
An understanding of the mechanisms of a healthy gingi-
val sulcus is necessary to appreciate the soft. tissue changes
adjacent to a subgingival crown. The epithelial cuff form-
ing the dentoepithelial junction is a dynamic tissue that
seals the underlying supportive structures.“* A smooth
tooth surface is necessary for the series of reactions in the
defense mechanism to take place.34 When the integrity of
the smooth surface is disturbed by an imperfect crown
margin, the proper function of the defense mechanism is
thwarted and rapid plaque accumulation ensues.34 Once
bacteria gain a foothold on the crown margin, and if oral
hygiene is inadequate because of poor access, subgingival
proliferation of plaque occurs, inducing unsightly gingival
inflammation.
FACTORS MEDIATING PLAQUE
ACCUMULATION
There are various reasons why plaque accumulates more
rapidly and to a greater degree on restorations than on a
natural tooth: (1) surface roughness, (2) marginal fit, and
(3) contour.
Adhesion and surface energy
Adhesion refers to the sticking to a surface; thus the sur-
face adhesion of plaque should be differentiated from
plaque accumulation.
Based on in vitro studies, theories were proposed that
differential plaque accumulation was attributed to inher-
ent surface energies of restorative materials.37, %
Sparse information is available on adhesion of bacteria
to popular dental materials. Most of the studies have been
concerned with accumulation or growth of dental
plaque.36T3g,*c Glantz36 discovered that plaque formed in
greater volume and adhered for a greater time to restor-
ative materials than to dentin and enamel. Skjorland3g and
Dummer and Harrison*O recorded substantially less plaque
accumulated on amalgam, because of the release of metal-
lic ions such as mercury, from the surface into the imme-
diate environment.*O Wise and Dykema4i monitored plaque
adherence by measuring the brush strokes to remove
plaque from intraoral samples. They concluded that por-
265

celain and acrylic resin had lower bacterial adhesion than
type III gold.41 An in vitro study revealed that polishing
diminished plaque adhesion whereas grinding elevated the
adhesion of plaque to gold materials.42 A thick plaque layer
was formed on both polished and ground surfaces of
ceramics, but this layer had low adhesion, so that the bac-
terial colonies were dislodged as the specimens were placed
vertically.
The surface energy of a material has been directly related
to the adhesive forces on the surface.43 At the same time,
tooth surfaces are covered by an acquired pellicle or
biofilmM that adsorbs microorganisms to develop dental
plaque.45 The surface properties of teeth affect the adhe-
sion of dental plaque36r46and the biofilm alters the adhe-
siveness of in vivo surfaces.47 In vivo studies by Glantz et
a1.48and Jendresen and Glantz4g indicated that the adhe-
siveness of the pellicle is essentially the same for one
expanded population. Therefore, the biofilm in adhesive
events is paramount and creates a solid liquid interface
intraorally.48* 4g
When dental materials with different surface tensions
were placed in humans, the surface properties were mod-
ified, making them indistinguishable from the chemistry of
the natural tooth.50 The biofilm transformed these mate-
rials with different surface chemistry to a similar state.
Various dental materials can influence biological adhesion
in a variety of ways as a precursor to periodontal disease.@-
Jendresen and Glantz4s emphasized that even if adhesive-
ness of materials is identical, molecular packing distribu-
tions and differences in microbial composition of the
pellicle51p52can cause desorption of film material or influ-
ence the microorganisms in the biofilm.50 Moreover, sur-
face roughness of a material may be transmitted to the film
surface and modify the adhesion of the absorbed film.50
Surface roughness (microtopography)
Rough surfaces of crowns facilitate bacterial plaque
retention.53-56Although the mechanism of selective adher-
ence and colonization plays a major role in plaque, coloni-
zation by outgrowth from fissures also is an origin of
plaque.
Prophylaxis can remove surface deposits, but microor-
ganisms are still viable in the grooves of teeth or restora-
tions. These organisms proliferate into plaque without
specific adherence phenomena.57e5gScanning electron mi-
croscopy (SEM) studies have confirmed that bacterial col-
onization begins in microscopic grooves.sC’*sfThe prolifer-
ation of growth proceeds more slowly than smooth-surface
colonization by adherence. This usually requires 24 hours,
but a mixed, more pathogenic flora appears sooner.139sass
Keenan et a1.62examined the relationship between the
surface finish on cast gold restorations and the plaque de-
posited on intraoral surfaces. Of the six finishes, the sand-
blasted and Carborundum disk surfaces accumulated the
greatest plaque, whereas the rouge finish retained the least
266
SORENSEN
plaque. Shafagh63 also compared plaque accumulation on
gold crowns with various polishing techniques. Artificial
crowns highly polished under a microscope had less plaque
accumulation than hastily polished crowns. Donovan and
Prince (unpublished data) evaluated the plaque accumu-
lation in metal ceramic restorations and discovered in or-
der of decreasing plaque: (1) aluminum oxide abraded
metal (greatest), (2) opaque porcelain, (3) polished metal,
and (4) glazed porcelain (least).
Originally, investigators believed that exposed cement at
the margins caused gingival inflammation from chemical
content. Waerhaugsl demonstrated only minor chemical
irritation from zinc phosphate cement and the major source
of inflammation was the roughness that harbored bacteria.
The bacteria are protected so they cannot be neutralized by
polymorphonuclear leukocytes, and bacterial plaque for-
mation is thus encouraged.
MARGINAL FIT
Perfect margins are impossible and to bacteria, all mar-
gins of metal or porcelain present surfaces for habitation.
The cement occupies the void between the restoration and
the tooth, but retains plaque around the crown.64 When
placed subgingivally, the porous surfaces are covered with
suthcient bacterial plaque to harbor microorganisms.4 De-
spite regimented oral hygiene, patients are incapable of
cleaning the tissues adjacent to crowns unless the margins
are accessible.6 Following colonization of bacteria, contin-
ual apical growth of plaque results in an unremitting pocket
depth. Unlike calculus, ragged subgingival margins are
difficult to remove and constitute a greater threat to the
periodontal tissues than subgingival calculus.4
The cement obturating the marginal gap is a weak
restorative link. The rough cement not only harbors bacte-
ria in the porosities, but it is dissolved by oral fluids, thus
creating space for plaque. 65 In addition, studies have
revealed that an incomplete seal occurs at the interface be-
tween tooth, cement, and crown.ss-6gUsing an impression
technique, 0ilo70 determined that the interfaces were from
10 to 100 pm with varying film thickness. SEM studies have
also confirmed that microbial plaque extends into the
interfaces.‘l, 72
Waerhaug31 emphasized the role of rough cement at the
crown margin and plaque retention. Karlsense histologi-
cally verified inflammatory reactions and plaque deposits
in the tissues adjacent to the tooth. The greater the mar-
ginal discrepancies, the more pronounced were the gingival
reactions. Two studies, reviewing crowns, provided evi-
dence that the severity of periodontal disease was elevated
with greater subgingival marginal discrepancies.7sp74Both
studies revealed that the severity of interproximal bone
loss was correlated with marginal misfit. Fifty-seven per-
cent of porcelain crowns had defective proximal margins
greater than 0.2 11~~~and the bone loss increased with the
age of crown and the patient’s age.73
SEPTEMBER 1980 VOLUME 62 NUMBER 3
PLAQUE-RETAINING PROPERTIES
The crown margin is critical because the marginal fit re-
flects the periodontal health.
CONTOUR
Plaque retention is greater on natural tooth surfaces that
are relatively inaccessible to routine oral hygiene methods,
the interproximal, lingual, and facial regions in the cervi-
cal portion of the tooth from the gingiva to the height of
contour.6, 76The relationship between plaque and gingival
health was demonstrated by Loe and Schiott74 who had
patients rinse orally twice daily with 0.2% chlorhexidine
gluconate while refraining from mechanical cleaning. Their
research demonstrated that the absence of plaque was
more important to health than stimulation of gingival tis-
sues. A protective bulge was formerly incorporated into
crown restorations to protect the free gingival from the
trauma of mastication.77-80 Research indicated that over-
contour of restorations predisposed to plaque accumula-
tion and gingival inflammation. When the dimensions of
artificial crowns exceed the natural teeth in the subgingi-
val areas, it severely restricts control of plaque.
Pere12” removed facial and lingual surfaces from the
teeth of mongrel dogs and overcontoured the facial surfaces
with acrylic resin. Undercontouring did not create gingival
pathosis, but overcontouring induced inflammation, debris
collection, marginal gingival hypertrophy, and engorge-
ment, decreased keratinization, and deterioration of the
gingival collar fibers. A similar study on teenage women
concluded that overcontouring the buccal, axial third of a
tooth predisposes the gingival tissues to inflammation.81
Studies have reported a definite association between
overhanging restorations and gingival inflammation”5, 82
with loss of alveolar bone.75383-85, 86,s7 An appreciable
reduction in bone height was reported on metal restora-
tions with marginal excess greater than 0.2 mm.84
Parkinsonss compared the facial-lingual dimensions of
crowned and natural contralateral teeth at the height of
contour. Eighty percent of the cast metal crowns had con-
tours greater than contralateral control teeth with a mean
excess of 0.36 mm. All of the metal ceramic crowns were
overcontoured by a mean excess of 0.71 mm, with a range
of 0.2 to 1.6 mm. A statistically higher mean plaque index
for restored teeth was recorded.
Frankhausers7 examined 200 3-year-old metal ceramic
crowns. Compared with contralateral natural teeth,
crowned teeth registered a mean value of overcontouring of
0.5 mm with an excess of to 1.6 mm. Even minute overcon-
touring was shown to markedly influence the degree of in-
flammation around the gingival margin. A substantial in-
crease in the papillary bleeding index and mobility were
attributed to teeth with artificial crowns.
In a review of the literature, the correlation between
placement of faulty, overcontoured crowns and periodon-
tal disease is evident.le4p87 Overcontouring of restorative
materials limits accessibility for oral hygiene and limits the
THE JOURNAL OF PROSTHETIC DENTISTRY
dentist’s ability to remove cement, resulting in a greater
surface of rough, plaque-retaining cement.
SUMMARY
The gingival responses to plaque formation were out-
lined with an acknowledgment that if plaque growth is
controlled, prolonged gingival health is possible. A correla-
tion has been drawn between poorly made metal ceramic
crowns and iatrogenic periodontal disease. Unsightly soft
tissue is caused by inflammation with hypertrophy or
recession from placement of esthetic crowns. The differ-
ence between the intention of treatment and the results is
discouraging.
When comparing esthetic crown systems, three critical
variables should be considered. The factors that mediate
plaque accumulation and influence gingival health at the
tissue-restoration interface are:
Surface roughness. Since bacterial colonization origi-
nates in the protected sites of microscopic grooves, the
crown microtopography is crucial. The linearity of the
marginal finish line, if irregular, increases roughness and
hence plaque accumulation.
Marginal fit. Marginal discrepancy determines the
amount of exposed cement retaining plaque and/or the
plaque niche between the crown and tooth. The degree of
marginal rounding determines the area of exposed cement
and possible plaque habitation.
Contour. An overcontoured margin compromises oral
hygiene and hinders professional scaling. Removal of
excess cement after cementation is severely restricted, re-
sulting in inaccessible remnants of cement.
Minimizing plaque accumulation is critical to gingival
health. An artificial crown that satisfies the three criteria
for diminishing plaque accumulation ensures prolonged
gingival health with superior gingival esthetics.
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Success of etched-metal bonded retainers with nonrigid

connections: A clinical study
B. J. Crispin, D.D.S., M.S.*
University of California, Los Angeles, School of Dentistry, Los Angeles, Calif.

The use of etched-metal bonded retainers in combination with conventional fixed

retainers has been described in the literature. This design creates several potential
problems that can be overcome by the use of an etched-metal bonded retainer with
a nonrigid connector as described in this article. Also presented are the prelimi-
nary results of a clinical study of 25 restorations that had been in place 13 to 46
months (average 22 months). The preliminary results are encouraging. No failures
have been recorded to date (September 198’7). (J PROSTHET DENT 19S9$3b269-72.)

E -
tched metal bonded retainers with rigid connec-
tors in combination with conventional cemented crown re-
tainers have been used for fixed partial dentures.‘m5 This
combination can present problems such as different ce-
menting techniques for each retainer, the inability to use
noble alloys, and different retainer retention potentials.
This article describes the use of etched-metal bonded re-
tainers with nonrigid connections and presents the prelim-
inary results of a clinical study.6
RETAINER DESIGN
Etched-metal bonded retainers (EMBRs) with nonrigid
connectors can be used with anterior and posterior fixed
partial dentures. They are useful for three- or four-unit
*Associate Professor, Section of Fixed Prosthodontics.
10/l/13271
fixed partial dentures in situations where one abutment
tooth is a candidate for a bonded retainer and the other
abutment tooth requires a conventional crown. Minimal
tooth reduction, tooth esthetics, and periodontal compat-
ibility are primary advantages. Enamel coverage for max-
imum bonding surface and 180 degrees plus circumferen-
tial retention on retainers is preferred.
Anterior preparation and retainer design
Retainer extensions on anterior teeth are limited by es-
thetic considerations and circumferential retention may
not be acceptable. Resistance to lingual displacement is
achieved by mesial and distal grooves (Fig. 1) that ensure
accurate seating of the casting. When the cingulum is in-
adequate for groove placement, a cingulum depression or
“dimple” (No. 6 to 8 round bur) will provide a guide for ac-
curate and reproducible alignment and seating. Finish lines

THE JOURNAL OF PROSTHETIC DENTISTRY 269