Periodontology 2000, Vol.

27, 2001, 29–44 Copyright C Munksgaard 2001

Printed in Denmark ¡ All rights reserved
PERIODONTOLOGY 2000
ISSN 0906-6713

Biological integration of aesthetic

restorations: factors influencing
appearance and long-term
success
S TEFANO G RACIS, M AURO F RADEANI, R ENATO C ELLETTI
& G UIDO B RACCHETTI

In the past few years, different authors have made

efforts to improve both techniques and materials to
meet the ever-increasing aesthetic requirements of
our patients. However, too often, the emphasis is
placed on these factors as the only keys to success.
It is instead the integration of a natural-looking pros-
thesis within a healthy periodontium that should
represent the ultimate goal of every component of
the dental team: general practitioner, periodontist,
hygienist, dental technician and prosthodontist. This
chapter summarizes the current knowledge of pros-
thetic materials and clinical procedures that play a
role in any clinician’s attempt to create biologically
acceptable and aesthetically pleasing long-lasting
restorations.

Restorative margin location and

implications for soft tissue
stability
Preservation of sound tooth structure and tooth vi-
tality is of the utmost importance in tooth prepara-
tion. Trauma to the pulp has to be minimized through Fig. 1. Tooth preparation should allow enough space cer-
the use of an air and water spray. At the same time, vically, occlusally and axially to give the technician the
there must be sufficient space: cervically to create the ability to create a mechanically sound and aesthetically
correct contour that facilitates plaque removal, oc- acceptable prosthesis. A shoulder preparation with no
clusally to allow the restoration of a proper occlusion, sharp angles is excellent for metal-ceramic crowns with
butt porcelain margins.
and axially to provide a proper thickness of veneering
material to achieve an aesthetically acceptable result
(Fig. 1) (44). Improper preparations may lead to over-
contouring of the restoration, poor occlusal design, However, for a restoration to become integrated in
and poor aesthetics (Fig. 2). the mouth, strength and aesthetic appearance alone

29
Gracis et al.
Fig. 2. An overcontoured restoration is often the result of
an underprepared abutment. Notice the inflamed gingiva
and the opaque appearance of the ceramometal crowns.
are not sufficient. A critical area is the crown–tooth
interface and its relation to the periodontal tissues.
Therefore, it is important to understand the necessi-
ty for a well-fitting restoration (provisional or defini-
tive) and how both the position of the preparation
margin with respect to the gingiva and the pro-
cedures necessary to define and record it affect the
quality of the final restoration and the health of the
surrounding tissues. Knowledge of the anatomy of
the periodontal tissues and an awareness of how,
under certain conditions, the prosthetic procedures
can lead to gingival inflammation, recession, or
pockets are prerequisites for any clinician doing this
work.
Anatomic considerations
The relationships among the tooth-supporting soft
and hard tissues, the junctional epithelium, the con-
nective tissue attachment and the bone crest have
been clarified in histological studies by Gargiulo et
al. (21). Even though the connective tissue attach-
ment was found to have an average apicocoronal
30
width of 1.07 mm and the junctional epithelium a
width of 0.97 mm, a high degree of individual vari-
ability was reported. The combined dimensions of
these two structures represent the biological width.
This structure should always be respected (33). How-
ever, many authors have highlighted the inevitability
of penetrating the epithelial attachment during the
prosthetic procedures without this maneuver caus-
ing any irreversible damage. Therefore, nowadays,
‘‘true’’ biological width violation means the place-
ment of a restorative margin in the connective tissue
attachment.
In health, the gingival margin and the alveolar
crest follow approximately the scallop of the
cementoenamel junction except interproximally,
where the soft tissue col is concave and thus does
not mimic the bone crest, which instead tends to be
convex or flat (41). The height of the interproximal
papilla depends not only on the bone architecture
but also on the relative tooth proximity: the closer
the crowns, the more accentuated is the papilla be-
cause the soft tissues tend to be supported by the
proximal contours of the crowns. The farther apart
the teeth (that is, in case of a diastema or a missing
tooth), the flatter the papilla will be. When preparing
a tooth, the tip of the bur should therefore follow the
gingival margin or the anatomic configuration of the
cementoenamel junction. It is important for the in-
terproximal preparation, especially of the front teeth,
not to become too flat; otherwise, there is a risk of
violating the connective tissue attachment and
therefore the biological width (62).
Depending on the thickness of the underlying
bone and the dimension of keratinized gingiva, dif-
ferent clinical and histological responses can result
from a supracrestal biological width violation.
Usually, with a thick periodontium (fairly flat
Fig. 3. Typical appearance of thick periodontium
 Biological integration of aesthetic restorations

Fig. 4. In a patient with a thin periodontium, it is often

wise to select supragingival margin placement.

cementoenamel junction and gingival scallops, thick

cortical plates and increased thickness of keratinized
gingiva), little apical migration of the dentogingival
unit and intrabony pocket formation are observed
(Fig. 3) (63). In the presence of a thin periodontium
(high gingival scallop, thin cortical plates and limited
thickness of keratinized gingiva), gingival recession
and apical migration of the dentogingival unit may
instead be observed (Fig. 4). This migration is some-
times self-limiting, as observed by Tarnow et al. (59).
Prominent roots need to be evaluated to identify
any fenestrations or dehiscences. These conditions
associated with a thin periodontium contraindicate
the placement of a restorative margin intracrevicul-
arly.

Supragingival versus intracrevicular

margins
Regardless of the preparation design and its co-
ronoapical position, a precise and well-defined mar-
gin should always be achieved. As Richter & Ueno
stated (51), marginal fit and finish may be more sig-
nificant to gingival health than the location of the
margin. Ideally, the margin of a prosthetic restora-
tion should be easily accessible for the following rea-
sons:

O to facilitate fabrication of the provisional restora-

tion;
O to facilitate impression taking;

Fig. 5. Supragingival margins are easier to prepare and A. Supragingival preparations of lower incisors. B, C. Mag-
record in the impression; furthermore, in conjunction nified views of supragingival preparations. D. Empress
with all ceramic restorations, they can allow a very natu- crowns after final cementation with resin cement.
ral-looking result. In this case, the crowns are in Empress.

31
Gracis et al.
Fig. 6. A shoulder preparation with an intracrevicular
margin. The ceramometal crown has emergence profile
that supports the soft tissues.
O to allow assessment of the fit of the restoration;
O to allow margin finishing and burnishing; and
O to facilitate plaque removal.
Supragingival margins stay away from the peri-
odontal tissues, and thus, they are easier to prepare,
record in the impression, and maintain (Fig. 5) (7).
This is in contrast to the ‘‘subgingival’’ margins,
which impinge on the junctional epithelium or even
the connective tissue attachment. Intracrevicular
margins are defined as those confined within the
gingival crevice (Fig. 6) (6, 33). Different studies (42,
60) have demonstrated conclusively that periodontal
tissues show more signs of inflammation around
crowns with intracrevicular or subgingival margins
than those with supragingival margins. There may be
a number of reasons for this result (17, 26):
O defective margins;
O inaccurate fit;
O roughness of the tooth–restoration interface;
O improper crown contour;
32
O violation of the connective tissue attachment; and
O greater pathogenicity of the subgingival dental
plaque.
However, even if from a periodontal point of view it
is preferable to have exposed (supragingival) mar-
gins, in clinical practice, the following factors may
force the clinician to place a restoration margin in-
tracrevicularly:
O need to improve the resistance and retention form
of a short clinical crown;
O presence of caries or restorations extending apical
to the gingival margin;
O modification of the emergence profile; and
O aesthetics.
In these cases, the key factors for achieving a healthy
and aesthetically pleasing result are proper margin
placement during tooth preparation, gentle tissue
management techniques during impression taking,
and the fabrication of restorations (both provisional
and definitive) with high-quality margins (25, 26, 51,
61).
Initial therapy should always be the first step in
the treatment of patients who need a restorative pro-
cedure. Intrasulcular preparations should be per-
formed exclusively in presence of a healthy crevice:
only when it is inflammation free is the gingival mar-
gin stable and less prone to recession and can be
probed and packed more accurately (63). The
healthy crevice is shallow, generally ranging in depth
from 0.5 to 1.0 mm on the facial aspect of the an-
terior teeth (12, 52). Therefore, an intracrevicular
margin should be placed 0.2 to 0.5 mm apical to the
free gingival margin on the facial side. Interproxim-
ally, because the sulcus normally is deeper, the prep-
aration can extend more apically to better support
the soft tissues. Be aware, however, that an increase
in gingival inflammation has been reported as the
restoration margin approaches the base of the sulcus
(42, 61).
Some authors (6, 63) suggest placing a retraction
cord in the sulcus before finalizing the preparation.
This maneuver has two advantages: it highlights the
base of the sulcus and therefore the ultimate limit of
the preparation before causing irreversible damage,
and it pushes the gingival margin outward and apic-
ally to better expose the unprepared tooth structure
to be removed (Fig. 7). Margin placement has to re-
spect the attachment apparatus and to allow for
some degree of error during the high-speed instru-
mentation (6).
 Biological integration of aesthetic restorations

colingually to allow the patient access to all areas to

maintain periodontal health (Fig. 8). This prepara-
tion depends on the patient’s periodontium type.
Some authors have stressed the importance of
avoiding overcontouring of highly scalloped thin
tissue; otherwise, recession may occur (62).
Much time and effort should also be dedicated to
assuring an optimal fit of the resin provisional,
avoiding open margins and overextension or under-
extension. When relining provisionals with the direct
method, a multiple reline technique should be used
(6). Alternatively, margins can be checked and final-
ized on a stone die poured from an impression of
the prepared tooth.
Special care should be directed to minimizing
mechanical and chemical trauma to the natural
dentition and to the periodontium during pro-
visional fabrication. In particular, the potential
trauma to the pulp of the direct technique caused
by the heat of polymerization and the presence of
the monomer is significant, especially if the thick-
ness of residual dentin is limited (5). To minimize
pulpal temperature rise and gingival irritation, it is

Fig. 7. A thin periodontium is readily displaced vertically

by a retraction cord.

The sequence of clinical steps consists of:

O tooth preparation to the gingival margin;

O placement of an extra-thin knitted retraction cord
that displaces the gingiva outward and apically;
and
O definitive margin preparation to the top of the
cord achieving a new, more apical position.

Role of provisional restorations

Fabrication of a provisional restoration is an ex-
tremely important phase of treatment. Provisional
restorations are needed to protect the prepared
teeth, to reduce the sensitivity of the vital abut-
ments, and to prevent tooth migration. They are also
instrumental in developing the correct aesthetics,
phonetics and occlusal scheme before fabrication of
the definitive restoration (65). More importantly,
well-contoured and well-fitting provisional restora-
tions allow the periodontal tissues to stay or become
Fig. 8. Provisional prosthesis should be fabricated with the
healthy. Special attention should be dedicated to the proper contours and emergence profile, both interproxim-
development of the proper emergence profile of the ally and buccolingually, to allow the patient access to all
provisional prosthesis both interproximally and buc- areas to maintain periodontal health.

33
Gracis et al.

tissue type (thick versus thin) and the position of

the preparation margin (at the gingival margin ver-
sus intracrevicular), different tissue management
procedures are indicated. The objective of tissue
retraction is to expose all of the prepared tooth
structure and, possibly, a portion of the unpre-
pared root beyond the margin by causing a hori-
zontal and vertical displacement of the marginal
gingiva. This can be achieved easily by placing in

Fig. 9. An ultrathin (000) cord is placed around prepared

teeth. If sulcus is shallow and cord causes sufficient dis-
placement of gingiva, no additional cord is placed.

strongly recommended that an external air–water

spray be used in combination with regular removal
from the preparation of the setting provisional res-
toration (39).

Impression technique
The impression technique can have a negative im-
pact on the soft tissues around the abutments,
even causing irreversible damage if the technique
is not properly carried out. Depending on the soft
Fig. 10. Use of double cord technique. The first cord is
ultrathin (000) cord, which will stay in place throughout
impression taking, while the second cord is one size big-
ger and will be removed just before injection of im-
pression material.

34
 Biological integration of aesthetic restorations

the sulcus one or two knitted cords (Ultrapak; Ul-

tradent Products, Salt Lake City, UT) of a suitable
size. A single-cord technique is the least traumatic
option and is normally employed when the sulcus
is shallow and the margin is placed only minimally
in the crevice (Fig. 9). The cord is usually impreg-
nated in a buffered aluminum chloride solution
(Hemodent; Premier Dental Products, Norristown,
PA), and it is removed at the time of impression.
The exposure of the tissues to the prolonged pres-
ence of an astringent solution is well documented
in the literature (8, 11, 40, 49). A double-cord tech-
nique is used when the sulcus is deeper (Fig. 10).
From the point of view of prosthetic convenience,
it may be desirable to employ this technique be-
cause it yields more extensive displacement. How-
ever, the soft tissue anatomy on the buccal aspect
of the anterior teeth rarely permits two cords to be
placed. In the presence of a limited facial crevice,
a selective double-string technique is better, the
second cord being placed only interproximally and
lingually. The second cord is usually one size big-
ger than the first, and it is soaked to control fluid
seepage and any slight bleeding. The first cord,
which stays in place throughout the impression
procedure, is left untreated.
Root proximity may create severe problems in ob-
taining good impressions because there will not be
enough space to accommodate the retraction cords
and, subsequently, a proper thickness of impression
material. The placement of cords in such restricted
interproximal spaces may cause irreversible damage.
Possible solutions to this problem are:

O partial- instead of full-coverage restorations to

avoid preparing and restoring the side of the tooth
with the proximity problem;
O more apical placement of the restorative margin if Fig. 11. Cementation of two feldspathic porcelain veneers
the root trunk tapers apically or an odontoplasty allows a high degree of light transmission, which makes
with a flame-shaped bur to increase the separ- the restorative margin virtually invisible.
ation;
O orthodontic movement to separate the teeth; and
O strategic extractions. any treatment plan that contemplates the placement
of one or more prosthetic restorations:

O tissue type;
Choice of restoration and O coronoapical position of the crown margin rela-
preparation designs tive to the gingival margin and to the need of
maintaining the tooth’s vitality;
The selection of the restorative material and the rela- O tooth vitality;
tive tooth preparation design should be performed O abutment integrity;
only after the clinician has considered the variables O abutment height;
that play a role in the decision-making process of O occlusal clearance for proper strength;

35
Gracis et al.
Fig. 12. Color of abutment and presence of metallic or
dark core materials are primary factors that can affect
color of gingiva and aesthetic appearance of prosthesis.
This is particularly true when full ceramic restorations are
planned, as was the case with these two Procera crowns.
O aesthetic needs of the patient; and
O parafunctional habits.
Only a careful evaluation of each of these features
can indicate which preparation design is most suit-
able in each particular case.
Full crowns versus porcelain veneers
The successful creation of adhesively luted conserva-
tive restorations (porcelain veneers) is challenging
36
more and more the traditional approach of full
crowns. This is especially true when restoring single
vital teeth. In the past few years, clinical evaluations
of porcelain veneers have documented positive re-
sults in terms of fracture rate, debonding, microleak-
age, soft tissue response, aesthetics and longevity
(13, 20, 30, 46, 47). Enamel-supported restorations
have a high light transmission and can be manufac-
tured with several porcelain systems (Fig. 11). For
the sake of this discussion, however, only full-cover-
age restorations will be considered, because they still
constitute the bulk of the prosthetic work performed
in a typical dental office and because they are the
real challenge as far as the integration with the sur-
rounding soft tissues. At the same time, it is interest-
ing to note how, for single teeth, the use of tra-
ditional cemented complete-coverage restorations
that may extend intracrevicularly is increasingly
limited to two situations: 1) restoration of severely
damaged teeth and 2) replacement of existing full-
coverage crowns (30).
Appearance and integrity of the
abutments
The color of the abutment and the presence of met-
allic or dark core materials, especially in endodont-
ically treated teeth where posts are often used, are
primary factors affecting the appearance of the pros-
thesis. This is particularly true in the cases in which
full ceramic restorations are planned (Fig. 12).
In order to have a preparation with an adequate
retention and resistance form, often, vital teeth and
all nonvital abutments need some form of prepros-
thetic reconstruction. The choice for a core build-
up material was traditionally made among amalgam,
glass-ionomer materials and composite resins. More
recently, the use of amalgam has decreased because
of biocompatibility issues, poor initial resistance
(need to wait 24 hours to finalize the preparation),
and fragility if its thickness is ⬍1 mm, among other
reasons. Glass–ionomer materials, even the re-
inforced ones (such as Ketac-Silver; ESPE, Seefeld,
Germany), are usually not recommended because
their low tensile strength makes them prone to frac-
ture (24, 28, 36), especially if they are used for large
build-ups not sustained by surrounding dentinal
walls.
When only a minimal amount of tooth structure
has been lost, the authors prefer employing a com-
posite resin, as it allows a conservative approach and
the possibility of matching the dentin’s color. How-
ever, even when adhesive agents and materials are

Fig. 13. Examples of aesthetic posts
used, it is a good habit not to rely solely on the
chemical adhesive’s strength for long-term retention
of the core. Because these restored abutments are
subjected to repeated stresses such as tensile
stresses when a provisional crown is removed, it is
highly recommended that some sort of mechanical
retention (undercuts, pins) be incorporated (45).
When a great amount of coronal tooth structure is
missing, as is the case with most endodontically
treated teeth, one of the main problems that needs
to be addressed is the retention of the build-up ma-
terial. In some cases, an adequate retention is ob-
tained by locking the material in the pulp chamber,
but very often, a post cemented in one of the canals
is needed (1, 38). There are several post systems
available. To choose the ‘‘ideal’’ post material, it is
important to consider features such as rigidity (stiff-
ness) and color.
Although the clinical effectiveness of rigid metal
posts is well established, some clinical reports have
linked a greater likelihood of root fracture to their
use (4, 37, 50, 57). For this reason, the use of posts
with a modulus of elasticity similar to that of dentin
has been recommended (16). In this study the
authors consider carbon fiber posts a valid alterna-
Biological integration of aesthetic restorations
tive since, according to the research they carried out,
the above-montioned physical property and the abil-
ity to be bonded apparently create a homogeneous
unit that can reduce stresses to the root and the po-
tential for fracture. On the other hand, some authors
(32, 55, 58) have highlighted the consequences of
using such a system in conjunction with a rigid ce-
ramic or metal-ceramic crown. One group (55) con-
cluded that ‘‘the potential for flexure of the carbon
fiber post on loading could result in the loss of the
cement lute marginal seal with the accompanying
microleakage of oral bacteria and fluids’’.
From an aesthetic point of view, a metal post has
a significant disadvantage in that its presence does
not allow sufficient light transmission through the
cervical portion of the root. Thus, it can affect nega-
tively the aesthetic quality of the final restoration.
This is particularly true in patients with a thin peri-
odontium and a high smile line. As a result, alterna-
tive ‘‘aesthetic’’ post systems have been developed in
the last few years (Fig. 13) (18). Table 1 summarizes
the indications, advantages, and disadvantages of
the different aesthetic post systems available.
It is senseless to use the aesthetic post systems
and highly translucent metal-free restorations if the
tooth’s substrate is dark as a result of prior endodon-
tic treatments. In these cases, internal bleaching has
been suggested before proceeding with the recon-
struction of the abutment (Fig. 14). However, there
are reports of external root resorption and decreased
bond strength to resin cements following such pro-
cedures when chemicals for chairside bleaching
Fig. 14. Clinical view of dark endodontically treated teeth
before and after walking bleaching procedure
37
Gracis et al.

Table 1. Aesthetic post and core systems

Metal-ceramic post and core
Indications
O To be used in presence of
a thick periodontium and
low lip line, as grayness
caused by metallic post
inside root has an impact
on the final result.
Advantages
O Strong and durable
material for the core.
O Predictability when
properly used.
Disadvantages
O The stiffness of the post
may cause root fracture.
Metal or carbon fiber post
with composite core
O To be used in presence of
a thick periodontium and
low lip line, as grayness
caused by these posts
inside the root has an
impact on the final result.
O Direct technique: only one O Natural root color.
appointment is required
for the fabrication of the
restoration.
O Carbon fiber post can
bond to tooth structure.
O Carbon post can allow too
much deformation of the
abutment and therefore
can result in marginal
leakage of the cemented
crown.
Zirconium post with
composite core, Cosmopost, Quartz and fiberglass post
In-Ceram post and core with a composite core
O Can be used in presence of O Can be used in presence of
a thin periodontium and a thin periodontium and
high lip line and in teeth high lip line and in teeth
with no discoloration or with no discoloration or
that have been bleached. that have been bleached.
O When the post space has
an adequate diameter.
O Natural root color.
O Direct technique: only one
appointment is required
for the fabrication of the
post and core.
O No long-term data are O No long-term data are
available on the clinical available on the clinical
performance of this performance of this
material. material.
O Stiffness of the post can O These posts can allow too
cause root fracture. much deformation of the
core and therefore can
result in marginal leakage
of the cemented crown.

were applied (2, 10). Therefore, it is suggested that a
walking bleaching procedure be performed and that
at least 2 weeks then elapse before luting a post. Re-
currence of the dark pigments is to be expected in
most cases.
Preparation designs
Preparation designs for full-coverage restorations
may be classified into four distinct types (Fig. 15):
celain firings and it can result in overcontouring of
the final restoration if porcelain is applied close to
the margin. For these reasons, its application is con-
fined to those situations where removal of a limited
quantity of tooth structure is of paramount import-
ance for the long-term preservation of the abut-
ment’s integrity and where the patient accepts the
presence of a metal collar (44).
Chamfer (‘‘hybrid’’ preparation)

O feather-edge; Widely used for cast restorations or for ceramometal

O chamfer; crowns with a minimal metal collar, the finish line
O shoulder with bevel; and
O shoulder.

A brief description of the salient features and indi-

cations of each type of design follows.

Feather-edge (vertical preparation)

Frequently used for gold cast crowns and porcelain

or resin-veneered crowns in periodontally involved
cases, the feather-edge preparation design requires
the least amount of tooth structure removal. The
finish line is often hard to read, however, and fin- Fig. 15. Diagrammatic representation of four types
ishing and polishing can be difficult (64). It yields of preparation design. A. Feather-edge. B. Chamfer.
limited resistance to marginal distortion during por- C. Shoulder with bevel. D. Shoulder.

38
 Biological integration of aesthetic restorations

of a chamfer preparation is easy for the clinician to

prepare and for the technician to read. However, ac-
cording to some authors (15, 54), the thin metal col-
lar may distort during the firing of porcelain, thus
producing inaccurate margins. A thermal cycle at
oxidation temperature immediately after casting ap-
parently decreases the likelihood of such distortion,
but there is no agreement among different authors
on this issue (9, 23). The visibility of the metal does
not allow these crowns to be used in areas where the
aesthetic demands are high (Fig. 16).

Shoulder with bevel (vertical preparation)

The shoulder with bevel can be used for ceramomet-

al crowns, full gold crowns and gold crowns with
resin facings. This design was originally advocated
by Rosner (53), who demonstrated how the bevel can
improve fit. Subsequently, this concept was demon-
strated to be effective only above 70 æ shoulder-to-
bevel angles, therefore losing most of its clinical util-
ity (35). It is more conservative than a full shoulder
preparation, but the presence of the metal collar
necessitates an intracrevicular preparation in aes-
thetic areas (Fig. 17).

Shoulder (horizontal preparation)

The shoulder is probably the most popular design

because it is very easily read by the technician, and
it allows sufficient bulk for porcelain to produce aes-
thetically pleasing restorations. It can be used for all-
ceramic or metal-ceramic crowns with either a metal
collar or a porcelain butt margin. The preparation
should display internal rounded axial angles (14) to
decrease stress concentration and reduce the risk of
porcelain failure. However, castings made for a flat
Fig. 16. The use of ceramometal restorations with por-
shoulder preparation may display a relatively poor celain butt joint has greatly improved aesthetic outcome,
fit, whereas excellent accuracy can be obtained with especially in the gingival third.
porcelain margins (48).

Metal-ceramic restorations
Because of their strength, durability and relative sim-
plicity of fabrication, metal-ceramic restorations are
the most widely used for both single crowns and
fixed partial dentures (6). However, these advantages
were often counterbalanced by a less-than-ideal aes-
thetic result when the appearance of both the crown
(especially of the cervical one third) and of the sur-
rounding soft tissues were analyzed. In recent years,
the effort to improve the aesthetic potential of
metal-ceramic restorations has brought about a
number of technical improvements and new metal
framework designs. The most important develop-
ment is without a doubt represented by collarless
metal frameworks (Fig. 16).
The aesthetic appearance of the traditional apic-
ally extended frameworks often leaves much to be
desired because of the lack of brightness and liveli-
ness in the marginal soft tissues surrounding the
prosthesis. As a consequence, they take on a bluish
hue. This is true both in the presence of a vital abut-
ment and in case of an endodontically treated tooth

39
Gracis et al.

sociated use of fluorescent porcelain margins are ef-

fective in obtaining a certain degree of brightness in
the root and allowing the illumination of the peri-
odontal tissues typical of natural dentition. At the
same time, collarless metal-ceramic restorations
have demonstrated the same resistance to axial
pressures as metal-ceramic restorations with a tra-
ditional framework (3, 27, 43).
If the tooth to be restored has no discoloration
and no previous restoration that extends intracrevic-
ularly, the choice of an all-ceramic crown allows the
operator to maintain the prosthetic margin supra-
gingivally or at the gingival margin. Thus, it is poss-
ible to avoid the time-consuming complications as-
sociated with an intracrevicular extension while still
achieving a very aesthetic result.

All-ceramic restorations
The increasing aesthetic awareness of patients has
led to the search for metal-free restorations and to
the development of new ceramic systems that chal-
lenge traditional metal-ceramic restorations (34).
The improved physical characteristics of these ma-
terials and the introduction of a new generation of
dental adhesives and resin cements have in fact re-
sulted in predictable and consistent clinical per-
formance, especially when they are used for single
anterior restorations (19, 31, 56). The likely expla-
nation is that the all-ceramic restoration and the re-
sidual tooth structure are mutually reinforced by the
adhesive cement (29). On the other hand, multistep
cementing procedures are demanding and tech-
nique sensitive, cement removal is difficult, and a
dental technician with adequate experience is
needed. Short-span fixed partial dentures may also
be fabricated with some of these ceramic systems.
Fig. 17. Hemisected molar is a typical situation where a
However, the standard for fixed partial dentures from
metal-ceramic crown with a metal collar is indicated.

restored with a post and core (Fig. 17). Magne et al.

(30) extended this notion, introducing the concept Table 2. Reduction requirements for full crowns
of the ‘‘umbrella effect’’; that is, the absence of in- and porcelain veneers
direct light penetration into the soft tissues because
Full crowns
of the shadow cast by the upper lip on the cervical Porcelain
Metal-ceramic All ceramic Cast veneers
part of a restoration with a metal substructure.
Facial
To solve these problems, Geller (22) suggested a 1.3–1.7 mm 1.2–1.5 mm 0.5–1.0 mm 0.5–1.0 mm
reduction of the metal to provide space between the Lingual
gingival margin and the most apical border of the 0.7 mm 1.0 mm 0.5–1.0 mm –
(if in metal)
framework, allowing room for the application of
Occlusal or incisal
shoulder porcelain and the passage of light. An ade- 1.5–2.5 mm 2.0 mm 1.0 mm 1.0–2.0 mm
quate reduction of the metal framework and the as-

40

Fig. 18. Two Procera caps being tried to determine color
base (A). B. Finished product.
a structural and biomechanical point of view is still
metal-ceramic restorations.
An all-ceramic restoration can be selected on the
basis of specific criteria, such as mechanical prop-
erties and light transmission. In this context, it is
useful to classify the materials used for single-unit
restorations in two main groups: alumina-based ce-
ramics and non-alumina-based (glass) ceramics. The
first group encompasses Spinell (Vita Zahnfabrik,
Bad Sackingen, Germany), In-Ceram (Vita Zahnfab-
rik), and Procera (NobelBiocare, Göteborg, Sweden).
In the second group can be included Dicor (Dent-
sply) and Empress and Empress 2 (Ivoclar-Vivadent,
Schaan, Liechtenstein). The materials in the former
group typically display higher strength and limited
translucency (alumina is relatively opaque) (Fig. 12,
18), whereas those in the latter group show a higher
translucency but more limited strength (Fig. 5). As a
matter of fact, so far, only two systems are appar-
ently indicated for use as single posterior crowns: In-
Ceram and Procera. All new ceramic systems share
a common goal: to limit the occurrence of complete
failures caused by fractures that encompass both the
Biological integration of aesthetic restorations
core and the veneering material. This goal has been
achieved by developing cores strong enough that the
fractures are limited to the veneering material, thus
approaching the failure pattern typical of metal-ce-
ramic restorations.
The reduction requirements for the two types of
crowns, metal-ceramic and all-ceramic, are listed in
Table 2.
Conclusions
Recent progress in restorative materials and clin-
ical techniques, especially those in the field of ad-
hesive dentistry, can indeed make it easier for a
general practitioner or a prosthodontist to create
natural-looking restorations. However, no matter
how significant new material developments may
be, by themselves, they will never provide the key
to success in prosthodontics. Tissue management
is of utmost importance and the real basis on
which to determine whether a prosthesis has been
properly fabricated and has been integrated in the
mouth of a patient. Bringing the periodontal
tissues to a state of health and maintaining such a
state throughout the therapy and beyond requires
careful planning and execution during all phases
of the restorative treatment (Fig. 19). This can be
achieved only through extreme attention to detail
and the allowance of an appropriate amount of
time to carry out every single procedure, as it is
necessary to do when relining provisional restora-
tions, making impressions and removing excess ce-
ment around the restorations.
This chapter reviewed some of the most signifi-
cant concepts and clinical considerations relating to
restorative procedures in light of recent and older
literature. The aim is to focus the attention of the
clinicians on the aspects that should always be kept
in mind when trying to replace missing tooth struc-
ture.
Acknowledgments
We thank Silvano Sandrini and Giancarlo Barducci,
Master Dental Technicians, for their invaluable ef-
forts in always providing restorations that enhance
the clinical work while adding an artistic flare to
something that otherwise would be a mere tooth
substitute at best.
41
Gracis et al.

Fig. 19. A. Typical appearance of the gingiva right after the

preparation of the teeth and the insertion of new pro-
visional crowns. B. Healing of the gingival tissues 4 weeks
later. C. Aspect of the tissues the day of impression taking.
D, E. Close-up view of the definitive Empress crowns 4
weeks after cementation. F, G. Aspect of the gingiva
around the same crowns 7 years later: the margin has re-
mained stable and no gingival recession has occurred.

42

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