Q U I N T E S S E N C E I N T E R N AT I O N A

Relationship between crowns and the periodontium: A literature update

Panagiota Kosyfaki, DDS1/Maria del Pilar Pinilla Martn, DDS1/ Jrg Rudolf Strub, DDS, Dr Med Dent, Dr hc, PhD2
Location of the crown margin, marginal fit, crown material, and crown contour all impact periodontal tissues. This literature review evaluated available data on their relationship with the periodontium and also examines whether any changes in established knowledge and/or perspectives have been published during the past 30 years. Electronic and manual searches conducted for in vivo investigations in the English and German literature for 1953 to 2009 provided 64 studies. Findings indicate that the supragingival location remains the most advantageous from the periodontal point of view; esthetic demands, however, dictated an intracrevicular location of the margin in the anterior zone. Metalceramic and all-ceramic crowns show a clinically acceptable marginal fit. Ceramic materials have the lowest plaque-retaining capacity, and a normal crown contour guarantees satisfactory periodontal health and esthetics. The accompanying data confirm the results reported in the literature, revealing that nothing has substantially changed, thereby supporting current approaches. (Quintessence Int 2010;41:109122)

Key words: crown contour, crown material, crowns, location of the crown margin, marginal fit, periodontium

The question of whether crowns have an effect upon the condition of periodontal tissues has been the subject of numerous studies in dental literature for many years.118 Particular interest has been paid to the relationship between periodontal health and the location of the crown margin, the marginal fit of the crown, the crown material, and the crown contour (Figs 1 and 2). These key factors, unless appropriately managed, may create niches for plaque growth,19 thus providing a protected environment in which the indigenous microbial population may mature into

an even more pathogenic and virulent flora.9,20,21 Under such circumstances, initiation or progression of periodontal disease is certain. With respect to the gingival crest, four options for positioning the crown margin are described in the literature: the supragingival location; the equigingival location, or location at the gingival margin; the intracrevicular or slightly subgingival location, in which the margin is confined within the gingival crevice2227; and the subgingival location. Originally, the term subgingival location referred to the location of the margin positioned somewhere between the free gingival margin and the alveolar crest,17 implying a possible impingement upon the junctional epithelium or the connective tissue.28 More recent studies have used the term intracrevicular location, which describes a crown margin placed and confined within the gingival sulcus.2227

Postgraduate Student, Department of Prosthodontics, School of Dentistry, Albert-Ludwigs University, Freiburg, Germany.

Professor and Chair, Department of Prosthodontics, School of Dentistry, Albert-Ludwigs University, Freiburg, Germany.

Correspondence: Dr Panagiota Kosyfaki, Department of Prosthodontics, School of Dentistry, Hugstetter Strasse 55, 79106, Freiburg, Germany. Fax: 49 (761) 270 4824. Email: panagiota. kosyfaki@uniklinik-freiburg.de

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Fig 1 Acrylic resinveneered crowns on the maxillary central and right lateral incisor(s) with overcontoured, insufficient, subgingival margins: bad result.

Fig 2 All-ceramic crowns on the maxillary central incisors with intracrevicular margins, clinically acceptable fit, and a normal tooth contour: good result.

Marginal fit is valued as an essential factor for the long-term success and overall acceptability of the restoration.1,3,4,7,2935 However, despite careful attention to waxing and casting procedures, marginal discrepancies, including the marginal gap, overextension, and underextension,36 do occur3739 and have been directly implicated in producing strong adverse inflammatory responses in the periodontium.9,29,33,4042 Every material in the oral cavitymetal, ceramic, or acrylic resinhas the potential to retain plaque deposits.43 However, because of the chemical and physical properties of each material,3,43,44 the composition and retention of built-up plaque and the subsequent periodontal response will vary from material to material. For example, acrylic resin, because of its porosity, shows the highest plaque-retaining capacity and is associated with chronic inflammation of the gingival tissues.44,45 For this reason, its use has been limited to the fabrication of provisional restorations.46 On the contrary, porcelain, owing to its chemical composition, is a highly biocompatible material that displays a low affinity to soft debris accumulation.44,45,47 Emulating the contour of the natural tooth,7 thus avoiding overcontouring or undercontouring the crown, is essential for supporting

the surrounding soft tissues, optimal hygiene,22,37,4851 and a natural-looking restoration.52 Natural teeth exhibit straight emergence profiles in the gingival third, with an emergence angle of 15 degrees in relation to the long axis of the tooth.49,53 The contact areas are high, 4 to 5 mm above the interproximal bone in patients with normal periodontium,54 while the triangular embrasure to the contact area is filled with the interdental papilla.13 The first critical review, which extensively examined the relationship between restorative procedures and the periodontium, was published in 1977.3 Since then, numerous studies on novel materials and techniques have been conducted, providing various observations and results about the close interaction between crowns and periodontium. However, no literature review has been undertaken to present the new data and summarize the current scientific knowledge on crowns and periodontal health until now. The aim of this review was to evaluate available literature on the impact of a crown its margin location, marginal fit, material, and contouron the periodontium and also to determine if any significant change in established knowledge or perspectives during the past 30 years has been recorded.

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LITERATURE SEARCH
On the basis of specific inclusion and exclusion criteria, a detailed search protocol was designed to identify studies examining the relationship between crowns and the periodontium.

Inclusion criteria
Studies considered for this review were in vivo studiesprospective, retrospective, randomized controlled trials, controlled clinical trials, or comparative studiesconducted on either human or animal subjects, focusing mainly on crowns and examining at least one of the following featureslocation of the crown margin, marginal fit, crown material, crown contourand its impact on the periodontium. For the purposes of this review, review articles were also included.

appropriateness by the two review authors (P.K. and J.R.S.) independently according to the defined criteria. Studies that did not meet the inclusion criteria were excluded from further evaluation. Subsequently, the full reports of the studies that appeared to fulfill the inclusion criteria were retrieved and assessed. At that stage, the search was narrowed using the following terms: supragingival, equigingival, intracrevicular, subgingival, marginal gap, overextension, underextension, metalceramics, all-ceramics, gold, acrylic resin, surface roughness, normal contour, overcontour, and undercontour. The bibliographies of all pertinent articles were further checked and reviewed using the defined inclusion and exclusion criteria. Any discrepancies were resolved by discussion between the two reviewers.

Exclusion criteria
Studies considered ineligible were in vitro studies, case reports, and studies focusing on restorations other than crowns, such as fixed partial dentures, inlays, onlays, direct restorations, veneers, or implant-supported restorations. However, several articles reporting on crowns and fixed partial dentures,41,5561 direct restorations,30 onlays,20 and inlays62 were included because of the difficulty of extracting data exclusively concerning crowns.

FINDINGS
The initial search yielded 1,138 titles. After screening by the two reviewers and application of the set inclusion and exclusion criteria, 130 pertinent articles were selected. Of the 130, 64 were identified as in vivo investigations (Table 1) and incorporated in the body of the review because of their clinical relevance to the topic. Of the 64, 56 in vivo investigations could be further classified into 7 tables, each table examining the relationship between the periodontium and location of the crown margin in humans (19 studies, Table 2) and in animals (2 studies, Table 3); marginal fit in humans, whereby the measured marginal discrepancy is reported (12 studies, Table 4); crown material in humans (17 studies, Table 5) and in animals (1 study, Table 6); and crown contour in humans (4 studies, Table 7) and in animals (2 studies, Table 8). One study63 has been included in both Tables 2 and 5. The results of another study were published in German in 199864 and in English in 2000.65 Due to the heterogeneity in the basic components of the study design, eg, population, intervention, and outcome, a statistical analysis of the data was not possible.

Search strategy
The Medline (PubMed) electronic database was explored for dental articles published between 1953 and 2009. Language restrictions were applied, and only relevant articles written in English or German were included. The search used a combination of key words and search terms: periodontium, crown, location of the crown margin, marginal fit, crown material, and crown contour. In addition, hand searches were performed on books and high-yield journals. The final electronic search was conducted in May 2009.

Study selection
The obtained titles, abstracts, and texts, identified through the electronic and manual searches, were scanned and evaluated for

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Ta b l e 1

In vivo studies in humans and animals on the relationship between crowns and the periodontium from 1953 to 2009
19601969
42

19531959

19701979
68

19801989

19901999

20002009

Waerhaug 1953

Marcum 1967

Karlsen 1970

72

Waerhaug 1956107

Perel 1971116 McLean and von Fraunhofer 197162 Jones 197296 Richter and Ueno 197369 Newcomb 197474 Larato 197573 Wise and Dykema 197547 Sackett and Gildenhuys 1976113 Valderhaug and Birkeland 197655 Parkinson 1976114 Strub and Belser 197859

Ehrlich and Hochman 1980130 Keenan et al 1980112 Valderhaug 198056 Marxkors 198091 Koth 198266 Lang et al 198320 Lindhe et al 198380 Riley et al 1983106 Belser et al 198586

Adamczyk and Boening et al 200089 Spiechowicz 199044 Carnevale et al 199060 Gnay et al 200065 Jensen et al 1990101 Lvgren et al 200057 Bader et al 199171 Felton et al 199134 Ferrari 199195 Tarnow et al 199254 Karlsson 199388 Gnay et al 200126 Kancyper and Koka 200176 Bindl and Mrmann 2002100 Gemalmaz et al 200263 Reitemeier et al 200267

Diedrich and Erpenstein 198592 Fransson et al 198587 Sjgren et al 1999102 Chan and Weber Sjgren et al 1999103 198645 Mller 198661 Shafagh 1986111 Spiekermann 198641 Tarnow et al 198675 Jger and Besimo 198793 Orkin et al 198770 Bieniek and Kpper 198894 Flores-de-Jacoby et al 198921 Kpper and Bieniek 1989105 Simonis et al 198999

Castellani et al 1996104 Sundh and Khler 2002115 Seeger et al 199864 Kohal et al 2003117 Kokubo et al 200590 Ohlmann et al 200697 Davidi et al 200746 Weishaupt et al 200798 Quante et al 200835

The outcomes of the selected studies were categorized into the following four subsections: relationship between location of the crown margin and the periodontium; marginal fit and the periodontium; crown material and the periodontium; and crown contour and the periodontium.

Location of the crown margin and the periodontium

The literature search identified 21 in vivo studies (Tables 2 and 3). Of these studies, 821,55,56,60,63,6668 assessed whether clinical differences with respect to the periodontium were present with supragingival, equigingival, and subgingival margins. Five studies59,6972 compared supragingival to subgingival margins and seven studies dealt with the placement of the margin at different levels in the

gingival crevice.26,64,65,7376 The overwhelming majority of human studies21,55,56,5961,66,70,71,73,74,76 implemented a retrospective design. A prospective design was employed in four studies.26,64,65,67 One study was identified as a controlled clinical trial.63 A comparison of earlier studies showed several authors held diametrically opposed opinions. On one hand, it was claimed that gingival inflammation is completely irrespective of the position of the crown margin, provided the patient participates in a personalized prophylactic dental care program.66 On the other hand, it was suggested that even among highly motivated patients with regular plaque control, supragingival margins, as well as subgingival margins, would adversely affect periodontal tissues.4,71

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However, the outcomes of a 10-year longitudinal investigation55,56 showed that while about 60% of the crown margins were originally located subgingivally, a little more than half of those (or about 36% of the original crown margins) remained subgingival after 10 years. Disease had taken its toll, obviously initiated by the subgingival margins. Generally, when comparing supragingival to subgingival margins, subgingival margins are associated with increased plaque accumulation, gingival inflammation,55,56,63,67,71,75 deep gingival pocket formation,55,56,71,73 greater attachment loss,55,56 and gingival recession70 as demonstrated by clinical parameters, namely, the higher Plaque Index, Gingival Index, and crevicular fluid flow rates,21,59 compared with those of supragingival margins. When comparing supragingival to equigingival margins, equigingival margins tend to show a slight increase in gingival inflammation and probing depths and slightly more attachment loss than supragingival margins.55,56,61 As a matter of fact, restorations terminating at the gingival margin or intracrevicularly show more similarities with subgingival restorations than with supragingival ones.21 Therefore, despite appearing less injurious than subgingival margins,76 intracrevicular and equigingival margins may cause inflammation. In contrast, one retrospective study60 demonstrated that a crown margin placed in a gingival or slightly subgingival location is not detrimental to periodontal health. It must be stressed, however, that a highly precise prosthetic margin was given and that effective plaque control in patients was achieved through an intensive oral hygiene program, conducted by professionals in the field. Moreover, when atraumatic preparation techniques are used,25,26 it is possible to maintain periodontal health even with intracrevicular margins.26 Compared to intracrevicular margins, margins placed within the zone of the biologic width were found to exhibit increased pocket depths and loss of attachment.64,65 Noteworthy was the absence of alteration of bone levels 2 years after insertion as diag-

nosed by means of intraoral radiographs. Nonetheless, it was indirectly implied that a possible three-dimensional change of the bony profile may have occurred, though not successfully depicted. As a rule, the deeper the margin is placed within the gingival crevice, the greater the severity of gingival inflammation65,74,77 and also the greater the danger of violating the biologic width.48,77,78 Subgingival margins create a sheltered environment, inaccessible for effective plaque removal by means of oral hygiene procedures.9 Thus, the subgingival extension may dynamically modify the distribution pattern of bacterial plaque and favor the establishment of gram-negative anaerobic microbiota.20,21,27,79 This shift in the subgingival microflora toward a more periodontopathic microflora represents a high risk for periodontal breakdown.80 This may result in epithelial proliferation (gingivitis) and, if unaffected by treatment, may lead to apical migration of the junctional epithelium75 and bone loss (periodontitis).78,81,82 Simultaneously, when the margin of the restoration is positioned subgingivally, it is possible that the epithelial attachment or the connective tissue fibers will become irreversibly inflamed.64,65 In an attempt by the periodontal structures to recreate the space between the alveolar crest and the crown margin,48 apical migration of the epithelium occurs.75 This results in an increase in gingival inflammation64,65 and deepened periodontal pockets in the case of thick biotype, or gingival recession75 in the case of thin biotype.83,84 Interproximally, loss of crestal bone might22,23,75,83,85 or might not64,65 be observed. In any case, the violation of the biologic width will certainly facilitate the development of the aforementioned plaque-related inflammatory process.9,65,85

Marginal fit and the periodontium

The literature search yielded 12 in vivo investigations reporting on the measured marginal discrepancy of crowns (Table 4). Six studies35,8690 evaluated the fit by means of replica technique before cementation of the crowns in patients. Of the six, four studies35,8688 reported on the marginal fit of metal-ceramic crowns and two studies89,90

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Ta b l e 2

In vivo studies in humans on the relationship between location of the crown margin and the periodontium
No. of examined restorations/ No. of patients/ No. of dropouts Location of crown margin/ No. of examined restorations

Author(s)

Parameters Observation assessed period

Results/observations

Larato 197573

111 crowns/111

Subgingival/111

PD

NR

Richter and Ueno 197369

12 crowns/12

Supragingival/12 Subgingival/12

GI, PD, absence of plaque

3y

Newcomb 197474

66 crowns/59

Strub and Belser 197859

315 crowns and FPDs/24 357 crown and FPDs/114/98

Subgingival location GI, PI at different levels within the gingival crevice Supragingival/37 PI, PD, Subgingival/278 TM, WAG Supragingival/30% Equigingival/29% Subgingival/41% GI, PI, PD, AL

8.23 mo

1y

Valderhaug and Birkeland 197655

5y

Valderhaug 198056

357 crowns and FPDs/114/82

Supragingival/37% Equigingival/28% Subgingival/36%

GI, PI, PD, AL

10 y

Koth 198266

46 crowns/28

Supragingival and Equigingival/41.3% Subgingival/58.7%

GCF

19 y (mean: 3.5 y)

Mller 198661

47 crowns and FPDs/5

Supragingival/25 Equigingival/22

Tarnow et al 198675

13 provisional crowns/2

Orkin et al 198770

423 crowns/423

Subgingival location, halfway between the gingival margin and bone crest Supragingival/68 Subgingival/355

PI, GI, PD, AL, GF, composition of microflora Histologic examination of the PDL GI, PI, R

1y

2 mo

2 y (supra) 4 y (sub)

Flores-de-Jacoby et al 198921

693 TS of crowns/19

Supragingival/415 TS Equigingival/135 TS Subgingival/143 TS

GI, PI, PD, CFFR, composition of microflora

1y

55% of the subgingival margins showed increased pocket depths compared to natural teeth. Precision of fit is more important than location of the margin. However, supragingival margins are better than subgingival. The deeper the margin is placed into the crevice, the more severe the gingival inflammation. Supragingival margins showed less inflammation than subgingival margins. Compared to supragingival margins, equigingival margins showed an increase in gingival inflammation and in pocket depths. Additionally subgingival margins showed increase in loss of attachment. Compared to equigingival and supragingival margins, subgingival margins showed higher gingival inflammation. Compared to supragingival location, equigingival margins showed increase in pocket depth, and a little more loss of attachment. Gingival inflammation is irrespective either of a supragingival, equigingival, or subgingival margin, when the patient attends a strict recall program. Equigingival margins show little inflammation in contrast to supragingival margins that showed minor signs of inflammation. Gingival recession, migration of the junctional epithelium, and resorption of crestal bone were observed. Gingival tissues tended to bleed 2.42 times more frequently with subgingival margins and have a 2.65 times higher chance of gingival recession. The supragingival location is the least detrimental to the peri odontium. Subgingival margins show the highest values for GI, PI, PD, and CFFR. Equigingival margins show more similarities to subgingival margins.

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Ta b l e 2

In vivo studies in humans on the relationship between location of the crown margin and the periodontium (continued)
No. of examined restorations/ No. of patients/ No. of dropouts Location of crown margin/ No. of examined restorations

Author(s)

Parameters assessed

Observation period

Results/observations

Carnevale et al 199060

510 crowns and FPDs/109

Supragingival/56 PI, GI, PD Equigingival/123 Slightly subgingival/331 Supragingival/90 Subgingival/509 PI, CI, GI, PD

13 y 35 y 69 y 5y

Bader et al 199171

599 crowns/367

Gnay et al 200065 116 crowns/41 Seeger et al 199864

Intracrevicularly/25 In junctional epithelium/59 In connective tissue/32 Intracrevicular/30

HI, PBI, PD, PAL

2y

Kancyper and Koka 200176

30 crowns/30/0

Gnay et al 200126

66 crowns/34/0

Intracrevicular/66

Gingival redness, 6 mo plaque, swelling, bleeding scores, composition of microflora HI, BOP, 1y PPD, PAL, FGM

An equigingival or slightly subgingiva but precise margin is not prejudicial to periodontal health in patients with effective plaque control. Supragingival and subgingival margins show higher inflammation and deeper probing depths compared to natural teeth even among regularly attending patients. Margins placed within the zone of biologic width result in increased pocket depths and gingival inflammation and clinical attachment loss No change in bone levels was noted. Gingival redness, plaque, swelling, and bleeding scores were low, and no pathogenic bacteria were detected with intracrevicular margins.

Gemalmaz et al 200263

37 crowns/20

Supragingival/20% Equigingival/25% Subgingival/55%

PI, GI

24.56 mo

There was no statistically significant difference between the HI, BOP, PPD, PAL, and FGM of the intracrevicular margin and natural teeth. Teeth had been prepared using an atraumatic preparation diamond.25,26 Subgingival margins showed higher values for PI and GI compared to natural teeth. Supragingival and equi gingival margins showed similar values to the natural teeth.

Reitemeier et al 200267

480 crowns/240

Supragingival/NR Equigingival/NR Subgingival/NR

PI, SBI

1y

Subgingival margins showed the greatest inflammation followed by the equigingival and then the supra gingival margins. The risk of bleeding with subgingival margins is double compared to supragingival margins.

(FPD) Fixed partial dentures; (TS) tooth surface; (PD/PPD) probing depth; (GI) Gingival Index; (PI) Plaque Index; (TM) tooth mobility; (WAG) width of attached gingiva; (AL/PAL) clinical attachment level; (GCF) gingival crevicular fluid; (GF) gingival fluid flow; (PDL) periodontal ligament; (R) recession; (CFFR) crevicular fluid flow rate; (CI) Calculus Index; (HI) Hygiene Index; (PBI) Papillary Bleeding Index; (SBI) sulcular bleeding index; (BOP) bleeding on probing; (FGM) level from the free gingival margin; (NR) not reported. Aside from Valderhaug and Birkeland55 and Valderhaug,56 the number of dropouts from all other studies was zero.

Ta b l e 3

In vivo studies in animals on the relationship between location of the crown margin and the periodontium
No. of examined crowns/No. of animal subjects Location of crown margin/No. of examined crowns

Author(s)

Observation period

Results/observations

Marcum 196768

12 crowns/6

Karlsen 197072

27 crowns/5

Supragingival/4 Equigingival/4 Subgingival/4 Supragingival/9 Subgingival/18

13 mo

Equigingival margins caused the least inflammatory response.

212 mo

Subgingival margins show more pronounced signs of inflammation than supragingival margins

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Ta b l e 4

In vivo studies in humans on the relationship between marginal fit and the periodontium
Study subjects Mean marginal gap (m) Wear time of crowns

Author(s)

No. of crowns

Method

Results/observations

Marxkors 198091

Over 100 gold crowns

Belser et al 198586

Fransson et al 198587

Diedrich and Erpenstein 198592 Spiekermann 198641 Jger and Besimo 198793

36 metalceramic crowns 27 (beveled metal margin, metal butt margin, porcelain butt margin) 55 metal-ceramic crowns (38 high gold crowns, 17 gold palladium crowns) 3 gold crowns

Extracted teeth of human patients (no.of patients NR) 27 human patients

Clinical evaluation

RT + SEM analysis

110270 (feather NR edge) 70160 (distinguish5y able margin finish line) < 50 NR

The marginal gap of feather edge margins wa greater than that of margins with distinguishable finish lines. The marginal fit of the three designs is clinically acceptable. Porcelain butt margins 50 m are feasible.

Human patients (no.of patients NR)

RT + LM analysis

100

3 mo

Metal-ceramic crowns have a clinically acceptable fit ( 120 m).62 Gold-palladium crowns show a better fit than high-gold crowns. The marginal gap is over the clinically acceptable value (>50 m).40 The marginal gap is over the clinically acceptable value (50100 m).40 The mean marginal discrepancy for both systems is under 50 m.

142 gold crowns (63 single crowns, 35 FPDs) 6 all-ceramic crowns (3

Extracted teeth SEM of human analysis patients 81 human jaw HA specimens Extracted teeth HA + CPM of 1 patient analysis

142.40

3 mo

382 (80.3% featheredge margins) < 50

47 mo

Bieniek and Kpper 198894

Cerestore crowns, 3 Dicor* crowns) 80 crowns (70 Hi- Extracted teeth HA + SEM Ceram, 10 gold) analysis of human

patients

Ferrari 199195

15 crowns (14 Dicor, 1 metalceramic)

Extracted teeth SM + SEM analysis of 6 human patients

68.9 7.5 (HA of Hi-Ceram crowns) 2.7 5.8 (SEM of Hi-Ceram crowns) 59.1 6.1 (HA of gold crowns) 50100 (for Dicor crowns)

The accuracy of fit of Hi-Ceram is in the range of clinical acceptance (50100 m).40

Karlsson 199388

12 Procera titanium crowns 80 Procera AllCeram crowns

Boening et al 200089

Kokubo et al 200590 90 Procera AllCeram/53 Quante et al 200835 28 metal-ceramic crowns fabricated with laser melting technology 28 (base alloy, precious alloy

Human patients (no.of patients NR) Human patients (no.of patients NR) 53 human patients 28 human patients

RT + LM analysis RT + LM analysis RT + LM analysis RT + LM analysis

70

Metal-ceramic crowns have better marginal adaptation than Dicor crowns. However, the marginal fit of Dicor crowns is clinically acceptable. The accuracy of fit is in the range of clinical acceptance ( 120 m).62 The accuracy of fit is in the range of clinical acceptance (100150 m).62 The accuracy of fit is in the range of clinical acceptance ( 120 m).62

8095 (anterior teeth) 90145 (posterior teeth) 36 36 (anterior teeth) 32 32 (premolar teeth) 35 33 (molar teeth)

7499 for both alloys

The accuracy of fit for both alloys is in the range of clinical acceptance ( 120 m).62

(RT) Replica technique; (SEM) scanning electron microscope; (LM) light microscope; (HA) histologic analysis; (CPM) computerized picture microscope; (SM) stereomicroscope; (NR) not reported.

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reported on the marginal fit of all-ceramic crowns, whereby slightly different fit values were provided. However, based on the six studies, both systems demonstrated the accuracy of fit to be within the limits of clinical acceptance ( 120 m).62 In addition, six retrospective studies investigated the marginal fit of crowns on extracted human teeth.41,9195 Sufficient clinical fit was found to be feasible with Cerestore (Johnson & Johnson), Dicor (Dentsply), and Hi-Ceram (Vita Zahnfabrik) crowns.9395 In contrast, large marginal discrepancies of 110 to 160 m,91 142.40 m,92 and 384 m41 were registered with gold cast crowns. Feather-edge margins could account for these results.41,91 Moreover, it was found in one of these studies that 41.5% of the crown margins were overextended and 33% underextended, which explained the presence of calculus deposits under most of the examined crown margins (75%).41 Overextending or overhanging margins constitute iatrogenic factors responsible for strong gingival inflammation96 due to the plaque-retentive capacity of the crown material1,3,47 and alterations in the subgingival microflora,20,34 as well as changes in the epithelial and connective tissues.42 One study20 found overhanging margins caused no loss of attachment, yet another study30 reported a compromised interproximal bone height around defective crowns. On the other hand, a short underextended margin exhibits an emergence profile incompatible with natural tooth morphology. This factor, in combination with the roughness of the exposed prepared tooth structure, contributes largely to plaque retention and chronic inflammation of the periodontium.34 Between the marginal discrepancy and inflammation of periodontal tissues, a significant quantitative relationship for subgingivally located crowns has also been documented.34 More specifically, a strong correlation was found between marginal discrepancy and Gingival Index and also between marginal discrepancy and crevicular fluid volume values, although no significant correlation was established between marginal discrepancy and pocket depth.

Crown material and the periodontium

Through the literature search, 18 in vivo studies were found providing information on plaque growth and accumulation relative to crown material (Tables 5 and 6). Three studies employed a prospective design,57,97,98 two of which were also identified as randomized controlled studies.97,98 The rest of the studies presented a retrospective design. The first randomized clinical trial98 evaluated the performance of galvanoceramic crowns placed in 52 patients with regard to periodontal conditions. Scores for Plaque Index, Gingival Index, gingival crevicular fluid flow rate, and immunoglobulin G were significantly lower for gingival tissues adjacent to galvanoceramic crowns than metal-ceramic crowns. More pronounced plaque accumulation was also observed on metal-ceramic surfaces compared with galvanoceramic surfaces during a period of 4 months to 4 years.99 In the second randomized clinical trial,97 conventional metal-ceramic crowns and metal-free polymer crowns with or without a glass-fiber framework were compared. After 1 year, polymer crowns with a fiber framework showed a significantly higher plaque accumulation and Gingival Index than metalceramic crowns, a fact that points to the drawbacks of fiber reinforcement. In contrast, no significant differences could be observed between polymer crowns without fiber reinforcement and metal-ceramic crowns. However, with the polymer crowns, the need for endodontic treatment and recementation was evident. Disagreement exists in the literature over whether metal-ceramic and all-ceramic crowns elicit a more inflammatory response from the periodontium than natural teeth. Procera titanium crowns (Nobel Biocare),57 In-Ceram Spinell (Vita Zahnfabrik) and InCeram Alumina crowns (Vita Zahnfabrik),100 IPS-Empress crowns (Ivoclar Vivadent),63 and Dicor crowns (Dentsply)101 reportedly provide lower scores for Plaque Index compared with natural teeth. Still, in other studies,102,103 no difference in plaque accumulation and bleeding on probing between natural teeth and Empress crowns or between natural teeth and Dicor crowns could be observed.

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Ta b l e 5

In vivo studies in humans on the relationship between crown material and the periodontium
Crown material/(No. of crowns/ No. of patients) Observation period

Author(s)

Results/observations

Wise and Dykema 197547

(40 disks/10); Type III gold (10/10) Gold alloy for veneering with porcelain (10/10) Porcelain (10/10),Acrylic resin (10/10)

48 h

Keenan et al 1980112 Chan and Weber 198645

Shafagh 1986111 Kpper and Bieniek 1989105

Gold (carborundum disk rubber wheel, tripoli, rouge, sandblasting) All-ceramics (50/19) Metal-ceramics (68/19) Cast gold (13/19) Acrylic resinveneered crowns (19/19) Natural teeth Gold (green stones, rubber wheels, bristle brushes, tripoli, rouge) Hi-Ceram crowns, version I (43/37) Hi-Ceram crowns, version II (89/37) Metal-ceramic crowns (132/37)

72 h 4 wk

Porcelain and acrylic resin have a lower plaqueretaining capacity than type III gold. No statistically significant difference was observed between the plaque-retaining capacity of acrylic resin and porcelain. However, these conclusions may be valid for only the particular experimental conditions Polished gold surfaces retained lower amounts of plaque than less well-finished gold surfaces. All ceramic crowns had the lowest plaque retention (lowest PI). Acrylic resin veneer crowns had the highest plaque retention (highest PI). Highly polished crowns showed under a microscope less plaque accumulation than hastily polished crowns. Compared to metal-ceramic crowns, Hi-Ceram crown margins (version I) showed increased porosity and plaque accumulation, while Hi-Ceram margins (version II) showed less plaque accumulation. Galvanoceramic crowns showed the least plaque accumulation (lowest PI) compared to natural teeth and the other restorative materials. The PBI values of galvanoceramic crowns were higher than those of natural teeth but lower than those of the other restorative materials. The largest amounts of plaque were found on metal, a large amount of plaque was found on acrylic resin, and a very low amount of plaque was found on porcelain. Dicor crowns showed less plaque accumulation and a decrease in the mean PI compared to natural teeth. There was no statistically significant difference in BI and GI between Dicor crowns and natural teeth. No statistically significant difference was observed between the plaque-retaining capacity of all-ceramic and metal-ceramic surfaces. Glazed surfaces showed less plaque accumulation than nonglazed surfaces. No significant difference was observed between Empress crowns and natural teeth with regard to the occurrence of plaque and bleeding on probing. No significant difference was observed between Dicor crowns and natural teeth with regard to the occurrence of plaque and bleeding on probing. There was less plaque accumulation on the teeth with Procera titanium crowns than on the control teeth. In-Ceram Spinell and In-Ceram Alumina showed lower plaque (PI) and bleeding scores (BI) than natural teeth. IPS-Empress showed less plaque growth (lower PI) than natural teeth. Polymer crowns with glass-fiber framework exhibited significantly higher plaque accumulation (higher PI) and Gingival Index (GI) than metal-ceramic crowns. Between polymer crowns without fiber reinforcement and metalceramic crowns there were no significant differences in PI and GI.

72 h 21 mo

Simonis et al 198999

Adamczyk and Spiechowicz 199044 Jensen et al 1990101

(377/48); Resin-veneered (32/48) 4 mo to 4 y Metal-ceramics (104/48) All-ceramics (14/48); Galvanoceramics (169/48) Cast gold (58/48); Natural teeth (465/48) Pontics (39/48) (17/10); Metal 24 h Acrylic resin; Glazed porcelain Dicor (77/77); Natural teeth 4y

Castellani et al 1996104

(disks/10); Dicor (shaded vs nonshaded) Metal-ceramics (glazed vs nonglazed)

48 h

Sjgren et al 1999102

Empress (110/29); Natural teeth

3.6 to 3.9 y

Sjgren et al 1999103

Dicor (98/46); Natural teeth

5.8 to 6.1 y

Lvgren et al 200057 Bindl and Mrmann 2002100 Gemalmaz et al 200263 Ohlmann et al 200697

Procera ceramicveneered titanium crowns (242 single crowns and 91 FPDs/260) Natural teeth In-Ceram Spinell (19/21) In-Ceram Alumina (24/21); Natural teeth IPS-Empress (37/20); Natural teeth (120/66); Polymer crowns with glass-fiber framework (40/66) Polymer crowns without glass-fiber framework (40/66); Metal-ceramics (40/66)

5y

39 11 mo 24.56 mo 12 mo

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Ta b l e 5

In vivo studies in humans on the relationship between crown material and the periodontium (continued)
Crown material/(No. of crowns/ No. of patients)
46

Author(s)

Observation period

Results/observations

Davidi et al 2007

(26/1); Self-cured acrylic resin (polished, polished and coated with bonding agent, polished and coated with light cured liquid polish)

12 h

Weishaupt et al 200798

(104/52); Metal-ceramics (52/52) Galvanoceramics (52/52)

24 mo

Significantly less biofilm was observed on the crowns coated with bonding agent, whereas no biofilm was observed on the crowns coated with liquid polish. Bonding resin or liquid polish coatings significantly reduce early biofilm formation, which in turn might influence the overall plaque accumulation on provisiona restorations. Gingival tissues adjacent to galvanoceramic crowns showed significantly less pronounced clinical and inflam matory reaction as shown by their lower PI, GI, Rec, CFFR, and IgG values, compared to metal-ceramic crowns

(PI) Plaque Index; (PBI) papillary bleeding index; (BI) Bleeding Index; (GI) Gingival Index; (Rec) recession; (CFFR) crevicular fluid flow rate; (IgG) immunoglobulin G.

Ta b l e 6

In vivo studies in animals on the relationship between crown material and the periodontium
Crown material/ (No. of crowns/No. of animals)
106

Author(s)

Observation period

Results/observations

Riley et al 1983

All-ceramic crowns (20/4) Metal-ceramic crowns (20/4)

6 mo

In the absence of oral hygiene, the plaque accumulation was greater for the metal-ceramic crowns than for the all-ceramic ones.

Several studies comparing the plaqueretaining capacity of metal-ceramics and allceramics proved contradictory. While in one study no statistically significant difference was clinically found,104 in another study HiCeram margins were reported to be porous and more plaque retentive than metal-ceramic margins.105 In the absence of meticulous oral hygiene, it was shown in an animal model that more plaque accumulates on metal-ceramic crowns than on all-ceramic ones.106 Just as important as the material is the surface roughness. Surface roughness does not in itself exert irritant effects on the periodontal tissues; rather, it influences the amount of adhesion of plaque components.1,3,5,42,107 It has been documented that glazed porcelain provides a smooth, glossy, and dense, well-wetted surface108,109 with low plaque-retaining capacity. As an alternative to glazing, polishing has also been proposed because it produces an equally smooth surface and better-controlled surface luster.109,110

Apart from porcelain, polished gold surfaces retain lower amounts of plaque than less well-finished gold surfaces.111,112

Crown contour and the periodontium

The literature review revealed six in vivo studies reporting on external crown morphology (Tables 7 and 8). All the studies gave evidence that overcontouring may produce an adverse effect on the periodontal tissues. Overcontouring the buccal and lingual surfaces of a crown113117 is associated with increased plaque accumulation at the gingival margin,116,118 increased scores for the Plaque Index and Gingival Index, as well as increased gingival crevicular fluid flow and pocket probing depths. In addition, an increased loss of clinical attachment levels might be observed, indicating the coronal migration of the periodontal attachment.117 Nonetheless, with professional oral hygiene, periodontal health may be only slightly affected by overcontoured crowns.117

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Ta b l e 7

In vivo studies in humans on the relationship between crown contour and the periodontium
Crown contour Observation period Results/observations

Author(s)

No. of crowns/No. of patients

Alteration in contour

Sackett and Gildenhuys 1976113 Ehrlich and Hochman 1980130 Parkinson 1976114

Natural teeth (42 pairs/12) Provisional splinted crowns (8/4) Cast metal (25/NR) Metal-ceramics (25/NR) Natural teeth Procera titanium crowns (7/6)

Overcontouring of axial and buccal third facings made of acrylic resin No overcontouring Overcontouring: +1 mm Undercontouring: 1 mm

4249 d 4 mo

Overcontoured teeth showed gingival inflammation and greater production of gingival sulcular fluid than natural teeth. A variation in contour in the range of 1 mm is tolerated by the gingival tissues. Overcontoured cast metal and metal-ceramic crowns exhibited greater mean plaque accumulation than natural teeth. An emergence profile of 10 degrees is more accessible to oral hygiene than emergence profiles of 20 degrees and 40 degrees. However, even a 40-degree emergence profile formed less plaque than natural teeth.

Sundh and Khler 2002115

Natural teeth
(NR) Not reported.

Overcontouring: 0.31.1 mm NR Overcontouring: 0.21.6 mm No overcontouring Emergence profile angle: 9d 10 degrees Emergence profile angle: 20 degrees Emergence profile angle: 40 degrees No overcontouring

Ta b l e 8

In vivo studies in animals on the relationship between crown contour and the periodontium
Crown contour Observation period Results/observations

Author(s)

No. of crowns/No. of patients

Alteration in contour

Perel 1971116

Natural teeth/ 6 mongrel dogs

Kohal et al 2003117

24 cast crowns made of high-noble alloy/ 4 beagle dogs Natural teeth

Overcontouring by applying cold-cured acrylic resin Undercontouring by removing tooth structure Overcontouring: 50 degrees Overcontouring: 30 degrees Normal contour No overcontouring

9 wk

5 mo

Overcontoured teeth showed gingival hyperplastic inflammatory changes. Undercontoured teeth showed no signs of inflammation. The 30-degree and 50-degree overcontour groups provided higher values for PI, GI, GCFF, PD, and CAL. For the normal contour and control group only minor changes were recorded.

(PI) Plaque Index; (GI) Gingival Index; (GCFF) gingival crevicular fluid flow; (CAL) clinical attachment level; (PD) probing depth.

Overcontouring the interproximal areas of a crown results in localized inflammation of the interdental gingival papillae,2,13,37,119 which normally protrude from the buccal and lingual sides into the interdental spaces.120 Accessibility to oral hygiene measures6,13,113,115,120 under such conditions is, of course, extremely limited. Overcontouring occurs mainly because of inadequate tooth preparation2,9,22,48 buccally, lingually, and interproximally.50 Overcontouring may also occur with overbuilding10 of the restoration because the gingival tissues near the margin were removed in trimming the dies to better finish the margin.2,37

Conversely, undercontouring may favor periodontal health,114,116 compared with overcontouring,1 because neither clinical nor microscopic alterations in the gingival area have been noted with undercontoured buccal and lingual surfaces of crowns. Indeed a slightly larger-than-normal interproximal embrasure may be desirable because it ensures sufficient space for the papilla and simultaneously facilitates effective plaque control.1,121 However, excessively open interdental contacts are responsible for food impaction or phonetic and esthetic problems.12,50,120

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DISCUSSION
The purpose of the present literature review was to critically evaluate and present up-todate data on crowns and periodontal tissues. The search process revealed 64 in vivo investigations conducted on human and animal subjects, dealing with the location of the crown margin, marginal fit, crown material, and crown contourfactors closely interrelated to one another and to periodontal health, as well. Despite the large number of identified studies and the significant new developments in materials and techniques, it can be concluded that well-established knowledge and/or perspectives, and consequently the clinical approach and orientation, remained unchanged over a long period of time. Most studies21,55,56,59,61,63,67,69,70 demonstrate clearly the advantage of the supragingival location of the margin, which enables not only the validation of accuracy of fit but also the future evaluation of marginal deterioration.91 Surprisingly, only one study in the animal model describes unfavorable histologic conditions with supragingival margins.68 However, it is not mentioned if the crowns before insertion were clinically or radiographically controlled with respect to their fit. Of particular importance is the intracrevicular placement of the crown margin27,77,79 in the anterior esthetic zone (maxillary incisors up to the first premolar).122 This can successfully mask the visible marginal transition between crown and tooth, achieving optimum esthetics.123 For the posterior region, where esthetics do not play a predominant role, a supragingival margin should be preferred to an intracrevicular margin.67,77 Nonetheless, it must be taken into consideration that, in most of the cases of intracrevicularly placed margins, proper finishing of the margin,9,48 adequate impression making,27 accurate fabrication of the provisional restoration, thorough removal of all cement remnants, or even moisture control during cementation123 are difficult to attain.8,9,24,73 Therefore, even given a highly precise fitting of the crown,60,69 an intensive oral hygiene regimen must also be executed in the case of an intracrevicular margin to control prospective gingival inflammation.4,58,60,66,74

Moreover, the available tooth structure is often compromised due to caries, insufficient preexisting restorations, fractures, cervical abrasion, or attrition.8,1012,17,18,37,48,79,85 To obtain adequate abutment height, many clinicians extend the margin below the free gingival crest. To avoid the subgingival extension and consequently a possible impingement on the biologic width, crown lengthening procedures, involving gingivectomy, osseous surgery with surgical removal of supporting alveolar bone, and forced orthodontic eruption, are recommended.1012,14,18,84,85,124,125 The marginal fit of a crown has long been a controversial topic. Apart from the theoretical requirements of cementation lines ranging between 25 and 40 m,126 which are seldom fulfilled clinically, the minimum detectable gap for a crown margin has been proposed to be 20 m,31 50 m,127 or in a range between 50 m and 100 m.40,41 Furthermore, a 5-year clinical study62 of more than 1,000 restorations indicated that a gap of 120 m or less can be clinically acceptable. According to the review results, metalceramics and all-ceramics exhibit sufficient accuracy of fit.89,90,9395 It is remarkable, however, that no in vivo investigations have been identified through the review process that give exact measurements in micrometers of the marginal fit of contemporary ceramic materials.128 In fact, two studies89,90 reported on Procera AllCeram (Nobel Biocare), and three studies9395 provided data concerning ceramic systems that appeared on the market 20 years ago but are no longer in clinical use. Many studies44,45,57,63,100104 came to the conclusion that ceramic materials offer the benefits of proven biocompatibility and reduced propensity for retaining bacterial plaque. Therefore, apart from the optical and physical properties of porcelain materials guaranteeing good esthetics and function, their low plaque-retaining capacity makes them to this day the material of choice as both veneering and core ceramics. Crown contour may clinically compensate for an undesirable soft tissue deficiency. In patients in need of prosthetic rehabilitation but with a history of advanced periodontal disease, the distance between the bone level and the approximal contact point is larger

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than 5 mm, which means that the gingival papillae do not completely fill the interdental space below the approximal contact point.54 Consequently, visible triangular spacesthe so-called black triangles117,124 emerge, compromising esthetics of the smile.129 In this case, always respecting the emergence profile, a slight extension of ceramic can be made.48,51 To avoid the appearance of an overbulked, rounded tooth,10,51 porcelain of higher chroma should be used. The proximal contact point becomes an interdental contact line while the shape of the crown remains unchanged. As a matter of fact, only a slight variation in crown contour of less than 1 mm of the original contour may be tolerated well by the periodontal apparatus.130

CONCLUSIONS
The data presented confirm results already known from the literature and reveal that nothing in essence has changed. The supragingival location of the crown margin is the most advantageous from the periodontal point of view. The intracrevicular location is indicated in the anterior zone for esthetic reasons. Metal-ceramic and all-ceramic crowns show a clinically acceptable marginal fit. Ceramic materials have the lowest plaque-retaining capacity. A normal contour of the crown contributes significantly to establishing and maintaining favorable periodontal conditions.

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13. Becker CM, Kaldahl WB. Current theories of crown contour, margin placement, and pontic design. 1981. J Prosthet Dent 2005;93:107115. 14. Amiri-Jezeh M, Rateitschak E, Weiger R, Walter C. The impact of the margin of restorations on periodontal healthA review [in German]. Schweiz Monatsschr Zahnmed 2006;116:606613. 15. Belser UC. Crown and bridgework prostheses. A survey of the literature [in German]. SSO Schweiz Monatsschr Zahnheilkd 1978;88:154173. 16. Vogt HP. Crown and bridge prosthetics. Review of the literature in 1978 [in German]. SSO Schweiz Monatsschr Zahnheilkd 1979;89:575588. 17. Ackerman MB. The full coverage restoration in relation to the gingival sulcus. Compend Contin Educ Dent 1997;18:11311138, 1140. 18. Burnett RR, Diaz R, Waldrop TC, Hallmon WW. Clinical perspectives of periodontal and restorative interactions. Compendium 1994;15:644, 646, 648655. 19. Nagy RJ, Novak MJ. Chronic periodontitis. In: Newman MG, Takei HH, Klokkevold PR, Carranza FA (eds). Carranzas Clinical Periodontology, ed 10. Philadelpia: Saunders, 2006:494498. 20. Lang NP, Kiel RA, Anderhalden K. Clinical and microbiological effects of subgingival restorations with overhanging or clinically perfect margins. J Clin Periodontol 1983;10:563578. 21. Flores-de-Jacoby L, Zafiropoulos GG, Ciancio S. Effect of crown margin location on plaque and periodontal health. Int J Periodontics Restorative Dent 1989;9:197205. 22. Gracis S, Fradeani M, Celletti R, Bracchetti G. Biological integration of aesthetic restorations: Factors influencing appearance and long-term success. Periodontol 2000 2001;27:2944. 23. Maynard JG Jr, Wilson RD. Physiologic dimensions of the periodontium significant to the restorative dentist. J Periodontol 1979;50:170174. 24. Wilson RD, Maynard G. Intracrevicular restorative dentistry. Int J Periodontics Restorative Dent 1981;1: 3449. 25. Gnay H, Robach H, Geurtsen W. Atraumatic tooth preparation respecting the biologic width [in German]. Dtsch Zahnarztl Z 2001;56:583588. 26. Gnay H, Schulze A, Robach H, Geurtsen W. Intracrevicular tooth preparation and periodontal healthA prospective clinical study [in German]. Dtsch Zahnarztl Z 2001;56:109113. 27. Nevins M, Skurow HM. The intracrevicular restorative margin, the biologic width, and the maintenance of the gingival margin [in German]. Int J Periodontics Restorative Dent 1984;4:3049. 28. Gargiulo AW, Wentz F, Orban B. Dimensions and relations of the dentogingival junction in humans. J Periodontol 1961;32:261267. 29. Le H. Reactions to marginal periodontal tissues to restorative procedures. Int Dent J 1968;18:759778.

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