THE BIOLOGIC WIDTH

INTRODUCTION
For restoration to survive long term the periodontium
must remain healthy so that teeth are maintained.

For the periodontium to remain healthy restoration
must be critically maintained so that they are in
harmony with their surrounding periodontal tissue.

To maintain and enhance the patients esthetic
appearance the tooth-tissue interface must present a
healthy natural appearance.

MARGIN PLACEMENT AND BIOLOGIC WIDTH
SUPRAGINGIVAL MARGIN EQUIGINGIVAL MARGIN SUBGINGIVAL MARGIN
Placed in non-
esthetic areas

Least impact on
periodontium
At the crest of
marginal gingiva.

More impact on
periodontium.

More plaque
retentive gingival
inflammation
Below the gingiva.

Greatest biologic
risk.

May violate the
gingival attachment
apparatus.
BIOLOGIC WIDTH
Biological width is defined as
the physiologic dimension of
the junctional epithelium &
connective tissue attachment.

The dimension of space that
the healthy gingival tissue
occupy above the alveolar bone
is now identified as the biologic
width.

This term was based on the
work of Gargiulo et al. (1961).
WHY RESTORATION EXTENDS SUBGINGIVALLY?
For adequate resistance and
retention form.
To make significant contact
and contour.
To mask the tooth-restoration
interface gingivally.
RESPONSE TO THIS INVASION
Unpredictable bone loss
Gingival inflammation
EVALUATION OF BIOLOGIC WIDTH
Clinical method

If a patient experiences
tissue discomfort when
the restoration margin
levels are being assessed
with a periodontal
probe, it is a good
indication that the
margin extends into the
attachment and that a
biologic width violation
has occurred.



Bone sounding

The biologic width can be identified by probing under
local anesthesia to the bone level (referred to as
"sounding to bone") and subtracting the sulcus depth
from the resulting measurement.

If this distance is less than 2 mm at one or more
locations, a diagnosis of biologic width violation can be
confirmed.

This measurement must be performed on teeth with
healthy gingival tissues and should be repeated on
more than one tooth to ensure accurate assessment,
and reduce individual and site variations.
Radiographic evaluation
Radiographic
interpretation can
identify interproximal
violations of biologic
width.

However, on the
mesiofacial and
distofacial line angles of
teeth, radiographs are
not diagnostic because of
tooth superimposition.


METHODS TO CORRECT BIOLOGIC
WIDTH VIOLATION
Can be corrected by

1. Surgical crown lengthening

2. Orthodontic technique
SURGICAL CROWN LENGTHENING
Indications

Subgingival caries or fracture
Inadequate clinical crown length for retention
Unequal or unesthetic gingival heights

Contraindications
Surgery would create an unesthetic outcome.
Deep caries or fracture would require excessive
bone removal on contiguous teeth.
The tooth with a poor restorative risk.





Very successful and
predictable surgical
procedure for
reconstruction of
biologic width.

Used only in situations
with hyperplasia or
pseudopocket and
presence of adequate
amount of keratinized
tissue.


Gingivectomy
Greater than 3 mm of soft tissue
between the bone and gingival
margin, with adequate attached
gingiva, allows crown lengthening by
gingivectomy.
Apically repositioned flap surgery
Indication

Crown lengthening of multiple teeth in a
quadrant or sextant of the dentition, root caries,
fractures.

Contraindication

Apical repositioned flap surgery should not be
used during surgical crown lengthening of a single
tooth in the esthetic zone.


With less than 3 mm of soft tissue between the bone and
gingival margin, or less-than-adequate attached gingiva, a flap
procedure and osseous recontouring are required for crown
lengthening.
Apically repositioned flap without osseous resection

Indication: When there is no adequate width of attached
gingiva, and there is a biologic width of more than 3 mm on
multiple teeth.

Apically repositioned flap with osseous reduction

Indication: When there is no adequate zone of attached
gingiva and the biologic width is less than 3 mm.

The alveolar bone is reduced by ostectomy and osteoplasty.
As a general rule, at least 4 mm of sound tooth structure
must be exposed, so that the soft tissue will proliferate
coronally to cover 2-3 mm of the root, thereby leaving only 1-
2 mm of supragingivally located sound tooth structure.


ORTHODONTIC TECHNIQUES
The extrusion can be performed in two ways.

1) Low orthodontic extrusion force: The tooth is erupted
slowly, bringing the alveolar bone and gingival tissue with
it.

The tooth is extruded until the bone level has been
carried coronal to the ideal level by the amount that will
need to be removed surgically to correct the attachment
violation.

The tooth is stabilized in this new position and then is
treated with surgery to correct the bone and gingival
tissue levels.


2) Rapid orthodontic extrusion : The tooth is erupted to
the desired amount over several weeks.

During this period, a supercrestal fiberotomy is performed
weekly in an effort to prevent the tissue and bone from
following the tooth.

The tooth is then stabilized for at least 12 weeks to
confirm the position of the tissue and bone, and any
coronal creep can be corrected surgically.
HEALING AFTER CROWN LENGTHENING

Restorative procedures must be delayed until new
gingival crevice develops after periodontal surgery.

In non-esthetic areas : 6 weeks healing period post
surgically prior to final restorative procedures is
recommended.

In esthetic areas: A longer healing period is
recommended to prevent recession (4 - 6 months).

The margin of the provisional restoration should not
hinder healing before the biologic width is established by
surgical procedures.



The health of the periodontal tissues is dependent on
properly designed restorations. It is preferable to give
supragingival margins in a restoration.

But subgingival margin placement is often unavoidable. If
restorative margins need to be placed near the alveolar
crest, crown-lengthening surgery or orthodontic extrusion
should be considered to provide adequate tooth structure
while simultaneously assuring the integrity of the biologic
width.

Although individual variations exist in the soft tissue
attachment around teeth, a minimum of 3 mm should exist
from the restorative margin to the alveolar bone, allowing
for 2 mm of biologic width space and 1 mm for sulcus depth.

CONCLUSION