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implant abutment. Histologically, it prevents esthetic demands or sites with bone removal19.
further supragingival plaque formation via a Hence, communication prior to treatments
zone of healthy connective tissue separating between periodontists and prosthodontists
the inflammatory cell infiltration and alveolar is essential to determine the treatment time-
bone crest10,11. frame, feasibility of surgery and the locations
The violation of BW has been widely of restorative margins.
discussed as a contributing factor which jeop- Most researchers believe that BW is one of
ardizes periodontal health12,13. BW invading the causes of early implant bone loss20,21. Dur-
could result from several reasons, such as ex- ing the initial phase of implant healing, peri-
tensive caries, subgingival restorations, short implant bone remodeling is from the process
clinical crown, and teeth fracture. From hu- of BW reformation to allow a stable soft tissue
man autopsies, Vacek and coworkers reported barrier22. In addition, the locations of micro-
greater length of epithelial attachments around gaps and smooth/rough-surface interfaces may
restored teeth than non-restored teeth 14. In be associated with the length of peri-implant
the group with supracrestal amalgam restora- BW23,24. Thus, one of the strategies to prevent
tions, BW violation would also lead to signifi- early implant bone resorption is control of
cant increases of gingival recession and crestal biologic width and microgap. In 2006, Laz-
bone loss12. Resulting from the breach of BW, zara and Porter introduced the concept of
histologically, attachment loss will be found to "platform-switching" for inward horizontal
reestablish the certain dentogingival junction repositioning of the implant-abutment junc-
around restorations and lead to periodontal tion25. Via connecting the implant fixture with
destruction. Clinically, the signs of BW viola- a narrow-diameter abutment, the inflammato-
tion consist of pain, gingival inflammation, lo- ry cell infiltration could be limited around the
calized gingival hyperplasia, pocket formation, implant neck with platform-switching design,
and loss of periodontal apparatus. Therefore, instead of further apical migration. Previous
further corrective procedures should be con- studies suggested that platform-switching may
sidered prior to restorative treatments if any benefit tissue preservation. On the other hand,
qualms about BW violation, including orth- limited effects of platform-switching on hard
odontic extrusion and surgical crown length- tissues have been claimed by some authors26-31.
ening procedures. The clinical significances of effects on marginal
Surgical crown lengthening could be per- bone preservation may be questioned. In con-
formed via multiple techniques: gingivectomy, clusion, the available data remained contro-
apically positioned flap surgery (APF), APF versial and further longitudinal studies are still
with osseous reduction. From periodontal needed.
point of views, several parameters should be
taken into account for the feasibility of this
surgery: esthetics, possible exposure of furca- Proximal relationship
tion involvement, remaining bony support Embrasure types, referring both horizontal
and crown/ root ratio for the future results. and vertical dimensions of the interproximal
In spite of individual and sites variations15, a spaces, show impacts on the presence of inter-
minimum of 3mm distance from bone to the proximal papilla. Loss of interproximal papilla
restorative margin has been suggested by most results in impaired esthetics and promotion
researches13,16. The ferrule effect for the future of food impaction, aggravating periodontal
prosthetic design should also be a key factor destruction. As for the distance from contact
in determination of the surgical plan17,18. Post- point to the alveolar crest, the maximum of the
operatively, final prostheses should only be distance should not exceed more than 5mm to
delivered once the tissue maturation was com- preserve the interdental papillae in natural den-
pleted. A minimum of 6-8 weeks of healing tition32. This concept has also been confirmed
period is highly recommended following surgi- by a retrospective study examining the vertical
cal crown lengthening that without bone re- dimension between single implant restora-
section. From a total of 85 teeth of 25 patients, tions and a natural tooth33. The demands for
Bragger and coworkers found that 12% of teeth implant-support prosthesis are more strict: a
sites showed further apically marginal dis- minimum of 3mm of inter-implant distance is
placement between 6 weeks to 6 months post- suggested to maintain the alveolar crestal level,
operatively16. As a result, 6 months of waiting preventing the possible papillary loss; whereas
period should be taken in those sites with high papillary loss would be expected if the verti-
cal dimensions between two implants is more ating 100 patients, Jeffcoat and Howell classi-
than 3mm34,35. fied overhang into 3 sizes: small (<20% of the
Contact types between prostheses may interproximal space), medium (20-50%) and
also play a role on periodontal health. The rela- large (>50%). A significant marginal bone loss
tionship between open contacts and periodon- affiliated to the restoration occupied more than
tal destruction has been a controversial issue 20% of interdental space46. Vice versa, removal
since last century. To verify the impacts of of overhang may also benefit the reduction of
open contacts on periodontium, Jenberg and pocket depth and clinical attachment gain47.
colleagues conducted a cross-sectional study To sum up, restorative overhang should be
enrolling 104 patients with unilateral open prevented by the proper uses of matrix bands
contacts. In addition to greater prevalence of and wedges. Meanwhile, inadequate crown re-
food impaction, the sites with open contacts duction for the restorative material should be
presented greater pocket depth and clinical avoided to prohibit the overcontoured crown.
attachment loss although there was no signifi-
cant difference for gingival index, bleeding and The location of restorative margins
calculus index between contact types36. More- Restorative margin locations should be
over, another cross-sectional study reported established based on several factors, including
an increase of bone loss (2.4%) in the patients extension of caries, retention/resistance forms,
with initiate periodontitis37. However, another and esthetics. Using free gingival margin as
classic study failed to approve the trend from a the references, the supra- and subgingival res-
total of 1040 contacts. On the other hand, the torations have their own pros and cons. With
authors suggested the increasing pocket depth respect to periodontal health, the supragingival
may be in relation to the presence of food im- restoration is the most favorable design since it
paction38. In spite of an indirect relationship is easy to be cleaned48. In spite of better esthet-
between open contact and periodontal inflam- ics, subgingival restorations were associated
mation, it could be speculated from these stud- with greater periodontal inflammation in the
ies that food impaction contributes to increas- sites with keratinized gingiva less than 2mm49.
ing pocket depth and clinical attachment level. In addition to tissue biotype, subgingival
Thus, clinicians should avoid to place open restorative margins may be harmful to peri-
contacts between fixed prostheses. Meanwhile, odontium/ peri-implant tissues because of the
through proximal cleaning should be addressed following reasons. First, the margin has higher
to patients. risk of BW invasion, enhancing further peri-
odontal destruction. From 59 patients, New-
Restoration contours comb investigated a total of 75 anterior veneer
Adequate crown contours could provide crowns with subgingival margins. A strong pos-
protection of gingival margins, allow cleans- itive correlation was found between gingival
ing action of the musculature and facilitate the inflammation and the subgingival extension of
access for oral hygiene39. Indeed, overcontour restorative margins50. The limited access is an-
may have negative influence on periodontium other possible cause when restorative margins
since it increases plaque retention40,41. Utilizing are placed subgingivally. In particular amalgam
acrylic facings as standard overcontour, Sackett or composite resin fillings, it is difficult for
and Gildenhuys compared tissue changes at operative dentists to polish restorations and
42 pairs of experimental and control sites (ad- thereby produce rough surfaces underneath
jacent teeth) over a period of 42-49 days. 59% gingiva. Rough surfaces are more prone to ac-
of mandibular test sites and 70% of maxillary cumulate dental plaque and, therefore, induce
test sites showed significant gingival inflamma- periodontal inflammation 51. Likewise, over-
tion in relation to overcontour. Besides, more hang and improper restorative margins could
than 50% of these sites had increasing amount be ascribed to the progression of periodontal
of gingival sulcular fluid compared with their destruction due to the inclination of plaque
controls42. accumulation43. Even though subgingival ce-
Restorative overhang is also considered as mentation margin is a common procedure on
a contributing factor of periodontal diseases. the implant in esthetic zone, moreover, it is
As a prevalent type of restorative defects43, fill- difficult to discover the excess cement residu-
ing excess may aggregate the plaque accumula- als around subgingivally placed implants. In-
tion which potentiates gingival inflammation vestigating the amounts of undetected cement
and worsen the periodontal status44,45. Evalu- following cleaning, Linkevicius and coworkers
ment methods, such as mechanical, chemo- and higher prevalence of peri-implant inflam-
mechanical and surgical are available. Ruel and mation93. Moreover, modifications on implant
coworkers reported that gingival displacement abutment and cementation techniques were
methods may cause 0.1-0.2 mm gingival re- also introduced to limit the amount of cement
cession and the destruction of the junctional extending into the gingival sulcus of implant-
epithelium that took 8 days to heal81. Chemical retained crowns 94,95 . Fortunately, most of
agents as well as the mechanical force of retrac- the cement-associated peri-implant diseases
tion cords could trigger temporary gingival could be solved following complete removal
recession and gingival inflammation82,83. It has of residual cement92. Recently, the use of zinc
been shown that the different time intervals of oxide-eugenol cement is advocated since the
the chemical retraction agent placement could subgingival residuals could be dissolved in the
cause different degree of tissue inflammation sulcular fluid93. Further studies are still needed
changes in the beginning84. Hence, the proper to prevent the peri-implant inflammation in-
manipulation different gingival retraction tech- duced by residual excessive cement.
niques such as materials and time-control are
the key factors to avoid permanent tissue dam- Conclusion
age while impression-taking process is made. The relationship between prosthodontics
Recently, cordless techniques have been and periodontics is intimate and inseparable.
introduced as an alternative to displacement Robust supporting periodontal/peri-implant
cord methods because of several advantages, tissues provide solid foundations for predict-
such as time-saving, ease of application, less able prosthetic therapy. In addition, regaining
pressure generation and enhanced patient stable periodontal conditions should rely on
comfort while being minimally invasive85,86. establishment of proper contact types, occlusal
Acar and colleagues evaluated the clinical per- scheme and quality prosthesis. Frequent and
formance and impression quality on the cord- efficient communications are essential between
less and conventional displacement systems. periodontists and prosthodontists through the
The results demonstrated that all methods can entire treatment procedures, including plan,
give the comparable and clinically acceptable treatment procedures and maintenance, since
impression qualities except for the nonimpreg- both specialty share a common goal: to create
nated cord group87. Furthermore, a random- pleasing esthetic with a harmonious stomato-
ized clinical trial was conducted to assess the gnathic system.
clinical and immunological factors related to
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