Full crown restorations and gingival
in a controlled population - -
David L. Koth, D.D.S., M.S.*
Medical College of Georgia, School of Dentistry, Augusta,
1 he relationship between extensive dental restora-
tions and gingival health as reported in the dental
literature is somewhat discouraging in regard to the
maintenanceof a healthy periodontium. Several studies
have suggestedthat full crown restorations with sub-
gingival margins sponsor an increase in gingival
inflammation.‘, 2Subgingival margins were also shown
to have a greater degreeof inflammation than margins
located coronal to the gingival crest.3-1’Another study
suggestedthat crown margins located at the gingival
crest cause less inflammation than margins placed
supragingivally or subgingivally,12while an in-depth
investigation found inflammation to be more severeas
the crown margin approachedthe apical portion of the
intracrevicular space. This author recommendedthat
subgingival margins be placed at or just into the
gingival crevice.‘) However, a study by Richter and
Ueno14revealed no difference between subgingival and
supragingival margin placement. The crowns were
prepared and inserted by one dentist. Other studiesof
artificial crown contour concluded that overcontoured
crowns contribute to gingival inflammation.‘5-‘7A sim-
ilar study demonstrated that temporary crowns con-
structed 1 mm from the original contour did not create
gingival inflammation.18 These conflicting reports
reveal the complex relationship between extensive
restorations and gingival inflammation.
There is also a disparity between these reports and
the observation of dentists in private practice whose
patients have maintained healthy periodontal tissues
for years with full coveragerestorations. The majority
of investigations have not evaluated patients treated in
a private practice, but in a dental school or hospital
outpatient facility. The dental restorations were com-
Presented at the annual meeting of the American Academy of Crown
and Bridge Prosthodontics, Chicago, Ill.
*Professor and Director of Fixed Prosthodontics, Department of
Restorative Dentistry.
0022-3913/82/120681 + 05SCO.5O/do 1982 The C. V. Mosby Co.
inflammation
Ga.
monly prepared and inserted by students5-8~‘3~i9 or
many different dentists.3 The results of institutional
investigations may differ from those in a private
practice, which tends to maintain more stringent
patient control.
No studieshave been directed toward private prac-
tice patients where the restorations were placed by one
experienced dentist in private practice. Therefore, this
study was undertaken to compare the health of gingi-
vae surrounding full crown restorations in a rigidly
controlled private practice to the results reported in the
dental literature.
MATERIAL AND METHODS
The Periotron instrument (Harco Electronics Ltd.,
Winnipeg, Canada) was usedto qua&ate the volume
of crevicular fluid present in the gingival sulcus.
Gingival fluid has been identified as an exudate,20-3’
and the volume of crevicular fluid has been established
asan index of the severity of gingival inflammation.23-27
The Periotron has been recognized as an accurate
instrument to record the volume of crevicular fluid and
assess the severity of inflammation.‘~“‘,W-”
Patients were selectedfrom a private practice. The
patients had previously received periodontal therapy
and extensive oral hygiene instruction and were in
rigid monitoring and maintenance programs. Oral
prophylaxis, scaling, root planing, and oral hygiene
instruction were performed by a dental hygienist every
3 months. Recall appointments were alternated
between periodontists’ and general dentists’ offices.
The patients selected for evaluation of gingival
inflammation surrounding full crown restorationswere
from 39 to 68 years of age with a mean age of 49.8
years. The restorations had been in place between 1
and 9 years with a mean of 3.5 years. The interval
since surgery varied between 1 and 10 years with a
mean interval of 3.5 years.
The state of inflammation of the tissuesurrounding
teeth restored with full crowns was comparedto that of
THE JOURNAL OF PROSTHETIC DENTISTRY 681
 KOTH

Table I. Frequency distribution chart for comparison of restored and unrestored teeth
Unrestored teeth Restoredteeth
Mandibular (17) Maxillary (20) Mandibular (17) Maxillary (21)
Frequency % Frequency % Frequency % Frequency %
Molars 6 35 3 15 5 29 3 14
Bicuspids 9 53 9 45 11 65 8 38
Cuspids 2 12 5 25 1 6 5 24
Incisors 3 15 5 24

Table II. Frequency distribution chart for RESULTS

comparison of margin placement
Mandibular teeth (21) Maxillary
Frequency % Frequency
Molars 5 24
Bicuspids 13 62
Cuspids 3 14
Incisors
tissue surrounding unrestored contralateral teeth in
each patient whenever possible.Where there was not a
contralateral unrestored tooth, an unrestored tooth
adjacent to the restoration was used as the control.
More than 90% of the control teeth were unrestored
contralateral teeth. Table I showsthe frequency distri-
bution for restored atid unrestored teeth.
Crevicular fluid was collected from the mesial and
distal facial surfacesof each tooth. The readings were
pooled for each tooth, and a mean value of crevicular
fluid volume was calculated for each restored and
nonrestored tooth. The fluid collection and measure-
ments were performed by one dentist according
to the manufacturer’s directions by placing the fil-
ter paper strip at the orifice of the gingival crev-
ice. A total of 38 restorations were evaluated on 26
patients.
In addition, the margin location was recorded. To
evaluate the effect of margin placement on gingival
inflammation, 28 patients who met the samecriteria as
the previous sampleand were between 33 and 74 years
of age with a mean age of 50.5 years were sampled.
Table II is a frequency distribution chart for compari-
son of margin placement. The tissuessurrounding a
total of 46 restorations were evaluated, and the values
of crevicular fluid volume readings for eachtooth were
pooled. Mean values were calculated and compared to
eachother according to margin placementto determine
the degree of inflammation.
Table III showsthe individual and mean values of
teeth (25) the Periotron readings comparing restored to nonre-
stored teeth. The degreeof gingival inflammation was
%
the samein the tissuesurrounding restored and nonre-
3 12 stored teeth. Although the mean value of the restored
10 40 teeth was higher, statistical analysis using a paired
7 28
samplet-test showedno difference in these values.
5 20
Table IV gives the number of crowns with margins
placed subgingivally, supragingivally, and at the gingi-
val crest, and the mean values of Periotron readings.
The degree of gingival inflammation did not differ
according to margin placement. A statistical analysis
using an independent samplet-test revealed no differ-
ence among the three locations.
DISCUSSION
The degreeof inflammation observedin the gingival
tissue prior to placement of full veneer crown restora-
tions is dependent on several factors, including the
amount of trauma induced during preparation, tissue
retraction, and impressionmaking. It is alsoinfluenced
by the quality of the provisional restorations and the
duration of temporization. When thesestepshave been
satisfactorily performed, the tissue surrounding the
prepared tooth will remain healthy. When a full veneer
crown restoration is placed in a healthy environment,
the maintenanceof this health apparently dependson
marginal integrity, crown contour, oral hygiene, and
the patient’s intrinsic resistanceto disease.
The gingival tissueassumedto be healthy when the
restorations were inserted, the differences between this
investigation and others cited were (1) patient popula-
tion, (2) frequericy of patient recall, and (3) operator
variability.
Patient population
The majority of the subjects selectedfor previous
studies were dental school patients,*~5-8,13*19
with the

682 DECEMBER 1982 VOLUME 46 NUMBER 6

FULL CROWN RESTORATIONS AND GINGIVAL INFLAMMATION

Table III. Mean values of gingival crevicular Table IV. Mean crevicular fluid volumes
fluid (GCF) volume for comparison of (Periotron readings) according to margin
restored and unrestored teeth for each patient placement
___ _-- -- ._--___
GCF means Margin Mean crevicular No. of
Patient -- placement fluid volume teeth evaluated SD
No. Restored teeth Unrestored teeth
Subgingival 6.7 2 ,” 4.53
1 5.5 3.75
Gingival crest 3.9 5.12
2 5.5 1.5
Supragingival 6.5 14 5.42
3 4.75 2.25
4 10.25 4.5 Results of independent l-test showed no significant dillirenrr accord-
5 20.5 5 ing 10 marginal placement (p > .OS).
6 6 16.5
7 11 1
8 13 9.5
9 4 5.33 previous studieshas repeated recall appointments four
10 2 5.5
times yearly.
11 6 14
12 4 4
Operator variability
13 7 2.5
14 4.5 8 In many of the previously cited studies, restorations
15 1.5 4 were placed by dental students.‘-3a 5,0,8.I1 In others
16 13 6.5
various dentists placed the restorations.‘..”In only one
17 3.5 6.25
18 11 11
were all restorations placed by the samedentist.14In
19 9.25 5.5 the present study all restorations were placed by one
20 2.75 3 experienced dentist.
21 2 0.75 The present study revealed no difference in degrees
22 2 1
of inflammation in gingival tissues surrounding full
23 2.5 5
24 7 7.5
crown restorationswhen comparedto tissuessurround-
25 7 1.5 ing nonrestoredteeth in the samepatient. This finding
26 23.5 18 differs with other investigations.‘.3,‘,*, l3 !’ Disagree-
Total 26 189 153.33 ment can be explained in part by the patient population
Mean GCF 7.27 5.89
usedin the studies.The patients in the present study
SD 5.53 4.62
were highly motivated toward dental health since they
Results of paired sample ~-test showed no significant difference had undergone the rigors and expense of extensive
between the means of restored and unrestored teeth 0, > .05). dental treatment. They were also participating in a
strict recall program. These conditions reflect a biased
exception of those of one author, who reported on population with predictable results.
patients selected from the population of a Veterans In addition, the present study revealed that gingival
Administration hospital. 3 In some of the previously inflammation was not influenced by various positions
cited studies, the patients had received periodontal of gingival margins, that is, supragingival,,subgingival,
therapy in conjunction with oral hygiene instruc- or even with the gingival crest. Several studies have
tion.7-9.l9 In other studiesonly oral hygiene instruction revealed that gingival inflammation was no greater in
was provided,5sI6 while it was not specified in most tissuesurrounding margins placed at or coronal to the
studies.‘~2~5~6~I3All the patients in this study were from gingival crest.7,8,‘9Another study noted no significant
a single private practice, had undergone periodon- difference in inflammation when the margins were
tal surgery, and received detailed oral hygiene in- placed supragingivally compared with those placed
structions. subgingivally providing, however, that the subgingival
margins ended 1 mm or more coronal to the depth of
Frequency of patient recall the gingival su1~u.s.‘~ Still another study revealed less
Many investigators did not report the frequency of inflammation when crown margins were located at the
patient recall for prophylaxis and oral hygiene rein- gingival crest compared to margins located above or
forcement.‘-3~5~6~8~
I3 Others incorporated it as an inte- below.” This investigation supports the findings of
gral part of the study7a9.‘4. 19; however, none of the these investigators with regard to gingival health

683
THE JOURNAL OF PROSTHETIC DENTISTRY
 KOTH

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