Received: 1 September 2016 Revised: 1 September 2017 Accepted: 9 September 2017

DOI: 10.1002/JPER.16-0569

2017 WORLD WORK SHOP

Dental prostheses and tooth-related factors

Carlo Ercoli1 Jack G. Caton2
1 Departments of Periodontics and
Abstract
Prosthodontics, Eastman Institute for Oral
Health, University of Rochester, Rochester, Objectives: This narrative review summarizes the current evidence about the role that
NY, USA the fabrication and presence of dental prostheses and tooth-related factors have on the
2 Department of Periodontics, Eastman
initiation and progression of gingivitis and periodontitis.
Institute for Oral Health, University of
Rochester Findings: Placement of restoration margins within the junctional epithelium and
Correspondence supracrestal connective tissue attachment can be associated with gingival inflamma-
Dr. Carlo Ercoli, Departments of Periodontics
tion and, potentially, recession. The presence of fixed prostheses finish lines within the
and Prosthodontics, Eastman Institute for Oral
Health, Suite 257, 625 Elmwood Avenue, gingival sulcus or the wearing of partial, removable dental prostheses does not cause
Rochester, NY 14620. gingivitis if patients are compliant with self-performed plaque control and periodic
Email: [email protected]
maintenance. However, hypersensitivity reactions to the prosthesis dental material
The proceedings of the workshop were
jointly and simultaneously published in the
can be present. Procedures adopted for the fabrication of dental restorations and fixed
Journal of Periodontology and Journal of prostheses have the potential to cause traumatic loss of periodontal supporting tissues.
Clinical Periodontology. Tooth anatomic factors, root abnormalities, and fractures can act as plaque-retentive
factors and increase the likelihood of gingivitis and periodontitis.
Conclusions: Tooth anatomic factors, such as root abnormalities and fractures, and
tooth relationships in the dental arch and with the opposing dentition can enhance
plaque retention. Restoration margins located within the gingival sulcus do not cause
gingivitis if patients are compliant with self-performed plaque control and periodic
maintenance. Tooth-supported and/or tooth-retained restorations and their design,
fabrication, delivery, and materials have often been associated with plaque reten-
tion and loss of attachment. Hypersensitivity reactions can occur to dental materials.
Restoration margins placed within the junctional epithelium and supracrestal connec-
tive tissue attachment can be associated with inflammation and, potentially, recession.
However, the evidence in several of the reviewed areas, especially related to the bio-
logic mechanisms by which these factors affect the periodontium, is not conclusive.
This highlights the need for additional well-controlled animal studies to elucidate bio-
logic mechanisms, as well as longitudinal prospective human trials. Adequate peri-
odontal assessment and treatment, appropriate instructions, and motivation in self-
performed plaque control and compliance to maintenance protocols appear to be the
most important factors to limit or avoid potential negative effects on the periodontium
caused by fixed and removable prostheses.

KEYWORDS
anatomy, classification, dental prostheses, dental restorations, gingivitis, periodontitis, tooth

© 2018 American Academy of Periodontology and European Federation of Periodontology

J Periodontol. 2018;89(Suppl 1):S223–S236. wileyonlinelibrary.com/journal/jper S223

S224 ERCOLI AND CATON

The anatomy, position, and relationships of teeth within the dimension.9 Biologic width dimensions (JE and SCTA) can
dental arches are among the factors that have been associated1 only be assessed by histology.3,4,11 Other methods, such as
with plaque retention, gingivitis, and periodontitis. Factors transgingival probing10,12–14 and parallel profile radiogra-
related to the presence, design, fabrication, delivery, and phy, can be used to clinically measure the dimensions of the
materials of tooth-supported prostheses have been suggested dentogingival unit, but are not appropriate to measure the
to influence the periodontium, generally related to localized true biologic width.6,15 Buccal crown margins placed within
increases in plaque accumulation and, less often, to traumatic the junctional epithelium and supracrestal connective tissue
and allergic reactions to dental materials. This article reviews attachment have been associated with recession, and histo-
the role of tooth-related factors and dental prostheses on the logic evaluation of these sites demonstrated crestal bone loss
initiation and progression of gingivitis and periodontitis. and supracrestal connective tissue remodeling within 0 to
8 weeks.16 However, this limited case series was not designed
to correlate the observed histologic changes to plaque indices
M AT E R I A L S A N D M E T H O D S or other mechanisms that could document, in humans, the
biologic rationale for the observed changes. Moreover, in a
For this narrative review, PubMed database was searched for
prospective clinical trial, comparing crowns with interproxi-
the time period from 1947 up to April 2017, with the strat-
mal margins placed within varying distances from the alve-
egy found on Table 1. The following filters were applied
olar bone crest (groups: I = < 1 mm between crown margin
to the search results: clinical trial, review, guideline, ran-
and alveolar crest, II = 1 to 2 mm, and III = > 2 mm) it was
domized controlled trial, meta-analysis, systematic reviews,
observed that, while the presence of supragingival plaque was
humans, and English. The articles obtained, including those
not different among groups, papillary bleeding index (PBI)
referenced in a previous article,1 were input into a reference
was greater in group 1, which was associated with increased
manager software.∗ One reviewer (CE) screened titles and
probing depths (PD) and a clear encroachment of the crown
abstracts for potential inclusion and discarded duplicates. If
margins within the supracrestal tissue attachment.17 Given
title and/or abstract did not provide sufficient information
the limited available evidence in humans, it is not possible to
regarding the article content, the article was obtained for
determine if the negative effects on the periodontium associ-
review. The selected articles were then obtained in full text
ated with restoration margins located within the supracrestal
and saved as .pdf files in the reference manager database. One
tissue attachment is caused by bacterial plaque, trauma, or a
reviewer (CE) performed all text reading of the selected pub-
combination of these factors.
lications. When titles of referenced articles, not included in
the electronic search, were identified as potentially related
to the area of interest of this review, these articles’ abstracts Fixed dental restorations and prostheses
were obtained, reviewed for potential inclusion, included in
For class II restorations, gingival inflammation is signifi-
the database, and their full text reviewed.
cantly greater around subgingival margins compared with
supragingival margins,18 even when supragingival plaque lev-
RESULTS els are not significantly different from prerestoration levels.19
Furthermore, PD around amalgam restorations with subgin-
Biologic width (BW) gival margins were found to be greater than around con-
tralateral unrestored teeth.20 Direct restorations with over-
BW has been defined as the cumulative apical–coronal dimen-
hangs greater than 0.2 mm are associated with crestal
sions of the junctional epithelium (JE) and supracrestal
bone loss.21 Unfortunately, a large prevalence of over-
connective tissue attachment (SCTA).2 In a cadaver study,
hanging amalgam restorations were found in several pop-
variable supracrestal tissue dimensions (i.e., histologic gingi-
ulations associated with increases in bleeding on probing
val sulcus [GS], JE, and SCTA) were recorded, with the SCTA
(BOP) and PD which exceeded the values found at sites
exhibiting the most constant average dimension.3 While JE
with well-fitting restorations and unrestored teeth.22 The
and SCTA exhibited average dimensions within 0.5 to 1 mm
correlation between overhanging margins and PD, gingi-
when examined on different tooth surfaces,4,5 this study3 and
val inflammation,23,24 and interproximal bone loss25–27 was
others6,7 showed that dimensions of JE and SCTA can vary
greater for larger overhangs.28 The removal of the over-
considerably,8 regardless of the association with other factors
hangs during scaling and root planing causes a resolu-
such as tooth type,9 surface,4,9 biotype,5 loss of attachment,3
tion of the gingival inflammation29 and a decrease in PD
presence of restorations,4 and crown elongation,10 so that
due to gingival recession (GR)30 similar to the resolution
it is impossible to clearly define a “fixed” biologic width
of gingivitis.31 From a microbiologic standpoint and sim-
ilar to indirect restorations,32 the elimination of amalgam
∗ Thomson Reuters, New York, NY. overhangs during periodontal therapy caused a decrease of
ERCOLI AND CATON S225

TABLE 1 Electronic search strategy used for the study

Topic Search strategy Search strategy
Biologic width (“biology“[MeSH Terms] OR ”biology“[All AND (Periodontitis OR Periodontal Diseases OR
Fields] OR ”biologic"[All Fields]) AND Gingivitis OR Gingival Diseases) NOT (“case
width[All Fields] reports”[Publication Type] OR
“comment”[Publication Type] OR
“editorial”[Publication Type] OR
“interview”[Publication Type] OR
“letter”[Publication Type] OR
“news”[Publication Type] OR “newspaper
article”[Publication Type])
Fixed dental restorations (“Crowns”[Mesh:NoExp] OR “Dental Prosthesis AND (Periodontitis OR Periodontal Diseases OR
and prostheses Design”[Mesh:NoExp] OR “Dental Gingivitis OR Gingival Diseases) NOT (“case
Restoration Failure”[Mesh] OR “Dental reports”[Publication Type] OR
Restoration, Permanent” [Mesh:NoExp] OR “comment”[Publication Type] OR
“Dental Veneers”[Mesh]) “editorial”[Publication Type] OR
“interview”[Publication Type] OR
“letter”[Publication Type] OR
“news”[Publication Type] OR “newspaper
article”[Publication Type])
Dental materials (“dental materials”[Pharmacological Action] OR AND (Periodontitis OR Periodontal Diseases OR
“dental materials”[MeSH Terms] OR “dental Gingivitis OR Gingival Diseases) NOT (“case
materials”[All Fields]) NOT (“dental reports”[Publication Type] OR
implants”[MeSH Terms] OR “dental “comment”[Publication Type] OR
implants”[All Fields] OR “dental implant”[All “editorial”[Publication Type] OR
Fields] OR “dental prosthesis, “interview”[Publication Type] OR
implant-supported”[MeSH Terms] OR “letter”[Publication Type] OR
“implant-supported dental prosthesis”[All “news”[Publication Type] OR “newspaper
Fields] OR “dental prosthesis, implant article”[Publication Type])
supported”[All Fields])
Removable dental (“Dentures”[MeSH] OR “Dental AND (Periodontitis OR Periodontal Diseases OR
prostheses Clasps”[MeSH]) Gingivitis OR Gingival Diseases) NOT (“case
reports”[Publication Type] OR
“comment”[Publication Type] OR
“editorial”[Publication Type] OR
“interview”[Publication Type] OR
“letter”[Publication Type] OR
“news”[Publication Type] OR “newspaper
article”[Publication Type])
Enamel pearls Enamel pearl [All Field] AND (Periodontitis OR Periodontal Diseases OR
Gingivitis OR Gingival Diseases) NOT (“case
reports”[Publication Type] OR
“comment”[Publication Type] OR
“editorial”[Publication Type] OR
“interview”[Publication Type] OR
“letter”[Publication Type] OR
“news”[Publication Type] OR “newspaper
article”[Publication Type])
Cervical enamel projections (“neck”[MeSH Terms] OR “neck”[All Fields] AND (Periodontitis OR Periodontal Diseases OR
OR “cervical”[All Fields]) AND (“dental Gingivitis OR Gingival Diseases) NOT (“case
enamel”[MeSH Terms] OR (“dental”[All reports”[Publication Type] OR
Fields] AND “enamel”[All Fields]) OR “comment”[Publication Type] OR
“dental enamel”[All Fields] OR “enamel”[All “editorial”[Publication Type] OR
Fields]) AND (“projection”[MeSH Terms] OR “interview”[Publication Type] OR
“projection”[All Fields] OR “projections”[All “letter”[Publication Type] OR
Fields] OR “forecasting”[MeSH Terms] OR “news”[Publication Type] OR “newspaper
“forecasting”[All Fields]) article”[Publication Type])
(Continues)
S226 ERCOLI AND CATON

TABLE 1 (Continued)
Topic Search strategy Search strategy
Developmental grooves grooves[All Fields] AND (Periodontitis OR Periodontal Diseases OR
Gingivitis OR Gingival Diseases) NOT (“case
reports”[Publication Type] OR
“comment”[Publication Type] OR
“editorial”[Publication Type] OR
“interview”[Publication Type] OR
“letter”[Publication Type] OR
“news”[Publication Type] OR “newspaper
article”[Publication Type])
Tooth and root fractures “tooth fractures”[MeSH Terms] OR (“tooth”[All AND (Periodontitis OR Periodontal Diseases OR
Fields] AND “fractures”[All Fields]) OR Gingivitis OR Gingival Diseases) NOT (“case
“tooth fractures”[All Fields] reports”[Publication Type] OR
“comment”[Publication Type] OR
“editorial”[Publication Type] OR
“interview”[Publication Type] OR
“letter”[Publication Type] OR
“news”[Publication Type] OR “newspaper
article”[Publication Type])
Root resorption “Tooth Root/pathology”[MAJR] AND Root AND (Periodontitis OR Periodontal Diseases OR
Resorption/pathology Gingivitis OR Gingival Diseases) NOT (“case
reports”[Publication Type] OR
“comment”[Publication Type] OR
“editorial”[Publication Type] OR
“interview”[Publication Type] OR
“letter”[Publication Type] OR
“news”[Publication Type] OR “newspaper
article”[Publication Type])
Tooth position (“malocclusion”[MeSH Terms] OR AND (Periodontitis OR Periodontal Diseases OR
“malocclusion”[All Fields]) AND Gingivitis OR Gingival Diseases) NOT (“case
(“tooth”[MeSH Terms] OR “tooth”[All reports”[Publication Type] OR
Fields]) AND position[All Fields]) “comment”[Publication Type] OR
“editorial”[Publication Type] OR
“interview”[Publication Type] OR
“letter”[Publication Type] OR
“news”[Publication Type] OR “newspaper
article”[Publication Type])
Root proximity (“tooth root”[MeSH Terms] OR (“tooth”[All AND (Periodontitis OR Periodontal Diseases OR
Fields] AND “root”[All Fields]) OR “tooth Gingivitis OR Gingival Diseases) NOT (“case
root”[All Fields]) AND proximity[All Fields] reports”[Publication Type] OR
“comment”[Publication Type] OR
“editorial”[Publication Type] OR
“interview”[Publication Type] OR
“letter”[Publication Type] OR
“news”[Publication Type] OR “newspaper
article”[Publication Type])
Open contacts “Diastema”[MAJR] OR Open contacts AND (Periodontitis OR Periodontal Diseases OR
Gingivitis OR Gingival Diseases) NOT (“case
reports”[Publication Type] OR
“comment”[Publication Type] OR
“editorial”[Publication Type] OR
“interview”[Publication Type] OR
“letter”[Publication Type] OR
“news”[Publication Type] OR “newspaper
article”[Publication Type])
ERCOLI AND CATON S227

Aggregatibacter actinomycetemcomitans and increase of The available literature supports the conclusion that a direct
Streptococcus mutans.33 restoration with subgingival margins can be associated with
For indirect restorations, overhangs between 0.5 and 1 mm localized gingivitis and increases in PD. A direct or indirect
are associated with an increase in gingival inflammation29 restoration with overhanging margins can be associated with
and a more apical crestal bone level, while overhangs of less localized gingivitis, increase in PD, and interproximal bone
than 0.2 mm are not.32,34 Other studies showed that subgingi- loss, especially for larger overhangs. These changes are likely
val margins were associated with increased signs of gingival caused by the overhang acting as a plaque-retentive factor
inflammation35–42 and, at times, increases in PD.43–47 and causing a qualitative shift toward a subgingival cultivable
A clear association is found between periodontal health microflora more characteristic of periodontitis.
and patient compliance with self-performed plaque control From cross-sectional studies, it can be concluded, espe-
and periodontal maintenance after prosthodontic therapy with cially when self-performed plaque control and periodontal
fixed dental prostheses.47–49 In a prospective clinical trial maintenance measures are not mentioned, that an indirect
where patients were instructed and motivated on adequate restoration subgingival margin is associated with gingivi-
measures of self-performed plaque control, plaque levels tis. However, in longitudinal studies, where self-performed
and gingival inflammation were not significantly different plaque control and periodontal maintenance measures are
between teeth that received crowns and controls.50 Similarly, described and patient compliance is achieved, subgingival
in a cohort of patients who were seen for periodontal mainte- prosthesis margins do not appear to act as plaque-retentive
nance every 1 to 6 months, no difference in plaque and gin- factors that cause gingivitis. Based on the available evidence,
gival indices were found between crowned and non-crowned it appears that plaque control by the patient and compliance
teeth regardless of the position of the crown margins,51 a find- with periodontal maintenance is of paramount importance
ing also reported by other studies.52–54 to maintain the health of the periodontium when subgingi-
While porcelain veneers were not associated with changes val margins are adopted in the prosthetic design. Permanent
in plaque levels and gingival inflammation for as long as 7 changes to the periodontium, such as gingival recession, could
years after delivery,55–59 gingival recession can be a common occur when subgingival margins are adopted for prosthesis
consequence of other fixed prosthodontic therapies.60–62 design; however, they appear to be mostly related to trauma
Prosthodontic procedures required for the fabrication of fixed to the periodontium exerted by the procedures, instruments,
prostheses can negatively affect the periodontium. Procedures and materials required to place and record the margins in a
and/or materials such as crown preparation, gingival dis- subgingival location, rather than the nominal position of the
placement during impression,63,64 impressions, provisional margin.
prostheses,65 and luting agents66 may be contributing factors
for the development of gingivitis, gingival recession, and
periodontitis. The placement of provisional crowns causes an Dental materials
increase in plaque retention regardless of the resin material Different dental materials, their surface characteristics, and
used for the prosthesis.65 In another study67 where all crown location in relation to the gingiva have been associated with
margins were designed in a subgingival location during variable periodontal responses.70–73 However, this response
crown preparation, only 82% of them were still located could be potentially affected, not only by the type of material,
subgingivally at crown delivery. This suggests that the actual but also by the surface characteristics, such as surface-free
crown margin location was less of a contributing etiologic energy and roughness, among others, that act as confound-
factor affecting the occurrence and magnitude of recession ing variables. For the latter, a minimum roughness threshold
than the prosthetic procedures required to design and record (Ra < 0.2 𝜇m) has been suggested, with increases in plaque
the crown margin position. In a short-term randomized, retention expected above this threshold, but no reduction
multicenter, controlled trial, different methods of gingival for lower Ra values.74 Similarly, when different alloys were
displacement produced different magnitudes and frequency used to fabricate onlays75 and other types of prostheses,50
distributions of gingival recession, and most of the recession they showed similar levels of plaque and gingival inflamma-
occurred before final crown delivery.68 The anatomy of the tion. Roughness changes, resulting from polishing, scaling, or
periodontium of teeth receiving crowns should be evaluated patient-related factors are material-specific and data on resul-
to minimize the likelihood of gingival recession because the tant plaque accumulation as a function of the change in Ra
presence of an initial shallow PD and narrow band of gingiva is scarce.76 Teeth restored with a variety of dental materials,
negatively influenced the level of periodontal attachment when compared with enamel, had similar plaque levels, gingi-
after crown delivery.69 These studies point out the critical val inflammation, interleukin (IL)-1𝛼, IL-1𝛽, and IL-1ra lev-
importance of including a complete periodontal assessment els, but most important, in a 10-day gingivitis experiment,
prior to prosthodontic manipulations when studying the showed no difference for the same parameters.49,77 Similar
response of the periodontium to indirect restorations.60 clinical gingival reactions in periodontially healthy patients
S228 ERCOLI AND CATON

were also seen when comparing class V restorations of com- maintenance procedures are performed, RDPs do not cause
posite resin or calcium aluminate/silicate material.78–82 These greater plaque accumulation, periodontal loss of attachment,
findings appear also valid when different restorative materials or increased mobility.113–118 On the other hand, if patients
are used to rebuild part of the tooth anatomy during mucogin- do not adequately perform plaque control and attend peri-
gival surgical procedures.83–88 Therefore, available evidence odic maintenance appointments, removable dental prostheses,
demonstrates that different dental materials act similarly to including overdentures,118–127 could act as plaque-retentive
enamel as plaque-retentive factors to initiate gingivitis. factors and indirectly cause gingivitis and periodontitis. In
Metal ions and metal particles can also be released from addition, especially distal extension RDPs, when not prop-
dental alloys and can be found locally within plaque, the peri- erly maintained and relined, have the potential to apply greater
odontum, and in several organs and tissues. While several of forces and torque to the abutment teeth, causing a traumatic
these ions (nickel [Ni], palladium [Pd], copper [Cu], titanium increase in mobility.107
[Ti] among others) have been shown, via in vitro studies, to
potentially affect cell count, viability, function, and the release
of inflammatory mediators, their influence on gingivitis and Tooth anatomy and position
periodontitis is largely unclear.89 Metal ions and particles, Cervical enamel projections (CEP) and enamel
especially Ni and Pd, have also been associated with hyper- pearls (EP)
sensitivity reactions which might clinically appear as gingivi-
Tooth anatomic factors, such as CEP and EP, have been asso-
tis, localized in the area of gingival contact with the dental
ciated with furcation invasion, increased PD, and loss of clin-
material that does not respond to adequate measures of plaque
ical attachment.128,129 The extent of CEP extension toward
control, and contact stomatitis, often with a lichenoid-type
the furcation area can be classified into three classes, with
appearance.90–93 For patients who have shown allergic reac-
grade I described as “distinct change in cemento-enamel junc-
tions to dental alloys, very limited evidence suggests that the
tion (CEJ) attitude with enamel projecting toward the fur-
replacement of these prostheses with zirconia-based protheses
cation;” grade II, “the CEP approaching the furcation, but
was associated with a resolution of the allergic reaction.94
not actually making contact with it;” and grade III, “CEP
extending into the furcation proper.”130 Prevalence of CEP
Removable dental prostheses for all extracted teeth varies, depending on the report, from
25% to 35.5% and 8% to 17% in mandibular and maxillary
In cross-sectional studies, where no information is present molars, respectively.130–135 When controlling for the pres-
on the level of self-performed plaque control and periodon- ence of furcation invasion (FI), CEP were found in 82.5% and
tal maintenance or where clearly heterogeneous baseline peri- 17.5% of molars with and without FI, respectively,136 with
odontal conditions are present,95 partial removable dental prevalence for CEP associated with FI ranging from 63.2% to
prostheses (RDPs) have been associated with increased preva- 90%130,137,138 and only one study finding no greater signifi-
lence of caries, gingivitis, and periodontitis.96–100 A study cant association between CEP compared with FI.134 While the
has shown no changes in PD, but increases in plaque lev- prevalence of grade III CEP varies in the literature from 4.3%
els and gingival inflammation in patients wearing RDPs.101 to 6.3%, these types of CEP might be more detrimental to the
Other authors have reported that when the patient was ade- furcation periodontal tissues than grade I and II CEP.136,139
quately instructed on self-performed plaque control and seen Enamel pearls are generally spheroidal in shape, occur
at frequent periodic maintenance visits, there was a decrease in roughly 1% to 5.7% of all molar teeth,140–142 vary in
in plaque levels and gingival inflammation.102 A recent study dimension from 0.3 to 2 mm, and occur most often iso-
showed no difference in PD, BOP, gingival recession, micro- lated on a tooth, potentially localized in the furcation area of
bial count, and species between teeth that supported RDPs molars.133,142–144 EP can act as a plaque-retentive factor when
and teeth that did not.103 Longitudinal studies of distal exten- periodontitis progresses to the point that they become part of
sion RDPs indicate that a favorable periodontal prognosis may the subgingival microbial ecosystem.
be expected provided the following conditions are satisfied:
1) periodontal disease, if present, is treated and an adequate
preprosthetic plaque control regimen established; 2) peri- Developmental grooves
odontal health and oral hygiene are maintained through self- The most frequent developmental groove appears to be the
performed plaque control measures104 and periodic mainte- palatal groove, most often located in the maxillary lateral
nance appointments,105 and 3) patient's motivation is rein- incisor with a prevalence of 1% to 8.5% at the subject level
forced to enhance compliance to self-performed plaque con- and 2.2% at the tooth level.145 Forty-three percent of grooves
trol and periodontal maintenance.106–112 Therefore, we can do not extend more than 5 mm apical to the CEJ and only
conclude that, if plaque control is established, the prostheses 10% are present 10 mm or more apical the CEJ.146 The
are correctly designed and regularly checked, and indicated mechanism suggested for developmental grooves to initiate
ERCOLI AND CATON S229

periodontal disease is related to plaque retention that causes as internal or external, cervical or apical.168,169 When root
localized gingivitis and periodontitis.133,145,147–150 Grooves resorption is located within the cervical third of the root, it can
are also present on other teeth151,152 and mostly in the inter- easily communicate with the subgingival microbial ecosys-
proximal areas, with few of these grooves extending to the tem. Plaque retention at such sites can cause gingivitis and
tooth apex.153 periodontitis. Cemental tears are localized areas of cemen-
tum detachment from the underlying dentin and can poten-
Tooth and root fractures tially lead to localized periodontal breakdown, although the
Tooth fractures biologic mechanism involved has not been elucidated.170,171
If tooth fractures occur coronal to the gingival margin and
do not extend to parts of the tooth surrounded by periodontal
Tooth position
tissues, they do not initiate gingivitis or periodontitis, unless Cross-bite,172,173 misalignment/rotation of a tooth,174 and
the surface characteristics of the fracture area predispose to crowding of the maxillary175 and mandibular anterior
greater plaque retention. sextant176 have been shown to be associated with increased
plaque retention176 and gingivitis, greater PD, and bone177
and clinical attachment loss.178 However, other studies assess-
Root fractures ing the effect of crowding on the periodontium did not find an
Root fractures can be classified based on the trajectory of the association with plaque retention and gingivitis.179–181 Tooth
fracture (vertical, transverse, or oblique), their extent (com- position and periodontal biotype and their interaction182 can
plete or incomplete), location (apical, midroot, or cervical also be factors that influence the likelihood of mucogingival
regions) and on the healing/repair mode.154 While fractures deformities, as it has been shown that a thin periodontal bio-
located within the midroot and apical regions were shown in type has a significantly thinner labial bone plate, narrower gin-
a 10-year study to have a very favorable prognosis (78% and gival width, and greater apico-coronal distance between the
89% tooth survival, respectively), fractures located within the CEJ and the alveolar crest.183 In subjects who exhibit trauma
cervical one-third of the root had a significantly worse prog- related to tooth brushing184–187 or tooth malposition within
nosis for tooth retention (33%).154–156 Since fractures located the alveolar process,187,188 a greater risk for gingival recession
within the cervical third of a root have a more likely possi- can be present. Tooth anatomy, and specifically the shape of
bility of being colonized by subgingival plaque, they can act the tooth and their approximation, have been shown to affect
as plaque-retentive factors and indirectly cause gingivitis and the height of the interproximal papilla.189
periodontitis. In addition, they can directly traumatize the sur-
rounding periodontium due to mobility of the fractured tooth Root proximity
surfaces. Limited short-term evidence suggests that fractures Root proximity (RP) in the maxilla is most prevalent between
located within the anatomic crown or slightly into the cervical the first and second molar and between the central and lat-
third of the root can be successfully repaired with adhesive eral incisors; in the mandible, it is generally seen between
techniques and that periodontal parameters, such as plaque the central and lateral incisors.190,191 However, RP has been
index, gingival index (GI), PD, and clinical attachment level, defined and measured in different ways in the literature,
are not different than control teeth.157–159 Vertical root frac- therefore producing inconsistent conclusions on its effect
tures are defined as longitudinal fractures that might begin on the periodontum.192,193 More recently, however, a lon-
on the internal canal wall and extend outward to the external gitudinal 10-year clinical study concluded that, while an
root surface. They occur most often on endodontically treated interproximal root distance (IRD) of mandibular central and
teeth, although they can be present on non-endodontically lateral incisors > 0.8 mm was not associated with a more api-
treated teeth, especially molars and premolars, as a result of cal position of the interproximal bone, an IRD > 0.8 mm was
apical extensions of coronal tooth fractures.160 A localized associated, even when controlled for age, smoking, plaque,
pocket, with loss of attachment and bone is usually associated and calculus, with interproximal crestal bone loss, and sites
with the fractured tooth161 and extends to variable lengths with IRDs < 0.6 mm were 28% and 56% more likely to
along the fracture line.162,163 Narrow, deep, V- or U-shaped lose > 0.5 mm and > 1.0 mm of bone during 10 years,
osseous defects are generally seen during surgical exposure respectively.194 Based on the limited evidence, we are not
of the fractured area with bone resorption and inflammation able to conclude which are the biologic mechanisms under-
related to bacterial infection from the gingival margin and root lying this increased bone loss.194 To standardize the location
canal system.164,165 and magnitude of RP, a classification has been proposed that
defines the location of the measured site of RP (cervical, mid-
Root resorption dle, or apical third of the root) and divides the severity of the
Root resorption can be classified into surface, inflammatory, RP into type 1: > 0.5 to ≤0.8 mm; type 2: > 0.3 to ≤0.5 mm;
replacement resorption,166,167 and depending on its location, type 3: ≤0.3 mm.190
S230 ERCOLI AND CATON

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ACKNOW LEDGMENTS AND DISCLOSURES
17. Gunay H, Seeger A, Tschernitschek H, Geurtsen W. Placement of
The authors wish to thank Lorraine Porcello (Librarian, Uni- the preparation line and periodontal health—a prospective 2-year
versity of Rochester Medical Center) for her contribution in clinical study. Int J Periodontics Restorative Dent. 2000;20:171–
designing the search strategy. The authors report no conflicts 181.
of interest related to this review paper. 18. Schatzle M, Land NP, Anerud A, Boysen H, Burgin W, Loe H.
The influence of margins of restorations of the periodontal tissues
over 26 years. J Clin Periodontol. 2001;28:57–64.
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