BIOLOGIC WIDTH

PRESENTED BY,
DR. SHIJA A.S.
 INTRODUCTION
 It is a well established fact that the periodontal
health and the restoration of teeth share an
intimate and inseparable inter-relationship.

 For the periodontium to remain healthy,

restorations must be critically prepared so that
the they will remain in harmony with the
surrounding periodontal tissues.
 Cervical margin placement in esthetic
restorations needs to be done in precision as
margin placed deep into the sulcus risks the
possibility of violation of biologic width.
 GINGIVA
 Gingiva is that part of the oral mucosa which
covers the alveolar processes of the jaw and
surrounds the neck of the teeth.
 Normal features:
1. Colour- Coral pink
2. Contour- scalloped and knife edged
3. Consistency- firm and resilient
4. Texture- stippled
 Parts of Gingiva:
1. Marginal (Free): or unattached gingiva is the
terminal edge or border of the gingiva
surrounding the teeth in a collar like fashion.

Anatomic landmarks
of Gingiva
 Attached gingiva:
-Is continuous with the marginal gingiva.
-It is firm, resilient, and tightly bound to the
underlying periosteum of alveolar bone.
-Demarcated from the alveolar mucosa by the
mucogingival junction.

Mucogingival line
demarcating
attached gingiva
from alveolar mucosa
 Interdental gingiva:
-Occupies the gingival embrasure, which is the
interproximal space beneath the area of contact.
-Can be “pyramidal” or “col” shaped.

Pyramidal Mandibular posterior region:

interdental facial & buccolingual view of
gingiva interdental col
Absence of interdental
papilla where proximal
tooth contact is missing
 Dento-gingival junction (DGJ) is a complex of
epithelial cell types and connective tissue
forming the gingival attachment to the tooth and
alveolar bone.
 HISTORY
 1921- Gottlieb first described “an epithelial
attachment of the gingiva to hard tissues”
 1959- Sicher described the DGJ
 1961- Garguilo described the dimensions of DGJ
- width of CT attachment was 1.07 mm
- width of epithelial attachment was 0.97 mm
- width of sulcus was 0.69 mm
- thus, Biologic width is 2.04 mm (1.07 + 0.97)
 BIOLOGIC WIDTH
 Biologic width: is defined as “the combined
physiologic width of the junctional epithelium
and connective tissue attachment.”

 It is the space between the base of the gingival

sulcus and the alveolar crest.

 The term “Biologic width” was coined by

“D. Walter Cohen” in 1962.
 According to Garguilo et al, BW was 2.04 mm

 According to Vacek at al (1994) although the

average biologic width finding was 2mm, there
was a range of different biologic widths that
were patient specific (0.75- 4.3 mm).
 CT attachment is the strongest part of the
attachment and provides resistance that , under
normal circumstances, prevents a periodontal
probe or retraction cord from penetrating the
bone.

 JE has a high turnover rate of 4-6 days.

 JE can attach to enamel, cementum, dentin and
even porcelain.
 Crestal relationships
 Total DG complex (Biologic Width +Sulcus) is
approx. 3mm

 Because the sulcus depth can be identified only

histologically, the distance from the free gingival
margin to the crest of the alveolar bone is the
only predictable measurement available to
determine intracrevicular margin location.

 This measurement is taken on the midfacial

aspect of tooth and at both facio-proximal line
angles
 There exists 3 types of relationship between
free gingival margin and alveolar crest in
anterior teeth:
1. Normal: facially- 3mm & interproximally- 3 to
4.5mm (85%)
- No recession and loss of interdental papilla
following intervention
2. Low: facially- >3mm & interproximally-
>4.5mm (13%)
- High risk for recession and loss of interdental
papilla ( Black triangles)
3. High: facially- <3mm & interproximally- <3mm
(2%)
- Greatest risk for violation of biologic width.
 Biologic width evaluation
 Radigraphic interpretation- can identify
interproximal violation of BW, but not the
violation of BW at the mesiofacial and distofacial
line angles of tooth

On the molar crown, distal margin

extends into the biologic width,
resulting in an area of localized
bone loss
 Biologic width violation on the
mesial surface interproximally

 If patient experiences tissue discomfort when

the restoration margin levels are being assessed
with a periodontal probe, it usually indicates that
the margin has extended in to the attachment
and there has been violation of BW.
 A more positive assessment can be made
clinically by measuring the distance between the
bone and the restoration margin using a sterile
periodontal probe.

 If the distance is less than 2mm, then the

diagnosis of BW violation can be confirmed.

 To identify the BW: probe to the bone level

(“sounding to bone”) and subtract the sulcus
depth from the resulting measurement.
 Placement of margins
 3 options for margin placement:
1. Supragingival: Least impact on periodontium
2. Equigingival: Also well tolerated
3. Subgingival: Required when there is caries,
existing restoration, fracture, uncontrollable
root sensitivity, cervical erosion or esthetic
concern.
- They may not only endanger the attachment
by overextension, but also do so by carrying
plaque into the sulcus.
Subgingival crown margins

Gingivitis present
 If the structural problems cannot be solved
without destroying the integrity of BW, surgical
lengthening of clinical crown or orthodontic
extrusion is indicated to re-establish this zone.

 If the esthetics are important, the crevice should

be entered minimally, with the restoration
usually 0.5-1mm apical to free gingival margin.

 A restorative attempt to hide a metal collar

within the confines of a shallow, healthy crevice
often is not possible without compromising
esthetics or BW.
 To maintain good esthetics and tissue health,
there should be minimal entrance into the
crevice and use of a porcelain shoulder margin,
or a margin supported by metal but without a
visible metal collar.

 If esthetics are secondary, and structural

evaluation permits, locate restorative margins
outside the gingival crevice.

 Its advantges: more accurately prepared,

predictably registered, accessible for evaluation,
finishing and patient maintanance
 According to Nevins M, Skurow HM, and
Fugazzotto PA: Restorative margins must be
kept 3mm above the alveolar crest, as biologic
width is 2 mm, and additional 1mm will keep the
margins 1mm above the coronal extent of the
junctional epithelium.

 Lang et al reported that overhanging margins

not only accumulate more plaque than properly
finished margins, but the plaque undergoes a
change in composition to that to that usually
seen in association with destructive periodontitis.
Guidelines for margin placement
 First step in using sulcus depth as a guide in
margin placement is to manage the gingival
health.
 Once the tissue is healthy the following three
rules can be used to place the intracrevicular
margins:
 Rule 1: if the sulcus probes 1.5mm or less, place
the restoration margin 0.5mm below the gingival
tissue crest.
 Rule 2: Sulcus probes more than 1.5mm, place
the margin half the depth of the sulcus below
the tissue crest. This places the margin far
enough below tissue so that it will still be
covered if the patient is at higher risk of
recession

 Rule 3: Sulcus greater than 2mm, see if

gingivectomy could be performed to lengthen
the teeth and create a 1.5mm Sulcus. Then treat
patient using Rule 1.
 Consequences of violation of
Biologic Width
 JE and CT attachment (comprising the Biologic
Width) , form a biologic seal around the neck of
the tooth that acts as a barrier to help prevent
migration of microorganisms and their products
into the underlying gingival CT and supporting
alveolar bone.

 Extension of margin apical to the base of the

histologic crevice will violate the BW.

JPD, 1991;66:733-6
 Thus allowing the bacteria, and their products
to penetrate the underlying CT with resultant
inflammation.

 There is loss of CT attachment and apical

migration of marginal attachment apparatus.

 Pathologic remodeling may occur as rapidly as 2

weeks after placement of sub-gingival margin.

JPD, 1991;66:733-6
Violation of biologic width

Mesial surface of left central

incisor, bone has not been lost,
but gingival inflammation occurs,
Distal surface bone loss has
occurred and a normal BW has
been re-established
 Formation of long junctional epithelium
 According to Stahl,
on injury to the attachment and sulcular tissues

there is inflammatory response

Lysis of CT fibres entering the root

Oral epithelium is now free to migrate apically
along the denuded root surface.
JPD, 1987;57:683-9.
 If alveolar bone is also resorbed, more CT will be
lost, and the epithelium can migrate even
further apically

Long JE extending below

alveolar crest
 This “Long JE” can be more than 5mm in length
and where osseous defects have been grafted,
they may even pass below the alveolar crest,
between the root surface and graft.

 Intact long JE if kept healthy, is just as resistant

to infection as normal JE or a true CT
attachment.
JPD, 1987;57:683-9.
 Correcting biological width violations
 When the margins of restorations must
terminate at or below the alveolar crest, surgical
lengthening of the crown is necessary.

 A full thickness mucogingival flap is reflected to

expose the alveolar crest around the teeth.

 The distance between the alveolar crest and

margin of tooth preparation should be between
3 and 4 mm.
 If not, bony crest should be reduced
(conservatively to prevent reverse architecture,
penetration into a furcation or destabilisation of
the tooth).

 Tissues should be replaced at alveolar crest and

sutured.

 6 to 8 weeks must elapse for proper healing and

stabilisation of the gingival margin before any
final restorations are placed.
Short clinical crown

1 week following crown

lengthening surgery
(tissues still healing)
 Potential risk of gingival recession after removal
of bone
 Removal of interproximal bone -- papillary
recession -- Black triangles (unesthetic triangle
of space below proximal contact
 If BW violation is on the interproximal side or
across the facial surface and the gingival tissue
level is correct, orthodontic extrusion is
indicated.
 It can be slow or rapid.
 REFERANCES
1. Clinical Periodontology (10th ed)- Carranza
2. Fundamentals of Operative Dentistry (2nd ed)- Summitt
3. Contemporary Periodontics- RJ Genco, HM Goldman,
DW Cohen
4. Periodontics (5th ed)- BM Eley, JD Manson
5. Periodontal and Prosthetic Management For Advanced
Cases- MM Rosenberg, Kay, Holt
6. Essentials of Clinical Periodontology and Periodontics-
Shantipriya Reddy
7. Decision making for Periodontal team- SL Noble, M
Kellett, ILC Chapple.
8. Foundations of Periodontics for the Dental Hygienist
(2nd ed)- JS Neid-Gehrig, DE Willman
9. Guide to Periodontics (3rd ed)- WMM Jenkins, CJ Allan
10. Restorative margin placement and Periodontal health-
WG Reeves (JPD,1991;66:733-6)
11. Restorative margins and Periodontal health: A new
look at an old perspective- PL Block (JPD,1987;57:683-
9)
Thank you