Full crown restorations and gingival inflammation in a controlled population

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Full crown restorations and gingival inflammationin a controlled population - -David L. Koth, D.D.S., M.S.*Medical College o f Georgia, School of Dentistry, Augusta, Ga.

1 he relationship between extensive dental restora-tions and gingival health as reported in the dentalliterature is somewhat discouraging in regard to themaintenanceof a healthy periodontium. Several studieshave suggestedthat full crown restorations with sub-gingival margins sponsor an increase in gingivalinflammation., 2Subgingival margins were also shownto have a greater degreeof inflammation than marginslocated coronal to the gingival crest.3-1Another studysuggestedthat crown margins located at the gingivalcrest cause less inflammation than margins placedsupragingivally or subgingivally,12while an in-depthinvestigation found inflammation to be more severeasthe crown margin approachedthe apical portion of theintracrevicular space. This author recommendedthatsubgingival margins be placed at or just into thegingival crevice.) However, a study by Richter andUeno14revealed no difference between subgingival andsupragingival margin placement. The crowns wereprepared and inserted by one dentist. Other studiesofartificial crown contour concluded that overcontouredcrowns contribute to gingival inflammation.5-7A sim-ilar study demonstrated that temporary crowns con-structed 1 mm from the original contour did not creategingival inflammation.18 These conflicting reportsreveal the complex relationship between extensiverestorations and gingival inflammation.

There is also a disparity between these reports andthe observation of dentists in private practice whosepatients have maintained healthy periodontal tissuesfor years with full coveragerestorations. The majorityof investigations have not evaluated patients treated ina private practice, but in a dental school or hospitaloutpatient facility. The dental restorations were com-

Presented at the annual meeting of the American Academy of Crownand Bridge Prosthodo ntics, Chicago, Ill.

*Professor and Director of Fixed Prosthodo ntics, Department ofRestorative Dentistry.

monly prepared and inserted by students5-8~3~i9ormany different dentists.3 The results of institutionalinvestigations may differ from those in a privatepractice, which tends to maintain more stringentpatient control.No studieshave been directed toward private prac-

tice patients where the restorations were placed by oneexperienced dentist in private practice. Therefore, thisstudy was undertaken to compare the health of gingi-vae surrounding full crown restorations in a rigidlycontrolled private practice to the results reported in thedental literature.MATERIAL AND METHODS

The Periotron instrument (Harco Electronics Ltd.,Winnipeg, Canada) was usedto qua&ate the volumeof crevicular fluid present in the gingival sulcus.Gingival fluid has been identified as an exudate,20-3and the volume of crevicular fluid has been establishedasan index of the severity of gingival inflammation.23-27The Periotron has been recognized as an accurateinstrument to record the volume of crevicular fluid andassessthe severity of inflammation.~,W-

Patients were selectedfrom a private practice. Thepatients had previously received periodontal therapyand extensive oral hygiene instruction and were inrigid monitoring and maintenance programs. Oralprophylaxis, scaling, root planing, and oral hygieneinstruction were performed by a dental hygienist every3 months. Recall appointments were alternatedbetween periodontists and general dentists offices.The patients selected for evaluation of gingivalinflammation surrounding full crown restorationswerefrom 39 to 68 years of age with a mean age of 49.8years. The restorations had been in place between 1and 9 years with a mean of 3.5 years. The intervalsince surgery varied between 1 and 10 years with amean interval of 3.5 years.The state of inflammation of the tissuesurroundingteeth restored with full crowns was comparedto that of

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Table I. Frequency distribution chart for comparison of restored and unrestored teethUnrestored teeth Restoredteeth

Mandibular (17) Maxillary (20) Mandibular (17) Maxillary (21)Frequency % Frequency % Frequency % Frequency %

Molars 6 35 3 15 5 29 3 14Bicuspids 9 53 9 45 11 65 8 38Cuspids 2 12 5 25 1 6 5 24Incisors 3 15 5 24

Table II. Frequency distribution chart forcomparison of margin placement

Mandibular teeth (21) Maxillary teeth (25)Frequency % Frequency %

Molars 5 24 3 12Bicuspids 13 62 10 40Cuspids 3 14 7 28Incisors 5 20

tissue surrounding unrestored contralateral teeth ineach patient whenever possible.Where there was not acontralateral unrestored tooth, an unrestored toothadjacent to the restoration was used as the control.More than 90% of the control teeth were unrestoredcontralateral teeth. Table I showsthe frequency distri-bution for restored atid unrestored teeth.Crevicular fluid was collected from the mesial anddistal facial surfacesof each tooth. The readings werepooled for each tooth, and a mean value of crevicularfluid volume was calculated for each restored andnonrestored tooth. The fluid collection and measure-ments were performed by one dentist accordingto the manufacturers directions by placing the fil-ter paper strip at the orifice of the gingival crev-ice. A total of 38 restorations were evaluated on 26patients.

In addition, the margin location was recorded. Toevaluate the effect of margin placement on gingivalinflammation, 28 patients who met the samecriteria asthe previous sampleand were between 33 and 74 yearsof 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 atotal of 46 restorations were evaluated, and the valuesof crevicular fluid volume readings for eachtooth werepooled. Mean values were calculated and compared toeachother according to margin placementto determinethe degree of inflammation.

RESULTSTable III showsthe individual and mean values of

the Periotron readings comparing restored to nonre-stored teeth. The degreeof gingival inflammation wasthe samein the tissuesurrounding restored and nonre-stored teeth. Although the mean value of the restoredteeth was higher, statistical analysis using a pairedsamplet-test showedno difference in these values.

Table IV gives the number of crowns with marginsplaced subgingivally, supragingivally, and at the gingi-val crest, and the mean values of Periotron readings.The degree of gingival inflammation did not differaccording to margin placement. A statistical analysisusing an independent samplet-test revealed no differ-ence among the three locations.DISCUSSIONThe degreeof inflammation observedin the gingivaltissue prior to placement of full veneer crown restora-tions is dependent on several factors, including theamount of trauma induced during preparation, tissueretraction, and impressionmaking. It is alsoinfluencedby the quality of the provisional restorations and theduration of temporization. When thesestepshave beensatisfactorily performed, the tissue surrounding theprepared tooth will remain healthy. When a full veneercrown restoration is placed in a healthy environment,the maintenanceof this health apparently dependsonmarginal integrity, crown contour, oral hygiene, andthe patients intrinsic resistanceto disease.The gingival tissueassumedto be healthy when therestorations were inserted, the differences between thisinvestigation and others cited were (1) patient popula-tion, (2) frequericy of patient recall, and (3) operatorvariability.Patient population

The majority of the subjects selectedfor previousstudies were dental school patients,*~5-8,13*19with the

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FULL CROWN RESTORATIONS AND GINGIVAL INFLAMMATION

Table III. Mean values of gingival crevicularfluid (GCF) volume for comparison ofrestored and unrestored teeth for each patient___ _-- -- ._--___GCF meansPatient --

No. Restored teeth Unrestored teeth1 5.5 3.752 5.5 1.53 4.75 2.254 10.25 4.55 20.5 56 6 16.57 11 18 13 9.59 4 5.33

10 2 5.511 6 1412 4 413 7 2.514 4.5 815 1.5 416 13 6.517 3.5 6.2518 11 1119 9.25 5.520 2.75 321 2 0.7522 2 123 2.5 524 7 7.525 7 1.526 23.5 18

Total 26 189 153.33Mean GCF 7.27 5.89SD 5.53 4.62

Results of paired sample ~-tes t showed no significant differencebetween the means of restored and unrestored teeth 0, > .05).

exception of those of one author, who reported onpatients selected from the population of a VeteransAdministration hospital. 3 In some of the previouslycited studies, the patients had received periodontaltherapy in conjunction with oral hygiene instruc-tion.7-9.l9 In other studiesonly oral hygiene instructionwas provided,5sI6 while it was not specified in moststudies.~2~5~6~I3All the patients in this study were froma single private practice, had undergone periodon-tal surgery, and received detailed oral hygiene in-structions.Frequency of patient recall

Many investigators did not report the frequency ofpatient recall for prophylaxis and oral hygiene rein-forcement.-3~5~6~8~I3 Others incorporated it as an inte-gral part of the study7a9.4.19; however, none of the

Table IV. Mean crevicular fluid volumes(Periotron readings) according to marginplacement

Margin Mean crevicular No. ofplacement fluid volume teeth evaluated SD

Subgingival 6.7 2 , 4.53Gingival crest 3.9 5.12Supragingival 6.5 14 5.42

Results of independent l-tes t showed no significant dillirenrr accord-ing 10 marginal placement (p > .OS ).

previous studieshas repeated recall appointments fourtimes yearly.Operator variabilityIn many of the previously cited studies, restorationswere placed by dental students.-3a5,0,8.I1 In othersvarious dentists placed the restorations...In only onewere all restorations placed by the samedentist.14Inthe present study all restorations were placed by oneexperienced dentist.The present study revealed no difference in degreesof inflammation in gingival tissues surrounding fullcrown restorationswhen comparedto tissuessurround-ing nonrestoredteeth in the samepatient. This findingdiffers with other investigations..3,,*, l3 ! Disagree-ment can be explained in part by the patient populationusedin the studies.The patients in the present studywere highly motivated toward dental health since theyhad undergone the rigors and expense of extensivedental treatment. They were also participating in astrict recall program. These conditions reflect a biasedpopulation with predictable results.

In addition, the present study revealed that gingivalinflammation was not influenced by various positionsof gingival margins, that is, supragingival,,subgingival,or even with the gingival crest. Several studies haverevealed that gingival inflammation was no greater intissuesurrounding margins placed at or coronal to thegingival crest.7,8,9Another study noted no significantdifference in inflammation when the margins wereplaced supragingivally compared with those placedsubgingivally providing, however, that the subgingivalmargins ended 1 mm or more coronal to the depth ofthe gingival su1~u.s.~Still another study revealed lessinflammation when crown margins were located at thegingival crest compared to margins located above orbelow. This investigation supports the findings ofthese investigators with regard to gingival health

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surrounding the margins of crowns placed at or coronalto the gingiva l crest. This artic le differs with otherstudies regarding subgingival margin placement.3z4

In the present study 41.3% of the crown marginswere located above or even with the gingiva l crest. Thiscould be sufficient bias to result in an insignificantdifference in inflammation. Further, the location of themargin within the sulcus was not recorded; it ispossible after periodontal treatment that the marginalextension of the existing crowns was 1 mm or morefrom the depth of the sulcus. If this were true, then theresults would be in agreement with those of New-comb.13 Maruyama et al. noted that occasionalinstances of normal capillary loop formation werefound in tissues surrounding fu ll crown restorations.He states: This find ing suggests that well-fitted andwell-contoured complete crowns may present normalcapillary loops in patients practicing good oralhygiene. The population bias in the present studymay have caused most patients to fall into this category.Further, it was not known what percent of crownmargins, though originally placed subgingivally, waslocated even with the gingiva l crest or occlusal to it atthe time of assessment for this study.

Final ly, the results of this study agree with anotherin which operator variability was controlled.14SUMMARY AND CONCLUSIONS

The volume of crevicular fluid around full crownrestorations was measured with a Periotron instrumentto compare the ging ival inf lammation between restoredand nonrestored teeth in the same patient. Thirty-eightfu ll crown restorations were compared to nonrestoredteeth used as controls in 26 patients. Forty-six ful lcrown restorations in 28 patients were also evaluatedaccording to gingiva l margin placement to determine ifthere was a difference in inflammation in gingiva ltissues. The highly motivated patients were selectedfrom a private practice because of their interest andinvestment in long-term dental health.

The results revealed the following findings.1. Full crown restorations have the potential for

causing gingiva l inflammation. However, they need notbe associated with a significant increase in gingiva linflammation when placed in the oral environment of ahighly motivated patient in a rigid dental recall pro-gram.

2. Gingival inflammation surrounding full crownrestorations may be controlled regardless of gingiva lmargin placement when the gingiva is healthy, therestorations are adequate, and the patient is in a strictrecall program.

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Kepl-lr,l rrqm/t Iti:DR. DAVIU I,. KOTHMEDICAL COLLEGE OF GEORGIAScH001. OF DENT WRYAuc;tsr\, GA 30912

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Full crown restorations and gingival inflammation in a controlled population