BIOLOGIC WIDTH AND ITS CLINICAL

IMPLICATIONS

GUIDED BY:
PRESENTED BY:
DR SANDEEP METGUD
DR NEETU JHA
DR PRASHANT SHETTY
 CONTENTS
• DEFINITION

• INTRODUCTION

• MARGIN PLACEMENT OF RESTORATIONS

• BIOLOGIC WIDTH CONSIDERATIONS AROUND AN IMPLANT

• EVALUATION OF BIOLOGIC WIDTH VIOLATION

• METHODS TO CORRECT BIOLOGIC WIDTH VIOLATION

• CONCLUSION

• REFERENCES
 DEFINITION
• The dimension of the soft tissue, which
is attached to the portion of the tooth
coronal to the crest of the alveolar
bone.
- Gargiulo et al.(1961)

• Term was coined by Cohen in 1962

 INTRODUCTION
Based on the measurements of the dentogingival
components in 237 teeth, Gargiulo et al., reported
following mean dimentions

• Sulcus depth of 0.69 mm

• Epithelial attachment of 0.97 mm
• Connective tissue attachment of 1.07 mm
• Biologic width to be 2.04 mm
MARGIN PLACEMENTS OF RESTORATIONS

SUPRAGINGIVAL

EQUIGINGIVAL

SUBGINGIVAL
SUPRAGINGIVAL MARGINS

• It has the least impact on the periodontium.

• This margin has been applied in non-esthetic areas

Advantages:

1. Preparation of the tooth and finishing of the margin is easiest

2. Duplication of the margins with impressions that can be removed past the
finish line without tearing or deformation is the easiest with supragingival
margins.
3. Fit and finish of the restoration and removal of excess
material is easiest
4. Verification of the marginal integrity of the restoration is easiest.
5. The supragingival margins are least irritating to the periodontal tissue
EQUIGINGIVAL MARGINS

• Traditionally was not desirable because they were thought to favour more
plaque accumulation than supragingival or subgingival margins

• Its not valid today because not only can the margins be esthetically blended
with the tooth but also because restorations can be finished easily to provide
a smooth, polished interface at the gingival margin
SUBGINGIVAL MARGINS

• Studies have concluded that subgingival restorations demonstrated more

quantitative and qualitative changes in the microflora, increased plaque index,
gingival index, recession, pocket depth and gingival fluid

• Special considerations have to be given to maintaining biologic width so as to

maintain the health of the periodontium
 VIOLATION OF BIOLOGIC WIDTH
1. Chronic, progressive gingival inflammation around the
restoration.
2. Bleeding on probing.
3. Localized gingival hyperplasia with minimal
bone loss.
4. Gingival recession
5. Pocket formation
6. Clinical attachment loss.
7. Alveolar bone loss
BIOLOGIC WIDTH AROUND AN IMPLANT
• When the implant-abutment connection was
placed at the gingival level supracrestal to the
alveolar bone, the biologic width measurement
was similar to natural dentition

• When the interface was placed at deeper level,

the biologic width decreased accordingly

• When the restoration margin is placed far below

the gingival tissue crest, it will impinge on the
gingiva and constant inflammation is created

• However,the implant level should always be

placed subgingivally to allow development of
Leblebicioglu
desired B, Rawal
profile and S, Mariotti A. A review of the functional and esthetic
aesthetics
requirements for dental implants. J Am Dent Assoc Mar 2007;138:321-29
EVALUATION OF BIOLOGIC WIDTH

CLINICAL
METHOD RADIOGRAPHIC
METHOD
 CLINICAL METHOD
• When a patient experiences tissue
discomfort when the restoration margin
levels are being assessed with a periodontal
probe, it is a good indication that the margin
extends into the attachment and that a
biologic width violation has occurred

• All or some of the signs of biological width

violations can be seen if there is evident
discomfort on probing
 BONE SOUNDING
• The biologic width can be identified by probing under local
anesthesia to the bone level (referred to as “sounding of bone”) and
subtracting the sulcus depth from the resulting measurement

• If the distance is less than 2 mm at one or more locations, a diagnosis

of biologic width violation can be confirmed

• This measurement must be performed on teeth with healthy gingival

tissues and should be repeated on more than one tooth to ensure
accurate assessment
 • Mid facial Measurement is 3mm
Normal Crest •
•
Proximal Measurement is 3-4.5mm
Occurs in 85% cases
In 2000,Kois proposed Patient • Margins of crown placed no less than 2.5mm from Alveolar
Crest
three categories of
biological width based
on total dimension of • Mid facial measurement is <3mm
attachment and the High Crest •
•
Proximal Measurent is <3mm
Seen in 2% cases
sulcus depth following
bone sounding Patient •
•
Commonly seen adjacent to an edentulous area
Subgingival margins are not placed
measurements

• Mid facial measurement is >3mm

Low Crest •
•
Proximal Measurent is >4.5mm
Seen in 13% of cases
Patient • More susceptible to recession after placement of subgingival
margins
(a) Normal crest showing biologic width on labial and interproximal site
(b) High crest showing biologic width on labial and interproximal site
(c) Low crest showing biologic width on labial and interproximal site
(d) Pateint A low crest unstable; and, Pateint B-. Low crest stable
 Importance of determining Crest Category
• When preparing anterior teeth for indirect restorations, it is essential that the
dentist should know about the Crest category

• This allows the operator to determine the optimal position of margin placement,
as well as inform the patient of the probable long-term effects of the crown margin
on gingival health and esthetics

SULCUS PROBING DEPTH LEVEL OF MARGIN OF RESTORATION

1.5mm 0.5mm below the Gingival Crest
>1.5mm Half of the Sulcus Depth
>2mm Gingivectomy to lengthen the tooth
and create 1.5mm Sulcus
 RADIOGRAPHIC METHOD
• Radiographic interpretation can identify
interproximal violations of biologic width

• However, on the mesiofacial and distofacial

line angles of teeth, radiographs are not
diagnostic because of tooth superimposition
METHODS TO CORRECT BIOLOGIC WIDTH
VIOLATION
External Bevel
Surgical Crown Gingivectomy
CROWN LENGTHENING Lengthening Internal Bevel
PROCEDURES Gingivectomy
Without Osseous
Apically Reduction
Repositioned Flap With osseous
Orthodontic Reduction
Extrusion of tooth
 Surgical Crown Lengthening
Indications

1. Inadequate clinical crown for retention due to extensive caries, subgingival caries or tooth
fracture, root perforation, or root resorption within the cervical 1/3rd of the root in teeth
with adequate periodontal attachment
2. Short clinical crowns
3. Placement of sub gingival restorative margins
4. Unequal, excessive or unaesthetic gingival levels
5. Planning veneers or crowns on teeth with the gingival margin coronal to the cemeto
enamel junction (delayed passive eruption)
6. Teeth with excessive occlusal wear or incisal wear.
7. Teeth with inadequate interocclusal space for proper restorative procedures due to
supraeruption.
8. Restorations which violate the biologic width.
9. In conjunction with tooth requiring hemisection or root resection.
10. Assist with impression accuracy by placing crown margins more supragingivally.

Contraindications

1. Deep caries or fracture requiring excessive bone removal.

2. Post surgery creating unaesthetic outcomes.
3. Tooth with inadequate crown root ratio (ideally 2:1 ratio is preferred)
4. Non restorable teeth.
5. Tooth with increased risk of furcation involvement.
6. Unreasonable compromise of esthetics.
7. Unreasonable compromise on adjacent alveolar bone support.
External bevel gingivectomy

• Gingivectomy is a very successful and

predictable surgical procedure for
reconstruction of biologic width;

• It can be used only in situations with

hyperplasia or pseudopocketing (> 3
mm of biologic width) and presence
of adequate amount of keratinized
tissue
Internal bevel gingivectomy

• Reduction of excessive pocket depth

and exposure of additional coronal
tooth structure in the absence of a
sufficient zone of attached gingiva
with or without the need for
correction of osseous abnormalities
 Apical repositioned flap surgery
Indication

• Crown lengthening of multiple teeth in

a quadrant or sextant of the dentition,
root caries, fractures

Contraindication
• Apical repositioned flap surgery should
not be used during surgical crown
lengthening of a single tooth in the
esthetic zone
Apically repositioned flap without osseous resection

• This procedure is done when there is no adequate width of attached

gingiva, and there is a biologic width of more than 3 mm on multiple
teeth

Apical repositioned flap with osseous reduction

• This technique is used when there is no adequate zone of attached

gingiva and the biologic width is less than 3 mm. The alveolar bone is
reduced by ostectomy and osteoplasty, to expose the required tooth
length in a scalloped fashion, and to follow the desired contour of the
overlying gingiva
Forced tooth eruption with fibrotomy
• If fibrotomy is performed during the forced tooth eruption
procedure the crestal bone and the gingival margin are retained
at their pretreatment location and the tooth-gingiva interface at
adjacent teeth is unaltered.

• Fibrotomy is performed by the use of a scalpel at 7 to 10 day

intervals during the forced eruption to sever the supracrestal
connective tissue fibers, thereby preventing the crestal bone
from following the root incoronal direction
Indication:
• Crown lengthening at sites where
it is important to maintain the
location of the gingival margin at
adjacent teeth

Contraindication:
• Fibrotomy should not be used at
teeth associated with angular
bone defects, ectopically erupting
tooth
 CONCLUSION
• The health of the periodontium is necessary for maintenance of the stability of the
teeth. Any jeopardy to the periodontium can cause instability of the teeth and cause
exfoliation

• Biological width is a key aspect in maintaining the periodontium

• Any encroachment of biological width would affect the healthy status of the
periodontium

• Meticulous care must be taken in designing the margin of the restorations to

maintain the periodontium
 REFERENCES
• Carranza’s Clinical Periodontology, 11th edition
• Cohen’s Pathways of Pulp, 11th edition
• Biologic width and its importance in periodontal and restorative dentistry. B Nugala, S Kumar ,
Sahitya, M Krishna. J Cons Dent Jan 2012;15(1): 12-17
• Biologic Width: Evaluation and Correction of its Violation. Nitin Khuller, Nikhil Sharma. Oral Health
Comm Dent 2009;3(1):20-25
• Biologic Width and its Clinical Importance. Preetha S. J Med Sci Clin Res May 2014;2(5): 1242-48
• Leblebicioglu B, Rawal S, Mariotti A. A review of the functional and esthetic requirements for dental
implants. J Am Dent Assoc Mar 2007;138:321-29
• Small PN, Tarnow DP. Gingival recession around implants: A 1-year longitudinal prospective study. Int J
Oral Maxillofac Impl 2000;15(4):527-532
• CROWN LENGTHENING BY ORTHODONTIC FORCED ERUPTION - A CASE REPORT Maheaswari R,
Jayshree TK, Golla UR, Hema JC. Int J Curr Res Rev 2015;7(13): 79-83