6/28/2015

ThePeriodontalCrown:CreatingHealthyTissue

ThePeriodontalCrown:CreatingHealthyTissue
Category:Periodontics Created:Friday,01May200900:00

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Increasingattentionisbeinggivenbyourpatientstotheirphysicalhealth.Withincreasinglife
expectancytheyhaveagreatdesiretolivetheirremainingyearsfeelingwell,maintainingagood
appearance,andahealthysmile.
ORALSYSTEMICHEALTH:ABRIEFBACKGROUND
Coronaryheartdisease(CHD)istheleadingcauseofdeathandmorbidityintheUnitedStatesand
manydevelopedcountries.Nearly500,000peoplein2002diedfromCHDandmillionsofothersare
livingwithit.1Itisestimatedthat,intheUnitedStatesin2006,heartdiseasecostmorethan258
billiondollarsinhealthrelatedcostsandlostproductivity,affectingmorethan80millionadults,with
38.2millionestimatedtobelessthan60yearsofage.2
Recently,chronicinflammationhasbeenimplicatedetiologicallyinCHDandcardiovascular
disease.3Periodontaldisease,aformofchronicinflammation,affectstoothsupportedstructures,with
anestimatedprevalenceofashighas75%ofadultsintheUnitedStates.4Thediseaseisnow
associatedwithelevationsofbloodmarkerswhichsignifychronicin
flammation.5Becauseofthe
evidenceimplicatingchronicinflammationintheetiologyofCHD,andpossibleetiologicrelationship
be
tweenperiodontaldiseaseandCHD,everydentaltreatmentprocedureshouldbedirectedtoward
addressingandreducinginflammation.
Sincemanyofthesepatientsidentifiedwithcardiacriskwanttomaintainorimprovetheirsmile,
cosmeticdentalmaterials,whichhaveantibacterial,antiinflammatoryproperties,mustbeutilized.
Fullcrownswithantibacterialsubgingivalmarginsshouldbethepreferenceforthiscategoryof
patients.Thisarticlewillfocusuponthistopicofdiscussion.
PERIODONTALEFFECTSOFRESTORATIVE
MATERIALSANDMARGINPLACEMENT
Unfortunately,dentalrestorationshavebeenconsideredamajor
contributoryfactorintheetiologyofperiodontaldisease,as
discussedbyLoe6inhisclassic1968paper.Hispaperreviewed
thereactionsoftheperiodontaltissuestorestorativeprocedures,
andtheeffectoftheserestorativematerialsontheperiodontal
tissue.Hebelievedandstatedthatanyknowntypeofdental
restorationthatextendsintothesubgingivalareacausesdamage
totheperiodontaltissue,eitherbyprovidingpossibilitiesfor
bacterialretention,and/orbyadirectirritationeffectfromthe
material.Intheauthorsopinion,iftheconnectionbetween
periodontaldisease/inflammationandcardiacdiseaseisavalid
one,thentheseproceduresmusteitherbeavoidedwherever
possibleor,theyshouldbedoneusingaperiodontalfriendly
materialthatreducesthebacterialload(contamination).
Becauseofthepossibleharmtotheperiodontaltissue,ithas
beensuggestedthatmarginsoffullcrowns,whendone,beplaced
coronaltothegingivalmargin.7However,Austinetal,8
suggestedsuchaplacementisoftencontraindicateddueto
aestheticrequirements,subgingivalcaries,existingsubgingival
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Figure1.Poorlyfitted
subgingivalmarginsonteeth
Nos.6and11,resultinginan
inflamed,darkenedcervical
tissuecolor,compromisingthe
appearanceoftherestoration.

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restorations,orashortclinicalcrown.Withthepatientsprimary
Figure2.Captekcrowns,
concernbeingaesthetics,itisobviousthatmostmargin
replacingpoorlyfittedPFM
placementsmustnowbesubgingival.
restorationsinFigure1,
Subgingivalmarginsareofgreatconcernbecauseofthe
exhibitingoptimalgingival
9
marginsandcrowncontours,
potentialproblemsthatcanoccur(Figure1).Waerhaug
producingahighlyaesthetic
suggestedthatthesubgingivalmarginfacilitatesbacterialplaque
appearance.
retention,whichcouldlatercontributetothedestructionofthe
10
periodontalsupportingapparatus.Silness, 20yearsfollowing
Waerhaug,in1980,describedsubgingivalmarginstoexhibitmoreseveregingivallesionsanddeeper
gingivalpocketsthanmarginsevenwithorabovethegingivalcrest.Con
sideringthepossible
connectionbetweenperiodontalandcardiacdisease,theseeffectsofcosmetictreatmentmustbe
avoidedatallcoststoreducetheriskofsystemicdiseaseoccurringfromoralconditions.
Amsterdam11wroteaclassictreatiseonperiodontalprostheses,morethan30yearsago,establishing
thestandardofcareforacrown.Mostcritically,hedescribedtheoptimalmargin/finishline.When
fullcoveragerestorationswereindicated,thismargin/finishlineshouldbeplaced(inahealthysulcus)
atminimaldepth,justshortofthejunctionalepitheliumorcompletelyawayfromthesulcus,
preferablyontheanatomiccrown.Hesuggestedthattheleastdesirablelocationtoplaceamarginis
justsupragingival,wheretheareaofgreatestplaqueaccumulationoccurs.Finally,inguidelinesstill
followedtoday,hesuggestedthattopreventplaquebuild
upitisnecessarytocreateoptimalcrown
contourswithpropercoronalform,embrasureform,andgoodsubgingivalfitatthemargin(Figure2).
Despitethisexcellenttreatise,onewhichdefinedthestandardofcarefortheplacementoffull
crowns,Morman,etal12reportedthatgingivalinflammationcouldresultfromtheplacementofgold
inlays,evenwithperfectlyadaptedandwellpolishedmargins.Withthemostprecisetechniques
utilizedtoavoidadverseeffectsincludingproperpreparation,impressions,wellfittedprovisionals,
anddefinitivecrownrestorations,therecouldstillbegingivalirritationandincreasedplaque
retentions.
RESTORATIVEMATERIALSVERSUSINFLAMMATION
Followingthestandardofcareestablishedby
Amsterdam,11alldentistsshouldconsiderusing
materialsthatwillmaintaingoodperiodontal
healthwithoptimalfit,reducingpossible
periodontalrisksforsystemicdisease.Whenthe
needexiststoemployfullcoveragecrowns,
Captek(PreciousChemicals)providesone
exampleofacosmeticrestorativecrownmaterial
availablethatcanhelpsatisfythegoalof
excellenthealth.Thisceramo
metalcrown
incorporatestheuseofagoldcompositemetal
coping.Good
son,etal13(Figure3)documenteda
reductionofupto91%inthenumberofbacteria
observedsurroundingCaptekrestoredteeth
versusnormaltoothsurfacesinthesamemouth.
Additionally,therewasapproximately96%less
bacterialadhesioncomparedtoceramicfusedto
noblemetalrestorations.
Chronicinflammationintheperiodontaltissue
hasbeentraditionallyreducedwithnonsurgical
13
periodontalcare,involvingscaling,rootplaning, Figure3.Goodsen,etal clinicalstudyresults
comparingsurfacematerialoftoothversus
andeffectiveoralhygienetoremovethebacteria
plaqueresponsiblefortheproblem.Ithasalways amountofbacteriapresentinsulcus.
beenunder
stood,followingthesuggestionsofAmsterdam,11thatproperplacementwouldhelpto
preventplaquebuildup,ineffectreducinginflammation.Withsignificantlypositivetissueresponses
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ThePeriodontalCrown:CreatingHealthyTissue

tocrownmaterials,dentistscannowachievepredictableaestheticrestor
ationswithahealthy
supportingperiodontium.Thesecrownsmightbestbedescribedasperiodontalcrowns,since
healthytissueresultsfromplacementonanyaffectedteeth.Intheauthorsopinion,thistypeofcrown
managementshouldbefollowed,ifthereiseventhesmallestpossibilityofreducingperiodontalrisk
forcardiacdiseasewithplacementofthesecrowns.
COMPOSITEGOLDALLOYMATERIALDESCRIPTIONANDPROPERTIES
TheCaptekcompositegoldalloycopingisfabricatedusingacapillarycastingtechnique.Itisnota
traditionalgoldalloy,butisbestdescribedasacompositemetalof97%goldreinforcedwithsmall
particlesofaveryhighfusing,highstrength,platinum/palladiumcore.14Theresultingwarmhue
presentsanidealbackgroundfornatural/vitalporcelainaestheticsinthecervicalareasofrestorations,
virtuallyeliminatingtissueshadowingoftencausedbythegraycoloroftraditionalcastceramometal
alloys.Thematerialdoesnotoxidize,whichcancreatedarkcolorreactionswithporcelain,creatinga
weaklinkatthebondingsurface.Captekhasasmallparticlesizeunder15to20m,allowing
marginstobefinishedtoafineedgewithoutalossofintegrity.Withnooxides15orgraymetalto
maskout,only0.05mmisrequiredforaproperopaquelayercomparedwithanaverageof0.3mmon
castmetal.
Becauseofthebacterialinhibitionproperties,theauthorprefersachamferbevelwithaprescribed
smallmetalcollarusedinallnonaestheticareas,generallyfrommidproximal(Figure4).13,1618These
margindesignsalsoworkwellwithbridgesthatinthepastrestrictedponticlengthto15mm.
However,anallnewCaptekmaterial,Bridge&Implant,hasbeenreinforcedwithtwicethenumber
ofplatinum/palladiumparticles,makingitmorethan30%strongerthanoriginalCaptek.19Developed
usingnanotechnologyandinuseforover2years,thisstrongerCaptekcanbeusedforcantileverand
longspanbridgesofferingatleastthesameleveloffitandplaqueinhibitionastheoriginalCaptek.19
TYPICALCLINICALCASEEXAMPLE
Thisexamplepatientcaseshowsaconcernabouttissuehealth,
aesthetics,strength,andfit.
A45yearoldfemalepresentedwithcongenitallymissingteeth
maxillarylateralincisorsteethNos.7and10.Previouslyshehad
haddualcantileverbridgesmadetoreplacetheseteeth.After
consultation,itwasdecidedtocompletetwo,3unitbridgesfor
teethNos.6to8and9to11.Whentheoldcrownswereremoved
ontheupperleftside,theinflammationofthetissuewherethe
previousfittedsemipreciousmetalcrownswereinplacewas
obvious.Withthebilateralplacementofperiodontalcrowns
(usingCaptekcompositemetalinthiscase),theimprovedfitand
tissuehealthiseasilyvis
ibleeven4yearsafterplacement
(Figure1).
CONCLUDINGREMARKS:SHOULDTHESTANDARD
OFCARECHANGE?
WhileDr.Amsterdam11establishedtheinitialstandardofcarefor
crowndesignandmarginplacement,clinicalstudiesandcase
historiesnowdictateanamendmentofthisclassicstandard.
Wheneveranyfullcrownrestorationisconsideredorrequiredfor
atooth(withbleedinginthetissuewhenprobedorwhere
periodontaldiseaseispresent)itisnowsuggested,basedonthe
knowledgeofcrowncontourandpossiblereductionoftissue
inflammation,thatusingperiodontallyhealthycrownsisan
appropriateindication.Becausethecrowns(Captek)discussedin
thisarticlehavebeenshowntobeoneex
ampleofamaterialthat
reducesplaqueontheassociatedtooth(perthestudiesof
Goodsen,etal13citedpreviously),perhapsthetermperiodontal
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Figure4.Captekmetal
anywherealongthemargin
willinhibitbacterialplaque
adhesion.

Figure5.Illustrationofhow
thehighgoldinfiltrates
capillarystructureof
reinforcing
platinum/palladiumcore.
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crownisaveryappropriateonetouse.
Intheauthorsopinion,restoringatoothwithamaterialthathasbeenshowntoreducetheinherent
riskofadditionalplaqueretentionshouldbeconsideredthetreatmentofchoice.Useofthesecrowns,
inthepresenceofperiodontaldisease,shouldberoutine.Shouldthisbeafuturestandardofcare?The
hopeisthatmoreattentionwillbegiventostudymaterialsthatcanprovidetheperiodontalbenefitsof
ahybridgold.Whenconsideringthepossibilitythatriskofcardiacdiseaseandadultonsetdiabetes
mightbereducedwithperiodontalcrowntreatment,thefutureisexciting!
References
1. KochanekKD,MurphySL,AndersonRN,etal.Deaths:finaldatafor2002.NatlVital
StatRep.200453:1115.
2. ThomT,HaaseN,RosamondW,etal.Heartdiseaseandstrokestatistics2006update:
areportfromtheAmericanHeartAssociationStatisticsCommitteeandStrokeStatistics
Subcommittee.Circulation.2006113:e85151.
3. RidkerPM,HennekensCH,BuringJE,etal.Creactiveproteinandothermarkersof
inflammationinthepredictionofcardiovasculardiseaseinwomen.NEnglJMed.
2000342:836843.
4. BrownLJ,BrunelleJA,KingmanA.PeriodontalstatusintheUnitedStates,19881991:
prevalence,extent,anddemographicvariation.JDentRes.199675:672683.
5. NoackB,GencoRJ,TrevisanM,etal.Periodontalinfectionscontributetoelevated
systemicCreactiveproteinlevel.JPeriodontol.200172:12211227.
6. LoeH.Reactionsofmarginalperiodontaltissuestorestorativeprocedures.IntDentJ.
196818:759778.
7. RichterWA,UenoH.Relationshipofcrownmarginplacementtogingivalinflammation.
JProsthetDent.197330:156161.
8. AustinGB,VogelR,DeasyM,etal.Effectofroughandsmoothmarginson
interproximalgingivalhealth.ClinPrevDent.19791:1926.
9. WaerhaugJ.Histologicconsiderationswhichgovernwherethemarginsofrestorations
shouldbelocatedinrelationtothegingiva.DentClinNorthAm.19605:161176.
10. SilnessJ.Fixedprosthodonticsandperiodontalhealth.DentClinNorthAm.198024:317
329.
11. AmsterdamM.Periodontalprosthesis:Twentyfiveyearsinretrospect.AlphaOmegan.
197467:852.
12. MormannW,RegolatiB,RenggliHH.Gingivalreactiontowellfittedsubgingival
proximalgoldinlays.JClinPeriodontol.19741:120125.
13. GoodsonJM,ShoherI,ImberS,etal.Reduceddentalplaqueaccumulationoncomposite
goldalloymargins.JPeriodontalRes.200136:252259.
14. McLarenE.Forwardtothepast:arenaissanceinceramometaltechnology.Contemp
EsthetRestorPract.19982(specissue):613.
15. ZappalaC,ShoherI,BattainiP.MicrostructuralaspectsoftheCaptekalloyforporcelain
fusedtometalrestorations.JEsthetDent.19968:151156.
16. ShoherI,WhitemanA.Captek:anewcapillarycastingtechnologyforceramometal
restorations.Quintes
senceDentTech.199518:920
17. KnorrS,CombeEC,WolffLS,HodgesJS.TheSurfaceFreeEnergyofGoldAlloy
Systems.Abstractpresentedat:32ndAnnualMeetingoftheAmericanAssociationfor
DentalResearchMarch2003SanAntonio.
18. WynneWPD.MarginDesignintheMostOverlookedAestheticZone.DentistryToday.
October200625:126129.
19. DiTollaM.FromtheLab.DentalEconomics.200797:44.
Dr.GottehrerhasbeeninpracticeinsuburbanPhiladelphiaformorethan30years,focusinghis
practiceoncosmetics,implantdentistry,andperiodontics.HeisagraduateoftheUniversityof
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ThePeriodontalCrown:CreatingHealthyTissue

MarylandDentalSchool,receivedhispostgraduateperiodontaltrainingattheUniversityof
Pennsylvania,andisaboardcertifiedPeriodontist.HeteachestheSeniorElectiveCoursein
PeriodonticsattheUniversityofMarylandDentalSchool.Hehasbeenpublishedandlectures
internationally.Dr.GottehreriscurrentlythepresidentoftheInstituteofAdvancedOralandPhysical
HealthinHavertown,Pa.Hecanbereachedat(610)4499500ordr.neilg@verizon.net.

Disclosure:Dr.Gottehrerreportsnoconflictofinterest.
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