Restaurações Protéticas Fixas e Saúde Periodontal - Narrativa 1

Journal of
Functional
Biomaterials
Review
Fixed Prosthetic Restorations and Periodontal Health: A
Narrative Review
Viritpon Srimaneepong 1 , Artak Heboyan 2, * , Muhammad Sohail Zafar 3,4 , Zohaib Khurshid 5 ,
Anand Marya 6,7 , Gustavo V. O. Fernandes 8 and Dinesh Rokaya 9, *
1 Department of Prosthodontics, Faculty of Dentistry, Chulalongkorn University, Bangkok 10330, Thailand;

[email protected]
2 Department of Prosthodontics, Faculty of Stomatology, Yerevan State Medical University after Mkhitar
Heratsi, Str. Koryun 2, Yerevan 0025, Armenia
3 Department of Restorative Dentistry, College of Dentistry, Taibah University, Al Madinah,
Al Munawwarah 41311, Saudi Arabia; [email protected]
4 Department of Dental Materials, Islamic International Dental College, Riphah International University,
Islamabad 44000, Pakistan
5 Department of Prosthodontics and Implantology, College of Dentistry, King Faisal University, Al-Hofuf,
Al Ahsa 31982, Saudi Arabia; [email protected]
6 Department of Orthodontics, University of Puthisastra, Phnom Penh 12211, Cambodia;
[email protected]
7 Center for Transdisciplinary Research, Saveetha Dental College, Saveetha Institute of Medical and Technical
Science, Saveetha University, Chennai 600077, India
8 Periodontics and Oral Medicine Department, University of Michigan School of Dentistry,
Ann Arbor, MI 48109, USA; [email protected]
9 Department of Clinical Dentistry, Walailak University International College of Dentistry, Walailak University,

Bangkok 10400, Thailand
* Correspondence: [email protected] (A.H.); [email protected] (D.R.); Tel.: +374-93-21-12-21 (A.H.)
Citation: Srimaneepong, V.;
Heboyan, A.; Zafar, M.S.; Khurshid,
Z.; Marya, A.; Fernandes, G.V.O.;
Abstract: Periodontal health plays an important role in the longevity of prosthodontic restorations.
Rokaya, D. Fixed Prosthetic The issues of comparative assessment of prosthetic constructions are complicated and not fully
Restorations and Periodontal Health: understood. The aim of this article is to review and present the current knowledge regarding the
A Narrative Review. J. Funct. various technical, clinical, and molecular aspects of different prosthetic biomaterials and highlight the
Biomater. 2022, 13, 15. https:// interactions between periodontal health and prosthetic restorations. Articles on periodontal health
doi.org/10.3390/jfb13010015 and fixed dental prostheses were searched using the keywords “zirconium”, “CAD/CAM”, “dental
Academic Editors: Joseph Nissan,
ceramics”, “metal–ceramics”, “margin fit”, “crown”, “fixed dental prostheses”, “periodontium”, and
Marco Tatullo and Gianrico “margin gap” in PubMed/Medline, Scopus, Google Scholar, and Science Direct. Further search criteria
Spagnuolo included being published in English, and between January 1981 and September 2021. Then, relevant
articles were selected, included, and critically analyzed in this review. The margin of discrepancy
Received: 5 January 2022
results in the enhanced accumulation of dental biofilm, microleakage, hypersensitivity, margin
Accepted: 29 January 2022
discoloration, increased gingival crevicular fluid flow (GCF), recurrent caries, pulp infection and,
Published: 1 February 2022
lastly, periodontal lesion and bone loss, which can lead to the failure of prosthetic treatment. Before
Publisher’s Note: MDPI stays neutral starting prosthetic treatment, the condition of the periodontal tissues should be assessed for their
with regard to jurisdictional claims in
oral hygiene status, and gingival and periodontal conditions. Zirconium-based restorations made
published maps and institutional affil-
from computer-aided design and computer-aided manufacturing (CAD/CAM) technology provide
iations.
better results, in terms of marginal fit, inflammation reduction, maintenance, and the restoration of
periodontal health and oral hygiene, compared to constructions made by conventional methods, and
from other alloys. Compared to subgingival margins, supragingival margins offer better oral hygiene,
Copyright: © 2022 by the authors. which can be maintained and does not lead to secondary caries or periodontal disease.
Licensee MDPI, Basel, Switzerland.
This article is an open access article Keywords: zirconia; ceramics; cobalt-chromium; CAD/CAM; crown; fixed partial denture; margin
distributed under the terms and fit; periodontium; gingival health; gingival inflammation; gingival crevicular fluid
conditions of the Creative Commons
Attribution (CC BY) license (https://
creativecommons.org/licenses/by/
4.0/).
J. Funct. Biomater. 2022, 13, 15. https://doi.org/10.3390/jfb13010015 https://www.mdpi.com/journal/jfb

J. Funct. Biomater. 2022, 13, 15 2 of 21
1. Introduction
Proper treatment planning and prosthetic treatment are essential for the long-term
outcome of prosthetic dental treatment. There is a strong association between prosthetic
dentistry and periodontics as periodontal health has an important role in the longevity of
fixed dental restorations [1–3]. On the other hand, defective prostheses may contribute to
the progression of periodontal diseases [4]. The final finish of the prosthetic restoration
also affects the development of biofilm, as increased surface roughness creates a favorable
environment for microbial growth. Hence, a good prosthesis surface finish from proper
manufacturing technique is important [5]. To achieve a successful treatment outcome,
prosthodontists and periodontists should collaborate, to enhance the longevity of the
restoration and improve periodontal health, as well as improve the quality of life for dental
patients [3,6].
Morpho-functional impairments of the maxillofacial complex conditioned by peri-
odontal pathology are five times more common compared with those arising from dental
caries [7]. Periodontitis is an inflammatory disease involving the periodontal tissues (ce-
mentum, periodontal ligament, alveolar bone, and gingiva) supporting the teeth [8]. It
results in teeth loss requiring prosthetic treatment. A delay in prosthetic treatment causes
biomechanical impairment of the stomatognathic system, worsening of the periodontal
condition, and adverse consequences on the patients’ general health and behavior [9–12].
Prosthetic treatment receives special attention in the case of patients with periodontal
pathology [13,14]. However, sometimes, inappropriate prosthetic treatment planning or
the prosthesis itself can cause periodontitis or gingival recession and associated clinical
characteristics (Figure 1).
Figure 1. The clinical characteristics of periodontal inflammation. GCF = gingival crevicular fluid;
PMNs = polymorphonuclear leukocytes.
The aim of this article is to review and present the current knowledge regarding the
various technical, clinical, and molecular aspects of different prosthetic biomaterials and
highlight the interactions between periodontal health and prosthetic restorations.
2. Materials and Method

Articles on periodontal health and fixed dental prostheses were searched using the
keywords “zirconium”, “CAD/CAM”, “dental ceramics”, “metal-ceramics”, “margin fit”,
“crown”, “fixed dental prostheses”, “periodontium”, and “margin gap” in PubMed/Medline,
Scopus, Google Scholar, and Science Direct. Further search criteria included being pub-
lished in English literature, and between January 1981 and September 2021. Then, relevant
articles were selected, included, and critically analyzed in this review.
3. Marginal Fit and Internal Adaptation of Fixed Dental Prostheses

Marginal as well as an internal discrepancy with an external gap in a prosthetic
crown/fixed partial denture are critical factors as they deal with the structural rigidity,
marginal integrity, and maintenance of pulpal and periodontal health [15]. Most im-
portantly, the position of a gap is of great importance; namely, if it is supragingivally,
paragingivally or subgingivally. In gaps occurring supragingivally, better oral hygiene can
be maintained and does not lead to secondary caries or periodontal disease. Subgingival
gaps do not permit maintenance of good oral hygiene and should be evaluated properly.
A commonly accepted approach to the optimal value of margin μ gap still has not been
recommended. Some researchers consider theμvalue <120 µm [16–18] to be optimal, while
others consider that it should be <100µm [19,20]. Moreover,
μ it is still believed that the
adequate value should range between 20 and 75 µm [15].
The accuracy of marginal and internal adaptation is essential for the final result
and survival of a fixed prosthetic treatment. A marginal discrepancy results in thick
cement, which is affected by the oral environment more, resulting in cement dissolution
and deposition of dental biofilm, microleakage, margin discoloration, increased gingival
crevicular fluid (GCF) flow, recurrent caries, pulp infection and, lastly, periodontal lesion
and bone loss, which lead to the failure of prosthetic treatments [15]. Figure 2 shows an
adequate margin fit of the crown and an inadequate margin fit leading to undesirable
consequences. Hence, to protect the periodontium, especially the gingival margin and
tissue-biomaterials interface, the fixed dental prosthesis should be appropriate, healthy,
and durable [21].
Figure 2. Good marginal fit of the crown and a poor marginal fit leading to consequences.
Although no substantial difference was seen in the internal precision in the computer-
aided design and computer-aided manufacturing (CAD/CAM) restorations [22], it has been
shown that the internal discrepancy of digitally manufactured CAD/CAM restorations

present a higher margin fit of inlays [23]. Riccitiello et al. [24] showed that both zirconia and
lithium disilicate CAD/CAM prosthetic restorations provide a better marginal fit than heat-
pressed lithium disilicate constructions. Another study showed no significant difference
in the margin fit, both horizontally and vertically between the lost wax and CAD/CAM
techniques for full coverage lithium disilicate crowns [25]. Though there are data showing
a margin discrepancy in crowns made by CAD/CAM technology [26], compared with
metal fused to porcelain restorations, all-ceramic constructions made by the CAD/CAM
method had a higher precision [27]. Moreover, the direct digitalization of prepared teeth
showed a better outcome for margin accuracy, compared to indirect digitalization, when
scanning is accomplished from a conventionally molded plaster model [28]. In addition,
the CAD/CAM fabricated prostheses show an improved adaptation compared to the
ones fabricated using the conventional method [29,30]. Furthermore, Sorrentino et al. [31]
demonstrated that zirconia copings did not show any sign of tetragonal to monoclinic
transformation at the margins, irrespective of the preparation geometry.
The deterioration of periodontal tissues due to margin misfit forms a retentive region
and enables the accumulation of dental plaque that occurs following prosthetic treatment
with conventionally fabricated metal–ceramic restorations. The consequences of the crown’s
margin misfit are shown in Figure 3. An undesirable consequence of metal–ceramic
constructions on the periodontium, resulting in periodontitis, is related to mechanical
trauma to the gum during tooth preparation and gingival retraction as well as with uneven
contours and the topography of the crown margin [32].
Figure 3. Consequences of the crown’s margin misfit.
The esthetics and longevity of the prosthesis are conditioned by the harmony and
biofunctionality between the prosthetic construction and the periodontium [3]. The biofunc-
tionality of a prosthesis refers to a function that is dependent on biological content. The life
span of fixed prosthetic constructions depends on the periodontal status of the supporting
teeth, since the mucosa in this region is subject to continuous mechanical trauma and
bacterial contamination [33,34]. Thus, numerous factors, such as the condition of abutment
teeth, pontic design, prosthesis construction, occlusion, and biomaterial have tangible
influence and should be considered when planning the prosthodontic treatment [35]. The
preservation of periodontal health around the crown’s margins is a serious challenge for a
dentist, and detecting the restoration margin relative to the neighboring bone is a signifi-
cant factor when providing for the long-lasting health of the gingival tissues [36,37]. The
emerging couture of the prosthetic construction can affect the gingiva reaction to the fixed
prosthesis. Moreover, the life span of fixed dental restorations is governed by the margin
adaptation of the prostheses [15].
An incorrectly fabricated dental prostheses construction may harm both the health
of the oral tissues and worsen any existing periodontal pathology. Rough and irregular
surfaces on the restorative biomaterials may create a favorable environment for microbial
invasion and biofilm formation [38–40]. Any rough and irregular margins on the fixed
prosthetic constructions can also result in microorganisms’ attachment. The aforementioned
factors can worsen oral hygiene conditions and cause gingivitis and further periodonti-
tis. Zirconia surface relief alterations and roughness following the application of laser
irradiation were studied by Popa et al. [41]. The group Nd:YAG consists of zirconia restora-
tions treated with a neodymium laser and the group Er:YAG included restorations treated
with an erbium laser. The authors noted that there were substantial differences between
the Nd:YAG and Er:YAG following surface irradiations. The Nd:YAG laser shaped more
changes in the zirconia surface than the Er:YAG. Thus, poor oral hygiene was detected
in 35% of the patients with conventionally fabricated metal–ceramic dental prostheses, in
30.3% of the subjects with CAD/CAM fabricated metal–ceramic prostheses, and 28.6% of
the patients with zirconia-based ceramic prostheses, one year after the insertion of the con-
structions [42]. In addition, fixed prosthetic restorations, such as crowns and bridges may
interfere with the host’s defensive mechanisms creating regions of microbial colonization
and resulting in bacterial biofilm formation, which subsequently damages the periodontal
tissues [43].
4. Biologic Width and Gingival Biotype Considerations in Fixed Prosthetic

Restorations and Periodontal Health
Biologic width is a natural seal that is present around the teeth, protecting the alveolar
bone from infection and diseases [44]. The biological width is defined as the dimension of
the soft tissue that is attached to the portion of the tooth coronal at the crest of the alveolar
bone [45].
Gargiulo et al. [46] described the dimension of biologic width as consisting of a sulcus
depth of 0.69 mm; junctional epithelium of 0.97 mm (0.71–1.35 mm); and supra-alveolar
connective tissue attachment of 1.07 mm (1.06–1.08 mm). So, the biologic width is commonly
stated to be 2.04 mm, representing the epithelial and connective tissue measurements.
The biologic width is an essential space that must be maintained to ensure periodontal
health in any dental prosthetic restorations [47]. Hence, it is important to preserve the
periodontal health and remove any irritation that might damage the periodontium such
as may occur during prosthetic restorations [45,48]. Considering this, an iatrogenic fixed
dental prosthesis that is constructed in violation of the biologic width predisposes the
development of subgingival caries in the involved teeth and results in an uncontrolled
inflammatory process and periodontal tissue destruction [47].
Nevins and Skurow [49] mentioned that, in cases where the subgingival margins are
indicated, the dentist should not disrupt the junctional epithelium or connective tissue
during tooth preparation and taking an impression. They also suggested limiting the
subgingival margin extension to 0.5–1.0 mm, as it is impossible for the dentist to detect
where the sulcular epithelium ends and the junctional epithelium begins.
In addition, the crown placement margins affect gingival health, especially in subgin-
gival areas. Reitemeier et al. [50] studied the effect of posterior crown margin placement on
gingival health. The variables were: alloy used, location of crown margins, oral hygiene
index score, plaque index, and sulcus bleeding index scores. They found that the lingual
surfaces showed the highest probability of plaque compared to the facial surfaces. The
risk of gingival bleeding at the posterior crown margins was approximately twice that
seen at the supragingival margins. Poor oral hygiene before treatment and the presence
of plaque were also associated with sulcular bleeding. The type of alloy did not influence
sulcular bleeding. The probability of plaque at 1 year increased with an increasing oral
hygiene index score before treatment. In addition, Ercoli and Caton [51] mentioned that
the restoration margins placement within the junctional epithelium and supracrestal con-
nective tissue attachment can be associated with gingival inflammation and, potentially,
recession [51]. The presence of the fixed prostheses finish lines within the gingival sulcus
does not cause gingivitis if the patients are compliant with self-performed plaque control
and periodic maintenance.
The gingival morphology is partially related to the tooth form and shape. Tooth
shapes can be square, triangular, or ovoid [52]. Patients with square-shaped teeth have
more favorable esthetic outcomes due to long proximal contacts and less papillary tissue,
whereas patients with triangular-shaped teeth have a proximal tooth contact located more
incisally and, thus, more tissue height to fill in and a high risk of gingival recession and
black triangle occurrence [53].
Likewise, overlooking the biotype of the gingiva when planning a fixed dental con-
struction could exacerbate the existing pathology [54,55]. For instance, the gingival crevice
depth and the gingival tissue thickness (biotype), as well as the alveolar crest location, vary
among patients and need consideration during the treatment [56,57]. It was found that
the gingival biotype plays an important role in the treatment result [6,21,58,59]. Having
knowledge of the characteristic features of gingival biotypes can help to minimize tissue
resorption and provide improved results in both tooth preparation and gum recession.
Biological width violation, as well as inappropriate tooth preparation, may lead to an
alteration in soft tissue thickness, transforming it into thin gingiva over time. It was con-
firmed that the thick gingiva may undergo alteration to a thin gingival biotype over time in
response to prosthetic treatment [41]. These thin, soft tissues have a higher predisposition
toward recession, which necessitates the supragingival placement of restoration margins
wherever possible.
León-Martínez et al. [60] studied the periodontal behavior of teeth prepared with
horizontal finishing crowns supporting fixed metal-ceramic, zirconia full-coverage crowns,
and fixed partial dentures. In the control teeth, they found higher plaque control and
bleeding upon probing, as well as probing pocket depth; whilst probing attachment levels
were higher around the teeth prepared with horizontal finishing lines supporting complete
coverage crowns and fixed partial dentures. Gingival migration was seen in periodontally
compromised teeth prepared with horizontal finishing lines. They concluded that the teeth
prepared with horizontal finishing lines supporting crowns and fixed partial dentures
present more periodontal disorders than untreated control teeth.
Another useful technique is the tooth preparation margin, a technique designed to
create an anatomic crown with a prosthetic emergence profile, which simulates the shape
of the natural tooth; it is also known as the biologically oriented preparation technique
(BOPT) [61,62]. This is a prosthetic technique for periodontally healthy teeth, which uses a
feather edge preparation in a flapless approach in both esthetic and posterior areas with
fixed prosthetic restorations, achieving high quality clinical and esthetic results in terms of
soft tissue stability at the prosthetic–tissue interface [63]. In addition, the BOPT technique
is simpler and faster during preparation impression taking, temporary crowns’ relining,
and creating the crowns’ profiles, up to the final prosthetic restoration when compared to
chamfer, shoulder, etc.
Agustín-Panadero et al. [61] studied the clinical behavior of crowns and fixed partial
dentures on teeth using a vertical preparation without finish line BOPT. They found that
two years after treatment, the vertical preparation without finish line BOPT produced
gingival thickening, margin stability, and optimal esthetics. Neither crowns nor fixed
partial dentures showed any mechanical complications.
5. Gingival, Periodontal, Hygienic Indexes, and Clinical Manifestations

The consequences of fixed prosthetic constructions fabricated by different biomate-
rials and technologies on healthy and pathological periodontium were investigated by
Avetisyan et al. [21]. The missing teeth of patients with partial edentulousness were recov-
ered with either conventional cobalt-chromium (Co-Cr) based, CAD/CAM Co-Cr based,
or CAD/CAM zirconium dioxide-based ceramic prosthesis. The oral health condition
together with the periodontium was evaluated before and after the placement of the pros-
thetic restorations using different periodontal and hygienic indexes, such as the modified
approximal plaque index (MAPI) and the community periodontal index (CPI). Addition-
ally, the gingival biotype was determined using the probe transparency technique. After
12 months of prosthetic treatment, the mean value of MAPI stayed practically unchanged
in the patients with diagnosed periodontitis with both conventionally manufactured Co-
Cr-based, and CAD/CAM Co-Cr-based ceramic restorations. Furthermore, zirconia-based
ceramic constructions demonstrated better periodontal outcomes, decreased inflammation,
and improved oral hygiene conditions. In addition, the individual periodontal biotype
should be considered before prosthetic rehabilitation to avoid periodontal tissue trauma
and to prevent the colonization of microorganisms [20].
A study by Abduo and Lyons [64] stated that there is no direct association between
the status of the periodontium and the longevity of fixed dental restorations. However, har-
mony between the periodontium and the prosthetic construction is imperative. Otherwise,
the esthetics and the survival of the restoration will be compromised. The gingival tissue
reaction to the prosthetic construction is conditioned by the position of the finish line, the
couture, and the emergence profile of the restoration. The clinical and esthetic results as
well as the gingival tissue reaction are also associated with the restoration cleanability and
pontic design. Even if the pontic design is adequate, it cannot preclude the development of
mucosal inflammation near to the pontic if the oral hygiene conditions are not preserved
via dental biofilm elimination. The patients’ capability to accomplish optimal oral hygiene
is indispensable for the survival of the prosthetic construction, and systematic checkups
provide a chance for the early recognition and management of complications.
The fixed prosthetic constructions may cause inflammation, and when it becomes
chronic, the adaptive mechanisms of immunity are stimulated, involving cellular and non-
cellular immunity. These immune mechanisms have a critical role for the further limitation
of the inflammatory reaction, and in the recovery process with the regeneration and the
restoration of injured tissues. Thus, self- and acquired immune mechanisms should be
synchronized to return the damaged tissue to homeostasis [65]. Ercoli and Caton [66] noted
that the accumulation of plaque and loss of periodontal attachment is related to the type of
prosthetic restorations. The margin of restoration located near the junctional epithelium
can cause periodontal inflammation and gingival recession.
The early development of the lesion takes place as a reaction of local leukocytes
and endotheliocytes to the dental plaque around the prosthetic restoration margins. The
metabolic byproducts of these microorganisms activate junctional epitheliocytes, promoting
cytokines and stimulating neuropeptides release, which leads to the dilatation of blood
vessels. With the development of the pathological process, increased numbers of various
cells such as neutrophils, macrophages, plasma cells, lymphocytes, and mast cells migrate
towards the pathological foci. When the pathological foci are formulated, a transformation
from the self- to the acquired immune response occurs. Plasma cells and macrophages,
as well as B and T lymphocytes prevail; IgG3 and IgG1 subtypes of B lymphocytes also
exist. Blood flow disturbance, as well as collagenolytic activity amplification, is also
observed. There is also an amplified collagen production by fibroblasts. This clinical
phase is accompanied by gingival bleeding, gingival color, and contour alterations, and is
assessed as moderate to severe gingivitis. Clinically, the advancement of lesions results in
the development of periodontitis. In this stage, irreversible periodontal attachment and

alveolar bone loss are detected, clinically and histologically. With the advancement of
inflammation, periodontal pocket development occurs [65,67].
The most common complaints among subjects following prosthetic treatment using
conventionally manufactured metal–ceramic restorations were the occurrence of discol-
oration of the gingival papilla, a dark shade around the restoration margin edges, and
development of gingivitis. Nevertheless, these clinical symptoms were absent when metal–
ceramic restorations were made using the CAD/CAM technology, which is possibly due to
an improved margin adaptation of the metallic base [19]. All of these signs were absent in
the subjects who received zirconia-based ceramic constructions as the zirconium does not
affect soft periodontal tissues and, instead, stimulates the protective mechanisms of the
periodontium. Additionally, clinical recovery was noted at the margin of zirconia-based
ceramic constructions. All mentioned properties are conditioned by less microbial adhesion
to zirconium when compared with base metal [68,69].
Subjects with fixed prosthetic restorations made by the CAD/CAM technology had
improved periodontal response in comparison with conventionally manufactured fixed
dental constructions [70–72]. These fixed restorations perform in an extremely complex
oral environment with uncontrolled elements such as masticatory load, temperature, and
pH changes. Thus, the performance of the prosthetic construction may be affected by the
biomaterials, fabrication technologies, operator skills, or host-related factors.
Before the prosthodontic treatment, no significant changes were found in the periodon-
tal index scores among subjects with various fixed dental restorations. Long-term outcomes
concerning the effects of the dental constructions based on the applied biomaterials and
technics on periodontium were observed in patients 1 year after the prosthetic treatment.
A significant variation was established in the subsequent parameters: healthy sextants
quantity, which was higher among subjects with periodontitis who received zirconia-based
ceramic restorations compared with those with Co-Cr-based ceramic groups. Likewise, the
number of sextants with 4–5 mm periodontal pockets was lower in the subjects with peri-
odontitis who received zirconia-based ceramic restorations compared with a conventionally
fabricated Co-Cr-based ceramic group. Statistical differences regarding the existence of
clinical symptoms such as the hygienic index, bleeding, 6 mm or more periodontal pockets,
as well as excluded segments, were not detected amongst all of the subjects, which were
also approved by the medical examination [21].
The gingival health and oral hygiene condition in subjects following the insertion of
fixed prosthetic constructions were investigated by Basynet et al. [73]. Various factors, such
as the prosthetic construction type (fixed partial denture, single crown) and biomaterial
(metal, metal–ceramic) are statistically related to the gingival condition and oral hygiene.
The gingiva and plaque index [74] was used to examine the teeth and gingiva. The analyses
were performed after 2 weeks and 6 months following the insertion of the prosthetic
construction. No difference was established in the plaque index among the subjects who
received crowns, whereas those with a fixed partial prosthesis presented with significance.
The results for the type of biomaterial were not significant. Statistically, similar outcomes
for the gingival index were displayed. The authors established that the prosthetic crown
had no substantial influence on the gingival and plaque indexes of the subject after 2
weeks and 6 months, whereas the bridges exhibited a considerable effect. Regardless of
the dental material (metal or metal–ceramic) no differences were found on the gingival
and plaque indexes for crowns [68]. The necessity for plaque control and oral health
education programs is needed for the fixed dental prostheses to decrease the occurrence of
periodontal pathology. Moreover, it was shown that fixed dental restorations of various
types affect gingival and periodontal health [21]. The latter statement is consistent with
other studies [66,75,76].
Patients with inflamed periodontal tissues demonstrate periodontal index changes
and clinical symptoms of inflammation (discomfort, bleeding of various severity, gum
tenderness, and halitosis) [77]. A fixed prosthetic restoration may worsen the periodon-
tal status of the mucosa under the pontic if the hygienic condition is not preserved via
plaque elimination. Therefore, the patients’ compliance regarding the preservation of good
hygienic conditions is essential for the survival of the dental construction [64,78].
Al-Sinaidi et al. [76] evaluated the periodontal health in subjects who received fixed
dental restorations, and the outcomes of subgingival and supragingival located crown
margins were also evaluated. The authors noticed higher gingival and plaque indexes as
well as a deeper periodontal pocket in the abutment teeth compared with non-abutment
teeth. Additionally, supporting teeth with higher gingival and plaque index scores as
well as probing pocket depth presented in patients who had their functioning fixed dental
restorations for approximately 5 years, as well as those who were older than 46-years old.
The teeth with subgingival positioned crown edges had considerably lower mean values
for their clinical parameters than the teeth with supragingival crown edges.
When dental prostheses demonstrate greater biofilm buildup and increased inflamma-
tory levels, this suggests that additional measures are required to control these factors [79].
These measures can be mechanical and chemical control aids. Mechanical control consists of
toothbrushes (manual or electric) and toothpaste as well as specific devices for interdental
cleaning. In addition, the chemical agents (antiseptics) exhibit antimicrobial benefits when
used for prosthesis disinfection, though only a few agents can be used safely without
causing damage. The most common chemical agents consist of three types of mouthwash
with antiplaque and antigingivitis effects, which are chlorhexidine (CHX); essential oils
(EOs), ranked second; and cetylpyridinium chloride (CPC) [80,81]. The CHX solution
(0.2%) is the most indicated [81]. EOs are the second choice as they are not as effective as
the CPC solution (0.05% to 0.75%), which, however, has a greater potential for adverse
reactions [80]. The adverse effects of mouthwash includes a transient loss of taste sensation,
bitter taste, soreness and burning sensation of the mucosa, dryness of the mucosa, and
epithelial desquamation [81]. Fluoride solutions can be used for high caries risk patients.
6. Cytomorphometric Analysis Following Fixed Dental Prosthesis

Cytomorphometric analysis is regularly performed in numerous diagnostic proce-
dures [82]. This method, which uses exfoliative cytology, is quite fast, straightforward,
and trustworthy, and permits the repetitive collection of biological substances without
influencing the integrity of the local tissues. Subsequently, the present method can be
accomplished repeatedly in screening programs as well as in the course of dental examina-
tions [83]. Nevertheless, the cytological method for the detection of periodontal pathology
was not defined appropriately until now, and it is infrequently used in dental and peri-
odontal practice [84,85]. The GCF cytomorphometric analysis aids in the identification of
the cellular structure and periodontal pocket composition in subjects with fixed prosthetic
constructions. Alterations in periodontal tissues occur during prosthetic treatment with
fixed prosthetic constructions, which take place during the initiation of the adaptive and
regenerative processes [86].
Recently, inflammation dynamics in the periodontium was studied by Heboyan et al. [77]
using the cytomorphometric method before and after the insertion of fixed prosthetic
restorations (Co-Cr-based ceramic restorations made by the conventional technique as
well as the Co-Cr and zirconium dioxide-based ceramic constructions made using the
CAD/CAM technology) among healthy patients and patients with periodontal pathology.
The authors concluded that, irrespective of the restoration type applied, no substantial
alteration in the parameters was recognized among healthy subjects, before and after 1 year
of prosthodontic treatment. Among all of the observation groups, the oral epitheliocyte
quantity considerably increased while the polymorphonuclear leukocyte (PMNs) count
significantly reduced following the insertion of the prosthetic constructions. Nevertheless,
the CAD/CAM restorations showed an improved periodontal response. The records were
similar to studies reported by other researchers [85,87].
Flat epitheliocytes and PMNs are the main constituents of the cellular scatter of gingi-
val cytograms. The existence of these cells was observed in healthy patients and subjects
with periodontal pathology. With the development of inflammation in the periodontal

tissues, the quantity of PMNs, which are considered harmful to the periodontium, increased
in all groups. The GCF sample analysis for the subjects with different fixed prosthetic
restorations showed cytomorphological variations that were possibly associated with the
fabrication technology and the biomaterial used in the dental restorations. The increased
amount of PMNs in the GCF smear samples demonstrated an alteration in vascular per-
meability of the tissues in contact with periodontal microorganisms and the existence of
an inflammatory reaction among the patients with periodontal pathology, which was also
accompanied by a reduction in oral epitheliocyte count [86].
CAD/CAM fabricated constructions display improved periodontal reaction. Several
CAD/CAM ceramics (e.max CAD HT, Empress CAD; e.max CAD LT; and Mark II) were
investigated on human oral keratinocytes (HOK), cell viability, adenylate kinase, and
excretion of human gingival fibroblasts (HGF) [71]. The authors stated that there were
no substantial differences in the migration ability and cell viability of HGF and HOK on
the CAD/CAM all-ceramic biomaterials. On the contrary, the conventional cast alloys
for making metal–ceramic restorations are composed of metals such as Co, Ni, Cr and
accompany multiple biocompatibility issues that influence the final result [72,88,89]. The
existence of saliva or electrolytes may produce corrosion byproducts from the various
ions from the cast alloy in tissues, which may modulate the immune system [90,91]. Ni
released from Ni-containing alloys release Ni ions, which causes various reactions [92,93].
For instance, Ni-free alloys are less vulnerable than Ni-containing alloys [88,92]. Zirconium
is an extremely biocompatible ceramic biomaterial and is stable in the corrosive oral
environment [94–96]. Shang et al. [96] found that interleukin-6, TNF-α, the bleeding
index, and the probing depth were all considerably high in nickel-chromium (Ni-Cr) based
ceramic constructions but not in the CAD/CAM fabricated zirconia. These indicate that
the all-ceramic and zirconia restorations are favorable to the health of the periodontium.
The alteration in the leukocyte-epithelial index is associated with the clinical signs of
the pathology. Certainly, as the pathology develops, the PMNs are the primary protectors,
and these typical modifications were detected in the GCF cytograms. The PMNs exist
while fixing various types of prosthetic constructions, but their quantity was diverse.
Better cytomorphometric data were noted among the subjects with periodontal pathology,
depending on the biomaterial of the dental constructions [86,96].
Numerous studies have demonstrated the cytological composition of the GCF in peri-
odontitis for diagnostic purposes [65,97–99]. Rizo-Gorrita et al. [100] studied the surface,
cellular proliferation, and cellular morphology between Yttrium-stabilized tetragonal zirco-
nium (Y-TZP) (VITA YZ® T, VITA Zahnfabrik, Postfach, Germany) and zirconia reinforced
lithium silicate ceramics (ZLS) (Celtra® Duo, Degudent, Hanau-Wolfgang, Germany). They
found that the ZLS surface has a porous, non-homogeneous, irregular structure with
crater-like areas and random distribution, while Y-TZP demonstrated a concentric, parallel
grooved pattern, resulting from the disc manufacturing process. In addition, higher pro-
liferation and spreading were seen on the surface of Y-TZP (Figure 4). This indicates that
Y-TZP is a better transgingival implant material.
It has been found that there is a lack of comparative records concerning the alteration
in the GCF parameters during prosthetic rehabilitation using fixed restorations manu-
factured from different biomaterials [100]. Without preventive measures, inflammatory
processes in the periodontal tissues might cause additional tissue damage resulting in
untimely tooth loss [101–103]. Pathological advancement may occur as a result of oral
keratinocyte reactions to the existence of periodontal lesions [104–106]. In a healthy peri-
odontium, oral keratinocytes are continuously shed and exchanged by basal progenitors
inside the gingival crevice. Particularly, the rate of transformation increases as the pathol-
ogy advances [107–109]. Moreover, the PMNs are abundant in the gingival pockets among
subjects with periodontal pathology. It was reported that 47% of the cells of the gingival
crevice were leukocytes, with 98% being PMNs. Particularly, the total quantity of cells
increases as the inflammation advances with the differential quantity of PMNs (95–97%),
mononucleocytes (2–3%), and lymphocytes (1–2%) [65,110].
Figure 4. Images of surface structure using scanning electron microscopy (at 200× magnification)
of ZLS (A1) and Y-TZP (A2); and confocal microscope images (20×) of fibroblasts on ZLS (B1) and
Y-TZP (B2) [100].
7. Salivary pH and GCF pH on Gingival and Periodontal Health

The normal pH of saliva is 6.7 (6.2–7.6), which is close to neutral, and the resting pH
of the mouth does not fall below 6.3 [111]. There is an association between saliva pH and
gingivitis and periodontitis. Plaque bacteria take calcium compounds and use the minerals
to protect them from the high pH [111,112]. The two key factors of plaque formation are
as follows: firstly, there must be oral bacteria to attack food particles and increase the pH;
secondly, the pH must elevate to above 7.6 in order to grow the dental plaque crystals that
cause periodontal disease. The saliva contributes to the maintenance of the pH via two
mechanisms [111]: firstly, the flow of saliva removes the carbohydrates that are metabolized
by bacteria and remove the acids produced by bacteria; secondly, the saliva neutralizes the
acidity produced by drinks, foods, and bacterial activity, by the buffering activity of saliva.
GCF is an environment of organism with a complex composition consisting of leuko-
cytes, desquamated epithelial cells, microorganisms, electrolytes, proteins, enzymes, and
other substances [72]. The normal pH of GCF is a more alkaline 7.5–8.7 [113]. One of the
most significant factors of the GCF is the pH, which is of great importance to providing
an optimal environment for metabolic processes. The amount of secreted gingival fluid
is known to serve as an objective criterion to assess the condition of periodontal tissues.
It is an informative indicator among other diagnostic tests to determine the presence and
severity of the inflammation in periodontal diseases [72,73].
Thus, alkaline pH is essential for plaque growth, as suggested by the mildly alkaline
pH of the saliva obtained from the subjects with generalized chronic gingivitis. In addition,
there is a correlation between the pH level and the microflora in periodontal pockets [114]
and it is found that the periodontopathogens grow at a mildly acidic pH [115,116]. Hence,
salivary pH in patients with chronic generalized gingivitis is more alkaline than that in
patients with clinically healthy gingiva. In patients with chronic generalized periodontitis,
the salivary pH is more acidic [111]. More studies are needed to study the physiology.
The qualitative and quantitative assessment of the GCF can be an indicator of the
periodontal status, and its examination helps in the diagnosis of oral diseases [117–120]. The
examination of the GCF can be a diagnostic tool to discover host-microbial communications
and to reveal the phase of periodontitis [121–123].
Heboyan et al. [42] studied the peculiar features of the GCF parameter dynamics
among subjects with fixed prosthetic constructions made using different biomaterials
and manufacturing techniques. The results of studying the amount of the excreted GCF
in subjects before the restoration of their masticatory function via dental prostheses of
various biomaterials and manufacturing techniques, as well as after prosthetic treatment,
found that the amount of excreted GCF increased 1.38-fold following restoration using
the conventionally fabricated cobalt-chromium-based ceramic prostheses. Furthermore,
the greatest amount of GCF is excreted in the first 6 months following the insertion of the
prosthesis. On the contrary, a decrease in the excretion of GCF volume is observed between
6 months and up to 1 year. An approximate 2-fold reduction in GCF volume was observed
in subjects with CAD/CAM fabricated restorations 12 months after prosthetic treatment.
The reduction in this value occurs progressively and approaches a value within the normal
range in the later period of up to 1 year. This tendency was noted in all prosthetic groups.
The results received upon studying the dynamics of the GCF volume before and after
the restoration of masticatory function found that the largest improvement in indexes is
noted among patients with zirconia-based dental prostheses, as well as with Co-Cr-based
ceramic prostheses fabricated by CAD/CAM technology. An insignificant GCF volume
increase seen a year after the insertion of a fixed metal–ceramic restoration among certain
subjects can be explained by poor oral hygiene, which influenced the statistical data of all
observation groups.
Furthermore, when the margins of the artificial crown are placed subgingivally, the
tissues of marginal gum are subjected to more noticeable inflammation. According to the
data, oral hygiene improves during the process of prosthetic treatment [21], with GCF
pH, and periodontal status changing [77,124] for the better. The study on the pH of GCF
found that following the restoration of masticatory function by dental prosthesis of various
frames and manufacturing techniques showed an increase in the pH index when compared
to the data obtained before the prosthetic treatment. The preventive measures lead to the
normalization of oral fluid pH due to the improvement of metabolic processes within the
oral cavity.
8. Bacteriological Evaluation Following Dental Prostheses

Oral microbiota and bacterial associations of the GCF among subjects with fixed
prosthetic restorations fabricated by different materials and manufacturing methods were
assessed by Heboyan et al. [124]. The observation of the clinical picture showed a diversity
in prosthetic treatment and presented some peculiarities depending on the nature of the
dental biomaterials and technologies used for production. Among the oral pathological
microflora, Porphyromonas gingivalis demonstrated an exceptional capability to coaggregate
with Fusobacterium spp. and with primary invaders, such as Streptococcus spp. [125,126].
This clarifies its initial existence in formulating dental plaque [127], which is commonly
released from the periodontal pockets among elder subjects with periodontal pathology.
The existence of Porphyromonas gingivalis is related to an increase in cytokine release by
defensive local cells [128,129]. Presenting a minor element of subgingival microflora, it
considerably impacts the microbiome, devastating self-immunity pathways. Gram negative
anaerobic microorganisms such as Fusobacterium nucleatum (F. nucleatum) have a central
role in biofilm development, providing a connection between early and late invaders and
forming the structure of the biofilm, and consequently, improving the adhesive properties
of more of the microbes related to periodontal pathology [130,131]. Both P. gingivalis and
F. nucleatum are also capable to join and enter into the host epitheliocytes and initiate
the immune-inflammatory process of the host. Peptostreptococci are associated with other
microorganisms and considered pathogens of mixed infections.
Generally, most microbes of the oral microbiome are symbionts that sustain a high
degree of homeostasis and the healthy condition of the mouth [132]. The vast majority
of oral microbial species are saprophytes and not harmful to the host. Although various
microbes of biocenosis alter frequently in different regions of the human body, each person
typically has more or less specific bacterial populations. The challenges in the microbiologic
differentiating of Bacteroids in healthy and in different pathological situations of the oral
tissues do not permit the recognition of a definite causative agent of the pathological
process [124].
The differential microbial species and metabolites in the GCF among those with
periodontal pathology and healthy subjects are potential biological indicators, indicating
a possible approach to forecast, diagnose, and accomplish individualized periodontal
treatment [133–136]. Periodontal pathology is related to misbalanced homeostasis in the
oral tissues, microbial progression, and development of the dental biofilm on the dental
prostheses. However, data on periodontal pathogens relative to periodontitis and in subjects
with healthy periodontium are insufficiently presented. Moreover, the inter-relationship
between host and microorganisms, as well as biochemical metabolic processes, has not
been acknowledged [137,138].
The colonization of the gingival crevice with various microorganisms was observed
at various fixed prosthetic restorations. Candida albicans noted in smear samples re-
sulted in an inflammatory reaction in the periodontium when using Co-Cr-based ceramic
dental restorations of the conventional fabrication technique, which possibly related to
the weakening of the immunity in the gingival crevice. The same picture was revealed
when fixed Co-Cr-based ceramic restorations were made using the CAD/CAM technique;
there was a difference in the microflora number in the subjects who received the con-
ventionally fabricated Co-Cr-based ceramic dental restorations. Zirconia-based ceramic
restorations showed the best outcomes both in the qualitative and quantitative composition
of microbiota in the gingival crevice. After 12 months of prosthetic rehabilitation with
cobalt-chromium-based ceramic and zirconia-based ceramic fixed full coverage restora-
tions, a quantitative reduction in various microorganisms, such as Prevotella intermedia,
Streptococcus haemolyticus, Porphyromonas gingivalis, Fusobacterium spp., and Corynebacterium
anaerobium was observed [124].
It is worth mentioning that Candida albicans were found during the bacteriologic and
bacterioscopic analyses of subjects with fixed prosthetic restorations, within 1 year of
follow-up, which reliably confirmed their existence. Candida albicans is also presented
in normal microbiota in the form of saprophytes. Hence, the qualitative and quantitative
elements of fungal pathology can be exposed only via bacterioscopy. Recent research
showed the existence of pathological reactions in identifying more than six well-stained
pseudomycelia [124].
Mechanical preparation of the teeth is found to be harmful and to cause the worsening
of periodontal status if not done properly. Nevertheless, after 1 year of prosthetic rehabilita-
tion with fixed prosthetic constructions, periodontal recovery occurs among patients who
received constructions made using the CAD/CAM technique. Additionally, a quite notice-
able transformation towards clinical healing was revealed among patients with zirconia
restorations because zirconium is less harmful to the periodontal tissues due to the reduced
risk of dental biofilm accumulation. Additionally, zirconium is more biocompatible and tol-
erable to soft tissues and oral cavity structures [5,42]. Thus, the periodontium was healthier
in cases where the prosthetic treatment was accomplished using restorations manufactured
by the CAD/CAM technic. This could have been due to the biomaterial rather than the
manufacturing technique only [71,96]. Souza et al. [139] evaluated biofilm formation on
various biomaterials used in prosthetic rehabilitation. No significant differences (P < 0.05)
in absorbance and CFU/cm2 between biofilm growth on zirconia, porcelain, and titanium
were found. A microbiological analysis related to microscopic examination discovered a

higher accumulation of oral biofilms on Co-Cr-based biomaterials than on Ti or Zr, which
are used for prosthetic constructions (Figures 5 and 6).
Periodontal pathology around abutment teeth can be assessed with numerous new
methods when fixed prosthetic restorations are performed. Oral metabolism and oral mi-
croflora, as well as the associations between them, have been investigated by Pei et al. [133].
They reported some possible biomolecules that could be used as valuable markers for
preventive, prognostic, and individualized medicine in advanced chronic periodontal
pathology. They demonstrated that the metabolic products and microorganisms in the GCF,
together with clinical data exhibited a clear trend. The periodontal pathology could be
reflected in the shift of the oral bacteria and the alteration in metabolic products in the GCF.
A combination of both N-carbamylglutamate and citramalic acid produced reasonable
accuracy for the prognostic diagnosis of widespread chronic periodontal pathology. Like-
wise, Oral Chroma™ was used to investigate the volatile sulfur compounds (VSCs) among
subjects with temporary and permanent fixed dental restoration by Sinjari et al. [140].
They established that the Oral Chroma™ provides a complete evaluation of the VSCs as a
diagnostic tool of oral malodor and that specialized oral hygienic procedures appeared to
impact VSC production.
Figure 5. SEM figures received on commercially pure Ti surfaces (A,B) and Cr-Co-Mo alloys (C,D)
covered with biofilms after 24 h (A,C) and 48 h (B,D) of growth in a BHI medium supplemented with
5% sucrose. Figures obtained using secondary electrons mode (SE) at 10 kV [139].
Figure 6. SEM figures received on feldspar-based ceramics (A,C) and Zr (B,D) covered with biofilms
after 24 h (A,B) and 48 h (C,D) of growth in a BHI medium supplemented with 5% sucrose. Figures
obtained using secondary electrons mode (SE) at 10 kV [139].
There has been considerable advancement in clinical dentistry [141–145]. With the use
of advanced 3D digital technologies, teeth preparation can be evaluated, and the prosthesis
can be fabricated accurately [146–148]. These help to minimize errors such as marginal gaps,
discrepancies, etc. At present, restorative dentists are refining their practice and dental
clinics are acclimatizing from conventional treatment methods to a digital workflow in the
fabrication of dental prostheses [149]. Indeed, 3D printing techniques are now employed in
developing simulators and models for dental education and the maintenance of prostheses.
However, expertise is needed for the digital additive manufacturing of dental restorations
used in prosthetic dentistry.
Finally, when planning a fixed dental prosthesis, adequate periodontal assessment
and treatment, appropriate instructions, and motivation in self-performed plaque control
as well as compliance to maintenance protocols, appear to be the most important factors
to limit or avoid any potential negative effects on the periodontium caused by fixed
prostheses [51,134].
9. Conclusions
Before starting prosthetic treatment, the condition of the periodontal tissues should be
evaluated for their oral hygiene status, as well as the gingival and periodontal conditions.
Determination of the gingival biotype, as well as the parameters of the GCF (amount, pH
index, microbiological and cytomorphometric parameters), helps in the assessment and
diagnosis of gingival and periodontal diseases as well as their successful management.
Zirconium-based restorations made from the CAD/CAM technology provide better results,
in terms of marginal fit, inflammation reduction, maintenance, and the restoration of
periodontal health and oral hygiene, as compared to constructions made by conventional
method and from other alloys. Compared to subgingival margins, the supragingival
margins offer better oral hygiene, which can be maintained and does not lead to secondary
caries or periodontal disease.
Author Contributions: Conceptualization, A.H., Z.K., V.S. and D.R.; methodology, A.H. and D.R.;
software, A.H.; validation, D.R. and V.S.; formal analysis, A.H. and G.V.O.F.; investigation, A.H. and
D.R.; resources, A.H. and D.R.; data curation, A.H. and A.M.; writing—original draft preparation, A.H.
and D.R.; writing—review and editing, A.H., M.S.Z., Z.K., A.M., D.R. and G.V.O.F.; visualization, V.S.,
A.H., M.S.Z., Z.K., A.M. and D.R.; supervision, D.R. and V.S.; project administration, A.H.; funding
acquisition, V.S. All authors have read and agreed to the published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Data Availability Statement: Not applicable.
Conflicts of Interest: The authors declare no conflict of interest.
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1 Department of Prosthodontics, Faculty of Dentistry, Chulalongkorn University, Bangkok 10330, Thailand;

J. Funct. Biomater. 2022, 13, 15. https://doi.org/10.3390/jfb13010015 https://www.mdpi.com/journal/jfb

2. Materials and Method

3. Marginal Fit and Internal Adaptation of Fixed Dental Prostheses

shown that the internal discrepancy of digitally manufactured CAD/CAM restorations

Figure 3. Consequences of the crown’s margin misfit.

4. Biologic Width and Gingival Biotype Considerations in Fixed Prosthetic

5. Gingival, Periodontal, Hygienic Indexes, and Clinical Manifestations

the development of periodontitis. In this stage, irreversible periodontal attachment and

6. Cytomorphometric Analysis Following Fixed Dental Prosthesis

with periodontal pathology. With the development of inflammation in the periodontal

7. Salivary pH and GCF pH on Gingival and Periodontal Health

8. Bacteriological Evaluation Following Dental Prostheses

were found. A microbiological analysis related to microscopic examination discovered a

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