J Clin Exp Dent. 2024;16(8):e1040-5.

Stabilization of gingival tissues

Journal section: Esthetic Dentistry doi:10.4317/jced.61837

Publication Types: Case Report https://doi.org/10.4317/jced.61837

Gingival margin stabilization using the final

prosthetic restoration (BOPT). A case report

María Granell-Ruiz 1,2

, Ruggero Bertolini 1,2
, Cristina Rech-Ortega 1,2
, Begoña Oteiza-Galdón 1,2
, Kheira
Bouazza-Juanes 1,2

1
Universidad Europea de Valencia. Faculty of Health Sciences. Department of Dentistry
2
Clinical and Applied in Dental and Implant-Prosthetics Research Group. Universidad Europea de Valencia. Faculty of Health
Sciences. Department of Dentistry

Correspondence:
Paseo Alameda, nº7, 46010, Valencia, España
[email protected]

Received: 22/06/2024
Accepted: 08/07/2024

Granell-Ruiz M, Bertolini R, Rech-Ortega C, Oteiza-Galdón B, Bouazza-

Juanes K. Gingival margin stabilization using the final prosthetic restora-
tion (BOPT). A case report. J Clin Exp Dent. 2024;16(8):e1040-5.

Article Number: 61837 http://www.medicinaoral.com/odo/indice.htm

© Medicina Oral S. L. C.I.F. B 96689336 - eISSN: 1989-5488
eMail: [email protected]
Indexed in:
Pubmed
Pubmed Central® (PMC)
Scopus
DOI® System

Abstract
One of the most contentious and extensively discussed topics in the field of dentistry when fabricating prosthetic
restorations is the location and design of the finishing line in relation to the gingival tissues. Upon completion of the
temporary crown and subsequent fabrication of the final restoration, two potential issues may arise: 1) the analog
or digital impression may not accurately reflect the shape of the gingiva obtained with the temporary crown due to
gingival collapse upon crown removal, even in the presence of retraction cords; and 2) the desired gingival shape
may not have been achieved with the temporary crown. The objective of this article is to describe the stabilization
of gingival tissues following twelve weeks of clinical observation. During this period, the provisional crown is
recontoured twice in the apical-coronal direction with a four-week interval. This approach allows for the growth of
sufficient gingival tissue in the horizontal direction at the point of the vestibular emergence profile, which will then
stabilize once more following a slight recontouring of the final restoration, which will be performed in the clinic.
The amount of gingival adaptation is not quantifiable in a numerical sense; rather, it is directly proportional to the
amount of tissue that can be obtained with the new emergence profile of the temporary crown. The outcome is
contingent upon the operator and there is no fixed quantity that can be achieved in every instance. In essence, there
is no fixed numerical value that can be relied upon to lower the gingival parabola in the apical-coronal direction
through the adaptation of tissues to the new shape of the temporary crown emergence profile.

Key words: Vertical preparation, BOPT technique, tissue stabilization, final restoration.

e1040
J Clin Exp Dent. 2024;16(8):e1040-5. Stabilization of gingival tissues

Introduction called for the preparation of teeth at the level of the os-
One of the most contentious and extensively discussed seous crest after the creation of a flap. This was done to
topics in the field of dentistry when fabricating prosthe- eliminate undercuts, facilitate the final preparation, and
tic restorations is the location and design of the finishing the impression. The protocol involved deepening the
line in relation to the gingival tissues (1). “barrelling-in” (accentuated preparation of the existing
Two principal trends have emerged in dental prepara- anatomical concavities on the coronal body at the bifur-
tions throughout history. The first is characterized by a cation), correcting the root proximities of adjacent teeth,
clearly defined finishing line, while the second is defined and reducing the concavity of the roots. Subsequently,
by a vertical preparation without a visible line but with a the tissues were allowed to heal. If possible, a slight
finishing area (2). Among the vertical preparations, two chamfer was made on the tooth as a finishing line for the
distinct types are described in the literature, with their prosthetic margin 8-12 weeks after surgery. In contrast,
definitions provided in the glossary of prosthodontic ter- if the residual tooth structure was insufficient to permit
ms (1): the chamfer to be made, the vertical preparation made
• FEATHER-EDGE FINISH LINE: the demarcation be- during surgery also served as the final prosthetic prepa-
tween prepared and unprepared tooth structure created ration (7,8).
by minimal tooth preparation without a defined visible In 2013, Ignazio Loi introduced his personal philosophy
line of reference for the cavosurface finish line such as a of vertical preparation, which he termed the Biologica-
shoulder or chamfer finish line. lly Oriented Preparation Technique (BOPT). The author
• KNIFE-EDGE FINISH LINE: a clearly defined junc- defines this technique as a simplified prosthetic protocol
tion of prepared and unprepared tooth structure that lac- that employs vertical “feather edge” preparation in the
ks a concavity at the gingival termination. initial phase of treatment, followed by the immediate
According to Shillinburg, vertical preparations have placement of a provisional restoration. This provisional
always been considered inappropriate for the fabrication restoration plays a fundamental role in the stabilization
of metal-ceramic or all-ceramic crowns. This is due to of the gingival tissues (2).
the lack of marginal adaptation, horizontal overcontou- The provisional crown, placed immediately after the
ring, and the potential distortion of the ceramic during preparation, facilitates the healing of the surrounding
firing, which can negatively impact periodontal health tissues in accordance with its shape. Loi has demonstra-
(3). However, recent studies have demonstrated that res- ted, through extensive research, that the gingiva adapts
torations with vertical preparations offer superior perio- to the shape of both the provisional crown and the final
dontal health compared to those with horizontal prepa- restoration over time. This is accomplished by reshaping
rations (4). the emergence profiles and adapting the gingival sca-
Historical introduction of vertical preparations llops obtained by the new prosthetic shape (2).
One of the first published articles to discuss vertical pre- Upon completion of the temporary crown and subse-
parations was by Morton Amsterdam and Luis Abrams, quent fabrication of the final restoration, two potential
members of the working group of M. Goldman and W. issues may arise:
Cohen of the Department of Periodontology at the Uni- • The analog or digital impression may not accurately
versity of Pennsylvania. Their article described the pos- reflect the shape of the gingiva obtained with the tempo-
sibility of performing a vertical preparation on periodon- rary crown due to gingival collapse upon crown remo-
tal teeth without periodontal surgery (5). val, even in the presence of retraction cords.
Subsequently, in 1974, V. Pollard conducted a study to • The desired gingival shape may not have been achie-
identify the optimal characteristics of the diamond burs ved with the temporary crown.
to perform a correct gingival curettage of the epithelial At this juncture, the laboratory technician assumes a pi-
sulcus. This procedure was performed simultaneously votal role in fabricating the final crown according to the
with tooth preparation. clinician’s specifications. These specifications include
In the 1980s, the technique was revived by Rex Ingra- the crown shape, emergence profile, gingival zenith, etc.
ham. In his article, Ingraham described a gingival cu- As previously stated, the gingiva will adapt to the new
rettage procedure with rotary instruments. This techni- prosthetic shape (2).
que was designed to prepare the tooth and the gingival The bisque try-in offers the opportunity to ascertain
sulcus. In practice, the procedure was performed in the whether the information provided to the laboratory was
intraepithelial sulcus using a bur to create an “elongated sufficient to fabricate a crown that meets the clinician’s
chamfer” (6). expectations. Nevertheless, it is possible that, at the time
In the 1990s, the working group of the Porta Mascare- of delivery of the final restoration, the gingival contour
lla School of Bologna in Italy, with Di Febo and Car- may not exhibit the optimal shape or the correct zenith
nevale, adopted a perio-prosthetic clinical protocol for position. This is the point at which minor modifications
cases with severe periodontal compromise. The protocol to the morphology of the new restoration can be made in

e1041
J Clin Exp Dent. 2024;16(8):e1040-5. Stabilization of gingival tissues

the clinic, with the aim of facilitating adaptation of the -Clinical sequence
tissues to the shape of the final restoration. Following the removal of the old bridge, the abutment
The objective of this article is to describe the stabiliza- teeth are prepared with a vertical preparation. A tem-
tion of gingival tissues following twelve weeks of cli- porary bridge is then placed and kept in place for four
nical observation. During this period, the provisional weeks, in accordance with the steps described in the
crown is recontoured twice in the apical-coronal direc- BOPT technique (2). In this case, the temporary bridge
tion with a four-week interval. This approach allows for is provided with a slightly more accentuated emergence
the acquisition of sufficient gingival tissue in the hori- profile to achieve a greater amount of gingival tissues
zontal direction at the point of the vestibular emergence horizontally (Fig. 1d). After this time, it is observed that
profile, which will then stabilize once more following a a considerable increase in the gingival tissues horizon-
slight recontouring of the final restoration, which will be tally has been achieved. As the soft tissues adapt to the
performed in the clinic. shape of the prosthesis and the intention of the treatment
is to modify the gingival parabola in an apical-coronal
Case Report direction, it is necessary to lower the contour of the
A 60-year-old female patient presented to the clinic with emergence profile of the provisional prosthesis by 1mm
generalized wear on all her teeth, which was attributed every four weeks.
to bruxism. Upon intraoral examination, it was obser- The extent of tissue adaptation to the novel emergence
ved that the patient had a metal-ceramic bridge on teeth profile is directly proportional to the quantity of tissue
23 to 26, with teeth 24 and 25 absent. Furthermore, a that has been successfully obtained horizontally (Fig.
notable gingival displacement was observed at the cer- 2a).
vical region of tooth 23. The proposed treatment plan The image (Fig. 2b,c) illustrates a good adaptation of
for the patient includes a complete rehabilitation with the gingival contour to the prosthetic morphology de-
minimally invasive restorations in both the anterior and termined by the temporary bridge. This adaptation was
posterior sectors. In the anterior sector, ceramic veneers achieved by lowering the bridge contour by 1mm every
will be utilized, while in the posterior sector, composi- 4 weeks, with the objective of leveling the gingival
te overlay restorations will be employed to restore the parabola of tooth 23 to that of tooth 13. Following the
vertical dimension lost as a result of bruxism. Additio- recontouring of the provisional bridge twice, it was de-
nally, the metal ceramic bridge will be replaced with a termined that the position of the gingival margin at 23
zirconia-ceramic bridge. This will entail attempting to was comparable to that of the contralateral side, and a
migrate the gingival tissues in an apical-coronal direc- final impression was taken for the fabrication of a zirco-
tion using the BOPT technique, after which they will nia-ceramic bridge from 23 to 26 by a laboratory techni-
be stabilized, obviating the need for a periodontal graft. cian. Upon receipt of the completed prosthesis, a slight
(Fig. 1a-c). asymmetry was observed between teeth 23 and 13. This

Fig. 1: a-c) Initial clinical photos showing the apical displacements of the gingival tissue. d) Temporary bridge.

e1042
J Clin Exp Dent. 2024;16(8):e1040-5. Stabilization of gingival tissues

Fig. 2: a) Scheme of the horizontal-vertical platform; b) Neo angiogenesis; c) Adaptation of the gingival parabola to the
new emergence profile, reduction of gingival thickness in the horizontal direction; d) Amount of tissue that was obtained
in a horizontal direction; e) The contour of the final prosthesis was lowered in an apical-coronal direction.

prompted the decision to recontour the emergence profi- displacements of the gingival tissues may occur. This
le of the final prosthesis in the position of tooth 23, due to can be attributed to various factors, including iatrogenic
the amount of available gingival tissue in the horizontal damage during dental preparation, failure of restoration
plane. Therefore, the contour of the final prosthesis was adjustment at this level, traumatic factors such as occlu-
lowered in an apical-coronal direction (Fig. 2d). This is sion, an incorrect and/or aggressive brushing technique,
done on a horizontal-vertical platform, with a reduction or it can even be related to the periodontal phenotype of
of approximately 1mm of the zirconia-ceramic, using a the patient (9-12).
120-micron truncated conical bur in a high-speed han- In contrast, the BOPT technique described by Loi, which
dpiece and abundant water. Subsequently, the ceramic is involves the creation of vertical “feather-edge” prepara-
manually polished using a handpiece and specific cups tions, does not have a defined “finishing line”. Instead, it
and discs designed for this purpose. Finally, the bridge is has a “finishing area”. The laboratory technician is res-
cemented with temporary cement. ponsible for determining the starting line of the restora-
In this context, it is of paramount importance that a thorou- tion, based on the information provided by the gingival
gh manual polishing of the ceramic be conducted following tissues (2). Restorations with vertical preparations have
the high-speed handpiece recontouring. This should be been demonstrated to offer superior periodontal health
done using specific polishing pastes and cups. compared to restorations with horizontal preparations (4).
At one week, the patient was examined and a slight displa- The gingitage performed during vertical preparation and
cement of the gingival tissues in an apical-coronal direction the use of a provisional restoration are essential for thic-
was already evident, adapting to the new emergence profile kening and stabilizing the gingival tissues (13,14). In the
of the final restoration. After three months, an optimal aes- original BOPT technique, Loi recommends recontouring
thetic situation was observed in which the gingival parabo- the temporary restoration to correct the gingival margin
la of tooth 23 was aligned with its contralateral tooth 13. coronally or apically (2). Given that soft tissues continue
This corroborates our hypothesis that the gingival parabola to remodel and adapt to the shape of the final crown over
adapts the to the new prosthetic shape, if there is adequate time (15), and the availability of sufficient tissue in the
tissue availability in the horizontal direction (Fig. 3). horizontal direction, it was decided to directly recontour
the emergence profile of the final crown.
Discussion
In horizontal “knife-edge” dental preparations, i.e. with Conclusions
a finishing line, where the final restoration is cemented According to the authors’ experience, the amount of gin-
at that level, it has been observed over time that apical gival adaptation is not quantifiable in a numerical sense;
e1043
J Clin Exp Dent. 2024;16(8):e1040-5. Stabilization of gingival tissues

Fig. 3: a) The bridge before ceramic recontouring; b) Juncture of ceramic recontouring; c) At 12 months, the gingival
parabola adapts the to the new prosthetic shape, because there is adequate tissue availability in the horizontal direc-
tion; d and f) A symmetry is observed at the level of the gingival parabolas of 13 and 23; e) Juncture at which ceramic
recontouring takes place; g) The first temporary bridge; h) Situation at 12 months.

rather, it is directly proportional to the amount of tissue Data Availability Statement

that can be obtained with the new emergence profile of The datasets used and/or analyzed during the current study are availa-
ble from the corresponding author.
the temporary crown. The outcome is contingent upon
the operator and there is no fixed quantity that can be Author Contributions
achieved in every instance. In essence, there is no fixed Not specified.
numerical value that can be relied upon to lower the gin-
Funding
gival parabola in the apical-coronal direction through None.
the adaptation of tissues to the new shape of the tempo-
rary crown emergence profile. Conflict of interest
The amount of tissue that will gradually adapt, through Declared none.
the adjustments of the temporary prosthesis, will decrea-
se until it stabilizes (reducing horizontally) with an ideal References
1. Keith J. Ferro, Steven M. Morgano, Carl F. Driscoll, Martin A. Frei-
shape that will depend on the anatomy of the complex lich, Albert D. Guckes, Kent L. Knoernschild, Thomas J. McGarry.
formed by the prosthetic element, the supporting tissue, The Glossary of Prosthodontic Terms, Ninth Edition GPT-9. Editorial
and the new prosthetic emergence profile. Staff Glossary of Prosthodontic Terms Committee of the Academy of
Once the final prosthesis has been cemented, the gin- Prosthodontics.
2. Loi I, Di Felice A. Biologically oriented preparation technique
gival tissues will continue to remodel and adapt to the (BOPT): a new approach for prosthetic restoration of periodontically
new prosthetic shapes. The embrasure spaces will subse- healthy teeth. Eur J Esthet Dent 2013; 8:10-23.
quently close, and the gingival margin will thicken and 3. Shillinburg HT, Hobo S, Fisher DW. Preparation design and margi-
assume a “gull-wing” silhouette. nal distortion in porcelain fused to metal restorations. J Prosthet Dent
1973; 29(3): 276-284.
Further clinical studies with patients are necessary to 4. Al-Haddad A, Arsheed NAA, Yee A, Kohli S. Biological oriented
confirm and contrast these results. preparation technique (BOPT) for tooth preparation: A systematic re-
view and meta-analysis. Saudi Dent J. 2024 Jan;36(1):11-19.
Acknowledgement 5. Amsterdam M, Abrams L. Periodontal prosthesis. In: Goldman HM,
Declared none. Cohen DW (eds). Periodontal therapy, 4th ed St. Louis: CV Mosby
Co, 1968.
Informed Consent Statement 6. Ingraham R, Sochat P, Hansing FJ. Rotary gingival curettage--a
The authors certify that the patient or patients involved have given technique for tooth preparation and management of the gingival
their permission for publication in the journal. sulcus for impression taking. Int J Periodontics Restorative Dent.
1981;1(4):8-33.

e1044
J Clin Exp Dent. 2024;16(8):e1040-5. Stabilization of gingival tissues

7. Di Febo G, Carnevale G, Freni Sterrantino S. Treatment of a case

of advanced periodontitis: Clinical procedures utilizing the “combined
preparation technique”. Int J of Perio Rest Dent. 1985;1:53-62.
8. Carnevale G, di Febo G, Fuzzi M. A retrospective analysis of the
perio-prosthetic aspect of teeth reprepared during periodontal surgery.
J Clin Periodontol. 1990;17:313-316.
9. Knoernschild KL, Campbell SD. Periodontal tissue responses af-
ter insertion of artificial crowns and fixed partial dentures. J Prosthet.
Dent. 2000;84:492-498.
10. Paniz G, Nart J, Gobbato L, Chierico A, Lops D, Michalakis K.
Periodontal response to two different subgingival restorative margin
designs: A 12-month randomized clinical trial. Clin Oral Investig.
2016;20:1243-1252.
11. Serra-Pastor B, Loi I, Fons-Font A, Solá-Ruíz MF, Agustín-Pana-
dero R. Periodontal and prosthetic outcomes on teeth prepared with
biologically oriented preparation technique: A 4-year follow-up pros-
pective clinical study. J Prosthodont Res. 2019;63:415-420.
12. León-Martínez R, Montiel-Company JM, Bellot-Arcís C, So-
lá-Ruíz MF, Selva-Otaolaurruchi E, Agustín-Panadero R. Periodontal
Behavior Around Teeth Prepared with Finishing Line for Restoration
with Fixed Prostheses. A Systematic Review and Meta-Analysis. J
Clin Med. 2020;9:249.
13. Rodríguez X, Vela X, Segalà M. Cutting-edge implant rehabilita-
tion design andmanagement: a tapered abutment approach. Compend
Contin Educ Dent. 2017;38:482-491.
14. Agustín-Panadero R, Serra-Pastor B, Fons-Font A, Solá-Ruíz MF.
Prospective clinical study of zirconia full-coverage restorations on tee-
th prepared with biologically oriented preparation technique on gingi-
val health: results after two-year follow-up. Oper Dent. 2018;43:482-
487.
15. Loi I, Caivano T, Rodríguez X. Bopt, concepto, antecedentes his-
tóricos y principios básicos clínicos. Perio Clínica. Revista científica
de Sepa. 2023;25:17-29.

e1045