Eilaf Al-Marei

BDS.MFDRSI.KBAGD/R5
OUTLINE

Definition
Anatomy of the periodontium
Indications
Contraindications
Types
Principles of crown lengthening surgery
Healing following crown lengthening

Surgical crown lengthening is defined as :
A procedure used to expose sound tooth
structure with or without removal of alveolar
bone for restorative purposes.






Glossary of periodontal terms, ed 4. 2001.

Gingival Margins must not invade Biological
Width Requirements for Periodontal Health.

Biological Width Requirements:
There must be a minimum of 1mm between the
apical level of the Junctional Epithelium and the
bone crest.



Crown Margins which extend apically beyond
the Junctional Epithelium can violate the
requirements for periodontal health.




This study measured dimensions of tissues
involved in Biological Width considerations.

Used histologic sections to measure average
dimensions of biologic width.

These are not clinically accurate due to
distortion with histologic processing.


This study concluded that the width of
junctional epithelium plus connective tissue
width was Biologic width; i.e. approximately
2 mm.


However since then it
has been shown that in
probing the sulcus, the
probe is generally at
the deepest position of
junctional epithelium.
Definition:

The width of the junctional epithelium and
supracrestal connective tissues that lie between the
base of the gingival sulcus and the alveolar crest and
represents the area of attachment of the periodontal
soft tissues to the tooth .

The average dimension of biologic width is 2.04 mm.



Gargiulo et al. Dimensions and relations of the dntoalveolar junction in humans. J Periodontol 1961.
Vacek et al. The dimensions of the human dentogingival junction. Int J Periodontics Restorative Dent
1994.


Ingber et al in 1977:

Suggested that the term biologic width relates
to the average value of the dentogingival
junction, that is 2 mm.
An additional 1 mm must be added coronal to
the 2 mm dentogingival junction as an optimal
distance between the bone crest and a
restorative margin.
When a subgingival crown margin is to be
placed it may be necessary to surgically
move the crestal bone margin apically so
that there is at least 2 mm space between
the margin and the bone.

The necessary for 1 mm of connective tissue
between the epithelium and bone is a
minimal requirement.



Localized gingival hyperplasia with minimal
bone loss.
Gingival recession and localized bone loss.
Localized infrabony periodontal pocket.
Combinations.


De waal & Castellucci: International J Periodont & Rest Dent 1993.


Restorative purposes.
periodontal purposes.
Esthetic needs.

Restorative needs:

1. To increase the clinical crown height.
2. To access subgingival caries.
3. To produce a ferrule for post crown
restoration.
4. To access a perforation in the coronal third
of the root.
5. To relocate the margins of the restorations
that are impinging on the biologic width.

Periodontal needs:

1. To excise hyperplastic gingiva.
2. To apically position gingiva where
there is altered or delayed eruption.

Esthetic needs:

1. To correct gummy smile.
2. To increase the length of short teeth.
3. To modify uneven gingival contour.

Non restorable teeth.

Teeth that are non functional or not of
strategic value.

Inability to maintain adequate plaque
control.


When adjacent teeth would be severely
compromised.

When extensive procedures are required
for salvaging the tooth.

Compromising medical conditions.


Smoking.

Thin gingival tissue biotype.

Narrow band of attached gingiva.

Functional crown lengthening.

Esthetic crown lengthening.
Techniques:

1. Gingivectomy or gingivoplasty.

2. Apically positioned flap procedure including
bone resection.

3. Forced tooth eruption with or without
fiberotomy.




Jan Lindhe. Clinical periodontology and implant dentistry. Fourth edition.
1) Gingivectomy:

External bevel gingivectomy.
Internal bevel gingivectomy.



2) Apically positioned flap with bone
recontouring:

At least 4 mm of tooth structure must be
exposed.

During healing the supracrestal soft tissues
will proliferate coronally to cover 2-3 mm
of the root.

Herrero et al. 1995, Pontoriero 2001.


Indications:
- Multiple teeth.

Contraindications:
- Single tooth.
3) Forced tooth eruption:

Orthodontic tooth movement can be used to
erupt teeth in adults.
The tooth must be extruded a distance
equal or slightly longer than needed.
A full thickness flap then is elevated and
bone recontouring is performed to expose
sound root structure.

Ritan 1967, Ingber 1974, Potashnick & Rosenberg 1982 .
Indications:
- At sites where removal of attachment and bone
from adjacent teeth must be avoided.
- Reducing PD at sites with angular bony defects.
- Level and align gingival margins.

Contraindications:
- Few teeth remaining.

t

Brown 1973, Ingber 1974, 1976.

Scalpel is used at 7-10 days intervals.

Indications:
- CL at sites where it is important to maintain
unchanged the location of the gingival margin at
adjacent teeth.

Contraindications:
- Teeth associated with angular bony defects.

Exposure of sound tooth structure.

1. Inadequate amount of tooth structure for
proper restorative therapy.
2. Subgingival location of fracture lines.
3. Subgingival location of carious lesions.




Jan Lindhe. Clinical periodontology and implant dentistry. Fourth edition.
Coslet classification: by Coslet et al 1977

- Type I: Adequate keratinized gingiva(2mm).
- Type II:Inadequate keratinized gingiva(<2mm).

- Subgroup A: CEJ-bone is 2mm.
- Subgroup B: CEJ-bone is < 2mm.
Depending on the clinical and radiographic
presentation, there are five modalities for
this procedure:

1. PD 4 mm and adequate KG
Gingivectomy or gingivoplasty

2. PD 4 mm and inadequate KG APF
osseous surgery



3. If there is a need to preserve adjacent
structures Orthodontic forced eruption

4. If crown : root ratio will be compromised
Extraction




Marianne Ong. Crown lengthening revisited. Clinical Advances in
Periodontics 2011.

Aims to correct either a gummy smile or
gingival over growth.

Normally, 2-3 mm of tooth is shown with
relaxed lips.

For a gummy smile with healthy
periodontium, the patients facial proportion
has to be assessed.

Classifications for excessive gingival
display:

Degree I : 2-4 mm of gingival display.

Treatment:
1. Orthodontic intrusion
2. ortho + CL
3. CL followed by restorations



Garber DA, Salama MA. The aesthetic smile: diagnosis and treatment. Periodontol
2000 1996.
Degree II: 4-8 mm of gingival display
Treatment:
1. CL & restorations.
2. Orthognathic surgery.

Degree III: 8 mm of gingival display
Treatment:
1. Orthognatic surgery with or without CL and
restorations
Following an assessment of the alveolar crest
position, four distinct clinical scenario may be
identified.

A classification system may be more dependent
on the relationship between the alveolar crest
position relative to the anticipated postsurgical
gingival margin level.


Ernesto A. aesthetic crown lengthening: classification, biologic rationale and
treatment planning considerations. Pract Proced Aesthet Dent 2004.
Functional Esthetic Factors to
consider
To maintain
periodontal health
and establish BW
around the tooth
( 2-3 mm )
To create an
esthetic smile line
and establish BW
around the tooth
Goal
FRM CEJ Reference line
1. Gingevictomy/G
ingivoplasty
2. APF + Osseous
3. Orthodontic
forced eruption
Type I
A: Gingivectomy/
Gingivoplasty
B: Flap + Osseous

Type II
A: APF
B: APF+ Osseous
Techniques
Functional Esthetic Factors to consider
1. Buccal and
palatal
2. Usually drop a
vertical incision
3. Follow APF
concept ( leave 2
mm KG behind)
1. Buccal only
2. No vertical
releasing incision
3. CEJ and follow
esthetic smile line
Incision
Not needed ( use
provisional crown )
Often needed Surgical stent
Buccal and palatal Buccal only ( no
raising of
interdental papilla/
palatal flap )
Flap raised
Both sides including
interproximal area
Only buccal side (
not interproximal
area )
Osseous surgery
location
Located at bone
crest
Located at CEJ or
slightly above CEJ
Final flap position
Functional Esthetic Factors to consider
Continuous sling/
vertical mattress
Horizontal
positional
Recommended
suture technique
Often required Not necessary Wound dressing
Not necessary Often needed Secondary surgery
Square-looking
crowns, long
contact points
An esthetic smile Final outcome
A concern of every clinician is the time
required between periodontal surgery and
the initiation of restorative procedures.

wound maturation.

Healing time needed to stabilize the
position of the gingival margin.
The time, rate and quality of these events
depend on the size of the wound and the
availability of appropriate tissue elements in
the adjacent undamaged tissue.

Systemic health, age, oral hygiene, and
smoking may affect the healing processes.


Clark RAF: Overview and general considerations of wound repair.1988
Ah MK, Johnson GK et al.: The effect of smoking on the response to periodontal
therapy. J Clin Periodontol 1994.
Within 12 hours : Epithelial cells at the wound
margin begin migration into the affected area.

One to two weeks: A new junctional epithelium
is formed.

Two weeks: Immature connective tissues
formed.

6-8 weeks: New cementum forms.
8 weeks: The surgical site has a mature
JE and CT that is incorporated into new
cementum.

2-3 months : A collagen fiber bundles
form and cross-linking between molecules
develops, solubility of the collagen
decreases and the tensile strength of the
wound increases
8 weeks- 6 months:

Maturation of the CT.
Additional cementum is deposited on the root
surface.
Decrease in the cellularity and vascularity of the
tissue.
Tensile strength of the healing wound increases, by 5
months it will be 90 % of normal tissue.


Hawley CE: Periodontal wound healing, in Clark JW: Clinical Dentistry 1985.
Embree A. Postsurgical timing of restorative therapy: A Review. Journal of
Prosthodontics 1994.
Becker et al. 1988:
Gingival margins moved coronally about 0.4mm during
a maturation period of 8 weeks to one year.

Kaldahl et al. 1988:
Coronal shift of the gingival margin of 0.45- 0.77 mm
one year after osseous surgery.

Bragger et al. 1992:
After crown lengthening of posterior teeth, free
gingival margins moved coronally by 1-3 mm six months
after surgery.



Lindhe & Nyman in 1980:
Ten years after APF, the gingival margin is
significantly more coronal as compared with the
position of the margin 2 months postsurgery.

Morris et.al in 1953:
The gingival margin of maxillary anterior teeth
receded an average of 0.63mm after a minor
surgical procedure.
Steiner et al. 1981:
The postsurgical results of crown lengthening in
anterior teeth showed an average of 1.6 mm of
gingival recession.

Bragger et al. in 1992:
The gingival margin of 29% of the test teeth
receded 1-4 mm in posterior teeth with thin
gingival biotype.

Gingivectomy or gingivoplasty 4-6 weeks.

If buccal flap was raised and bone exposed
8-12 weeks.

If bone was removed 6 months.




Engler WO et al. Healing following simple gingivectomy. J Periodontol 1966.
Wagenberg BD, Langer B. Exposing adequate tooth structure for restorative dentistry. Int J
Periodontics Restorative Dent 1989.
Definitive restoration of teeth in the easthetic
zone should be carried out at least six months
after surgery.

In cases of only soft tissue removal, a period of
2 months is required before construction of the
definitive restoration.




Geoffrey J Bateman. Principles of crown lengthening surgery. Dental update
April 2009.
Types of studies:
- Clinical & radiographic studies as well as
literature reviews.
Conclusion:
- Initiation of final prosthetic treatment should
wait at least three months and possibly up to six
months for esthetically important areas, as the
free gingival margin requires a minimum of three
months to establish its final vertical position.
Methods:
- 25 patients requiring crown lengthening of 43 teeth
were included.
Conclusions:
- There is a significant tissue rebound following
crown lengthening surgery that has not fully
stabilized by 6 months.
- The amount of tissue rebound seems related to the
position of the flap relative to the alveolar crest at
suturing.
- these findings support the premise that clinicians
should establish proper crown height during surgery
without overreliance on flap placement at the
osseous crest.
Methods:
- 30 patients were included ( 84 teeth )
requiring surgical exposure of tooth substance.
Results:
- Immediately after surgery, a significantly
increased clinical crown length was achieved.
- Healing resulted in a statistically significant
coronal displacement of the gingival margin.
- So, the amount of tooth structure immediately
after surgery decreased at the 12-month
examination.
Conclusions:
- During a 1-year period of healing following
surgical crown lengthening, the marginal
periodontal tissue showed a tendency to grow in
a coronal direction from the level defined at
surgery.
- This pattern of coronal displacement was
more pronounced in patients with thick tissue
biotype and also appeared to be influenced by
individual variations in the healing response not
related to age or gender.
Restoration margin must not extend 0.5 mm
within the gingival sulcus.

Maintaining the biologic width without any
violation by restorations ensures periodontal
health.

Excessive gingival display due to short
clinical crown can be corrected by crown
lengthening.
In the locations where the periodontium is
judged to be thick and in non aesthetic
areas, restorative treatment may begin 2-3
months after surgery.

In aesthetic areas, the restorative procedure
may require delays postsurgically up to 6
months, particularly where the periodontium
is thin.