Crown lengthening

1. SURGICAL CROWN
LENGTHENING IN THE ESTHETIC
ZONE
Trijani Suwandi, drg, Sp. Perio

2. CROWN LENGTHENING
 periodontal procedure that reshapes the
ggv and supporting tissues to expose
more of the tooth.
CROWN
LENGTH
ENING
PERIODONTA
L
ESTHETI
C
RESTORATIV
E
-Function
- Form
-Retention
-Marginal seal

3. INDICATIONS for Crown Lengthening
(Cohen, 2009)
Gingival asymmetries
excessive gingival display = altered
gingival eruption = gummy smile
Exposure of sound tooth structure
(caries, trauma/fracture)
Restorative requirements

4. GINGIVAL ASYMMETRIES
Gingival
hyperplasia
Altered
passive
eruption
Tooth or teeth
malpositionin
g
Over tooth
brushing
Periodontal
disease
Crown length discrepancies.
Some teeth appear longer while others appear shorter
(Patil. 2002)

5. SMILE LINE
HIGH SMILE LINE
>75% interprox ggv
All of marginal ggv
MEDIUM SMILE LINE
25-75% interprox ggv
Marg ggv terlihat
LOW SMILE LINE
<25% interprox ggv
Marg ggv tdk terlihat

6. Excessive Gingival Display (Gummy
Smile)
 A gingival display >3 mm in active /
moderate smile (Patil, 2002; Jim Hinrich, 2007)
Maxillary
overgrowth
Tooth
malposition
Delayed apical migration
of ggv margin
Altered
passive
eruption
Short
upper lip

7. Exposure of sound tooth
structure
Inadequate amount of tooth structure
for proper restorative therapy
Subgingival location of fracture lines
Subgingival location of carious
lesions

8. Clinical Evaluation before CL (Cohen,
2009)
Sulcus depth Biologic width Osseous crest
Pulpal involvement Gingival health
Apical extent of
fracture, caries,
perforations
Loss of mesial, distal
or oclusal space
Final margin
placement

9. Radiographic analysis (Cohen, 2002)
Level of alveolar
crest
Apical extent of
fracture or caries
Pulpal involvement
Root length
Root form
Crown to root ratio
(at present and
post treatment)

10. CONTRAINDICATION & LIMITATING
FACTOR (Cohen, 2002)
Inadequate crown
to root ratio
Esthetic
compromise
Nonrestorability of
caries or root
fracture
Compromise of
adjacent
periodontium or
esthetic
Insufficient
restorative space Non maintainability

11. Sequence of Treatment (Allen, 2002)
1. Clinical & radiographic evaluation
2. Caries control
3. Placement of provisional restoration
4. Endodontic therapy
5. Control ggv inflammation : plaque
control, Scaling root planing
6. Reevaluation for ortho th
7. surgery

12. SURGICAL DIAGNOSIS &
TREATMENT
Kois (1994) : only 3 mm is necessary to satisfy
requirements for a stable BW (2.04 mm BW, 1
sulcus depth)  determining total dentoggv
complex (DGC)
location
Crest facial
DGC (mm)
Crest
interprox
DGC
Treatment
CL
Low
Normal
High
> 3
3
< 3
> 3 – 4.5
3 – 4.5
< 3 – 4.5
No
No
Yes

13.  BW considerations during restorative
procedure  natural architecture of the
gingiva
 The distance that must exist between a
dental restoration and the alveolar bone
 Consider :
◦ Location of the restorative margins
◦ Location of the gingival margin
◦ Location of the crestal bone
1. BIOLOGIC WIDTH = BW

14. BIOLOGIC WIDTH
BIOLOGIC
WIDTH =
2.04 MM
(Takei et all, 2002)

15.  In case Healthy Perio after the exact
position of the restoration margin is
decided  the position of ggv margin is
surgically established, with recontouring
osseous crest min 3 mm of the flap can
be placed coronal to the position of the
recontoured osseous crest
 A minimum 6 weeks of healing is
required before final restoration

16.  When restorations do not take these
considerations into BW :
Chronic pain
Chronic
inflam
ggv
Unpredictabl
e bone loss

17. Esthetic crown lengthening
Ratio of 1.3 to 1.0
1. Typical distance between facial CEJ
and incisal edge of I1 = 11 - 12 mm
2. Typical mesial/distal width of I1 = 8.5 -
9.5 mm
3. Consequently 11.5 / 9 =length verses
width ratio of 1.27

18. LENGTHENING
PROCEDURE
1. Gingival reduction only
- Bone removal not required
- Gingivectomy or gingival flap surgery
2. Mucoperiosteal flap with osteotomy
* BONE REMOVAL REQUIRED

19.  Deeply placed crown margins causing
gingival inflammation and pockets

20.  Both central incisors and right lateral
incisor have crowns violating biologic
width concepts

21. Surgical procedures for crown
lengthening
1. Gingivectomy
2. Flap surgery for osseous
recontouring
Choice depends on :
1. Gingival crevice depth
2. Need to maintain minimum of 1 mm
conn tissue between depth of crevice
and bone
3. Adequate width of keratinized gingiva

22.  Adequate ggv and >
3 mm of tissue
coronal to the bone
crest :
◦ Gingivectomy or flap
 Inadequate ggv and <
3 mm of tissue
coronal to the bone
crest :
◦ Flap procedure and
bone recountouring

23.  Crevice depth 5 mm
will allow 3 mm of
crown lengthening
by GINGIVECTOMY
 If more than 3 mm
needed use FLAP
SURGERY

24. GINGIVECTOMY
TECHNIQUE
 This patient requires
3 mm of CL
 Sufficient crevice
depth and keratinized
tissue

25. The lateral incisors were congenitally missing
The canine teeth in the position of the lateral incisors
added to the esthetic harmony
CASE 1

26. A gingivectomy was performed to expose the anatomical
crowns of the teeth

27. One month post surgery

28. Toothform and proportional balance were improved by bonding

29. a years post treatment

30. BEFORE AND AFTER

31. Sufficient crevice depth and keratinized gingiva
Frenum correction also needed
CASE 2

32. Scalpel used to established 10 mm crown length on
central incisors. Height of contour ggv is distalised

33. Kirkland knife used to refine ggv contours by gentle
scraping

34.  Length of I1 serves as basis for I2 and C
 I2 ggv margin 1 mm coronal to central
 C ggv margin at same level as I1

35. The I 2 also has distalized gingiva margin

36. Left I1 margin shapes for symmetry with right central

37. Gingivectomy completed with bilateral symmetry

38. Initial incision for frenectomy

39. Removal of wedge of tissue from frenum
interdental papilla is untouched

40.  Incision made through periosteum to expose
bone
 This ensures no muscle pull exists to
interdental papilla

41. Wound closed with 4.0 gut sutures

42. Healing after 12 weeks

43. BEFORE AND AFTER

44. ESTHETIC CROWN
LENGTHENING
 Left/right side
height discrepancy
 Perform by :
◦ Gingivectomy or
flep with osseous
resection
◦ Only in facial
aspect

45. Esthetic CL
 The dotted line
indicate the oblique
vertical incision
without involving
the interdental
papillae

46. Esthetic CL
 A full thickness flap
is raised to gain
acces for osseous
reduction, the bone
dotted line
indicated the
amount of bone to
be resected

47. Esthetic CL
 The flap is sutured
back into placed

48. Gingival asymmetry between central incisors
CASE 3

50. A full thickness flap

51. With a low speed hand piece and carbide bur, osseous reduction
is carried out

52. The flap repositioning back into place using suture

53. Post operative frontal view after the placement of veneers

54. BEFORE AND AFTER

55. FUNCTIONAL CL
A labial and palatal view of a fractured central incisor; the blue
dotted line
indicates the incision to be followed for the raising of a full
thickness flap
The gingiva and bone follow a definite pattern
interproximally, facially and palatally (> 2 mm
of bone resection)

56. Functional CL
A full thickness flap raised labially as well as palatally , here
the blue dotted
Line indicated the amount of bone to be resected

57. Functional CL
Osseus reduction carried out around the tooth using a round diamond bur

58. Functional CL
The flap sutured back in place

59. Flap surgery and osseous correction
CASE 4

60. INITIAL INCISIONS
 I1 and C new ggv
margins at same
level
 Sulcular incision
used on I2 to make
it harmonious with
I1 and C
 Interprpox incisons
preserve papillae

61.  Incisions on left symmetrical with right
 Use new blade for each two teeth to
minimize tissue trauma

62.  Flap carefully dissected with sharp scalpels
 3 mm of bone crest exposed
 Bone recontouring needed to provide
adequate conn tissue apical crevice depth

63.  Bone margin has been moved apically of I1
and C

64. Flap sutured with apical
positioning of ggv margin on I1
and C
12 weeks

65. BEFORE AND AFTER

66. ALTERED PASSIVE ERUPTION =
GUMMY SMILE
A gingival display > 3 mm in active or moderate smile :” gummy “

67. TOOTH ERUPTION (Weinberg & Eskow, 2000)
ACTIVE ERUPTION PASSIVE ERUPTION
 The physical movement
of the tooth from its
prefunctional subggv
position through the ggv
tissue, into the oral cavity
 finally, into functional
occlusion
 The continued apical
movement of the free
ggv margin epithelial
attachment or junct epith
and connec tissue
attachm that occurs after
the tooth reaches
functional occlusion

68. Classified passive eruption (Gargiulo et al (1961)
Stage I = sulcus & JE are on the enamel
Stage II = sulcus on enamel. JE is part on the enamel and part on the
cementum
Stage III = sulcus at CEJ, JE completly on cementum
Stage IV = sulcus and Je apically to CEJ

69. Classification Delayed or Altered
Passive Eruption (Coslet et all, 1977)
TYPE IA
Type I = ggv margin is incisal to CEJ, MGJ is apical to crest of bone
Subgroup A = the alv crest is located 1.5 – 2 mm from CEJ
Therapy = GINGIVECTOMY

70. TYPE I B
Type I = ggv margin is incisal to CEJ, MGJ is apical to crest of bone
Subgroup B= the alv crest is coincident with CEJ
Therapy = GINGIVECTOMY or SCALLOPED inverse bevel flap &
osseous reduction

71. TYPE II A
Type II = ggv dimension is normal. The free ggv margin is incisal to CEJ,
MGJ is positioned at the CEJ
Subgroup A = the alv crest is located 1.5 – 2 mm from CEJ
Therapy = APICALLY POSITIONED FLAP

72. TYPE IIB
Type II = ggv dimension is normal. The free ggv margin is incisal to CEJ,
MGJ is positioned at the CEJ
Subgroup B = the alv crest is coincident with CEJ
Therapy = Apically positioned flap with osseous reduction

73. The causes gummy smile
Maxillary overgrowth
Tooth malposition
Delayed apical migration of ggv
margin or altered passive
eruption

74. Planning for gummy smile
Location of the cemento
enamel junction
Root length, form and
position
Width of attached
gingiva

75. CASE 5

76. Gingivectomy in the maxillary arch

77. Flap sutured back after osseous reduction

78. Veneer preparation performed after 2 months of post
operative healing

79. Post operative view after veneer placement

80. Postoperative view after 6 months.
Note : the convex smile line, Good progressive abating and
adequate periodontal health

81. BEFORE AND AFTER

82.  Pontoriero and Carnevale (2001)
- CL : considered removal of osseous
support
- in esthetic area, sulcular marginal
placement await final ggv stability (
3 weeks)
 Lanning et al (2003)
◦ ≥ 3 mm osseous reduction  stable BW,
adequate tooth exposure

83. CONCLUSION
• Ggv esthetic surgery, improved ggv health
with adequate BW
CL : procedure to increase the
amount of clinical tooth exposed
• Removal of soft tissue and / or alv bone
Surgical CL

84. CONCLUSION
• Gingivectomy or flap procedure
Adequate attached ggv, >3 mm of tissue
coronal to the bone crest
• Flap procedure and bone recountouring
Inadequate attached ggv, < 3 mm of soft
tissue

86. Biologic width peridental and
implant

87. Biologic width peridental and
implant

89. A Systematic Approach to Treatment
Plan
STAGE 1 : initial periodontal th/,
restorative th/ to create a sound &
healthy foundation for further restoration
STAGE 2 : modification/enhancement :
orthodontics, surgical periodontics for
disease control or aesthetic/restorative
reason : ridge augmentation, crown
length, implant placement and bone grafting
STAGE 3 : provisionalization and
stabilization, soft tissue control

90. STAGE 4 : Definitive Restoration
STAGE 5 : Ongoing recall and
maintenance
Mankoo, 2002

91. Biologic width
 When implant-abutment connection
was placed at the ggv level
supracrestal to the alv bone (single
implant placement) : BW was similar
to that of natural dentition
  facilitated maintenance of the BW
with minimal apical bone resorption

92. In Aesthetic Zone
 implant level should always be placed
subgingivally  produce the proper
emergence profile & soft tissue
contours around the implant
restoration
 As general rule, the implant head
should be placed 3 mm apical to the
desired labial gingiva margin position
in order to allow emergence profile &
aesthetics

93. The Role of Interdental Bone on Papilla
Development
Distance From interdental
bone to apical of contact area
Incidence of the Papilla Being
Completely Present
5 mm or less 100%
6 mm 56%
7 mm 27%
(Tarnow et all, 1992)

96. trijani suwandi@yahoo.com