surgical crown lengthening

SURGICAL CROWN SURGICAL CROWN LENGTHENING IN THE ESTHETIC LENGTHENING IN THE ESTHETIC

ZONE ZONE

Trijani Suwandi, drg, Sp. Perio

CROWN LENGTHENINGCROWN LENGTHENINGperiodontal procedure that

reshapes the ggv and supporting tissues to expose more of the tooth.

-Function- Form-Retention-Marginal seal

INDICATIONS for Crown INDICATIONS for Crown Lengthening Lengthening (Cohen, 2009)(Cohen, 2009)

GINGIVAL ASYMMETRIESGINGIVAL ASYMMETRIES

Crown length discrepancies.Some teeth appear longer while others appear shorter

(Patil. 2002)

SMILE LINESMILE LINE

HIGH SMILE LINE>75% interprox ggvAll of marginal ggv

MEDIUM SMILE LINE25-75% interprox ggvMarg ggv terlihat

LOW SMILE LINE<25% interprox ggvMarg ggv tdk terlihat

Excessive Gingival Display Excessive Gingival Display (Gummy Smile)(Gummy Smile)

A gingival display >3 mm in active / moderate smile (Patil, 2002; Jim Hinrich, 2007)

Exposure of sound tooth Exposure of sound tooth structurestructure

Clinical Evaluation before CL Clinical Evaluation before CL (Cohen, 2009)(Cohen, 2009)

Apical extent of fracture, caries, perforations

Loss of mesial, distal or oclusal space

Final margin placement

Radiographic analysis Radiographic analysis (Cohen, 2002)(Cohen, 2002)

CONTRAINDICATION & CONTRAINDICATION & LIMITATING FACTOR LIMITATING FACTOR (Cohen, 2002)(Cohen, 2002)

Non maintainability

Sequence of TreatmentSequence of Treatment (Allen, 2002)(Allen, 2002)

1. Clinical & radiographic evaluation2. Caries control3. Placement of provisional

restoration 4. Endodontic therapy5. Control ggv inflammation : plaque

control, Scaling root planing6. Reevaluation for ortho th7. surgery

SURGICAL DIAGNOSIS & SURGICAL DIAGNOSIS & TREATMENTTREATMENT

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 facialDGC (mm)

Crest interprox DGC

TreatmentCL

Low

Normal

High

> 3

3

< 3

> 3 – 4.5

3 – 4.5

< 3 – 4.5

No

No

Yes

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

BIOLOGIC WIDTHBIOLOGIC WIDTH

BIOLOGIC WIDTH =2.04 MM

(Takei et all, 2002)

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

When restorations do not take these considerations into BW :

Esthetic crown Esthetic crown lengtheninglengthening

Ratio of 1.3 to 1.01.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

LENGTHENING LENGTHENING PROCEDUREPROCEDURE1. Gingival reduction only

- Bone removal not required- Gingivectomy or gingival flap

surgery

2. Mucoperiosteal flap with osteotomy* BONE REMOVAL REQUIRED

Deeply placed crown margins causing gingival inflammation and pockets

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

Surgical procedures for Surgical procedures for crown lengtheningcrown lengthening1. Gingivectomy2. Flap surgery for osseous

recontouring

Choice depends on :1. Gingival crevice depth2. Need to maintain minimum of 1 mm

conn tissue between depth of crevice and bone

3. Adequate width of keratinized gingiva

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

Crevice depth 5 mm will allow 3 mm of crown lengthening by GINGIVECTOMY

If more than 3 mm needed use FLAP SURGERY

GINGIVECTOMY GINGIVECTOMY TECHNIQUETECHNIQUE

This patient requires 3 mm of CL

Sufficient crevice depth and keratinized tissue

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

CASE 1

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

One month post surgery

Toothform and proportional balance were improved by bonding

a years post treatment

BEFORE AND AFTERBEFORE AND AFTER

Sufficient crevice depth and keratinized gingiva

Frenum correction also needed

CASE 2

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

Kirkland knife used to refine ggv contours by Kirkland knife used to refine ggv contours by gentle scrapinggentle scraping

Length of I1 serves as basis for I2 and C

I2 ggv margin 1 mm coronal to centralC ggv margin at same level as I1

The I 2 also has distalized gingiva margin

Left I1 margin shapes for symmetry with right central

Gingivectomy completed with bilateral symmetry

Initial incision for frenectomyInitial incision for frenectomy

Removal of wedge of tissue from frenumRemoval of wedge of tissue from frenuminterdental papilla is untouchedinterdental papilla is untouched

Incision made through periosteum to expose boneThis ensures no muscle pull exists to interdental

papilla

Wound closed with 4.0 gut suturesWound closed with 4.0 gut sutures

Healing after 12 weeksHealing after 12 weeks

BEFORE AND AFTERBEFORE AND AFTER

ESTHETIC CROWN ESTHETIC CROWN LENGTHENINGLENGTHENING

Left/right side height discrepancy

Perform by :◦Gingivectomy

or flep with osseous resection

◦Only in facial aspect

Esthetic CLEsthetic CLThe dotted line

indicate the oblique vertical incision without involving the interdental papillae

Esthetic CLEsthetic CLA full thickness

flap is raised to gain acces for osseous reduction, the bone dotted line indicated the amount of bone to be resected

Esthetic CLEsthetic CLThe flap is

sutured back into placed

Gingival asymmetry between central incisors

CASE 3

A full thickness flap

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

The flap repositioning back into place using suture

Post operative frontal view after the placement of veneers

BEFORE AND AFTERBEFORE AND AFTER

FUNCTIONAL CLFUNCTIONAL 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 mmof bone resection)

Functional CLFunctional CL

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

Functional CLFunctional CL

Osseus reduction carried out around the tooth using a round diamond bur

Functional CLFunctional CL

The flap sutured back in place

Flap surgery and osseous correction

CASE 4

INITIAL INCISIONSINITIAL 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

Incisions on left symmetrical with rightUse new blade for each two teeth to

minimize tissue trauma

Flap carefully dissected with sharp scalpels3 mm of bone crest exposedBone recontouring needed to provide

adequate conn tissue apical crevice depth

Bone margin has been moved apically of I1 and C

Flap sutured with apical positioning of ggv margin on I1 and C

12 weeks

BEFORE AND AFTERBEFORE AND AFTER

ALTERED PASSIVE ERUPTION = ALTERED PASSIVE ERUPTION = GUMMY SMILEGUMMY SMILE

A gingival display > 3 mm in active or moderate smile :” gummy “

TOOTH ERUPTION TOOTH ERUPTION (Weinberg & Eskow, 2000)(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

Classified passive eruption Classified passive eruption (Gargiulo et al (Gargiulo et al (1961)(1961)

Stage I = sulcus & JE are on the enamelStage II = sulcus on enamel. JE is part on the enamel and part on the

cementumStage III = sulcus at CEJ, JE completly on cementumStage IV = sulcus and Je apically to CEJ

Classification Delayed or Classification Delayed or Altered Passive Eruption Altered Passive Eruption (Coslet et (Coslet et all, 1977)all, 1977)

TYPE IAType I = ggv margin is incisal to CEJ, MGJ is apical to crest of boneSubgroup A = the alv crest is located 1.5 – 2 mm from CEJTherapy = GINGIVECTOMY

TYPE I BType I = ggv margin is incisal to CEJ, MGJ is apical to crest of boneSubgroup B= the alv crest is coincident with CEJTherapy = GINGIVECTOMY or SCALLOPED inverse bevel flap & osseous reduction

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

TYPE IIBType II = ggv dimension is normal. The free ggv margin is incisal to CEJ, MGJ is positioned at the CEJSubgroup B = the alv crest is coincident with CEJTherapy = Apically positioned flap with osseous reduction

The causes gummy smileThe causes gummy smile

Planning for gummy smilePlanning for gummy smile

CASE 5

Gingivectomy in the maxillary arch

Flap sutured back after osseous reduction

Veneer preparation performed after 2 months of post operative healing

Post operative view after veneer placement

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

BEFORE AND AFTERBEFORE AND AFTER

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

CONCLUSIONCONCLUSION

CONCLUSIONCONCLUSION

Biologic width peridental and Biologic width peridental and implantimplant

Biologic width peridental and Biologic width peridental and implantimplant

A Systematic Approach to A Systematic Approach to Treatment PlanTreatment Plan

Mankoo, 2002

Biologic widthBiologic 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

In Aesthetic ZoneIn Aesthetic Zoneimplant 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

The Role of Interdental Bone on The Role of Interdental Bone on Papilla DevelopmentPapilla 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)

trijani suwandi@yahoo.com