compendium 1997 sonick eclmat

7/27/2019 Compendium 1997 Sonick ECLMAT

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807Vol. 18, No. 8 Compendium/ August 1997

CE 5

Esthetic CrownLengthening for MaxillaryAnterior Teeth

Michael Sonick, DMDAssistant Clinical Professor of SurgerySchool of MedicineYale University

New Haven, Connecticut

Assistant Clinical Professor of PeriodonticsSchool of Dental MedicineUniversity of ConnecticutFarmington, Connecticut

Private Practice of Periodontics and DentalImplants

Fairfield, Connecticut

Abstract: In the maxillary anterior region, the gingival labial margin positionis an important parameter in the achievement of an ideal smile. The relation-ship between the periodontium and the restoration is critical if gingival healthand esthetics are to be achieved. Periodontal therapy is a necessary and usefuladjunct when any anterior restoration is undertaken. Anterior surgical crownlengthening may be undertaken to avoid restorative margin impingement on thebiologic width. Crown lengthening is also used to alter the gingival labial pro-files. This article discusses the esthetic parameters of ideal gingival labial posi-tions and presents a classification of crown-lengthening procedures and the

procedure for a two-stage crown-lengthening technique. The two-stage crown-

lengthening technique is surgically precise because healing is predictable.

Dentistry has undergone a significant evolution in the last 2 decades.Sophisticated advances in the development of newer restorative mate-rials and techniques have led to an unprecedented improvement in

esthetic rehabilitation. It is no longer enough to merely replicate lost toothstructure. Patients demand and expect anterior rehabilitations to be esthetic.There is a tremendous focus on cosmetics today. One has only to gaze throughmagazine advertisements to see the emphasis that is placed on being attractive.

Dentists are blessed with the unique ability to not only improve patientshealth but also enhance their attractiveness. The relationship between a per-

sons physical appearance and his or her self-esteem is well documented1,2(Psychology Today, November, 119-131, 1973). Studies have shown that a per-sons face is the prime source of determining physical attractiveness.1 Patientshave stated that their teeth have the greatest impact on improving their phys-ical appearance, and hence self-esteem. Therefore, dentists play a significantrole in helping to improve their patients psychological health.

Dentists are called on to provide restorations that are in harmony with thelips, the face, the adjacent teeth, and a healthy periodontium. Until recently,the scope of esthetic rehabilitation was limited to a close replication of toothstructure on a healthy periodontal foundation. In the past, periodontal therapywas aimed primarily at the elimination of disease, sometimes at the expense of

esthetics. However, the scope of periodontal therapy has expanded. The prima-ry goal remains to maintain the dentition with a healthy intact dentogingivalunit. However, periodontics has now entered the age of periodontal plasticsurgery.3 Many periodontal therapies lead to esthetic amelioration of the denti-tion. These techniques allow for the ability to cover denuded roots, correctlocalized alveolar defects, regenerate bone, increase the amount of keratinizedgingiva, enhance papilla reformation, and alter dental gingival levels.

The preservation of a sound periodontium remains the sine qua non of asuccessful esthetic and functional restoration. A thorough knowledge of thenormal anatomy and the interplay between the restoration and the periodon-tium is essential to achieve a predictable successful esthetic rehabilitation of the

smile when prosthetics are planned in the maxillary anterior sextant.Communication between the restorative dentist and periodontist is essential in

Learning Objectives:

After reading this article, the readershould be able to:

describe the indications forcrown lengthening in themaxillary anterior sextant.

discuss the parameters ofdental gingival labial rela-tionships to achieve esthet-

ics and harmony. determine how to position

the restorative margin sothe biologic width is notviolated.

explain the indications forthe variety of crown-length-ening techniques available.


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these cases. Periodontal therapy plays animportant role in the esthetic rehabilitation ofthe maxillary anterior segment, especially ifperiodontal disease is present. If the periodon-tium is healthy, the role of periodontics insmile rehabilitation is limited to crown length-ening and gingival augmentation.

Many indications for clinical crown

lengthening exist. These include cariesremoval, increasing crown length for restora-tion retention, restoration of the tooth with-out violating the biologic width, and estheticsvia an alteration of the gingival labial profile.This article introduces a two-stage crown-lengthening technique. The focus will be onthe maxillary anterior sextant. The esthetic

parameters and biologic rationale must first bediscussed before the technique is elucidated.

Esthetic Parameters of the PeriodontiumThe gingival labial position is but one of a

few factors that can contribute to an estheticsmile. The evaluation of a smile should includean analysis of the amount of gingival displaywhen the lips are parted. The smile is dynamicand variable and changes with age. Agingleads to a decrease in the amount of maxillary

central incisor display when smiling.4Depending on the relationship of the upper lipto the cervical margin of the maxillary centralincisors,5 a smile is one of three types: high lipline, low lip line, and medium lip line. Themedium lip line is felt to be the most ideal,harmoniously displaying the dental and gingi-val elements in proportional symmetry (Figure5H). A low lip line is rarely a problem for therestorative dentist. In fact, it often serves as adrape for imperfect dental relationships and

dentistry. A high lip line, which displays a dis-proportionate amount of gingival tissue, cansometimes be altered if the clinical crowns canbe lengthened. This is possible if there isexcess gingival display, as in delayed passiveeruption, or if the teeth will be restored andthe dental gingival relationships reestablishedat the new dental gingival junction. This isdependent on tooth length, incisal edge posi-tion, and the functional occlusion.

Healthy, esthetic gingival tissues should be

pink in color and firmly bound down to thenecks of the teeth. The surface texture of thegingival tissues is stippled, with an orange-peelappearance. The interdental papillae extendfrom the free gingival margin and should befirm and knife-edged. They should fill the gin-gival embrasures to the contact point (Figure1). Care should be taken to avoid loss of gingi-val papillae in all periodontal and restorativeprocedures because they are difficult, if notimpossible, to re-create after being destroyed.

The gingival zenith is located distal to thelong axis of the tooth on the labial surface of

808Compendium/ August 1997 Vol. 18, No. 8

CE 5

Figure 1A clinical

illustration of peri-

odontal health and

ideal esthetic gingi-

val balance.

Figure 2AThe pre-

operative view of

uneven, dissimilar

gingival margins.

Figure 2BPost-

operatively, gingival

symmetry and a

more esthetic

appearance are

evident.

Figure 3AThe pre-

operative view of

older anterior crowns.

Note the gingival

recession and uneven

gingival margins.

The dental gingival

position of the cen-

trals is too incisal.

The patients left and

right laterals are

more apical in posi-

tion than the centrals.


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the maxillary central incisors and canines. Incontrast, the maxillary lateral incisors have asymmetrical gingival height of contour withthe gingival zenith at the midline of the labialtooth surface5-7 (Figure 1).

As stated earlier, the gingival height ofcontour ideally follows the contour of theupper lip. Closer inspection reveals that the

gingival height of contour of contralateralteeth should be symmetrical. The height ofcontour of the central incisors should be sym-metrical and at a level coincident with themaxillary canines. The lateral incisors shouldhave a gingival level slightly more incisal(about 1.5 mm) than the adjacent centrals andcanines.5,8 Uneven gingival margins createvisual tension and violate one of the mostimportant parameters of estheticsthat ofsymmetry (Figures 2A, 3A, 5A, 5B, and 6A).

The exact amount of attached gingival tis-sue required for health varies. However, if arestoration is being considered and a minimumof attached tissue is present, preprosthetic aug-mentation is recommended so that teeth willnot be predisposed to recession.9-11 If a minimalamount of keratinized gingiva exists beforecrown lengthening, all of it must be preservedduring the procedure via sulcular incisions.Gingivectomies and external bevel incisionsare contraindicated.

In addition to the above periodontal con-cepts, some other factors that contribute to therestoration of a pleasing esthetic smile are thelips, the facial profile and structure, the incisaledge position, tooth shade, color and hue, theincisal embrasures, the incisogingival height ofthe teeth, tooth contour, texture, alignment,and the plane of occlusion.

Biologic WidthA Concept Under SiegeThe dental gingival unit is composed of

two partsthe epithelial attachment, or junc-tional epithelium, and the connective-tissueattachment.12,13 A gingival sulcus is also pres-ent. In the seminal study by Gargulio et al,14 aproportional relationship was establishedbetween the crest of alveolar bone, the con-nective-tissue attachment, the epithelialattachment, and the gingival sulcus. Theirresearch presented an average sulcus depth of0.69 mm, an average epithelial attachment of0.97 mm, and an average connective-tissue

attachment of 1.07 mm. The combineddimension of the epithelial and connective-

tissue attachment averaged 2.04 mm, and hascome to be known as the biologic width.15

Numerous articles have discussed the needto maintain a minimum biologic width of2 mm relative to the margin of the restora-tion.16-27 This has become the standard forwhich numerous crown-lengthening proce-dures have been performed over the last 3

decades. Clinicians have questioned the needfor a minimum of 3 mm (2 mm for biologic


CE 5

Figure 3BSurgical

view of a one-stage

crown-lengthening

procedure, classifica-

tion II A 1. Ostectomy

is performed to alter

the gingival position

of the central incisors.

A periodontal probe is

used to determine thenew position of the

biologic width and

where the crown mar-

gin can be placed.

Figure 3CThe flap

is sutured 2 mm from

the crest of bone.

The free gingival

margin will form

1 mm incisal to this

position. The papillae

have not been violat-

ed. Note how far the

epithelium must trav-

el to close the surgi-

cal wound margin.

Figure 3DThe

postoperative healing

at 1 week. The gingi-

va is inflamed, and

no sulcus is evident.

The maturation of

gingival sulcus and

the final gingival

scallop for this

patient took6 months.

Figure 3EThe final

restoration 10 months

after crown-length-

ening surgery. The

central incisors are

equal in length and

in proper relation-

ship with the laterals

and canines.

(Restoration by Dr.

David Wohl, Fairfield,

Conn.)


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width and 1 mm for gingival sulcus) of soundtooth structure between the restoration andthe crest of alveolar bone in all situations.28,29

The wisdom of not needing a minimumdimension of space between the restorationand the alveolar bone and applying it to allhuman situations is based on clinical impres-sion.28,29 In 1961, Gargulio et al14 reported

ranges in sulcus depth from 0.0 mm to5.36 mm, in epithelial attachment from0.08 mm to 3.72 mm, and in connective-tissue

attachment from 0.0 mm to 6.25 mm. In 1981,Ramfjord30 questioned the surgical need for thecreation of a 2-mm to 3-mm biologic widthapical to the proposed restoration margin. Hetheorized that it may be better for the body tocreate its own biologic width, as long as thepatient maintains adequate oral hygiene. Databy others show that this may, in fact, be impos-

sible. The average marginal fit of gold andceramic crowns has been shown to be 20 m to57 m.31,32 Because the average size of amicroorganism is between 4 m and 10 m, wecan assume that even a clinically acceptablefitting crown would be capable of harboringdental plaque. Waerhaug33 postulated that theinflammatory lesion exerted its influence2 mm from the plaque front. Therefore, therationale for placing the crown margin 3 mmfrom the alveolar bone might be to eliminate

the influence of plaque from the 2.7-mm zoneof influence described by Waerhaug.

Numerous experimental studies haveshown the potential for attachment loss whenrestorative tooth margins are placed within2 mm of the alveolar crest.20,22,23,33 It has alsobeen shown that the placement ofintracrevicular margins predisposes the toothto recession34 (Figure 3A). Other studies havecorroborated these observations, noting thatsubgingival crown margins are associated with

more inflammation compared to supragingivalmargins.17,24 Therefore, placing a crown marginsubgingivally does not guarantee that it will bestable. In the esthetic zone, crown marginsmust be hidden. Therefore, it is beneficial toerr on the side of caution and maintain at least2 mm between the crown margin and the alve-olar bone. Violation of the biologic width canresult in recession or inflammation.35,36

Depending on the inflammatory state ofthe gingiva and/or the force of the probe, human

variability makes the precise determination ofthe individual components of the biologicwidth difficult. The exact histological depth ofthe gingival sulcus is impossible to determineclinically. The probe might penetrate theepithelium or connective-tissue attachment.This is a constant dilemma for the practition-er. It has been proposed that the complex berenamed the dentogingival complex and thatits dimension be 3 mm on the direct labial ofthe maxillary anterior teeth.27 Also, the exact

dimension of the various components of thedentogingival complex cannot be determined


CE 5

Figure 4ACrown

lengthening, classifi-

cation II A 3, is per-

formed. No restora-

tive dentistry is

planned, so the maxi-

mum clinical crown

exposure is the thera-

peutic endpoint. Agingivectomy

removes a collar of

tissue slightly incisal

to the CEJ.

Figure 4BCrown-

lengthening proce-

dure postgingivecto-

my. Note the

increased exposure

of the clinical crown.

However, if the bone

is not removed, gin-

gival tissues willregenerate incisally

3 mm from the crest

of bone.

Figure 4CThe full-

thickness mucoperi-

osteal flap is reflect-

ed after gingivecto-

my. This allows

access for ostectomy.

Figure 4DAfter

ostectomy, the flap

is sutured to the

intact papillae with

interrupted sutures.

The tissue will usu-

ally maintain itself in

this position.


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CE 5clinically. How can the clinician then decidewhere to place the margin of the restoration ifthe base of the sulcus cannot be determined?Kois27 has suggested that the position of theosseous crest be used to determine marginplacement. When the patient is under anes-thesia, the alveolar crest of bone can be sound-ed and its position determined. The clinician

can then place the crown margin3 mm from the crest of bone, assuming the pre-viously discussed concepts of biologic widthare understood and agreed on.

Types of Crown-Lengthening ProceduresThe two indications for maxillary anterior

crown-lengthening procedures are: (1) toincrease the amount of labial exposure of theclinical crown, and (2) to increase the amountof tooth exposed superior to the bone to prevent

impingement of the restoration on the biologicwidth. Depending on the situation and the ther-apeutic endpoint required, a number of surgicalprocedures are available. A classification ofthese procedures is shown in Table 1.

Gingival Reduction OnlyRarely are these techniques called for

because bone reduction is usually needed toachieve enough exposure of the clinicalcrown. However, if bone removal is not neces-

sary, it is possible to perform either a gingivec-tomy or gingival flap surgery without ostecto-my. In the case shown here, a gingivectomyalone is done. The preoperative view (Figure2A) shows uneven, dissimilar margins. Thegingiva is inflamed and in need of plaque con-trol. The clinical crowns are not completelyexposed because of excess gingival display. Thedistance from the free gingival margin to thebone is 6 mm.

Oral hygiene instructions are given and

root planing is completed. After 6 weeks, gin-gival healing is complete and a gingivectomyis performed. The postoperative photograph(Figure 2B) shows gingival symmetry,improvement of oral health, and a much moreesthetic appearance. This level of improve-ment is seldom achieved without osseoussurgery.

Mucoperiosteal flaps with ostectomy areusually required to achieve enough exposure ofthe clinical crown. Either one-stage or two-

stage procedures can be done. The three types ofone-stage procedures are: (1) flaps, ostectomy,

Figure 5BWith

short central incisor

crowns, the centrals

are in balance with

each other but are

not in proper gingival

or incisal relationship

with the canines and

laterals. After peri-

odontal treatment,

restorative treatment

will improve the in-

cisal and the gingivallabial relationship.

Figure 4EGingival

healing 1 year post-

operatively. Tissues

have remained stable

where they were

sutured. No restora-

tive dentistry was

performed.

Figure 5AThe pre-

operative unesthetic

smile. The incisal

edges do not follow

a similar curvature.

The centrals are not

in harmony with the

anterior dentition.

Table 1Classification of Crown-Lengthening Procedures

I Gingival reduction onlybone removal notrequired

A Gingivectomy

B Gingival flap surgery

II Mucoperiosteal flap with ostectomyboneremoval required

A One-stage procedures, which require one ofthe following:

(1) Flaps, ostectomy, apical positioning

(2) Flaps, ostectomy, gingivectomy,positioning

(3) Gingivectomy, flaps, ostectomy,positioning

B Two-stage procedure, which requires:

Flaps, ostectomy, and repositioning

4 to 6 weeks latergingivectomy


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CE 5and apical positioning; (2) flaps, ostectomy,gingivectomy, and positioning; and (3) gin-givectomy, flaps, ostectomy, and positioning.Two of the three one-stage techniques and thetwo-stage technique are reviewed here.

One-Stage Surgical Crown-LengtheningTechniques

The technique listed in Table 1 as classifi-cation II A 1 involves raising a mucoperiostealflap, followed by ostectomy and then the api-cal positioning of the tissues at or near the

crest of bone7,26,37,38 (Figures 3A through 3E).This technique is useful if the amount of kera-tinized gingiva is limited. The advantage ofthis procedure is that all of the keratinized gin-giva is preserved and a healthy band ofattached and free gingiva remains after thesurgery. However, if healing is delayed (Figure3D), it can take months for the sulcus to re-

form. A minimum of 3 mm from the alveolarcrest to the restoration margin is necessary toavoid violation of the biologic width. The finalposition of the free gingival margin isunknown because the tissues may shrink orswell, depending on the individual patient.The tissue position at the conclusion of peri-odontal surgery may be altered by the healingprocess and may not be stable for months. Thisdelays the final impression and thus delays thecompletion of the restoration. A second minor

gingivectomy may also be needed to place thefree gingival margin at the precise position toachieve a harmonious esthetic balance.

The second mucoperiosteal flap withostectomy technique, classification II A 3, isalso a one-stage approach. The indicationsinclude an inadequate amount of exposed clin-ical crown and a requirement for boneremoval. The technique begins with an inter-nal bevel gingivectomy, placing the margin ofgingival tissues at their final anticipated labial

position (Figure 4A), regardless of their rela-tionship to the underlying alveolar bone. Anadequate amount of keratinized tissue mustremain after the removal of a collar of freemarginal gingiva (Figure 4B). Less than ade-quate postsurgical keratinized gingiva is a con-traindication to this technique. After the gin-givectomy, an incision is made in the new sul-cus and a full-thickness mucoperiosteal flap isreflected, exposing the underlying bone(Figure 4C). When restorative dentistry is not

planned, removal of 2 mm of bone from thecementoenamel junction (CEJ) is recom-mended to expose the maximum amount ofclinical crown without causing recession andpossible root exposure. Care is taken to leavethe interdental papillae intact, because losswould lead to esthetic compromise. Only athin labial flap of tissue is raised over the papil-lae to avoid papillary collapse. Labial ostecto-my is now performed, positioning the labialbone at least 3 mm from the newly created

facial free gingival margin. The flap is thenrepositioned and sutured to the nonviolated

Figure 5CCrown

lengthening, classifi-

cation II B, is per-

formed. The initial

incision and a full-

thickness mucoperi-

osteal flap reflection

are shown. Incisionsare made at the distal

labial line angles of

the centrals without

violating the papillae.

Figure 5DOstecto-

my is performed on

both central incisors.

The zenith of bone

curves slightly to the

distal. The new

crown margin will be

3 mm from the newly

created crest of alve-

olar bone. The labial

ostectomy is blended

with the interproxi-

mal bone.

Figure 5EThe flap

is sutured back in its

original position with

interrupted sutures.

Figure 5FAn inter-

nal bevel gingivecto-

my is performed

5 weeks postopera-

tively. The distance

from the free margin-

al gingiva to the alve-

olar crest was 6 mm.

Therefore, 3 mm of

marginal gingivacould be excised.


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815

papillae (Figures 4D and 4E). The advantageof this technique is that it is one-stage.However, healing is not always predictable,despite adherence to biologic principles.Alterations in healing occasionally lead toless-than-ideal esthetics, resulting in reentrysurgery or an additional gingivectomy. For thisreason, a two-stage crown-lengthening proce-

dure was developed.

Two-Stage Surgical Crown-LengtheningTechnique

A two-stage crown-lengthening procedureis indicated when an increase in clinical crownlength is necessary and labial bone removal isrequired (Figures 5A, 5B, and 6A). The firstprocedure involves initial reflection of a full-thickness mucoperiosteal flap to achieveaccess to the facial alveolar bone (Figure 5C).

The palatal tissues are not included and thepapillae are preserved. In isolated areas, verti-cal incisions may be useful to minimize flap sizeand to avoid a labial flap reflection over papil-lae. The vertical incisions are made at the flapmargins on the labial line angle of the teethbeing lengthened (Figures 5C, 5D, and 6C).This avoids the possibility of papilla shrinkage.Bone removal is then performed after flapreflection (Figures 5D and 6C). The positionof the restorative margin must be anticipated

so that the appropriate amount of bone can beremoved. There must be at least 3 mm of spacebetween the crown margin and the bone sothat the biologic width will not be impingedon or compromised. Esthetic principles shouldbe taken into account during the ostectomyprocedure because the gingival tissue followsthe bony contour. The zenith of bone over thelabial root surface should mimic the anticipat-ed gingival position (Figures 5D and 6C). Theheight of alveolar contour should be at the

midline of the lateral incisors and slightly dis-tal on the centrals and canines.5-8,38-40 The labi-al crest of bone is positioned at least 3 mmfrom the anticipated position of the restora-tion margin to allow for adequate biologicwidth (Figures 5D and 6C).

If restorations are not contemplated andthe procedure is performed solely to exposeadditional natural clinical crown, the labialalveolar bone margin should be positioned2 mm from the CEJ. The body will re-form a

2-mm biologic width and a 1-mm sulcus, lead-ing to a free margin of gingival tissue 3 mm

from the alveolar bone. However, this does nottake into consideration alveolar bone resorp-tion, which is possible whenever thin alveolarlabial bone is surgically exposed. If this occurs,the gingival tissues will re-form in relation tothe alveolar bone and not the CEJ. This canresult in root exposure of a natural tooth. The

Vol. 18, No. 8 Compendium/ August 1997

CE 5

Figure 5GTwo

weeks postgingivec-

tomy, complete heal-

ing of the tissues is

seen. The patient can

now have provisional

restorations placed.

When stability is

seen in the provision-

als, the final impres-

sions can be taken.

Figure 5HThe

final, well-balancedsmile 2 weeks after

insertion of veneers

on teeth Nos. 6

through 11.

(Restoration by

Dr. Stephen Guss,

Fairfield, Conn.)

Figure 6AA single-

tooth implant was

placed in the posi-

tion of the right cen-

tral incisor with the

anticipation ofcrown-lengthening

the adjacent central

incisor and placing a

labial veneer after

implant integration.

Figure 6BRadiograph of the tempo-

rized dental implant. Note the depth of

the implant placement to move the

dental gingival junction apically.


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CE 5outcome is esthetic compromise in an areabeing treated for esthetic improvement. Afterthe ostectomy procedure, the flap is reposi-tioned at its original position with interruptedsutures (Figure 5E). Two weeks postoperative-ly, gingival healing appears complete (Figure6D). Visually, it appears as if no surgery wasperformed because the gingival levels have

remained unaltered. At 4 to 6 weeks postoper-atively, gingival tissues are stable and the

patient is seen for the second procedure, aninternal bevel gingivectomy (Figures 5F, 6D,and 6E). The alveolar crest is sounded and themillimeters of supra-alveolar gingiva deter-mined. This number minus 3 mm is theamount of gingiva that can be removed withno change in the free gingival margin. A collarof gingival tissue is excised, leaving additional

root exposed. To achieve esthetic accuracy,calipers or periodontal probes can be used.Complete gingival healing is achieved at2 weeks (Figure 5G).

This technique can be combined withother procedures. Occasionally, a situation willarise where gingivectomy is required on someteeth and ostectomy as well as gingivectomyon others. As demonstrated, these techniqueshave many indications, independent of thetypes of dentistry that are being performed.

Often they are useful when performing anteri-or reconstruction with dental implants andnatural teeth. The esthetic principles remainthe samethe achievement of an esthetic,harmonious, symmetrical smile.

ConclusionMany of todays dental patients are cos-

metically oriented. Many others come intodental offices unaware of the benefits and exis-tence of cosmetic dental rehabilitation. An

important role for dentists is to teach patientswhat is possible and available to them.Dentists are fortunate today to be able to com-pletely reconstruct what has been lost. Few dis-ciplines of medicine can make this claim.Periodontal therapy has seen a tremendousgrowth in technology, which allows dentists tore-create almost all lost periodontium withpredictability. The focus of periodontics haschanged from resective to regenerative andesthetic. Likewise, restorative dentistry has

seen a tremendous evolution in the quality ofdental materials. Natural-looking restorationsare now possible. Dental implants have made athird set of teeth possible for patients. Theknowledge and technology for complete dentalrehabilitation exists.

For all of this to be well orchestrated, how-ever, communication must exist between thepatient and the dentist. The dentist must beaware of what patients want and need. Thepatient must be knowledgeable as to what is

possible, and must understand the costs, risks,and benefits of treatment. Communication

Figure 6CCrown-

lengthening surgery,

classification II B, is

performed on a cen-

tral incisor. Incisions

are made at the

mesial and distal line

angles of the central

incisor. Bone is

removed 3 mm apicalto the gingival height

of contour of the adja-

cent central incisor

implant.

Figure 6DSix

weeks after crown

lengthening, calipers

are used to measure

the implant crown

length. This mea-

surement will be

transferred to the

adjacent central

incisor so an accu-rate gingivectomy

can be performed.

Figure 6EThe

central incisor

immediately after

completion of

caliper-measured

gingivectomy. Note

the symmetry of the

gingival margins.

Figure 6FThe final

restoration 2 years

postoperatively. A

ceramic crown is on

the implant on the

right central incisor.

A labial veneer is on

the left central

incisor. (Restoration

by Dr. Keith Rudolph,

Westport, Conn.)


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Compendium/ August 1997 Vol. 18, No. 8

also must exist among dentists. The various dental disciplines must main-tain a dialogue about what is possible in each field. The impact of eachdentists treatment on the final result must be known by all participatingclinicians. Lastly, excellent communication between the dentist and den-tal technician should exist. Total esthetic rehabilitation is a teamapproach.

It is hoped that the crown-lengthening techniques presented will makeanterior cosmetic restorations more predictable. With proper treatment

planning and communication, a predictable, controlled, esthetic, harmo-nious result can be achieved for many patients. The beneficiaries will be allwho participate in the process.

AcknowledgmentThe author wishes to express his sincere appreciation to Cheryl Lynn

Ives for her helpful cooperation and editorial expertise in preparing thismanuscript.

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COLGATE

PREVIDENT 5000

1/3 B/W

DENTALOGIC

1/3 4C

Circle 28 on Reader Service Card


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Q & B FOODS

1/3 B/W

Circle 29 on Reader Service Card


11/11

820

CE 5

Compendium/ August 1997 Vol. 18, No. 8

Quiz5

1. Possible indications for crown-

lengthening include:

a. increasing crown length for

restoration retention.

b. restoring the tooth without

violating the biologic width.c. esthetics via an alteration of

the gingival labial profile.

d. all of the above

2. Placing the margin of the

restoration within the biologic

width can result in:

a. recession.

b. chronic inflammation.

c. the re-creation of a newly

positioned dental gingival

complex.d. all of the above

3. In an ideal esthetic situation, the

marginal gingival height of the

maxillary central incisors relative

to the maxillary lateral incisors is

located:

a. approximately 1.5 mm more

incisally.

b. coincident with the central

incisors.

c. approximately 1.0 mm moreapically.

d. approximately 4.0 mm more

incisally.

4. In the maxilla, the gingival

zenith is located along the mid-

line of the labial surface of the:

a. central incisors.

b. lateral incisors.

c. canines.

c. lateral and central incisors.

5. A mucoperiosteal flap can be

performed when:

a. ostectomy is required.

b. excess gingiva covers the clin-ical crown.

c. a minimal band of keratinized

gingiva exists.

d. all of the above

6. A gingivectomy for crown

lengthening is contraindicatedwhen:

a. excess keratinized gingiva exists.

b. access to bone is not required.

c. the margin of the provisional

restoration lies within the

biologic width.

d. the gingiva is extremely

fibrotic.

7. The two-stage crown-lengthening

procedure requires:

a. a gingivectomy.b. increased clinical skill.

c. crowning of all teeth.

d. reflection of a palatal flap.

8. Ref lection of the papillae is

avoided because:

a. it adds time to the procedure.

b. it eliminates papillary reces-

sion.

c. there is never a need to

lengthen teeth interproximally.d. none of the above

9. The restorative tooth-marginposition should be determined

before the first stage of the two-

stage crown-lengthening proce-

dure so that:

a. the appropriate amount of

bone can be removed.

b. the biologic width will not be

compromised later.

c. neither a nor bd. both a and b

10. At stage 2 surgery, the total

millimeter (mm) amount of gingi-

va that can be excised without

violating the dental gingival

complex is:

a. the distance from the free

gingival margin to the alveo-

lar crest minus 3 mm.

b. the clinical sulcus depth.

c. not able to be determinedwithout performing a

mucoperiosteal flap.

d. the distance from the

mucogingival junction to the

alveolar crest.

This article provides 1 hour of CE credit from Dental Learning Systems, Co., Inc., inassociation with the University of Southern California School of Dentistry and theUniversity of Pennsylvania School of Dental Medicine. Record your answers on theenclosed answer sheet or submit them on a separate sheet of paper.

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