esthetic crown lengthening for maxillary anterior teeth

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807 Vol. 18, No. 8 Compendium / August 1997 CE 5 Esthetic Crown Lengthening for Maxillary Anterior Teeth Michael Sonick, DMD Assistant Clinical Professor of Surgery School of Medicine Yale University New Haven, Connecticut Assistant Clinical Professor of Periodontics School of Dental Medicine University of Connecticut Farmington, Connecticut Private Practice of Periodontics and Dental Implants Fairfield, Connecticut Abstract: I In n t th he e m ma ax xi il ll la ar ry y a an nt te er ri io or r r re eg gi io on n, , t th he e g gi in ng gi iv va al l l la ab bi ia al l m ma ar rg gi in n p po os si it ti io on n i is s a an n i im mp po or rt ta an nt t p pa ar ra am me et te er r i in n t th he e a ac ch hi ie ev ve em me en nt t o of f a an n i id de ea al l s sm mi il le e. . T Th he e r re el la at ti io on n- - s sh hi ip p b be et tw we ee en n t th he e p pe er ri io od do on nt ti iu um m a an nd d t th he e r re es st to or ra at ti io on n i is s c cr ri it ti ic ca al l i if f g gi in ng gi iv va al l h he ea al lt th h a an nd d e es st th he et ti ic cs s a ar re e t to o b be e a ac ch hi ie ev ve ed d. . P Pe er ri io od do on nt ta al l t th he er ra ap py y i is s a a n ne ec ce es ss sa ar ry y a an nd d u us se ef fu ul l a ad dj ju un nc ct t w wh he en n a an ny y a an nt te er ri io or r r re es st to or ra at ti io on n i is s u un nd de er rt ta ak ke en n. . A An nt te er ri io or r s su ur rg gi ic ca al l c cr ro ow wn n l le en ng gt th he en ni in ng g m ma ay y b be e u un nd de er rt ta ak ke en n t to o a av vo oi id d r re es st to or ra at ti iv ve e m ma ar rg gi in n i im mp pi in ng ge em me en nt t o on n t th he e b bi io ol lo og gi ic c w wi id dt th h. . C Cr ro ow wn n l le en ng gt th he en ni in ng g i is s a al ls so o u us se ed d t to o a al lt te er r t th he e g gi in ng gi iv va al l l la ab bi ia al l p pr ro o- - f fi il le es s. . T Th hi is s a ar rt ti ic cl le e d di is sc cu us ss se es s t th he e e es st th he et ti ic c p pa ar ra am me et te er rs s o of f i id de ea al l g gi in ng gi iv va al l l la ab bi ia al l p po os si i- - t ti io on ns s a an nd d p pr re es se en nt ts s a a c cl la as ss si if fi ic ca at ti io on n o of f c cr ro ow wn n- -l le en ng gt th he en ni in ng g p pr ro oc ce ed du ur re es s a an nd d t th he e p pr ro oc ce ed du ur re e f fo or r a a t tw wo o- -s st ta ag ge e c cr ro ow wn n- -l le en ng gt th he en ni in ng g t te ec ch hn ni iq qu ue e. . T Th he e t tw wo o- -s st ta ag ge e c cr ro ow wn n- - l le en ng gt th he en ni in ng g t te ec ch hn ni iq qu ue e i is s s su ur rg gi ic ca al ll ly y p pr re ec ci is se e b be ec ca au us se e h he ea al li in ng g i is s p pr re ed di ic ct ta ab bl le e. . D entistry 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 tooth structure. Patients demand and expect anterior rehabilitations to be esthetic. There is a tremendous focus on cosmetics today. One has only to gaze through magazine advertisements to see the emphasis that is placed on being attractive. Dentists are blessed with the unique ability to not only improve patients’ health but also enhance their attractiveness. The relationship between a per- son’s physical appearance and his or her self-esteem is well documented 1,2 (Psychology Today, November, 119-131, 1973). Studies have shown that a per- son’s face is the prime source of determining physical attractiveness. 1 Patients have stated that their teeth have the greatest impact on improving their phys- ical appearance, and hence self-esteem. Therefore, dentists play a significant role in helping to improve their patients’ psychological health. Dentists are called on to provide restorations that are in harmony with the lips, the face, the adjacent teeth, and a healthy periodontium. Until recently, the scope of esthetic rehabilitation was limited to a close replication of tooth structure on a healthy periodontal foundation. In the past, periodontal therapy was 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 dentogingival unit. However, periodontics has now entered the age of periodontal plastic surgery. 3 Many periodontal therapies lead to esthetic amelioration of the denti- tion. These techniques allow for the ability to cover denuded roots, correct localized alveolar defects, regenerate bone, increase the amount of keratinized gingiva, enhance papilla reformation, and alter dental gingival levels. The preservation of a sound periodontium remains the sine qua non of a successful esthetic and functional restoration. A thorough knowledge of the normal 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 reader should be able to: describe the indications for crown lengthening in the maxillary anterior sextant. discuss the parameters of dental gingival labial rela- tionships to achieve esthet- ics and harmony. determine how to position the restorative margin so the biologic width is not violated. explain the indications for the variety of crown-length- ening techniques available.

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Page 1: Esthetic Crown Lengthening for Maxillary Anterior Teeth

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

CE 5

EEsstthheettiicc CCrroowwnnLLeennggtthheenniinngg ffoorr MMaaxxiillllaarryyAAnntteerriioorr TTeeeetthh

MMiicchhaaeell SSoonniicckk,, DDMMDDAssistant Clinical Professor of SurgerySchool of MedicineYale UniversityNew Haven, Connecticut

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

Private Practice of Periodontics and DentalImplants

Fairfield, Connecticut

Abstract: IInn tthhee mmaaxxiillllaarryy aanntteerriioorr rreeggiioonn,, tthhee ggiinnggiivvaall llaabbiiaall mmaarrggiinn ppoossiittiioonniiss aann iimmppoorrttaanntt ppaarraammeetteerr iinn tthhee aacchhiieevveemmeenntt ooff aann iiddeeaall ssmmiillee.. TThhee rreellaattiioonn--sshhiipp bbeettwweeeenn tthhee ppeerriiooddoonnttiiuumm aanndd tthhee rreessttoorraattiioonn iiss ccrriittiiccaall iiff ggiinnggiivvaall hheeaalltthhaanndd eesstthheettiiccss aarree ttoo bbee aacchhiieevveedd.. PPeerriiooddoonnttaall tthheerraappyy iiss aa nneecceessssaarryy aanndd uusseeffuullaaddjjuunncctt wwhheenn aannyy aanntteerriioorr rreessttoorraattiioonn iiss uunnddeerrttaakkeenn.. AAnntteerriioorr ssuurrggiiccaall ccrroowwnnlleennggtthheenniinngg mmaayy bbee uunnddeerrttaakkeenn ttoo aavvooiidd rreessttoorraattiivvee mmaarrggiinn iimmppiinnggeemmeenntt oonn tthheebbiioollooggiicc wwiiddtthh.. CCrroowwnn lleennggtthheenniinngg iiss aallssoo uusseedd ttoo aalltteerr tthhee ggiinnggiivvaall llaabbiiaall pprroo--ffiilleess.. TThhiiss aarrttiiccllee ddiissccuusssseess tthhee eesstthheettiicc ppaarraammeetteerrss ooff iiddeeaall ggiinnggiivvaall llaabbiiaall ppoossii--ttiioonnss aanndd pprreesseennttss aa ccllaassssiiffiiccaattiioonn ooff ccrroowwnn--lleennggtthheenniinngg pprroocceedduurreess aanndd tthheepprroocceedduurree ffoorr aa ttwwoo--ssttaaggee ccrroowwnn--lleennggtthheenniinngg tteecchhnniiqquuee.. TThhee ttwwoo--ssttaaggee ccrroowwnn--lleennggtthheenniinngg tteecchhnniiqquuee iiss ssuurrggiiccaallllyy pprreecciissee bbeeccaauussee hheeaalliinngg iiss pprreeddiiccttaabbllee..

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 patients’health but also enhance their attractiveness. The relationship between a per-son’s physical appearance and his or her self-esteem is well documented1,2

(Psychology Today, November, 119-131, 1973). Studies have shown that a per-son’s 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 ofesthetics. 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 thesmile 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 for

crown lengthening in themaxillary anterior sextant.

• discuss the parameters ofdental gingival labial rela-tionships to achieve esthet-ics and harmony.

• determine how to positionthe restorative margin sothe biologic width is notviolated.

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

Page 2: Esthetic Crown Lengthening for Maxillary Anterior Teeth

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 estheticparameters 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 maxillarycentral incisor display when smiling.4

Depending 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 anddentistry. 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 bepink 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

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

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Figure 1—A clinicalillustration of peri-odontal health andideal esthetic gingi-val balance.

Figure 2A—The pre-operative view ofuneven, dissimilargingival margins.

Figure 2B—Post-operatively, gingivalsymmetry and amore estheticappearance are evident.

Figure 3A—The pre-operative view ofolder anterior crowns.Note the gingivalrecession and unevengingival margins.The dental gingivalposition of the cen-trals is too incisal.The patient’s left andright laterals aremore apical in posi-tion than the centrals.

Page 3: Esthetic Crown Lengthening for Maxillary Anterior Teeth

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 thegingival 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 esthetics—that 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 Width—A Concept Under SiegeThe dental gingival unit is composed of

two parts—the 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-tissueattachment 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 3decades. Clinicians have questioned the needfor a minimum of 3 mm (2 mm for biologic

809Vol. 18, No. 8 Compendium / August 1997

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Figure 3B—Surgicalview of a one-stagecrown-lengtheningprocedure, classifica-tion II A 1. Ostectomyis performed to alterthe gingival positionof the central incisors.A periodontal probe isused to determine thenew position of thebiologic width andwhere the crown mar-gin can be placed.

Figure 3C—The flapis sutured 2 mm fromthe crest of bone.The free gingivalmargin will form 1 mm incisal to thisposition. The papillaehave not been violat-ed. Note how far theepithelium must trav-el to close the surgi-cal wound margin.

Figure 3D—Thepostoperative healingat 1 week. The gingi-va is inflamed, andno sulcus is evident.The maturation ofgingival sulcus andthe final gingivalscallop for thispatient took 6 months.

Figure 3E—The finalrestoration 10 monthsafter crown-length-ening surgery. Thecentral incisors areequal in length andin proper relation-ship with the lateralsand 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 reportedranges in sulcus depth from 0.0 mm to 5.36 mm, in epithelial attachment from 0.08 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 µm to 57 µm.31,32 Because the average size of amicroorganism is between 4 µm and 10 µm, wecan assume that even a clinically acceptablefitting crown would be capable of harboringdental plaque. Waerhaug33 postulated that theinflammatory lesion exerted its influence 2 mm from the plaque front. Therefore, therationale for placing the crown margin 3 mmfrom the alveolar bone might be to eliminatethe 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 withmore 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, humanvariability 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 exactdimension of the various components of thedentogingival complex cannot be determined

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

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Figure 4A—Crownlengthening, classifi-cation II A 3, is per-formed. No restora-tive dentistry isplanned, so the maxi-mum clinical crownexposure is the thera-peutic endpoint. Agingivectomyremoves a collar oftissue slightly incisalto the CEJ.

Figure 4B—Crown-lengthening proce-dure postgingivecto-my. Note theincreased exposureof the clinical crown.However, if the boneis not removed, gin-gival tissues willregenerate incisally3 mm from the crestof bone.

Figure 4C—The full-thickness mucoperi-osteal flap is reflect-ed after gingivecto-my. This allowsaccess for ostectomy.

Figure 4D—Afterostectomy, the flapis sutured to theintact papillae withinterrupted sutures.The tissue will usu-ally maintain itself inthis position.

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

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 cliniciancan then place the crown margin 3 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 preventimpingement 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.

GGiinnggiivvaall RReedduuccttiioonn OOnnllyyRarely 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 androot 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 5B—With“short” central incisorcrowns, the centralsare in balance witheach other but arenot in proper gingivalor incisal relationshipwith the canines andlaterals. After peri-odontal treatment,restorative treatmentwill improve the in-cisal and the gingivallabial relationship.

Figure 4E—Gingivalhealing 1 year post-operatively. Tissueshave remained stablewhere they weresutured. No restora-tive dentistry wasperformed.

Figure 5A—The pre-operative unestheticsmile. The incisaledges do not followa similar curvature.The centrals are notin harmony with theanterior dentition.

Table 1—Classification of Crown-Lengthening ProceduresI Gingival reduction only—bone removal not

requiredA GingivectomyB Gingival flap surgery

II Mucoperiosteal flap with ostectomy—boneremoval requiredA One-stage procedures, which require one ofthe following:

(1) Flaps, ostectomy, apical positioning(2) Flaps, ostectomy, gingivectomy,

positioning(3) Gingivectomy, flaps, ostectomy,

positioningB Two-stage procedure, which requires:

Flaps, ostectomy, and repositioning4 to 6 weeks later—gingivectomy

Page 6: Esthetic Crown Lengthening for Maxillary Anterior Teeth

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

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.

OOnnee--SSttaaggee SSuurrggiiccaall CCrroowwnn--LLeennggtthheenniinnggTTeecchhnniiqquueess

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 minorgingivectomy 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 labialposition (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 notplanned, 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 createdfacial free gingival margin. The flap is thenrepositioned and sutured to the nonviolated

Figure 5C—Crownlengthening, classifi-cation II B, is per-formed. The initialincision and a full-thickness mucoperi-osteal flap reflectionare shown. Incisionsare made at the distallabial line angles ofthe centrals withoutviolating the papillae.

Figure 5D—Ostecto-my is performed onboth central incisors.The zenith of bonecurves slightly to thedistal. The newcrown margin will be3 mm from the newlycreated crest of alve-olar bone. The labialostectomy is blendedwith the interproxi-mal bone.

Figure 5E—The flapis sutured back in itsoriginal position withinterrupted sutures.

Figure 5F—An inter-nal bevel gingivecto-my is performed 5 weeks postopera-tively. The distancefrom the free margin-al gingiva to the alve-olar crest was 6 mm.Therefore, 3 mm ofmarginal gingivacould be excised.

Page 7: Esthetic Crown Lengthening for Maxillary Anterior Teeth

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.

TTwwoo--SSttaaggee SSuurrggiiccaall CCrroowwnn--LLeennggtthheenniinnggTTeecchhnniiqquuee

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 anticipatedso 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 themidline 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

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Figure 5G—Twoweeks postgingivec-tomy, complete heal-ing of the tissues isseen. The patient cannow have provisionalrestorations placed.When stability isseen in the provision-als, the final impres-sions can be taken.

Figure 5H—Thefinal, well-balancedsmile 2 weeks afterinsertion of veneerson teeth Nos. 6through 11.(Restoration by Dr. Stephen Guss,Fairfield, Conn.)

Figure 6A—A single-tooth implant wasplaced in the posi-tion of the right cen-tral incisor with theanticipation ofcrown-lengtheningthe adjacent centralincisor and placing alabial veneer afterimplant integration.

Figure 6B—Radiograph of the tempo-rized dental implant. Note the depth ofthe implant placement to move the“dental” gingival junction apically.

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

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 haveremained 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 additionalroot 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 same—the achievement of an esthetic,harmonious, symmetrical smile.

ConclusionMany of today’s dental patients are cos-

metically oriented. Many others come intodental offices unaware of the benefits and exis-tence of cosmetic dental rehabilitation. Animportant 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 hasseen 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 ispossible, and must understand the costs, risks,and benefits of treatment. Communication

Figure 6C—Crown-lengthening surgery,classification II B, isperformed on a cen-tral incisor. Incisionsare made at themesial and distal lineangles of the centralincisor. Bone isremoved 3 mm apicalto the gingival heightof contour of the adja-cent central incisorimplant.

Figure 6D—Sixweeks after crownlengthening, calipersare used to measurethe implant crownlength. This mea-surement will betransferred to theadjacent centralincisor so an accu-rate gingivectomycan be performed.

Figure 6E—Thecentral incisorimmediately aftercompletion ofcaliper-measuredgingivectomy. Notethe symmetry of thegingival margins.

Figure 6F—The finalrestoration 2 yearspostoperatively. Aceramic crown is onthe implant on theright central incisor.A labial veneer is onthe left centralincisor. (Restorationby Dr. Keith Rudolph,Westport, Conn.)

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also must exist among dentists. The various dental disciplines must main-tain a dialogue about what is possible in each field. The impact of eachdentist’s 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 treatmentplanning 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.

References1. Patzer GL: Understanding the causal relationship between physical attractiveness and self-

esteem. J Esthet Dent 3:144-146, 1996.2. Patzer, GL: Self-esteem and physical attractiveness. J Esthet Dent 7:274-277, 1995. 3. Miller PD: Concept of periodontal plastic surgery. Pract Periodontics Aesthet Dent 5(5):15-20, 1993.4. Vig RG, Brundoo GC: The kinetics of anterior tooth display. J Prosthet Dent 39:502, 1972.5. Rufenacht CR: Fundamentals of Esthetics. Chicago, Quintessence Publishing Co, Inc, 1990.6. Wheeler RC: An Atlas of Tooth Form, ed 4. Philadelphia, WB Saunders Co, 1969.7. Allen EP: Surgical crown lengthening for function and esthetics. Dent Clin North Am 37(2):163-

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CE 5179, 1993.

8. Chiche GJ, Pinault A: Esthetics of Anterior Fixed Prostho-dontics. Chicago, Quintessence Publishing Co, Inc, 1994.

9. Studer S, Zellweger U, Scharer P: The aesthetic guidelinesof the mucogingival complex for fixed prosthodontics.Pract Periodontics Aesthet Dent 8(4):333-342, 1996.

10. Maynard JG, Wilson RD: Physiologic dimensions of theperiodontium significant to the restorative dentist.J Periodontol 50:170-174, 1979.

11. Stetler KJ, Bissada NB: Significance of the width of kera-tinized gingiva on the periodontal status of teeth with sub-marginal restorations. J Periodontol 58:696, 1987.

12. Schroeder HE, Listgarten RA: Fine structures of the devel-oping epithelial attachment in human teeth. Monographsin Developmental Biology. Basel, S Kaarger, 1971.

13. Sicher H: Changing concepts of the supporting dentalstructures. Oral Surg 12:31-35, 1959.

14. Gargulio AW, Wentz FM, Orban BJ: Dimensions and rela-tion of the dentogingival junction in humans. J Periodontol32:261-267, 1961.

15. Cohen DW: Lecture, Walter Reed Army Medical Center,June 3, 1962.

16. Ingber JS, Rose LF, Coslet JG: The “biologic width”—aconcept in periodontics and restorative dentistry. AlphaOmegan 70:62-65, 1977.

17. Sillness J: Fixed prosthodontics and periodontal health.Dent Clin North Am 24:317-329, 1980.

18. Dragoo MR, Williams GB: Periodontal tissue reactions torestorative procedures. Int J Periodontics Restorative Dent2(1):9-23, 1982.

19. Dragoo MR, Williams GB: Periodontal tissue reactions torestorative procedures. Part II. Int J Perio-dontics Restorative Dent 2(2):35-45, 1982.

20. Carnevale G, Sterrantino SF, DiFebo G: Softand hard tissue wound healing following toothpreparation to the alveolar crest. Int JPeriodontics Restorative Dent 3(6):37-53, 1983.

21. Nevins M, Skurow HM: The intracrevicularrestorative margin, the biologic width, andthe maintenance of the gingival margin. Int JPeriodontics Restorative Dent 4(3):31, 1984.

22. Pharma-Benfenati S, Fugazzotto PA, RubenMP: The effect of restorative margins on thepostsurgical development and nature of theperiodontium. Part I. Int J PeriodonticsRestorative Dent 5(6):31-52, 1985.

23. Pharma-Benfenati S, Fugazzotto PA, FerriraPM, et al: The effect of restorative marginson the postsurgical development and natureof the periodontium. Part II. Int J PeriodonticsRestorative Dent 6(1):64-75, 1986.

24. da-Jocoby Lavina F, Ziafiropoulos GG,Ciancioa S: The effect of crown margin loca-tion on plaque and periodontal health. Int JPeriodontics Restorative Dent 9(3):197-205, 1989.

25. de Waal H, Castellucci G: The importance ofrestorative margin placement to the biologicwidth and periodontal health. Part I. Int JPeriodontics Restorative Dent 13(5):461-467,1993.

26. de Waal H, Castellucci G: The importance ofrestorative margin placement to the biologicwidth and periodontal health. Part II. Int JPeriodontics Restorative Dent 14(1):70-83, 1994.

27. Kois J: Altering gingival levels: the restora-tive connection. Part I: biologic variables. J Esthet Dent 6(1):3-9, 1994.

28. Dello Russo NM: Biologic width and crownlengthening (letter to the editor). J Peri-odontol 64:1993.

29. Mishkin DJ, Gellin RG: Biologic width and crown length-ening (letter to the editor). J Periodontol 64:920-921, 1993.

30. Ramfjord SP: Periodontal considerations of operative den-tistry. Oper Dent 10:144-159, 1988.

31. Holmes JR, Sulik WD, Holland GZ, et al: Marginal fit ofcastable ceramic crowns. J Prosthet Dent 67:594-599, 1992.

32. Christensen GJ: Marginal fit of gold castings. J ProsthetDent 16:297-305, 1966.

33. Waerhaug J: Subgingival plaque and loss of attachment inperiodontitis as observed in autopsy material. J Periodontol47:636-642, 1976.

34. Tal B, Soldinger M, Dreiangel A, et al: Periodontalresponse to long-term abuse of the gingival attachment bysupracrestal amalgam restorations. J Clin Periodontol16:650-659, 1989.

35. Valderhaug J, Birkeland JM: Periodontal conditions inpatients 5 years following insertion of fixed prostheses.J Oral Rehabil 3:237-243, 1976.

36. Kois J: The gingival is red around my crowns—a differen-tial diagnosis. Dent Econ 101-105, April 1993.

37. Wagenburg BD, Eskow RN, Langer B: Exposing adequatetooth structure for restorative dentistry. Int J PeriodonticsRestorative Dent 9:23, 1989.

38. Allen EP: Use of mucogingival surgical procedures toenhance esthetics. Dent Clin North Am 32(2):307-330, 1988.

39. Moskowitz ME, Nayyar A: Determinants of dental esthet-ics: a rationale for smile analysis and treatment. CompendContin Educ Dent 16(12):1164-1186, 1995.

40. Kovich V: Esthetics and anterior tooth position: an ortho-dontic perspective. Part I: crown length. J Esthet Dent5(1):19-23, 1993.

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QQuuiizz5511.. PPoossssiibbllee iinnddiiccaattiioonnss ffoorr ccrroowwnn--

lleennggtthheenniinngg iinncclluuddee::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

22.. PPllaacciinngg tthhee mmaarrggiinn ooff tthheerreessttoorraattiioonn wwiitthhiinn tthhee bbiioollooggiiccwwiiddtthh ccaann rreessuulltt iinn::a. recession.b. chronic inflammation.c. the re-creation of a newly

positioned dental gingivalcomplex.

d. all of the above

33.. IInn aann iiddeeaall eesstthheettiicc ssiittuuaattiioonn,, tthheemmaarrggiinnaall ggiinnggiivvaall hheeiigghhtt ooff tthheemmaaxxiillllaarryy cceennttrraall iinncciissoorrss rreellaattiivveettoo tthhee mmaaxxiillllaarryy llaatteerraall iinncciissoorrss iissllooccaatteedd::a. approximately 1.5 mm more

incisally.b. coincident with the central

incisors.c. approximately 1.0 mm more

apically.d. approximately 4.0 mm more

incisally.

44.. IInn tthhee mmaaxxiillllaa,, tthhee ggiinnggiivvaall

zzeenniitthh iiss llooccaatteedd aalloonngg tthhee mmiidd--lliinnee ooff tthhee llaabbiiaall ssuurrffaaccee ooff tthhee::a. central incisors.b. lateral incisors.c. canines.c. lateral and central incisors.

55.. AA mmuuccooppeerriioosstteeaall ffllaapp ccaann bbeeppeerrffoorrmmeedd wwhheenn::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

66.. AA ggiinnggiivveeccttoommyy ffoorr ccrroowwnnlleennggtthheenniinngg iiss ccoonnttrraaiinnddiiccaatteeddwwhheenn::a. excess keratinized gingiva exists.b. access to bone is not required.c. the margin of the provisional

restoration lies within thebiologic width.

d. the gingiva is extremelyfibrotic.

77.. TThhee ttwwoo--ssttaaggee ccrroowwnn--lleennggtthheenniinnggpprroocceedduurree rreeqquuiirreess::a. a gingivectomy.b. increased clinical skill.c. crowning of all teeth.d. reflection of a palatal flap.

88.. RReefflleeccttiioonn ooff tthhee ppaappiillllaaee iiss

aavvooiiddeedd bbeeccaauussee::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

99.. TThhee rreessttoorraattiivvee ttooootthh--mmaarrggiinnppoossiittiioonn sshhoouulldd bbee ddeetteerrmmiinneeddbbeeffoorree tthhee ffiirrsstt ssttaaggee ooff tthhee ttwwoo--ssttaaggee ccrroowwnn--lleennggtthheenniinngg pprrooccee--dduurree ssoo tthhaatt::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

1100.. AAtt ssttaaggee 22 ssuurrggeerryy,, tthhee ttoottaall mmiilllliimmeetteerr ((mmmm)) aammoouunntt ooff ggiinnggii--vvaa tthhaatt ccaann bbee eexxcciisseedd wwiitthhoouuttvviioollaattiinngg tthhee ddeennttaall ggiinnggiivvaall ccoommpplleexx iiss::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 determined

without performing amucoperiosteal flap.

d. the distance from themucogingival junction to thealveolar crest.

This article provides 1 hour of CCEE 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.