Surgical crown lengthening

building a solid foundation

for restorative excellence

A case reports

Adityo widaryono
DR.Yuniarti Soeroso drg, Sp.Perio(K)
  Subgingival caries,
 fractures,
 perforations,
 excessively worn dentition,
 common problems.

 Retention and resistance of the restoration

(Stankiewicz 2001)

 Violation of the periodontium attachment

 Crown lengthening ensure the marginal placement

of restorations remains supragingival to fulfill
biologic and restoration requirements
(Danesh-meyer, 2012)
 Definition

 Procedure that
employs combination
of tissue reduction,
osseus surgery and/or
orthodontic for tooth
exposure (Cohen, 2007)
 Procedure objectives
 Removal of subgingival caries (Sato, 2000)

 To restore gingival health when the biological width has

been violated (Dibart, 2006)

 Cosmetic proportion improvement (Dibart, 2006)

 Facilitate proper tooth preparation (in the margin area)

without violating biological width thus provide stable
dento-gingival complex (Cohen, 2007)

 Facilitation of improved oral hygiene (Sato, 2000)

 Indications
 Subgingival caries

 Fracture / trauma

 Altered passive eruption

 Restorative requirements

 Root perforation

 External root resorption

 Contraindication and limiting
factors
(Cohen 2007, Sato 2000, Huynh-Ba 2007)

 Not restorable tooth

 Inadequate crown root ratio

 Less then 1:1

 Insufficient restorative space

 Less then 4mm interocclusal space

 Compromise of adjacent periodontium or esthetics

 Unmaintainable
 Biological consideration
(Danesh-meyer, 2012)

 Biologic width

 Dimensions 2.75-3.00mm

 establishment of a stable dentogingival complex

 Consists of the sulcus depth, epithelial and

connective tissue attachments

 A restorative margin should never be placed within

less than 3mm from the crestal bone height
 Anatomical consideration
(Huynh-Ba 2007, Danesh-meyer 2012, Sato 2000)

 Length and shape of the root

 Fracture or caries position

 The height of the furcation

 the height of the upper lip (smile line)

 the interdental space

 the attached gingival tissue. Ideally, a zone of 2-3mm of

attached gingival tissue should be preserved around teeth
 Restorative consideration
(Cohen 2007, Sato 2000)

 Importance of the tooth in the arch

 Anticipated final margin placement

 Retention

 Marginal seal

 Form

 Esthetic
Techniques (Huynh-Ba, 2007)

 Gingivectomy

 Apically repositioned flap

 Orthodontic forced
eruption
Sato , 2000
The gingivectomy has very limited usage as a
crown lengthening technique because it
requires

(1)an adequate zone of attached gingiva,

(2) at least 3 mm of sound tooth structure

coronal to the bone

Sivers 1985
 Possible complications
(Sato,2000 Danesh-meyer, 2012)

 Incresing tooth mobility due to loss of perio

support
 esthetic defect
 Difficulties in adequate plaque control
 furcation exposure
 pulpal exposure
 Damage of the adjacent tooth
 Recession of the adjacent tooth
Case 1

 41 y.o male with fractured maxillary anterior

dentition
 trauma history due to traffic accident 1 year
ago
 Refered by his endodontist to manage the
hygiene issue and subgingival fracture line on
the palatal area
 Exposure of the palatal tooth structure needed
to provide adequate endodontic access and
restorative requirement (ferrule)
 Case 1 clinical considerations
 General :
 smoker , 1 pack a day
 Hyperthyroid history in 2004, complete treatment,
stable and no present medication
 Loss several posterior tooth (extracted, caries, non-
restorable)
 Several tooth with caries
 No mobile tooth
 OHI-s : 4,28
 Fractured maxillary anterior dentition
 Case 1 clinical considerations

 Local
 Length and shape of the root (adequate)
 Fracture or caries position (adequate)
 the interdental space (adequate)
 the attached gingival tissue (adequate)
 Crestal bone to gingival margin distance (bone
sounding)
 Incisive canal (bleeding control)
 Thick palatal tissue (flap difficulties)
 Case 1 treatment plan
1. Dental health education and oral physiotherapy
2. Scaling and root planning
3. Caries control
4. Evaluation of DHE-OP, tissue inflammation and
probing depth improvement
5. 11,21,22 crown lengthening
 Expose 2mm of tooth structure above gingival margin
 2mm bone removal (estimation)
6. Restoration
 11,21,22 crown
 24,26,36,44,46 removable denture
Case 1 procedure

 Gingivectomy
Bone
removal
1st control (1 week)
2nd control (2 weeks)
3rd control and completion of
endodontic (4 weeks)
Before and after crown
lengthening
Restoration(7 week post-op)
Saved by the lip
Case 2

 37 y.o. male
 With trauma history in the upper anterior
dentition
 Avulsed 11
 12 and 21 fractured in the palatal area down
below the gingival line
 12 and 21 planed with post core plus 3 unit
bridgework
 12 and 21 endodontic treatment finished
Pre-op

Courtesy of R.Salim dds.

Incision and flap reflection

Courtesy of R.Salim dds.

Measuring bone removal and flap closure

Courtesy of R.Salim dds.

1 week suture removal

Courtesy of R.Salim dds.

1 month post-op

Courtesy of R.Salim dds.

 Long term temporaries

Biologic width
violation
Courtesy of R.Salim dds.
 Discussion
 Severely broken tooth, with little tooth structure remaining, can provide a
significant challenge for restoration

 When restoring these cases, the restoration’s ability to brace solid sound
tooth structure (ferrule) is the key for long-term success (Jotkowitz, 2009)
•Biologic width is essential for preservation of periodontal health and
removal of irritation that might damage the periodontium (prosthetic
restorations, for example) Padbury 2003

•Approximately 5 mm of keratinized gingiva, composed of 2 mm of free

gingiva and 3 mm of attached gingiva, is necessary to maintain periodontal
health (Nevins 1986)
Surgical crown lengthening basically moving the dentogingival complex apical
relative to the tooth, exposing more of the tooth/root supra-gingivaly

Facilitate proper tooth preparation (especiallty in the margin area) without

violating biological width thus provide stable dento-gingival complex

(Danesh meyer 2012)

 When the restoration margin is placed too far
below the gingival tissue crest, it impinges on
the gingival attachment apparatus and creates a
violation of biologic width (Khuller 2009)
If the biologic width is violated, it is impossible to maintain periodontal
health. (Jorgie-Srdjak 2000)
1. Bone loss under the preparation margin. Pocket and progressive
periodontal tissue loss (periodontal ligament and bone)
develop.
2. Gingival recession and localized bone loss develop. where the
labiobuccal bone is thin
3. Localized gingival hyperplasia with minimal bone loss.
Hyperplasia is most frequently found in altered passive eruption
and subgingivally placed restoration margins.
 Summary
 Severely broken tooth, with little tooth structure
remaining, can provide a significant challenge for
restoration

 When all clinical considerations are feasible, surgical

crown lengthening can provide both, mechanical
(ferrule) and biological (bio.width) requirement

 However the apical restoration margin should not

violate the newly established biological width
otherwise stable dento-gingival complex would not
be achieved
 The following three rules can be used to place
intracrevicular margins (Orkin 1987)

1. If the sulcus probes 1.5mm or less, place the restoration

margin 0.5mm below the gingival tissue crest

2. If the sulcus probes more than 1.5mm, place the margin

one half the depth of the sulcus below the tissue crest.

3. If a sulcus greater than 2mm is found, especially on the

facial aspect of the tooth, then evaluate to see whether
a gingivectomy could be performed to lengthen the
teeth and create a 1.5mm sulcus. Then the patient can
be treated using Rule 1.
 Supragingival margin

the best margin placement,

simplifying impression detail,
cementation and
most maintainable dental-restoration junction.
??Not esthetics??