SURGICAL CROWN
LENGTHENING IN THE ESTHETIC
ZONE
Trijani Suwandi, drg, Sp. Perio
CROWN LENGTHENING
periodontal
procedure that
reshapes the ggv and supporting
tissues to expose more of the
tooth.
-Function
- Form
-Retention
-Marginal seal
INDICATIONS for Crown
Lengthening
(Cohen, 2009)
GINGIVAL ASYMMETRIES
Crown length discrepancies.
Some teeth appear longer while others appear shorter
(Patil. 2002)
SMILE LINE
HIGH SMILE LINE
>75% interprox ggv
All of marginal ggv
MEDIUM SMILE LINE
25-75% interprox ggv
Marg ggv terlihat
LOW SMILE LINE
<25% interprox ggv
Marg ggv tdk terlihat
Excessive Gingival Display
(Gummy Smile)
A
gingival display >3 mm in
active / moderate smile (Patil, 2002;
Jim Hinrich, 2007)
Exposure of sound tooth
structure
Clinical Evaluation before CL
(Cohen, 2009)
Apical extent of
fracture, caries,
perforations
Loss of mesial, distal
or oclusal space
Final margin
placement
Radiographic analysis (Cohen, 2002)
CONTRAINDICATION &
LIMITATING FACTOR (Cohen, 2002)
Non maintainability
Sequence of Treatment (Allen, 2002)
1.
2.
3.
4.
5.
6.
7.
Clinical & radiographic evaluation
Caries control
Placement of provisional
restoration
Endodontic therapy
Control ggv inflammation : plaque
control, Scaling root planing
Reevaluation for ortho th
surgery
SURGICAL DIAGNOSIS &
TREATMENT
Kois (1994) : only 3 mm is necessary to
satisfy requirements for a stable BW (2.04
mm BW, 1 sulcus depth) determining
total dentoggv complex (DGC)
Treatment
CL
location
Crest
Crest
facial
interprox
DGC (mm) DGC
Low
>3
> 3 4.5
No
3 4.5
No
<3
< 3 4.5
Yes
Normal
High
1. BIOLOGIC WIDTH = BW
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
BIOLOGIC 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
minimum 6 weeks of healing is
required before final restoration
When
restorations do not take
these considerations into BW :
Esthetic crown
lengthening
Ratio of 1.3 to 1.0
1.Typical distance between facial CEJ
and incisal edge of I1 = 11 - 12
mm
2.Typical mesial/distal width of I1 =
8.5 - 9.5 mm
3.Consequently 11.5 / 9 =length
verses width ratio of 1.27
LENGTHENING
PROCEDURE
1.
Gingival reduction only
2.
Bone removal not required
Gingivectomy or gingival flap
surgery
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
crown lengthening
1.
2.
Gingivectomy
Flap surgery for osseous recontouring
Choice depends on :
1. Gingival crevice depth
2. Need to maintain minimum of 1 mm
conn tissue between depth of crevice
and bone
3. Adequate width of keratinized gingiva
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
TECHNIQUE
This
patient
requires 3 mm of
CL
Sufficient crevice
depth and
keratinized tissue
CASE 1
The lateral incisors were congenitally missing
The canine teeth in the position of the lateral incisors
added to the esthetic harmony
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 AFTER
CASE 2
Sufficient crevice depth and keratinized gingiva
Frenum correction also needed
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
gentle scraping
Length
of I1 serves as basis for I2 and
C
I2 ggv margin 1 mm coronal to central
C ggv margin at same level as I1
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 frenectomy
Removal of wedge of tissue from frenum
interdental papilla is untouched
Incision
made through periosteum to expose bone
This ensures no muscle pull exists to interdental
papilla
Wound closed with 4.0 gut sutures
Healing after 12 weeks
BEFORE AND AFTER
ESTHETIC CROWN
LENGTHENING
Left/right
side
height
discrepancy
Perform by :
Gingivectomy or
flep with
osseous
resection
Only in facial
aspect
Esthetic CL
The
dotted line
indicate the
oblique vertical
incision without
involving the
interdental
papillae
Esthetic CL
A
full thickness
flap is raised to
gain acces for
osseous
reduction, the
bone dotted line
indicated the
amount of bone
to be resected
Esthetic CL
The
flap is
sutured back into
placed
CASE 3
Gingival asymmetry between central incisors
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 AFTER
FUNCTIONAL CL
The gingiva and bone follow a definite pattern
interproximally, facially and palatally (> 2 mm
of bone resection)
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
Functional CL
A full thickness flap raised labially as well as palatally , here
the blue dotted
Line indicated the amount of bone to be resected
Functional CL
Osseus reduction carried out around the tooth using a round diamond bur
Functional CL
The flap sutured back in place
CASE 4
Flap surgery and osseous correction
INITIAL INCISIONS
I1
and C new ggv
margins at same
level
Sulcular incision
used on I2 to
make it
harmonious with
I1 and C
Interprpox incisons
preserve papillae
Incisions
on left symmetrical with right
Use new blade for each two teeth to
minimize tissue trauma
Flap
carefully dissected with sharp
scalpels
3 mm of bone crest exposed
Bone 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 AFTER
ALTERED PASSIVE ERUPTION =
GUMMY SMILE
A gingival display > 3 mm in active or moderate smile : gummy
ACTIVE ERUPTION
PASSIVE ERUPTION
The
The
physical
movement of the
tooth from its
prefunctional subggv
position through the
ggv tissue, into the
oral cavity finally,
into functional
occlusion
TOOTH ERUPTION
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
(Weinberg & Eskow, 2000)
Classified passive eruption (Gargiulo et al
(1961)
Stage I = sulcus & JE are on the enamel
Stage II = sulcus on enamel. JE is part on the enamel and part on the
cementum
Stage III = sulcus at CEJ, JE completly on cementum
Stage IV = sulcus and Je apically to CEJ
Classification Delayed or
Altered Passive Eruption
(Coslet et
all, 1977)
TYPE IA
Type I = ggv margin is incisal to CEJ, MGJ is apical to crest of bone
Subgroup A = the alv crest is located 1.5 2 mm from CEJ
Therapy = GINGIVECTOMY
TYPE I B
Type I = ggv margin is incisal to CEJ, MGJ is apical to crest of bone
Subgroup B= the alv crest is coincident with CEJ
Therapy = GINGIVECTOMY or SCALLOPED inverse bevel flap &
osseous reduction
TYPE II A
Type II = ggv dimension is normal. The free ggv margin is incisal to CEJ,
MGJ is positioned at the CEJ
Subgroup A = the alv crest is located 1.5 2 mm from CEJ
Therapy = APICALLY POSITIONED FLAP
TYPE IIB
Type II = ggv dimension is normal. The free ggv margin is incisal to CEJ,
MGJ is positioned at the CEJ
Subgroup B = the alv crest is coincident with CEJ
Therapy = Apically positioned flap with osseous reduction
The causes gummy smile
Planning 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 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
CONCLUSION
CONCLUSION
Biologic width peridental and
implant
Biologic width peridental and
implant
A Systematic Approach to
Treatment Plan
Mankoo, 2002
Biologic width
When
implant-abutment connection
was placed at the ggv level
supracrestal to the alv bone (single
implant placement) : BW was similar
to that of natural dentition
facilitated maintenance of the BW
with minimal apical bone resorption
In Aesthetic Zone
implant
level should always be
placed subgingivally produce the
proper emergence profile & soft
tissue contours around the implant
restoration
As general rule, the implant head
should be placed 3 mm apical to the
desired labial gingiva margin
position in order to allow emergence
profile & aesthetics
The Role of Interdental Bone on
Papilla Development
Distance From interdental Incidence of the Papilla
bone to apical of contact
Being Completely Present
area
5 mm or less
100%
6 mm
56%
7 mm
27%
(Tarnow et all, 1992)
trijani [email protected]
