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P E R IO D O N T A L-R E S T O R A T IV E IN T E R F A C E S
WHAT IS THE PHYSICAL DIMENSION OCCUPIED BY
THE SUPRA-ALVEOLAR ATTACHMENT APPARATUS
▸ Dentogingival Unit ▸ Dentogingival Junction
▸ Anatomic Relationships:
Functional unit consisting of
a fibrous connective tissue
attachment and the
junctional epithelium
▸ Dimensions and Relations:
Biological width:
CLINICAL CROWN LENGTHENING Dimensions and relations of
the dentogingival junction
in humans.
Andrew Tawse-Smith
Gargiulo et al, 1961 J of Periodontology
Nevins & Cappetta, 1998, Periodontal therapy
P E R IO D O N T A L-R E S T O R A T IV E IN T E R F A C E S
KEY POINTS CROWN LENGTHENING INDICATIONS
▸ Short Clinical Crown-Poor Retentive Form
▸ Biological Width ▸ Dentogingival Junction
▸ Caries that violate the biologic width
▸ Dimensions and Relations:
Biological width: ▸ Crown Fracture
Dimensions and relations of
the dentogingival junction
▸ Wear
in humans.
Gargiulo et al, 1961 J of Periodontology
▸ Subgingival restoration margins
Nevins & Cappetta, 1998, Periodontal therapy
▸ “Gummy Smile” – Delayed Passive Eruption
▸ Root Resorption
▸ Perforations
Camargo PM, et al. 2007. Clinical crown lengthening in the esthetic zone
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CAUSES
INJURY OF BIOLOGIC WIDTH VIOLATION OF BIOLOGIC WIDTH
▸ Rotary instruments ▸ Persistent gingival inflammation
▸ Retraction cord – Impression making
▸ Electrosurgery/Laser surgery
▸ Tooth Preparation
TOOTH WEAR DEEP SUBGINGIVAL MARGINS
▸ Short
Dolt AH, Robbins JW . Altered passive eruption: an etiology of short clinical crow ns. Q uintessence
Int. 1997 Jun;28(6):363-72.
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ALTERED/ DELAYED PASSIVE ERUPTION PASSIVE ERUPTION
Passive Eruption Four classic stages
Characterized by the apical shift ▸ Apical shift of the
of the dentogingival junction. dentogingival junction
The length of the clinical crown
increases as the epithelial
attachment migrates apically
Dolt AH, Robbins JW. Altered passive eruption: an etiology of short clinical crowns.
Quintessence Int. 1997 Jun;28(6):363-72.
Gargiulo AW, el al. Dimensions and rotations of the dentogingival junction in
Dolt AH, Robbins JW. Altered passive eruption: an etiology of short clinical humans. J Periodontol i96i;32:261-267.
crowns. Quintessence Int. 1997 Jun;28(6):363-72.
ALTERED PASSIVE ERUPTION PERIODONTAL TISSUE RESPONSE AND POSSIBLE
REACTION TO INVASION OF THE BIOLOGICAL WIDTH
Four types of altered passive
eruption
Violation of the biological width
▸ Type 1: wider band of gingiva
apical to CEJ & B: Apical shift of
the Gingival inflammation
▸ Type 2: All the gingiva is at the • Thin Periodontium
anatomical crown dentogingival Loss of Periodontal
• Horizontal bone loss/recession
junction ligament and bone
• Thick Periodontium
A B A B • Periodotnal pocketing/infraosseous defect
▸ A : level of bone is 1.5 to 2mm
form CEJ Periodontal
treatment
▸ B: Level of bone is at CEJ level
Periodontal surgery (Clinical
Dolt AH, Robbins JW. Altered passive eruption: an etiology of short clinical crowns.
crown lengthening)
Quintessence Int. 1997 Jun;28(6):363-72.
Coslet JO. et al. 1977 Diagnosis and classification of delayed passive eruption of the
dentogingival junction in the adult. Alpha Omegan 1977;3:24-28.
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RESTORATIVE DENTISTRY IMPLICATION RESTORATIVE DENTISTRY IMPLICATION
▸ Overhanging Restorations ▸ Strategies to avoid violation of Biologic Width
▸ Effects of Preparation
▸ Margin Placement
▸ Strategies to avoid violation of Biologic Width
RESTORATIVE DENTISTRY IMPLICATION RESTORATIVE DENTISTRY IMPLICATION
▸ Overhanging Restorations: ▸ Effects of Tooth Preparation
▸ Niche for Plaque accumulation ▸ Tooth preparation can traumatize tissues. Studies
showed bone loss when tooth preparation
▸ Affects oral home care
violated the biological width.
▸ Invade biologic width and Increases caries ▸ Adequate restorative and tooth preparation
susceptibility
techniques can avoid violation of the biological
▸ Increased Bone loss width (Retraction cord).
Carnevale G, Sterrantino SF, Di Febo G. Soft and hard tissue wound healing
following tooth preparation to the alveolar crest. The International Journal of
Periodontics & Restorative Dentistry. 1983;3(6):36–53.
Dragoo MR, Williams GB. Periodontal tissue reactions to restorative procedures, part
II. The International Journal of Periodontics & Restorative Dentistry. 1982;2(2):34–45.
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RESTORATIVE DENTISTRY IMPLICATION RATIONALE FOR CROWN LENGTHENING
SURGERY
▸ Margins ▸ Esthetics: short clinical crowns (developmental abnormality,
▸ The best restorative margin is one that is placed excessive gingival display (gunny smile, high lip line).
coronal to the marginal tissue. (supragingival,
equigingival) ▸ Functional/Restorative: exposure for subgingival caries
/subgingival fracture, perforation in the coronal third of the
▸ Aesthetic factors may prevent this in some cases. In root/ extensive occlusal wear
these cases a technically perfect, slightly
intracrevicular margin may be indicated ▸ Combination of the above
Hempton TJ, Dominici JT. Contemporary crown-lengthening therapy: a review. J Am
Nevins & Mellonig, 1998 Periodontal therapy (Nevins & Capetta) Dent Assoc. 2010 Jun;141(6):647-55.
CROWN LENGTHENING CONSIDERATIONS TISSUE MANAGEMENT
▸ Patient Selection ▸ Amount of attached gingiva
▸ Biological width ▸ Tooth mobility
▸ Soft tissues: Importance on the width of attached gingiva.
▸ Length and shape of the root ▸ Amount of remaining bone support/ Crown to Tissues can be excised - scalpel, laser or electrosurgery even
Root Ratio
▸ Furcation position some rotary instruments. Based on the quality and quantity of
▸ Height of interproxinmal bone
▸ Lip line at rest, speech and smiling
the tissue this can excised or apically repositioned
▸ Bony defects, dehiscence or fenestrations
▸ Local hard and soft tissue anatomy and ▸ Hard tissues: Bone resection or bone recontouring can be
muscle insertions ▸ Quality of remaining tooth structure achieved with rotary instruments - Burs, piezo-electric and
▸ Gingival biotype ▸ Strategic value of the tooth hand instruments chisels.Terms osteoplasty(recontouring of
the bone / removal of non-supporting bone – osseous ledge
▸ Gingival margin position and symmetry, ▸ Esthetic need and expectations of the patient,
Principles of anterior esthetics phonetics /exostosis)
▸ Probing pocket depth ▸ Patient’s oral hygiene
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FERRULE
FERRULE
▸ Ferrule: defined as an encircling band of cast metal.
▸ Ferrule effect: is a 360-degree metal collar of the crown
surrounding the parallel walls of the dentin extending
coronal to the shoulder of the preparation.
▸ The result is an elevation in resistance form of the crown from
the extension of dentinal tooth structure
Sorensen JA, Engelman MJ. Ferrule design and fracture resistance of endodontically Sorensen JA, Engelman MJ. Ferrule design and fracture resistance of endodontically
treated teeth. J Prosthet Dent. 1990 May;63(5):529-36 treated teeth. J Prosthet Dent. 1990 May;63(5):529-36
WHAT AMOUNT OF CROWN LENGTHENING IS NEEDED CROWN LENGTHENING TECHNIQUES
▸ Tissue Shrinkage
▸ Based on the Biological Width and Dentogingival unit:
▸ Gingivectomy-Scalpel , Laser, Electrosurgery
▸ At least 3 mm of root surface must exist between the
▸ Apically Positioned Flap
alveolar crest and the restorable margin to allow for
▸ With Osseous Correction
▸ Epithelial attachment
▸ Without Osseous Correction
▸ Supracrestal fiber attachment
▸ Forced Tooth Eruption
▸ Sulcus
▸ Extraction
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ALTERNATIVES TO CROWN LENGTHENING GINGIVECTOMY
▸ Fixed Prosthodontics
▸ Removable Prosthodontics
▸ Osseointegrated Implant
GINGIVECTOMY GINGIVECTOMY
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GINGIVECTOMY APICAL POSITIONED FLAP
▸ With or without osteotomy
CASE 1
‣ Delayed Passive Eruption
APICAL POSITIONED FLAP
▸ Indicated For Clinical Crown
Lengthening and Pocket
reduction
▸ Combined with and without
Bone recontouring
▸ Releasing Incisions (depends on
the case
▸ Flap Elevation Beyond MGJ
▸ Ideal to maintain adequate
keratinised tissues
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CASE 1 CASE 2
‣ Delayed Passive Eruption ‣ Crown Lengthening Surgery
CASE 3 CASE 3
‣ Crown Lengthening Surgery ‣ Crown Lengthening Surgery
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CASE 4 CASE 4
‣ Crown Lengthening Surgery
CASE 4 ORTHODONTIC TOOTH EXTRUSION – FORCED ERUPTION
‣ Periodontics and Prosthodontics interrelationships ‣ Orthodontic Tooth Extrusion – Forced Eruption
‣ Fracture
‣ Resorption
‣ Caries
‣ Iatrogenic perforation
‣ Infraosseous defect
‣ Extraction
Sabri R , 1989, Ingber, 1974,
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CASE 5 CASE 5
‣ Orthodontic Tooth Extrusion ‣ Orthodontic Tooth Extrusion
COMPLICATIONS REFERENCES
▸Poor Esthetics – black triangles ▸ Camargo PM, Melnick PR, Camargo LM. Clinical crown lengthening in the esthetic zone. J Calif
Dent Assoc. 2007 Jul;35(7):487-98.
▸Soft tissue rebound ▸ Carnevale G, Sterrantino SF, Di Febo G. Soft and hard tissue wound healing following tooth
preparation to the alveolar crest. The International Journal of Periodontics & Restorative
Dentistry. 1983;3(6):36–53.
▸Root sensitivity ▸ Dragoo MR, Williams GB. Periodontal tissue reactions to restorative procedures, part II. The
International Journal of Periodontics & Restorative Dentistry. 1982;2(2):34–45.
▸Root resorption ▸ Gargiulo et al, 1961 J of Periodontology
▸Temporary/Permanent tooth mobility ▸ Hempton TJ, Dominici JT. Contemporary crown-lengthening therapy: a review. J Am Dent
Assoc. 2010 Jun;141(6):647-55.
▸ Nevins & Cappetta, 1998, Periodontal therapy
▸Swelling, pain and bruising
▸ Sorensen JA, Engelman MJ. Ferrule design and fracture resistance of endodontically treated
teeth. J Prosthet Dent. 1990 May;63(5):529-36.
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