ABIOMETRICAPPROACHTOAESTHETICCROWNLENGTHENING

contemporaryperiodontaltherapyalsoencompassesaesthetictreatmentwhere
needsarefrequentlyassociatedwithchangesintoothsize,shape,proportion,and
balancethatcannegativelyaffectsmileappearance.1
Thereexistsasynergybetweenperiodonticsandrestorativedentistry,wherethe
disciplinesareinterdependent.Inaestheticdentistrywheredevelopmentofthe
propertoothsize,form,andcolorofrestorationsarecriticaltoclinicalsuccess,
oftentheperiodontalcomponentisconsiderableandmustbeaddressedfora
predictableaestheticoutcome.Theneedtoestablishthecorrecttoothsizeandthus
individualtoothproportiondrivestheperiodontalcomponentofaesthetic
restorativedentistry.Onespecificareaofconcernisexcessivelyshortteeth,2
wherethelackoftoothdisplayandexcessivegingivaldisplayrequireclinical
crownlengtheningthatcanpresentaclinicaldilemmafortheaestheticoriented
.periodontist
Thereareamyriadoftechniquesthathaveevolvedoverseveraldecadestotreat
thissituation.Techniquesthatsimplifyaswellasenhancethequalityoftreatment
canprovidesubstantialbenefittobothpatientsandtreatingpractitionersalike.This
articledescribesaninnovativeapproachtoperiodontalaestheticcrownlengthening
utilizingmeasurementgaugesspecificallydesignedforapredictablesurgical
outcome,thussettinganewstandardofdiagnosisandtreatmentwithinthe
aestheticzone.Midfacialsurgicalcrownlengtheninghastraditionallybeen
performedtoestablishahealthybiologicdimensionofthedentogingivalcomplex
(DGC)asanadjuncttoaestheticrestorativeprocedures.Whileconsiderable

variationinthemagnitudeorlengthofthiscomplexhasbeenreported,themean
sulcusdepthwas0.69mm,epithelialattachmentwas0.97mm,andtheconnective
tissuewas1.07mm.3Therefore,thetotallengthoftheDGCwas2.73mm.Based
onthesedimensions,severalauthorshavesuggestedthat3mmofsupracrestal
toothstructurebeobtainedduringsurgicalcrownlengthening.4,5Otherauthors
havesuggestedthatsupracrestaltoothstructurerangesfrom3.5mmto5.25mm,
dependingontheplacementoftherestorativemarin.6,7Itisimportant,therefore,
toestablishaconsistentmeasurementrepresentativeoftheDGCdimension,which
iscriticalforhealthandrestorativesuccesswhenperformingsurgicalcrown
lengthening

Figure1.DiagramofTBarProportionGaugetip(ie,ChusAesthetic
Gauges,HuFriedyInc,Chicago,IL).Oncethedesiredtoothdimensions
aredetermined,theadjunctiveperiodontalprocedurecanbe
performedwhethertreatmententailscrownlengtheningorcoverage

Figure2.TheProportionGaugetipisdesignedforsimultaneous

.widthandlengthmeasurementsofthemaxillaryanteriordentition
Theaveragecentralincisormeasures8.5mminwidthby11mmin
length(seeredmarkings)
Herreroetalnotedthatestablishingaconstantanddesiredsurpracrestaltooth
lengthisnotroutinelyachievedduringsurgicalcrownlengthening.8Walkerand
Hansendescribedthefabricationofasurgicaltemplateforaestheticrestorative
,crownlengthening.9This,however
requiredmultiplevisitstofabricatesuchatemplatepriortosurgery.Inaddition,
stabilityofthetemplateduringthesurgicalprocedurewasquestionableandcould
leadtoinconsistentandunsatisfactoryresults.Leedescribedatoothformed
provisionalrestorationtobeusedasaremovabletemplateforsurgicalcrown
,lengthening.10Thisapproachrequiresmultiplepresurgicalvisitstofabricate

Figure3.TheTBartipencompassesthetotalrangeoftoothwidth
andlengthdimensionsofthemaxillaryanteriordentition.The
measurementsaremathematicallyalignedwithapresetindividual
toothproportionratioof78%

Figure4.TheSoundingGaugeisfabricatedtopiercethesupracrestal
gingivalfibers.Thecurvedtipis1mmwideanddesignedtofollow
thetoothandCEJanatomiccontours
presentsstabilizationconcernsatthetimeofsurgery,andincreasesthecostof
treatment.Thesetechniquesattemptedtostandardizetheamountofsupracrestal
lengthoftheDGCtobeestablished,yettheyallrequiredadditional
.timeandlaboratoryprocedurestoaccomplish
Traditionally,dentalinstrumentssuchasperiodontalprobeshavebeenusedas
clinicalindicatorsofdiseasessuchasperiodontitis,withtheirnumericalvalues
indicativeofhealthorstagesofdisease.11Morerecently,instrumentation(ie,
ChusAestheticGauges,HuFriedyInc,Chicago,IL)hasbeencreatedtodiagnose
.andpredictablytreataesthetictoothdiscrepanciesanddeformities
Aestheticandanatomictoothdimensionscannowbeevaluatedandtreatedby
quantitativestandards.Theseinnovativeaestheticgaugeshavebeendevelopedto
eliminatethesubjectiveaestheticoutcomesaffordedbydirectvisualassessmentof
aesthetictoothproportions
InnovativeInstrumentation
ProportionGauge
TheProportionGauge(ie,ChusAestheticGauges,HuFriedyInc,Chicago,IL)
enablesanobjectivemathematicalappraisaloftoothsizerangesinavisualformat
fortheclinicianorlaboratorytechnician.Throughtheuseofsuchinstrumentation,
thedentalprofessionalisabletoapplyaestheticvaluesandmeasurementstoa
patientchairside(directly)orinthelaboratory(indirectly)forprojectedtreatment

planningandobjectiveforecastingoftheintendedtreatmentoutcome(Figure1).
Thecorrectincisaledgepositionmustbeestablishedbeforeanydiagnosticand
procedurebasedmeasurementismade.Inaddition,thecorrectincisaledge
positionandtoothsizemustbedeterminedpriortoanyirreversibleaesthetic
periodontalprocedurewhetheritisclinicalrootcoverageorlengthening.The
ProportionGaugeisdesignedasasinglehandle,doubleendedinstrumentwithT
BarandInLinetipsscrewedintothehandleatopposingends.13The
TBargaugeisusedtomeasureanoncrowdedanteriordentitionandtheInLine
foracrowdeddentition.The
TBartipfeaturesanestablishedrestpositionattheincisaledgeposition(ie,an
incisalstop);whenthegaugeisseatedaccordingly,thepractitionercanaccurately
evaluateitslength(verticalarm)andwidth(horizontalarm)dimensions
simultaneouslyand,therefore,visuallyassessthecorrecttoothsizeandproportion.
Thewidthisindicatedin0.5mmincrementsofcolor,eachwithaverticalmarkin
correspondingcolor.Thus,acentralincisorwitharedwidthof8.5mmwillbein
.properproportionifitsheightisalsotheredheight(ie,11mm)(Figure2)
ThemeasurementsoftheProportionGaugearebasedonclinicalresearchofrange
andmeandistributionvaluesofindividualtoothsize,width,12andaccepted
anatomicandclinicalproportionratios.14,15Themajorityofpatientswerefound
tohaveameasurementwithin0.5mmofthemeanaverages;centralincisors(8
mmto9mm),lateralincisors(6mmto7mm),andcanines(7mmto8mm),being
withintheserangesinwidth(Figure3)

Figure5.Assessmentofthesulcusdepthusingthe
SoundingGauge(ie,ChusAestheticGauges,HuFriedy

Inc,Chicago,IL).Thefirstlasermarkingdenotes1mmfor
theaveragesulcusdepth,whichcanvarybetween0.5
mmto3mminhealth
SoundingGauge
Midfacialclinicalcrownlengtheninginvolvesamultifaceteddecisionmaking
process,withtheendpointbeingwhetherhardandsofttissuescanbeexcised
and/orshouldberepositioned.16TheSoundingGauge(ie,ChusAesthetic
Gauges,HuFriedyInc,Chicago,IL)isusedinaestheticperiodontalcrown
lengtheningprocedurestodeterminethelevelofthebonecrestpriortoflap
.reflection
Thisgaugehelpsprovidequickandsimpleanalysisoftheosseouscrestlocation
midfaciallyandinterdentally.16,17Ithasadeliberatecurvatureofthetip
coincidentwiththecurvatureofthetoothandrootespeciallyatthe
cementoenameljunctionwhereitismostprominent.Thisallowseasiernegotiation
oftheosseouscrestlocation,particularlyinthinbiotypecaseswherethecrestis
thinanddifficulttodetect.Thetipofthegaugeisalsowiderthanthatofa
periodontalprobeat1mmindimension.Thisincreaseddimensionallowsgreater
.stabilityandconfidenceduringthesoundingprocess
TheSoundingGaugeisfabricatedfromsurgicalgradestainlesssteelhonedto
preciselyandatraumaticallypiercethesupracrestalgingivalfibers(Figure4).
Lasermarkingsdefinetheaveragesulcusdepth(1mm)andmidfacialDGC(3
mm).Inaddition,amarkingat5mmdenotestheinterdentalDGC(5mm)(Figures
5through7)

Figure6.Illustrationshowsevaluationofthemidfacial

osseouscrest.Thesecondlasermarkingdenotes3mmfor
theaveragemidfacialDGCdimension

Figure7.Evaluationoftheinterproximalosseouscrest.The
thirdlasermarkingdenotes5mmfortheaverageinterdental
DGCdimension,understandingthatthiscanvary
between3mmand5mminhealth

Figure8.CrownLengtheningGaugeaccessesclinical
crownlength(CCL)requiredbasedontheresultsoftheTBar
ProportionGaugetipinFigure1.Shortarmoftipprojects
clinicalcrownheightandlongarmprojectswherethe
bonecrestshouldberelativetoCCLaftersurgery

Figure9.Thecolorcodingdenotespredeterminedteethat
apresetproportionratioandtoothlength.Thesamecolors
denotethesameteethnomatterwhatinstrumenttipis
selectedandused

,Figure10.Duringaestheticcrownlengtheningprocedures
simultaneousvisualizationofCCLandbiologiccrown
length(BCL)allowsthecliniciantofocusonthegoalof
treatmentwithoutquestion,sincetheblueprintforosseous
resectionisclearlydelineated

Figure11.TheBLPGtipoftheCrownLengtheningGauge
allowsprecisevisualverificationthattheproperamount
andshapeofosseousresectionwasperformedtothe
highestlevel

Figure12.Postorthodontictherapyrevealsaskewed
incisalplaneonthepatientsrightsideandexcessspace
betweenthecentralincisorsintheefforttoreestablish
themidline
CrownLengtheningGauge
TheCrownLengtheningGauge(ie,ChusAestheticGauges,HuFriedyInc,
Chicago,IL)hasaBLPGTipdesignedtomeasurethemidfaciallengthofthe
anticipatedrestoredclinicalcrownandthelengthofthebiologiccrown(ie,bone
cresttotheincisaledge)simultaneouslyduringsurgicalcrownlengthening(Figure
8).TheBLPGtipisdesignedtoreplaceexistingaestheticcrownlengthening

techniques,employingtheuseofpolymerbasedsurgicalguidesortemplates.The
advantagesoftheCrown
LengtheningGaugeoversuchconventionalmeansareprecisionduringthe
procedure,wherepotentialmovementofthesurgicalguideisanonfactor,aswell
ascostefficiencyfromdecreasedtimeandlaboratoryproceduresrequiredfor
.guide/templatefabrication
Thedisposableplasticinstrumenttipwithanincisalrestiscolorcodedwitha
presetmidfacialDGCmeasurementof3mm(Figure9).Thisisbasedontheideal
3mmDGCordifferencerecommendedbetweentheclinicallengthandthe
biologiclengthofthecrown.Thecolorcodedmarksontheshorterarmrepresent
theclinicalcrownlength,andthecorrespondingcolormarkingsonthelongerarm
.representthebiologiccrownlength
Duringtheosseousresectionprocedure,thevisualizationofboththeseparameters
simultaneouslyservesthecliniciantofocusontheendgoaloftreatmentsincethe
blueprintforboneremovalisclearlydelineated(Figures10and11).Theshortarm
oftheBLPGtipisofthesamelengthandmeasurementasthelongarmoftheT
bartipoftheProportionGauge(Figures3and9)

Figure13.Oneweekafterinsertionoftheprovisional
,restorationwithreestablishmentoftheincisaledgeposition
occlusalplane,midline,andmesialdistalwidthofthe
anteriorteeth

Figure15.Sulcusdepthof1mmto2mm,midfacial
osseouscrestdepthof3mm,andinterproximalosseous
crestlocationof4mmcanbeaccuratelyassessedwiththe
SoundingGauge
CasePresentation
A54yearoldfemalepatientpresentedforanaestheticrestorativeconsultation
duringorthodontictreatment.Shewasundergoingorthodontictreatmenttocorrect
.adeepoverbiterelationshipaswellascorrectamidlinediscrepancy
Thepatientdidnotlikehersmilebecausethepreexisting,20yearold,full
coveragerestorationswerewearingandlookedartificial.Comprehensiveclinical
andradiographicexaminationrevealedlossofmarginalintegrityofthefull
coveragerestorationswithgingivalrecessionexposingtherestorativemargins.In
addition,mildtoothrotationsandexcessspacingwaspresentfollowing
orthodontictreatment(Figure12).Themaxillaryandmandibularincisorswere
proclinedwithinadequateoverjet,overbite,andinterarchrelationships.Thepatient
exhibitedahighsmilelinewithasymmetricalfreegingivalmarginarchitecture

Figure14.Oncetheexistingcrownsareremovedand
theincisaledgeposition,midline,andtoothwidthare
corrected,accuratemeasurementcanbemadefor
aestheticcorrection

Figure16.TheBLPGtipisusedtomeasurethemidfacial
lengthofthenewclinicalcrownaswellasthebiologic
crownsimultaneously.Theincisalstophelpspositionthe
gaugeduringmeasurement
ObjectiveAnalysisofToothProportion
Aninitialphaseoftreatmentincludedorthodontictoothmovementtocorrectarch
form,spacing,andoverjet/overbiterelationships.Thesecondphaseoftreatment
addressedfabricationofprovisionalrestorationsfromadiagnosticwaxupto
reestablishafunctionalocclusionaswellasthecorrectincisaledgepositionthat
harmonizedwiththeaestheticandphoneticneedsofthepatient(Figure13).
AssessmentofattachmentlevelswasperformedinconjunctionwiththeProportion
,Gauge,followinginsertionoftheprovisionalrestorations(Figure14)

Figure17.Theproperamountofosseousresectioncanbe
performedquantitativelytoestablishbiologicwidthwithout
estimation

Figure18.Anapicallyrepositionedflapwassecuredwith
periostealverticalinterruptedsuturesand50chromic
gutsutures

Figure19.Thefinaltoothsizeandshapeoftherestoration
wascreatedinthelaboratoryusingtheTBartipofthe
ProportionGaugeandwasverifiedclinicallypriortofinal
cementation

Figure20.Aestheticrestorativeintegrationandharmony
ofthezirconiabasedrestorationsisachievedthroughpredictable
planningwiththeProportionandCrown
LengtheningGauges
andSoundingGaugetoaccuratelyidentifythegingivalsulcus,gingival
attachment,andcrestofbone,respectively(Figure15).Toothsizeandproportion
werefoundtobeundesirablewithawidthtolengthratiothatwasgreaterthen
78%forthemaxillaryanteriorteeth.Inadequatemidfacialbiologicwidthwas
identifiedontooth#8(11).Surgicalcrownlengtheningwasproposedbasedonthe
.findingsofthegauges(ie,ChusAestheticGauges,HuFriedyInc,Chicago,IL)

Thepatientwasanesthetizedusinglocalanesthesia,4%articaineHCL1:200,000
epinephrine,bilateralbuccalinfiltrations,andbilateralpalatalAMSAinjections
performedusingtheSTASystem(MilestoneScientific,Livingston,NJ).Apapilla
preservationincisionwasperformedattheinterproximalareatoretaintheintegrity
ofthepapillatissue.Anintrasulcularincisionwasperformedoverthedirectfacial
oftheanteriorteethtoexposetheunderlyingcrestandfacialalveolarbone
Dissectionofafullthicknessflapexposedtheunderlyingosseoustopography.
DirectclinicalassessmentutilizingtheBLPGtipoftheCrownLengtheningGauge
indicatedtheproperamountofosseousresectiontobereestablished(Figure16).
Theproperverticalpositiontoestablishabiologicwidthof3mmwasdetermined
basedonidealizedtoothproportions,whichwerefirstconfirmedwiththeBLPG
tip.Anapicallyrepositionedflapwassecuredwithperiostealverticalinterrupted
suturesand50chromicgutsutures(Figure17).Theoptimumtoothlengthand
freegingivalmarginlocationwereestablishedpriortoandduringcrown
lengtheningsurgeryusingtheTBartip(Figure18),thusensuringthatthefinal
toothproportionbeingestablishedposthealingwouldbecongruentwiththefinal
aestheticrestorativeoutcome.Thepatientwasrecalledatfourmonths,wherethe
amountofclinicalcrownlengthestablishedcouldbeverifiedwiththeCrown
LengtheningGaugeortheProportionGauge.Finalrestorationserefabricatedin
.thelaboratoryandcementedatsixmonthspostsurgery(Figures19and20)
Theintegrationoftoothproportionanddesiredmeasuredamountofosseous
resectionbasedontoothdimensions,proportion,andbiologicwidthmadethese
instrumentsbeneficialwhenutilizedinaestheticcrownlengtheningsurgery
(Figure21)

,Figure21.Throughpredictablecorrectionoftoothsizeandproportion

amoreaestheticallypleasingsmile