CROWNLENGTHENING AccordingtotheGlossaryofPeriodontalTerms2001: Crown lengthening is a surgical procedure designed to increase the extent of supragingival tooth structure for restorative

ve or esthetic purposes by apically positioning the gingival margin, removing thesupportingbone,orboth.Maybeaccomplishedbyorthodontictoothmovement. TwoMainTypes: 1. Restorative 2. Esthetic Objectives(Kois2000,Studer1996): To increase clinical crown length for access to subgingival caries/restorative margins/fracture lines, retention for tooth preparation, facilitate impressions, placement of restorative margins, avoidinflammationorrecessionandadjustgingivallevelsforesthetics Factorstoconsider: 1. Adequatecoronaltoothstructureremainingforcrownplacement (JotkowitzandSamet2010BritDentJ) Ideally,youneedtohave i. 2mmofsoundtoothstructurebetweencorematerialandcrownmargin/finishline=Ferrule ii. 1mmofsounddentinethickness iii. Minimum axial wall height of 3mm for anterior teeth and premolar, and 4mm for molars (Goodacreetal.2001JProsthetDent) Axial wall height = Vertical distance between coronal end of crown prep and crown margin/finishline Note: All existing restorations and carious tooth structure have to be removed before you can determineifadequatecoronaltoothstructureispresent. We often compromise ideal axial wall height for molars on patients with healthy periodontium, in order to avoid crown lengthening procedures.The simple fact is that natural teeth are just not that tall, once appropriate occlusal reduction is performed. This mustbecompensatedforbyimprovedretentionandresistanceform(i.e.parallelaxialwalls, particularly in the cervical 1.5mm of the preparation or auxillary retentive features e.g. groovesandboxes). 2. Ferrule(JotkowitzandSamet2010BritDentJ) Isdefinedasanencirclingbandofcastmetalaroundthecoronalsurfaceofatooth Bracesthetooth,providedresistancetodislodgementandpreventingfracture 1.52mmofverticalheightisneeded 1mmthicknessisneeded 360 ferrule is ideal, if not, partial ferrule (i.e. remaining coronal tooth structure) can be considered. 1
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3. Biologicwidth Is defined as the dimension of soft tissue, which is attached to the portion of the tooth coronaltothecrestofthealveolarbone(Padburyetal.2003JClinPeriodontol) Equivalenttothedistancebetweenbaseofsulcustobonecrest =Connectivetissueattachment+Junctionalepitheliumi.e. =1.07mm+0.97mm(Gargiuloetal.1961JPeriodontol) =2.04mm Therefore,fromtherestorativemargin/finishlinetobone,aminimumdistanceof2.04mm isneeded The biologic width varies from site to site and people to people because the height of epithelial attachment varies while the height of connective tissue attachment is fairly constant(Gargiuloetal.1961JPeriodontol),thereforetoaccuratelydeterminethebiologic widthofapersonataparticularsite,bonesoundingisneeded Howtoperformbonesounding? GiveLA Recordtheprobingdepth(PD)ataparticularsite At the same site, probe down to bone; note the distance from free gingival margin (FGM)tobone Biologicwidth=FGMtobonePD WhyweDONOTwanttoplacetherestorativemarginwithinthebiologicwidth? Because,itviolatesthebiologicwidth,leadingto Development of an inflammatory response to microbial plaque located at subgingival restorativemargins(Padburyetal.2003JClinPeriodontol) Thusresultingin i. Chronicgingivalinflammationi.e.erythematousandedematousgingiva(Newcomb 1974JPeriodontol) ii. Clinicalattachmentloss(Valderhaug1980NitDent) iii. Boneloss(ParmaBenfenatietal.1986IJPRD) iv. Gingivalrecession(Valderhaug1991ActaOdontolScand) v. Deeper periodontal pockets (Valderhaug 1980 Nit Dent, Valderhaug 1991 Acta OdontolScand) 4. Sulcusdepth(NevinsandSkurow1984IJPRD) Itisrecommendedthattherestorativemarginbeplaced0.51mmabovethebaseofthe sulcus so as to avoid tearing the junctional epithelium or connective tissue attachment duringtoothpreparationorinsertionofretractioncordsduringimpressiontaking.

Havingadequateferruleatsiteswherethelateralforcesareexertedontheremainingtooth structureduringfunctionalloadingisofparamountimportance.Assumingthatthepatientis ofaClassIocclusionwithcanineguidance,theremainingtoothstructureorpartialferrule shouldbeat: Formaxillaryanteriorteeth,palatalferruleisneeded Formandibularanteriorteeth,buccalferruleisneeded Formaxillarypremolars,buccalandpalatalferrulesareneeded Formandibularpremolars,buccalferruleisneeded Formolars,buccalandpalatal/lingualferrulesareneeded

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Thereforeaminimumof3mm(0.51mmforsulcusdepthand2.04mmforbiologicwidth) ofspacebetweentherestorativemarginandalveolarboneisrecommended(Padburyetal. 2003JClinPeriodontol)

5. WHYrestorativemarginsareplacedATMOST0.5mmbelowthefreegingivalmargin? Becausetheclosertherestorativemarginistothebaseofthesulcus,theGREATERthe i. Gingivalinflammation(Orkinetal.1999IJPRD) ii. Gingivalrecession(Orkinetal.1999IJPRD) iii. Clinicalattachmentloss(Waerhaug1980DentClinNorthAmer) iv. Probingdepths(FloresdeJacobyetal.1989IJPRD) v. Numberofspirochetes,fusiforms,rodsandfilamentousbacteria(FloresdeJacobyetal. 1989IJPRD) 6. Crowntorootratioaftercrownlengtheningisperformed MeasuredasaratioofverticalheightsCoronaledgeofcrowntobonecrest:Bonecrestto rootapex Minimum1:1 7. Exposureoffurcations Needtolookatthelengthoftheroottrunk,whichisfromcementoenameljunctiontothe furcationentrance Longroottrunkimplieslesserriskofexposingthefurcationduringcrownlengthening Shortroottrunkimpliesgreaterriskofexposingthefurcationduringcrownlengthening WHYisexposingfurcationsabigdeal? Becauseoftheinherentconcavitiesontheinnersurfacesoftherootandtheroofofthe furcations, it is difficult for the patient and clinician to debride the area. Therefore leadingtoincreaseriskofcariesformationorprogressionofperiodontaldisease HOWtodecidetheamountofcrownlengtheningneeded? Youneed Ferrule2mm+Sulcusdepth1mm+Biologicwidth2mm=5mm Youmeasuretheamountoftoothstructureabovethebaseofsulcus =Heightfromcoronaledgeofsoundtoothstructuretobaseofsulcus =Xmm Amount of crown lengthening needed in cases where level of sound tooth structure is at base of sulcus =(Ferrule2mm+Sulcusdepth1mm)Xmm Amountofcrownlengtheningneededincaseswherelevelofsoundtoothstructureisatbonecrest =Ferrule2mm+Sulcusdepth1mm+Biologicwidth2mm =5mm Note considerations: Furcations are not exposed and a minimum crown to root ratio of 1:1 is maintained. 3
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Examples:

HealingTimeNeededAfterCrownLengthening (HemptonandDominici2010JAmDentalAssoc) Ideally: Crownplacementintheanteriorregionisdonetypically6monthsaftercrownlengthening Crownplacementintheposteriorregionisdonetypically3monthsaftercrownlengthening Becausestudieshaveshownthat: 12% of the sites with crown lengthening performed at 24mm of gingival recession between 6 weeks to 6 months after the procedure. Therefore it is recommended that in highly esthetic areas, the apical displacement of the free gingival margin after crown lengthening be closely monitoredpriortoplacementoftheprosthesis.(Braggeretal.1992JClinPeriodontol) Therewerenosignificantchangesinthepositionofthefreegingivalmarginfrom3to6months (Lanningetal.2003JPeriodontol)

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