Crown lengthening procedures: A literature

review
Zeina A.K. Majzoub, DCD, DMD, MScD,1 Alain Romanos, CAGG, DMD, MS,2
and Giampiero Cordioli, MD, DDS3

Dentists are often faced with clinical conditions requiring (1) exposure of
subgingivally located deep restorative margins, extensive caries or fractures,
(2) increase of supragingival tooth dimension of short crowns, and (3)
correction of excessive gingival display and/or discrepant gingival margins.
This therapeutic goal can be achieved surgically, orthodontically, or by a
combination of both. Clinical crown lengthening is defined as a surgical
procedure that aims at exposing sound tooth structure for restorative
purposes via apical repositioning of the gingival tissue with or without
removal of alveolar bone (AAP Glossary of Terms 2001). This definition
applies to what has been categorized as “restorative” or “functional” crown
lengthening while “esthetic” crown lengthening refers to indications in the
context of esthetic surgery in the anterior sextants. This literature review will
highlight the biologic basis for crown lengthening procedure (CLP), the
variants of surgical crown lengthening with their indications and contra-
indications, and the orthodontic contribution to crown lengthening in the
multidisciplinary approach. (Semin Orthod 2014; 20:188–207.) & 2014 Elsevier
Inc. All rights reserved.

Biologic considerations of CLP: Biologic an early histologic description of the BW in cadav-

width versus height of supracrestal ers2 and using a mean value of 2.04 mm as the sole
gingival tissues indicator for the amount of bone removal needed
during surgery. This value has been challenged in
iologic width (BW) is defined as the com-
B bined dimension of epithelial and connective
tissue attachments coronal to the crestal bone.
anatomical studies and clinical investigations where
the amount of tooth lengthening achieved
postoperatively was frequently inconsistent.3–6
There is a general agreement that placement of
Whenever fixed predetermined ostectomy meas-
restorative margins within the zone of BW negatively
urements were applied during CLP, the surgical
alters the periodontal health of restored teeth.1
outcome related to the final level of the free gingival
Correction of BW violation can be achieved
margin was not predictable.3
surgically by removing bone away from the
In the last decade, the BW concept in
restorative margin by a distance that allows
periodontal-restorative therapy has been increas-
reestablishment of the BW in a more apical
ingly replaced by a model represented by the
location and a stable and predictable long-term
apico-coronal dimension of soft tissues coronal to
exposure of the desired amount of tooth structure.
the osseous crest including the BW and the sulcus
For decades, CLP has been performed by applying
depth.7 This dimension has been referred to as
the dentogingival complex,8 supracrestal gingival
1
Department of Periodontology School of Dentistry, Lebanese tissues (SGT),7,9 supracrestal gingival height
University, Hadath, Beirut, Lebanon; 2University of Alabama at (SGH),10 and supraosseous gingiva (SOG)6 and
Birmingham, Birmingham, AL; 3Private Practice, Padova, Italy. has been proposed as a more representative
Address correspondence to Zeina Majzoub, DCD, DMD, MScD,
dimension to apply in CLP as it accounts for
via Paruta, 33, 35126 Padova (PD), Italy. E-mail: dr.zeinamaj
zoub@yahoo.it
the variability of sulcular depth (Fig. 1).
& 2014 Elsevier Inc. All rights reserved.
Similarly to the BW, SGT has been reported to
1073-8746/12/1801-$30.00/0 be variable with a range between 2.83 mm and
http://dx.doi.org/10.1053/j.sodo.2014.06.008 4.50 mm in healthy human gingiva prior to CLP.6

188 Seminars in Orthodontics, Vol 20, No 3 (September), 2014: pp 188–207

 Crown lengthening procedures 189

to the nearest millimeter, half millimeter, or

1/10 of a millimeter. Measurement resolu-
tion—which refers to how fine a detail can be
measured—affects the ability of a statistical
test to detect differences and therefore
influences conclusions.
(2) Length of the postoperative period: Longer follow-
up periods following CLP are associated with
more stable SGT values that are closer to the
original baseline dimensions.4,9,16,19
(3) Amount of postsurgical crestal resorption: Differ-
ences in postsurgical bone resorption as a
Figure 1. Supracrestal gingival tissues (SGT) dimen-
sion is assessed through bone sounding with a period- result of osseous recontouring have been
ontal probe. SGT refers to the apico-coronal distance reported in several animal and human
between the gingival margin and the osseous crest. In studies.3,20–23
this case, buccal SGT dimension at the central incisor (4) Flap margin position relative to the alveolar bone
is approximately 1.5 mm.
at surgical closure: Earlier marginal tissue
stability can be achieved if the gingival
With the current acceptance of the wide variability margin is placed at the time of suturing in
in SGT dimensions between individuals, arches, a position that accounts for the reformation
gingival biotypes, tooth types, and sites,6,11–15 of the BW.5 This finding corroborates with
ostectomy in CLP has become patient-custom- the conclusions of Arora et al.24 that
ized, based on individual and localized soft and
hard tissue parameters. Several clinical studies
seem to agree that the vertical height of SGTs is a
dimension that reestablishes itself following sur-
gical CLP9,16,17 (Fig. 2). It seems therefore that the
presurgical assessment of SGT dimension could
facilitate the surgical planning of crown
lengthening by giving precise indications as to
the expected postoperative soft tissue levels and
therefore the correct amount of osseous resection
required prosthetically for specific sites and
individuals.7,9,17,18 Other publications indicated
that postsurgical SGT dimensions are somewhat
reduced when compared to presurgical meas-
urements. Perez et al.6 reported an overall mean
reduction of 0.51 mm in SOG dimension at 6
months postsurgery in 19 patients that underwent
CLP. Ayubian19 concluded that the vertical
dimension of SOG significantly decreased by
0.65 mm 2 months following CLP while the BW
remained stable before and after surgery,
indicating that the reduction of SOG merely
reflected a reduced sulcular depth. These
discrepancies related to the dimensional
changes of SGTs following CLP could be
attributed to several factors such as the following:
Figure 2. SGT measurements on the mid-buccal
aspect of this canine indicate that baseline SGT
(1) Measurement rounding (i.e., 0.1 mm versus dimension (A) is similar to that re-established 6
0.5 mm versus 1 mm): When measuring SGT months following surgical crown lengthening proce-
values, investigators can report their readings dure (B). (Courtesy of Dr. F. Hamasni.)
190 Majzoub et al

confirmed the statistically significant from the cemento–enamel junction (CEJ) or

correlation between postsurgical soft tissue
rebound and postsuturing flap position.
(5) Gingival biotype: Thin gingival biotypes tend
to have more postoperative recession when
compared to thicker biotypes.4 In a recent
study, postsurgical soft tissue rebound
significantly correlated with the gingival
biotype.15 More tissue rebound should be
expected in thick biotypes and consequently
more time should be allowed for tissue
maturation and for the gingival margin to
reach its final position.
(6) The surgical procedure itself where the
amount of osseous resection and intra-operative
root reshaping would have resulted in greater
changes in the local anatomic tooth-related
and bone-related variables. The interprox-
imal SGT dimension hypothetically associ-
ated with the interdental papilla height seem
to be influenced by the width of the
interradicular space and the distance
between the contact point and the alveolar
crest in the presence of healthy periodon-
tium.25–27 As these variables could be pro-
foundly modified during CLP, it could be
speculated that postsurgical re-established
interdental papilla and SGT dimension will
also be affected.
finished restoration margin to alveolar bone crest
around the tooth/teeth involved, crown-to-root
ratio, root anatomy, SGT dimension, gingival
biotype, and thickness of the buccal
alveolar bone.
Width of keratinized gingiva (KG)
Surgical crown lengthening should be planned to
preserve an adequate apico-coronal height of
KG, especially in the presence of thin gingival
biotypes and subgingival restorations (Fig. 3).
There is no consensus as to the minimal amount
of KG needed to maintain gingival health in the
presence of subgingival margins. The values
reported in the literature vary according to
different authors between 2 mm28 and 5 mm.29
In view of such large discrepancy, most clinicians
have anecdotally adopted average values of
2–3 mm of KG as being acceptable if
restorative margins are to be placed in the
gingival sulcus.

It should be noted that some of the above-

mentioned variables (2, 4, and 5) merely affect
the temporal stability of SGTs following CLP,
while the other factors (3 and 6) could yield a
true modification of postoperative SGT values
when compared to those measured presurgi-
cally. There are no indications in the literature
relative to the surgical modification of soft and
hard tissue thicknesses in the CLP area from
thick to thin biotype through excessive thin-
ning out of the buccal flap and underlying
facial bone. The question whether these
changes are associated with more reduced SGT
in the long-term postsurgically remains to be
answered.

Figure 3. (A) Violation of the biologic width at the

Presurgical considerations
When planning a crown lengthening surgery, the
key considerations include assessment of the
width of keratinized gingiva (KG), the distance
mandibular premolars and first molar with minimal
baseline apico-coronal height of keratinized gingiva.
(B) Crown lengthening achieved using intrasulcular
incisions and apically positioned flaps to preserve
buccal keratinized tissues.
 Crown lengthening procedures 191

Distance from CEJ or restoration margin to the This trend is in accordance with the findings of a
crestal bone randomized blinded study14 conducted for first
molars and second premolars.
This distance allows to assess the presence or
Significantly lower SGT values have been
absence of violation of the BW and subsequently
observed at the mid-buccal sites when compared
dictates the amount of tooth structure that needs
with the interproximal sites (Fig. 6) at maxillary
to be exposed. In a study comparing 3 different
anterior teeth.31 Similar conclusions can be
methods used for planning of CLP, transgingival
extrapolated from the findings of Barboza et
probing was the most accurate measurement
al.,14 although the study did not perform
when compared to periapical and bite-wing
comparative statistical tests. The authors obse-
radiographs.30
rved mean SGT values ranging between 2.2 mm
and 3.0 mm at the mid-buccal sites versus 3.4–
Crown-to-root ratio
4.2 mm at the interproximal surfaces in second
In the presence of short roots and/or poor premolars and first molars. In a clinical study
crown-to-root ratio, CLP with supporting bone including 100 periodontally healthy patients,
removal further reduces the residual periodontal Kois32 indicated that the total dentogingival
attachment and has a negative influence on complex dimension was greater interproximally
crown-to-root ratio, tooth mobility, and long-
term tooth stability. Therefore preliminary per-
iapical radiograph is essential in planning CLP
(Fig. 4).

Root anatomy and root relationships

Root taper and root divergence are important to
consider prior to crown lengthening, as they
dictate the diameter of the root remaining fol-
lowing CLP and the interdental distance between
the involved teeth (Fig. 4).

SGT
A careful case-by-case presurgical analysis of the
local anatomy and the distance from the gingival
margin to the bone crest allows to anticipate the
postoperative SGT dimension of a particular
tooth by knowledge of its preoperative meas-
urement. When SGT measurements at the sur-
gical site are not feasible because of tissue
inflammation associated with deep subgingival
fracture/caries/preparation margins, measure-
ment of SGT contralaterally prior to crown
lengthening may give guidelines as to the
amount of bone removal required and predict Figure 4. (A) Root dimensions, root taper, and
the final postoperative location of the gingival interdental relationships can be evaluated radiogra-
phically at baseline prior to CLP. Roots are long and
margin. In a cross-sectional study comparing the expected crown-to-root ratio following crown
contralateral SGT dimensions at the maxillary 6 lengthening is adequate. (B) Following surgical CLP,
anterior teeth in periodontally healthy young crown-to-root ratio is reduced but still satisfactory, the
adults (age range between 18 and 25 years), distance between the 2 roots is slightly increased
Abou Arraj et al.31 reported high percentages of because of root taper (red arrows), and root diameter
at the future prosthetic margin is slightly smaller
identical measurements ranging between 71% (yellow arrows). (For interpretation of the references
and 92% when a difference equal or less than to colour in this figure legend, the reader is referred to
0.5 mm was considered insignificant (Fig. 5). the web version of this article.)
192 Majzoub et al

sounding to direct bone level measurements

immediately after flap reflection.6,9,28

Figure 5. Contralateral SGT measurements at the
mid-buccal aspects of the right (A) and left (B) central
incisors in the same individual are similar. Note the
relative transparency of the periodontal probe through
the buccal gingiva confirming the presence of a fairly
thin gingival morphotype.
Gingival biotype
Gingival biotype is also a crucial variable to assess
presurgically. Transparency of the periodontal
probe through the gingival margin while probing
the buccal sulcus (Fig. 5) is a reliable and objective
method in evaluating gingival biotype, whereas
visual assessment by itself is not sufficiently
reliable.34 While some studies have confirmed a
positive correlation between gingival biotype and
SGT dimension,15,31 other investigators failed to
demonstrate such correlation.10 Beyond the effect
of the gingival biotype on baseline SGT and
postoperative marginal tissue alterations, the
thickness of buccal tissues is significantly
correlated with the degree of gingival
discoloration at endodontically treated teeth
(Fig. 8), with more pronounced discolorations
in cases of thinner soft tissue.35 Care should be
taken to avoid extensive mid-buccal flap thinning
through partial thickness dissection to maintain

(3.0–5.0 mm) than facially (3.0 mm) and

attributed this variation to the difference in
the amount of scalloping between bone and
gingiva. When buccal/lingual and interproximal
flaps are positioned at a similar distance from the
crest, a differentiated behavior of tissue rebound
(Fig. 7) can be expected postoperatively with
more coronal regrowth at interproximal sites.33
This finding questions the standard practice of
partial flap approach at the interproximal
papillae and suggests that papillae should be
elevated in full thickness to allow flap suturing at
a distance equivalent to the presurgical SGT
dimension.
The measurement of SGT height is better
carried out using transgingival probing through
the sulcus to the bone level under local anes-
thesia (referred to as bone sounding). The
Figure 6. Interproximal SGT dimension at the
accuracy and reliability of this method in mesial aspect of this lateral incisor (A) is greater than
assessing crestal bone levels have been confirmed that measured at the mid-buccal site (B) of the
in various publications that compared bone same tooth.
 Crown lengthening procedures 193

Figure 7. Violation of the biologic width (A) corrected with CLP (B). The buccal flap has been elevated in partial
thickness in the interproximal area (thinned out papillae). The buccal and interproximal flap margins have been
sutured at a similar distance of about 1 mm coronally to the osseous crest. Differentiated tissue rebound between
the interproximal and mid-buccal gingival margins resulting in more coronal migration of the gingiva in the
interdental area at 4 months (C) and 1 year (D) following CLP. This finding reflects the greater baseline SGT
dimensions at interproximal sites when compared to the mid-buccal site of the same tooth.

enough facial gingival thickness that can conceal
the esthetically unpleasing grayish transparency of
teeth with endodontic treatment.
Thickness of buccal bone
Buccal bone overlying the 6 maxillary anterior
teeth is predominantly thin.36,37 The mean width
of the facial alveolar bone wall is increased
toward posterior regions.37,38 Contradictory
findings have been reported relative to the
relationship between the thickness of buccal
gingiva and that of the underlying facial osseous
plate. In maxillary anterior teeth, Cook et al.39
found a significant association between gingival
biotype and labial plate thickness while only a
moderate or no correlation was demonstrated in
other studies.40,41 The crown width/crown
length (CW/CL) ratio has been positively cor-
related to the thickness of buccal gingiva at the
CEJ and to the thickness of the alveolar crest.42
Therefore baseline CW/CL could be used as an
indicator for alveolar bone crest thickness. This
abovementioned information should be applied
when performing buccal osteoplasty (removal of
non-supporting bone, i.e., thinning out of
alveolar bone thickness without removal of bone
directly attached to the root via the periodontal
ligament) during CLP to minimize biologic
damage to the thin buccal bone. Extensive
thinning out of the labial plate during surgical
crown lengthening can result in postsurgical
dehiscences and fenestrations. Human histological
evidence indicated that the thickness of buccal
bone seemed to be a determinant of the amount of
bone loss following osseous surgery.22 More bone
loss and less bone repair of the surgically reduced
periosteal bony surface are to be expected in the
presence of thin buccal bone. No such postsurgical
alterations were demonstrated histologically22 or
radiographically43 in thick proximal bone.
Postsurgical resorption of thin buccal bone can
further alter the positional stability of the gingival
margin during the healing period following CLP
and results in more tooth surface exposure than
anticipated. Furthermore, thinned out buccal bone
in combination with thin facial gingival tissues loses
its ability to hide the grayish transparency of
194
Figure 8. Esthetically unpleasing grayish transparency
of the endodontically treated root of the lateral incisor
can be noticed through the moderately thin facial
gingiva: (A) frontal view and (B) close-up view.
discolored endodontically treated teeth in both
supra- and subcrestal locations and negatively alters
the esthetic outcome.
Crown lengthening: Operative variants
Several techniques have been proposed for
clinical crown lengthening including gingivec-
tomy, apically positioned flap with or without
osseous resection, and forced eruption alone or
in combination with surgical crown lengthening.
Surgical crown lengthening
Surgical techniques
When the abovementioned parameters are
assessed prior to surgical CLP, the clinician can
anticipate postsurgical gingival and osseous levels
at the treated and neighboring teeth.44 It is
crucial that clinicians consider in their decision-
making process the quantity and quality of soft
and hard tissues that remain in situ after the
treated area has healed completely.
A key decision in surgical CLP is the need for
osseous resection. Gingivectomy is indicated in the
Majzoub et al
presence of excess KG and an underlying bone
crest at 3 mm or more from the level of gingival
resection. Adequate apico-coronal height of kera-
tinized gingival tissues of at least 3 mm should
remain after surgery in the presence of subgingival
restorations.29 Gingivectomy can be performed
using conventional scalpels, electrosurgery,
radiosurgery, or laser. If gingivectomy would
yield less than 3 mm of postoperative KG, then
apically positioned flap without osseous resection
should be considered as an alternative approach to
a simple gingivectomy.45
When the underlying bone crest needs to be
visualized, apically positioned flap with bone
resection is recommended for cases where the
osseous level is at less than 3 mm from the level of
gingival resection. In such cases, if gingivectomy is
performed, the postsurgical BW dimension and
probing depths tend to return to presurgical
values resulting in more tissue rebound and less
crown exposure when compared with apically
positioned flap combined with ostectomy.17
Osseous resection can be described in terms of
ostectomy and osteoplasty. In contrast with
osteoplasty, ostectomy refers to the removal of
supporting bone attached to the root surface via
periodontal ligament. Various types of
instruments can been used in osseous resection
including traditional burs, hand chisels,
piezoelectric tips,46 and potentially Er:YAG
laser.47 The bony contours have to be shaped to
create a scalloped positive architecture (Fig. 9)
that will support a scalloped gingival architecture
with minimal pocket depths. If the osseous
architecture created through osseous resection
is not positive (reverse architecture), then excess
gingival tissue may rebound during the healing
phase following CLP. This would result in
insufficient exposure of the treated tooth/teeth.
In the corono-apical dimension, ostectomy has to
be first carried out at the site/sites requiring tooth
exposure. This is followed by ostectomy at the
adjacent mesial and distal sites to reestablish a
positive architecture. Ostectomy is best performed
according to the amount needed to accommodate
the reformed supraosseous gingival tissues
equivalent to the preoperative SGT measure-
ments.6 Osteoplasty is needed to reduce osseous
enlargements and minimize the risk of
postoperative rebound of soft tissues.45 Flaps are
then sutured coronally to the alveolar crest at a
distance similar to baseline presurgical SGT. In
 Crown lengthening procedures
Figure 9. Maxillary anterior teeth of a dry skull with
normal crestal bone levels. Positive osseous architec-
ture is characterized by interproximal bone levels
coronally located relative to the buccal and lingual
radicular bone. It is crucial that the marginal osseous
form produced through ostectomy during CLP follows
similar scalloped outline in a more apical location to
support scalloped gingival margins. Failure to establish
a positive osseous architecture can result in excess
gingival tissue rebound during the healing phase
following CLP.
this way, the postoperative gingival margin levels
are less likely to significantly change through the
healing period and the final position of the
gingival margin will be attained earlier.33
Indications and contraindications
The indications of functional CLP are mainly
related to the following:
 violation of the BW including subgingival
caries, fractures, perforations, and cervical
resorptions that extend deep within the sulcus;
 surgical exposure of 1–2 mm of tooth struc-
ture in addition to the BW to allow ferrule
effect; and
 inadequate tooth structure for crown retention.
Short clinical crowns, if unmodified, can result in
crowns that are subject to repeated loosening.
Surgical CLP with ostectomy is contra-
indicated in the following clinical conditions:
 if it significantly compromises crow-to-root
ratio of the treated and adjacent teeth;
 if adequate supporting bone will not remain
postoperatively;
 in areas where buccal or interproximal soft
tissue recession is not a desired outcome, and
195
black triangles are likely to develop if the
postresection distance between the contact
area and the interdental bone crest
increases;48 and
 a small distance (o4 mm) between furcation
entrance relative to the final restorative
margin in furcated molar teeth. In a retro-
spective study evaluating the outcome of
crown lengthening surgery in mandibular
molars, Dibart et al.49 reported that 40% of
the molars developed a furcation lesion at 5
years after crown cementation. An initial
distance from the furcation entrance to the
margin of the restorations of o4 mm
eventually developed a furcation involve-
ment, while none of the molars with
44 mm developed a furcation involvement.
Orthodontic forced eruption
Technique
Forced extrusion (Fig. 10) can be achieved using
various approaches including conventional fixed
or removable orthodontic appliances, magnets,
and mini implants. Orthodontic extrusion has
been demonstrated to result in bone apposition
at the alveolar crest of the relocated tooth/
teeth50 while maintaining a normal relationship
(1–2 mm) between the alveolar crest and CEJ in a
healthy periodontium. By applying low
orthodontic extrusion forces, the tooth is
erupted slowly, bringing the alveolar bone and
gingival tissue with it.51 In these cases, after the
tooth has reached the intended position and has
been stabilized, surgical CLP is performed
without compromising soft and hard tissue
levels at the adjacent teeth. Supracrestal
fiberotomy with or without root planing has
been suggested to reduce or eliminate gingival
and bone coronal migration during forced
eruption.52 In a randomized clinical trial, the
authors demonstrated that after a supracrestal
fiberotomy and root planing, the roots extruded
with 2 mm less coronal tissue migration,
compared to the control group without
supracrestal fiberotomy and root planing. This
approach maintains the crestal bone and the
gingival margin at their pretreatment location
and the tooth–gingival interface unaltered at
adjacent teeth53 and therefore eliminates the
need for surgical CLP following forced eruption.
A retention phase of at least 2 months is required
196 Majzoub et al

Figure 10. (A) Patient displays poor prosthetic margins with discrepant gingival contours in the maxillary anterior
area. The overall amount of gingival and incisor display is satisfactory. (B) The maxillary right lateral incisor has the
buccal gingival margin located noticeably apical to that of the adjacent and contralateral canines and central
incisors.(C) The lateral incisor has been erupted slowly to allow coronal migration of the facial gingiva and achieve
better gingival alignment. (D) Final prosthetic outcome with more harmonious gingival scalloping. (E) Periapical
radiograph prior to forced eruption. (F) Post-orthodontics radiograph. Comparison of the 2 radiographs—
although not standardized—shows the coronal migration of the osseous crest mesial to the right lateral incisor
(yellow arrows). (Courtesy of Dr. Nadim Abou Jaoudé.) (For interpretation of the references to colour in this
figure legend, the reader is referred to the web version of this article.)

to stabilize the tooth in its new position and  when the amount of anticipated
prevent relapse by root intrusion.52 Minor osseous resection during surgical CLP
coronal gingival rebound can be corrected will significantly compromise the period-
surgically when needed. ontal attachment apparatus of neigh-
boring teeth;
 when the amount of anticipated osseous
Indications and contraindications
resection during surgical CLP will likely result
Forced eruption is indicated as an alternative to in furcation exposure at the involved/adjacent
surgical CLP in several clinical conditions: tooth or teeth;
 Crown lengthening procedures
 when existing gingival levels are ideal and
when the anticipated apical positioning of the
gingival margins at the involved and neighbor-
ing teeth in surgical CLP will create non-
harmonious gingival outlines in highly
esthetic areas of the mouth or expose pros-
thetic crown margins at adjacent teeth;
 when the anticipated crown-to-root ratio
obtained with surgical CLP is inadequate.
Crown-to-root ratio of a tooth that has under-
gone forced eruption may remain unchanged
or even be improved compared to a tooth that
has been subjected to surgical CLP with
osseous reduction;54 and
 when teeth adjacent to the involved tooth
require coronal repositioning because of
gingival recessions or malocclusion. In these
cases, forced eruption helps align the gingival
margins, thus reducing or eliminating the
need for periodontal mucogingival surgery
and/or restorative therapy.
Contraindications of orthodontic forced
eruption include the following:
 lack of adequate anchorage to perform ortho-
dontic extrusion;
 the buccal gingival outline at the involved
tooth/teeth is more coronal to the ideal
desired level;
 narrow root taper. Similarly to surgical CLP,
forced eruption yields a smaller diameter of
the root after extrusion, resulting in (1) a
crown with a large cervical excess to offset this
discrepancy and (2) loss of papilla height with
interdental “black triangles” and compro-
mised esthetics; and
 patient's rejection towards orthodontic
therapy.
Esthetic crown lengthening
Knowledge of the normal dental/gingival mor-
phologic characteristics and peri-oral variables is
essential in understanding the smile frame and
achieving a predictable successful rehabilitation
of the smile. The mean vertical height of the
maxillary central incisor averages 10.6 mm in
males and 9.8 mm in females.55 With the lip line
at rest, the average maxillary incisor display is
1.91 mm for men and nearly twice that amount
(3.40 mm) in women.55 This statistically
197
significant sexual dimorphism relative to the
height of visible maxillary incisor crown at rest is
confirmed in more recent studies.56 The smile
line refers to the position of the upper lip relative
to the maxillary incisors and gingiva during a
natural full smile.57 A high smile line displays the
entire crown of the tooth and an abundant
amount of gingiva. In the average smile line,
75–100% of the crown is revealed along with the
interproximal gingiva. Less than 75% of the
crowns are displayed in low lip line cases. A low
smile line is predominantly a male characteristic
and a high smile line is around 2.5 times more
prevalent in women.56 With aging, there is a
gradual decrease in exposure of the maxillary
incisors both at rest and during smiling.58,59
Some degree of gingival display may be estheti-
cally pleasing and is considered youthful.60
Excessive gingival display and altered passive
eruption
Excessive gingival display can be associated with
several anomalies including (1) short upper lip,
(2) hypermobile upper lip, (3) vertical maxillary
excess generally associated with excessive lower
facial height (4) anterior dentoalveolar extrusion
and (5) short clinical crown. While the first 4
conditions require orthodontics, orthognathic,
or maxillofacial surgery, the fifth involves a dif-
ferent approach. A short crown can be due to
attrition or altered passive eruption (delayed
apical migration of the gingival margin). When
incisor display is minor or absent at rest, but the
lip line is normal in smiling, the crown height
should be increased incisally with cosmetic
dentistry. In contrast, when short clinical crowns
are associated with a “gummy” smile and normal
incisor display at rest,61 an esthetic CLP is
recommended with or without restorative
treatment.
Therefore, in the presence of excessive gin-
gival display in a healthy periodontium with
normal upper lip length and mobility and with-
out vertical skeletal and/or dentoalveolar
abnormalities, the diagnosis of altered passive
eruption (APE) should be made. This condition
is defined as a dentogingival relationship where
the gingival margin is positioned coronally on the
enamel of the anatomic crown in a location
incisal to the CEJ in adult individuals. In these
cases, the clinical crown length (gingival margin
198 Majzoub et al
to incisal edge) is less than the anatomic crown
length (CEJ to the incisal edge) measured clin-
ically or on radiographs. The frequency of
occurrence of APE in the general population has
been scarcely documented in the literature,
possibly because of the lack of clear diagnostic
criteria. Based on a series of 1025 patients with a
mean age of 24.2 ⫾ 6.2 years, Volchansky and
Cleaton-Jones62 reported a 12.1% incidence of
APE. It is crucial to note that age is a significant
parameter when treating APE cases as increase in
crown length through passive eruption has been
demonstrated until the age of 19 years.63
The next consideration is to classify the case of
APE based on the amount of KG present buccally
and the distance between the alveolar crest level
and the CEJ. The selection of the surgical
approach is based on case classification as
described by Coslet et al.64 In Type I cases where
wide gingival dimension from the margin to the
mucogingival junction is present, gingivectomy is
indicated if the distance CEJ–bone is more than
2 mm (subgroup A) while apically positioned
flap with osseous resective surgery is necessary if
bone is at the CEJ level or at less than 2 mm from
the CEJ (subgroup B). In Type II cases with
normal width of KG, an apically positioned flap is
required for subgroup A. For subgroup B,
apically positioned flap with osseous surgery is
needed.
Alpiste-Illueca65 defined APE as a variant of
habitual periodontal morphology, characterized
at upper central incisor level by gingival
overlapping on the anatomical crown of more
than 19% of its height. From the clinical
perspective, APE is associated with increased
gingival band width, thick bone crest, and
connective tissue attachment, with a long
biological space. Similarly to Coslet et al.,64 the
author statistically confirmed the presence, in
adults ranging in age between 20 and 40 years, of
2 morphological patterns of APE, characterized
by a longer and shorter CEJ–bone crest
dimension of 1.23 and 2.53 mm for APE Type
2 and 1, respectively.
Traditionally, diagnosis and classification of
APE is based on (1) bone sounding to assess the
level of the CEJ relative to the buccal bone
(Figs. 11 and 12) and the position of the gingival
margin, (2) standard radiographs, and (3) par-
allel profile radiographs.66 The identification of
the CEJ–bone crest dimension on the buccal
aspect with or without radiopaque markers is
unreliable on standard periapical radiographs
and gives only a hint as to the relationship of
buccal bone to the CEJ. The parallel profile
radiographs allow to measure the dimensions of
the various components of the dentogingival unit
on the buccal surfaces of maxillary central
incisors including the CEJ–bone crest distance,
BW, dimension of the connective tissue
attachment, and gingival overlap on the
enamel surface.66 More recently, accurate
evaluation of the distance between the CEJ and
the bone crest can be performed using cone-
beam computed tomography.67,68 Soft tissue
cone-beam computed tomography has been
reported to improve soft tissue image quality and
allow the determination of the dimensions and
relationships of the structures of the dentogin-
gival unit68 (i.e., the distance of the gingival
margin to the facial bone crest, the gingival
margin to the CEJ, and width of the facial
gingiva).
In addition to the diagnostic radiographic
parameters, probing depth has been suggested as
a diagnostic tool to identify APE cases. While
some authors indicated that gingival sulcus depth
of over 3 mm without concomitant pathological
inflammatory signs is suggestive of APE,69 Alpiste-
Illueca65 observed no such relation with no case
exceeding 3 mm of probing depth and the most
frequent value being 1.5 mm.
Apical positioning of the gingival tissues in
cases of APE can be accomplished using mean
values of crown length and width for the max-
illary anterior teeth as guides70 or the Proportion
Gauge Tip.71 A better approach that accounts for
all the variables that may play a role in the case-
specific final esthetic outcome and encompasses
all the components of a smile frame is repre-
sented by the surgical template. This technique
has been suggested to assist in the placement of
the buccal incisions according to the esthetic
smile line.18,44 The template allows the
periodontal-restorative team to (1) anticipate the
treatment outcome in terms of specific tooth
position and proportions, maxillary incisal edge
position, ideal tooth and gingival display through
preoperative imaging of the final result in the
mouth, (2) improve communication between
patients and all care providers involved, and (3)
guide soft and hard tissue recontouring during
surgery (Fig. 13). The initial incisions are made at
 Crown lengthening procedures 199

Figure 11. (A) The patient's smile reveals uneven gingival contours with altered passive eruption Type 1
characterized by a gingival margin located coronally to the CEJ and a wide apico-coronal band of keratinized
gingiva at teeth 9, 10, and 11. (B) Sounding to bone allows to detect the location of the CEJ and the crestal bone
(black dot on the facial aspect of keratinized gingiva). The osseous crests of the 2 incisors are in similar apico-
coronal position and the CEJ of the left central incisor is in normal relationship with the crest margin, indicating a
classification of Type 1 subgroup A. (C) Internal bevel gingivectomy is performed at teeth 9, 10, and 11. (D) Four
months post-gingivectomy. No attempt was made to level the gingival margins of the 2 canines with those of the
central incisors to avoid esthetically unpleasing gingival discrepancies between the canines and the premolars.

the buccal aspect following the outline of the
surgical template while the interproximal
incisions are intrasulcular leaving the papilla
totally intact interproximally. A full-thickness flap
is elevated buccally and over the papillae,
maintaining the volume of the interproximal
gingival tissues. A palatal flap is not raised. The
surgical template is re-inserted and ostectomy is
performed only at the mid-buccal area and
mesio- and disto-buccal line angles. Anecdotally,
an average distance of 2.5–3 mm between the
apical buccal contour of the template and the
newly created crestal bone level is created to
accommodate for the newly formed SGTs.72 This
is based on the finding that a mean dimension of
approximately 2 mm between the alveolar crest
and CEJ is present in 85% of the population.8 In
cases of APE, baseline SGT values are higher than
those documented in periodontally healthy
maxillary anterior teeth. Therefore, presurgical
SGT dimension cannot be used as a guide to
perform ostectomy. Following osseous resective
surgery, the buccal flap is sutured coronal to the
level of the osseous crest according to the outline
of the template. In this case, the long-term
postoperative position of the gingival margin is
likely to be close to the flap margin at closure.
A shortcoming of this reasoning is that the case-
and site-specific height of postsurgical SGTs
cannot be identified nor can it mirror baseline
values of SGTs in APE cases. In addition to the
abovementioned advantages of the surgical
template, it can be used postsurgically to assess
tissue maturation and the ideal timing to deliver
the definitive restorations.73
In some cases, the intended gingival margin
position is not accurately achieved and a sec-
ondary surgery is needed to refine the esthetic
outcome. This could be due to a slight coronal
or apical displacement of the gingival margins at
200 Majzoub et al
Figure 12. (A) Assymetrical gingival margins at the
central incisors suggesting altered passive eruption at
tooth 8. (B) Exposure of the buccal surfaces reveals
that the short clinical crown corresponded to a truly
short anatomic crown and not an abnormal position of
the gingival margin of the tooth enamel.
one or more teeth in the postoperative healing
period caused by non-passive buccal flap closure
at suturing or subsequent unforeseen recession-
or rebound-type marginal shifts. An alternative
2-stage crown lengthening technique has been
advocated to manage this shortcoming. In this
alternative approach, the first phase is to com-
plete osseous resective surgery by placing the
osseous crest in the correct position corre-
sponding to the intended free gingival margin
position.74 However, rather than simultaneously
repositioning the gingival margins apically, the
flap is sutured back to its original presurgical
location. Following an appropriate healing
period, a gingivectomy is performed according
to the template outline without violating the
BW. In addition to its advantages in giving the
surgeon the possibility of fine-tuning tissue
levels at a later stage and achieving more pre-
dictable long-term gingival margin position, this
alternative surgical approach has a second sig-
nificant benefit in cases where restorative
treatment is planned with surgical crown
lengthening. When the traditional variant of
esthetic CLP is performed, a significant amount
of time is required after surgery for tissue
maturation before initiating provisional restor-
ative therapy or relining existing temporary
restorations. The alternate CLP technique
eliminates this esthetically unpleasing phase—
where roots are exposed—by delaying
apical gingival positioning till after tissue
maturation.
A closed approach to esthetic CLP has been
suggested as a predictable alternative technique
for the treatment of excessive gingival display.75
This flapless procedure uses gingivectomy
incisions first then osseous resection through
the incision lines without flap reflection using
the Er,Cr:YSGG laser47 or standard hand
instrumentation.76 This flapless approach is
extremely technique-sensitive and does not
allow osteoplasty when indicated. Ostectomy
along the buccal aspect and line angles is difficult
to perform without damaging the overlying soft
tissues. It should be reserved to specific clinical
cases with fairly thick or at least intermediate soft
tissue biotypes without thick bone that would
require full exposure through buccal flap
elevation.
In addition to incisor and gingival displays
that are essential in smile esthetics, the smile arc
is also a crucial parameter when designing a
smile through a diagnostic/surgical stent. The
smile arc is the relationship between a hypo-
thetical curve drawn along the edges of the
maxillary anterior teeth and the inner contour
of the lower lip in the posed smile.60 The
curvature of the incisal edges appears to be
more pronounced in women than in men and
tends to flatten with age. During smiling, the
curvature of the maxillary incisal edges
coincides with or parallels the border of the
lower lip in an optimal smile arc.77 Higher
esthetic scores were obtained in subjects whose
lower lip touched or did not touch the incisal
edges compared to individuals whose incisal
edges were slightly covered.78 A flat smile arc
concomitant with poor incisor display at rest is
often associated with excessive incisal tooth wear
(Fig. 14). The surgical/diagnostic stent should
account for these esthetic parameters and adjust
incisor edge display according to patient-
optimal smile line.
 Crown lengthening procedures 201

Figure 13. (A) Short clinical crowns with excessive gingival display and uneven gingival contours in the maxillary
anterior sextant associated with moderate incisal edge wear. (B) A surgical template allows to account for all the
parameters relevant in the final esthetic outcome mainly the ideal amounts of tooth and gingival display. In this
case the crowns need to be lengthened apically through CLP and incisally through restorative dentistry. (C) The
template guides the mid-buccal incisions. (D) Marginal osseous bone levels following full-thickness flap reflection.
(E) Ostectomy is performed leaving approximately 3–3.5 mm of distance between the surgical guide and the
osseous crest. (F) Flaps are sutured along the outline of the template. (G) Healing at 3 months, with the newly
established gingival margins stabilized at a position equivalent to that achieved at flap closure (H).

A last consideration in esthetic crown teeth from second premolar to second premolar
lengthening is the harmony of the gingival out- while smiling.79 The extension of surgical crown
line between anterior and posterior segments. lengthening should in some cases include all
About 80% of adult subjects expose the maxillary teeth between the first molars to achieve an
202 Majzoub et al

Figure 14. (A) Flat smile arc with excessive gingival display and severe tooth wear. (B) Baseline buccal
photograph. (C) Submarginal internal bevel incisions prior to flap reflection. (D) Ostectomy created an
approximate distance of 3 mm between the ideal location of the gingival margin and the osseous crest. (E) Flaps
sutured. (F) Soft tissue healing at 4 months. (G) Improvement of the facial gingival contours and reduction of
gingival display. The incisal edges are still, however, not parallel to the curvature of the lower lip and need to be
corrected. (H) Final restorations. (I) Harmonious smile with adequate combination of gingival and incisor display.
 Crown lengthening procedures 203

Figure 15. Female patient with short clinical crowns at the maxillary lateral incisors. The gingival margin of the
lateral incisors is excessively coronal when compared to the marginal gingiva of the adjacent centrals and canines
(A and B). Flap outline with submarginal internal bevel incisions at the lateral incisors with intrasulcular incisions
at the level of the canines and central incisors (C). The level of the CEJ of the 2 lateral incisors is difficult to assess
after flap elevation because of the pre-existing restorations (D) but ostectomy was performed to a level slightly
coronal to that of the adjacent central and canines to support ideal soft tissue contours following healing. (E) Flaps
at closure. (F and G) Final restorations with satisfactory smile esthetics.
204 Majzoub et al
esthetically pleasing gingival architecture
blending in harmoniously the gingival contours
of the maxillary anterior and posterior teeth.
Discrepant gingival margins
In patients with excessive gingival display, any
irregularities in the alignment of the gingival
margin may negatively affect the smile esthetics.
The gingival contours of the maxillary anterior
teeth should be parallel to the curvature of the
lower lip with the gingival margins of the lateral
incisors more coronal than the adjacent centrals
and canines.80 These authors considered
symmetry of the gingival margins at the 2
central incisors to be crucial in an esthetically
pleasing smile while a certain amount of
asymmetry is permissible more laterally. In
addition, the gingival zenith at the buccal
aspect of the maxillary central incisors and
canines is located distally to the long axis of
the tooth while the maxillary lateral incisors have
their gingival zenith located at the midline of the
buccal surface.81 Similar parameters and
diagnostic tools can be used as above-
mentioned to recreate ideal gingival contours
(Fig. 15).
Combining orthodontic and periodontal
treatments
When APE is combined with malocclusion and/
or crowding requiring orthodontic therapy,
orthodontic treatment typically precedes perio-
dontal therapy since extrusion or intrusion of
teeth may influence gingival marginal levels.
Once the orthodontic goals are accomplished
with the best achievable position of the incisal
edges relative to the lower lip line, a smile analysis
is performed to assess the nature and extent of
gingival display and establish the need for
periodontal and/or restorative management of
the smile line when needed. If the desired gin-
gival margin locations have not been fully ach-
ieved with the orthodontic therapy, then surgical
crown lengthening is performed according to the
abovementioned guidelines. Postorthodontic
timing of CLP has not been thoroughly evaluated
in the literature although the biologic rationale
calls for complete mineralization of the crestal
bone before any further surgical CLP is consid-
ered. It is essential to note that by ideally posi-
tioning the teeth orthodontically within the
framework of the face and the intra- and inter-
arch relationships, periodontal therapy and
restorative dentistry can be eliminated or kept to
a minimum.
Conclusions
CLP has been routinely performed using mean
values of 2.04 mm for the BW. This has yielded
inconsistent amounts of crown extension post-
operatively. When applying site-specific SGT
dimensions to assess the extent of osseous
resection needed during CLP, more predictable
postsurgical position of the gingival margin is
achieved as SGTs are re-established to their
baseline preoperative values. When esthetic CLPs
are carried out in the presence of APE, baseline
SGTs are abnormal and average values of no less
3 mm should be established between the mar-
ginal bone crest and CEJ or final restorative
margins.
Surgical crown lengthening can be achieved
using soft tissue excisional procedures via gin-
givectomy or apically positioned flaps without
osseous resection only if the underlying bone
crest is at 3 mm or more from the level of gingival
resection. Otherwise, apically positioned flaps
with bone resection should be used to accom-
modate adequate dimensions for SGTs to reform
and avoid significant postsurgical tissue rebound.
Orthodontic forced eruption is a valuable alter-
native to crown lengthening when expected loss
of periodontal support associated with osseous
resective surgery is considerable. In the presence
of malocclusion or malalignment in the esthetic
areas, orthodontic forced eruption should be
considered to help align gingival margins and
correct the incisor display, thus reducing or
eliminating the need for periodontal and/or
restorative therapy.
References
1. Günay H, Seeger A, Tschernitschek H, et al. Placement of
the preparation line and periodontal health—a prospec-
tive 2-year clinical study. Int J Periodontics Restorative Dent.
2000;20:171–181.
2. Gargiulo AW, Wentz FM, Orban B. Dimensions and
relations of the dentogingival junction in human.
J Periodontol. 1961;32:261–267.
3. Brägger U, Lauchenauer D, Lang NP. Surgical length-
ening of the clinical crown. J Clin Periodontol.
1992;19:58–63.
 Crown lengthening procedures
4. Pontoriero R, Carnevale G. Surgical crown lengthening: a
12 month clinical wound healing study. J Periodontol.
2001;72:842–848.
5. Deas DE, Moritz AJ, McDonnell HT, et al. Osseous
surgery for crown lengthening: a 6-month clinical study.
J Periodontol. 2004;75:1288–1294.
6. Perez JR, Smukler H, Nunn ME. Clinical evaluation of the
supraosseous gingivae before and after crown length-
ening. J Periodontol. 2007;78:1023–1030.
7. Smukler H, Chaibi M. Periodontal and dental consid-
erations in clinical crown extension: a rational basis for
treatment. Int J Periodontics Restorative Dent. 1997;17:
464–477.
8. Kois JC. Altering gingival levels: the restorative
connection. Part I: biologic variables. J Esthet Dent. 1994;6:
3–9.
9. Lanning SK, Waldrop TC, Gunsolley JC, et al. Surgical
crown lengthening: evaluation of the biologic width.
J Periodontol. 2003;74:468–474.
10. Fischer KR, Grill E, Jockel-Schneider Y, et al. On the
relationship between gingival biotypes and supracrestal
gingival height, crown form and papilla height. Clin Oral
Implants Res. 2014;25(8):894–898.
11. Vacek J, Gher M, Assad D, et al. The dimension of the
human dentogingival junction. Int J Periodontics Restorative
Dent. 1994;14:154–165.
12. Xie GY, Chen JH, Wang H, et al. Morphological measure-
ment of biologic width in Chinese people. J Oral Sci.
2007;49:197–200.
13. Perez JR, Smukler H, Nunn ME. Clinical evaluation of the
supraosseous gingivae in healthy periodontium. J Perio-
dontol. 2008;79:2267–2272.
14. Barboza EP, MonteAlto RF, Ferreira VF, et al. Supra-
crestal gingival tissue measurements in healthy human
periodontium. Int J Periodontics Restorative Dent.
2008;28:55–61.
15. Arora R, Narula SC, Sharma RK, et al. Supracrestal
gingival tissue: assessing relation with periodontal bio-
types in a healthy periodontium. Int J Periodontics
Restorative Dent. 2013;33:763–771.
16. Shobha KS, Mahantesha, Seshan H, et al. Clinical
evaluation of the biological width following surgical
crown-lengthening procedure: a prospective study.
J Indian Soc Periodontol. 2010;14:160–167.
17. Ganji KK, Patil VA, John J. A comparative evaluation for
biologic width following surgical crown lengthening using
gingivectomy and ostectomy procedure. Int J Dent.
2012;2012:479241. http://dx.doi.org/10.1155/2012/479
241 [Epub 2012 Aug 26].
18. Scutellà F, Landi L, Stellino G, et al. Surgical template for
crown lengthening: a clinical report. J Prosthet Dent.
1999;82:253–256.
19. Ayubian N. Evaluation of dimensional changes of supra-
osseous gingiva following crown lengthening. J Periodontol
Implant Dent. 2010;2:61–65.
20. Pennel BM, King KO, Wilderman MN, et al. Repair of the
alveolar process following osseous surgery. J Periodontol.
1967;38:426–431.
21. Donnenfeld OW, Hoag PM, Weissman DP. A clinical
study on the effects of osteoplasty. J Periodontol. 1970;41:
131–141.
205
22. Wilderman MN, Pennel BM, King K, et al. Histogenesis of
repair following osseous surgery. J Periodontol. 1970;41:
551–565.
23. Oakley E, Rhyu I-C, Karatzas S, et al. Formation of the
biologic width following crown lengthening in non
human primates. Int J Periodontics Restorative Dent.
1999;19:529–541.
24. Arora R, Narula SC, Sharma RK, et al. Evaluation of
supracrestal gingival tissue after surgical crown length-
ening: a 6-month clinical study. J Periodontol. 2013;84:
934–940.
25. Martegani P, Silvestri M, Mascarello F, et al. Morphometric
study of the interproximal unit in the esthetic region to
correlate anatomic variables affecting the aspect of soft
tissue embrasure space. J Periodontol. 2007;78:2260–2265.
26. Chen MC, Liao YF, Chan CP, et al. Factors influencing the
presence of interproximal dental papillae between
maxillary anterior teeth. J Periodontol. 2010;81:318–324.
27. Chang LC. Factors associated with the interdental papilla
height between two maxillary central incisors: a radio-
graphic study. J Periodontol. 2012;83:43–49.
28. Stetler KJ, Bissada NF. Significance of the width of
keratinized gingiva on the periodontal status of teeth
with submarginal restorations. J Periodontol. 1987;58:
696–700.
29. Maynard JG Jr, Wilson RD. Physiologic dimensions of the
periodontium significant to the restorative dentist.
J Periodontol. 1979;50:170–174.
30. Zanatta FB, Giacomelli BR, Dotto PP, et al. Comparison of
different methods involved in the planning of clinical
crown lengthening surgery. Braz Oral Res. 2010;24:
443–448.
31. Abou Arraj RV, Allam M, Kourshounian K, et al.
Dimensions of Supracrestal Gingival Tissues in Natural
Dentition in Humans. 95th AAP (American Academy of
Periodontology) Annual Meeting. Boston, MA: Research
Forum Poster Session; 2009.
32. Kois JC. New paradigms for anterior tooth preparation.
Rationale and technique. Oral Health. 1998;88:19–30.
33. Abou Arraj RV, Allam M, Mouchref-Hamasni F, et al.
Supracrestal Gingival Tissue Dimension. Preliminary Results
Following Crown Lengthening Procedures in Humans. 95th
AAP (American Academy of Periodontology) Annual Meeting.
Boston, MA: Research Forum Poster Session; 2009.
34. Kan JY, Morimoto T, Rungcharassaeng K, et al. Gingival
biotype assessment in the esthetic zone: visual versus
direct measurement. Int J Periodontics Restorative Dent.
2010;30:237–243.
35. Benic GI, Wolleb K, Hämmerle CH, et al. Effect of the
color of intraradicular posts on the color of buccal
gingiva: a clinical spectophotometric evaluation. Int J
Periodontics Restorative Dent. 2013;33:733–741.
36. Ghassemian M, Nowzari H, Lajolo C, et al. The thickness
of facial alveolar bone overlying healthy maxillary
anterior teeth. J Periodontol. 2012;83:187–197.
37. Zekry A, Wang R, Chau AC, et al. Facial alveolar bone wall
width- a cone-beam computed tomography study in
Asians. Clin Oral Implants Res. 2014;25(2):194–206.
38. Jin SH, Park JB, Kim N, et al. The thickness of alveolar
bone at the maxillary canine and premolar teeth in normal
occlusion. J Periodontal Implant Sci. 2012;42:173–178.
206
39. Cook DR, Mealey BL, Verrett RG, et al. Relationship
between clinical periodontal biotype and labial plate
thickness: an in vivo study. Int J Periodontics Restorative Dent.
2011;31:345–354.
40. Fu JH, Yeh CY, Chan HL, et al. Tissue biotype and its
relation to the underlying bone morphology. J Periodontol.
2010;81:569–574.
41. La Rocca AP, Alemany AS, Levi P Jr, et al. Anterior
maxillary and mandibular biotype: relationship between
gingival thickness and width with respect to underlying
bone thickness. Implant Dent. 2012;21:507–515.
42. Stein JM, Lintel-Höping N, Hammächer C, et al. The
gingival biotype: measurement of soft and hard tissue
dimensions—a radiographic morphometric study. J Clin
Periodontol. 2013;40(12):1132–1139.
43. Diniz DE, Okuda KM, Fonseca CR. Surgical crown
lengthening: a 12-month study—radiographic results.
J Appl Oral Sci. 2007;15:280–284.
44. Jorgensen MG, Nowzari H. Aesthetic crown lengthening.
Periodontology 2000. 2001;27:45–58.
45. Hempton TJ, Dominici JT. Contemporary crown-
lengthening therapy: a review. J Am Dent Assoc.
2010;141:647–655.
46. Vercellotti T, Nevins ML, Kim DM, et al. Osseous
response following resective therapy with piezosurgery.
Int J Periodontics Restorative Dent. 2005;25:543–549.
47. Lowe RA. Clinical use of the Er,Cr:YSGG laser for osseous
crown lengthening: redefining the standard of care. Pract
Proced Aesthet Dent. 2006;18(suppl 4):S2–S9.
48. Tarnow DP, Magner AW, Fletcher P. The effect of the
distance from the contact point to the crest of bone on
the presence or absence of the interproximal dental
papilla. J Periodontol. 1992;63:995–996.
49. Dibart S, Capri D, Kachouh I, et al. Crown lengthening in
mandibular molars: a 5-year retrospective radiographic
analysis. J Periodontol. 2003;74:815–821.
50. Batenhorst KF, Bowers GM, Williams JE. Tissue changes
resulting from facial tipping and extrusion of incisors in
monkeys. J Periodontol. 1974;45:660–668.
51. Khuller N, Sharma N. Biologic width: evaluation and
correction of its violation. J Oral Health Comm Dent.
2009;3:20–25.
52. Carvalho CV, Bauer FP, Romito GA, et al. Orthodontic
extrusion with or without circumferential supracrestal
fiberotomy and root planing. Int J Periodontics Restorative
Dent. 2006;26:87–93.
53. Felippe LA, Monteiro Junior S, Vierira LC, et al.
Reestablishing biologic width with forced eruption.
Quintessence Int. 2003;34:733–738.
54. Ingber JS. Forced eruption: part II. A method of treating
nonrestorable teeth—periodontal and restorative consid-
erations. J Periodontol. 1976;47:203–216.
55. Vig RG, Brundo GC. The kinetics of anterior tooth
display. J Prosthet Dent. 1978;39:502–504.
56. Miron H, Calderon S, Allon D. Upper lip changes and
gingival exposure on smiling: vertical dimension analysis.
Am J Orthod Dentofacial Orthop. 2012;141:87–93.
57. Peck S, Peck L, Karaja M. The gingival smile line. Angle
Orthod. 1992;62:91–100.
58. Van der Geld P, Oosterveld P, Kuijpers-Jagtman AM.
Age-related changes of the dental aesthetic zone at rest
Majzoub et al
and during spontaneous smiling and speech. Eur J Orthod.
2008;30:366–373.
59. Desai S, Upadhyay M, Nanda R. Dynamic smile analysis:
changes with age. Am J Orthod Dentofacial Orthop. 2009;136
(310):e1–e10 [discussion 310–311].
60. Sarver DM. The importance of incisor positioning in the
esthetic smile: the smile arc. Am J Orthod Dentofacial Orthop.
2001;120:98–111.
61. Garber DA, Salama MA. The aesthetic smile: diagnosis
and treatment. Periodontol 2000. 1996;11:18–28.
62. Volchansky A, Cleaton-Jones PE. Delayed passive erup-
tion. A predisposing factor to Vincent´s infection? J Dent
Assoc S Afr. 1974;29:291–294.
63. Morrow LA, Robbins JW, Jones DL, et al. Clinical crown
length changes from age 12–19: a longitudinal study.
J Dent. 2000;28:469–473.
64. Coslet JG, Vanarsdall R, Weisgold A. Diagnosis
and classification of delayed passive eruption of the
dentogingival junction in the adult. Alpha Omegan. 1977;
70:24–28.
65. Alpiste-Illueca F. Morphology and dimensions of the
dentogingival unit in the altered passive eruption. Med
Oral Patol Oral Cir Bucal. 2012;17:e814–e820.
66. Alpiste-Illueca F. Dimensions of the dentogingival unit in
maxillary anterior teeth: a new exploration technique
(parallel profile radiograph). Int J Periodontics Restorative
Dent. 2004;24:386–396.
67. Batista EL Jr, Moreira CC, Batista FC, et al. Altered passive
eruption diagnosis and treatment: a cone beam com-
puted tomography-based reappraisal of the condition.
J Clin Periodontol. 2012;39:1089–1096.
68. Januário AL, Barriviera M, Duarte WR. Soft tissue cone-
beam computed tomography: a novel method for the
measurement of gingival tissue and the dimensions of the
dentogingival unit. J Esthet Restor Dent. 2008;20:366–373
[discussion 374].
69. Kokich VG. Esthetics: the orthodontic–periodontic
restorative connection. Semin Orthod. 1996;2:21–30.
70. Sterrett JD, Oliver T, Robinson F, et al. Width/length
ratios of normal clinical crowns of the maxillary
anterior dentition in man. J Clin Periodontol. 1999;26:
153–157.
71. Chu SJ, Hochman MN, Fletcher P. A biometric
approach to aesthetic crown lengthening: part II—
interdental considerations. Pract Proced Aesthet Dent. 2008;
20:529–536.
72. Amato F, Macca U, Borlizzi D. Guided soft and hard tissue
preparation: a novel technique for crown lengthening.
Am J Esthet Dent. 2013;3:24–37.
73. Landi L, Manicone PF, Piccinelli S, et al. Determining
osseous resection during surgical crown lengthening in
the esthetic zone with the use of a radiographic and
surgical template. Quintessence Dent Technol. 2004;27:
101–113.
74. Kinzer GA. Esthetic crown lengthening: an alternated
technique for surgical communication. Adv Esthet Inter-
discip Dent. 2008;4:24–32.
75. Ribeiro FV, Hirata DY, Reis AF, et al. Open-flap versus
flapless esthetic crown lengthening: 12-month clinical
outcomes of a randomized-controlled clinical trial.
J Periodontol. 2014;85(4):536–544.
 Crown lengthening procedures
76. Joly JC, de Carvalho PFM, da Silva RC. Flapless aesthetic
crown lengthening: a new therapeutic approach. Revista
Mexicana de Periodontol. 2011;2:103–108.
77. Sarver DM, Ackerman MB. Dynamic smile visualization and
quantification: part 1. Evolution of the concept and dynamic
records for smile capture. Am J Orthod. 2003;124:4–12.
78. Dong JK, Hin TH, Cho HW, et al. The esthetics of the
smile: a review of some recent studies. Int J Prosthodont.
1999;12:9–19.
207
79. Tjan AH, Miller GD. The JG. Some esthetic factors in a
smile. J Prosthet Dent. 1984;51:24–28.
80. Chiche GJ, Pinault A. Esthetics of Anterior Fixed Prosthodon-
tics. Chicago: Quintessence Publishing Co., Inc; 1994.
81. Allen EP. Surgical crown lengthening for function and
esthetics. Dent Clin North Am. 1993;37:163–179.