RestorativeDentistry

Joanne Cunliffe Nick Grey

Crown Lengthening Surgery Indications and Techniques

Abstract: Crown lengthening is a surgical procedure aimed at removal of periodontal tissue to increase the clinical crown height. As a restorative dentist using this technique of crown lengthening, one needs to have an understanding of biological width, indications, technique, as well as some possible limitations. The authors aim to discuss these concepts in order that the restorative dentist can use crown lengthening as part of an overall treatment plan in a controlled and predictable manner, taking into account biological factors. Clinical Relevance: Todays restorative dentist faces an apparent increase in patients exhibiting toothwear that may result in shortened teeth, making crowning these teeth problematic. In addition, it is evident that patients are becoming more aware of the importance of a pleasing smile. This article discusses crown lengthening as one way in which the restorative dentist can address both clinical demands. Dent Update 2008; 35: 29-35 Results of a recent review study have indicated that few general dental practitoners are happy to carry out surgical crown lengthening.1 It is hoped that this article will enable them to identify situations where such a procedure would benefit the patient and allow a referral as appropriate. significantly compromise the gingival health, if placed below the gingival margin. In a study3 it was found that subgingival margins demonstrated higher plaque, gingival index scores and probing depths. In addition, when the bacterial morphotypes were examined, there was an increase in the spirochetes, fusiforms, rods and filamentous bacteria. There is an additional benefit of ease of impression taking, cleansing4 and detection of secondary caries. Periodontal health is the cornerstone of any successful restorative procedure. Therefore the correct handling of the periodontal tissues during restoration of the tooth is important to the restorations future success. In order to aid the restorative dentist in understanding crown lengthening procedure for restorative and aesthetic reasons, the indications, contraindications, biological concepts and surgical techniques will be discussed.

Introduction
The need for crown lengthening is dictated by dental and patient factors. After crown lengthening it should be possible to put restoration margins above, or at, the gingival margin. It is well documented in the literature that this creates a more favourable condition to allow periodontal health. Silness2 found that margins of fixed prosthodontics

Figure 1. Thick tissue biotype with crown margin impinging on the biological width. This has led to hyperplasia.

Joanne Cunliffe, BChD, MRD, FDS RCS, DPDS, SpR, Restorative Dentistry and Nick Grey, BDS, PhD, MDSC, DRD, MRD, FDS RCSEd, MILT, Senior Clinical Teacher/ Honorary Consultant Restorative Dentistry, Manchester Dental Hospital, Higher Cambridge Street, Manchester, UK. January/February 2008

Indications
The indications for crown lengthening are:
Restorative needs

to caries, fracture or wear; To access subgingival caries; To produce a ferrule for post crown provision; To access a perforation in the coronal third of the root; To relocate margins of restorations that are impinging on biological width.
Aesthetics

To increase clinical crown height lost due

Short teeth; Uneven gingival contour; Gummy smile. DentalUpdate 29

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fracture, it has been shown that, when providing a post crown, teeth prepared with a ferrule of 12 mm have an increased resistance to fracturing (Figure 3).5 There may also be a loss of tooth tissue due to attrition and/or erosion. This may leave inadequate tooth tissue to gain enough vertical height to gain adequate retention of an indirect restoration (Figure 4).
Figure 2. (b) Patient shows no upper teeth and would benefit from an overdenture. Aesthetics

Figure 2. (a) Wear on the upper anterior teeth with no alveolar compensation.

Figure 3. (a) Failed post crowns with very little coronal tissue.

Figure 3. (b) Surgical crown lengthening with electrosurgery to allow a ferrule to be used.

Symmetrical smiles are deemed aesthetically pleasing and, ideally, there should be 1 mm of gingivae visible when smiling. The proportions of the crown lengths are also important. The length of the centrals should be equal to the canines and the laterals slightly shorter than both (Figure 5). The highest point of the scallop should be slightly distal for the centrals, mid point for the laterals and slightly distal for the canines.6 If there is sufficient supracrestal tissue, this outcome may be achieved with a gingivectomy alone; otherwise, bone removal is required. Whichever method is used, it is very important that the interdental papillae are maintained through careful planning and consideration of biological and anatomical factors.

Contra-indications
Figure 4. (a) Amelogenesis imperfecta patient with posterior toothwear. There is adequate tooth height to place an indirect restoration on the lower left first molar.

Figure 4. (b) Patient has had surgical crown lengthening to increase the vertical height of the lower left first molar.

Restorative

When planning a restoration where the margin will be within 3 mm of the crestal bone, crown lengthening should be considered; as the restoration may impinge on the biological width, which is the distance from the crest of the bone to the margin of the gingivae. If it is encroached upon, then this may lead to gingival recession in thin tissue biotypes or hyperplasia in thick tissue biotypes (Figure 1). Where there has been toothwear, compensatory alveolar eruption may or may not have occurred. In situations

where it does not occur, a better aesthetic result may be produced by providing an overdenture because the incisal edge is in a more apical position (Figure 2). In cases where compensatory alveolar eruption has occurred, the lip position and the incisal edge relationship may have remained constant. This being the case, it may be preferable to crown lengthen in order to avoid a gummy smile, gain adequate tooth structure, provide both a retentive restoration, as well as improve the aesthetics. When there has been loss of tooth structure due to caries or tooth

Crown lengthening of a single tooth or teeth with long clinical crowns may yield unfavourable aesthetic results, such as a black triangle (Figure 6). As with any treatment, crown lengthening is contraindicated in patients with poor oral hygiene. There should also be caution when treating a smoker because of reports of poorer results in both non-surgical therapy7 and surgical therapy8 for treatment of periodontitis in smokers.

Biological considerations
Biological width

When crown lengthening is planned to increase the length of available tooth, the biological width needs to be considered and not encroached upon as this may lead to periodontal breakdown.9 Gargiulo et al 10 described the biological width in a histological study. Large variations in this measurement January/February 2008

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Figure 6. Black triangles.

Figure 5. (a) Uneven gingival contour around the upper anterior teeth with a temporary bridge. This patient had a high lip line which made the contour of the gingival important.

Figure 5. (b) Electrosurgery was used to recontour and increase the length of the upper left central and right lateral.

Figure 7. (a) Pigmented gingiva needing crown lengthening.

Figure 7. (b) Internal bevel gingivectomy undertaken to keep the pigmented gingiva.

found, but the average was 0.69 mm mean sulcus depth, 0.97 mm epithelial attachment and 1.07 mm for connective tissue attachment. This then totals 2.73 mm mean length of the dentogingival complex. Owing to the concept of biological width, it has been proposed that there should be 3 mm of supracrestal tooth tissue between the bone and the margin of the proposed restoration.9 But there have been other recommendations of between 3.5 mm and 5.25 mm11,12 While these measurements are provided as a guide, one needs to remember that there are variations between individuals and around different teeth. It was observed that there was a re-establishment of the biological width in teeth that were crown lengthened by 6 months. The re-established biological width was found to be the same vertical dimension as the pre-surgery measurement.13

Anatomical considerations
Anatomical considerations need

to be taken into account when a patient is being assessed for crown lengthening, including: Length and shape of root; Furcation position; Lip line (at rest and smiling); Width of interdental bone; Local soft/hard tissue anatomy and muscle insertions; Amount of attached gingival tissue. There needs to be a favourable crown:root ratio after treatment, as well as adequate tooth tissue to allow the accommodation of the restoration. If the tooth narrows considerably apically, there may be a risk of pulp exposure during preparation or risk of overcontouring the restoration owing to insufficient space. In addition, there is a risk of compromising the appearance if the crown has to be over contoured. If the furcation is exposed during the bone removal, an area of plaque stagnation, which may lead to more bone loss, may occur. It has been demonstrated that there needs to be 4 mm from the

furcation to the crestal bone pre-operatively in order to reduce the risk of furcation exposure.14 If the roots are close together, there may be very little interdental bone, which may make it impossible to use an instrument in between the teeth for bone removal without risking damaging the roots. If the bone is not removed from the interproximal area, then it may be difficult to reposition the soft tissues, and there will be a reduction in the length that is gained, thereby compromising the retention of a restoration. The position of the lip on smiling will have an effect on the aesthetic outcome. Therefore, the examination of the lip position is important, as it will determine the amount of tooth and gingiva on display.15 If only one tooth needs treatment and there is a higher lip line, then the gingival discrepancy will be seen and the resultant aesthetics poor. Other soft tissue considerations are the muscle insertions, as a high muscle insertion may affect the apical repositioning of the flap. This is also true if there is a shallow vestibular sulcus or a high external oblique ridge, as it may limit the position of the flap. The amount of attached gingiva needs to be measured as part of the assessment. It has been shown that, to maintain periodontal health, there should be 23 mm of attached gingival.16

Techniques
Soft tissue recontouring

This technique is generally used to improve aesthetics and takes the form of a gingivectomy to excise the soft tissue. Normally, the gingival margin is 1 mm coronal to the CEJ. If it is greater, then the clinical crown is shorter than the January/February 2008

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Figure 8. (a) Shows the first incision and the second incision being undertaken.

Figure 8. (b) Full thickness flap raised to expose the bone. Note there are no relieving incisions required in this case.

Figure 8. (c) Osseous recontouring using a rosehead bur with copious saline.

Figure 8. (d) Flap repositioned before suturing.

pigment returns slowly. If the patient wishes to keep the pigment, then an internal bevel incision is needed to produce an internal gingivectomy (Figure 7).
Soft tissue and bone recontouring

Figure 9. A surgical stent made of acrylic to use during surgery to indicate the proposed restoration margins. The bone can be removed 3mm apical to this margin.

anatomical crown. In thin tissue biotypes, a gingivectomy will expose more of the crown and improve the appearance. It may be achieved with a scalpel, or with the use of electrosurgery. If there is pigmentation in the tissue, it needs to be determined if the patient wishes to maintain or lessen this amount. An external bevel incision will remove pigment, and it may be necessary to extend the gingivectomy to the premolar region to stop a marked transition being visible on smiling. This colour change may be permanent, but occasionally the

When there is a thick tissue biotype, especially with a ledge on the crestal bone, an apically repositioned flap and bone recontouring may be preferable. If there is adequate attached gingiva, labially or buccally, then an inverse bevel incision can be made 23 mm from the gingival margin, following a scalloped pattern around the gingival margins. This would be followed by a second incision into the intracrevicular sulcus (Figure 8a). The incision should be extended distally 12 teeth to blend into the gingival sulcus of the untreated teeth. A third incision is then placed interproximally to release the interdental papillae, after which a full thickness flap is raised to allow bone exposure, the osseous recontouring. If there is inadequate attached gingiva, then a vertical releasing incision should be made and the flap apically repositioned. Vertical releasing incisions are also used if there is a need for increased visibility or to avoid the

exposure of a crown margin. Palatally, a scalloped inverse bevel incision using a number 15 blade should be made, again following a scalloped pattern, but this time the scallop is much deeper than the original gingival margins. Alternatively, intra-crevicular incisions can be used and a full thickness flap raised (Figure 8b); after the bone recontouring, the flap is then recontoured to follow the new position of the bone. Bone recontouring can be carried out using fissure burs or coarse diamond stones with copious amounts of normal saline (Figure 8c). The bone is thinned until there is a thin layer remaining over the surface. To reduce the risk of damaging the root surface, the authors consider that this final thin layer of bone should be removed by using a bone chisel, files or an ultrasonic scaler. Then any bone ledges should be smoothed to aid the repositioning of the flap (Figure 8d). Enough bone is removed to create a 3 mm space between the crest of the bone and the new restorations margin. This can be measured using a periodontal probe, or a surgical stent can be made in the laboratory to show the restorations expected margin (Figure 9). If the last tooth to be crown lengthened is the most distal tooth, then the incision needs to blend into a wedge flap to reduce the bulk of the tissue distal to the last tooth.
Sutures and dressing

Continuous or interrupted sutures can be used. The continuous sutures are particularly useful if there have been several teeth with apically repositioned flaps. The use of a periodontal dressing is one of personal preference. The authors do not use them and prefer to achieve full bone coverage with the soft tissue flaps.
Complications

As with any procedure, the patient needs to be informed of any potential complications. For crown lengthening these include: Possible poor aesthetics due to black triangles; Root sensitivity; Root resorption; Transient mobility of the teeth. January/February 2008

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Restoration of the teeth

The gingival margin does not stabilize until at least 20 weeks post surgery.17 This is of particular importance when in the anterior region as the aesthetics may be more crucial. After a 23 week post surgery period, temporary crowns may be used until there has been full healing and the gingival margin is in a stable position.

References
1. Wyatt G, Grey N, Deery C. A cross sectional survey of clinicians performing periodontal surgical crown lengthening. Eur J Prosthodont Restor Dent 2004; 12:109114. Silness J. Fixed prosthodontics and periodontal health. Dent Clin N Am 1980; 24: 317339. Flores-de-Jacoby L, Zafiropoulas GG, Cianco S. The effect of crown margin location on plaque and periodontal health. Int J Perio Rest Dent 1989; 9: 197205. Silness J. Periodontal conditions in patients treated with dental bridges II. The influence of full and partial crowns on plaque accumulation and development of gingivitis and pocket formation. Int J Perio Rest Dent 1970; 5: 219224. Hemmings KW, King PA, Setchell DJ. Resistance to torsional forces of various post and core designs. J Prosthet Dent 1991; 66: 325329. Kay HB. Esthetic considerations in the definitive periodontal prosthetic management of the maxillary anterior segment. Int J Perio Rest Dent 1982; 2: 45. Preber H, Bergstrom J. The effects of non-surgical therapy on periodontal pockets in smokers and non smokers. J Clin Periodontol 1986; 13: 319323. Preber H, Bergstrom J. Effect of cigarette smoking on periodontal healing following surgical therapy. J Clin Periodontol 1990; 17: 324328.

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10.

2.

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Discussion
Crown lengthening should be within the capabilities of a specialist restorative dentist. The most likely specialist to perform this procedure has been shown to be a periodontist.1 There is no reason why general practitioners who are comfortable with surgical dentistry should not perform crown lengthening. However, if this procedure lies outside their comfort zone then a referral to a specialist is appropriate. 4.

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6.

Conclusion
Surgical crown lengthening has an important role in restorative dentistry and, in dentitions that are worn, it is a necessary consideration when treatment planning is being undertaken.
Acknowledgement

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Thanks to Stephen Brindley for the help on some of the clinical photos.

Nevins M, Skurow HM. The intracrevicular restorative margin, the biological width and maintenance of the gingival margin. Int J Perio Rest Dent 1984; 4: 3049. Gargiulo A, Wentz F, Orban B. Dimensions and relations of dento gingival junction in humans. J Periodontal 1961; 32: 261267. Rosenberg ES, Garber DA, Evian C. Tooth lengthening procedures. Compend Continuing Educ Dent 1980; 1: 161172. Wagenberg BD, Eskow RN, Langer B. Exposing adequate tooth structure for restorative dentistry. Int J Perio Rest Dent 1989; 9: 322333. Lanning SK, Waldrop TC, Gunsolley J, Maynard JG. Surgical crown lengthening: evaluation of the biological width. J Periodontol 2003; 74: 468474. Dibart S, Capri D, Kachouh I et al. Crown lengthening in mandibular molars; a 5 year retrospective radiological analysis. J Periodontol 2003; 74: 815882. Tjan AHL, Miller GD, The JGP. Some aesthetic factors in a smile. J Prosthet Dent 1984; 51: 2428. Maynard JG Jr, Wilson RDK. Physiological dimensions of the periodontium significant to the restorative dentist. J Periodontol 1979; 50: 170177. Wise MD. Stability of the gingival crest after surgery and before anterior crown placement. J Prosthet Dent 1985; 53: 2023.

Abstract
HOW WELL DO YOUR COMPLETE DENTURE PATIENTS CHEW? RCT comparing posterior occlusal forms for complete dentures. Sutton AF, Worthington HV, McCord JF. Journal of Dental Research 2007; 86: 651655. Technicians make complete dentures with different occlusal forms, often at their own discretion rather than the clinicians prescription. The flatter the occlusal plane the easier to construct the denture, but there is some evidence that cusped posterior teeth actually function January/February 2008 better and give improved patient satisfaction. This research aimed to compare patient satisfaction with three different types of posterior occlusal form, zero-degree, anatomic and lingualized occlusions. Forty-five patients were randomly assigned three sets of dentures to wear over an eight-week period. The dentures were identical other than the occlusal tables. Statistical analysis of the results revealed no difference in patient satisfaction between the lingualized and anatomical occlusal forms, but that both of these were significantly preferable to the zero-degree form. Interestingly patients preferred the lingualized and anatomical occlusal forms in four of the five aspects of the survey, appearance, cleaning, stability and chewing. The results for speech showed no difference between the three forms. Clinicians should be aware of these findings when writing the technical prescription for complete denture fabrication in the laboratory. Peter Carrotte Glasgow Dental School DentalUpdate 35