Periodontics

Rajiv M Patel Paul Baker

Functional Crown Lengthening

Surgery in the Aesthetic Zone;
Periodontic and Prosthodontic
Considerations
Abstract: Crown lengthening surgery aims to increase the amount of supragingival tooth tissue by resection of the soft and/or hard tissues
to enable otherwise unrestorable teeth to be restored by increasing the retention and resistance forms of the teeth. Restoration of the
worn dentition may require significant prosthodontic knowledge and skill. A prosthodontist should be involved from the beginning of the
management of the patient. A number of key stages should be considered for correct management. Although the periodontist may
guide the prosthodontist with regards to what may or may not be possible surgically, the overall treatment plan should be
prosthodontically driven.
Clinical Relevance: Toothwear of the anterior dentition provides a unique challenge to restore not only function but also to manage the
aesthetic demands of the patient. To ensure that the correct outcome is reached, clinicians should be familiar with the normal anatomical
proportions and relationships to enable planning and treatment to take place.
Dent Update 2015; 42: 36–42

Crown lengthening surgery aims to increase
the amount of supragingival tooth tissue
by resection of the soft and/or hard tissues
to enable otherwise unrestorable teeth to
be restored by increasing the retention and
resistance forms of the teeth.
As restoration of the significantly
worn dentition requires significant
prosthodontic knowledge and skill; the
restoring dentist should be involved from
Rajiv M Patel, BDS, MClinDent(Perio),
MFDS RCS(Eng), MPerio RCS(Ed),
Specialist in Periodontics and Paul
Baker, BDS, MSc, MClinDent(Perio),
FDS RCS(Eng), MRD RCS, Specialist in
Periodontics, Perio London, 4 Queen
Anne Street, London, W1G 9ZF, UK.
36 DentalUpdate January/February 2015
the beginning of the management of the
patient and, indeed, lead treatment. Where
necessary, the advice of a prosthodontist
may also be sought.
Planning
Management of a patient
with severe toothwear requiring crown
lengthening surgery will require a number of
planning stages:
1. Pre-prosthodontic planning;
2. Combined prosthodontic and periodontic
planning;
3. Pre-surgical planning.
Pre-prosthodontic planning
The restoring dentist has a
number of decisions to make regarding the
rehabilitation of the worn dentition based on
the extent of toothwear and its distribution,
and the general restorative and endodontic
status of the whole dentition. The occlusion
will also have to be assessed prior to planning
restorations. Where the existing intercuspal
position (ICP) is unsatisfactory or does not
exist due to excessive wear, centric relation
may be used as the basis for reconstructing
a new ICP. There are two other principles to
consider when reorganizing the occlusion in
this manner:
1. Decide the vertical dimension: Where
there has been a loss of vertical dimension
(reduced lower face height) it may be possible
to increase it. Generally speaking, if the
occlusal vertical dimension is being increased
to produce teeth with ‘normal’ dimensions,
the space required for the restorations will
determine the increase.

2. Create stability in ICP and avoid damage in
excursions: The occlusal scheme should be
designed to optimize transmission of occlusal
forces while providing stability and harmony
in order to allow the patient to adapt. This
may be a mutually protected scheme that in
ICP will allow the posterior teeth to support
maximum biting forces whilst the anterior
teeth are just out of contact. In excursions,
the anterior teeth provide guidance to
disclude the posterior teeth and protect
them from lateral loading. This may be
important if attrition from parafunctional
habits has been part of the aetiology of wear.
Study casts mounted on a semi-
or fully adjustable articulator will allow the
restoring dentist to determine some of the
aspects outlined above and to construct
diagnostic wax-ups. Chairside try-ins (with
the aid of a blow down stent of the wax-ups
filled with a temporary acrylic restorative
material placed directly over the teeth)
will allow the clinician and the patient to
determine the appearance of the proposed
restorations in relation to the soft tissues and
lips. This is an important process as it informs
the restoring dentist by how much the teeth
Figure 1. Pre-operative view of the anterior
dentition demonstrating severe tooth surface loss.
a b c
Figure 3. (a) Upper occlusal view of diagnostic wax-ups. (b) Articulated casts with diagnostic wax-ups with tooth form restored to correct dimensions. (c)
Lower occlusal view of diagnostic wax-ups.
January/February 2015 DentalUpdate 37
must be lengthened at the gingival margin
and by how much the length of the teeth can
be increased from the incisal edge. Excessive
tooth display (more than 2 mm) in relation to
the upper lip at rest is an indication for crown
lengthening surgery to allow tooth length to
be increased at the gingival margin (Figures 1,
2, 3, 4).
Combined prosthodontics and periodontic
planning
The periodontist should liaise with
the restoring dentist to ensure that the new
proposed positions of the gingival margins are
in the correct relationship to one another.
Principles of planning gingival aesthetics
 Determining the position of the gingival
zeniths: Studies examining gingival
morphology in periodontal health have noted
that the gingival zeniths of the upper central
incisors are usually located approximately
1 mm distal to the midline of the crowns.1,2
These studies have also shown that the zeniths
of the upper lateral incisor and upper canine
teeth are located in the midline of the teeth,
a b
Figure 2. (a, b) Pre-operative view of the upper and lower occlusal surfaces demonstrating severe tooth
surface loss consistent with erosive tooth loss.
Periodontics
though they may appear distal when viewed
from in front of the patient owing to the
relative disto-angulation of the roots (Figure 5).
 Relative gingival margins: The same studies
mentioned above have also demonstrated
that gingival zeniths of upper lateral incisor
teeth are approximately 1 mm coronal to
those of the upper central incisor and canine
teeth (Figure 6).
 Papillae height: Chu et al3 suggested that
papillae length should be approximately 40%
of the length of the crowns of the teeth. A
study by Tarnow et al4 showed that papillae
formation may be successful where the
contact area between teeth is approximately 5
mm from the alveolar crest. These dimensions
may help guide the restoring dentist to plan
for crown morphology that will help achieve
optimal (gingival) aesthetics (Figure 7).
Once a study cast has been
modified (keeping in mind the principles
discussed above) to create the new proposed
gingival margin position, a blow down
acrylic surgical stent can be created from
the modified model to allow the proposed
gingival margin position to be transferred with
a degree of accuracy at the time of surgery.
 Periodontics

Pre-surgical planning as measured from the apical extent of periodontium, eg a biologic width of
Some of the surgical planning the gingival sulcus to the alveolar crest. approximately 3 mm plus a pocket depth
will be common to the prosthodontics It comprises approximately 1.5 mm of of 2 mm would require bone adjustment
planning (smile/lip line, general restorative/ junctional epithelial attachment and 1 such that a distance of 5 mm was present
endodontic status). The patient’s medical mm of connective tissue attachment.5 from the new gingival margin position to
history should also be checked for any The measurement does not include the the alveolar crest. In thin gingival tissues,
contra-indications to surgery. Poor oral sulcus or probing depth. Therefore the encroachment of restoration margin on
hygiene should be addressed prior to biologic width can be measured clinically the biologic width may result in gingival
surgery to allow easier handling of the by subtracting the probing depth from the recession. In thick tissues it may result in
tissues during surgery and allow adequate depth to the alveolar crest. The biologic chronic inflammation.
post-operative healing. Periodontal width can then be used to determine how  Extent of interproximal and palatal
treatment should also be carried out much bone removal is required (if required) tooth tissue required: This information
prior to surgery if indicated. A healthy in order to maintain healthy marginal provided by the prosthodontist will help
periodontium is a prerequisite to surgery.
Specific factors to consider:
 Amount of keratinized tissue: Depending
on the amount of tooth substance
required by the restoring dentist, the
amount of attached keratinized tissue will
determine the surgical approach; resective
versus apically positioning tissues (or a
combination of both). It is preferable to
leave at least 2 mm of keratinized tissue
post surgery. This will enable the patient
to maintain good plaque control more
comfortably than if there was only lining
mucosa remaining.
 Pocket depths and bone sounding (with Figure 5. Ideal gingival zenith points demonstrated by yellow line crossing gingival margin. Red line
local anaesthesia): This allows the biologic demonstrating relative position of gingival zenith point to midline of tooth.
width to be assessed. The biologic width
is said to represent the tissue attachment

Figure 6. Gingival margins of the upper central incisor and canine teeth approximately 1 mm apical to
the upper lateral incisor teeth.
b

Figure 4. (a) Modification of the gingival margin

positions; an upper study cast to the proposed
new gingival margin positions. (b) Construction
of the acrylic surgical guide on the modified cast. Figure 7. Illustration of the length of the central incisor papilla relative to the length of the crown.

38 DentalUpdate January/February 2015


plan flap design (in association with the
amount of attached tissue present). If
no interproximal crown lengthening is
required, it may be possible to design a
flap that is papilla sparing. If interproximal
space is required it is important to
remember the cement-enamel junction
(CEJ) runs more coronally interproximally
and therefore bone levels should also
remain more coronal relative to the mid
labial and mid palatal crestal levels after
ostectomy.
 Peri-apical radiographs: Good quality
peri-apical radiographs will allow
assessment of the interproximal bone
levels (and their relative positions to the
CEJs) as well as root form and length.
Short roots will severely limit the extent of
crown lengthening that may be possible,
otherwise teeth with dramatically
reduced support and increased crown to
root ratios may be produced. Teeth with
narrow roots may be difficult to restore;
restoration margins placed on roots may
increase the risk of devitalization of the
teeth. The emergence profile of the crown
of the tooth will also be compromised
and, in some instances, result in ‘dark’
interproximal triangles or voids (Figure 8).
a b c
Figure 8. Peri-apical radiographs of teeth to be crown lengthened.
January/February 2015 DentalUpdate 41
Surgical procedure
Resective approach
Once planning has been
completed, the surgical guide (constructed
from the modified study cast) can be
located on the teeth to be lengthened
and the positions of the gingival margins
marked out with a probe if a resective
technique is proposed. The gingivae
can then be resected to create the new
gingival margin followed by full thickness
flap elevation (maintaining papilla height
if raised). Alveolar crest position can also
be adjusted relative to the surgical guide
to allow space for biologic width and the
periodontal crevice.
The ostectomy (removal of bone
supporting teeth) and bone recontouring
may be carried out with a combination of
bone chisels, burs and ultrasonic tips. Bone
removal may also be required in the region
between the roots to maintain a natural
anatomy and contour of the bone and avoid
‘flat ledges’ or ‘platforms’ being formed.
Exposed root surfaces should also be root
planed to prevent re-attachment of the
periodontal tissues and minimize the risk of
rebound of the gingival margin to the pre-
surgical position.
Periodontics
An everting vertical mattress
suture technique may be useful in trying to
maintain papilla height and position post
surgically. Sutures are commonly removed
7−10 days post surgery.
Non-resective approach
If a resective technique is not
possible owing to insufficient keratinized
tissue, full thickness flaps raised from
crevicular incisions or conservative inverse
bevel incisions would have to be utilized.
Apical displacement of the periodontal
tissues (and exposure of further tooth
tissue) may be achieved by elevating the
flap past the muco-gingival junction and
by incorporating vertical relieving incisions
into the flap design. Management of the
hard tissues would be as described above
for the resective approach (Figures 9−13).
Restorative phase
The crown lengthened teeth
may be prepared soon after surgery
(1−2 weeks) to allow the placement of
provisional restorations if healing has
occurred in an uncomplicated manner.
The periodontist can provide the restoring
 Periodontics
b Figure 11. Relationship of the new gingival
Figure 9. (a, b) Surgical guide in situ, buccal and
palatal views providing a guide for the amount
of gingiva to be resected both buccally and
palatally.
a
b
Figure 10. (a, b) Gingival margin position
following gingivectomy.
dentist with advice on healing and when
to proceed to provisional restorations.
If crowns are considered,
it would be worthwhile waiting six
months prior to placement of the
definitive restorations. There is limited
research in this matter but a study by
Wise6 demonstrated that the position of
the gingival crest may continue to change
(both coronal and apical movement) for up
to five months post periodontal surgery,
though it should be noted that this study
42 DentalUpdate January/February 2015
margin position (demonstrated by the surgical
guide) to the position of the alveolar crest.
a b
Figure 13. (a, b) Immediate post-operative appearance in comparison to the pre-operative view
demonstrating an increase in crown height.
a b
Figure 14. (a, b) Comparison of pre-operative appearance with the appearance 6 months post surgery
(provisional crowns in situ).
did not look at crown lengthening surgery
(Figure 14).
Conclusion
Planning the case from both
prosthetic and periodontal aspects is key to a
successful outcome. Though the periodontist
may guide the restorative dentist with
regards to what may or may not be possible
surgically, the overall treatment plan should
be prosthodontically driven.
Acknowledgement
Thanks to Dr Cullen Mussington,
Specialist in Prosthodontics, for Figures 3, 4
and 14b.
References
1. Mattos CM, Santana RB. A quantitative evaluation
Figure 12. Appearance of the alveolar crest
following completion of alveolar re-contouring
(ostectomy and osteotomy).
of the spatial displacement of the gingival zenith
in the maxillary anterior dentition. J Periodontol
2008; 79 (10): 1880−1885.
2. Chu SJ, Tan JH, Stappert CF, Tarnow DP.
Gingival zenith positions and levels of the
maxillary anterior dentition. J Esthet Restor
Dent 2009; 21(2): 113−120.
3. Chu SJ, Tarnow DP, Tan JH et al. Papilla
proportions in the maxillary anterior dentition.
Int J Periodont Rest Dent 2009; 29(4): 385−393.
4. 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(12): 995−996.
5. Gargiulo AW, Wentz F, Orban B. Dimensions
and relations of the dentogingival junction
in humans. J Periodontol 1961; 32: 261−267.
6. Wise MD. Stability of gingival crest after
gingival surgery and before anterior crown
placement. J Prosthet Dent 1985; 53(1): 20−23.