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Biologic width and crown lengthening: Case reports and review

Article  in  General dentistry · November 2009

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 Crown-Lengthening Surgery

Biologic width and crown lengthening:

Case reports and review
Se-Lim Oh, DMD, MS

The biologic width includes both the connective tissue attach- caries or fractures below the gingival attachment, a clinical
ment and the junctional epithelium and has a mean dimension crown-lengthening procedure is needed to establish the biologic
of approximately 2 mm. Invading the biologic width with a width. This article presents three case reports that utilized
restoration can result in localized crestal bone loss, gingival crown-lengthening procedures.
recession, localized gingival hyperplasia, or a combination Received: June 8, 2009
of these three. When restoring teeth that have subgingival Accepted: August 28, 2009

T
he biologic width includes both three.5 Therefore, when restoring and the margin of restoration.8
connective tissue attachment teeth with subgingival caries or These procedures should be consid-
and the junctional epithelium. fractures below the gingival margin, ered when the patient has gingival
Different studies have offered differ- a dentist has to determine if the overgrowth and a sufficient amount
ent mean dimensions of the biologic tooth is salvageable, whether the of sound tooth structure over the
width: Gargiulo et al reported an crown needs to be lengthened, and alveolar crest or has a thick con-
epithelial attachment of 0.97 mm which crown-lengthening procedure nective attachment and junctional
and a connective tissue attachment is appropriate. epithelium; the lattere200
can be September/October
deter- 2010

of 1.07 mm, while Vacek et al Clinical crown lengthening is per- mined by bone sounding. 8

reported mean measurements of formed to achieve margins on sound Gingivectomy is indicated only
1.14 mm for epithelial attachment tooth structure, maintenance of the for teeth with more than 3–4 mm
and 0.77 mm for connective tissue biologic width, access for impression of attached gingiva.9 The APF
attachment.1,2 Both studies found techniques, and esthetics.7 Clini- procedure is recommended when
that measuring the connective cal crown-lengthening procedures a gingivectomy procedure could
tissue attachment produced more include gingivectomy, an apically lead to removal of all or most of the
consistent results than measuring positioned flap (APF), an APF with existing attached gingiva or when
the epithelial attachment. Studies osseous reduction, forced eruption pocket reduction is required at the
that utilized bitewing radiographs combined with surgery, and forced same time.9
reported an average dimension eruption combined with fiberotomy.
between the cementoenamel junc- This article presents three cases in Case report No. 1
tion (CEJ) and the alveolar crest of which crown-lengthening proce- A 54-year-old woman was referred
0.4–2 mm.3,4 dures were used to restore teeth with for an evaluation of her periodontal
The dimension of the biologic subgingival caries and/or fractures status and for clinical crown length-
width can vary based on the position below the gingival margin. ening (due to subgingival caries) on
of a tooth, from tooth to tooth, and teeth No. 4–6 and 11–13. These
from surface to surface on the same Gingivectomy and APF six teeth had probing depths of
tooth.5 However, this dimension is As a clinical crown-lengthening 2–3 mm and 4–7 mm of attached
present in all healthy dentitions.6 method, gingivectomy and APF gingiva on the labial side (Fig. 1).
Invasion of the biologic width have limited indications, since a gin- No mobility was present on these
due to restorations could result in givectomy does not allow clinicians teeth. Since the teeth had thick
crestal bone loss, gingival recession to remove bone. It is often necessary connective tissue attachment and
with localized bone loss, localized to remove the supporting bone from junctional epithelium on the palatal
gingival hyperplasia with minimal around a tooth to achieve adequate side, an APF with submarginal inci-
bone loss, or a combination of the distance between the alveolar crest sion was attempted.
 Fig. 2. Top: The patient in Figure 1, after a 1
Fig. 1. A 54-year-old woman with subgingival mm submarginal incision was made on the
caries. Top: Caries on teeth No. 11–13. labial side of teeth No. 11–13. Bottom: A 2 mm Fig. 3. Top: Vertical mattress sutures on teeth
Bottom: Caries on teeth No. 4 and 5. submarginal incision was made on the palatal No. 11–13. Bottom: Vertical mattress sutures
side of teeth No. 11–13. on teeth No. 4 and 5.

September/October 2010 e201

A 1 mm submarginal incision
was made on the labial side and a
2 mm submarginal incision was
made on the palatal side from teeth
No. 11–13 (Fig. 2). Flap retraction
revealed that these teeth had a suffi-
cient amount of sound tooth struc-
ture above the alveolar crest so that
an ostectomy was not necessary. The
palatal flap was thinned with a No.
15 blade and apically positioned
with vertical mattress sutures; the Fig. 4. The patient in Figure 1, three months after placement of the final restoration.
same procedure was performed on
teeth No. 4 and 5. After the sutures
were used to reposition the flap,
all previous subgingival caries was
exposed above the gingival margin teeth No. 6 and 7 to tooth No. 11, APF with osseous surgery.10,11 This
(Fig. 3). Periodontal dressing (Coe- and splinted crowns on teeth No. technique exposes dental structure
pak, GC America Inc.) was placed. 12 and 13. Figure 4 shows a clinical to accommodate a new connective
New cores were built on teeth No. photograph taken at a three-month tissue attachment and junctional
4, 5, and 11–13; two months later, recall appointment. epithelium. The literature has
a final impression was taken. A glass suggested a minimum distance
ionomer reinforced luting cement APF with osseous surgery of 3–4 mm from the restorative
was used to secure splinted crowns The most common procedure for margin to the alveolar crest.10,11
on teeth No. 4 and 5, a bridge from clinical crown lengthening is an For teeth requiring post-and-core,
Crown-Lengthening Surgery  Biologic width and crown lengthening

Fig. 5. A bitewing radiograph of a 62-year-old Fig. 6. A periapical radiograph of the patient Fig. 7. The patient in Figure 5, after core buildup
man with the palatal cusp of tooth No. 13 in Figure 5. and initial preparations on tooth No. 13.
broken below the gingival margin.

of tooth No. 13 was determined

to be fair even after the clinical
crown-lengthening procedure.13 The
patient’s options included placing a
bridge from tooth No. 11 to tooth
No. 13 or implant placement (with
bone grafting) for tooth No. 12.
The patient chose the bridge option.
After root canal therapy, a post-
Fig. 8. The patient in Figure 5 during clinical Fig. 9. The patient in Figure 5, following and-core was built on tooth No.
crown-lengthening surgery. Note that the fracture osseous reduction on tooth No. 13. 13. Initial crown preparation was
line is located 1 mm above the alveolar crest. made before starting the clinical
crown-lengthening procedure. An
APF with osseous reduction was
planned since the palatal gingiva
was inflamed and was covering
Wagenberg et al recommended crown-to-root ratio. Once the the fracture margin (with probing
5 mm of exposed tooth structure prognosis is determined to be good depths of 3 mm) (Fig. 7).
above the alveolar crest to establish or fair, an APF with osseous surgery A crevicular incision was made
the biologic width and achieve the can be performed before or after on the buccal side and a submar-
ferrule effect.12 post-and-core or core build-up and ginal incision was made on the
Before planning an APF with initial crown preparation. palatal side from teeth No. 11–14.
osseous surgery, the dentist should Flap retraction revealed that the
determine the prognosis of the Case report No. 2 fracture line was located 1 mm
tooth, evaluating the bone loss A 62-year-old man had a fractured above the alveolar crest (Fig. 8). To
(in %), probing depth, furcation tooth No. 13, with the palatal cusp achieve the biologic width, a 3–4
involvements, mobility, crown- broken below the gingival margin mm osseous reduction was made
to-root ratio, root form, pulpal (the patient was missing tooth (Fig. 9). The flap was positioned
involvement, and strategic value.13 No. 12). The tooth had 1–2 mm apically using vertical mattress
Performing osseous reduction to pocket depths on the palatal side. sutures (Fig. 10) and periodontal
expose adequate sound tooth struc- A bitewing radiograph showed a dressing was placed.
ture could compromise periodontal normal interproximal bone level Four weeks after clinical crown-
support of the tooth, jeopardize (Fig. 5), while a periapical radio- lengthening surgery, a new core
the adjacent teeth, and result in graph showed a long root length was built on tooth No. 13; four
furcation involvement and a poor (Fig. 6); as a result, the prognosis weeks later, the final impression was

e202 September/October 2010 General Dentistry www.agd.org

Fig. 10. The patient in Figure 5, after vertical mattress sutures were placed. Fig. 11. The patient in Figure 5, after cementation of the finished restoration.

Fig. 12. A 38-year-old man with a fractured palatal cusp on tooth no. 13. Fig. 13. The patient in Figure 12, after bonding of a sectional orthodontic
appliance and placement of nickel-titanium wire.

taken. The finished restoration was alveolar bone growth, which plays tic extrusion, surgical crown
cemented with glass ionomer rein- an active role in shortening the lengthening may be needed to
forced luting cement (Fig. 11). extended fibers.19 remove the gingiva and bone
Forced eruption has been tissue that follows the tooth in its
Forced eruption combined recommended for treating isolated coronal path.14
with osseous surgery teeth, since it minimizes both
While removing supporting bone gingival recession and the loss of Case report No. 3
to expose sound tooth structure is bone support on adjacent teeth.14 A 38-year-old man was referred for
generally recommended for clinical The crown-to-root ratio of a tooth a clinical crown-lengthening proce-
crown lengthening, studies have that has undergone forced eruption dure on tooth No. 13 after finishing
discussed using forced eruption for may remain unchanged or even root canal therapy. A palatal cusp
treating horizontal fractures below be improved compared to a tooth was fractured below the gingival
the gingival attachment or crest of that has undergone an APF with margin, with probing depths of
the alveolar bone.14-17 The rationale osseous reduction.14 2–3 mm and no mobility (Fig. 12).
for using forced eruption is that Orthodontic extrusion requires Because an APF with osseous reduc-
eruptive tooth movement stretches an activation period of four to tion would result in bone loss on
the gingival and periodontal fibers, six weeks and a six-to-eight week teeth No. 12 and 14 and a poor
producing a coronal shift of gingiva retention period for the tooth crown-to-root ratio on tooth No.
and bone.18 Periodontal ligament to become stabilized in its new 13, forced eruption was planned to
and supracrestal fibers often adapt position.14,20 To re-establish the expose the sound tooth structure of
to tooth movements through biologic width after orthodon- tooth No. 13.20

www.agd.org General Dentistry September/October 2010 e203

Crown-Lengthening Surgery  Biologic width and crown lengthening

Fig. 14. A 3 mm submarginal incision was made on the palatal side of Fig. 15. The patient in Figure 12, after placement of vertical mattress sutures.
tooth No. 13.

and final impression were

made six weeks later. The final
porcelain-fused-to-metal crown
was cemented with glass ionomer
luting cement (Fig. 16).

Summary
There is a significant relationship
between restorative dentistry and
periodontal health. As restoration
margins get deeper subgingivally,
inflammation becomes more
severe.21 Restoration margins
Fig. 16. The patient in Figure 12, after cementation of the final restoration. placed near alveolar bone cause the
formation of periodontal pockets
and bone loss.22,23 Periodontal
surgery is recommended to support
restorative dentistry and improve
Scaling and root planing was per- removed at the patient’s request; long-term prognosis.
formed prior to orthodontic forced in addition, a corrective APF was Depending on the specific clini-
eruption. A sectional ortho-dontic performed. The APF consisted cal situation, a dentist can perform
appliance (Mini-Twin, Ormco of a full-thickness flap with a one of several clinical crown-
Orthodontics) was bonded directly crevicular incision on the labial lengthening procedures. Surgical
to teeth No. 11–15; in addition, a side to attempt osteoplasty and a lengthening would be the most
bracket was placed apically on tooth full-thickness flap with a 3 mm immediate and common approach,
No. 13. Occlusal reduction was submarginal incision on the palatal since it will expose the sound tooth
performed on tooth No. 13 before a side of tooth No. 13 to expose the structure immediately after sur-
nickel titanium wire (0.016 in.) was fractured margin (Fig. 14). No osse- gery.10,11 Orthodontic forced erup-
engaged (Fig. 13). As the tooth had ous reduction was performed on the tion could be performed to avoid
erupted orthodontically, occlusal palatal side. The gingival margin any negative effects due to surgical
reduction was performed as needed. was positioned apically using verti- crown lengthening.14
The tooth erupted approximately 4 cal mattress sutures (Fig. 15). After the surgical clinical
mm over a period of five weeks. A core was built on tooth No. crown-lengthening procedure, the
During the retention period, 13 two weeks after the APF was provisional restoration must be
the bracket on tooth No. 11 was performed. A final preparation readapted. A waiting period of 12

e204 September/October 2010 General Dentistry www.agd.org

 weeks has been suggested prior represents bone loss? J Periodontol 1991;62(9): 16. Al-Gheshiyan NA. Forced eruption: Restoring
to starting the final restoration, 570-572. nonrestorable teeth and preventing extraction
5. de Waal H, Castellucci G. The importance of re- site defects. Gen Dent 2004;52(4):327-333.
although Bragger et al reported storative margin placement to the biologic 17. Smidt A, Lachish-Tandlich M, Venezia E. Ortho-
no change in attachment levels or width and periodontal health. Part I. Int J Perio- dontic extrusion of an extensively broken down
probing depths after six weeks of dontics Restorative Dent 1993;13:461-471. anterior tooth: A clinical report. Quintessence
6. Lanning SK, Waldrop TC, Gunsolley JC, Maynard Int 2005;36(2):89-95.
healing.12,24 However, due to the JG. Surgical crown lengthening: Evaluation of 18. Kajiyama K, Murakami T, Yokota S. Gingival re-
possibility of recession, Bragger et the biological width. J Periodontol 2003;74(4): actions after experimentally induced extrusion
al recommended a waiting period 468-474. of the upper incisors in monkeys. Am J Orthod
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Acknowledgements between the gingiva and the margin of resto- 20. Ingber JS. Forced eruption. I. A method of treat-
The author thanks Dr. Robert Sachs rations. J Clin Periodontol 2003;30(5):379- ing isolated one and two wall infrabony osseous
for his assistance in writing this 385. defects-rationale and case report. J Periodontol
9. Oh SL. Attached gingiva: Histology and surgical 1974;45(4):199-206.
article. augmentation. Gen Dent 2009;57(4):381-385. 21. Reitemeier B, Hansel K, Walter MH, Kastner C,
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Author information lengthening: A 12-month clinical wound healing placement on gingival health. J Prosthet Dent
study. J Periodontol 2001;72(7):841-848. 2002;87(2):167-172.
Dr. Oh is an assistant professor, 11. Deas DE, Moritz AJ, McDonnell HT, Powell CA, 22. Gunay H, Seeger A, Tschernitschek H, Geurtsen
University of Maryland Dental Mealey BL. Osseous surgery for crown lengthen- W. Placement of the preparation line and perio-
School in Baltimore. ing: A 6-month clinical study. J Periodontol dontal health—A prospective 2-year clinical
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