ISSN: 2320-5407 Int. J. Adv. Res.

8(02), 253-256

Journal Homepage: - www.journalijar.com

Article DOI: 10.21474/IJAR01/10461

DOI URL: http://dx.doi.org/10.21474/IJAR01/10461

RESEARCH ARTICLE
CROWN LENGTHENING: LE MAQUILLAGE FOR THE ANTERIOR PERIODONTIUM

Sharanya Bose[1],Subhapriya Mandal[1],Soumyadeep Mondol[2],Ravi Prakash B S[3],Abhijit Chakraborty[4]

1. Post Graduate Student, Department of Periodontics, Guru Nanak Institute of Dental Sciences and
Research, Kolkata.
2. Post Graduate Student, Department of Conservative Dentistry and Endodontics, Guru Nanak
Institute of Dental Sciences and Research, Kolkata.
3. Professor, Department of Periodontics, Guru Nanak Institute of Dental Sciences and Research,
Kolkata.
4. Head of the Department and Professor, Department of Periodontics, Guru Nanak Institute of Dental
Sciences and Research, Kolkata.

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Manuscript Info Abstract:-
……………………. ………………………………………………………………
The aim of this case report is to highlight and describe crown lengthening
Manuscript History procedure keeping in mind the increasing demand of esthetic dentistry. As
Received: 07 December 2019 mentioned by 2003 American Academy of Periodontology (Practice Profile
Final Accepted: 10 January 2020 Survey), crown lengthening is the most conventional surgical periodontal
Published: February 2020 treatment. The present case is managed with the surgical approach of crown
lengthening without compromising esthetics and tooth support.
Key words :-
Crown Lengthening,
Biologic width,
Anterior restoration,
Esthetic restoration

Copy Right, IJAR, 2020,. All rights reserved.

……………………………………………………………………………………………………....
Introduction:-
As William Shakespeare had rightly quoted “Smile cures the wounding of a frown” hence it is of utmost importance
to maintain a perfect smile in this highly aesthetic applauding society. To uphold a perfect smile it is of paramount
importance to maintain a healthy and an equitable relationship between the gingiva, lips and teeth. It is estimated
that 10% of the population has excessive gingival display and most of them are women [1]. The notion of crown
lengthening was first initiated by D.W. Cohen (1962)[2] and is presently described as a surgical approach that often
avails amalgamation of tissue reduction or removal, osseous surgery, and / or orthodontics for tooth exposure. The
common causes of short clinical crown include caries, erosion, tooth malformation, fracture, attrition, excessive
tooth reduction, eruption disharmony, exostosis, and genetic variation [3]. Therefore, this deficiency in clinical crown
length should be increased when margins of caries or margins of the tooth fractures are subgingivally placed, the
crown is too short for retention of the restoration, there is an excess of gingiva, and anatomical tooth crown is
partially erupted [4].

Corresponding Author: - Sharanya Bose, Post Graduate Student,GNIDSR, Kolkata.

Address: 92, Uday Shankar Sarani, Kolkata – 700033, West Bengal, India.
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The ultimate goal of crown lengthening is to provide a tooth crown dimension adequate for a stable dentogingival
complex and for the placement of a restorative margin, so as to achieve the best marginal seal and an aesthetically
pleasing final restoration [5]. The amount of tooth structure exposed above the osseous crest (about 4 mm) must be
enough to provide for a stable dentogingival complex and biologic width to permit proper tooth preparation and
account for an adequate marginal placement, thus ensuring a good marginal seal with retention for both provisional
and final restorations [6].

The various indications [7] for crown lengthening are:

1. Restorative needs
2. To increase clinical crown height lost due to caries, fracture or wear
3. To access subgingival caries
4. To produce a “ferrule” for restoration
5. To access a perforation in the coronal third of the root
6. To relocate margins of restorations that is impinging on biological width.
7. Aesthetics
8. Short teeth
9. Uneven gingival contour
10. Gummy smile.

The various contra-indications [8] and limiting factors are:

1. Inadequate crown to root ratio
2. Non restorability of caries or root fracture
3. Esthetic compromise
4. High furcation
5. Inadequate predictability
6. Tooth arch relationship inadequacy
7. Compromise adjacent periodontium or esthetics
8. Insufficient restorative space
9. No maintainability

Biologic width is defined as the physiologic dimension of the junctional epithelium and connective tissue
attachment, according to the pioneering study conducted by Gargiulo et al. [9] Usually, the biologic width is reported
to be 2.04 mm which comprises of 0.97 mm of junctional epithelium and 1.07 mm of connective tissue attachment.
But this can definitely vary with age, due to orthodontic treatment as well as due to tooth migration due to loss of
arch or occlusal integrity.

Case report:-
A 21 year old female patient was referred to the Department of Periodontics, GNIDSR, with a complaint of
inadequate crown structure to produce a ferrule length facilitating prosthetic management with respect to tooth
number 12. [Figure: 1] There was absence of periapical radiolucency on radiographic examination, the periodontal
ligament was within the realm of normalcy, and the crown-to-root ratio was around 1:3. On clinical evaluation, the
width of attached gingival was recorded to be around 5 to 6  mm in width and pocket depth of 3 mm or less was
encountered. No potential periodontal disease neither tooth mobility was encountered. The tooth was endodontically
treated. The principal arena of interest for treatment was to resolve the issue of inadequate crown structure for crown
replacement.

In this particular case it was decided to pursue surgical technique of crown lengthening procedure, to increase the
extent of supragingival tooth structure and also to maintain a potent, superlative relationship between the restoration
and the periodontium. The patient was educated about the pros and cons of the procedure and a consent form was
signed.

After administering local anaesthesia, transgingival probing was done to check for the crest of the alveolar bone.
Usually it is considered that bone crest should be ideally 2 mm away from the gingival margin. Hence if the distance
between the two is not so or less, it is recommended to advance with osseous resection. The level at which the final
incision will be placed was marked and using a no. 15 Bard-Parker blade, the initial internal bevel incision was
placed 2 mm above the gingival margin to achieve the goal of obtaining ideal contour both labially and palatally.

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[Figure: 2] Post incision, the mucoperiosteal flap was raised reflecting the bony contours of the particular tooth.
[Figure: 3 & 4] After reflection and access, osseous resection was performed using a low speed hand piece and
carbide bur using copious amount of saline irrigation. [Figure: 5] On achieving the satisfactory distance, gauze
compressions were done to achieve haemostasis. The reflected flap was repositioned and sutured. [Figure: 6 & 7]
Patient was given appropriate postoperative instructions and was asked to rise with 0.2% chlorhexidine digluconate
mouthwash twice daily for two weeks. The patient was recalled after 7 days, [Figure: 8] followed by 30 days
[Figure: 9] and post placement of the crown for evaluation.

Discussion:-
The entire protocol of crown lengthening procedure is based on two important doctrines: biologic width and amount
of keratinized gingiva around the tooth. Studies have revealed that a minimum of 3 mm of space between restorative
margins and alveolar bone would be adequate for periodontal health, allowing for 2 mm of biologic width space and
1 mm for sulcus depth.[10] whenever possible, an adequate width of keratinized gingiva (≥2 mm) should be
maintained around a tooth for gingival health.[11]

As mentioned by Nevins and Sukrow in relation to cases where subgingival margins are advisable, the junctional
epithelium or the dentogingival apparatus should not be disheveled, thus recommending to maintain the subgingival
extension to 0.5-1.0 mm. If there is violation of biologic width on impingement of the gingival apparatus, there
maybe two major consequences. One of them is boss loss of unpredictable nature along with tissue recession. The
other outcome is development of gingival inflammation and persistence of the same.

In the above described case report, the treatment plan comprised of internal bevel incision as choice so that the
periodontal health and the postoperative esthetics of the patient is unhindered. The most appealing feature of this
surgical approach comprising internal bevel incision is that as it thins down the marginal gingiva, the knife edge
contour is maintained as well as superlative amount of keratinized gingiva is also withheld.

Conclusion:-
Crown lengthening is often considered a feasible option for aiding restorative treatment plans or enhancing esthetic
appeal of the patient. The dominant factors which makes the surgical technique of crown lengthening procedure
appealing is the benefit of good tissue healing, reduced inflammation of the surgical field and minimized post
operative unpleasantness.

Figure 1:- Pre Operative. Figure 2:- Incision Given.

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Figure 3:- Reflection Of Buccal Flap. Figure 4:- Reflection Of Palatal Flap.

Figure 5:- Ostectomy And Osteoplasty Done. Figure 6:- Suture Placed.

Figure 7:- Immediate Post Operative. Figure 8:- 7 Days Post Operative.

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Figure 9:- 21 Days Follow Up.

References:-
1. Cesar JJ, Mesquita De Carvalho PF, Da Silva CR (2011) Flapless aesthetic crown lengthening: A new
therapeutic approach. R Mex de Periodontologia.
2. Cohen DW. Lecture, Walter Reed Medical Center 1962 June 3
3. M. Davarpanah, C. E. Jansen, F. M. A. Vidjak, D. Etienne, M. Kebir, and H. Martinez, “Restorative and
periodontal considerations of short clinical crowns,” International Journal of Periodontics and Restorative
Dentistry, Vol. 18, No. 5, pp. 425–433, 1998.
4. N. Tomar, T. Bansal, M. Bhandari, and A. Sharma, “The Perio-esthetic-restorative approach for anterior
rehabilitation” Journal of Indian Society of Periodontology, vol. 17, no. 4, pp. 535–538, 2013.
5. K. Pradeep, N. Patil, T. Sood, U. Akula, and R. Gedela,“Full mouth rehabilitation of severe fluorozed teeth with
an interdisciplinary approach (6 handed dentistry),”Journal of Clinical and Diagnostic Research, vol. 7, no. 10,
pp. 2387–2389,2013.
6. Ingber FJS, Rose LF, Coslet JG, “The biologic width. A concept in periodontics and restorative dentistry.”
Alphan Omegan 1977; 10:62-5
7. Camargo PM, Melnick PR, Camargo LM. Clinical crown lengthening in esthetic zone. C D A Journal 2007;3 5,
Number 7:487- 498
8. Cohen ES. Crown lengthening. Atlas of Cosmetic & Reconstructive Periodontal Surgery. Third edition.
9. A. W. Gargiulo, F.M. Wentz, and B. Orban, “Dimensions and Relations of the dentogingival junction in
humans”, Journal of Periodontology, vol. 32, no. 3, pp. 261–267, 1961.
10. Nevins M, Sukrow HM. The intracrevicular restorative margin, the biologic width and the maintenance of the
gingival margin. Int. J Periodontics Restorative Dent 1984; 4:30‑49.
11. Lang NP, Löe H. The relationship between the width of keratinized Gingiva and gingival health. J Periodontol
1972; 43:623‑7.

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