CROWN LENGTHENING

PROCEDURES

- PERIO & PROSTHO

INTERDISCIPLINARY
APPROACH
 CONTENTS
 PRE – SURGICAL PLANNING Dr. DEBARGHYA PAL
(DEPT. OF
PERIODONTICS)
Dr. SHARANYA BOSE
 SURGICAL PLANNING

 PRE – PROSTHODONTIC PLANNING

 COMBINED PROSTHODONTIC Dr. SHRADDHA AGARWAL

AND PERIODONTIC PLANNING

(DEPT. OF PROSTHODONTICS)
- ESTHETIC CONSIDERATIONS
Dr. NANDANA BOSE

- RESTORATIVE CONSIDERATIONS
 INTRODUCTIO
N
Crown lengthening is defined as a surgical procedure designed to increase the extent of supragingival
tooth structure for restorative or esthetic crown purposes.

(GPT – 9th edition)

RESTORATIVE ESTHETIC

 Insufficient clinical crowns for retention

 Short clinical crowns
 Subgingival caries
 Excessive gingival display
 Subgingival fractures

Karateew ED, Newman T, Shakir F. Crown Lengthening and Prosthodontic Considerations. In Advances in Periodontal Surgery 2020 (pp. 193-205). Springer, Cham.
 PROTOCOL FOR TREATMENT
PLANNING

COMBINED
PRE -
PROSTHODONTIC AND PRE - SURGICAL
PROSTHODONTIC
PERIODONTIC PLANNING
PLANNING
PLANNING

Patel RM, Baker P. Functional crown lengthening surgery in the aesthetic zone; periodontic and prosthodontic considerations. Dental update. 2015 Jan
2;42(1):36-42.
 CROWN LENGTHENING:
BIOMECHANICAL CONSIDERATIONS

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 for the restoration’s future success.

•Biological Considerations

•Anatomical Considerations
 BIOLOGIC WIDTH
The biologic width is defined as the

physiologic dimension of the junctional

epithelium and connective tissue attachment.

This measurement has been found to be

relatively constant at approximately 2 mm

(±30%).

[Gargiulo 1961]

Ref- NEWMAN AND CARRANZA’S CLINICAL PERIODONTOLOGY THIRTEENTH EDITION

It has been theorized that infringement on the biologic width

by the placement of a margin of a restoration within its zone

may result in gingival inflammation, pocket formation, and

alveolar bone loss.

Consequently, it is recommended that there be at least 3 mm

between the gingival margin and bone crest which allows for

adequate biologic width when the restoration is placed 0.5 mm

within the gingival sulcus

Ref- NEWMAN AND CARRANZA’S CLINICAL PERIODONTOLOGY THIRTEENTH

 Greater than 3 mm of soft tissue between the bone and

gingival margin, with adequate attached gingiva, allows

crown lengthening by gingivectomy

With less than 3 mm of soft tissue between the bone and

gingival margin, or less-than-adequate attached gingiva, a

flap procedure and osseous recontouring are required for

crown lengthening

Ref- Newman And Carranza’s Clinical Periodontology Thirteenth Edition

 According to Nevins and Skurow (1984), when subgingival
margins are indicated, the restorative dentist must not disrupt the
junctional epithelium or connective tissue apparatus during
preparation and impression taking.

Because it is impossible to perfectly restore a tooth to the precise

coronal edge of the junctional epithelium, it is often recommended
to remove enough bone to have 3mm between the restorative
margin and the crest of alveolar bone

In the case of caries or fracture, at least 1 mm of sound tooth

structure should be provided above the gingival margin for proper
restoration.
Ref- Newman And Carranza’s Clinical Periodontology Thirteenth Edition
 BIOLOGIC WIDTH VIOLATION

Two different responses can be observed from the involved gingival

tissues.

 One possibility is that bone loss of an unpredictable nature and

gingival tissue recession occur as the body attempts to recreate
room between the alveolar bone and the margin to allow space for
tissue reattachment.

 The other possibility is that the bone level appears to remain

unchanged, but gingival inflammation develops and persists.

Ref- Newman And Carranza’s Clinical Periodontology Thirteenth Edition

 BONE SOUNDING

The level of the alveolar crest must be

determined prior to any considerations
regarding aesthetic crown lengthening so as
to determine the feasibility, surgical aspects,
and treatment sequence

During this periodontal evaluation, bone  The biologic width can be identified by probing under local
sounding assists in determining the level of anesthesia to the bone level and subtracting the sulcus depth from

the alveolar crest and thus the need for the resulting measurement.

osseous contouring
 If this distance is less than 2 mm at one or more locations, a
diagnosis of biologic width violation can be confirmed
 ANATOMICAL CONSIDERATIONS

1. Length and shape of root;

2. Furcation position;

3. Lip line (at rest and smiling);

4. Width of interdental bone;

5. Local soft/hard tissue anatomy and muscle insertion

6. Amount of attached gingival tissue.

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
[Dibart et al. 2003]
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.

Ref- Newman And Carranza’s Clinical Periodontology Thirteenth Edition

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 amount of attached gingiva needs to be measured as
the flap part of the assessment. It has been shown that, to maintain
periodontal health, there should be 2–3 mm of attached
gingiva

Ref- Plastic-esthetic periodontal and implant surgery : A microsurgical approach (2012)

Presurgical Analysis Smukler and Chibi (1997) recommended the following presurgical
clinical analysis prior to crown lengthening procedures:

1] Determine the finish line prior to surgery

2] If non determinable, it should be anticipated
3] Transcrevicular circumferential probing prior to surgery is performed for establishing the biologic
width (Bone Sounding)
a. Surgical site
b. Contralateral site
4] The biologic width requirements will determine the amount of alveolar bone removal
5] The combination of biologic width and prosthetic requirements determines the total amount of tooth
structure necessary for exposure
6] Tooth structure topography, anatomy, and curvature are analyzed for determining
a. Osseous scallop
b. Gingival form
GENERAL TISSUE ASSESSMENT BEFORE UNDERTAKING

Soft Tissue Assessment :

Situation1- If width of attached gingiva adequate-(>3mm)-

external bevel gingivectomy or internal bevel gingivectomy

Situation 2- If width of attached gingiva inadequate (<3mm)-

apically positioned flap

Ref- Plastic-esthetic Periodontal And Implant Surgery : A Microsurgical Approach(2012)

HARD TISSUE ASSESSMENT :
Situation 1- If bone crest is low i.e. more apically – no ostectomy

Situation 2- If bone crest is high i.e. more coronal- ostectomy performed

Ref- Plastic-esthetic Periodontal And Implant Surgery : A Microsurgical Approach (2012)

 THE NEED TO KNOW ABOUT
CROWN LENGTHENING PROCEDURES
With the increasing popularity of aesthetic-oriented
treatment, an understanding of the therapeutic synergies
brought about by an interdisciplinary approach has developed.

As a result, crown lengthening procedures have become an integral

component of the aesthetic armamentarium and are utilized with
increasing frequency to enhance the appearance of restorations
placed within the aesthetic zone.
 INDICATIONS OF CROWN LENGTHENING PROCEDURES
Restorative needs
To increase clinical crown height lost due to caries, fracture or wear
To access subgingival caries
To produce a “ferrule” for restoration
To access a perforation in the coronal third of the root
To relocate margins of restorations that are impinging on biological width.
Aesthetics
Short teeth
Uneven gingival contour
Gummy smile.

REF : Camargo PM, Melnick PR, Camargo LM. Clinical Crown Lengthening in Esthetic Zone. C D A Journal 2007;3 5,Number 7 : 487- 498
CONTRA-INDICATIONS & LIMITING FACTORS

Non restorability of caries or root fracture

Esthetic compromise
High furcation
Inadequate predictability
Tooth arch relationship inadequacy
Compromise adjacent periodontium or esthetics
Insufficient restorative space
No maintainability

REF : Cohen ES. Crown lengthening. Atlas of Cosmetic & reconstructive periodontal surgery. Third edition.
 SEQUENCE OF TREATMENT
(ALLEN, 1993)

1. Clinical and radiographic evaluation

2. Caries control

3. Removal of defective restorations

4. Placement of provisional restorations

a. Control inflammation
b. Better assessment of crown lengthening required
c. Improved surgical access, especially interproximally
d. Enhanced predictability of margin placement postsurgically

Ref : Cohen Es. Crown Lengthening. Atlas Of Cosmetic & Reconstructive Periodontal Surgery. Third Edition.
5. Endodontic therapy

a. Precedes surgery

b. If not possible, then completion is 4 to 6 weeks post surgery

6. Control of gingival inflammation

a. Plaque control

b. Scaling and root planing

7. Reevaluation for

a. Orthodontic treatment

b. Surgical therapy

8. Surgery
Ref : Cohen Es. Crown Lengthening. Atlas Of Cosmetic & Reconstructive Periodontal Surgery. Third Edition.
TREATMENT OPTIONS FOR CROWN LENGTHENING
PROCEDURES
SURGICAL COMBINED

A) GINGIVECTOMY
1. Conventional ( Scalpel or Kirkland knife) A) SURGICAL & NON SURGICAL -
2. Laser Orthodontic Treatment
3. Electrocautery  Low Orthodontic forces
 Rapid Orthodontic forces
B) INTERNAL BEVEL GINGIVECTOMY with
or without ostectomy (also referred as flap
surgery with or without osseous surgery)

C) APICAL POSITIONING of flap with or

REF :
without ostectomy 1. Wennstrom J L, PiniPrato GP.Mucogingival therapy-priodontal plastic surgery;
Clinical Periodontlogy & Implant dentistry. 4th edition
2. HH Takei. Preparation of the periodontium for restorative dentistry. Clinical
Periodontology. Tenth Edition.
Excessive
Gingival
Display…..
 Patients who have a high lip line expose a broad zone of
gingival tissue and may often express concern about their
“gummy smile”

 It is possible by a combination of periodontal and prosthetic

treatment measures to improve dentofacial esthetics in this
category of patient.

 If excessive gingival exposure is due to insufficient length of

the clinical crowns, a crown‐lengthening procedure is
indicated to reduce the amount of gingiva exposed, which in
turn will favorably alter the shape and form of the anterior
teeth.
 As a base for treatment decisions, a careful analysis of the dentofacial
structures and how they may affect esthetics should be performed which
include :

 Facial symmetry
 Interpupillary line; even or uneven
 Smile line : low, median or high
 Dental midline in relation to facial midline
 Gingival display during speech and during a broad, relaxed smile
 Harmony of gingival margins
 Location of gingival margins in relation to the CEJ
 Periodontal phenotype
 Tooth size and proportions/harmony
 Incisal plane/occlusal plane.
 1. GINGIVECTOMY / GINGIVOPLASTY :

Pretreatment views. The clinical

crowns are considerably shorter than
the anatomic crowns. The lateral
incisors were congenitally missing
and orthodontic treatment had been
carried out to move the posterior Gingivectomy was performed to
teeth anteriorly. The canine teeth in expose the anatomic crowns of the
the position of the lateral incisors teeth.
added to the esthetic disharmony.

Three months post surgery and

prosthetic rehabilitation.
2.CROWN LENGTHENING SURGERY USING INTERNAL
BEVEL GINGIVECTOMY: (With Or Without Ostectomy)

Pre-treatment view

An internally beveled path of incision

was use to effect an “internal
gingivectomy” to maintain the
pigmentation in the tissues.

5‐0 gut sutures were used to

stabilize the papillae.

Crown lengthening that was

achieved with maintenance of
color harmony can be seen in this
view at 3 months post surgery.
 3. CROWN LENGTHENING USING LASERS:

(A) Periodontal sounding after the initial gingivectomy,

which indicated the need for osseous contouring to (C) Final surgical photograph shows minimal
achieve biologic width. bleeding with no need for sutures. A frenectomy
(B) The osseous contouring was done via was also completed at the time of surgery.
intrasulcular access. Sounding confirms 3 mm from (D) Smile at 3 months
thegingival to osseous crest. Final small fragments of
bone are checked and removed with a small chisel.
Expose
Sound
Tooth
Structure….
 EXPOSE SOUND TOOTH
STRUCTURE

1. APICALLY 2. FORCED
POSITIONED TOOTH
FLAP ERUPTION
1. Apical positioning of the flap :
1. Goal : At least 4 mm of sound tooth structure must be exposed at the time of surgery.

2. Indication : Crown lengthening of multiple teeth in a quadrant or sextant of the dentition.

3. Contraindication : Surgical crown lengthening of single teeth in the esthetic zone.

4. Things to note :

 In order to retain the gingival margin at its new and more apical position, bone
recontouring must
Surgical be performed
resective not
therapy for onlylengthening
crown at the problem
cannot betooth but also
confined to theat the adjacent
teeth to gradually reduce
tooth in need the osseous
of treatment. profile.of osseous resection require that bone
The principles
be removed from the adjacent teeth to create a gradual rise and fall in the
 profile of
For esthetic the osseous
reasons, crest. This
symmetry causes length
of tooth a loss ofmust
attachment apparatus between
be maintained and the right
recession of the adjacent teeth as well.
and left sides of the dental arch.
 PRETREATMENT VIEW.
The patient had a wide zone of
attached gingiva and thick
crestal bone. Palpation
indicated bony exostoses.

An apically positioned flap and osseous

resective surgery, from second
premolar to second premolar, were
used to lengthen the teeth. The surgery
was confined to the labial surfaces.

Vertical mattress sutures

were utilized to hold the
flap apically.

Three years post‐treatment.

Note that the gingival tissues
retain the morphology created
at the time of surgery.
 A CASE OF SURGICAL CROWN LENGTHENING

NAME : TAHOSIMA KHATOON

SHORT CASE HISTORY :

Ms. Tahosima Khatoon , 18 years old female patient, referred from the
Dept. of Prosthodontics to the Department of Periodontics, GNIDSR PRE OPERATIVE INCISION PLACED
with a problem of unaesthetic look due to shift of zenith
 
ON EXAMINATION :
 Root canal treated 12
 Zenith points of 12 were below the level of 11,13.
 Attached gingiva present was sufficient.
 Present crown height was 3 mm
FLAP REFLECTION : BUCCAL FLAP REFLECTION : PALATAL
 
RADIOGRAPHIC EVALUATION: No periapical lesion, favourable crown-
root ratio .

TREATMENT EXECUTED : Scaling followed by crown lengthening in

which first gingivectomy was performed using no. 15 BP blade followed
by osseous recontouring in 12 region under local anesthesia.
OSTECTOMY DONE SUTURE PLACED
Interrupted figure of Eight sutures given.

POST SURGERY FOLLOW UP : Clinical photograph 1 week after

surgery and 21 days of surgery was taken.

COMMENTS : The patient was referred back to Department of

Prosthodontics for further management. Crown length was increased by
2 mm which required 2 mm bone removal during surgery.
7 DAYS FOLLOW UP 21 DAYS FOLLLOW UP
 A CASE OF SURGICAL CROWN LENGTHENING
(FLAPLESS TECHNIQUE )
NAME : MANISH SHAW

SHORT CASE HISTORY :

Mr. Manish Shaw, a 24 years old male patient, referred from
PRE OPERATIVE
the Dept. of Endodontics to the Department of Periodontics,
GNIDSR with a problem of fractured tooth requiring
restoration OSTECTOMY DONE

ON EXAMINATION:
 Root canal treated 11
 Attached gingiva present was sufficient.

RADIOGRAPHIC EVALUATION: No periapical lesion was detected

TREATMENT EXECUTED:
Scaling followed by crown lengthening was performed using
IMMEDIATE POST OPERATIVE
bur followed by osseous recontouring in 11 region under local (LABIAL AND PALATAL ASPECT)
anesthesia.

POST SURGERY FOLLOW UP:

Clinical photographs 1week after surgery and 21 days after
surgery were taken.

COMMENTS:
The patient was referred back to Department of Endodontics
for further management. Crown length was increased by 2
mm above the gingival margin.

7 DAYS FOLLOW UP 21 DAYS FOLLLOW UP 6 WEEKS FOLLOW UP

LINK : http://www.ijmscr.com/issue/current
 Article DOI :
 10.21474/IJAR01/10461
 PRE – PROSTHODONTIC
PLANNING
 Extent of tooth wear and its distribution – crown - root ratio
 General restorative and endodontic status of whole dentition
 Occlusion
 Existing ICP
 Two important principles to consider when reorganizing occlusion:
a) Decide the vertical dimension
b) Create stability in ICP and avoid damage in excursions
 Mounted study casts
 Diagnostic wax up and mock up
 Chair side try in

Patel RM, Baker P. Functional crown lengthening surgery in the aesthetic zone; periodontic and prosthodontic considerations. Dental update. 2015 Jan 2;42(1):36-42.
 COMBINED PROSTHODONTIC AND PERIODONTIC
PLANNING
PRINCIPLES OF PLANNING GINGIVAL ESTHETICS
 Determining the position of the gingival zeniths:
 Gingival zenith positions (GZP) of the maxillary central incisors are usually located ~1mm
distal to the vertical bisected midline (VBM) axis of the crowns.
 Zeniths of upper lateral incisor and upper canine teeth are located in the midline of the teeth

1. Mattos CM, Santana RB. A quantitative evaluation 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.
  Relative gingival margins:
 gingival margin of upper lateral incisor teeth are approximately 1 mm
coronal to those of the upper central incisor and canine teeth

1. Mattos CM, Santana RB. A quantitative evaluation 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.
 Height of papillae:
 Papillae length should be ~ 40% of the length of the crowns of the teeth

 Papillae formation may be successful where the contact area between teeth is
approximately 5mm from the alveolar crest.

1. 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
2. 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.
 Once a study cast has been modified 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.

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.
 ESTHETIC
CROWN
LENGTHENING
  DIAGNOSTIC INFORMATION:
 Periodontal charting
 Radiographic assessment
 Diagnostic wax – up
 Mock up (Digital mock-up for DSD)
 Indicated in cases of short clinical crowns and excessive gingival display
 Excessive gingival display may be unaesthetic to patients
 May influence self esteem and confidence
 Reasons for excessive gingival display:
- Altered active or passive eruption
- Vertical maxillary excess
- Hypermobile lip
- Pseudopocket due to inflammation.

Patel RM, Baker P. Functional crown lengthening surgery in the aesthetic zone; periodontic and prosthodontic considerations. Dental update. 2015 Jan 2;42(1):36-42.
  Altered active eruption refers to the emergence of a tooth into the oral cavity and is regulated by the
periodontal ligament, occlusal contact and soft tissue like the tongue.

 Vertical maxillary excess – diagnosed with cephalometric imaging and be corrected by LeFort I
osteotomy with vertical impaction.

 Altered passive eruption (APE) – Gottlieb and Orban – soft tissue interference remaining incisal to
the cementoenamel junction – thickness – impedes normal eruption – SHORT CLINICAL CROWNS
and GUMMY smile due to excessive gingival display

 Coslet et al –

Type I - excessive tissue overlies crown; normal CEJ and alveolar crest relationship

Type II – proximity of CEJ to alveolar crest due to failure of active tooth eruption.

Karateew ED, Newman T, Shakir F. Crown Lengthening and Prosthodontic Considerations. In Advances in Periodontal Surgery 2020 (pp. 193-205). Springer, Cham.
 CLASSIFICATION OF ESTHETIC CROWN
LENGTHENING
CLASSIFICATIO CHARACTERISTICS ADVANTAGES DISADVANTAGES
N
Sufficient gingival tissue coronal to No osseous recontouring
the alveolar crest needed

Surgical alteration of gingival No violation of biologic width

margins without need for osseous
Type I recontouring and violation of biologic May be performed by the None reported
width restorative dentist

Provisional restorations may

be placed immediately

Lee EA. Aesthetic crown lengthening: classification, biologic rationale, and treatment planning considerations. Pract Proced Aesthet Dent. 2004 Nov;16(10):769-78.
 Fig. 2
Fig. 1

Fig. 3 Fig. 4
Lee EA. Aesthetic crown lengthening: classification, biologic rationale, and treatment planning considerations. Pract Proced Aesthet Dent. 2004 Nov;16(10):769-78.
 CLASSIFICATIO CHARACTERISTICS ADVANTAGES DISADVANTAGES
N
Will tolerate a temporary violation of
the biologic width.
Sufficient soft tissue allows
gingival excision without Allows staging of the gingivectomy Requires osseous
Type II exposure of the alveolar crest and osseous contouring procedures. recontouring
but in violation of the biologic
width. Provisional restorations of the
desired length may be placed
immediately.

Lee EA. Aesthetic crown lengthening: classification, biologic rationale, and treatment planning considerations. Pract Proced Aesthet Dent. 2004 Nov;16(10):769-78.
 Fig. 1 Fig. 2 Fig. 3

Fig. 4 Fig. 5 Fig. 6

Lee EA. Aesthetic crown lengthening: classification, biologic rationale, and treatment planning considerations. Pract Proced Aesthet Dent. 2004 Nov;16(10):769-78.
 Fig. 7 Fig. 8 Fig. 9

Fig. 10

Lee EA. Aesthetic crown lengthening: classification, biologic rationale, and treatment planning considerations. Pract Proced Aesthet Dent. 2004 Nov;16(10):769-78.
 CLASSIFICATIO CHARACTERISTICS ADVANTAGES DISADVANTAGES
N

Staging of the procedures and Requires osseous

Gingival excision to the alternative treatment sequence contouring.
Type III desired clinical crown may minimize display of exposed
length will expose the subgingival structures. May require a
alveolar crest. surgical referral.
Provisional restorations of
desired length may be placed at Limited flexibility
second-stage gingivectomy

Lee EA. Aesthetic crown lengthening: classification, biologic rationale, and treatment planning considerations. Pract Proced Aesthet Dent. 2004 Nov;16(10):769-78.
 Fig. 1 Fig. 2 Fig. 3

Fig. 4 Fig. 5 Fig. 6

Lee EA. Aesthetic crown lengthening: classification, biologic rationale, and treatment planning considerations. Pract Proced Aesthet Dent. 2004 Nov;16(10):769-78.
 CLASSIFICATIO CHARACTERISTICS ADVANTAGES DISADVANTAGES
N
Limited surgical options.

Gingival excision will No flexibility

Type IV result in inadequate band
of attached A staged approach is not
gingiva advantageous

May require a surgical referral.

Lee EA. Aesthetic crown lengthening: classification, biologic rationale, and treatment planning considerations. Pract Proced Aesthet Dent. 2004 Nov;16(10):769-78.
 TREATMENT PLANNING
CONSIDERATIONS
 Conventional healing - 4 to 6 weeks

 Esthetic zone – tissue maturation – 3 months

- if bony resection done – additional 6 months

 Recession of 2 – 4mm post-operatively between 6 weeks to 6 months (Bragger, 1992)

Thus final restoration is to be avoided until tissue has completely healed, especially in the esthetic zone.

 Violation of biological width

 Gingival contour rehabilitation for a good esthetic outcome.

 Gingival zenith position, vertical bisected midline axis, gingival margin level and height of the
papillae.

Karateew ED, Newman T, Shakir F. Crown Lengthening and Prosthodontic Considerations. In Advances in Periodontal Surgery 2020 (pp. 193-205). Springer, Cham.
  Aesthetic tooth size
 Tooth width:
- central – 9.10 to 9.24 mm
- Canines – 7.90 to 8.06 mm
- Lateral 7.0 mm to 7.38 mm
- Premolars 7.84 mm.
 Tooth length:
- unworn central incisors – 11.69 mm
- unworn canines – 10.83 mm
- worn incisor – 10.67 mm
- worn canine 9.90 mm
- worn and unworn lateral incisor – 9.34 to 9.55 mm
- premolars 9.33 mm.
 Width/length ratio should also be considered for esthetic purposes with 78% for unworn central incisors, up to
87% for worn teeth.

Dre Nancy Mouradian et al. Aesthetic Crown Lengthening. Oral Health Group; 2019: 1-12

Magne P, Gallucci GO, Belser UC. Anatomic crown width/length ratios of unworn and worn maxillary teeth in white subjects. The Journal of prosthetic dentistry. May 2003;89(5):453- 461.
CHU’S AESTHETIC GAUGES
SOUNDING GAUGE

P
R
O
Crown Lengthening Gauge accesses
P clinical crown length (CCL) required
based on the results of the Tbar
O Proportion Gauge tip in Figure 1. Short
Assessment of the sulcus depth using the
R Sounding Gauge. The first laser marking
Fabricated to pierce the supracrestal
gingival fibers. The curved tip is 1 mm
arm of tip projects clinical crown
height and long arm projects where the
T The Proportion Gauge tip is designed
denotes 1 mm for the average sulcus
depth, which can vary between 0.5 mm to
wide and designed to follow the tooth
and CEJ anatomic contours
bone crest should be relative to CCL
after surgery
I for simultaneous width and length
measurements of the maxillary anterior
3 mm in health
The third laser marking denotes 5
O dentition. The average central incisor Evaluation of the mid facial osseous crest. mm for the average interdental DGC
measures 8.5 mm in width by 11 mm in The second laser marking denotes 3 mm dimension, understanding that this
N length for the average mid facial DGC can vary between 3 mm and 5 mm in
dimension health

G
A
U
G
E CROWN
LENGTHENING
GAUGE
Stephen J. Chu, Mark N. Hochman. A Biometric Approach to Aesthetic Crown Lengthening: Part I-Midfacial Considerations. Pract Proced Aesthet Dent 2007;19(10):A-X
CROWN LENGTHENING
FOR RESTORATIVE
PURPOSE
 INDICATIONS
RESTORATIVE PURPOSE
 Insufficient Clinical Crowns Height

 Subgingival Caries

 Subgingival Fractures

 Ferrule For Restoration

 To Access A Perforation In The Coronal Third Of The Root

 To Relocate Margins Of Restorations That Are Impinging On Biological

Width
Ref : Rosenberg ES, Garber DA, Evian CI (1980) Tooth lengthening procedures. Compend Contin Educ Dent 1:161
 TREATMENT RULES
Rule 1: If the sulcus probing depth is 1.5 mm or less than that, the
restorative margin is placed 0.5 mm below the
gingival margin.

Rule 2: If sulcus probing depth is more than 1.5 mm, the margin of
restoration is placed one half the depth of the sulcus below the
gingival margin.

Rule 3 : If the sulcus depth is more than 2 mm the gingival tissue is

evaluated for going gingivectomy and for crown lengthening.
Once gingival sulcus depth around 1.5 mm is achieved the restoration
margin is placed following rule 1.

Ref: Carranza F.Carranza’s Clinical Periodontology,10th Edition,st.Louis: Saunders 2006

Normal crest:
 A normal crest measurement is 3mm at mid facial region and 3 mm
to 4.5 mm at proximal region.

 The margin of the restoration should be placed no closer than 2.5 mm

from alveolar bone or 0.5 mm subgingivally.

Ref: F.Carranza’s clinical periodontology,10th edition,St.Louis:saunders 2006

High crest :
 The mid facial & proximal measurement is less than 3 mm.

 In such cases it is not possible to place an intra crevicular

restoration margin because the margin will be too close to the
alveolar bone, resulting in biological width violation and chronic
inflammation.

Ref: Carranza f.Carranza’s clinical periodontology,10th edition,St.Louis:saunders 2006

Low crest:
 In this cases mid facial measurement is greater than and 3 mm and
the proximal measurement is greater than 4.5 mm.

 The low crest is found in approximately 13% of all cases .

In some patients quite stable attachment apparatus may form
which maintains long term stability and health.

Ref: Carranza f.Carranza’s clinical periodontology,10 th edition,St.Louis:saunders 2006

 In aesthetic zone if gingival sulcus depth is more than 2 mm then gingivectomy is
recommended and margins of restoration are prepared 0.5 mm subgingivally

 If the crest of alveolar bone is less than 3 mm away from the anticipated restorative
margin, then bone resection is necessary.

Ref: Carranza f.Carranza’s clinical periodontology,10th edition,St.Louis: Saunders 2006

 INTERPROXIMAL PAPILLA & EMBRASURE DESIGN
 Black triangles may develop if the post-resection distance between the contact area
and the interdental osseous crest is greater than 5 mm.

 According to Tarnow et al (1992), interdental papilla fills the interdental space when
the distance between the alveolar crest and the contact point is less than 5mm.

Ref :Carranza f.Carranza’s clinical periodontology,10th edition,St.Louis:saunders 2006

  When the vertical distance from the contact point to the crest
of the bone is 5 mm or less, the papilla is present almost 100%
of the time.
When the distance is 6 mm or more, the papilla is usually
missing(Approximately 56% of cases)
 In 27% of cases papilla present where distance was 7 mm or more.

Ref: Apoorva et al. Inter dental papilla management: A review International Journal of Current Research Vol 10, Issue, 01, pp.64650-
64653, January, 2018
 PROVISIONAL AND DEFINITIVE PROSTHETIC
MANAGEMENT

Marzadori M et al, Crown lengthening and restorative procedures in the esthetic zone, Periodontology 2000, Vol. 0, 2018,
1–9
 CROWN LENGTHENING FOR RESTORATIVE
PURPOSE

Illustration of the procedure of crown lengthening involving the reflection of the gingiva and trimming of the
bone

A Review of the Crown Lengthening Surgery; The Basic Concepts ,Mohammad Reza Talebi Ardakani. British Journal of Medicine & Medical Research
13(3): 1-7, 2016
 DEEP MARGIN ELEVATION (DME)
 In cases where subgingival margins are present, Deep Margin Elevation (DME) can be a useful
technique to help restore teeth to the proper form and function.

 This procedure involves placing a material to raise the restorative margin to an equigingival or
supragingival location [Dietschi and Speafico in 1998]

 This technique has been referred to by many different names, including “open sandwich
technique,” “proximal box elevation” and “margin elevation technique.”

 The concept gained traction in 2012 when Pascal Magne discussed the concept as a paradigm
shift for direct and indirect restorations.

Ref :Deep margin elevation paradigm shift,pascal magne,American journal of esthetic dentistry,2012
 This technique can elevate the deep cervical margin with composite
resins, usually leaving 1–1.5 mm supragingival , which will facilitate
taking impressions, correct rubber dam isolation

 3 criteria to make a DME:

1) Ability to completely isolate the operative field
2) Ability to place a matrix that is capable of properly
isolating margins and ensuring a perfect seal
3) No invasion of the connective tissue space by the
matrix. Otherwise, crown lengthening would be
indicated, which will be true whenever the alveolar
crest is close
 The matrix band should be adapted in order to accommodate the subgingival aspect of
the preparation. 

 Subgingival composite restoration with a perfectly adapted marginal seal is generally well
tolerated by the surrounding tissues (if not reaching to invade the connective tissue)

 Martins et al. (2012) showed the binding capacity of the fibers of epithelial tissue to the surface of
resin restorations, provided good adaptation.
 (A) (B) (C)

(D) (E) (F)

Ref :Deep margin elevation paradigm shift,pascal magne,American journal of esthetic dentistry,2012
 FERRULE EFFECT
 It defines as a metal band or ring used to fit the root or crown of a tooth. [The Journal of
Prosthetic Dentistry’s 2005 ]

 Sorensen and Engelman redefined the ferrule effect as “a 360-degree metal collar of the crown
surrounding the parallel walls of the dentine extending coronal to the shoulder of the
preparation.”
  More precisely, parallel walls of dentin extending coronally from
the crown margin provide a ‘‘ferrule,’’ which after being encircled
by a crown provides a protective effect by reducing stresses
within a tooth, resulting increase resistance form of the crown .

 Ferrule heights 2mm and 1mm thickness required to significantly

improve fracture resistance when exposed to static loading.

Ref : Juloski, J. Radovic, I., Goracci, C. Vulicevic, Z. R., & Ferrari, M. (2012). Ferrule Effect: A Literature Review. Journal of Endodontics,
38(1), 11–19. 
 Patient comes in for aesthetic or restorative
rehabilitation

Diagnosis for crown lengthening by the

restorative dentist

Referral to periodontist

Pre-surgical, Surgical, Combined Prostho –

Perio and Post surgical planning done

Crown lengthening surgery is perfomed by the

periodontist followed by healing phase

After adequate healing of hard and soft tissues,

prosthodontist perfoms the aesthetic or
restorative planning (pre-prosthodontic
planning)

Aesthetics and restorative considerations are

taken care of, by previously mentioned corrective
measures, by a prosthodontist
SUMMARY…
 CONCLUSION
• Crown-lengthening surgery can be an option for facilitating restorative therapy or improving
esthetic appearance.

• Surgical enhancement of the clinical crown is generally necessary to provide a sufficient crown
height which permits acceptable tooth preparation and fabrication.

• Proper treatment planning will ensure an optimal result for both the patient and the clinician.

• An accurate diagnostic and interdisciplinary approach is necessary for obtaining improved

result.
 REFERENCES
 Karateew ED, Newman T, Shakir F. Crown Lengthening and Prosthodontic Considerations. In Advances in Periodontal Surgery 2020 (pp. 193-205).
Springer, Cham
 Patel RM, Baker P. Functional crown lengthening surgery in the aesthetic zone; periodontic and prosthodontic considerations. Dental update. 2015
Jan 2;42(1):36-42.
 Mattos CM, Santana RB. A quantitative evaluation of the spatial displacement of the gingival zenith in the maxillary anterior dentition. J Periodontol
2008; 79 (10): 1880−1885.
 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.
 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.
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interproximal dental papilla. J Periodontol 1992; 63(12): 995−996.
 Lee EA. Aesthetic crown lengthening: classification, biologic rationale, and treatment planning considerations. Pract Proced Aesthet Dent. 2004
Nov;16(10):769-78.
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prosthetic dentistry. May 2003;89(5):453- 461.
 Dre Nancy Mouradian et al. Aesthetic Crown Lengthening. Oral Health Group; 2019: 1-12
 Juloski, J., Radovic, I., Goracci, C., Vulicevic, Z. R., & Ferrari, M. (2012). Ferrule Effect: A Literature Review. Journal of
Endodontics, 38(1), 11–19. 

 Contemporary crown-lengthening therapy A review, Timothy J. Hempton et al, American Dental Association, 2010;141(6):647-655

 Mini-Implant-Supported Orthodontic Extrusion and Restorative Treatment of Fractured Teeth, k Nivedita et al, Journal of clinical orthodontics:June
2016

 Karateew, E. D., Newman, T., & Shakir, F. (2019). Crown Lengthening and Prosthodontic Considerations. Advances in Periodontal Surgery, 193–
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 Rosenberg ES, Garber DA, Evian CI (1980) Tooth lengthening procedures. Compend Contin Educ Dent 1:161

 Jorgic-Srdjak K, Dragoo MR, Bosnjak A, Plancak D, Filipovic I, Lazic D (2000) Periodontal and prosthetic aspect of biological width part II:
reconstruction of anatomy and function. Acta Stomatol Croat 34:441–444

 Surgical lengthening of the clinical tooth crown Liudvikas Planciunas et al, Stomatologija, Baltic Dental and Maxillofacial Journal, 8:88-95, 2006

 Crown Lengthening Procedures- A Review Article ,Gunjan Gupta et al, Journal of Dental and Medical Sciences.Volume 14, Issue 4 Ver. I (Apr.
2015), PP 27-37

 Carranza f.Carranza’s clinical periodontology,10 th edition,St.Louis:saunders 2006

 A Review of the Crown Lengthening Surgery; The Basic Concepts ,Mohammad Reza Talebi Ardakani. British Journal of Medicine & Medical
Research 13(3): 1-7, 2016
ANY
QUESTIONS