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Esthetic Parameters
Clinically, the patient’s tissue biotype is classified according to how thick or
thins the supporting bone and gingival soft tissues are defined.
Becker and Oschenbein (1997)
Three distinct types; pronounced scalloped, scalloped and flat.
• A thin periodontium will be pronounced scalloped or scalloped.
• A thick periodontium will present with flat gingival architecture, and
usually be supported by thick buccal and lingual plates of alveolar bone.
Response to inflammation, restorative and surgical injury:
Thin-scalloped periodontium → some degree of soft-tissue recession.
Thick flat periodontium →resists recession and reacts with pocket formation.
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• Inadequate amount of gingival.
• Gingival recessions.
• Deficient pontic areas.
• Frena impinging on the gingival margin.
• Excessive gingival display.
• Deficient interproximal papillae.
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• There are several variations in dimension of the biologic width between
individuals as well as within the same person, depending on the location
of the tooth in the dental arch.
Crown Lengthening
Aim:
To increase the extent of the supragingival tooth structure for restorative or
esthetic purposes by apically positioning the gingival margin, removing bone, or
both.
Rrationale:
• Obtaining physiological or biologic width for the periodontal-restorative
interrelationship.
• A minimum of two millimeters of tooth surface should be available above
the alveolar bone crest for tissue attachment.
Therefore the biologic width is two millimeters (1 mm for connective tissue
above crestal bone and 1 mm for epithelial attachment) + sulcus depth (1mm)
and resistance form (1-2 mm).
Restorations that invade the zone of biologic width will cause inflammation,
bone loss and periodontal pocketing.
Indications:
a) Caries. b) Tooth fracture. c) External resorption.
d) Short clinical crowns e) Loss of tooth structure through attrition and
abrasion.
Contra-indications:
1- When postsurgical healing will result in significant exposure of inaccessible
molar or premolar furcations.
2 - If Reduction of the supporting bone will result in a poor crown- root ratio.
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3- When postsurgical esthetics will be compromised (orthodontic forced
eruption may be an alternative).
4 - If there is no attached or keratinized gingiva and the patient will not accept
mucogingival surgery prior to crown lengthening.
5 - In cases with thin periodontium and dehiscence or fenestration of alveolar
bone (severe postsurgical gingival recession is likely).
6 - If the prognosis of the tooth to be lengthened is poor and adjacent teeth have
a fair to good prognosis to act as abutments for a fixed or removable partial
denture.
Presurgical Planning:
• Evaluation of periapical radiographs and periodontal charting including:
probing depths, width of keratinized gingiva, thickness of the
periodontium including soft tissues and bone, to estimate how much bone
will need to be removed prior to surgery.
• When the keratinized gingiva is 2 mm or less, intrasulular incisions are
indicated.
• In cases with wide zone of keratinized gingiva, facial incisions are made
with a scallop design, i.e., 0.5-1 mm buccal or lingual to the sulcus.
• If the width of keratinized gingiva is a millimeter or less and the
thickness of the tissue is at least 1 mm, a partial thickness flap should be
considered. (Fig.2)
• Positioning a partial thickness flap apical to the alveolar crest at a
distance equal to the width of remaining keratinized tissue will result in:
o Doubling of the width of the keratinized tissue.
utilized.
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Fig.2 Split thickness flap
• Probing of the sulcus depth and sounding the underlying bone will assist
the clinician in flap design.
• Wherever bone is to be a reduced, full thickness flap are indicated.
• If periodontal pockets are present, incisions should be planned that will
allow for apical positioning of the flap.
• A free gingival soft tissue, pedicle or connective tissue graft is indicated
when only alveolar mucosa covers the facial surface of a tooth that
requires crown lengthening. Gingival grafting establishing at least 2 mm
of keratinized gingiva should precede lengthening of the clinical crown.
Surgical procedure :
1- Initial incisions:
• Local anesthesia, using Lidocaine 2% with epinephrine 1:100,000.
• A minimal of three teeth are exposed, at least one tooth on each side of
the tooth to be surgically lengthened.
• Using a #15 scalpel blade an inverse bevel incision approximately 1 mm
from the free gingival margin with a scalloped design is made (Scalloped
incisions should not be used when the width of keratinized tissue is less
than 2mm}.
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• Thin keratinized gingiva requires an intra sulcular incision.
• A vertical releasing incision is cut at a 45o angle at the mesiobuccal line
angle of the tooth.
• On the palatal aspect, the same parabolic inverse bevel incision design is
performed.
• Vertical releasing incisions cut at a 45o angle enhance flap coadaptation.
Vertical releasing incisions should be made at the line angles of the teeth
so that papillary tissue is available to affix the suture (Fig. 3)
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3-Removing connective and granulation tissue:
• Using the #7 K-N knife into the sulcus and parallel to the tooth surface,
the connective tissue collar is excised and elevated from the tooth
surface. Interproximal tissue is removed with the #Buck knife.
Connective and granulation tissue tags are removed from the tooth and
intrabony craters using a #4 curette.
• Once the craters and tooth are free of tissue, the root is examined and
planed free of calculus and roughness.
• Most crown lengthening procedures do not require root planing since
periodontal pockets normally are not associated with this procedure.
• It is important to root plane only those surfaces of the tooth that have
been exposed to the oral environment.
• Connective tissue and periodontal ligament fibers should be spared injury
so that wound healing will result in connective tissue reattachment rather
than repair with a long junctional epithelium.
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• When ostectomy/osteoplasty is completed, the bone should have
physiologic osseous architecture i.e., interproximal bone more coronal to
the facial and lingual radicular bone.
• The alveolar crest will parallel the cementoenamel junction. (Fig 4)
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5- Flap suturing-closure:
• When the bony architecture is of equal height on the buccal and lingual
surface, simple interrupted sutures are appropriate.
• In esthetic areas and where the tissues are thin, small monofilament
suture, e.g. 4-0 or 5-0 Gut or GoreTex® suture, provide for ideal closure
with minimal scarring or tissue necrosis.
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