Esthetics and Anterior Tooth Position: An Orthodontic Perspective. Part I: Crown Length Figure 1. A, Proper bilaterally metrical diplay ofthe max central incisor f shorter the left. None the alteration in roving neve gingival VINCENT KOKICH, DDS Oates gage maior dental esthetis, other than aligning malposed anterior teeth. Factors such as anterior erown length, crown width, midline pro- portions, tooth angulations, and vertical tooth positions may be criti- cal to anterior dental esthetics and treatable with orthodontic therapy. This article discusses che evaluation and treatment of diserepancies in anterior crown length. EVALUATING CROWN LENGTH DISCREPANCIES Ideally maxillary central incisors are equal in length and the lateral incisors are slightly shorter! The gingival margin of the lateral incisor is located more incisally than the central incisor (Fig. 1). ‘The maxillary canines are about the same length as the central incisors, and their cusp tips are located at the same level as the incisal edges of the centrals. The gingival margins ‘of the canines are at the same height as the central incisors. “Professor and Director, Graduate Gntoonic Reseorcy Unversity of Washington col of Demis SeteEsthetics and Anterior Tooth Position An Orthodontic Perspective. Part I: ( Figure 38. Initial ortho dione alignment ith Derststenterown length {increpame Figure 3G. Gingioal surgery t0 establish equal crown lengths, Figure 3D. Aligned gin ‘itl heights folowing Srgery. The most common crown length discrepancy occurs when one max- illary central incisor is shorter than the other, but the incisal edges are even (Fig. 1B). The difference in crown heights is due to uneven gin sival margins, Depending on the height of che patient’ lip line, the difference may be noticeable during siniling (Fig. 1C). The following options exist for cor- recting crown length differences: 1. Gingival surgery to correct the soft tissue form; 2. Intrusion and restoration of the shorter tooth; or 3. Slow extrusion and equilibration of the longer tooth. In order to choose the proper treat- ‘ment the clinician must evaluate these factors (Fig. 2): a ~~ crown = Figure 2. Factors that influence treat ment corrections of anterior crown Tength discrepancies: 1. Suleular depth of the central incisors; 2. Inferior border of the upper lip height during smiling; 3. Relative crown lengths; and 4. Amount of incisal wear of the central incisors.Figures 44 and 4B, Unequal maxillary crown eights and wneven gingival margins. Figures 4C and 4D. Intrusion of maxit- lag let central incisor The following descriptions will help the clinician choose the proper Ifthe incisal edges are even, probe the labial sulci Ifthe CEJs are treatment for each situation. level, the shorter tooth has extra ingival tissue, which will be con- CORRECTING GINGIVAL FORM fiemed on probing, Perform a gin- When there are differences in czown lengths prior to orthodontic sivectomy in this case, if there is an adequate band of attached gingiva (Fig. 3C)27 When the zone of actached gingiva is narrow or a ment (Fig. 3A), simple ali ment will not solve problems due to improper gingival forms (Fig. 3B). difference exists in the labial bone heights, a flap procedure with ‘ous recontouring is preferred. ied Figure 5A. Overerupted, short masil lab central ceon ob intel placed gingival margin Figure SB. Intrusion of central incisors. Figures 4E and 48. Bracket remors and inal restoration of the eft coma incisor showing equal gingival margins sand crown heights Gingival surgery is performed prior to removal of orthodontic appli= ances to allow fine tuning of crown lengchs. The final case should have a proper gingival display, in addi- tion to orthodontic alignment of the incisal edges (Fig. 3D). preter Figure $C. Final result illustrating proper gingival margins and crown heaghsEsthetics and Anterior Tooth Position: An Orthodontic Perspective. Part 1 Crown Length There are nwo alternatives for treatment. One choice is to slowly extrude the longer tooth and equi- librate it to equal the size of che shorter tooth. As the longer tooth is extruded, the gingival margin will come down with it. This option is Figure A, Pretreatment view of iareioe Seee en e viable as long as the centrals remain with a porcelainsfuced-tovnaetal crate longer than the lateral incisors after treatment, INTRUDING SHORT OR ABRADED When the probing depths of the central incisors are the same, the incisal edges are relatively even, res Band 6C: To flit ima and the crown lengths are different the edge of the right contral incisor (Figs. 44 and 48), an evaluation of the incisal edge of the shorter tooth may indicate the solution. If the edge is wider or thicker than the other central incisor, the tooth has been previously reduced in size and hhas supererupted, thereby the discrepancy in crown heights Figure 6D. Osscous surgery to align gga margins, creating A second solution is to intrude the shorter central ineisor until the gingival margins are aligned (Figs. 4C and 4D), and then restore the incisal eige of she intruded central to its pre-abraded length (Figs. 4E and 4) If both central incisors are shorter than the lateral incisors (Fig. SA), treatment consists of simultaneous. intrusion to apically reposition the gingival margins and create space for the incisal restorations (Fig. 5B and 5 ‘margins aligned, and new right central incisor restoration lances crown heightsCOMBINED INTRUSION/GINGIVAL SURGERY ‘When a crown length discrepancy exists between two central incisors, and the shorter tooth has been restored with a full crown (Fig. 6A), the response to intrusion varies with the placement of the crown margin, because the gingival margin docs not always move apically Ifthe crowned tooth is intruded, and inflammation occurs because of a violation of the biologic width (Figs. 6B and 6C), surgery is neces- sary to complete the repositioning of the gingival margin (Fig. 6D). For each millimeter that the tooth is incruded, the gingival margin moves apically the same distance. ‘The amount of intrusion néeded is ‘estimated by measuring the pre- treatment differences in the gingival heights. Surgery is recommended when the tooth is intruded a dis tance greater than the original gin aval discrepancy, and the gingival margins are not yet aligned. Tooth inteusion is monitored by measur- ing the change in distance between the incisal edges: It is best to perform periodontal surgery prior to the removal of the orthodontic appliances. If there is incomplete alignment of the ging val margins, the central incisors can still be adjusted accordingly. Any final restoration should be inserted no sooner than 6 months following orthodontic treatment (Fig. 6E). SUMMARY ‘The relationship berween maxillary incisor crown lengths and anterior dental esthetics is discussed. Dis- crepancies in crown heights are common in adule orthodontic patients, and unesthetic in the pres- ence of a high lip line. Differences in incisor crown lengths are corrected with gingival surgery, intrusion and restoration of the shorter incisor, or extrusion and equilibration of the longer incisor. Selecting the most appropriate treatment choice depends on (1) the suleular depth of the central incisors, (2) the level of the upper line during smiling, (3) the amount of incisal wear of the central incisors, and (4) the relative erown lengths ofthe lateral and central incisors. This article emphasizes the need for orthodontic consultation in evaluating discrepancies in maxil- lary anterior crown height, so that predictable esthetic results can be achieved. Jounnat or estieric oenrisray REFERENCES 1. Lombardi R. The principles ofl Perception aia ther cle appication 0 ‘Eomane ethers) Ponte Bom 197 aie 2. Fridman Ny Levine H. 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Tae rerrangoment daring ret tion of othedantcalty rotated th ‘gle Ort 1988 39:08, Reprint requests: Vincent Kosch, DDS, Director Graduate Orolo Research, Unversity of Washington School of Denny, Saate. WA9NOS 1595 Decker Perma In