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SCIENTIFIC ARTICLES

Stomatologija, Baltic Dental and Maxillofacial Journal, 8:88-95, 2006

Surgical lengthening of the clinical tooth crown
Liudvikas Planciunas, Alina Puriene, Grazina Mackeviciene

SUMMARY

To understand why the crown lengthening may be desirable, a review of periodontal anatomy is in
order. The odontologists know, but often underestimate importance of periodontal tissues health to
restoration of defected teeth or dental arches. In order to avoid pathological changes, to predict treat-
ment results more precisely, it is necessary to keep gingival biological width unaltered during teeth
restoration. If there are less than 2 mm from restoration's margin to marginal bone clinical crown length-
ening possibility should be considered in dental treatment plan. The choice depends on relationship of
crown-root-alveolar bone and esthetical expectations. In order to keep margins of restoration
supragingivally the distance from marginal bone to margins of restoration should not be less than 3 mm.
Ideally the margins of restoration should be supragingivally or in the same level as marginal gingiva.
When the margins of restoration are prepared subgingivally, the distance from marginal gingiva to
margins of restoration should not be more than 0.7 mm. To continue dental treatment in operated area is
recommended not earlier than in 4 weeks, and making restorations in esthetical area - not earlier than in
6 weeks.

Key words: crown lengthening, gingival biological width, periosurgery.

INTRODUCTION

The odontologists know, but often underestimate im- Gingival biological width (biologic membrane,
portance of periodontal tissues health to restoration of de- dentogingival attachment) is the area of gingiva attached
fected teeth or dental arches. It is necessary to prepare pe- to the surface of the tooth coronary from the alveolar bone.
riodontal tissues properly before restorative treatment to This determination is based on the study of Garguilo A.
ensure good form, function and esthetic of masticatory ap- W., Wentz F. and Orban B. in 1961 on dentogingival junc-
paratus and patient comfort. In time bad quality restora- tion of cadavers [1]. It was established the width neces-
tions alters periodontal tissues. Precision of restorations is sary for gingiva to attach to the tooth. They studied 287
important as well as relationship with periodontium. Some- teeth of 30 cadavers and established the relationship be-
times even precise restoration can induce inflammation of tween marginal alveolar bone, connective tissue attach-
periodontal tissue. It is important to know what is gingival ment (CTA), epithelial attachment (EA) and gingival sul-
biological width, what does happen when it is altered, what cus (GS). Results showed the mean connective tissue at-
is lengthening of the clinical crown, when it should be done. tachment is 1.07 mm, epithelial attachment – 0.97 mm, den-
There is a lot of literature on separate questions, but it is tal sulcus – 0.69 mm. Gingival biological width (GBW) was
incoherent, non-accentuated. We tried to summarize and calculated by adding widths of connective tissue attach-
systematically present data from literature. ment and epithelial attachment: GBW = CTA + EA = 2.04
Clinical crown of the tooth is the distance from gin- mm (Fig. 1). It was calculated mean values, though values
gival margin to incisal edge or occlusal surface of the tooth. in the study varied, especially width of epithelial attach-
This distance should be increased when: ment (1 mm to 9 mm), however connective tissue attach-
– margins of caries lesion are subgingivally; ment width value was almost constant [1].
– margins of tooth crown fractures are subgingivally; The studies of Vacek J. S. and co-authors (1994) con-
– tooth crow is too short for retention of restoration; firmed previous results of Garguilo A. W., Wentz F. and
– there is excess of gingiva and anatomical tooth Orban B. (1961). After examination of 171 teeth of cadavers
crown is opened partially. values were established: connective tissue attachment –
In these cases, except the last, it is necessary to evalu- 0.77 mm, epithelial attachment – 1.14 mm, depth of gingival
ate the gingival biologic width (GBW), to clear out if it is sulcus – 1.34 mm. It was stated, the mean value of gingival
no altered, will it remain healthy after tooth restoration. biological width is 2 mm and value of connective tissue
attachment almost constant [2].
*
Institute of Odontology Medical Faculty Vilnius University
ALTERATIONS OF GINGIVAL BIOLOGICAL
Liudvikas Planciunas * – D.D.S. WIDTH
Alina Puriene* – D.D.S., PhD, assoc. prof.
Grazina Mackeviciene* – D.D.S., assist. prof
Direct or indirect restorations of tooth crown defects
Address correspondence to Liudvikas Planciunas Institute of Odon- with margins located in the gingival biological width area
tology, Faculty of Medicine, Vilnius University, Zalgirio 115, 08217
Vilnius, Lithuania. induce gingival inflammation, loss of connective tissue

88 Stomatologija, Baltic Dental and Maxillofacial Journal, 2006, Vol. 8., No. 3.

Early Leasion 4 . Vol. etc. PMNs. It was prepared 43 Class V cavities in 43 dog teeth be manifested as: with margins near alveolar bone. According data of literature we created scheme of gingival biological width cause loss of periodontal liga. All cavities were – periodontal pocket formation. Baltic Dental and Maxillofacial Journal. tal tissues response to restorations with margins altering Gunay H. Initial Lesion 2 . alveolar bone to keep periodontium healthy [7. Periodontal tissues response to the alterations of 2 mm needed gingiva to attach to bone. It could be larger biological width ( Tal H. flow Vasculitis II. restored and 82 healthy teeth of 41 patients. Carranza F. showing how periodontium reacts to alteration of gingival biological width (Fig. stasis texture.16 mm 1. with margins in cementoenamel junction.21 Same as Stage Same as Stage II but Plasma cells Continued loss Changes in Lesion II plus blood more advanced col or. and co-authors (1986) observed tance less than 1mm from restoration margins to alveolar bone resorbtion to 5 mm in the dog teeth when restoration bone [6]. 2002) Stage Time Blood Vessels Junctional and Predominant Collagen Clinical (Days) Sulcular Epithelium Immune Cells Findings I. Gingival biologi- Test group 3. 89 . Tal H. filled with amalgam. G. and co-authors (1989) proved that alterations 12. 14]. biological width alteration 2002) attachment and unpredictable bone loss. 9. H.15 mm restoration margin to alveolar bone. After 2 years ment and proved: deeper subgingivally restoration mar. 13. It was evaluated 116 with margins in various distance from epithelial attach. 11. size. After one year gingival retraction and – gingival retraction. H. Gingival biological width (Newman M.. 2006. 2).5 mm 0. It is established minimal width of Table 1. Established 14 . M. and co-authors (2000) showed how mar- gingival biological width confirmed these statements. It is Serve bone resorbtion could be found in the areas of thin necessary minimal distance of 3 mm from restoration to cortical and interdental bone [4]. Stages of gingivitis (Newman M. 8. Carranza's Clinical Periodontology 9-th edition. Clinically it could ment.17 mm cal width would be altered if there be less than 2 mm from Control group 0. (1974) examined 66 front teeth crowns cause pathology of periodontium. 1. 1989) but just because of epithelial attachment. 8. SCIENTIFIC ARTICLES Fig. gins of restorations in area of gingival biological width Newcomb G. connective tis- Gingival retraction Bone loss sue attachment is constant (CTA = 1 mm). than in control group (Table 1) [5]. Polymorphonuclear neutrophils Stomatologija. 3. Carranza's Clinical Periodontology 9-th edition. margins were near alveolar bone. A. creased index of gingival bleeding in the areas with dis- Parma-Benfenati S. and gingival biological width showed similar results. and in control group – – gingival bleeding. Fig. 10. and no bone resorbtion Other studies comparing relationship of restorations when restoration margins were 4 mm from alveolar bone. Takei H. severer inflammation they course [3]. No.7 Vascular Same as Stage I Rete Lymphocytes Increased loss Erythema proliferation peg formation around infiltrate Bleeding on Atrophic areas probing III. Periodontal tissues response and possible reaction to the Carranza F. In that case gingival Table 2. et al. 2. A.L. results showed formation of periodontal pockets and in- gins are. Takei H. Planciunas et al.4 Vascular Infiltrated by PMNs PMNs Perivascular loss Gingival fluid dilatation. bone loss was pronounced more in experimental group Histological and clinical investigations of periodon. G.

Carranza F. No. A. allowing for vertical bone loss (C) (Newman M. G. H. 5. P. 3.SCIENTIFIC ARTICLES L. A. Baltic Dental and Maxillofacial Journal. Vol. marginal bone (Newman M. . Planciunas et al. A. 8. Fig. Takei H. KarringTh. Takei H. Excessive gingival display resulting in an unproportional appearance of the clinical crown: (a-b) pretreatment view. 2002) 9-th edition. Carranza F. Clinical Periodontology and Implant Dentistry. Upper molars with thin facial bone. G. Carranza F. Upper molar with a thick facial bone. Bone loss can become vertical only when it reaches thicker bone in apical areas. Ramifications of a biologic width violation if a restorative Fig. 4-th edition. 2006. 6. Takei H. 2002) A B C D Fig. (Newman M. c) post-treatment view showing the color changes of anterior gingiva. H. Lang N. A lower incisor with thin labial bone (A). 3. Types of marginal bone: a) thin marginal bone.. 2002) Fig. G. 2003) 90 Stomatologija. Carranza's Clinical Periodontology 9-th edition. Carranza's Clinical Periodontology Carranza's Clinical Periodontology 9-th edition. 4. d) post-treatment view showing the same color of anterior gingiva (Lindhe J. b) thick margin is placed within the zone of the attachment. where only horizontal bone loss can occur (B). H.

or will be altered furcation worse possibility of self cleaning. thin marginal bone. The excessive display of gingiva is caused by vertical maxillary Fig. however. If there are less than 2 mm from restoration’s margin to The consequences of this change could be various. G. area. 5). Vol. if cleaning is bad the inflammation persists. ated. the level could be reached. 2003) Periodontology 9-th edition. – furcation defects. bone logical width and gingival sulcus formatting would be cre- resorbs and periodontal pocket forms. The clinical tooth crown could be 1. In order to avoid pathological changes. KarringTh. 2003) th edition. Carranza F. 91 . Lang N. The principles of osseous resection require that bone be removed from the adjacent teeth to create a gradual rise and fall in the profile of the osseous crest (a). 8. or will be reached unfavorable relationship of crown- matting and probable development of: root. 2002) inflammation (gingivitis) starts. tic eruption and surgery. bone defects in which periodontal attachment structures will be too week and unfavorable bone contour form more often. Baltic Dental and Maxillofacial Journal. thick marginal SURGICAL LENGTHENING OF CLINICAL TOOTH bone. should be removed so that enough space for gingival bio- ever. periodontal pocket for. It causes to withstand tooth function. Clinical Periodontology and Implant Takei H. How. KarringTh. 4-th edition. 7. width 5-6 mm and more. The choice de- are two biotypes of periodontium and intermediate vari. induces loss of periodontal ligament ment results more precisely. No. 4) [17]: thetical expectations. 2002) Fig. P. Clinical (Newman M. H. Interproximal craters (a-c).5-5 mm. 3. A. It is necessary to consider situations. earlier or later. P. etc. pends on relationship of crown-root-alveolar bone and es- ants (Fig. different techniques for the management of such defects ( M. indirect restoration when higher clinical tooth crown is ginal bone resorbs horizontally quicker and if cleaning of necessary [19]. Depending on clinical situation bone the area is good gingival retraction happens often.. Lang N. SCIENTIFIC ARTICLES Fig. till it is enough width for gingival val biological width unaltered during teeth restoration [18]. A. There be considered in dental treatment plan. H. 4-th edition. Human body tries to repair this dimension of 2 mm by – tooth mobility because of loss of tooth attachment resorbing bone as much as needed to create the space for apparatus gingival attachment between restoration and alveolar bone. 9.L. This causes a loss of attachment Fig. Stomatologija. width – 3. Bone contour: a) normal bone contour. Gingival inflammation depending on status of immune sys. 2. Takei H. Thin periodontium – thickness of attached gingiva lengthened surgically or combining methods of orthodon- less than 1 mm. The shaded areas illustrate apparatus and recession on adjacent teeth as well (b) (Lindhe J. when after re- In case of thick periodontium gingival retraction is moving bone around the tooth. Carranza's Clinical Periodontology and Implant Dentistry. to predict treat- tem.3 mm. – tooth loss. Thick periodontium – thickness of attached gin- giva to 1. 10. Carranza's Clinical Periodontology 9- Dentistry. When periodontium is thin mar. 2006. marginal bone clinical crown lengthening possibility should It depends on biotype of individual periodontium. it can be seen all typical – root caries. 8. it is necessary to keep gingi- and bone of this area. Planciunas et al. 3) [16]. Surgical treatment is faster and more favorable for ment and bone (Fig. Then treatment plan should be reconsidered. b) osseous crater excess and a long midface (Lindhe J. rarer and bone loss is more slowly. Carranza F. CROWN In both cases periodontal pocket could form and gin- gival retraction could happen after loss of periodontal liga. G. inflammation characteristics (Table 2) [15]. attachment (Fig.

bone. 3. G. 9). Histological examination showed re- flap with osteoplastic is recommended. tance is longer and tooth crown visually seems shorter. These methods could be used 3 mm distance from marginal bone to restoration margin to in case of “gummy smile”. Oakley E. The best way is to make temporary crowns or tray- alveolar bone and gingiva. In these cases there are ex. Carranza F. 21. [30]. Carranza F. 25. It is necessary to inform the that connective tissue attachment forms on account of patient (it is worth to have visual material) and incision to resorbtion of marginal bone. This width should be created during periosurgery. formed before prosthetic to increase retention of restora- tomy is carried out applying internal oblique incision (Fig. No. The main method performing surgical clinical tooth 2. 2002) th edition. 26. The mucoperiosteal odontal ligament altering flap is lifted according extend of operation and visual area. sions depends on gingival biotype. M.6 – 0. 7). A. Three monkeys received surgical front teeth – in case of thick periodontium apically positioned crowns lengthening. and co-authors established spontane- [20. mary preparation is reference point for surgeon who is Some patients show wide area of gingiva during smil. 12. If patient requires keeping pigmentation gingivec.. attachment forms coronally from marginal bone and proved giva change after healing. Bone reduction: osteoplastic and osteoectomy (Newman Fig. because of excess of keep it supragingivally: CTA + EA + GS (1 + 1 + 1). tions in case of short clinical crowns. In some individuals this dis. A. contour (Fig. be 5 mm. Apically positioned flap. 2002) The methods of surgical clinical tooth crown restora. formatting of epi- Performing gingivectomy it is necessary to pay atten. ment plan includes operations of maxillary bone recon- tions are: struction [37]. The surgical quide during the surgery (Newman M. crowns gingival biological width is not altered. Surgical lengthening of clinical tooth crown is per- tion. anatomical tooth crown is opened partially but prosthetic work. Gingivectomy. 27]. Vol. . Takei H. and co-authors (1999) per- – in case of thin periodontium with sufficient width of formed study on monkeys to clear out why during healing attached gingiva gingivectomy is recommended. It is chosen according biotype of periodon. clinical tooth crown lengthening. 22]. when. The treat. Doing so surgeon could 92 Stomatologija. covering of gingival biological width. During gingiva. Per. extend to premolars to hide areas of different pigmenta. Marginal gingiva should cover inlays or fillings 1. In 1970 that case surgical method is used to lengthen tooth crown Wilderman M. ventions. 11. 2006. Apically positioned flap with bone reduction: osteoectomy and osteoplastic [18]. according recommendations. guide with the margins of final restoration before surgical cess of maxillary bone vertical high (Fig. after surgical procedures on marginal bone it resorbs and – in case of thin periodontium with short width of how gingival-tooth attachment forms after surgical inter- attached gingiva apically positioned flap is recommended. ous bone resorbtion of 0. 8. 1. 10 and 11) [23. nective tissue attachment during marginal bone resorbtion forming gingivectomy in conventional way (external ob. The margins of pri- 6) [37. N. Carranza's Clinical Periodontology 9- Periodontology 9-th edition. thelial attachment to marginal bone and formatting of con- tion to pigmentation especially in black individuals. 8). This study denies the opinion that connective tissue lique incision) pigment is removed and the color of gin. 38]. Planciunas et al. G.SCIENTIFIC ARTICLES L. Fig. The technique of inci- a) Osteoplastc – bone reduction without peri. H. 24.5-2 mm and all distance in individuals with healthy periodontium is 1 mm coronally from margin of tooth/root defect to marginal bone should from cementoenamel junction. dures do not increase the distance between margins of Most of scientists agree that it is necessary minimum defect and marginal bone. In This (mathematic) calculating is not correct.8 mm in one year after surgi- tium [37]: cal procedure [29]. Carranza's Clinical Takei H. b) Osteoectomy – bone and periodontal ligament In order to form continuous gingival and bone contour reduction adjacent teeth are included (Fig. and apically positioned flap with osteoplastic for clinical osteoplastic should be done to get most acceptable bone tooth crown lengthening are limited because these proce. H. asked to increase the distance of 1-2-3 mm to marginal ing but have proportional relationship of tooth crown. crown lengthening is apically position flap with 3. Baltic Dental and Maxillofacial Journal. If there are or it forms Indications of gingivectomy. apically positioned flap during osteoectomy unfavorable bone contour (Fig.

93 . KarringTh. The distance between marginal bone and show the "positive" angular crest on the "control" distal side (blue margins of root/tooth defect do not change. 33]. restoration margin and preparation step not influencing giva contour. Lang N. The other impor. totally re. i. 3. Between 6 weeks and 6 months side of orthodontically erupting tooth without touching of in 85 % of cases there were no or minimal +1 mm changes distal side (Fig. In any case it is tal treatment prognosis and extraction is planed [59. 63. The step should be prepared subgingivally in es- – clinical tooth crown higher than adjacent teeth. 2006. especially in front teeth area: of restoration supragingivally [16]. 52. The periodontal struc- tures should be lifted so that after osteoectomy (leveling define more exactly the relationship between margins of of marginal bone of particular and adjacent teeth) enough final restoration and marginal bone during surgical proce. SCIENTIFIC ARTICLES • Unfavorable crown-root relationship. No. Vol. Clinical Periodontology and Implant Dentistry. lengthening could be such [36]: It would be ideally for periodontium to keep margins • Unsatisfactory esthetic. is performed surgical clinical tooth crown lengthening. 47. N. ) Accelerated orthodontic eruption (rapid tooth eruption) ment and alveolar bone are extruded during slow eruption in conjunction with fiberotomy procedure (a. 58]: 1. uncomfortable for patient. This method could be difficult or im- tant reason to delay dental treatment in the operated area possible if there are no adjacent teeth or loss of a lot of is still week. 41. Launchenauer D. 13). 2. level in the area of roots/teeth when it is unfavorable den- val contour of teeth in esthetical area. 53. The harder force is used and fibrotomy. of marginal gingiva it is necessary to evaluate: smile line • To increase height of alveolar bone and gingival (is marginal gingiva seen during smiling or not) and gingi. They stay at the pri- The study of Bräger U. If changes of marginal bone still hap- of marginal gingiva level. espe- cially in esthetical area. and Lang mary level. 51. It is easier to tion tooth is pulled from alveola while marginal bone and explain patients using visual means. it could be corrected surgically. 61. easy injured gingiva. odontic appliances. tively long and expensive. thetical area (sometimes it could be avoided by making Stomatologija. Baltic Dental and Maxillofacial Journal. epithelial basal membrane – membrana basalis (lat. The orthodontic eruption is performed with fixed orth- mended to wait longer in esthetical areas. periodontal structures do not move. 12) [31.L. performing clinical tooth crown lengthening but it is rela- covers just after 4 weeks [34. All periodontal structures: gingival. pen in coronal direction. The orthodontic tooth eruption should be performed to avoid negative sequences of surgical treatment. 56. The orthodontic treatment has a lot of advantages ing epithelium with connective tissue under it. 44. space would be created for self-formation of gingival bio- dure (Fig. 32. the level of marginal gingiva established during marginal bone to follow after root of tooth coronally. 42. 57.60. 4-th edition. After six weeks every 7-10 days to maintain inflammation of this area (near after operation attachment level and probing depth did not marginal bone). e. P... 46. 43. the teeth. • Loss of periodontal ligament and marginal bone of adjacent teeth. Accelerated. 35].) bond. the loss of periodontal structures of adjacent teeth could formed in the area of front teeth. and because of possible retraction it is recom. 45. 54. 55. Slow. It is established. 38. According the study final This method could not be applied when vertical bone restoration should be made not earlier than 6 weeks after resorbtion is observed near particular tooth. b). was proved in the test applying fibrotomy in the medial ginal gingiva after healing. In 12 % of cases gingival retrac. width. logical width and gingival sulcus. 49. There are two methods of treat- ment [37. In order to create continues bone contour it is necessary to resect marginal bone and periodontal ligament. necessary to clear up esthetical expectations of the pa. periodontal liga- Fig. and The complications after surgical clinical tooth crown surgical treatment is still necessary. Resection of marginal bone leads to longer distance to occlusal curve. it is necessary to solve be avoided and the same bone and gingival level kept. The surgical marks) and the unchanged crest on the mesial "test" side (red procedure as well as orthodontic would be necessary if marks) (Lindhe J. tient. operation. 48. Planciunas et al. The radiographs of root/tooth. 64] . tion occurs more than 1 mm [33]. 40. gingival biological width alters periodontium less than – possible loss of gingival papilla – opening of ideally made and fitted crown altering gingival biologic interdental spaces. 39. The esthetical problem: the crown of particular tooth would be same treatment method is applied in order: different from adjacent teeth and the contour of marginal • To reduce depth of periodontal pockets in case of gingiva would change. Slow orthodontic eruption requires slight force to ap- ply. 62. 8. to prove him (her) the orthodontic eruption is neces. Applying this method If surgical clinical tooth crown lengthening is per. (1992) showed how periodontal tissues change after cutting of connective tissue attachment fibers. This operation almost precisely corresponds to the level of mar. P. Inflammatory trauma does not allowed change. 2003) gingival biological width altered. 13. Applying accelerated orthodontic rapid tooth erup- sary as well as surgery for optimal result. 50. In order to get continuing contour vertical bone loss. Inaccuracy between – gingival retraction – change of marginal gin.

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When the m argins of restorat ion ar e prepared Attempts to prepare margins of restoration as deep as pos. full ceramic crowns or ceramic-bonded-to-metal crowns clean it decrease and probability of periodontal pocket for- with cervical material).

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