Crown lengthening is a surgical procedure performed by a dentist to expose a

greater amount of tooth structure for the purpose of subsequently restoring the
tooth prosthetically.[1] This is done by incising the gingival tissue around a
tooth and, after temporarily displacing the soft tissue, predictably removing a
given height of alveolar bone from the circumference of the tooth or teeth being
operated on. While some general dentists perform this procedure, others frequently
refer such cases to periodontists.
Biomechanical considerations
Biologic width
Biologic width is the natural distance between the base of the gingival sulcus (G)
and the height of the alveolar bone (I). The gingival sulcus (G) is a little
crevice that lies between the enamel of the tooth crown and the sulcular
epithelium. At the base of this crevice lies the junctional epithelium, which
adheres via hemidesmosomes to the surface of the tooth, and from the base of the
crevice to the height of the alveolar bone (C) is approximately 2 mm.

Biologic width is the distance established by "the junctional epithelium and

connective tissue attachment to the root surface" of a tooth.[1] In other words, it
is the height between the deepest point of the gingival sulcus and the alveolar
bone crest. This distance is important to consider when fabricating dental
restorations, because they must respect the natural architecture of the gingival
attachment if harmful consequences are to be avoided. The biologic width is patient
specific and may vary anywhere from 0.75-4.3 mm.[2]

Based on the 1961 paper by Gargiulo, the mean biologic width was determined to be
2.04 mm, of which 1.07 mm is occupied by the connective tissue attachment and
another approximate 0.97 mm is occupied by the junctional epithelium.[1][3] 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.[4][5][6] When
restorations do not take these considerations into account and violate biologic
width, three things tend to occur:[2]

chronic pain
chronic inflammation of the gingiva
unpredictable loss of alveolar bone

Ferrule effect

In addition to crown lengthening to establish a proper biologic width, a 2 mm

height of tooth structure should be available to allow for a ferrule effect.[7] A
ferrule, in respect to teeth, is a band that encircles the external dimension of
residual tooth structure, not unlike the metal bands that exist around a barrel.
Sufficient vertical height of tooth structure that will be grasped by the future
crown is necessary to allow for a ferrule effect of the future prosthetic crown; it
has been shown to significantly reduce the incidence of fracture in the
endodontically treated tooth.[8] Because beveled tooth structure is not parallel to
the vertical axis of the tooth, it does not properly contribute to ferrule height;
thus, a desire to bevel the crown margin by 1 mm would require an additional 1 mm
of bone removal in the crown lengthening procedure.[9] Frequently, however,
restorations are performed without such a bevel.
These two X-ray films depict the teeth of the upper right quadrant. In the upper
film, there is a tooth, #5, with a large, defective DO composite restoration. The
lower film depicts the ideal bone level after a crown lengthening procedure has
been completed, as well as the margin of the prosthetic crown in relation to the
reduced height of bone. Note: this is a dramatization of the procedure. The lower
film is a digital manipulation of the upper film, and not an actual film of the
teeth after a crown lengthening procedure and crown cementation have been
performed.
Some recent studies suggest that, while ferrule is certainly desirable, it should
not be provided at the expense of the remaining tooth/root structure.[10] On the
other hand, it has also been shown that the "difference between an effective, long-
term restoration and a failure can be as small as 1 mm of additional tooth
structure that, when encased by a ferrule, provides great protection. When such a
long-lasting, functional restoration cannot be predictably created, tooth
extraction should be considered."[11]
Crown-to-root ratio

The alveolar bone surrounding one tooth will naturally surround an adjacent tooth,
and removing bone for a crown lengthening procedure will effectively damage the
bony support of adjacent teeth to some inevitable extent, as well as unfavorably
increase the crown-to-root ratio. Additionally, once bone is removed, it is almost
impossible to regain it to previous levels, and in case a patient would like to
have an implant placed in the future, there might not be enough bone in the region
once a crown lengthening procedure has been completed. Thus, it would be prudent
for patients to thoroughly discuss all of their treatment planning options with
their dentist before undergoing an irreversible procedure such as crown
lengthening.
Treatment planning

Crown lengthening is often done in conjunction with a few other expensive and time-
consuming procedures of which the combined goal is to improve the prosthetic
forecast of a tooth. If a tooth, because of its relative lack of solid tooth
structure, also requires a post and core, and thus, endodontic treatment, the total
combined time, effort and cost of the various procedures, as well as the impaired
prognosis due to the combined inherent failure rates of each procedure, might
combine to make it reasonable to have the tooth extracted. If the patient and the
extraction site make for eligible candidates, it might be possible to have an
implant placed and restored with more esthetic, timely, inexpensive and reliable
results. It is important to consider the many options available during the
treatment planning stages of dental care.

An alternative to surgical crown lengthening is orthodontic forced eruption, it is

non-invasive, does not remove or damage the bone and can be cost effective. The
tooth is extruded a couple of millimeters with simple bracketing of adjacent teeth
and using light forces this will only take a couple of months. A fiberotomy is
performed after crown lengthening and is easily performed by the general dentist.
In many cases such as this one shown, surgery and extraction may be avoided if
patient is treated orthodontically rather than periodontally.