The international Journai of Periodontics & Restorative Dentistry

4Ó5

Periodontal ond Dentol

Considerotions in Ciinicoi
Crown Extension:
A Rotionoi Bosis for Treotment

Hyman Smukier. BDS. DMD, HDD* The successful treatment of

Mohammed Chaibi. DDS. MSD" teeth destined for full-coverage
restorations is governed by five
basio principles. These are the
preservation of tooth structure,
creation of retention and resis-
tance form, structurai durabiiity
of the restorotion, achievement
When the clinical crowns of teeth aro dimensionally inadequate, esthefi- of morginai integrity, and
caily and bioiogicaity occeptabie restorotion of these dentai units is difñ- preservation of the periodon-
cult. Often an acceptable restoration connot be accompiished without tium.'' When teeth have been
first surgicaily increasing the length of the existing ciinicai crowns; therefore, extensively destroyed by caries,
successful management requires an understonding of both the dentai and
fracture of the ciinical crowns,
periodontal porameters of treatment This report provides further inslghf
or pathoiogic wear, or require
into fhis interdependenoe by examining the effects of tooth form on the
revised tooth preparation, it
periodontal morphology and surgicai treatment whiie relating them to
requirements for esfheticaily and biologlcaily acceptabie fuil-coverage
may not be possibie to ade-
dentai restorations. This report also expiains the role that resforafion morgin quately prepare and restore
taootion ond emergence profile play in the maintenance of periodontqi the teeth by means ot full cov-
ond dental symbiosis. The effects of violation of the supracrestol gingivae erage restorations without vio-
by improper full-coverage restorations is also iliustrated. (Int J Periodont lation ot these principles. In
Rest Dent 1997;17:4Ó5-'177.) such instanoes it is advanta-
geous to have greater ciinical
orown height avaiiable to per-
'Professor, Department of Peri odontology and Orai Biology, Boston mit successful restorotion of the
University, H. M Goldman School of Graduate Denfistry, Boston, dental units.^-"
Massoohusetts.
"Formerly Assistont Protessar. Boston University, H. M. Goidrnan School
Winen ottempts ore made
of Graduóte Dentistry, Boston, iviassa chu setts; Presentiy, Privóte to obtain sufficient retention
Practice, Tunis. Tunisia. ond resistance form by extend-
ing preparations subgingivoily,
Reprint requests: Dr Hyman Smukier, Deportment of Periodontoiagy
and Orol Biology, Boston Universify, H. M. Goldman School of the periodontium wiil most
Graduate Dentistry, lOOEost Newton, Boston, Massachusetts 02118. otten be deieteriously atfected.

Volume 17,Number5,1997
46Ó

ñ g í f o and Ib Transcrevicuiar probing fa determine the dimension at the SGI (iett) Transcrevicuiar prabing
to bone using a tempiate to estabiish reference points, (right) Reflection of gingiva indicates that the probe
has reached the crestai bane—the accuracy ot the transarevicuiar reading is canflrmeü.

as demonstrated by Parma-
Benfenati et al,^ In their study
on beagle dogs, placement of
subgingival restorations resuited
in disruption of fhe periodon-
tium with inflammation ond
bone ioss, it wouid therefore
seem to be more prudent to
incredse the dimension of the
clinical crown rather than risi< a
violotion of the periodontium
by injudioious subgingivai tooth
preparation.^"
The rationoie for and mefh-
ods of olinioal crown extension
or lengthening using osseous
resective surgery have been
described by ingber et al* and
Rosenberg et al,'' This article wiii
provide further information for
the development of a rationoi
basis for treatment. It wiii also
deai with important surgical
and restorative therapeutic
principles that are mandatory
for successful restoration of
teeth vi/ith dimensionaliy or
structuraiiy inadequate clinicai
crowns.
Surgical and restorative
principles for successful
treatmenf
Supracrestai gingivai tissue
(SGJ)
in 19Ó2, Cohen^ defined the
"bioiogic width" of supracrestai
gingivai tissue as those junc-
tionai epithelial and connective
tissue elements of the dentogin-
givoi continuum that occupy
the space between the base of
the gingivai crevice and the
alveolar crest. Based on the
work of Gdrgiulo et al,'' the
dimension of the bioiogic width
was estimated as being in the
vicinity of 2,04 mm. This was
made up of a junctionai epithe-
lial dimension of 0,97 mm plus
1,07 mm of connective tissue
ottachment in a corondl-apicai
direction. The sulcuiar depth
was estimated by Gargiuio et
ai'' to be in the vicinity of 0.Ó9
mm, thus, the total dimension of
supracrestai gingival tissue (SGT)
would be in the vicinity of 2,73
mm,
Bosed on these dimensions,
Ingber et al* stated that during
ciinicai crown extension sur-
gery sutficient bone should be
resected to permit 3 mm of
sound tooth structure above
the crest of bone: Rosenberg
et ar preferred 4 mm of tooth
exposure. This bone resection is
necessary to accommodate
the SGT, which wiii deveiop in
the surgical site, and yet leave
sufficient tooth exposed to

The internatiandl Journai of Periodontics & Restorative Dentistry


complete the tooth prepara-
tion, in the absence of perio-
dontai disease, transcreviculor
probing (Figs l a and lb), via
the crevice to the crest of aive-
oiar bone, may be used to
determine dimension ot the
SGT at any speoifio site prior to
surgery. This may be accom-
plished about the tooth to be
iengthened or in equivalent
areas in other parts ot the
some mouth. The meosure-
ments may be used os the de
facto gauge for the supra-
crestal space required tor the
deveiopment of the new SGT.
Preliminary data from an ongo-
ing ciinicai study (unpublished
dota, 1995) seem to confirm
the viabiiity ot this approach, in
general, the dimension of the
SGT wiii be in the order of 3
mm, but bioiogic variation does
exist, and preoperatively it is
most heiptui to have a more
definitive idea ot this dimen-
sion. Once the finish iine of the
tooth preparation has been
determined and the desired
position ot the final gingivai
margin has been estimated, ali
that remains is to accompiish
sufficient osseous resection to
permit accommodation ot the
newiy deveioping SGT and to
expose sufficient tooth length
to complete the preparation.
if provisionalizotion or caries
controi is undertaken prior to
the surgery, as it shouid be, then
a fairiy acourate finai position
of the gingivoi margin can be
predicted and attained, it not,
the surgeon shouid be capa-
ble of estimating the position ot
the finish iine, or better stili, car-
rying out restorative proce-
dures to define it prior to or dur-
ing the surgery. This implies that
the surgeon shouid have an
understanding of the principies
of tooth preparation to be obie
to carry out those tooth prepa-
ration procedures necessary to
establish the basis for sucoessfui
compietion of the ciinicai
crown lengthening procedure.
When considering ciinicai
crown extension, the clinician
shouid bear in mind that a pre-
destined dimension of SGT wiii
reform over fhe subjocent oive-
olar crest of bone foilowing
surgery This wiii occur irrespec-
tive of whether soft tissue exci-
sionai therapy or osseous
surgery with apicai repositioning
of the tissue is the treatment
modality used to accomplish
the iengthening. Sott tissue exci-
sion aione can oniy be success-
fui when there is either an
excess of sott tissue present
(hyperpiasia), or when probing
depths are excessive (supra-
bony pockets ot periodontitis).
In most other instances, where
attachment levels ore essen-
tiaiiy within normai iimits, soft tis-
sue excision aione wiii resuit in
reformation of the predestined
4Ó7
amount of SGT and no real gain
in ciinicai crown iength. Con-
sequentiy, tooth lengthening is
usuaiiy carried out by means
osseous resective surgery
Osseous gingivai continuum
in 1977, ingber et ai* introduced
a surgical technique to ensure
correct repositioning ot the
periodontai tissues prior to fuii-
coverage restoration of teeth.
in essence, they conciuded
that enough supporting Pone
must be removed to permit an
appropriate Pioiogic width ot
tissue to deveiop postsurgicaiiy
between the margin of the
preparation ond the underiying
alveolar crest ot bone, in 1980
Rosenberg et a i ' emphasized
the recreation ot the originol
scaiioped orchitecture around
the teeth when osseous resec-
tive procedures are pertormed.
The nature ot the scolloped
osseous architecture and its
relationship to the overlying gin-
giva and adjacent teeth, the
osseous gingivai continuum, has
iargeiy been based on onec-
dotai observation and edu-
cated specuiation. However,
Daza De Bastos,'° in a compar-
otive study in animals, studied
the topography of the gingivae
and underiying bone as they
reiate to one another and to
the surface anatomy ot the
teeth. The foiiowing important
observations were mode (Figs
2a ond 2b):
Voiume 17,Number5,1997
4Ó8

Fig 2a (left) Gingivai margin level has

been soored on a baboon maxillary
canine tooth and stained with India
ink. The soft tissue has been stripped
away, and fhe osseous crest level is
scored and stained in the same man-
ner The gingival margins and osseous
crests are seen to be parallel. Nofe the
sharp peaking ot osseous tissue in the
concavity of the taofh surface. The saft-
er, more blunted peak of fhe gingiva,
indicated by the scored and stained
iine. is related to the less acute con- Fig 2b On fhe distal surface of a
cavity in which it is situated. The perio- baboon maxillary malar, the maiar dis-
aontai tissues tall away apicaliy over tal to the tooth Peing viewed has been
the convex surfaces of the feeth. and reduced to the gingivoi ievei. Note the
the morphology is seen to vary with the reiafionship of the gingivai coi (depres-
acuity ot the adjooenf tooth surfaces. sion between fhe paiatai and buccal
g = gingival peak: b = osseous peak: gingivai papillae) fa the interproximal
c = concavity: arrow = inferproximal contact area. The osseous ievel exhibits
contact area. a shallaw valley topography because it
IS reiated to a siightiy canvex tooth sur-
face. The osseaus and gingival margins
are nat parailei.

1. In a healfhy periodontium, vaiieys of the osseous gingi- it oppeors therefore, fhat

the gingivol margin was con-
sistently parallel to the alveo-
lar crest of bone, both labi-
aily ond lingualiy (Fig 2a).
2. This parailei arrangement
was aiso constant in the
facial and lingual concovi-
ties of foofh surfaces, where
the tissues were seen to rise
coronoily, ond on convex
surfaces, where fhe tissues
feil away apicaiiy (Fig 2a),
3. The peaks and vGiieys of the
osseous gingivai continuum
are further influenced by
the surface topography of
fhe feefh in thaf the more
acute the concavity, the
sharper the peak. The
reverse is true when con-
oavities are iess acute. The
val continuum are simiiariy
reiated to the surface cur-
vatures of the convex sur-
faces of the teeth. The val-
leys of the confinuum are
deeper and norrower on
the more sharpiy curved
surfoces and shallower and
broader on the less accen-
tuated ones (Figs 2o).
4, The form of the gingiva in
the inferproximal areas wos
not paraiiel to the underly-
ing bone but was col
shaped, as described by
Cohen," and influenced by
the size, shape, and position
of the contact area be-
tween the adjacent teeth,
as noted by Kohi and
Zander'2(Fig2b).
during ciinicai crown lengthen-
ing procedures, the alveolar
bone around the teeth must be
scalloped to harmonize with the
surface topography of the tooth
being treoted: rising coronaiiy in
the concavities and failing
away apicaiiy over oonvexities.
The greater the acuity of the
oanvexities or concavities of the
tooth surfaces, the more accen-
tuated the scalloping of bone.
The opposite hoids true tor sur-
face curvatures that ore less
acute; the gingiva will automat-
ically assume a position paraiiel
to that of hewly scaiioped aive-
oior bone. Application of these
principies is demonstrated in the
tooth lengthening surgery iiius-
troted in Figs 3a and 3b.

The internatjonoi Journai of Reriodontics & Restorative Dentistry

 469

figs 3a and 3b Clinical crown lengthening surgery iilustrating some of the principies mentioned in text. Poiatai
view during clinicai crown extension of tne maxillary premolar region (left), Nate the relationship of oiveoiar
bane to the preparation margins and thick palatal ridge of bone prior to astectomy/osteopiasty. Bone height
has been reduced to accommodate the predestined amount ofSGT that wiii deveiop and scalloped to be
harmonious with the surface topography of the teeth (rigfit). Note peaks of bane in the concavities on the
mesiai surñaces af the premolar teeth and distal at the canine. Odontoplasty. ta fiatten the mesial concavities
of the premolars. has permitted achievement of less accentuated osseous peaks during the osseous recon-
touring phase.

In the interproximal areas, Dentogingivai junction tionoi epitheiium, while the

apical positioning ot the os-
seous gingival continuum will
result in a complex of tissues
remote from fhe infiuence of
odjacent teeth and contact
areas. Thus, foiiowing tootii
lengthening surgery it is possibie
to achieve a constant and par-
aliel osseous gingivoi continuum
circumferentiaily about the
teeth. Col formations can only
recur in fhose instances in
which newly fabricated restora-
tions impinge upon the recently
formed convex inferdentai
papiiia causing a col-iike modi-
fication of form.
According to Schroeder and
Lisfgarten,'^ the continuum
between the tooth and the gin-
giva, the dontogingival junc-
tion, represents o "sandwich" of
heterogeneous yet intimoteiy
connected tissues. These in-
clude the enamel or tooth sur-
face, the dental cuticie, the
internai basement lamina, the
junctional epitheiium, the exter-
nai basement lamina, and the
gingivoi connective tissue. The
actual epitheiiai ottochment to
the tooth is effected by hemi-
desmosomes ond the internol
basement iamina that adhere
to the tooth surface. The floor of
the crevice is made up of the
superior elements of the june-
crevicuiar woli is derived from
oral epitheiium, Schroeder and
Listgarten^^ also point out that
tiie adhesion of the juncfional
epithelium to the tooth is dis-
rupted relatively eosiiy. When
this occurs, the cohesion be-
tween the epitheiiai cells and
other tissue layers of the den-
togingivai unit is weakened,
ond infiommatory change wiii
ensue, setting the stage tor
periodontoi destruction.
Ciinicaiiy, disruption of the
Junctionoi epithelium can be
caused by piacement of
restoration morgins too tor api-
cally, exaggeration of emer-
gence protiles of restored
teeth, and injudicious manipu-
iotion of the SGT during tooth

Volume 17, Number 5,1997

470
Figs da ar\d 40 (left) Preporation of left maxillary central inoisor with margins no
deeper than 0.5 mm into the suicus. Nate that the preparation margin is parailel. cir-
cumferentially ta the gingival margin, (right) Ceramic restoration postinsertian.
(Restorative dentist Dr R. S. Stein.)
preparation or the impression-
making process, it is therefore
obvious that when restoration
margins ore placed subgingi-
vaiiy greot care must be taken
to avoid irreversible distur-
bance of the adhesion of the
junctionai epithelium to the
tooth.^ Strictly speaking, the
preparation margins need not
be deeper than 0.5 mm into
the crevice, even in those
ooses where orevicular depth is
greater than 1 mm. Piacement
of weii-fitfing margins to this
depth will generally be well tol-
erated by periodontal tissues
and still be esthetic (Figs 4a
and 4b).
According to Shiiiingburg et
al,' there are three basic
requirements for bioiogicaliy
acceptabie restoration mar-
gins:
The International Journal of Periodontios S Restorative Dentistry
1, They shouid fit as olosely as
possible to minimize the
width of exposed cement,
2, They should be able to with-
stand occiusai forces trans-
mitted to them.
3, Wherever possible, they
should be iocated where
they oan be seen, eosily
managed, and cleaned by
the patient.
To these should be added
a fourth oriterion, nameiy that
the preparation margin, when
located subgingivally, should
always porallei the gingival mar-
gin and must not vioiate the
integrity of 1he SGT (Figs 4a and
4b).
Based on the mistaken
premise of Block'" that oories
will not oocur at the restoration
margins as iong as these are
covered by gingiva, gingival
preparation margins, irrespec-
tive of type, have traditionaliy
been piaced subgingivaily. The
recommended position has
ranged anywhere from just
below the gingival margin^^ to
half-way into the crevice,"'
and, in some instanoes, to the
epitheliai attachment,'^ The
preponderance of more our-
rent information'^"^^ ieads to the
inescapabie conclusion that
routine piacement of restora-
tion margins in the subgingivol
area is no longer acceptable.
In some oases, where it is impor-
tant that restoration margins
not be seen, the use of modern
restorative materiais and ce-
ments may preclude the need
for subgingival placement of
restoration margins (Figs 5o and
5b), However, there are stili
some instances in which cari-
ous extensions of previous
restorotions, subgingival tooth
fracture, and esthetics cannot
be managed without subgingi-
val piacement of restoration
margins. Provided that the
manipulation of the tissues or
placement of the margin does
not irreversibiy vioiate the SGT,
this approaoh may still be con-
sidered. If subgingival margin
piaoement can only be
achieved at the expense of the
soft tissue continuum, then
surgery must be undertaken to
reposition the SGT apicaily,
Faiiure to do so will adversely
affect the periodontium.*'°
When restoration margins
are pioced intraorevicuiarly,
they should be no deeper than
 471

0,5 mm and parallei to the gin-

gival margin. In anterior portions
of the mouth, it is not uncom-
mon to see the preparation iine
finish deeper interproximaliy
than it does in the cervioal
areas. In such instances, if the
preparation is deep enough to
vioiote the attaohment of the Figs 5a and Sb Treated case iiiustroting the use of gloss-ceramic restorations with
SGT to the tooth, the conse- supragingivaily situated margins The suprogingival location of the restorations are
quent periodontal changes can difficult to mai<e out goad esthetics have been realized, and gingivai health has
been maintained. (Restorotive dentist Dr C. M. Trauring )
hove long-term disease and
esthetic ramifications. Violations
of this type aiso occur in the fur-
cation areas ot moiar teeth
(Figs 6a and ob). Placing the
preparation margin minimaiiy
into the orevicuiar area and
keeping it paraiiei to the gingi-
val margin will heip avoid these
adverse consequences.
In posterior interproximai
Figs 6a and ob Restorotive vioiotion ot the SGt and heaiing affer treatment. Buccoi
areas, caries often extends api- view af maxiiiary left sextant 10 months postsurgicaiiy and i month after campietion
caiiy into the coi area, if these qf the restorative phase of treatment (ieft). Note inflamed hypertraphic tissue in the
problems ore treated with aiioy buccai furcation af the moxiiiory second molar. During flap elevation, the restorative
margin was found ta have vialated the SGT in the furcatian area because fhe fi/i/s/i
or synthetic or partiol coverage margin of the restorotian wos not kept paroliel to the gingival margin. The overex-
cast restorations, then the papii- tended crown was reduced in the furcation area, reshaped, and the tiap was then
repioced. Three manths after surgery fhe gingivai tissues are heaithy (right) Note
iae adjacent to these areas will that the crown margin is naw lacafed supragingivqiiy.
generaiiy not be vioiated during
the treatment. If, however fuil-
ooverage restorations are used
and the preparations are car-
ried faciaily or linguaiiy at the
same apicocoronai height as
the deepest interproximai por-
tion of the preparation, then the
ottachment of the papillae to
the tooth will be compromised.
In these situations, clinical crown
extension procedures to api- Figs 7a and 7b Clinicai crawn lengfhening fa treat violations of the SGT related to
cally reposition the periodon- excessive subgingivai toath preparation. Preparation af teeth apicaiiy beyand exist-
ing alioy restorations is not possibie without further violation of the periodontium
tium must be undertaken to (Iett), Two months foiiowing tooth lengthening procedures (jlghf). The provislonais
avoid gingivai attachment dis- hove been reiined, and final tooth preparations can now be contemplated withaut
viaiatlan af the SGT complex. (Restorative dentist Dr L C. Victor.)
ruption (Figs 7a and 7b),

Volume 17,NumbGr5,1997
472
Postsurgical SGT and prepa-
ration margins of restorations
in a 3-year study invoiving
osseous resecfive tooth length-
ening procedures where muco-
periosteai flaps were repioced
to the orest of Pone, Van der
Velden^^ noted that the post-
operotive opicocoronoi dimen-
sion of the SGT was in the vicin-
ity of 4,00 mm. in 1980, Smith et
ai^'' tound that 2.6 mm ot SGT
had developed in ó months fol-
iowing osseous surgery which is
much oioser to fhe 2.73-mm
dimension described by
Gargiulo et a i . ' it seems that
the ditferences seen in these
studies are related to one or aii
ot the tollowing: the surgicai
techniques used, the configuro-
tion given to aiveoiar bone dur-
ing the osseous surgery, and the
duration ot the observation
period. These previous studies
indicate thot the postsurgicai
dimension of SGT can vary.
However, it is most likely that the
amount ot SGT formed wiii
approximote the amount pre-
sent prior to the surgery. Thus,
onoe the preoperative amount
ot SGT present in a heaithy
operation site or in a contraiot-
erai area in the same individuai
is known and the situation ot
the preparation margin has
been determined, it is reiativeiy
easy to assess the extent of
osseous resection that wiii be
necessary to provide accom-
modation for the regenerated
SGT,
The Internafionai Journal af Periodontics & Restorative Dentistry
During surgery when the
tiops are repiaced at or apicoi
to the ievei of the aiveoiar
crest, the gingiva wiii creep in a
coronal direction until the fuli
dimension of the predestined
SGT is formed, if the flaps are
placed slightly supracrastally,
the same predestined amount
ot SGT will reform. Thus, if the
dimension of the SGT for a
given situation is i<nown, it is
possibie to reiiaPiy predict the
finai position of the gingivai
margin that wiii be attained in
approximateiy 1 year, if the finoi
footh preparation is contem-
piated within the tirst year after
surgicci crown extension, the
preporation margin shouid not
immedioteiy be piaced subgih-
givaily. it it is, as the SGT redevel-
ops the preparation margin
can easiiy end up being lo-
cated too tar subgingivaiiy. This
is generaiiy biomorphologicaliy
unacceptabie, and the stage is
set tor progressive periodontoi
breakdown.
On the other hand, it is possi-
Pie to utiiize these events to
advantage and carry out final
tooth preporotion, placing the
preparation margins minimaiiy
coronai to the gingivai margin 3
to 6 months postsurgicaiiy (Figs
8a to 8b). The creeping of the
501-25-26 ^Q 1^3 predestined
dimension wouid ensure that
the preparation margin ends up
in an acceptabie subgingivol
location, it is thus obvious that, in
those situations in which prepa-
ration margins must be piaced
 473

in the gingival crevice, the oper-

ator would be wise to delay the
final preparation as iong os pos-
sible. When this is not possible,
the creeping attochment phe-
nomenon may be used odvan-
tageously

Figs 8a and 8b Harnessing of the creeping attachment phenomenon to hide

Emergence profile of the preparafian margins. Six months after tocth lengthening at stage of ^nai tooth prepa-
tooth and the SGT ration (ieft). The preparation margin is parallel to the gingival margin and is aniy mini-
mally subgingivai. Six months after final tooth préparation, just prier to oementafian of
finai restorations (right). JTie preparation margins are now 0.5 to 1 mm subgingival as
As teeth erupt into the oral cav- a resuit af the gingival creep. (Restorative dentist Or L G.Victor.)
ity, the periodontium drapes
itselt around the tooth; thus, the
final determinant ot gingival
and osseous torm is the surtoce
topogrophy of the tooth. This
relationship between tooth
morphology and the periodon-
tium was observed by Doza De
Bastos'^ and is demonstrated
on the experimental tooth
shown in Fig 2a. In the distal
depression seen in this canine Figs 9a ond 9b illustration of fhe intluence of surface topography on fhe gingival
tooth, a very ocute conoavity torm. Fig 9a shows the separation afa disfai root with an L'shaped toafh prepara-
ot the more apicai osseous fian (ieft). Flattening ar 'softening'of the initial 'f shaped preparation during surgery
by judicious odontopiasty hos resuited in an harmonious denfogingivai reiationship
level was seen to be less acute (right).
coronaiiy at the gingival Ievei.
The gingivai form is iess sharp
and softer than the underlying
osseous topography becouse
the concavity in which it is situ-
ated is iess acute and more sites ot amputated roots is oor- SGT can be advantageously
shallow. Based on the Daza De ried out to modify and "soften" used to alter gingival form and
Bastos'° conclusions, it may be the dental concavity created to enhance periodontol main-
inferred that altering the during the resection, blend with tenance and also esthetics.
supracrestal surface anafomy the osseous topography, and These contingencies moy also
of the tooth can resuif in an thus permit the formotion of a be used to guide the formation
accompanying change in the matched and harmonious gin- of the peri-implant SGT to a suit-
adjacent soff tissues. This phe- givai element (Figs 9a and 9b), abiy scalloped gingivai archi-
nomenon may be exempiitied This type of tooth topography tecture resembiing that found
when odontoplasty or "barrei- modification to favorably influ- in the natural dentition (Figs 10a
ing" of the tooth surface in the ence the form of the adjocenf tolOd).

Volume 17,Number5,1997
474
Figs lOa to lOd Modification of implant abutment emergence profiles to guide the torm ot the developing peri-impiant
tissues.
Fig ¡Oa Occiusoi view of implant fixture 1 month after inser-
tion of a ridge iap-type provisionai restoration.
Fig 10c Study cast illustrating peri-implant tissues associated
with the ridge iap provisional.
The Infernotional Journai of Periodantics & Restorative Dentistry
gingivai
Fig 10b Occlusai view of same area 3 months later. A new
provisional restoration had been fabricated to the face of the
impiant, incorporating concave praximal and convex labia-
lingual surfaces. The emergence profile of the restoration has
guided peri-implant saft tissue form.
Fig Wd Working cast illustrating the topographic changes in
the peri-implant tissues affected by the second provisional
restoration. Note the more apicai situation of the iabiai peri-
implant tissues and the mare caronai interproximal papillae.
(Restarative dentist Dr A. Suiikowsky.)
 475

Figs I l a and 1 lb Etfects af an excessive emergence profile on the SGT and the management of the prob-
lem. Note gingival reaction to the overoontoured metal bonded porcelain restoration (left). Two months after
fabrication of a provisionai restorotian with improved emergence profile, the gingivae have returned to nor-
mal (right). (/ÍestofOíiVe dentist Dr L C. Victor)

It is also possible to adverseiy from periodontai disease or

influence the gingivai integu-
ment when using restorations
with subgingivally piaced mar-
gins by unduly exaggerating the
profiles ot the restorations as
they emerge into the orai oavity.
This type of distortion can disrupt
the integrity of the SGT and
exert adverse inflammatary and
esthetic changes on the gingiva
(Fig 11 a). These ohanges are
often seen when attempts are
made to close naturaiiy occur-
ring diastemata or enlarged
interproximo! spaces resulting
treatment by overbuiiding and
overoontouring tull-coverage
restorations of the teeth in-
voived. According to Stein and
Kuwata,^' the gingival suiouiar
wall shouid be presented with a
flat emerging tooth profile that
does not distort or disrupt it. Such
profiies, which should be tested
by observihg tissue reactions in
the provisional restoration phase
of treatment, wiii ensure biologic
ond esthetic acceptability ot
the gingivai and dental contin-
uum (Fig lib).

Volume 17, Number 5,1997

47Ó
Summary and conclusions
Estheticdiiy and bioiogicaliy
acceptabie restorations are
difficult to achieve when the
remaining clinical crowns of
teeth to be restored are
dimensionaliy inadequate.
Extension of the preparations
subgingivoliy to ottain better
retention form may have
adverse reactions in the peri-
odontium and may compro-
mise esthetios. In these cases,
surgical enhonoement of the
ciinicai crown is generoiiy nec-
essory to provide o dimension
of clinicol crown thot permits
occeptable tooth preparation
and fabrication of a restoration
oompotibie with the surround-
ing suprocrestal gingival tissues
in estabiishing a biologio
basis for tooth lengthening, the
foiiowing principles shouid be
considered;
The internationai Journal of Periodontics & Restorative Dentistry
1, Whenever possibie, the finish
line of the restoration should
be determined prior tc
surgery,
2, When fhe obove is not pos-
sible, the finish line should be
anticipoted at surgery
3, Sufficient aiveoiar bone
shouid be removed to per-
mit the deveiopment ot an
occeptable dimension of
SGT between the actuoi or
anticipated finish iine of the
preparation ond the alveo-
iar crest.
4, Transcrevicuior probing cir-
oumferentialiy prior to sur-
gery, in heaithy areas in the
operation site or in contralat-
erai areas, shouid be the
gouge for estimating the
space needed for deveiop-
ing the SGT compotibie with
individual patient require-
ments,
5, The degree ond configuro-
tion of osseous scolloping is
determined by the surface
topography of the tooth.
6, Gingival form is dictoted
both by the osseous config-
urotion and the surface
onotomy of the tooth.
7, Within iimitotions, gingival
form may be modified by
oitering the topography of
the tooth. This applies both
to notural or implant-re-
stored dentitions,
8, Restorative procedures must
not disrupt the epitheiial
attachment and the SGT
a. The emergence profiie of
the restoration must not dis-
rupt the crevicuiar woll of
the SGT.
b. Preparatioh margins must
not irreversibly disturb the
dentogingivai relationship,
need be no more than 0,5
mm subgingivaily, ond
should aiways paraliel the
gingivai margins,
c. The final preparation and
restoration should be de-
iayed as long as possibie
after tooth lengthening to
permit the gingivoi morgin
to attoin its predestined situ-
ation.
9, Where possible, preporation
margins shouid be i<ept
supragingival.

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Voiume 17, Number 5,1997