The International Journal af Pejiodanfics & Resforative Dentistry

425

Restorative and Periodontai

Considerations of Stiort
Ciinicai Crowns

MItridade Davarpanah, MD, DDS' The short ciinicai crown cannot

Curtis E. Jansen, DDS^' be oompieteiy evaluated by
Frani< MA. Vidjak, DDS"' visual inspecticn alene, A thor-
Daniel Etienne. DDS"" ough clinical examination that
Myriam Kebir, DDS'"" includes current radiographs
Henry Martinez, DDS*"'" (with vertioal bite wings) ond
The purpose of this review wds to exdmine the periadontai and restorative fac- properly mounted diagnostic
tors related ta restoring teeth with short oiinicdi crowns. Mcdes of therapy are oasts is required, Fcr the pur-
usuaiiy combined ta meet the biologic, restorative, dnd esthetic requirements poses of this review, a shcrf clini-
imposed by short clinical crowns. The compiioations presented by teeth with
short oiinioai orowns demand o comprehensive treatment plan and proper ool orown is defined as any
sequencing of therdpy ta ensure a satisfdotory result. Visudtization of the tooth with iess than 2 mm of
desired resuit is a prerequisite of successful therapy Short clinical crowns pre- sound, opposing parallel walls
sent many prabiems to fhe restorative dentist. Restordtiahs shauid have proper
farm, function, dnd esthetics while promoting the maintenance of tissue health
remaining otter odequate oc-
in the surrounding areas. However, adequate taath structure for achieving ciusal and oxioi reduction (Fig
fhese godis may not diways be availabie. While it is diffioutt to precisely define 1). Common causes of short ciin-
minimum crown iength. this study offers guidelines for defining a shart ciinicai icai crowns (SCO) inciude'"^'^:
crown and suggests procedures for achieving a prediofabie resuit without
compromising the pericdontium. The consequences ofpiaoing a restoratian on disease (caries, erosion, tooth
d tooth with insufflaient crown iength ore discussed and vorious treatment malformation), traumo (frac-
methods ore reviewed. (Int J Periodont Rest Dent 1998:18:'125-433,) tured teeth, ottrition), iotrogenic
'Assistant Professor, Department af Periodontoiogy University of dentistry (excess tooth reduc-
Paris, France; Ciinicai Assistant Professor, Department of tion, iarge endedontic access
Periodontoiogy University of Southern Califarnia, Los Angeles,
openings), eruption disharmony
Calitornia; and Private Practice, Porls, France.
"Private Practice, Prosthodontics, Monterey, California. (insufficient passive eruption,
"'Assistant Professor, Department ot Restorotive Dentistry, mesiaily tipped teeth), exostosis,
University of Southern Calitornia, Los Angeies, Coiifornia, and genetic variotion in tooth
"•'Associote Pratessor, Department of Periadontoiogy, University
form.'
of Paris: ond Private Prootlce, Paris, France.
••""Privóte Practice, Paris, France. Crcwn retention ond resis-
••"'•Ciinicai Assistant, Department ot Orai Surgery Focuity of tance form are primarily re-
Odantaiogy, University cf Paris, Fronce.
loted to crown iength, total
Reprint requests: Dr Mitridade Dovarpanah. 174 Rue de ocolusol convergence degree,
Couroelies, 75017 Paris, France, and axial surface area (Presten

Volume 18, Number 5,1998

42ó

Fig 1 Short olinicai orown.

Fig 2 Biologic width and minimum amount of tooth structure Fig 3 Reaction to invasion af bioiogic width.
needed in posterior sextants.

JD, personai communicaticn,
1989). Secondary retention ond
resistance form may be de-
rived from boxes, grooves, or
pins placed in solid tooth struc-
ture." The relationship oi axiai
wali height to prepared tooth
width olso greatiy influences
crown retenticn and resistonce
torm.The axial wall height niust
be great enough to prevent
the rotation of fhe casting
around a point on the opposite
margin. A crown on a short
tooth preparation has o
greater tendency tov^/ard dis-
placement than a crovi/n on a
tooth ot the same oxioi woii
height with a smaller diame-
ter."-'^ Sound tooth structure
should provide the principal
source of retention." Foun-
dotion restorations (buildups)
should not be relied upon be-
cause it is ditficuif fo know hovi/
weil the foundation itselt is
refained (Preston JD, personal
communicaticn, 1989). It is im-
portant to piace the tinish iine
on a sound tcoth structure to
ensure a fovorabie prognosis
for the restoration.
When restoring a tooth with
an s e c the ciinician may ot-
tempt to gain length by placing
a subgingivol finish line. However,
deep subgingivai margins that
encroach upon the biologic
pericdontai width'^"'^ jeopor-
dize the periodontium ond are
therefore not desirobie. The bio-
logic width—approximateiy 1
mm ot epitheliai attachment
and 1 mm ot connective tissue
attachment (Fig 2)—is o physio-

The International Journai af Periodontics S Restorative Dentistry


iogic enfity that should not be
violated. Invading the biologic
width during tooth preparation
can resuit in chronic inflammo-
tion (Fig 3), loss of alveolor bone,
gingival recession, and perio-
dontai pocket formation. The
amount of pathologic response
is related to the individual pa-
tient's susceptibility to perio-
dontai disease.'^'^ The chronic
inflammation resulting from vio-
iation of fhe biologic width com-
promises both esthetics and
periodontai health. Subgingivai
margins make adequate margin
placement difficult compromise
provisional restoration mointe-
nance, complicóte impression-
moking procedures, ond may
preclude occurate evaluation
of the final restorotion and isola-
tion tor cementation,^^'^'^
Restorative decisior^s and
treatment sequence
The resforafion of teeth with
SCCs has included the follow-
ing techniques; alteration of
tooth preparation design and
placement of auxilliary reten-
tion and resistance form feo-
tures, placement ot foundation
restorations, surgicol crown
lengthening, orthodontic erup-
tion, endodontic treatment.
and overlay removable partial
dentures. However, betöre any
treatment is initiated on a tooth
with sec, restorability must be
established.' Restorative assess-
ment should include considera-
tion of fhe arch position of the
tooth, strategic value of the
tooth, periodontai considera-
tions, crown-to-root ratio, inter-
arch spooe occlusion, endo-
dontic treatment feasibility, and
esthetics (Preston JD, personal
communication, 1989).
Proper treotment sequenc-
ing is critioal (Bohat O, personal
communiotion, 1987). Oral hy-
giene instruction, scaling, root
planing, and cories control are
mandotory in the initial treat-
ment phose. Initial tooth prepa-
rotion should be completed
ond the provisional restoration
placed to determine the
omount of crown lengthening
required. The appropriote treat-
ment procedures can then be
selected. It is important to con-
serve as much tooth structure
as possible, and toundation
restorations should provide as
much basic retention as possi-
ble. If endodontic therapy is
indicated, it should be initiated
prior to surgery.
Ttierapeutic modalities
Aitering tooth preparation
design
The short clinical crown does
not permit the use of routine
tooth preparation design.
Additionol design features are
required to compensate for
deoreased retention and resis-
tance form." Retention and
resistance factors in tooth
427
preparation are related primar-
ily to surface area and height
of the preparation, axial wall
convergence, and texture of
the prepared surface, and sec-
ondorily to intracoronal reten-
tive devices.^'^"^'' The walls of an
sec should be as parallel as
possible. Increosed tapering oi
the walls deoreoses resistance
and retention form, necessitat-
ing the use of seoondory reten-
tion factors (pins, grooves, or
boxes).
Foundation restorations
Increosed crown length can
be goined by the addition ct
foundation moterials. Such
foundation restorotions moy
also be used to eliminate
voids, undercuts, and irregulari-
ties in the tooth preparation.
Foundotion restorations can
be classified according to
both the tooth vitality ond the
means of foundotion reten-
tion. The retention methods for
vital teeth are chemical adhe-
sion, mioromechanical reten-
tion, pins, and grooves. For
nonvital teeth the means cf
retention include both prefab-
ricated ond cast posts and
oores, in addition to the meth-
ods used for vital teeth.
Volume 18, Number 5,1998
428
Fig 4a Short clinical crown with insufñ-
cient keratlnized tissue on buccal aspect
of the mandibular right first maiar.
Surgical crown iengthening
consideratioris
Surgical considerations for onte-
rior teefh differ from fhose used
posteriorly because of esthetic
demands.^^ The patient's ex-
pectations and smile iine ore
important factors in the presur-
gical evaluation. The surgicoi
result may be limited by
anatomic facfors^'^-* such as
the iocation of the maxiiiory
sinus, fhe vestibuiar depfh, the
position of fhe ramus and exter-
nal oblique ridge, fhe amounf
of available kerafinized tissue
(especially on fhe distal aspecfs
of fhe mondibular molars), and
fhe fhickness of the periostium
(if facking sufures are fo be
placed), if surgical procedures
are required, gingival widfh and
thickness must be considered.
Adequate gingival width for
infracrevicuiar margin place-
The International Journal of Perlodontics & Restorative Dentistry
Fig 4b Crown lengthening procedure
with lateral and apical positioning
of the paplliae. Note tacking suture
on periostium.
ment is approximafely 5 mm,!^-^''
including 2 mm of free gingiva
and 3 mm of aftached gingiva.
Esfhetic demands may necessi-
fafe subgingival finish lines, and
gingivai fhickness must be eval-
uoted by placing a periodonfal
probe into fhe sulcus; if mefal is
fo be piaced at the margin, an
esthetic restoration will not be
possibie if the probe is visibie
through fhe gingivol tissue.
When the fissues are thin and
franslucent, a soff fissue grafting
procedure should be incorpo-
rated into the surgical crown
lengthening procedure to ob-
tain adequote tissue thickness
(Figs 4G to 4c),2'-23
The concept of biologic
widfh is criticoi for the periodon-
tai prosthetic interface. Ac-
cording to Gqrguiio et aP^ the
average biologic width is 2.04
mm, ronging from 1.19 ta 2.88
mm. Average bioiogic width
Fig 4c Finoi restoration with proper
sett tissue contours.
decreases with age. Numerous
publications have studied the
effects of invasion of the bio-
logic width. Moditication of the
standard procedure could be
considered because a shorter
bioiogic width allows the res-
toration of teeth thot are other-
wise considered difficult to
retain,2' However, a significant
soft tissue recession couid occur
offer deep subgingival preparo-
tions. During a 6-month healing
period Brdgger ef aP° sfudied
the chonges in periodonfal tis-
sue levéis as an immediate
resuit ot a crown iengfhoning
procedure. During the surgery
the Giveaiar crest was reduced,
creoting a distance of 3 mm fo
the future reconsfrucfion mor-
gin. The authors reporfed 2 to 4
mm of recession of the free gin-
gival margin in 12% of fhe sites
treated with the crown length-
ening procedure.
 429

Fig Sa Lingual view of fractured mandibuiar ñrst moiar with Fig 5b Final toofh preparation.
short iinguai surface.

Fig 6a Restored teeth with SCCs. Fig 6b Final tooth preparation 3 Fig 6c Final restorations wifh proper
months afler periodonfai surgery. embrasures.

Posterior crown lengthening
Figures 5 and 6 show exampies
of fhe posterior crown iength-
ening procedure.
Soft tissue cansideratians
Proper flap design is an essen-
fial eiement of the surgical
procedure in posterior crown
iengthening,^' The amount of
kerafinized tissue on the buc-
cai or iinguai aspect dictates
the use of the internally
beveied and/or apicaily posi-
tioned flap fa maintain an
adequate amount of gingiva.
The absence of a mucogingi-
vai junction on the palatal soff
tissue surface mandates fhe
use of an internaiiy beveled
fiap. The fhickness of the perio-
donfium dictates the angie of
the surgicai blade used to
obtain adequate tissue thin-
ning (Bahat O, personal com-
munication, 1987), The flap
may have an envelope
design, or it may inciude verti-
cal reieasing incisions; retiec-
tion shouid inciude at least
one tooth on either side to
permit proper osseous sur-
gery,^^ The classic gingi-
vectomy (externally beveied

Volume 18, Number 5,1998

430
Fig 7a Note dimensions of exostosis
visible after flap eievation.
gingivectomy) is no longer
considered a viabie technique
becuase it aliows no access to
the bone.
Osseous considérations
Osseous surgery-'^'^*' should
always begin withi the recon-
touring of nonsupporting bone
(osteoplasty), which prcvides
the guideline fer resection cf
the supporting bone (ostec-
tomy), Surgicai crown lengthen-
ing procedures usuaiiy require
at least q minimal ostectomy.
Put they sheuld not ccmpro-
mise the periodontium of the
adjacent teeth. During surgery
the amount of sound tooth
structure must be measured cir-
cumferentially with a periodon-
tai probe: there must be 5 mm
of tooth structure coronai to the
alveolar crest, 2 mm of tooth
structure to maintain the bio-
iogic width, 1 mm of tooth struc-
ture to maintain the sulcular
The International Journal of Periodontics & Restorative Dentistry
Fig 7b Completed osseous surgery.
depth, and 2 mm of tooth struc-
ture for minimol retention ond
resistance form. The remeval ot
exostoses or tori is performed in
the osteoplasty phase of os-
seous surgery. The remevai of
these growths is an inherent parf
ef the crown lengthening sur-
gery faciiitating restorative pro-
cedures and maintenance (Figs
7a to 7c),
Taoth morphology
Odcntopiosty^^ is an important
surgioai step that can focilitate
the estabiishment of a proper
embrasure space, eliminate the
hcrizohtol component of early
te moderate Class II furcation
invoivements, ond allow greater
access to fiuted and concave
areos for maintenonce (Bahat
O, personal communication,
1987), When a deep Class II fur-
cation cannct be resolved by
edontoplasty, roet resection
should be considered.
Fig 7c Final restoration.
Anterior crown lengthening
A maximaliy esthetic anterior
resuit con Pe achieved oniy if
the sett tissue contours blend
from tooth to teoth,253''-3û The
surgioai procedure must eften
be augmented by forced erup-
tion te ebtain the desired con-
tour^^'^* For piacement of an
intracrevicuiar restoration, there
must be 5 mm of tooth structure
incisai te the alveoiar bone
crest, including 2 mm te moin-
tain the biologio width, 2 mm ot
suicular depth for introcrevicular
margin plocement, and 2 mm
for retention, with the tinish line 1
mm into the suicus (Fig 8),
Anteriorly it is criticai te provide
a postsurgical sulcular depth
into which a margin can be
piaced. When the tiap is sutured
it sheuld be piaoed 4 mm oorc-
nai to the aiveolar bone crest.
To meet these criteria and avoid
a peor esthetic result, osseous
surgery must atten be com-
bined with orfhodontic therapy

Fig 8 Bloiogic width ond minimal amount of tooth structure
needed in anteriar sextdnts (compare io posterior sextants
in Fig 2).
Tooth preparation should be
performed 4 to 6 weeks otter
surgical crown lengthening for o
supragingivai finish iine and 8
weeks offer orown iengthen-
ing'*' if fhe margins are to be
piooed in the suicus. Surgicai
complications such as sioughing
or infection may proiong the
healing period.
Orthodontic eruption
Foroed eruption
is the intentionai ccronai dis-
piacement of a tooth, attach-
ment apparatus (bone, con-
nective tissue attachment, ond
epithelial attachment), and gin-
giva. Such therapy positions the
root segment coronaliy, result-
ing in a more favorable crown-
to-root ratio.^'' In the absence
cf infiammation extrusion can
progress 1 mm in 1 to 2 weeks.
A iag period has been ob-
served between the movement
cf a tooth and the movement
of its attachment apparotus.
The attachment apporotus and
gingivai unit follow the tooth
after it begins to erupt from the
aiveoius."*^ The speed ot erup-
tion end the cmount of force
influences the coronai shift of
various tissues. The faster fhe
eruption is achieved, the ionger
the iag period.
The degree of root fapering
of singie-roofed feefh is an
important considerotion. if the
extruded root diameter is too
smaii for the mesiodisfoi spoce
between fhe odjacenf teefh,
on unesfhetic embrasure space
and overcontoured restoration
will result.^^'^^ The divergence cf
molor roots ccuid be a ccn-
traindication for forced erupficn
if there is a potenfiai for resulfing
root proximity and/or résorption.
Tipped moiors trequentiy
have short clinicai crowns me-
siai ly, and orthodontic up-
righting"^ shouid be ccnsidered
prior to surgery Molar uprighting
invoives a forced eruption
431
component on the mesiai side
of the tooth. Orthodontic reposi-
tioning can often create ade-
quate crown iength cr iimit the
surgical prccedure to soft tissue
changes.
Conclusion
This review has defined short
ciinioai crowns and discussed
focfors thof relafe tc pofenfiol
periodonfoi and restorafive
treafmenfs. Various modes of
therapy may be combined fo
fulfiii the biologic, restorafive,
and esthetic demands imposed
by the short ciinicai crown. The
complications presented by the
short ciinicai crown demond a
circumspect treotment plan
and prcper sequencing cf fher-
apy to ensure on optimal resuit
for both the patient ond the
ciinician.
Volume 18, Numbor 5,1998
432

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yoiume 18, Number 5,1998