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Dentistry
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 413

Surgical Extrusion Technique for

Clinical Crown Lengthening:
Report of Three Cases

Chang-Sung Kim, DDS, PhD*/Seong-Ho Choi, DDS, PhD**/ Clinical crown lengthening has been
Jung-Kiu Chai, DDS, PhD***/Chong-Kwan Kim, DDS, PhD****/ described as a common periodontal
Kyoo-Sung Cho, DDS, PhD**** surgical procedure for the following
Although a number of techniques have been proposed for clinical crown lengthen- objectives: exposure of sufficient
ing procedures, all have some limitation in terms of function and esthetics. This sound tooth structure in cases of
report presents the clinical and radiographic results of a surgical extrusion tech- deep subgingival carious lesion and
nique for clinical crown lengthening. Atraumatic surgical extrusion using a specially tooth fracture, enhancement of the
designed instrument (Periotome) was performed in three cases in which it was retentive quality of restorations, cor-
expected that extensive resective osseous surgery would have to be used for crown
rect placement of the margin of
lengthening. Full-thickness mucoperiosteal flaps were raised both labially and
palatally. The tooth was carefully luxated and extruded to the desired position with- restorations without violating the
out damaging the marginal bone area or root apex. No rigid splint was applied. biologic width, and improved
Clinical examinations performed for more than 1 year after surgery revealed prob- esthetics in patients with uneven gin-
ing depths
3 mm around the teeth at all sites, without bleeding on probing. The gival margin and excessive gingival
teeth functioned normally, with near-normal mobility. Radiographs showed normal display.1,2
periodontal contour consistent with new bone formation in the periapical area.
Several techniques have been
Radiographic analysis did not show any evidence of root or crestal bone resorption
or endodontic problems. The technique presented could constitute an alternative proposed for clinical crown length-
surgical approach to performing crown lengthening; it does not induce functional ening, such as gingivectomy, api-
or esthetic deformities, especially in the anterior region. (Int J Periodontics cally positioned flap with or without
Restorative Dent 2004;24:412–421.) resective osseous surgery, and
*Assistant Professor, Department of Periodontology, Research Institute for
orthodontic forced eruption with or
Periodontal Regeneration, Oral Science Research Center, College of Dentistry, without fibrotomy.2 The selection of
Brain Korea 21 Project for Medical Science, Yonsei University, Seoul, Korea.
one technique over another de-
**Associate Professor, Department of Periodontology, Research Institute for
Periodontal Regeneration, College of Dentistry, Brain Korea 21 Project for Medical pends on several patient-related fac-
Science, Yonsei University, Seoul, Korea. tors: (1) esthetics, (2) clinical crown-
***Professor, Department of Periodontology, Research Institute for Periodontal
Regeneration, College of Dentistry, Yonsei University, Seoul, Korea.
to-root ratio, (3) root proximity, (4)
****Professor, Department of Periodontology, Research Institute for Periodontal root morphology, (5) furcation loca-
Regeneration, College of Dentistry, Brain Korea 21 Project for Medical Science,
tion, (6) individual tooth position, (7)
Yonsei University, Seoul, Korea.
collective tooth position, and (8) abil-
Correspondence to: Dr Chang-Sung Kim, Department of Periodontology, ity to restore the teeth.3–5
Research Institute for Periodontal Regeneration, Oral Science Research Center,
College of Dentistry, Yonsei University, 134 Shinchon-Dong, Seodaemun-Gu,
There are clinical situations,
Seoul, Korea. Fax: + 082-2-392-0398. e-mail: dentall@yumc.yonsei.ac.kr however, in which the conditions are

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414
Fig 1 Periotomes specially designed for
atraumatic extraction in this type of proce-
dure.
unfavorable for surgical and restora-
tive procedures. Often in cases of
deep subgingivally located caries,
lesions, and tooth fracture, exten-
sive resective osseous surgery may
result in increased pocket depth and
mobility, furcation involvement, poor
crown-to-root ratio, and loss of sup-
porting periodontal tissues of the
neighboring teeth.6 Particularly in
the anterior region, where esthetics
is of great concern, the preservation
of the interproximal papillae and gin-
gival labial margin position is manda-
tory for obtaining a satisfactory final
esthetic outcome.7 In the case of
resective osseous surgery, the loss of
papillae, uneven gingival margins,
and poor crown-to-root ratios might
result in a compromised situation
from both the esthetic and functional
points of view.
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Orthodontic forced eruption
with or without repeated fibrotomy
overcomes these disadvantages.3
However, these procedures are with-
out a doubt much more cumber-
some than surgical crown lengthen-
ing8 because of the: (1) necessity of
a surgical and retention phase of
clinical crown lengthening after
orthodontic forced eruption; (2)
need for several sessions of fibro-
tomy to prevent the periodontal tis-
sues from being pulled coronally
together with the orthodontically
moving root; and (3) relapse ten-
dency.
To treat teeth with deep cervical
root fractures and deep cervical root
caries that are difficult to treat con-
servatively, the surgical extrusion
technique has been proposed, with
predictable short- and long-term
results.9–12 Occasionally, however,
apical root resorption and marginal
bone loss are observed, phenom-
ena suspected to be induced by sur-
gical trauma.10–12 The purpose of
this report is to present three cases
wherein the atraumatic surgical
extrusion technique for clinical crown
lengthening was used, with more
than 1 year of follow-up after the
surgical procedure, and for which no
esthetic or functional deformities
were induced.
Operative technique
On initial examination, the patients’
medical histories were reviewed to
rule out any local or systemic dis-
eases that might contraindicate sur-
gical procedures. Careful clinical and
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radiographic evaluations were per-
formed prior to the surgical proce-
dure for the sake of case selection.
Surgical extrusion was performed
only when extensive resective os-
seous surgery was expected to be
required. All patients received oral
hygiene instruction and complete-
mouth scaling prior to the surgical
procedure.
Following local anesthesia (lido-
caine 2% with 1:80,000 epineph-
rine), an internal beveled incision
was made around the tooth to be
treated. The intrasulcular incision
was then extended to each side of
the adjacent teeth. Full-thickness
mucoperiosteal flaps were raised
both labially and palatally. All asso-
ciated granulation tissue was thor-
oughly removed with periodontal
curettes. The distance from the tooth
fracture margin to the surrounding
marginal bone was measured with a
periodontal probe to calculate the
amount of extrusion necessary. The
tooth was carefully luxated to avoid
damaging the marginal bone area or
root apex of the tooth to be treated.
For this purpose, the blade of a
Periotome (Nobel Biocare) (Fig 1)
was placed into the periodontal lig-
ament (PDL) space of the tooth to be
treated. The Periotome was manip-
ulated in the PDL space of the tooth
in “walking motion” to luxate the
tooth without inducing surgical
trauma. After careful luxation, the
tooth was extruded to the desired
position using a hemostat as atrau-
matically as possible to protect the
vital PDL. The simple interrupted
suture technique was employed for
closure of the flaps. Fixation of the

tooth was achieved only with
sutures. No rigid splint was applied.
Patients were instructed to rinse
twice a day with 0.12% chlorhexi-
dine solution (Hexamedin, Bukwang
Pharmaceutical) during the first 2
weeks following surgery. Antibiotic
regimens were prescribed for 7 days.
The sutures were removed after 10
days. Patients were checked every 1
or 2 weeks for the first 2 months,
and then once a month for the fol-
lowing 6 months; to date, they have
been followed up for more than 1
year postsurgical. Radiographic and
clinical examinations were per-
formed to assess changes in peri-
apical and periodontal healing,
probing depth, and tooth mobility.
Case reports
Case 1
A healthy, 42-year-old, nonsmoking
woman with a horizontal fracture of
the maxillary left lateral incisor was
referred to the Department of Peri-
odontology, College of Dentistry,
Yonsei University, Korea, for a clinical
crown lengthening procedure (Fig
2). Clinical and radiographic exami-
nation revealed that the fracture
margin was situated subgingival and
extended almost to the alveolar
crest level on the labial aspect (Figs
2a and 2e). The decision was made
to perform surgical extrusion for clin-
ical crown lengthening and subse-
quent crown treatment.
Following local anesthesia, a
mucoperiosteal flap was reflected
labially and palatally. The fracture
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415
margin at the labial bone crest level
was evident (Fig 2b). Atraumatic sur-
gical extrusion using a Periotome
was performed according to the
above-mentioned method (Fig 2b).
The tooth was extruded and placed
at a level such that the fracture mar-
gin was situated at least 3 mm from
the bone crest (Figs 2c and 2e).1,13
The flap was sutured, and the patient
received postoperative care. Soft tis-
sue healing was uneventful.
Postoperative tooth mobility
after the first week was marked but
decreased gradually during the sec-
ond week. Clinically, minimal gingi-
val inflammation and tooth mobility
were evident after 4 weeks. The im-
mediate postoperative radiographs
showed empty, radiolucent space
around the periapical area. However,
an increase in radiographic density
suggesting new bone formation was
observed around the periapical area
at the 2-month examination.
Endodontic treatment followed by
provisional crown treatment was per-
formed 2 months after the surgery.
Clinical examination 17 months
after surgery revealed probing
depths
3 mm around the tooth at
all sites, without bleeding on prob-
ing (Fig 2d). The tooth functioned
normally, with near-normal mobility.
A periapical radiograph showed a
radiopaque periapical area consis-
tent with new bone formation and
normal PDL space. Radiographic
analysis did not show any evidence
of root resorption, crestal bone
resorption, or endodontic problems
(Fig 2e).
416

Fig 2a (left) Preoperative clinical exami-

nation of maxillary left lateral incisor reveals
subgingival fracture margin.

Fig 2b (right) Surgical extrusion procedure

using a Periotome. Note that fracture mar-
gin extends almost to alveolar bone crest.

Fig 2c (left) Tooth is extruded approxi-

mately 3 mm.

Fig 2d (right) At 17 months postopera-

tive, lateral incisor and provisional crown
are in place. Note the favorable clinical
esthetic result.

Fig 2e Left: Preoperative radiograph shows that root fracture of lateral incisor extends almost
to alveolar crest. Center: Surgical extrusion is performed. Note periapical radiolucent area.
Right: Periapical radiograph 17 months after surgical extrusion. Normal PDL space is evident.

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 417

Fig 3a (left) Intraoperative view shows

fracture margin at bone crest level on
mesial and distal aspects. Labially, fracture
margin is situated approximately 1 mm
below the labial bone.

Fig 3b (right) Surgical extrusion proce-

dure using a Periotome.

Fig 3c (left) Tooth is extruded approxi-

mately 4 mm and fixed only by means of
sutures.

Fig 3d (right) Restoration 18 months

postoperative. Note the favorable clinical
esthetic result.

Fig 3e Left: Radiographic evaluation of lateral incisor reveals horizontal tooth fracture at
alveolar crest level. Center: Surgical extrusion is performed. Note periapical radiolucent area.
Right: Periapical radiograph 18 months after surgical extrusion. Normal PDL space is evident.

Case 2 referred for clinical crown length- state, and gingival and radiographic
ening of the mandibular right lateral evaluation revealed a horizontal
A 40-year-old man with an unre- incisor (Fig 3). Clinically, the tooth fracture at the alveolar crest
markable medical history was involved tooth was in a submerged level (Fig 3e).

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418
Following local anesthesia, a
mucoperiosteal flap was reflected
on both the labial and lingual as-
pects. The fracture margin at the
bone crest level was evident on the
mesial and distal aspects. Labially,
the fracture margin was detected 1
mm below the labial bone crest (Fig
3a). Atraumatic surgical extrusion
was performed using a Periotome
(Fig 3b). The tooth was extruded and
placed at the desired level. The
amount of extrusion was approxi-
mately 4 mm (Figs 3c and 3e). The
postoperative tooth mobility de-
creased gradually during the third
week. After 4 weeks, the clinical
tooth mobility stabilized. New bone
formation and a normal periodontal
contour were observed around the
periapical area at the 3-month radi-
ographic examination. Endodontic
treatment followed by crown treat-
ment were performed 3 months
after the surgery. A clinical examina-
tion 18 months after surgery re-
vealed probing depths
3 mm
around the tooth at all sites. The
tooth functioned normally, with near-
normal mobility (Fig 3d). Radi-
ographic analysis did not show any
evidence of root or crestal bone
resorption or endodontic problems
(Fig 3e).
Case 3
A 45-year-old man was referred for
a clinical crown lengthening proce-
dure at the maxillary right canine (Fig
4). Clinical and radiographic exami-
nation revealed that the tooth frac-
ture and secondary dental caries
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were situated subgingival (Figs 4a
and 4c). The decision was made to
perform surgical extrusion for clinical
crown lengthening. At surgery, the
fracture margin at the bone crest
level was evident on the mesial and
distal aspects. The tooth was
extruded, and the fracture margin
was placed approximately 4 mm
above the bone crest (Fig 4c).
Clinical and radiographic healing
were uneventful. Endodontic treat-
ment followed by crown treatment
were performed 2 months after the
surgery. After 13 months, a healthy
gingival condition associated with
normal periodontal contour was evi-
dent on clinical and radiographic
examination (Figs 4b and 4c).
Discussion
In cases of deep subgingivally
located caries lesions and tooth frac-
tures, extensive resective osseous
surgery inevitably has to be per-
formed to provide adequate tooth
structure for the proper placement
and retention of a restoration. As a
consequence, the attachment appa-
ratus and gingival margin of the
involved tooth may be positioned
more apically compared to the adja-
cent teeth. These periodontal
changes could result in esthetic and
functional deformities.1,3,14,15 The
surgical extrusion technique for clin-
ical crown lengthening presented in
the present article was successful
from both the esthetic and functional
points of view, since resective
osseous surgery was not carried out.
Several studies have demonstrated
 419

Fig 4a Preoperative clinical examination of maxillary right canine Fig 4b Restoration 13 months postoperative. Note the favorable
reveals subgingival fracture margin. clinical esthetic result.

Fig 4c Above: Radiographic evaluation

of canine reveals horizontal tooth fracture
at alveolar crest level. Right: Tooth is
extruded approximately 4 mm. Far right:
Periapical radiograph 13 months after sur-
gical extrusion. Normal PDL space is evi-
dent.

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420
the clinical feasibility of surgical
extrusion, also referred to as intra-
alveolar transplantation, with favor-
able short- and long-term results,
and suggest that this method is
much more economical than implant
or fixed partial denture treat-
ment.9–12
The evaluation of periodontal
repair on transplanted or surgically
extruded teeth usually shows slight
marginal bone and apical root
resorption.16,17 Apical root resorp-
tion is observed more frequently
when bone transplants are used
periapically for stabilization.10 The
precise mechanism of this phe-
nomenon is not fully understood.
However, there are two possible
explanations. First, surgical trauma
during luxation of the root may
induce marginal bone resorption
and periapical root resorption.
Several different instruments can
be used to extrude the roots, in-
cluding crown removal hammers,9
carvers,11 elevators,12 and forceps;
the possibility that these instru-
ments exert a degree of traumatic
pressure on the marginal bone and
root apex cannot be excluded.
Second, dehydration of the PDL
cells can also lead to root resorp-
tion.10–12,17 Previous studies found
that the viability of the PDL cells
along the root surface could be
reduced depending on the extra-
alveolar period.18,19 Since the via-
bility of PDL cells is undoubtedly of
importance for healing of the
socket and formation of the peri-
odontal structures, dehydration of
the root surface should be avoided
during the surgical procedure. In
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terms of marginal bone loss and healing of transplanted teeth using
apical root resorption, the surgical the nonrigid fixation tech-
extrusion technique described in nique.10–12,22,23 It is possible that the
this case report should be more nonrigid fixation used had a posi-
favorable than those previously tive influence on healing.
reported, since we employed a To fully understand the precise
Periotome, which is specially de- changes that occur in the periodon-
signed for atraumatic extraction or tal tissue during the healing period,
luxation, and the root never left the a controlled trial of this surgical pro-
socket during surgical manipula- tocol is needed. However, the clini-
tion, thus minimizing the risk of cal and radiographic findings pre-
dehydration of the PDL. sented here suggest that this
Interestingly, tooth mobility was protocol offers several advantages
minimal after 4 weeks, and there was over the conventional surgical ap-
radiographic evidence of new peri- proaches. The proposed technique
apical bone formation as early as 2 could constitute an alternative sur-
months postoperative. Additionally, gical approach to performing clinical
no endodontic problems could be crown lengthening. This technique
found. Case 1, with incomplete root can be used to successfully treat a
canal treatment, showed the normal severely damaged tooth without
process of periodontal and periapi- producing functional and esthetic
cal healing observed in cases 2 and deformities, especially in the anterior
3. Based on these clinical and radi- region, where esthetics is of great
ographic observations, it seems rea- concern.
sonable to suggest that endodontic
treatment followed by restorative
treatment should be postponed until
at least 2 months after surgery.
The fixation of the extruded
teeth was accomplished only by
means of sutures. This method
seems to allow for some mobility,
thus allowing functional stimulation
throughout the healing period.
Slight mobility during the fixation
period is said to be favorable for the
prognosis by preventing ankylosis
and resorption.20,21 Clinically stable
mobility of the extruded teeth was
achieved within the first month and
maintained during the observation
period. No relapse tendency was
observed. These observations may
corroborate prior studies about the
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Acknowledgment
This work was supported in part by Yonsei
University College of Dentistry, Fund of 2003.
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