DENTAL TECHNIQUE

Periodontal plastic surgery for esthetic crown lengthening by

using data merging and a CAD-CAM surgical guide
Gerardo Mendoza-Azpur, DDS, MSc,a Heydi Cornejo, DDS,b Milton Villanueva, DDS,c Renato Alva, DDS,d and
André Barbisan de Souza, DDS, MSce

Esthetic clinical crown length- ABSTRACT

ening (ECL) is a widely used
This article introduced a digital workflow by using data merging and a computer-aided design and
procedure to treat cosmetic computer-aided manufacturing (CAD-CAM) milled surgical guide for an esthetic crown lengthening
problems related to excessive procedure. The superimposition of intraoral scanning, digital photographs, cone beam computed
gingival display and short tomography, and a CAD-CAM surgical guide should increase the predictability of esthetic crown
clinical crowns.1,2 Some situa- lengthening surgery. (J Prosthet Dent 2020;-:---)
tions might also include
restorative treatment and appropriate surgical and pros- The digital workflow has been demonstrated to
thetic planning becomes paramount for predictable increase the predictably of dental procedures, including
results.3 Different protocols have been developed to computer-aided design and computer-aided manufacturing
achieve correct surgical planning and satisfactory es- (CAD-CAM) restorations and computer-assisted implant
thetics outcomes.4 Diagnostic waxing, image manipula- surgery.8 However, evidence and standardization regarding
tion, numerical guide patterns, radiographic evaluations, the digital workflow applied for periodontal plastic surgical
and measurements of the gingival tissue are among the procedures is lacking. Therefore, the purpose of this dental
resources available for the ECL procedure.5 However, technique was to introduce a digital workflow by using data
none of them provide a precise reference.6 Another merging and a CAD-CAM surgical guide for an ECL
important factor is optimal communication between procedure.
restorative dentist and periodontist for treatment plan-
ning the appropriate pink and white esthetics.5 TECHNIQUE
A comprehensive periodontal evaluation is essential
to identify the clinical dimensions of the periodontal 1. Make intraoral surface scans of the maxilla and
tissues and their association with radiographic or tomo- mandible and an occlusal record in maximum
graphic landmarks.4,7 In addition, although a series of intercuspal position with an intraoral scanner
photographs is helpful for esthetic planning, information (Medit i500; MEDIT Corp), obtain standard tessel-
to predict the management of the bone structure and lation language (STL) files (Fig. 1A), and export
gingival tissues before the surgical procedure is lacking. them from the scanner to software program (Medit
Therefore, merging 3-dimensional (3D) cone beam Link V2.1.2; MEDIT Corp).
computed tomography imaging with intraoral surface 2. Obtain standardized photographs for the digital
scanning would increase the predictability of the ECL design record as minimally processed image data
procedure. (RAW) files consisting of a front smile photograph

a
Chairman, Department of Periodontology, School of Dentistry, Universidad Cientifica Del Sur, Lima, Peru.
b
Graduate student, Department of Periodontology, School of Dentistry, Universidad Cientifica Del Sur, Lima, Peru.
c
Periodontist, Private Practice, Lima, Peru.
d
Graduate student, Department of Periodontology, School of Dentistry, Universidad Cientifica Del Sur, Lima, Peru.
e
Assistant Professor, Department of Prosthodontics, Tufts University School of Dental Medicine, Boston, Mass.

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Figure 1. A, Intraoral scan. B, Outline of crown lengthening based on smile design. C, Superimposition of intraoral surface scan with digital
photographs.
Figure 2. A, Computer-assisted design of surgical guide superimposed with cone-beam computed tomography. B, Surgical design including outlines
for gingivectomy and ostectomy.
and one with lip retractors in manual mode with
an aperture of ISO200, f11, shutter speed 1/250,
and ring-flash at one-third power. Superimpose
the photographs with the STL file (Fig. 1B,1C) by
using specific landmarks in the CAD-CAM soft-
ware program (DentalCad 2.2 Valletta; Exocad
GmbH).
3. Make a cone beam computed tomography
(CBCT) (Dental Picasso Master 3D; VATECH)
scan to obtain a digital imaging and communi-
cations in medicine (DICOM) file. Import the STL
files from intraoral scanning, the RAW files from
the photographs, and the DICOM file into a
CAD-CAM software program (DentalCad 2.2
Valletta; Exocad GmbH). A smile creator module
should be used to process a digital smile design to
achieve outstanding clinical outcomes and meet
the patient’s expectations (Fig. 1B,1C).
4. After digital diagnostic waxing, obtain a new 3D-
printed cast (Photon S 3D Printer; ANYCUBIC).
Trial restorations could also be made based on the
3D-printed cast to confirm the acceptability of the
proposed procedures. At the virtual planning,
record the distance between the initial gingival
margin and bone crest as a baseline measurement
of the patient’s biologic width. Subsequently,
produce a 3-mm-thick surgical guide delimiting
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the new gingival margin and the location of the
patient’s marginal bone crest in a CAD software
program (Meshmixer 3.5; Autodesk Inc) (Fig. 2).
Once the design has been successfully completed,
export the file to a milling machine (Rainbow
Mill-Zr Plus; Dentium) and mill a transparent
polymethyl methacrylate (PMMA) block (Telio
CAD; Ivoclar Vivadent AG) (Fig. 3).
5. Clinically evaluate the fit of the surgical guide
(Fig. 4). The surgical technique consists of an in-
ternal bevel incision using the PMMA guide as
reference, starting from the gingival margin with a
15C scalpel or an SM64 scalpel and being careful
to preserve the gingival papillae. Subsequently,
remove the surgical guide and gently elevate a full-
thickness flap with a periosteal elevator (PGerardo
Elevator; USA-Delta) (Fig. 5).
6. Verify the marginal bone crest position assisted by
the surgical guide (Fig. 6) to determine where
ostectomy is necessary with predictable bone con-
tour guidance. For the ostectomy, use a flat-tipped
truncated cone drill (958 FG Surg End Cutting
Carbide; BRASSELER USA) with smooth lateral
surfaces and only an active tip which allows bone
removal without touching tooth structure (Fig. 7).
7. Reposition the flap and place vertical mattress sutures
using polyglactin 910 (Coated Vicryl 5.0; Ethicon)
Mendoza-Azpur et al
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Figure 3. Milled polymethyl methacrylate (PMMA) surgical guide.
Figure 5. Papilla elevation following gingivectomy.
Figure 7. Ostectomy using cone drill with only active tip.
with the suture ending toward the palate to decrease
its visibility from the facial aspect (Fig. 8).
8. Provide comprehensive postoperative instructions
to the patient. Prescribe postoperative medications
as per the surgical protocol.
9. Fourteen days after the surgical procedure, remove
the sutures and follow up at 3 and 6 months (Fig. 9).
Mendoza-Azpur et al
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Figure 4. Intraoral presurgical facial view of surgical guide in position.
Figure 6. Surgical guide in position after full-thickness flap elevation
showing outlines for ostectomy.
Figure 8. Palatal view immediately after surgery.
DISCUSSION
This dental technique introduces a digital workflow
consisting of data merging and a computer-milled sur-
gical guide for ECL. A virtually designed and milled
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Figure 9. Frontal photographs. A, Before surgical procedure. B, At
3-month follow-up.
surgical guide can be used as a reference for the amount
of gingivoplasty, ostectomy, and osteoplasty in situations
requiring esthetic planning.
Computer software programs enable data merging
and manipulation for appropriate diagnosis, surgical,
and restorative digital planning.8 In the virtual planning,
not only can the tomographic imaging be seen but also
clinical crowns, periodontal soft tissues, and diagnostic
waxing or trial restorations. With a 3D-printed or milled
surgical guide, predictable ECL surgery and restorative
outcomes can be achieved.9 Where the treatment plan
includes restorative procedures, adequate healing time
for the periodontal tissues should be provided.7,10 The
digital workflow using this protocol brings together
clinical evaluation with periodontal probing, evaluation
of periodontal phenotype, and assessment of hard tis-
sues with CBCT imaging, which specifies the disposition
and angle of the facial bone and inclination of the roots.
All this information together with digital photographs
and intraoral scanning allows the preparation of the
surgical guide for greater precision in the surgical steps
guided by the prosthetic goals.
This dental technique described how a digital work-
flow with data merging can be applied for ECL
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procedures with the aid of a CAD-CAM surgical guide.
However, comparative clinical trials are necessary to
validate the technique. Future investigations should also
evaluate different impression materials or scanner sys-
tems to determine the most appropriate protocols.
SUMMARY
This article introduced a novel digital workflow with data
merging for ECL procedure. The superimposition of a
data set and fabrication of a CAD-CAM surgical guide
should increase predictability and reduce surgical time for
ECL surgery.
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Corresponding author:
Dr André Barbisan De Souza
Assistant Professor
Tufts University School of Dental Medicine
One Kneeland St, DHS 1242 e 02111
Boston, Mass, USA
Email: andre.de_souza@tufts.edu
Copyright © 2020 by the Editorial Council for The Journal of Prosthetic Dentistry.
https://doi.org/10.1016/j.prosdent.2020.09.041
Mendoza-Azpur et al