Restoring teeth following crown lengthening procedures

David Assif, D.M.D.,* Raphael Pilo, D.M.D.,** and Barry Marshak, B.D.S.**
The Maurice and Gabriella School of Dental Medicine, Sackler Faculty of Medicine, Tel-Aviv
University, Tel Aviv, Israel

Crown lengthening procedures are often necessary to successfully restore teeth

that have been mutilated at or below the level of the bone crest. Forced eruption is
preferred to surgical removal of supporting alveolar bone, since forced eruption
preserves the biologic width, maintains esthetics, and at the same time exposes
sound tooth structure for the placement of restorative margins. To properly
construct a crown, the minimal distance from the alveolar crest to the coronal
extent of sound tooth structure should be 4 mm. Before initiation of forced eruption,
the restorability of the root after completion of the orthodontic phase must be
considered. A technique is suggested to calculate the root-to-crown ratio that will
be created after root extrusion with respect to the coronal level of sound tooth
structure before treatment. (J PROSTHET DENT 1991;65:62-5.)

I n order to support and retain a cast restoration, the Table I. Values of average crown height, root length,
clinical crown of the tooth must provide adequate bracing, and root-to-crown ratio for maxillary and mandibular
retention, and resistance.l Sound tooth structure may be teeth
present only at or below the level of the bone crest. The Crown height Root length
presence of sufficient sound tooth material coronal to the Tooth (mm)* (mm)* R/C
bone crest is essential to satisfy the following criteria2: (1)
Maxilla
the placement of the margins of the cast restoration on
Central incisor 10.5 13.0 1.24
sound tooth structure; (2) preservation of the biologic Lateral incisor 9.0 13.0 1.44
width together with a healthy periodontium; (3) the abil- Canine 10.0 17.0 1.70
ity to make an impression of the prepared tooth; and (4) First premolar 8.5 15.0 1.76
esthetics. Second premolar 8.5 14.0 1.65
These teeth usually have undergone endodontic therapy.
The first step in the reconstruction is the construction of Mandible
a post and core. The margins of the final restoration must Central incisor 9.0 12.5 1.39
Lateral incisor 9.5 14.0 1.47
embrace at least 2 mm of sound tooth structure apical to
Canine 11.0 15.0 1.36
the inferior border of the core material, which usually re-
First premolar 8.5 14.0 1.65
quires a crown lengthening procedure. This procedure can Second premolar 8.0 14.5 1.81
be carried out by surgical or orthodontic techniques, or by
a combination of the two.3 *Data from Kraus BS, et al. Dental anatomy and occlusion. Baltimore: The
Williams & Wilkins Co., 1980:5-115.
SURGICALLY LENGTHENING CLINICAL
CROWNS
Lengthening the clinical crown by removing supporting from adjacent teeth to create a normal bony architecture
alveolar bone to expose more sound tooth structure may be may severely compromise these teeth; (5) should the
effective, but usually produces other problems.4 Some of ostectomy expose furcations, exceptional oral hygiene
these are: (1) it is difficult to perform an ostectomy on a measures are needed to preserve the tooth; and (6) teeth
single anterior tooth without creating an esthetic defor- that have short or concial roots may exhibit excessive mo-
mity; (2) following’removal of bony support, an inverse and bility after surgery, and should the conditions for splinting
unfavorable root-to-crown ratio (R/C) can be expected due of adjacent teeth not be favorable, alternative treatment is
to the resultant long clinical crown; (3) if the osseous sup- indicated.
port of the tooth is questionable before surgery, additional
removal of bone further decreasesthe R/C so that restora-
FORCED ERUPTION OF TEETH
tion becomes impractical; (4) removal of supporting bone Heithersay5 and Ingbe# suggested the use of forced
eruption for treatment of teeth with sound tooth structure
at or below the bone crest, and for isolated osseousdefects.
*Coordinator, Senior Clinical Lecturer, Department of Pros-
thodontics. The objectives include conservation of bone, preservation
**Instructor, Department of Prosthodontics. of biologic width, exposure of sound tooth structure for the
10/l/23149 placement of restorative margins, and maintenance of es-

62 JANUARY 1991 VOLUME 86 NUMBER 1

ROOT-TO-CROWN RATIO PRETREATMENT STUDY

Table II. Expected values of root-to-crown ratio following extrusion

Amount of sound tooth
structure coronal to Amount of sound tooth structure
alveolar crest (mm) apical to alveolar crest (mm)
Alveolar
Tooth 3 2 1 crest 1 2 3 4 5

Maxillary 1.60 1.50 1.40 1.30 1.20 1.10 1.00 0.90 0.80
canine
Mandibular 1.69 1.56 1.43 1.31 1.19 1.06 0.94 0.81 0.69
2nd premolar
Maxillary 1.65 1.53 1.41 1.29 1.18 1.06 0.94 0.82 0.71
1st premolar
Maxillary 1.53 1.41 1.29 1.18 1.06 0.94 0.82 0.71 0.59
2nd premolar
Mandibular 1.53 1.41 1.29 1.18 1.06 0.94 0.82 0.71 0.59
1st premolar
Mandibular 1.37 1.26 1.16 1.05 0.95 0.84 0.74 0.63 0.53
lateral incisor
Maxillary 1.33 1.22 1.11 1.00 0.89 0.78 0.67 0.56 0.44
lateral incisor
Mandibular 1.27 1.18 1.09 1.00 0.91 0.82 0.73 0.64 0.54
canine
Mandibular 1.28 1.17 1.05 0.94 0.83 0.72 0.61 0.50 0.39
central incisor
Maxillar 1.14 1.05 0.95 0.86 0.76 0.67 0.57 0.48 0.38
central incisor

Values to left of solid zig-zag line are acceptable; vslues to right of solid zig-sag line are unacceptable.

thetics. For these reasons, the method of forced eruption is
preferable.
Forced eruption facilitates the preservation of biologic
width of the periodontium, which has been defined as the
total dimension. of the epithelial and connective tissue at-
tachment to the root. In periodontal health, this dimension
averages 2.04 mm and consists of 0.97 mm width for the
junctional epithelial attachment plus 1.07 mm of connec-
tive tissue attachment above the bone crest (the bone crest
ideally is located 1 mm apically to the cementoenamel
junction [CEJ]). An additional 2 mm of sound tooth struc-
ture is necessary coronal to the epithelial attachment to al-
low placement of the restorative margin. A properly con-
structed crown :must have bracing on sound tooth structure
and should not impinge on the epithelial attachment. Thus
the distance from the alveolar crest to the coronal border
of sound tooth structure should be a minimum of 4 mm.7
Forced erupt:ion is indicated in the anterior region of the
dentition where esthetics is of major concern. Posteriorly
in the dental arch, surgical crown lengthening may be more
appropriate because flared molar roots may present prox-
imity problems if extruded, and esthetics is of less impor-
tance. Tipping and unfavorable axial tooth position may
also preclude extrusion.7
DETERMINING RESTORABLE TEETH
A simple approach is suggested to assesswhether teeth
can be restore’d according to the principles previously
mentioned; i.e., by creating 4 mm of sound tooth structure
coronal to the alveolar crest with 2 mm bracing on sound
tooth structure and 2 mm biologic width, and at the same
time maintaining suflicient alveolar support for preserva-
tion of the tooth.
Tables I and II present the basis for establishing whether
the restorative procedures needed to maintain the tooth in
the arch are compatible with the previously mentioned
principles. Table I presents the values of the average crown
height (coronal to the CEJ) and root length for maxillary
and mandibular teeth.8 Table II presents the R/C ratio that
will be achieved following extrusion as related to coronal
level of sound tooth structure before extrusion (with
respect to the alveolar crest).
Calculations are based on two assumptions: (1) the clin-
ical crown remains unchanged following extrusion as the
bone crest remains untouched and (2) the root length is re-
duced by the amount of extrusion needed to create 4 mm
of sound tooth structure coronal to the alveolar crest.
Table II is divided into two sides. To the left of the solid
vertical zig-zag line, an R/C ratio of 1 or more is created. To
the right of the solid vertical zig-zag line,’ an R/C ratio of
less than 1 is created. The number 1 was chosen because an
R/C ratio of less than 1 is considered unfavorable, with a
poor prognosis for a lasting restoration.’
The maxillary canine may be used as an example for po-
tential restorability. The canine has an average crown
height of 10 mm and a root length of 17 mm, with an R/C
of 1.7 (Table I). For a fracture 3 mm apical to the alveolar
crest, the root must be extruded 7 mm to render the tooth

THE JOURNAL OF PROSTHETIC DENTISTRY 63


Fig. 1. Arrow indicates space available for clinical
crown.
restorable. The 7 mm includes 3 mm needed to bring the
root to the level of the crest and to provide sufficient reten-
tion for the restoration.
The remaining effective root length will be 10 mm (17 - 7
mm) and, as the crown height remains 10 mm, the new
R/C ratio will be 1. Thus the tooth can be extruded 7 mm
and yet still be restored within its biologic and mechanical
limits. The maxillary canine is the tooth with the most fa-
vorable prognosis for successful treatment (Table II). The
poorest candidate is the maxillary central incisor. Even le-
sions 1 mm coronal to the alveolar crest (CEJ) cannot be
treated by extrusion and create a favorable R/C ratio of 1
or more.
INITIATION OF FORCED ERUPTION
Before initiation of forced eruption, the restorability of
the tooth after the orthodontic phase should be considered.
The following steps are advised.
1. Estimate the length of the healthy root embedded in
bone from the radiograph.
2. Estimate the space available for the clinical crown.
Articulated diagnostic casts may be used as an aid (Fig. 1).
3. Calculate the amount of eruption necessary to restore
the tooth (4 mm sound tooth structure coronal to the alve-
olar crest).
4. Calculate the effective root length remaining after
root extrusion and divide it by the clinical crown height as
measured in step 2. If the result is 1 or more, then favor-
able conditions exist for completion of the restorative pro-
cedures. If the result is less than 1, then root extrusion will
not provide the necessary basis for a properly constructed
cast restoration.
DISCUSSION
A basis has been presented for calculating the restorabil-
ity of any tooth. When the numbers fall within those pre-
sented inTable I, Table II will show the restorability of the
tooth when the defect in the root is related to the alveolar
64
ASSIF, PILO, AND MARSHAK
crest. For example, if a maxillary second premolar has a
coronal level of sound tooth structure 1 mm apical to the
alveolar crest before extrusion, the resulting R/C following
extrusion will be 1.06. This number is to the left of the zig-
zag line, with subsequent favorable conditions for restora-
tion.
Teeth that have undergone endodontic therapy and have
lost most or all coronal structure will require a post to re-
tain a core for support and retention of the final cast res-
toration. Ideally, the optimal post length should at least
equal that of the clinical crown9 A minimum 3 mm apical
seal should be left after creating the space for the post.
From this it can be determined that the effective root
length supporting the clinical crown should be at least 3
mm longer than the clinical crown. Any length less than
this will require a shorter post (a minimal apical seal of 3
mm must be left untouched). To meet the demands of
maintaining such an effective root length, (previously de-
fined as clinical crown length plus 3 mm apical seal), the
zig-zag line in Table II must be shifted three steps to the
left. This effective root length severely limits the potential
restorability of these teeth, even following successful ex-
trusion. Placing a post to the depth recommended in the
literature further limits the reconstruction procedure.gl lo
Thus most teeth needing posts and requiring extrusion will
not have sufficient length to provide the recommended post
length (Table II). Shorter posts may be necessary to avoid
placing these teeth in an unrestorable category.
REFERENCES
1. Shillingburg HT, Hobo S, Whit&t LD. Fundamentals of fixed pros-
thodontics. 2nd ed. Chicago: Quintessence Publishing Co, 1981:19-20,
79-86.
2. Ingber JS. Forced eruption. Part II. A method of treating non-restor-
able teeth-periodontal and restorative considerations. J Periodont
1976;47:203-16.
3. Stern N, Brocker A. Forced eruption: biological and clinical consider-
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4. Baima RF. Extension of clinical crown length. J PROSTHET DENT
1986;55:547-51.
5. Heithersay GS. Combined endodontic-orthodontic treatment of trans-
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1973;36:404-15.
6. Ingber JS. Forced eruption. Part I. A method of treating isolated one
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Periodont 1974;45:199-206.
7. Thomson GK, Sivers JE. Forced eruption in crown lengthening proce-
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8. Kraus BS, Jordan RE, Abrams L. Dental anatomy and occlusion. Bal-
timore, Md: The Williams & Wilkins Co, 1980:5-115.
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Reprint requests to:
DR. DAVID A~SIF
THE MAURICE AND GABRIELLA SCHOOL OF DENTAL MEDICINE
TEL-AVIV UNIVERSITY
RAMAT-AVN 69978
TEL-AVIV
1SRAEL
JANUARY 1991 VOLUME 61 NUMBER 1