KEY WORDS Learning objectives authors

Crown lengthening surgery, gingival • To understand the role of crown
enlargement, altered passive eruption, lengthening surgery and its indications
drug-influenced gingival enlargement, • To be able to evaluate the parameters
hereditary gingival fibromatosis of the history in relation to the patient’s
concerns and formulate a diagnosis
• To consider the correct technique
to achieve the best outcome
Harpoonam Jeet Kalsi, Deborah I. Bomfim, Zahra
Hussain, Jose M. Rodriguez, Ulpee Darbar
Prim Dent J. 2019;8(4):48-53
Harpoonam Jeet Kalsi BDS (Hons),
MSc (Cons), MJDF RCS (Eng) FDS
(Rest Dent) RCS (Eng)
Consultant in Restorative Dentistry, Guy’s
and St Thomas’ NHS Foundation Trust
Deborah I. Bomfim BDS (Hons),
MSc (Cons), MJDF RCS (Eng) FDS
(Rest Dent) RCS (Eng)
Consultant in Restorative Dentistry,
Eastman Dental Hospital
Zahra Hussain BDS, BSc, MSc
(Cons) MFDS RCS (Eng) FDS (Rest
Dent) RCS (Eng)

Crown lengthening Consultant in Restorative Dentistry,

Eastman Dental Hospital

surgery: an overview
Jose M. Rodriguez DDS, MSc,
MFDS, MPros, MRD, PhD
Consultant in Restorative Dentistry, Guy’s
and St Thomas’ NHS Foundation Trust

Ulpee Darbar BDS, MSc, FDS

ABSTRACT (Rest Dent) RCS Eng, FHEA
The term ‘crown lengthening surgery’ refers to a variety of techniques which aim Consultant in Restorative Dentistry,
Eastman Dental Hospital
to expose a greater amount of tooth structure around a tooth or group of teeth.
The decision to treat and which technique to use will depend upon: the underlying
aetiology; a thorough history and examination; results of any supporting
investigations and a clear understanding of the intended outcome of treatment.
This paper aims to provide an overview of crown lengthening surgery and is
illustrated with clinical cases.

Introduction Crown lengthening is a surgical procedure of the patient’s concerns; a detailed

This paper provides an overview of
crown lengthening surgery and highlights
the importance of detailed patient
assessment and treatment planning in
order to achieve the desired outcome.
A brief discussion of the different surgical
techniques and specific factors to
consider will also be covered.
undertaken to expose a greater amount
of the tooth structure either around a
single tooth or a group of teeth. The type
of surgical procedure undertaken will
depend on the indications for treatment,
which can be categorised into two
groups as shown in Table 1.
Successful management of such cases
will depend upon: a thorough assessment
clinical and radiographic examination;
and a clear understanding of the
underlying aetiology. Failure to do
so can leave the patient in a more
compromised position, especially
when aesthetics is the main concern.
Following an initial general discussion
about patient assessment and surgical
treatment planning, this paper is

Ta b l e 1
Indications for treatment and types of surgical procedure undertaken

Indications for treatment Procedures Clinical examples

Group 1 To improve the smile
aesthetics/access for
cleaning in patients with
gingival tissue excess
Group 2 To facilitate restorative
treatment
Usually involves reshaping a Altered passive eruption
and recontouring of the b Hereditary gingival fibromatosis
gingival tissues.
c Drug induced gingival enlargement
In some cases osseous
d Reactionary gingival enlargement
recontouring may be
indicated
Usually involves removing a Access to subgingival caries/other defects
and reshaping of the bone b To create a ferrule for a post crown
and gingival tissues
c To increase clinical crown height prior to restoration

48 p r i m a r y d e n ta l j o u r n a l

Figure 1: A patient with a characteristic
‘gummy smile’ in this case caused by
altered passive eruption
divided into two main sections: crown
lengthening surgery to manage gingival
tissue excess; and crown lengthening
surgery to facilitate restorative treatment.
This should then provide an overview of
the different techniques used to manage
a variety of clinical presentations.
Patient assessment and
surgical treatment planning
In order to achieve predictable, successful
outcomes, careful patient assessment is
required. This is especially important in
Group 1 patients, for whom aesthetics are
often a primary concern. Detailed histories
including medical and family history are
especially important for those patients who
present with gingival tissue enlargement.
This process enables the patient to be
engaged in the decision making and
enables proper valid consent to be gained
for the proposed surgical procedure.
As a part of this process, factors that may
affect the outcome of the surgery must be
discussed, including smoking. Smoking
itself is not an absolute contraindication
to surgical treatment, however a meta-
analysis conducted by Kotsakis et al.
Vol. 8 No. 4 winter 2019/20
in 2015 concluded that the therapeutic
effect of periodontal surgical procedures
in smokers is compromised, therefore
smokers should be encouraged to abstain,
and should always be warned about the
substantial reduction in clinical outcomes.1
A thorough clinical examination should
follow to ensure that any primary disease
has been stabilised and that a crown
lengthening procedure is suitable. A
careful assessment of the patient’s gingival
biotype, and an assessment of the amount
of keratinised tissue present must be taken
into account when planning the type of
surgical procedure required. All normal
pre-surgical assessments must also be
made, including the proximity of nerves,
especially when working in higher risk
zones such as the mandibular premolar
regions. Patients should also be warned
about the possibility of increased spacing
between the teeth which may compromise
the aesthetics; transient root mobility,
transient or long-term root sensitivity
and a small risk of root resorption.2
The following are a number of specific
factors that should be considered
where relevant.
Smile line assessment
An assessment of a patient’s smile line
is essential when considering surgery
within the aesthetic zone. The amount
of gingival shown at rest and at full
smile should be noted and recorded
using clinical photography at baseline.
These photographs will also help with
engaging the patient and getting a better
understanding of their expectations.
Patients may have a ‘gummy smile’
(Figure 1) if they present with ‘altered
passive eruption’, when gingival tissues
fail to retract to their full extent during
eruption; or in patients who have an
enlargement in gingival tissue.
It is equally important to assess the
gingival margin heights and smile line
when considering localised crown
lengthening to a single or small of group
of teeth, for example, for the purposes
of managing broken down or worn teeth.
Often the management of a single tooth
can be more challenging if the effects
on the adjacent teeth and the aesthetics
are not properly considered.
Crown-to-root ratio
and root configuration
High quality periapical radiographs are
essential and allow for the bone support,
endodontic status and root configuration
to be properly assessed. Additional
information such as: root length; proximity
of adjacent teeth; and position of the
furcation in multirooted teeth, can also
be gained and may impact upon the
decision to treat. A radiographic analysis
study conducted by Dibart et al. compared
teeth restored with cast restorations, with
and without surgical crown lengthening,
and suggested that a minimum distance
of 4mm is required from the furcation to
the crestal bone pre-operatively, to reduce
the risk of furcation exposure,3 which may
not always be feasible. Planned exposure
of the furcation must be considered very
carefully due to associated difficulties with
maintenance and increased risk of caries.
Cemento-enamel
junction (CEJ) position
The cemento-enamel junction should
be assessed by inserting a periodontal
probe subgingivally to evaluate its
proximity to the gingival margin and
the alveolar crest. This is especially
important when managing cases
of altered passive eruption as bone
covering the CEJ will need to be
removed in an osseous recontouring
procedure, in combination with apical
flap repositioning.
Types of surgical procedure
The choice of the type of procedure
undertaken will depend on the planned
outcome and the clinical findings,
especially the width of keratinised tissue
present relative to the alveolar crest.
The procedures can be categorised into
three main types:
1 Gingivectomy (the removal of excess
tissue) with or without gingivoplasty
(reshaping and recontouring of
gingival tissue);
2 Apical repositioning of the tissues
with no bone removal;
49
 Crown lengthening surgery:
an overview
Figure 2: Osseous recontouring
being undertaken using Piezosurgery
around a microdont lateral incisor
Figure 3: A patient with the characteristic
features of altered passive eruption
50
3 Apical repositioning of the tissues with
bone removal/osseous recontouring.
Osseous recontouring can be undertaken
using different techniques, such as:
• Hand instrumentation: using periodontal
hand instruments such as chisels and
bone files, but it is technique sensitive
and can be time consuming.
• Use of burs and handpieces: a round
bur may be used in a slow handpiece,
with adequate irrigation; however,
it can be difficult to prevent damage
to root surfaces, especially when
working interdentally.
• Piezosurgery, which is a method of
bone removal based upon ultrasonics,
developed by Vercellotti.4 Voltage
applied across polarized piezoceramic
material causes micromovements within
the handpiece which are capable of
osteoplasty and osteotomy.5 Various
tips are available which can be used
to access difficult areas, such as
interproximally, with the added benefit
that on the ‘bone setting’, it is not
possible to cut tooth (Figure 2).
The type of surgical procedure will also
depend upon whether a patient is in
Group 1 or Group 2.
Group 1: Crown
lengthening in patients
with gingival tissue excess
Excess gingival tissue can have a negative
effect upon smile aesthetics, resulting in a
so-called ‘gummy-smile’, which is often the
reason that treatment is sought. This can
have a significant impact upon a patient’s
confidence and well-being, with many
patients being very conscious of how
they look, particularly if they are being
teased. Treatment is primarily sought
to improve the appearance; however,
a good understanding of the underlying
aetiology is essential for successful
management of these patients.
Prior to treatment, patients should also
be advised that depending upon the
reason for the enlargement they may
be at risk of recurrence of gingival
enlargement and so may require further
surgery in the future. If the patient has
racial pigmentation of their gingivae,
they must be advised that following the
surgery, the colour of their gingivae may
be altered to appear pinker in colour.
Aetiology
Altered passive eruption (APE)
Altered passive eruption (APE) is a
clinical situation produced by excessive
gum overlapping over the enamel
limits, resulting in a short clinical crown
appearance.6 It occurs as a result of a
failure of the gingival tissues to retract to
their full extent, during the passive phase
of tooth eruption. It was first defined
by Goldman and Cohen in 19687
and is characterised by patients with:
a high smile line; thick gingival tissue
biotype and a square appearance of
the clinical crown (Figure 3). Coslet et
al. developed the classification of APE,
which is based upon the relationship
between the gingivae and the underlying
alveolar bone and is outlined in Table 2.8
The management of a case of APE in a
14-year-old girl is shown in Figure 4.
Hereditary gingival fibromatosis
Hereditary gingival fibromatosis (HGF)
is also known as idiopathic gingival
hyperplasia. It is a rare condition
characterised by slow fibrous enlargement
of the keratinised gingivae, which is
non-haemorrhagic, of normal colour
and firm consistency (Figure 5). It can be
associated with a syndrome or present in
isolation. The tissue can often cover the
full extent of the crown of the tooth and
cause discomfort and interference with
function.9
It normally presents in the permanent
dentition, has no sex predilection and
the prevalence is reported as low, at
1/175,000, although several cases
may present within the same family.10
The gingival tissue enlargement will
not resolve spontaneously, and surgical
intervention is often needed. The timing
of this is much debated within the
literature, due to the risks of recurrence.
It has been suggested that treatment
should be delayed until the permanent
teeth have all erupted, however, due
p r i m a r y d e n ta l j o u r n a l
Figures 4a-4d: This 14 year old patient 4a 4b
presented with APE (4a). The first stage
of treatment involved a gingivectomy to
debulk the tissues (4b). This was followed
by a second procedure to undertake further
gingivectomy and osteoplasty. The intra-
surgical photographs pre-osteoplasty (4c)
and post-osteoplasty (4d) are shown. 4e
shows the final post-operative photograph

4c 4d 4e

to the poor associated appearance and • calcium channel blockers, including

effect on oral hygiene, earlier interventions
are often undertaken to maximise local
and psychological benefits.11
In such patients the type of surgery usually
indicated is a combination of gingivectomy
and gingivoplasty. Pre-operative
photographs and study casts can be very
useful in such cases to help with patient
engagement and surgical planning.
Drug-influenced gingival enlargement
Drug-influenced gingival enlargement
(DIGE) is a side-effect of three main
groups of medications administered
for non-dental uses:
• anticonvulsants used to manage
epilepsy such as phenytoin and
sodium valproate;
• immunosuppressant drugs, such
as ciclosporin, prescribed following
organ transplantation or for the
treatment of various auto-immune
diseases;
nifedipine and amlodipine, commonly
used for the management of
hypertension and peripheral
vascular disease.
The gingival enlargement is usually seen
in patients with poor plaque control, which
has been noted to be an exacerbating
factor. It has been suggested that the
medications cause the production of an
inactive form of collagenase, which then
indirectly leads to enlargement of gingival
tissue.12 The first line management of these
patients includes: communication with their
general medical practitioner; alongside
an initial phase of periodontal treatment
involving optimising the plaque control
followed by debridement. In cases where
the medication is changed, resolution may
be seen of the excess tissues, however,
those of long-standing enlargement often
need subsequent surgical correction of
the tissues. Figure 6 shows a case of
DIGE affecting a 68-year-old woman.

Ta b l e 2
Classification of altered passive eruption
as defined by Coslet et al.8
Type 1
Increased width of keratinised tissue
Subgroup A: Distance between CEJ and
alveolar bone crest 1.5-2mm
Subgroup B: CEJ and alveolar bone crest
close or at same level
Figure 5: A 13-year-old male Usually associated with a thick gingival
who presented with HGF and an tissue biotype
associated syndrome
Type 2
Narrow width of keratinised tissue
Subgroup A: Distance between CEJ and
alveolar bone crest 1.5-2mm
Subgroup B: CEJ and alveolar bone crest
close or at same level
Usually associated with a thin gingival
tissue biotype

Vol. 8 No. 4 winter 2019/20 51

 Crown lengthening surgery:
an overview

6a 6b

Reactionary gingival enlargement

Reactionary gingival enlargement is
often seen in patients where there is a
combination of mouth breathing and
possible APE. Figure 7 shows a case
where, after orthodontic treatment, there
was excess gingival tissue compromising
the appearance. The tissue was simply
resected and reshaped, and one-week post-
surgery there was significant improvement.
Group 2: Crown
lengthening to facilitate
restorative treatment
There are a number of clinical situations
which may require surgical crown
lengthening to facilitate the provision of
a predictable restoration or restorations,
which have been outlined in Table 1. In
each of these scenarios, crown lengthening
surgery is required to maintain the health
of the gingival tissues by preserving the
supracrestal tissue attachment, formerly
known as the biologic width.
Figure 6a: (pre-operative) and 6b (post-operative): This 68-year-old presented with
a primary complaint of bleeding swollen gums. She was taking Nifedipine to manage
her hypertension. She was managed with a change in medication through her GP,
intensive oral hygiene instruction and two courses of non-surgical debridement under
local anaesthetic. Her teeth of poor prognosis in the maxilla were also extracted
and a denture was provided. Surgery was also planned around the lower left quadrant
where the enlargement failed to fully resolve
sulcus depth (0.69mm), epithelial Evidence from human studies
attachment (0.97mm) and connective demonstrates that infringement within the
tissue attachment (1.07mm), which supracrestal connective tissue attachment
gave a mean length of 2.73mm for the is associated with gingival inflammation
dentogingival junction, i.e. between the and loss of periodontal supporting
crestal bone level and gingival margin. tissue, however it is not yet clear whether
Recently this terminology has been these negative effects are due to dental
reviewed and it has been suggested plaque biofilm, trauma, toxicity of
that the term ‘biologic width’ be replaced dental materials or a combination of
with ‘supracrestal tissue attachment’.14 these factors.14 Nevins and Skurow

Biologic width/supracrestal 7a 7b
attachment
The ‘biologic width’ concept was first
described by Gargiulo in 1961, following
a histological study in human autopsy
specimens, examining the relationship
between the various components
involved in periodontal attachment.13
Average values were calculated for

7c

7d

Figures 7a-7d: Management of

reactionary gingival enlargement.
7a: Pre-operative 7b: Intra-operative
7c: Immediate post-operative
7d: one-week post-operatively

references
1 Kotsakis GA, Javed F, Hinrichs JE,
Karoussis IK, Romanos GE. Impact
of cigarette smoking on clinical
outcomes of periodontal flap surgical
procedures: a systematic review and
meta-analysis. J Periodontol. 2015
Feb;86(2):254-63.
2 Cunliffe J, Grey N. Crown
lengthening surgery--indications
and techniques. Dent Update.
2008 Jan;35(1):29-5.
3 Dibart S, Capri D, Kachouh I,
Van DT, Nunn ME. Crown
lengthening in mandibular molars:
a 5-year retrospective radiographic
analysis. J Periodontol. 2003
Jun;74(6):815-21.
4 Vercellotti T. Technological
characteristics and clinical
indications of piezoelectric bone
surgery. Minerva Stomatol. 2004
May;53(5):207-14.
5 Labanca M, Azzola F, Vinci R,
Rodella LF. Piezoelectric
surgery: twenty years of use.
Br J Oral Maxillofac Surg. 2008
Jun;46(4):265-9.
6 Alpiste-Illueca, F. Altered passive
eruption (APE): a little known
clinical situation. Med Oral
Patol Cir Bucal. 2011 Jan 1;
16(1)e100-4.
7 Goldman HM, Cohen DW.
Periodontal Therapy, de 4 St. Louis,
C.V. Mosby Company 1968.
8 Coslet GJ, Vanarsdall R, Weisgold
A. Diagnosis and classifica- tion
of delayed passive eruption of the
dentogingival junction in the adult.
Alpha Omegan. 1977;10:24-8.
9 Bozzo L, de Almedia OP, Scully
C, Aldred MJ. Hereditary gingival
fibromatosis. Report of an extensive
four-generation pedigree. Oral
Surg Oral Med Oral Pathol.
1994 Oct;78(4):452-4.

52 p r i m a r y d e n ta l j o u r n a l
8a 8b Figures 8a-8d: Figure 8a shows the
pre-operative photograph of a patient
with tooth wear planned for crown
lengthening surgery prior to restoration
of the teeth. Planning was undertaken
on the study casts to determine where the
final gingival margins would be located
(8b). A stent to use during surgery was
constructed from a duplicate of the wax-up
(8c). Following surgery and a period
8c 8d of healing, the final resin composite
restorations were placed (8d)

also described the importance of a
3mm biological dimension separating
the osseous crest from the plaque
associated with crown margins; it was
recommended that the extension of
crown margins be limited to 0.5-1mm
subgingivally, as it is impossible for
the clinician to detect exactly where
the sulcular epithelium ends and the
junctional epithelium begins.15
Pre-operative planning
In these patients, the preoperative
planning is essential to ascertain the
degree of crown lengthening which
will maintain health but allow for the
intended outcome to be achieved.
Once the basic assessment has been
completed and a decision has been
made to crown lengthen, the intended
clinical crown height can be planned
using study casts and diagnostic wax-
ups. The wax-up is undertaken by
reshaping the ‘gingival tissues’ to the
desired position. This cast may then
be duplicated and used to construct
a surgical stent which can be trimmed
accurately to the planned gingival
margin and used to assist bone removal
at the time of surgery. For complex cases
such as management of tooth wear, this
can help to achieve predictable outcomes
as demonstrated in Figure 8. For single
teeth, this is not essential but failure to
consider the adjacent teeth can result in
poor outcomes and dissatisfied patients.
Post-operative
considerations
Once the surgery has been completed,
a decision has to be made regarding
the ideal time to place the definitive
restoration. In terms of healing, patients
with thick gingival biotypes are more
likely to suffer from rebound, whereas
those with thinner gingival tissue will
be more prone to recession.
It has been demonstrated that it can
take up to twenty weeks for the gingival
margin position to stabilise post-surgery
in the anterior region.16 Bragger assessed
the changes post crown lengthening
surgery over a six-month period; 25
patients with 85 teeth were included in
this study and the conclusion was that
creating a distance of 3mm from the
alveolar crestal bone level to the gingival
margin leads to stable periodontal tissue
after six months.17 Attachment levels
did not change after six weeks which
supports restoration placement after six
weeks for teeth not within the aesthetic
zone. However, anteriorly it is sensible to
wait for six months before placement of
the definitive restorations especially when
planning indirect restorations. If direct
restorations such as resin composites
are planned, it may be more feasible
to restore sooner than this as some
degree of modification is possible.
Conclusions
Crown lengthening surgery can provide
patients with improved smiles and
outcomes with predictability if executed
with care and attention to detail. A clear
understanding of the aetiology and the
different techniques available is crucial
for the clinician to be able to ensure that
the patient receives the best possible care.
As with every patient, successful outcomes
depend upon an accurate diagnosis
formed on the back of a thorough history
and clinical examination, with careful
planning tailored to the individual.

10 Alminana-Pastor PJ, Buitrago
PJ, Alpiste-Illeuca FM, Catala-
Pizarro M. Hereditary Gingival
Fibromatosis: Characteristics and
treatment approach. J Clin Exp Dent
2017 Apr;9(4)e599-e602.
11 Coletta RD, Graner E. Hereditary
gingival fibromatosis: a systematic
review. J Periodontol. 2006
May;77(5):753-64.
12 Kataoka M, Shimizu Y, Kunikiyo K,
et al. Cyclosporin A decreases the
degradation of type I collagen in rat
gingival overgrowth. J Cell Physiol.
2000 Mar;182(3):351-8.
13 Gargiulo AW, Wentz FM, Orban
B. Dimensions and Relations of the
dentogingival junction in Humans.
Oral Surg Oral Med Oral Pathol.
1961 Apr;14:474-92.
14 Jepsen S, Caton JG, Albandar JM,
et al. Periodontal Manifestations
of Systemic Diseases and
Developmental and Acquired
Conditions: Consensus Report of
workgroup 3 of the 2017 World
Workshop on the Classification
of Periodontal and Peri-Implant
Diseases and. Conditions. J Clin
Periodontol. 2018;45(Suppl
20):S219-S229.
15 Nevins M, Skurow HM. The
intracrevicular restorative margin,
the biologic width, and the
maintenance of the gingival
margin. Int J Periodontics Restorative
Dent. 1984;4(3):30-49.
16 Wise MD. Stability of gingival
crest after surgery and before
anterior crown placement. J Prosthet
Dent. 1985 Jan;53(1):20-3.
17 Bragger U, Lauchenauer D, Lang
NP. Surgical lengthening of the
clinical crown. J Clin Periodontol.
1992 Jan;19(1):58-63.

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