Esthetic Crown Lengthening

ECL

Abdusalam Alrmali
OMFS
Faculty of dentistry
Tripoli University Libya
 Types of crown lengthening

 Clinical significance of Biological width : spurabony

component of the root

 Altered passive eruption

 Plan for ideal gingival margin

 Incision & flap design

 Bone surgery osteoplasty & osteoectomy &

Clinical cases
Esthetic VS functional CL
Esthetic Crown Lengthening
 “ Biologic width is the combined width of
connective tissue and epithelial attachment
superior to the crestal bone.”

(Garguilo et al. 1961)

 “ Biologic width is the sum of the space occupied

by the supracrestal fibres, junctional epithelium and
the gingival sulcus and has a proposed minimal
dimension of 3 mm.”

(Nevins and Skurow)

• Mean depth of the
histologic sulcus is 0.69
mm,
• Mean junctional
epithelium measures 0.97
mm (0.71-1.35 mm),
• Mean supraalveolar
connective tissue
attachment is 1.07 mm
(1.06-1.08 mm).
• A minimum biologic width of only 1.0mm
is necessary. An additional 1 to 3mm of
exposed root coronal to the bone is
required for the creation of a healthy
gingival sulcus

Palomo and Kopczyk

(JADA – 1978)
Supragingival
or 0.5 mm
subgingival
 SEQUEL OF BIOLOGICAL WIDTH
VIOLATION
Signs and symptoms:

Chronic pain
Chronic progressive
inflammation of gingiva
Bleeding on probing
Gingival recession
 Pocket formation
Clinical attachment loss
Gingival hyperplasia
Unpredictable loss of alveolar bone
Localized gingival hyperplasia with minimal
bone loss
 Biologic width violations can be
corrected by

• 1. Either surgically removing bone away from

proximity to the restoration margin,

• 2. Orthodontic ally extruding the tooth and

thus moving the margin away from the
bone.
Gummy smile
Understanding patient’s concern
Vertical maxillary Orthognathic
excess with orthodontic

Altered active Orthodontic

eruption treatment

Altered passive Periodontal

eruption surgery
 SY N O P T I C T R EAT M E N T P L A N N I N G
Shaza Bishti, BDS, Dr.med.dent Abdusalam Alrmali , BDS,MSc, FICOI
Department of Prosthodontics and Biomaterials, Department of Oral and Maxillofacial Surgery, Faculty of
RWTH Aachen University Hospital Dentistry, Tripoli University
EST H E T I C C H EC K L I ST ( F RO N T T E E T H )
 EST H E T I C C H EC K L I ST ( F RO N T T E E T H )

 Midline
 Tooth axis
 Gingival course
 Zenith of the marginal gingiva
 Interdental triangle
 Interdental contact point
 Tooth form
 Incisal edge
 Interdental angle
 Grooves and fissures
 Smile line
 Course of the incisal edge
Esthetic Crown Lengthening

Altered passive eruption

 Teeth eruption
Active eruption Passive eruption
• Bodily movement of teeth • Apical recession of soft
toward functional position tissue
 Altered active eruption

• Overeruption of teeth • Incomplete eruption of

• Coronal incisial edge
• Normal clinical crown
• ABC has normal
relationship with CEJ
teeth
• Apical incisal edge
• Short clinical crown
• ABC has abnormal
relationship with CEJ
Clinical diagnosis of altered passive eruption

Locate CEJ

No yes

Short clinical crown

Diagnosed as is due to incisal
Perform bone
altered passive wear or variation in
sounding
eruption anatomy
1. BONE SOUNDING
CATEGORIES OF
BIOLOGIC WIDT

 Normal crest
 Low crest
 High alveolar
crest

Kois(1996)
Normal
 dentogingival complex
normal crest

a crown margin which is placed 0.5 mm subgingivally

tends to be welltolerated by the gingiva
not possible to place an intracrevicular margin because
the margin will be too close to the alveolar bone
 As the injured attachment heals, it tends to heal
back to a Normal Crest position, resulting in gingival
recession.
2. Chus
gauge
3. CBCT
4. Surgical guide
 Classification of altered passive
eruption
Type 1 Wide band of keratinized tissue

Type 2 Narrow band of keratinized tissue

Subgroup Distance between ABC & CEJ < 1mm

A

Subgroup B Distance between ABC & CEJ >1mm

 Amount
of KG

Gingival
margin
position
CEJ
CEJ & ABC
relationship
 Gingival
Width of KG phenotype
  Distance from crest of gingiva to
Gingivectomy alveolar crest is 5 mm
 2mm of gingiva is removed
 Sufficient cervice depth

 CEJ is at the base of the sulcus

Apically  Distance from crest of gingiva to crest

displaced flap
of bone is 3mm (bone sounding)
 Short clinical crows with inSufficient
cervice depth
 Surgical steps
• Internal or external bevel incision
1 • Apically displaced flap or gingivectomy

• Osteotomy
2 • Reduction of bone height

• Osteoplasty
3
• Reduction of bone thickness
 Situation 1
Gingival overgrowth
Normal ABC relationship with CEJ
Sufficient width of KG

GINGIVECTOMY
 Situation 2
 Gingival overgrowth
 Abnormal ABC relationship with CEJ
 Sufficient width of KG

GINGIVECTOMY &
OSSEOUS RESECTION
 Situation 3
Gingival overgrowth
Abnormal ABC relationship with CEJ
Insufficient width of KG

OSSEOUS RESECTION
FLAP??
Type of incision
 Type of flap

Partial thickness Full thickness

 Bone reduction
Vertical Horizontal
Osteoectomy Osteoplasty
 3mm apical to the NEW gingival margin
To accommodate the sulcus depth & the attachment
Esthetic Crown Lengthening
Esthetic Crown Lengthening