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Contemporary Crown-lengthening Therapy

2010 Jun;141(6):647-55. Timothy J. Hempton, DDS; John T. Dominici, DDS, MS School of Dental Medicine, Tufts University, Boston, MA, USA.

Presenter: R2 Instructor: VS Date: 2012-11-30

Introduction
Significant caries or subgingival fractures
Clinical findings vs. patients' concerns extracted or restored? An age of dental implants

Outlines
1 2 3 4

Rationales Basic procedures Wound healing Discussion

Rationale

A. Esthetic and functional concerns

B. Biological width
C. Ferrule length

Rationale

A. Esthetic and functional concerns


Exposure of subgingival caries Exposure of a fracture High lip line, delayed passive eruption, excess gingival display contact area~interdental osseous crest >5 mm

Rationale

B. Biological width
Gargiulo and colleagues

Rationale

B. Biological width
Chronic inflammation Bone resorption
Ingber and colleagues

Biologic width > 3 mm


Reduce periodontal attachment loss induced by subgingival restorative margins

Rationale

B. Biological width
Chronic inflammation Bone resorption
Ingber and colleagues

Biologic width > 3 mm


Reduce periodontal attachment loss induced by subgingival restorative margins

Rationale

C. Ferrule length
A metal band or ring used to fit the root or crown of a tooth. (The
Journal of Prosthetic Dentistry's 2005)

A 360-degree metal collar of the crown surrounding the parallel walls of the dentine extending coronal to the shoulder of the preparation. (Sorensen and Engelman)

Rationale
Foundation restorative material

C. Ferrule length
1~2mm the ferrule height
forces of occlusion dispersed onto the PDL rather than post and core
Libman and Nicholls 1.5 mm

Apical 1/3 of the preparation


the greatest retention and resistance of the restoration

Rationale
Biological width of 3 mm
Ferrule length of 1.5 mm
Gegauff:
1) Biomechanical leverage: more apicalthinner cross section 2) Unfavorable crown-root ratio

Orthodontic extrusion

Basic procedures

A. Soft tissue

B. Osseous management
The extent of bone resection Contraindications to osseous resection

Basic procedures

A. Soft tissue
Flap design: height of gingiva on the facial & lingual aspects
Gingivectomy: with scalpel, electrosurge, radiosurge or laser Maynard and Wilson: 3 mm of attached gingiva subgingival OD tx. If post-op height of gingiva would <3mm apically positioned flap If bone crest~free gingival margin <3 mm elevated flap for access

Basic procedures

B. Osseous management
3D analysis : occlusoapical, mesiodistal, buccolingual
Ostectomy and osteoplasty: hand chisels, high-speed rotary instrumentation or a piezoelectric cutting device Moistened constantly during the procedure Failure to eliminate osseous deformities poses a risk of pockets

Basic procedures

B. Osseous management
The extent of bone resection
Class V: one-tooth flap with 2 vertical releasing incisions to gain 3 mm biological width. Class II or cr.: interproximal bone Crown-root ratio Furcation region with the root trunk

Contraindications to osseous resection

Wound healing

Apically positioned flap with osseous resection biological width reestablishes itself Flap margin placed at osseous crest post-op vertical gain in supracrestal soft tissues averages 3 mm When the final tooth preparation can begin and when impressions? Which the treated dentition is of esthetic concern to the patient?

Wound healing

Lanning and colleagues: coronal advancement of the healing tissues from the osseous crest averages 3 mm by 3 months time after surgery. 6 months after surgery, no further significant changes Brgger and colleagues: during a 6month healing period, periodontal tissues were stable The waiting period after a crownlengthening procedure: > 6 months

Wound healing Discussion

1. Resective procedure used to induce recession surgically 2. The underlying osseous structure is critical in the final wound healing. 3. Underlying bone must be evaluated in 3-D 4. Class II or cr.: changes in the MD dimension to establish positive architecture.

Wound healing Discussion

5. More cleansable gingival embrasure areas 6. The final position of the free gingival margin can occur at 3 months/6 months after surgery 7. Esthetic zone, a waiting period of 6 months is advisable

Case Report
58 y/o female Subgingival restoration over #15 Adequate for osseous resective therapy

Case Report
Flap: from #16 (D) to #13 (M) line angle Establish 4.5 mm of supraosseous tooth structure on the buccal and palatal aspects Biological width/ferrule.

Case Report
Area after the osseous resection

Case Report
Positioned the flaps apically by means of periosteal sutures, which attaches the flap at an apical level to connective tissue still present on the facial aspect of the buccal bone. 8 wks later

Case Report
Photograph and radiograph 8 years later

Wound healing Conclusion


1.
2.

3.

4.

Crown-lengthening surgery can be a viable option for OD tx. or esthetics. Evaluate the complete periodontal condition and disclose all possible treatment options. In cases involving the possibility of a negative esthetic outcome, compromise to the support of the dentition. Extraction and implant therapy or conventional prosthetic therapy may be a more compelling solution.

References
1. Contemporary crown-lengthening therapy: a review. Hempton TJ, Dominici JT. School of Dental Medicine, Tufts University, Boston, MA, USA. 2010 Jun;141(6):647-55.

Thank you for your attention!!