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TARRSON FAMILY ENDOWED CHAIR IN PERIODONTICS

UCLA SCHOOL OF DENTISTRY

Presents

Presents

Dr. E. Barrie Kenney

Professor & Chairman Section of Periodontics

Surgical Techniques for

Crown Lengthening

E. Barrie Kenney B.D.Sc., D.D.S., M.S., F.R.A.C.D.S.

Tarrson Family Endowed Chair in Periodontics.

Professor and Chairman Division of Associated Clinical Specialties UCLA School of Dentistry

Indications for Crown Lengthening

1)Development of Adequate

Crown Preparation

2)Esthetics

Development of Adequate Crown

Preparation

Gingival Margins must not

invade Biological Width

Requirements for Periodontal

Health.

Biological Width Requirements

There must be a minimum of

1mm between the apical level

of the Junctional Epithelium

and the bone crest.

Crown Margins which extend

apically beyond the Junctional

Epithelium can violate the

requirements for periodontal

health.

An inappropriate crown

margin increases plaque

accumulation in close

proximity to bone crest.

Deeply placed crown margins causing gingival inflammation and pockets.

Deeply placed crown margins

causing gingival inflammation

and pockets.

Both Central Incisors and right lateral incisor have crowns violating Biologic Width concepts.

Both Central Incisors and

right lateral incisor have

crowns violating Biologic

Width concepts.

Gargiulo A., Wentz F., Orban F.

Dimensions and Relations of

the Dentogingival Junction in

Humans.

J. Periodontol 1961 32:261

This study measured

dimensions of tissues

involved in Biological Width

considerations.

Used histologic sections to

measure average dimensions

of biologic width.

These are not clinically

accurate due to distortion

with histologic processing.

Sulcus

depth

Sulcus depth Gingival sulcus Junctional epithelium Connection tissue attachment coronal to bone 0.69 mm 0.97 mm

Gingival sulcus

Junctional epithelium

Connection tissue

attachment coronal

to bone

  • 0.69 mm

  • 0.97 mm

1.07 mm

Biologic

Width

This study said width of

junctional epithelium plus

connective tissue width was

Biologic width; i.e.

approximately 2 mm.

However since then it has been shown that in probing the sulcus, the probe is generally

However since then it has

been shown that in probing

the sulcus, the probe is

generally at the deepest

position of junctional

epithelium.

If a subgingival crown margin is placed in the middle of the gingival sulcus, the crest

If a subgingival crown margin

is placed in the middle of the

gingival sulcus, the crest of

bone should be a minimum of

2 mm apically positioned.

When a subgingival crown

margin is to be placed it may

be necessary to surgically

move the crestal bone margin

apically so that there is at

least 2 mm space between

the margin and the bone.

The necessary for 1 mm of

connective tissue between the

epithelium and bone is a

minimal requirement. Larger

dimensions can be compatible

with healthy tissues.

Use of Flap Surgery with

Osseous Resection

This is the method of choice

when crown margins will

impinge on the Biologic

Width.

Periapical Radiographs are needed to ensure sufficient root length is available. This case cannot have surgical

Periapical Radiographs are

needed to ensure sufficient root

length is available. This case

cannot have surgical crown

lengthening and both premolars

need to be extracted.

This patient had extensive tooth wear and loss of Vertical Dimension

This patient had extensive

tooth wear and loss of Vertical

Dimension

There was insufficient clinical crown volume of the incisors for adequate retention so flap surgery was

There was insufficient clinical

crown volume of the incisors for

adequate retention so flap

surgery was indicated.

Prior to Flap Surgery

Prior to Flap Surgery

Full thickness labial and lingual flaps .

Full thickness labial and lingual

flaps .

Full thickness labial and lingual flaps .
Bone is recontoured so that 2 mm distance between level of proposed crown margin and crest

Bone is recontoured so that 2

mm distance between level of

proposed crown margin and

crest of bone.

The lingual side required minimal bone surgery.

The lingual side required

minimal bone surgery.

Flaps are positioned apically to increase length of clinical crowns.

Flaps are positioned apically to

increase length of clinical

crowns.

Similar apical positioning on Lingual.

Similar apical positioning on

Lingual.

Crown preparations 12 weeks after crown lengthening surgery.

Crown preparations 12 weeks

after crown lengthening

surgery.

Final upper and lower restorations.

Final upper and lower

restorations.

Before After

Before

Before After

After

Inadequate clinical crowns for retention of new restorations.

Inadequate clinical crowns for

retention of new restorations.

Flap design on buccal. Intrasulcular incisions, mesial vertical incision, distal wedge.

Flap design on buccal.

Intrasulcular incisions, mesial

vertical incision, distal wedge.

Flap design on palatal. Reverse bevel incision removing gingival margin ,mesial vertical incision, distal wedge.

Flap design on palatal. Reverse

bevel incision removing gingival

margin ,mesial vertical incision,

distal wedge.

Buccal full thickness flap elevation to expose at least 3 mm of crestal bone.

Buccal full thickness flap

elevation to expose at least 3

mm of crestal bone.

Palatal flap elevation to expose at least 3 mm of crestal bone.

Palatal flap elevation to expose

at least 3 mm of crestal bone.

The gingival level of new crown margin is estimated and bone removed so crestal level is

The gingival level of new crown

margin is estimated and bone

removed so crestal level is 2

mm apical to this.

Buccal crown margins will be subgingival for esthetics. So margins will be in middle of gingival

Buccal crown margins will be

subgingival for esthetics. So

margins will be in middle of

gingival sulcus i.e. 1 mm

coronal to probing depth, add

another 1 mm for connective

tissue to determine bone level.

Palatal crown margin will be supragingival. So allow 1mm for connective tissue plus 2 to 3

Palatal crown margin will be

supragingival. So allow 1mm

for connective tissue plus 2 to 3

mm for sulcus with bone level 3

to 4 mm apical to level of crown

margin.

Buccal flap sutured apically with increased tooth structure for crown preparation.

Buccal flap sutured apically with

increased tooth structure for

crown preparation.

Palatal flap repositioned with continuous sling mattress sutures and simple U shaped sutures of distal wedge

Palatal flap repositioned with

continuous sling mattress

sutures and simple U shaped

sutures of distal wedge and

vertical incisions.

Buccal Healing at 3 weeks.

Buccal Healing at 3 weeks.

Palatal Healing at 3 weeks.

Palatal Healing at 3 weeks.

Crowns placed at 6 weeks.

Crowns placed at 6 weeks.

After Before

After

After Before

Before

After Before

After

After Before

Before

Gingivectomy for Crown Lengthening

Most cases need flap and

osseous surgery.

Gingivectomy used when have

adequate band of Keratinized

tissue and bone crest is

positioned apically with an

initial wide Biological Width.

Poor crowns with recurrent caries.

Poor crowns with recurrent

caries.

Soft tissue removal will be adequate for exposure of sound tooth for margins with a 1

Soft tissue removal will be

adequate for exposure of sound

tooth for margins with a 1 mm

Ferrule Extension.

Electrosurgery used for gingivectomy. This can also be done with scalpels or laser.

Electrosurgery used for

gingivectomy. This can also be

done with scalpels or laser.

Tissue recontoured to expose root surfaces for adequate preparation of margins.

Tissue recontoured to expose

root surfaces for adequate

preparation of margins.

Provisional restorations at 12 weeks. Marginal gingiva is now stable so final subgingival crowns can be

Provisional restorations at 12

weeks. Marginal gingiva is now

stable so final subgingival

crowns can be completed.

Final crown restorations

should not be completed until

a minimum of 6 weeks after

surgery in order to minimized

further tissue loss due to

trauma of impressions.

In esthetic areas a minimum

of 12 weeks after-surgery is

required to be sure no further

gingival recession will occur.