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Key Considerations for Successful Crown Lengthening Procedures

Explore the critical factors influencing the success of crown lengthening procedure — from precision incisions to nuanced bone reduction techniques.

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The planning and execution of the crown lengthening procedure chiefly depends on the width of the attached gingiva, as well as the crestal bone position.1 It is generally accepted that a minimum of 2 to 3 mm of attached gingiva should be maintained at all times to prevent gingival inflammation and irritation.1 The primary incisions are placed based on the amount of attached gingiva. If the attached gingiva is sufficient, the incisions are placed submarginally to account for osseous resection. Conversely, if the attached gingiva is insufficient, the incisions will be intrasulcular, with the flap apically positioned.

Initial exam prior to crown lengthening procedure
FIGURES 1A through 1C. Initial examination: A 36-year-old female presented to the clinic with a chief concern of a short tooth and excessive gingival display at tooth #8 (which had a history of restorative work). The patient was unwilling to approve any restorative work at the initial examination and only wanted to address the excessive gingival display (high smile line), as shown in the extraoral figure (A). The intraoral image shows the same concern with a high frenum pull (B). The periapical radiograph shows the bone level within the normal range to the cementoenamel junction (C).

A second consideration for the surgical procedure is the extent of bone reduction. The bone sounding technique is a reliable method to address biologic width variations at different sites and among individual patients. Performed under local anesthesia, bone sounding involves probing the sulcus to the point it stops at the crestal bone.1 The measurement is descriptive of the epithelium attachment, connective tissue attachment, and the gingival sulcus.

Crown lengthening procedure
FIGURES 2A through 2F. Intraoperative: A surgical template fabricated to account for the final esthetic parameters — the amount of gingival and tooth display (A). In this case, the crown of tooth #8 needs to be lengthened apically through the crown lengthening procedure. Template-guided, internal bevelsubmarginal incisions were placed from distal of #8 to distal of #9 and extended either side intrasulcularly (B). Full-thickness flap reflection using an elevator (C). Marginal osteoplasty and osteotomy are performed to level the bone levels with adjacent teeth (D). After osteoplasty and osteotomy (E). Flaps are sutured in an interrupted fashion (F).

Various studies have shown that the biologic width that was noted preprocedurally is redeveloped after healing. The extent of osseous reduction is decided based on the preoperative assessment of biologic width. The same distance is maintained from the cementoenamel junction or future crown margin to the crestal bone.

Bone reduction involves both osteotomy and osteoplasty procedures to create a positive architecture and smooth bony surfaces, which are achieved with the help of high-speed rotary or piezoelectric cutting instruments and hand instruments, such as chisels. A case report of a crown lengthening procedure for tooth #8 is described in Figures 2A through 4C.

FIGURES 3A through 3C. Postoperative: The intraoperative picture after suturing and frenectomy (A). Healing at one week (B). Healing at four weeks, with minimal inflammation and gingival margin stability (C).

Reference

  1. Fugazzotto PA. The Role of Crown-Lengthening Therapy. In: Fugazzotto PA. PeriodontalRestorative Interrelationships: Ensuring Clinical Success. Hoboken, New Jersey: John Wiley and Sons, Inc; 2011:31–87.

This information originally appeared in Goel A, Mott DA, Wilkerson C, Ellzey AT. Concepts and considerations for surgical crown lengthening. Decisions in Dentistry. 2021;7(1):36–39.

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