FOLIA MEDICA CRACOVIENSIA

Vol. LV, 3, 2015: 25–35

PL ISSN 0015-5616

Clinical crown lengthening — a case report

Weronika Lipska1, Marcin Lipski2, Małgorzata Lisiewicz3, Andrzej Gala3,

Krzysztof Gronkiewicz3, Dagmara Darczuk1, Maria Chomyszyn-Gajewska1

Department of Periodontology and Oral Medicine, Dental Institute, Jagiellonian University Medical College
1

ul. Montelupich 4, 31-155 Kraków, Poland

2
Department of Anatomy, Jagiellonian University Medical College
ul. Kopernika 12, 31-034 Kraków, Poland
3
Department of Prosthodontics Jagiellonian University Medical College
ul. Montelupich 4, 31-155 Kraków, Poland

Corresponding author: Dr n. med. Weronika Lipska, Department of Periodontology and Oral Medicine,
Dental Institute, Jagiellonian University Medical College
ul. Montelupich 4, 31-155 Kraków, Poland; Phone +48 12 424 54 20; E-mail: [email protected]

Abstract: Maintaining healthy parodontium during teeth restoration procedures is an indispensable condition for obtain-
ing regular functionning and esthetics. Thus, the knowledge of correct anatomy and the influence of filling and comple-
ment on paradontium tissue is vital. Difficulty in maintaining appropriate gingival biological width (GBW) is a frequent
problem encountered in this type of reconstruction. Preservation of unchanged biological width conditions predictible
treatment result and, what is more, lack of inflammatory lesions in marginal parodontium. The ideal situation for paro-
dontium is localizing the filling/complement border supragingivaly, which is at least 3 mm from alveolar process edge. In
the case, when the above conditions are impossible to fulfil, elongation of clinical crown is a metod of choice. The effect is
possible to achieve by surgical treatment or combined orthodontic — surgical treatment. Surgical treatment is faster and
preferred procedure for indirect reconstruction, where achieving high clinical crown is necessary.
Three clinical cases of performing method of surgical clinical crown elongation were presented in the article. Performing
the described procedure enables correct tooth crown reconstruction and, what is most important, keeping individual
toothing.

Key words: clinical crown lengthening, biological width, periosurgery.

Introduction
The development of modern dentistry offers numerous methods of restoration of missing
teeth. The use of advanced clinical procedures makes it possible to keep teeth once con-
sidered a poor prognosis. The increase in aesthetic expectations and the knowledge of the
26 Weronika Lipska, Marcin Lipski et al.

rules of aesthetics obligates one to perform restorations in harmony with the arrangement
of lips, face, homonymous teeth, and with preservation of a healthy periodontitis. A sig-
nificant increase in the range of periodontal treatments is observed today. In addition to
the treatment of periodontal diseases techniques such as recession coating, alveolar defect
correction treatments, regeneration treatments, augmentation of an attached gingiva, papilla
restoration techniques and change of gum level have emerged.
Maintaining a healthy periodontium during tooth reconstruction procedures is a pre-
requisite for obtaining aesthetics and function. For this purpose it is necessary to know the
correct anatomy and the effects of fillings and prosthetic appliances on periodontium [1].
A common problem encountered with this type of restorations is the difficulty in main-
taining adequate biological width. The term “biological width” (gingival biological width,
GBW) means the gingival area attached to tooth surface, located coronally in relation to
the alveolar ridge (Fig. 1).

Fig. 1. The approximate value of biological width. It consists of: epithelial attachment — EA (1 mm) and
connective tissue attachment — CTA (1 mm) [1, 2].

As early as in 1961 studies were performed which included the measurement of the
relationship between the alveolar ridge, connective tissue attachment (CTA), epithelial at-
tachment (EA) and the gingival sulcus (GS). They proved the average value of the epithelial
attachment at 0.97 mm and the connective tissue attachment at 1.07 mm. Biological width
was calculated as: GBW = CTA + EA= 2.04 mm [3, 4]. Subsequent studies have confirmed
a certain stability of the measurement of connective tissue attachment and the average value
of biological width: 2 mm [3, 5]. This value can vary with the age, movement of teeth or
orthodontic treatment. It was shown that the 2 mm biological width is present in 85% of
 Clinical crown lengthening – a case report 27

the population, in approximately 13% of the population the value is higher and in approx-
imately 2% of the population it is less than 2 mm [6, 7]. In order to precisely determine
biological width one must carry out an individual measurement under local anaesthesia,
from the edge of the alveolar process to the edge of the gum, passing through the epithelial
and connective tissue attachments. The accuracy of measurement is affected by the biotype
of the gum, the presence of recessions, the shape of root surface, bone dehiscence and the
thickness of alveolar bone [8].
The relative stability of biological width makes any interference in this area cause a de-
fensive reaction of the body and an attempt to restore these relations (Fig. 2).

Fig. 2. The consequences of infringing the biological width by badly performed prosthetic reconstruction.
On the mesial surface of incisor there is no bone loss and an inflammation is present. On the distal surface,
biological width has been restored by way of bone resorption.

The consequences can be different and they are generally related to the biotype of
the gum. In both cases, this can lead to retraction of the gum and creation of periodon-
tal pockets. This is the result of bone and attachment loss as a result of inflammation.
Thin gingival biotype is characterized by faster horizontal bone resorption. Good oral
hygiene stops the inflammatory process and only a recession is formed. Plaque supports
this process and there is further bone resorption and formation of periodontal pockets.
Thick gingival biotype is a predisposition towards less frequent retraction of the gum and
slower bone resorption, but bone defects and adverse remodelling of the bone occurs
more often here. This results in impaired cleaning potentiality, formation of periodon-
tal pockets, as well as root caries, exposing the furcation, loosening and loss of the tooth
(Fig. 3).
28 Weronika Lipska, Marcin Lipski et al.

Fig. 3. Diagram showing tissue response and the possible reaction to an upset biological width.

To avoid pathological lesions and obtain predictable outcomes of treatment it is necessary

to maintain unchanged biological width [2, 3, 7]. The ideal situation for periodontitis is to
locate the border of filling/restoration supragingivally, and therefore at least 3 mm from the
alveolar ridge. In the aesthetic zone, where the polishing limit is located subgingivally, the
following rules must be observed:
— if GS ≤ 1.5 mm, the limit of filling may be located 0.5 mm subgingivally
— if GS is 1.5–2 mm, the limit of filling may be located 0.7 mm subgingivally
— if GS>2 mm, the limit of filling may be located 0.5 mm subgingivally [2, 3].
If the distance of the expected filling limit from the edge of the bone violates the pres-
ervation of biological width, the treatment plan should take into account a clinical crown
lengthening surgery. Typical indications for clinical crown lengthening are:
— subgingival tooth fracture
— carious loss located subgingivally
— the presence of a short crown, not providing sufficient retention of prosthetic restoration
 Clinical crown lengthening – a case report 29

— uneven course of the gingival garland

— gingival overgrowth obscuring visibility of anatomical crown
— shortening of tooth crowns in the course of pathological abrasion
— perforations during endodontic or prosthetic treatment
— root resorption
— disorder of tooth eruption (delayed passive eruption) [3, 6].
Lengthening of clinical crown can be achieved by surgery alone, or by combined or-
thodontic and surgical treatment. Surgical treatment is a faster procedure, preferable for
intermediate reconstruction of a tooth, where it is necessary to achieve high clinical crown.
The procedure involving a bone resection may adversely affect its prognosis because of the
risks of:
— weakened keeping of the tooth
— uncovering of furcation
— obtaining an unfavourable relation of the crown to the root
— periodontal damage to an adjacent tooth
— adverse aesthetic effect (recessions, disruption of the course of the gingival garland, loss
of the papilla and opening of interdental space, asymmetry of crown length in relation
to adjacent teeth).
These risks must be taken into account already when planning treatment [3].
Procedures of lengthening clinical crowns are divided into two categories, depending
on the need for osteotomy.
I Gum reduction
A. Gingivectomy
B. Apical displacement of the flap
II Ostectomy with full thickness of flap
A. one-step procedures:
1. flap-ostectomy-apical displacement
2. flap-ostectomy-gingivectomy-repositioning
3. gingivectomy-flap-ostectomy-repositioning
B. two-step procedure: flap-ostectomy-repositioning-gingivectomy after 4–6 weeks [1, 3].

Case study
Case 1

Patient A.S., aged 25 years, referred for periodontal consultation from the Prosthodontics
Clinic. Tooth 15 after subgingival fracture of the crown, with significant destruction of hard
tissue (Fig. 3) and after endodontic treatment. Underfilled root canal can be seen radio-
graphically (Fig 4).
Treatment plan was prepared, comprising: endodontic retreatment, surgical length-
ening of clinical crown and prosthetic reconstruction with the use of individual cast post
and prosthetic crown. This treatment plan was accepted by the patient. After completion of
re-endodontic treatment the lengthening of clinical crown procedure was performed (Fig. 5).
A wide area of gum attached on the buccal surface, distance from the edge of the fracture
30 Weronika Lipska, Marcin Lipski et al.

Fig. 3. Clinical tests.

Fig. 4. Radiographic tests.

to the alveolar process <3 mm (palatally and mesially). The surgery with the procedures of
producing a full-thickness flap, gingivectomy, ostectomy and reposition was performed un-
der Scandonest infiltration anaesthesia. The wound was secured with non-resorbable sutures
and Solcoseryl healing paste. At a follow-up visit after 7 days the wound was found to heal
normally and the sutures were removed (Fig. 6). After 6 weeks work on the final prosthetic
reconstruction was started.
 Clinical crown lengthening – a case report 31

Fig. 5. X-ray image taken after the completion of endodontic treatment.

Fig. 6. Visit following the removal of sutures.

Case 2

Patient B.Ch, aged 27, referred for periodontal consultation. Tooth 25 with a significant loss
of hard tissue due to root caries on the palatal side (Fig. 7). Underfilled root canal can be
seen radiographically, standard cast post. The root post was removed at the Prosthodontics
Clinic. Due to the inability to keep the treatment area clear from saliva in order to carry
32 Weronika Lipska, Marcin Lipski et al.

out the re-endodontic treatment, performance of the surgical lengthening of the clinical
crown was scheduled first.

Fig. 7. Image prior to surgery. A cavity extending subgingivally, inflammatory reaction of the gingiva on the
palatal side.

The distance to the edge of the tooth cavity from the edge of the bone <3 mm in the
palatal and palatal-mesial area. Gingivectomy, ostectomy in the palatal and mesial area and
reposition of full-thickness flap were carried out under Scandonest infiltration anaesthesia
The wound was secured with non-resorbable sutures and Solcoseryl healing paste (Fig. 8).
At a follow-up visit after 7 days the sutures were removed. Healing by granulation was found
in the interdental spaces (Fig. 9). The patient was referred for endodontic retreatment.

Fig. 8. Condition after surgery.

 Clinical crown lengthening – a case report 33

Fig. 9. Image of healing at the follow-up visit after 7 days.

Case 3

Patient E.Z, aged 68 years, referred for periodontal consultation from the Prosthodontics
Clinic. Tooth 26 with extensive composite filling and subgingival fracture of the palatal wall
(Fig. 10). Because of the depth of the fracture reconstruction of the tooth with preservation
of the biological width was found impossible. Radiographic image of the condition after
endodontic treatment (Fig. 11).

Fig. 10. Fracture of the palatal wall of tooth 26 can be seen.

34 Weronika Lipska, Marcin Lipski et al.

Fig. 11. Radiographic image of the endodontic treatment performed.

Clinical crown lengthening surgery and prosthetic reconstruction in the second stage
were proposed. Gingivectomy and ostectomy procedure in the palatal-mesial area with
full-thickness flap repositioning were carried out under Mepidont 3% infiltration and con-
duction anaesthesia. The wound was sutured. The sutures were removed after 7 days. Plaque
control and further prosthetic treatment were recommended (Fig. 12).

Fig. 12. Condition after 7 days.

 Clinical crown lengthening – a case report 35

Summary

There are two primary indications for clinical crown lengthening surgery. The first one is an aesthetic indi-
cation for increasing the length of clinical crowns. The second indication, and the most common, as practice
shows, is the positioning of the tooth preparation border supragingivally or gingivally, in order to avoid
the negative impact of dental restorations on the biological width, resulting in chronic inflammation of the
periodontium around the applied prosthetic restoration [9]. In addition, supragingival or gingival border
of tooth hard tissue preparation creates the right conditions for adhesive cementation. This is particularly
important for all-ceramic restorations requiring that treatment area is kept clean and dry during the pro-
cedure of adhesive deposition of dental restorations. Lengthening of clinical crowns of teeth is one of the
most frequently performed periodontal treatments carried out as part of pre-prosthetic procedure [10–12].

References
11. Sonick M.: Esthetic crown lengthening for maxillary anterior teeth. Compend Contin Educ Dent. 1997;
18 (8): 807–819.
12. Zucchelli G., Mazzotti C., Monaco C.: A standardized approach for the early restorative phase after
esthetic crown-lengthening surgery. Int J Periodontics Restorative Dent. 2015; 35 (5): 601–611.
13. Planciunas L., Puriene A., Mackeviciene G.: Surgical lengthening of the clinical tooth crown. Stomatologi-
ja. 2006; 8: 88–95.
14. Gargiulo A., Wentz F., Orban B.: Dimentions and relations of the dentogingival junction in humans.
J Periodontol. 1961, 32: 261–267.
15. Vacek J., Gerhr M., Asad D., Richardson A., Giambarresi L.: The dimensions of the human dentogingival
junction. Int J of Periodontics Restorative Dent. 1994; 14: 154–165.
16. Camargo P., Melnick P.R., Camargo L.M.: Clinical crown lengthening in the esthetic zone. J Calif Dent
Assoc. 2007; 35 (7): 487–498.
17. Kois J.: The restorative-periodontal interface: biological parameters. Periodontol. 2000, 1996; 11: 29–38.
18. Lee E.: Aesthetic crown lengthening: classification, biologic rationale and treatment planning consid-
erations. Pract Proced Aesthet Dent. 2004; 16 (10): 769–778.
19. Bajaj P., Chordiya R., Rudagi K., Patil N.: Multidisciplinary approach to the management of complicated
crown-root fracture: a case report. Int Oral Health. 2015; 7 (4): 88–91.
10. Tomar N., Bansal T., Bhandari M., Sharma A.: The perio-esthetic-restorative approach for anterior
rehabilitation. J Indian Soc Periodontol. 2013; 17 (4): 535–538.
11. Parwani S.R., Parwani R.N.: Surgical crown lengthening: a periodontal and restorative interdisciplinary
approach. Gen Dent. 2014; 62 (6): 15–19.
12. Patel R.M., Baker P.: Functional crown lengthening surgery in the aesthetic zone; periodontic and
prosthodontic considerations. Dent Update. 2015; 42 (1): 36–38, 41–42.