TARRSON FAMILY ENDOWED CHAIR IN PERIODONTICS

UCLA SCHOOL OF DENTISTRY

Presents

Dr. E. Barrie Kenney

Professor & Chairman Section of Periodontics

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

Tarrson Family Endowed Chair in Periodontics.

ESTHETIC SURGICAL PROCEDURES FOR CROWN LENGTHENING

Professor and Chairman Division of Associated Clinical Specialties

UCLA School of Dentistry

Choice depends on

1. Gingivectomy
2. Flap surgery for osseous recontouring

Gingival crevice depth

Need to maintain minimum of 1 mm connective tissue between depth of crevice and bone Adequate width of Keratinized gingiva

Need minimum of one millimeter connective tissue coronal to bone margin Gingival margin will be two millimeters coronal to this with 2 mm crevice depth.

Red line- Gingival margin.Pink area connective tissue. Black line probe to depth of crevice.

1mm. Distance of gingival margin to bone on labial is 3mm.Two mm of this is crevice depth, and 1mm. is for connective tissue between probable depth and crest of bone. 2mm

Five millimeters of crevice depth with adequate band of Keratinized tissue Gingivectomy can be used to increase crown length by up to 3 mm

Advantages of Gingivectomy Precise control of gingival contours Low risk of inadvertent necrosis of tissue during healing

Advantages of Flap Procedure Wide range of suitable cases

Crevice depth of five millimeters will allow three millimeters of crown lengthening by Gingivectomy
If more than three millimeters needed use Flap Surgery

Gingivectomy Techniques This patient requires 3 mm of crown lengthening Sufficient crevice depth and Keratinized tissue

Gingivectomy completed with surgical scalpels and knives

Healing at three weeks

Crowns placed twelve weeks after Gingivectomy

Next slide Before and After

Gingivectomy to correct lack of symmetry and short crowns

Sufficient crevice depth and Keratinized gingiva

Frenum correction also needed

Scalpel used to establish 10 mm crown length on central incisor Height of contour of gingiva is distalized

Kirkland Knife used to refine gingival contours by gentle scraping

Length of central incisor serves as basis for lateral incisor and cuspid Lateral incisor gingival margin 1 mm coronal to central Cuspid gingival margin at same level as central

The lateral incisor also has distalized gingival margin

Left central incisor gingival margin shaped for symmetry with right central

Gingivectomy completed with bilateral symmetry Right central incisor edge will need shortening

Initial incision for Frenectomy

Removal of wedge of tissue from frenum Interdental papilla is untouched

Incision made through periosteum to expose bone This ensures no muscle pull exists to interdental papilla

Wound closed tightly with 5.0 gut sutures

Healing at twelve weeks Next Slide Before and After

Crown Lengthening requires Flap Surgery and osseous correction

Initial Incisions Central incisor and cuspid new gingival margins at same level

Sulcular incision used on lateral incisor to make it harmonious with central and cuspid
Interproximal incisions preserve papillae

Incisions on left symmetrical with right Use new blade for each two teeth to minimize tissue trauma

Flap carefully dissected with sharp scalpels 3 mm of bone crest exposed

Bone recontouring needed to provide adequate connective tissue apical to crevice depth

Bone Margin has been moved apically of central incisor and cuspid

Flap sutured with apical positioning of gingival margins on central incisors and cuspids

Final Result at Twelve Weeks

Next Slide Before and After

Short clinical crowns with large gingival display on smiling

Insufficient gingival crevice depth for Gingivectomy

Premolars are included because of exposure with smiling

15 c scalpel used to distalize gingival margin equally on central incisors

12 B scalpel begins sharp dissection of full thickness flap with preservation of interdental papillae

Incised gingiva gently removed with sharp back action hoe

Flap elevated and bone recontoured

Flaps sutured with simple 5.0 gut interproximal sutures

Central incisors lengthening to 11 mm

Firm pressure applied to flap for 5 minutes

Healing at one week No post surgical brushing or flossing Chlorhexidine mouth washes three times per day

Healing at twelve weeks

Gingival margins now stable Gentle brushing with soft brush and chlorhexidine from second week post operative

Gentle flossing after four weeks healing

Next slide Before and After

Short clinical crowns and excessive gingival display following orthodontic treatment

Level of Incisal edge is established Central incisor and cuspid incisal edges at same level Lateral incisal edge 1 mm apical to central incisor Incisal plane parallels lower lip

Gingival crevice too shallow for Gingivectomy

New gingival margins established with incisions

Central incisor length at 10.50 mm

Flap elevated to expose bone margin

Bone recontoured to provide sufficient connective tissue for Biologic width

Flaps sutured in final position

Healing at twelve weeks

Next slide Before and After

Upper and lower incisors, cuspids, and premolars with asymmetry and small clinical crowns

Size of clinical crowns too short for facial dimensions and smile

Flap elevated to expose bone margins

Osseous recontouring to move bone margins apical Long anatomical crowns on central incisors

Flaps sutured with apical position of gingival margins including premolars

Healing at twelve weeks Cuspids elongated to give masculine emphasis

Next two slides Before and After

Altered passive eruption

Short asymmetrical clinical crowns

Healing at one week

Healing at 12 weeks Next Slide Before and After

Gingival and tooth esthetics unacceptable to patient

Flaps and osseous recontouring completed

Final Restorations completed after 24 weeks of healing Next Slide Before and After

ONE WEEK POST SURGERY

TEN WEEKS POST SURGERY

Crown lengthening for esthetics and to provide sufficient root volume for crown retention Need to establish incisal edge as baseline for gingival dimensions

Provisional acrylic template establishes final crown dimensions and incisal edge

Patient can view template and suggest any necessary changes

At time of Flap Surgery, gingival margins outline on tissues

Incisions made following template dimensions

Flaps elevated to expose bone margins

Bone recontoured to mirror final gingival margins

Position of new gingival margins confirmed with stent

Flap positioned with polytetraflurethylene sutures

Palatal view

Healing at 6 weeks Lower incisors also treated Next Slide Before and After

If amount of crown lenthening needed will result in depth of crevice being less than 1mm from bone margin then flap sugery and bone removal is required to give adequate BIOLOGICAL WIDTH