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Crown Lengthening

To increase the extent of the supragingival tooth structure for restorative or esthetic.

Indications
Caries. Tooth fracture. External resorption. Short clinical crowns Loss of tooth structure through attrition and abrasion.

Contra-indication
When postsurgical healing will result in significant exposure of inaccessible molar or premolar furcations. If Reduction of the supporting bone will result in a poor crown- root ratio. When postsurgical esthetics will be compromised (orthodontic forced eruption may be an alternative). If there is no attached or keratinized gingiva and the patient will not accept mucogingival surgery prior to crown lengthening. In cases with thin periodontium and dehiscence or fenestration of alveolar bone (severe postsurgical gingival recession is likely). If the prognosis of the tooth to be lengthened is poor and adjacent teeth have a fair to good prognosis to act as abutments for a fixed or removable partial denture.

Presurgical Planning:
Evaluation of periapical radiographs and periodontal charting including: probing depths, width of keratinized gingiva, thickness of the periodontium including soft tissues and bone, to estimate how much bone will need to be removed prior to surgery. When the keratinized gingiva is 2 mm or less, intrasulular incisions are indicated. In cases with wide zone of keratinized gingiva, facial incisions are made with a scallop design, i.e., 0.5-1 mm buccal or lingual to the sulcus. If the width of keratinized gingiva is a millimeter or less and the thickness of the tissue is at least 1 mm, a partial thickness flap should be considered. Positioning a partial thickness flap apical to the alveolar crest at a distance equal to the width of remaining keratinized tissue will result in doubling of the width of the keratinized tissue and also allows for precise flap placement because periosteal suturing can be utilized. Probing of the sulcus depth and sounding the underlying bone will assist the clinician in flap design. Wherever bone is to be a reduced, full thickness flap are indicated. If periodontal pockets are present, incisions should be planned that will allow for apical positioning of the flap. A free gingival soft tissue, pedicle or connective tissue graft is indicated when only alveolar mucosa covers the facial surface of a tooth that requires crown lengthening. Gingival grafting establishing at least 2 mm of keratinized gingiva should precede lengthening of the clinical crown.

Surgical procedure
Stage 1 Initial incisions Full thickness flap elevation Removing connective and granulation tissue Bone reduction Flap suturing-closure Stage 2 Gingivectomy

Postoperative instructions
After each surgical procedure, the patient was instructed to take 600 mg of ibuprofen every 46 hours hydrocodone 7.5 mg/acetaminophen 750 mg every 46 hours as needed for pain 100 mg of doxycycline a day for 10 days.