Statistical Analysis Used. Initial baseline values of biologic width were 2. Within the limitations of the study the biologic width, at treated sites, was re-established to its original vertical dimension by 3 months. Ostectomy with apically positioned flap can be considered as a more effective procedure than Gingivectomy for Surgical Crown Lengthening. The preservation of a healthy periodontium is critical for the long-term success of a restored tooth. Dentists must constantly balance the restorative and esthetic needs of their patients with periodontal health [ 1 ].
One factor that is of particular importance is the potential damage that results in the periodontium when margins are placed subgingivally. Garguilo et al. These dimensions may vary from tooth to tooth, but it is present in all healthy dentition [ 3 ]. It was shown that crown margins positioned subgingivally were associated with the most gingival inflammation leading to violation of biologic width, whereas supragingivally located crown margins were associated with the least gingival inflammation.
Supragingival placement of restoration margins allows for ease of impression making, cleansing [ 4 ], and detection of secondary caries and is associated with maintainable probing depths [ 4 , 5 ]. Subgingival restorations can have damaging effects on the neighboring hard and soft tissues, especially when they encroach on the junctional epithelium and supracrestal connective tissue [ 6 ].
These subgingivally placed restorations have been associated with gingival inflammation, loss of connective tissue attachment, and bone resorption [ 3 , 7 , 8 ]. Allen [ 9 ] reports that wherever the biologic width is violated, there is a reaction by the periodontium.
Alveolar bone will resorb inconsistently in an attempt to provide space for a new connective tissue attachment, which will result in an increase in probing depth.
It would therefore seem to be more prudent to increase the dimension of the clinical crown through surgical crown lengthening rather than risk a violation of the periodontium biologic width by injudicious subgingival tooth preparations [ 10 , 11 ]. It also provides clinical tooth structure to enable the placement of margins either coronal or equigingival. To avoid these potential problems to the supporting structures of teeth, surgical crown lengthening can provide adequate clinical crown structure.
Surgical crown lengthening has been proposed as a means of facilitating restorative procedures and preventing injuries in the teeth with structurally inadequate clinical crown or exposing tooth structure in the presence of deep subgingival pathologies that may hamper the access for proper restorative measures. Surgical crown lengthening can be performed by gingivectomy and ostectomy with apically positioning flap, in order to facilitate restorative procedures and to prevent periodontal injuries in teeth with structurally inadequate clinical crowns; the apically positioned flap technique with osseous resection has been recommended [ 11 — 13 ].
In the past literature, however, sufficient information has not been provided regarding the dimension of the postsurgical soft tissue modifications or the amount of time necessary to achieve the complete healing of the periodontal tissues; therefore, the stability of the soft tissue levels exists.
The few clinical studies on periodontal tissue alterations, which occur during healing after surgical crown lengthening, reported conflicting results [ 17 , 18 ]. Vander Velden [ 17 ] observed 3 years after surgery a considerable amount of coronal regrowth of the interproximal gingival tissue from the level where the osseous crest was located after surgery [ 17 ]. Previously reported clinical studies [ 16 — 18 ] on surgical crown lengthening have followed positional changes of the free gingival margin immediately after surgery and during healing but have not focused on the biologic width.
A few histological studies utilizing animal models have shown postoperative crestal resorption after denudation [ 19 ] and scaling and root planing [ 20 ] allowed the reestablishment of connective tissue attachment. However, very little work has been done to conform these results in human clinical trials.
Therefore, the purpose of the study was to evaluate the positional changes of the periodontal tissues, particularly the biologic width, for a period of 6 months where in two surgical crown lengthening procedures gingivectomy and ostectomy with apically positioned flap were performed and assessment of changes in periodontal tissues was done prior to and after crown placement. The clinical study included 30 patients, of 20 to 40 years of age mean age 30 , selected on the basis of various conditions hampering proper restorative measures for placement of full crown, one or more teeth and requiring surgical crown lengthening to i gain retention in sites with insufficient supracrestal tooth structure necessary for prosthetic reconstruction, ii gain accessibility to deep, subgingivally located lesions or preexisting faulty preparation margins for restorative treatment.
The patients were selected from the Department of Prosthodontics and Periodontics, H. Dental College Gulbarga. The study and the procedures were explained to the patients and a written informed consent was taken. The selected patients are divided into 2 groups randomly. Group A In this group about 10 patients were selected who actually required crown lengthening but the crown lengthening was not done and crown margins were placed subgingivally. Group B1 In this group about 10 patients were selected requiring crown lengthening and surgical procedure was carried out only by soft tissue removal, that is, gingivectomy and after surgical procedure margins of the restoration were placed supragingivally.
Group B2 In this group about 10 patients were selected requiring crown lengthening and surgical procedure was carried out by soft and hard tissue removal, that is, ostectomy with apically positioned flap and after surgical procedure margins of the restoration were placed supragingivally.
After 1 week of plaque control supervision, the patients were recalled for a baseline examination. At the baseline examination, the following parameters were recorded for each tooth at 4 sites mesiobuccal, distobuccal, buccal, and lingual of both the groups. In order to standardize probe placement and angulation during measurements, a full acrylic stent was fabricated for the required tooth and vertical grooves were created at appropriate interproximal sites.
All measurements were obtained with a standardized Williams Graduated probe and rounded up to the nearest millimeter. It is estimated using the acrylic stent fabricated preoperatively. The vertical grooves made on the acrylic stent guide the probe to maintain the site specificity. The stent is marked with the horizontal line, which acts as a reference mark. The position of the gingival margin is calculated by measuring the distance between the reference mark on the stent placed on the tooth and the gingival margin at various interval of examination.
It is determined using Williams Graduated Periodontal Probe. Firstly the depth of the gingival sulcus is measured and anesthesia is given then bone sounding is done, that is, the distance from the gingival margin to the alveolar bone is measured. Then, the biologic width is determined by subtracting the gingival sulcus depth from the distance from the gingival margin to the alveolar bone. Following the baseline examination sequential surgical therapy was carried out as shown in Table 1.
After treatment plan presentation, patients were provided information about the study and indicated willingness to participate, by providing written informed consent. An alginate impression was taken of each arch to be surgically treated in order to fabricate customized probing stents. Probing stents were made from self-cure acrylic resin material using dough method. Stents were trimmed to the height of contour of all teeth, and grooves were placed at the sites to be measured with a fissure bur.
To improve visualization, the apical margin of the probing stent was traced with a black permanent marker. Using the probing stent, the following baseline measurements were taken for each tooth at the surgical appointment prior to administering local anesthetic: 1 the probing depth, 2 relative attachment level from base of sulcus to stent, 3 the distance from stent to gingival margin.
All measurements of the parameters were taken by single examiner using a Williams Graduated periodontal probe. Surgical procedure was accomplished under local anesthesia. The following guidelines were taken into consideration. Test of significance between B1 and B2 Groups is calculated.
Standard error is calculated and designated as SE. The peak hike in probing depth values might be a result of loss of attachment, which is due to violation of biologic width. In other words margins placed subgingivally are associated with increased probing depth as shown in Figure 1 associated with violation of biologic width. The periodontium tried to maintain the same biologic width and shifted apically at the expense of crestal bone loss. Biologic width at the 12th week was 2.
The change in mean values from the 3rd week to the 6th week indicates coronal movement of the gingival margin. It is demonstrated that once the biologic width is established after 6 weeks postsurgically the value remained same and there was no significant difference between the 6th and 12th week as shown in Figure 4.
At the 6th week the mean value was about 9. The result indicates that there was no coronal movement of gingival margin from reference stent during an evaluation period of about 3 months and stability of the free gingival margin was noticed as shown in Figure 5.
During the 6th to 12th weeks there was significant difference in mean biologic width of B1 Group, that is, 1. There was significant change in B1 Group between the 3rd week and the 6th week when compared with B2 group. This indicates progressive loss of attachment over a period of time as shown in Figure 8. These may dissolve over time or require removal. The dentist may also use wire or a splint to anchor the tooth to the surrounding teeth. Recovery can depend on the type of procedure, and the dentist who performed it will give detailed instructions.
The area is numbed during the procedure so that the person does not experience pain. However, the person may experience discomfort or pain as the anesthesia wears off. Some people require anti-inflammatory medication, such as acetaminophen or ibuprofen, to relieve pain and inflammation after the procedure. Minor swelling and bleeding can be expected for the first few days after a crown lengthening.
The dentist may recommend applying a cold compress to the area to help with pain and swelling. During recovery, consume a soft diet and rinse the mouth with water after meals. The dentist may also prescribe a chlorhexidine mouthwash for use twice a day after the surgery. After the initial healing phase, the pain and swelling will fade and the gums will continue to shrink.
If the dentist is going to fit a device, such as a bridge, they may wait for healing to complete. According to the American Academy of Periodontology , full healing in the back of the mouth may take 6—12 weeks, while healing at the front may take 3—6 months. Not everyone is eligible for crown lengthening surgery.
If a person has a gummy smile and wishes to change it, they should discuss the option of a crown lengthening with a dentist. The dentist may refer the person to a periodontist — a gums specialist — or another dentist with training in gum surgery. A person may also need to undergo crown lengthening before a dentist can repair tooth damage or fit a device, such as a bridge.
In this case, the dentist may wait for up to 6 months before fitting the device, to give the gums time to fully heal. Not everyone is eligible for crown lengthening, and a general dentist can provide information about its suitability.
Once the gums recede, they cannot grow back. However, many dental treatments can help restore the gums around the teeth. Learn more about receding….
Dry socket can last up to 7 days. It can occur after tooth extraction and causes symptoms, including intense pain. Learn more here. Fluoride treatment may offer benefits to those at risk of tooth decay.
Natural health advocates, however, question the safety of fluoride. Your teeth — and not your gums — are what people will see when you smile. Crown lengthening is an outpatient procedure. You can leave the clinic right after you finish the surgery. After completing the operation, the periodontist will clean the area. He uses sterile salt water for this purpose. The periodontist will use sutures and sometimes a surgical bandage. These tools are to help secure the new gum-to-tooth relationship.
He will need to see you in fourteen days to remove the sutures and check your healing. The final treatment of the exposed tooth area does not occur for at least six weeks. This period is to allow for tissue maturation. Insurance should cover at least a part of the amount if the procedure is a medical necessity. The total amount you will end up paying depends on a few different factors, including:. You may get a discount if you need lengthening for several teeth.
The price will increase if you need more treatments, for example, a root canal. Yes, there is a slight risk of the gum growing back after crown lengthening.
The procedure is a predictable way of exposing more of your tooth. But the periodontist cannot guarantee that it will always be successful. After he raises your gum flap, he may discover surgery is not possible. This discovery will mean that he has to change the treatment plan. We trim back the bone and then suture the gum back at a lower level. We remove enough bone to allow the gum to reattach to the tooth. If the tissue does grow back, we may need to remove it again.
There is a possibility of infection, as with any surgery. It can affect the alveolar bone or the tissue at the incision site if not treated.
One of the causes is when patients mess with the incisions. Another reason is poor dental hygiene during the recovery. If you experience the following symptoms, you may have an infection:. Some of the symptoms are common with surgery. The periodontist will prescribe antibiotics to stop the symptoms from getting worse. You may also experience excessive bleeding during the surgery.
This bleeding may persist even a few hours after the procedure. The dentists will administer coagulants if you experience this symptom. Another side effect is sensitivity to hot and cold foods. When we brush our teeth, the fluoride from the toothpaste shields the tooth. Fluoride makes your teeth less sensitive to ordinary food and liquids. The teeth uncovered by this procedure have not been insulated. They can be cold sensitive until they build up an insulating layer.
This effect will go away after a few days. Another result is that the affected tooth can seem longer than those around it. This new look can surprise some patients. They get surprised even if this lengthening was the intention when doing the surgery.
The procedure is not reversible. Cutting away bone tissue around a tooth may affect future operations, though.
For instance, if later on, you wish to put in an implant, the decreased bone tissue may not be enough to support it. Another possible complication is the compromise of the structural support of the repaired tooth. If that happens, the tooth or those around it may feel looser than usual. Your dentist may need to prescribe antibiotics. Limit physical activity right after surgery. Light work is okay on the day following surgery.
Eat soft, nourishing food, and avoid hot foods. Instead, use a warm salt water rinse, or dab the treated teeth with a cotton swab. Avoid dabbing the gums. You can brush the areas of your mouth that were not affected by the procedure. T he underlying bone is then gently contoured so that the gum tissue can be positioned in in the most esthetic position. Without proper bone contouring, the gum often bounces back to its original position, which would make it require a second corrective surgery.
For this reason I do not recommend just using a laser for trimming the gum tissue without addressing the underlying bone.
While crown lengthening patients can return to work and begin eating soft foods the day after surgery, full recovery of the gum tissue generally takes one or two weeks. Crown Lengthening and Gummy Smile Reduction. Crown Lengthening vs.
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