Periodontology 2000, Vol. 27, 2001, 4558 Copyright C Munksgaard 2001Printed in Denmark All rights reserved

PERIODONTOLOGY 2000ISSN 0906-6713

Aesthetic crown lengtheningMICHAEL G. JORGENSEN & HESSAM NOWZARI

Aesthetic considerations have influenced the man-agement of dental maladies in varying degrees formany years. Patient awareness and expectationshave increased recently to the point that less thanoptimal aesthetics are no longer an acceptable out-come (27). In the 21st century, the dental prac-titioner must be prepared to meet the challengesnecessary to provide care that will result in a truecondition of oral health. Current standards dictatethe importance of avoiding procedures that will re-sult in aesthetic compromise as well as the conceptof providing patients with improved aestheticswhenever possible (14). An essential goal of treat-ment is long-term stability of the result; for this to beachieved the integrity of the dentogingival junctionmust be respected, and dental restorations and theperiodontium must be in harmony. A predictable,successful outcome can only be expected if a com-plete and accurate diagnosis is obtained and used togenerate an appropriate treatment plan. This chap-ter discusses crown-lengthening procedures withparticular attention to aesthetic considerations.

Collection of data

Prior to developing a suitable treatment plan, it isessential to establish a complete and accurate as-sessment of conditions with which the patient pres-ents. First, it is important to determine the chiefcomplaint or the patients reasons for seeking treat-ment. These could include pain, swelling, impairedfunction, unsatisfactory aesthetics or a combinationof these reasons. Next, the medical status of the pa-tient must be reviewed and vital signs recorded. Thiswill determine the patients suitability for dentaltreatment and identify any special precautions thatmust be taken. A common example of such pre-cautions is premedication for the prevention of bac-terial endocarditis (7). Medications having the po-tential to adversely affect gingival health and aes-thetics include phenytoin, cyclosporin and variouscalcium-channel blockers (25). Poorly controlled

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diabetes and smoking have been reported to predis-pose patients to periodontal disease and adverselyaffect response to treatment (13, 31, 38). Anticoagu-lant therapy, including low-dose aspirin, often mustbe modified in order to ensure adequate hemostasisduring and after surgical procedures (34, 36). Whilethere is some controversy over the absolute necessityto discontinue aspirin for 1 week prior to surgery,prudent clinical judgment and appropriate medicalconsultation when needed are in the best interest ofthe patient (1, 37).

Following thorough review of the patients medicalstatus, the clinical examination is conducted. Thisshould begin with extraoral conditions, with atten-tion to facial symmetry, face height, lip length andthickness, profile and smile line. The reference pointfor assessment of facial symmetry is generally theinterpupillary line (2). Face height is usually ana-lyzed by dividing the face into thirds. The upperthird is often quite variable depending upon the pa-tients hairstyle. The middle and lower thirds of theface are more involved in aesthetic considerationsfor the dentist. The midface is measured from gla-bella, the most prominent point of the forehead be-tween the eyebrows, to subnasale, the point directlybelow the nose. The lower face is measured fromsubnasale to soft tissue menton, which is the lowerborder of the chin. When measured in repose, thelength of the middle third of the face should equalthe length of the lower third (33). Lip length is meas-ured from subnasale to the lower border of the upperlip and tends to increase with age. In young womenaverage lip length is 2022 mm, and in young men2224 mm. In repose approximately 34 mm of themaxilary central incisors are displayed in youngwomen; in young men the amount of display is ap-proximately 2 mm less. The smile line should be ob-served in a variety of situations, including rest,speech, smiling and laughter. During a normal fullsmile, the upper lip should rest at the level of themid-facial gingival margins of the maxillary anteriorteeth. The lower lip should rest at the incisal edgesof the maxillary anterior teeth; the incisal edges of

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the maxillary anterior teeth should be parallel to thecurvature of the lower lip during a full smile. Whenany significant discrepancies exist in one or moreextraoral parameters, it may be unrealistic to expectintraoral procedures alone to provide a satisfactoryresult. In these cases orthognathic and/or plasticsurgery procedures may need to be considered, orpatient expectations may need to be modified.

Next, a thorough intraoral examination is con-ducted, combining clinical and radiographic obser-vations. The condition and dimensions of the teethshould be determined, including caries, fracturesand pulpal pathoses. The height of the anatomiccrown is measured from the cementoenamel junc-tion to the incisal edge, while the height of the clin-ical crown is measured from the gingival margin tothe incisal edge. A comparison of these two meas-urements will determine whether short clinicalcrowns are a result of incisal wear or a coronal posi-tion of the gingival margin. If excessive incisal wearhas occurred, then parafunctional habits must be in-vestigated and dealt with appropriately. Once thecause of the incisal wear has been identified andcontrolled, then restorative procedures can beplanned to replace lost tooth structure. Coronal po-sition of the gingival margin with respect to thecementoenamel junction may be the result of delay-ed passive eruption or of gingival enlargement. De-layed passive eruption occurs when the dentoging-ival junction fails to migrate apically to the vicinityof the cementoenamel junction after the tooth haserupted into occlusion. Width of keratinized gingivamay be excessive or within the normal range, andthe alveolar crest may be at or 12 mm apical to thecementoenamel junction (6). Gingival enlargementis most often due to inflammation caused by dentalplaque, but is also associated with medications suchas phenytoin, cyclosporin and calcium-channelblockers, and with pathological conditions such ashereditary gingival fibromatosis (9). The width andthickness of keratinized gingiva must be measuredas well as probing depths, clinical attachment levelsand the level of the alveolar crest with respect to thecementoenamel junction. Interproximal bone levelscan be estimated using radiographs taken parallel tothe long axes of the teeth. Facial and lingual bonelevels can be determined with sounding using localanesthesia, often in conjunction with another pro-cedure which requires local anesthesia, such as scal-ing and root planing or at the beginning of a surgicalprocedure. Thickness of alveolar bone and any ir-regularities of hard or soft tissue should also be re-corded. The condition of the teeth must be carefully

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evaluated and any necessary restorative treatmentnoted.

Diagnosis

Following collection of data, the findings are ana-lyzed and a concise diagnosis is formulated. This willidentify conditions that require treatment and mayinvolve a single discipline, such as restorative den-tistry, periodontics, endodontics, orthodontics ororal and maxillofacial surgery. More often, however,conditions will be related to a combination of two ormore disciplines. A healthy periodontium and incisalwear with adequate tooth structure for restorationsmay require only restorative treatment. A sound, in-tact dentition with gingival hyperplasia may requireonly periodontal treatment. A tooth that has beendamaged by caries or trauma to the extent that thereis less than 3 mm of sound tooth structure coronalto the alveolar crest will require periodontal and per-haps orthodontic treatment prior to fabrication of adefinitive restoration (15). This should result in ap-proximately 1 mm of connective tissue attachment,1 mm of junctional epithelium and 1 mm of sulcusdepth (12). Failure to respect the integrity of thedentogingival junction is likely to result in chronicinflammation and subsequent attachment loss,which will have adverse aesthetic consequences.When significant discrepancies exist in face height,lip length or lip thickness, periodontal and restora-tive treatment may need to be coordinated withorthognathic and/or plastic surgery procedures (4,23, 33). If the patient is unwilling or unable to obtainthis additional care, then he or she must be informedthat limited improvement may result from peri-odontal and restorative treatment. It is absolutely es-sential that a complete, comprehensive diagnosis bedeveloped in order to plan treatment that will pre-dictably produce optimal results with long-term sta-bility. The shortcomings of an incomplete diagnosisare illustrated in case reports describing a simplecorrection of the gummy smile (22). The reportedprocedure basically reduced the buccal vestibule byexcising alveolar mucosa and binding down theupper lip to restrict gingival display. Long-term fol-low-up for this procedure was not published; how-ever, a later publication expressed disappointmentwith the technique and recommended amputationof the levator labii superioris muscles to prevent thelip from elevating and thus reduce gingival display(26). Another report identified the limitations oftreating only the lip and suggested a Le Forte I osteo-

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tomy to reduce the excessive gingival display (18). Itis important to keep in mind that excessive gingivaldisplay, often referred to as the gummy smile maybe the result of several factors, including gingival en-largement, altered or delayed passive eruption, in-sufficient clinical crown length, vertical maxillary ex-cess and a short upper lip (21). When the cause ofthe condition is identified and an accurate diagnosisis obtained, a treatment plan can be formulated thatwill predictably produce optimum long-term results.

Treatment planning

Following the formulation of a complete and accu-rate diagnosis, a comprehensive plan for treatmentis developed. When full-coverage restorations are in-dicated, it is preferable to avoid placing margins sub-gingivally; however, in anterior areas margins fre-quently must be placed within the sulcus for aes-thetic reasons. In order to minimize colonization ofthe sulcus by microorganisms associated with peri-odontitis, it is important to avoid overhangs and toreproduce the original contours of the tooth asclosely as possible (20). Margins should generally beplaced not more than 0.5 mm subgingivally. In ad-dition, proper embrasure space must be restored topromote periodontal health and an esthetic appear-ance (10).

Extensive caries or crown fracture may create asituation where placement of the restoration marginon solid tooth structure would result in violation ofthe biological width necessary for health and long-term stability of the periodontium. The distancefrom the restoration margin to the alveolar crestshould be at least 3 mm (11, 12). In posterior areasthis may be accomplished by surgical resective pro-cedures, as long as sufficient bone support will re-main (24). The amount of bone support required willdepend upon several factors, such as the opposingocclusion, whether or not the tooth will serve as anabutment for a fixed or removable partial denture,and whether or not the patient demonstrates para-functional habits. In anterior areas where aestheticconsiderations are highly significant, surgical crownlengthening alone may have an unacceptable result.If the gingival margin of the tooth to be restored isin harmony with adjacent teeth and at an acceptablelevel with regard to aesthetics, then crown lengthen-ing would need to be performed on all of the ad-jacent anterior teeth, and this could adversely affectaesthetics. In such cases, forced eruption combinedwith localized fibrotomy and thorough root planing

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or limited crown lengthening may be indicated (16,17, 19, 30). When a tooth is extruded, the resultingcoronal-incisal height of the restoration that will beplaced is less than if only a resective crown lengthen-ing procedure were performed; consequently, the re-sulting crownroot ratio will be more favorable fol-lowing extrusion than it would be with surgicalcrown lengthening alone. Because roots are taperedto varying degrees, a tooth which has been extrudedwill have a decreased root diameter at the level ofthe gingival margin. Since the mesiodistal distancebetween the adjacent teeth remains constant, therestoration of the extruded tooth will exhibit greatertaper from the incisal edge to the gingival margin,and particular attention is necessary to avoid over-contouring. Teeth with limited tapering in the co-ronal third of the root are better candidates for ex-trusion than those with more pronounced tapering.Proper sequencing of treatment is essential for anoptimal result. Complete caries removal and/or theremoval of fractured tooth structure should be ac-complished first. This will help to determine whetheror not the tooth is restorable, and whether or notendodontic therapy is necessary. If endodontic ther-apy is indicated, it should be performed next. Aftersuccessful completion of endodontic therapy, appro-priate build-up of the tooth should be done, fol-lowed by preparation and provisionalization. When-ever possible, the finish line of the preparation forthe provisional restoration should closely approxi-mate the margin of the final restoration. It is import-ant to keep in mind the original contour of thecementoenamel junction when preparing teeth forfull-coverage restorations so that the resulting mar-gin will be in harmony with the osseous architecture(35). The margin on the mesial and distal aspects ofthe anterior teeth must be coronal to the facial andlingual aspects, with the magnitude of these differ-ences dependent upon the particular gingival mor-photype of the patient (flat, scalloped, pronouncedscalloped) (3). If this principle is not observed, a bar-rel-shaped preparation is created that will result inviolation of the biological width interproximally,with subsequent inflammation, pocket formationand attachment loss (28). If it is not possible to ac-complish provisional restorations prior to surgicalcrown lengthening, then the restorative dentist canfabricate a template based on the diagnostic wax-upthat will provide guidance in establishing appropri-ate hard and soft tissue architecture (39). The surgi-cal procedure must be planned based on diagnosisand the principles of wound healing. Flap designmust be done with consideration for the width and

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thickness of keratinized tissue, the amount of at-tached keratinized tissue, vestibular depth, existingosseous topography and anticipated osseous levelsfollowing the procedure. As with soft tissue, a three-dimensional assessment must be done when evalu-ating bony architecture, noting both the height andthe thickness of bone. Obvious examples of in-creased bone thickness are tori and exostoses, but itis also important to recognize areas of thin radicularbone in order to more accurately predict the courseof healing. Depending upon the thickness of alveolarbone and assuming that the bone is treated kindlyduring surgical therapy, it is reasonable to expectslightly less that 1 mm of crestal resorption followingosseous resective surgery (29). If the width of kera-tinized tissue must be preserved or augmented, thenthe flap may be apically positioned at or slightly api-cal to the alveolar crest. As the site heals, the dento-gingival junction will reform, with approximately 1mm of supracrestal connective tissue attachment, 1mm of junctional epithelium and 1 mm of sulcusdepth. Thus, if 1 mm of crestal resorption occurs,there will still be an overall increase of 2 mm in thewidth of keratinized tissue. While the new junctionalepithelium will form in approximately 2 weeks, for-mation and maturation of the underlying connectivetissue attachment takes considerably longer (40).The degree of maturation must be taken into con-sideration when planning restorative treatment fol-lowing periodontal surgery. In areas where marginswill be supragingival and tissue is reasonably thick,restorative treatment may be performed 2 monthspostsurgically, though it must be kept in mind thatcoronal migration of the gingival margin may occurduring subsequent months. In cases with a very thin

Fig. 1. A 16-year-old girl had completed orthodontic treat-ment, but was dissatisfied with the aesthetic outcome dueto excessive gingival display.

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periodontium it is reasonable to expect some apicalmigration of the gingival margin during healing.These changes may also be related to age, withyounger patients showing a greater tendency for co-ronal migration of the gingival margin postsurgically.In areas where aesthetics is critical, a healing periodof at least 6 months is recommended following peri-odontal surgery (5). The restoration margin shouldthen be placed 0.5 mm subgingivally. With effective,atraumatic plaque control, a stable gingival marginand optimal aesthetics can then be achieved (8). Incases with extremely thin gingival tissue, soft tissuegrafting procedures may be used to increase thethickness of keratinized tissue 6 to 8 weeks prior tosurgical crown lengthening (32). In anterior areaswhere there has been loss of interdental bone height,care must be taken to avoid any surgical procedurethat would compromise the blood supply to theinterdental papilla, as this is likely to result in loss ofpapilla height. In some cases it may be possible toreflect soft tissue from only the palatal or buccal as-pect and utilize a tunneling approach for any inter-proximal osseous recontouring. In other cases it maybe necessary to perform surgical treatment separ-ately from the buccal and lingual aspects with a 6-to 8-week healing interval between procedures in or-der to avoid compromise of the blood supply to theinterdental papilla. Restoration of lost interdentalpapilla height is usually unpredictable, though itmay be accomplished in some cases using ortho-dontic extrusion; it is preferable, therefore, to plantreatment that will preserve the interdental papilla.

Case reportsCase 1

A 16-year-old girl presented to the dental service ata large teaching hospital with a chief complaint of anunacceptable aesthetic result following orthodontictreatment. The patient was in excellent generalhealth with no known allergies, did not take anymedication and denied use of tobacco. Traditionalnonsurgical orthodontic treatment had been per-formed over a period of 3 years, resulting in favor-able tooth alignment, but excessive gingival displayin the maxillary arch significantly compromised theaesthetic outcome (Fig. 1). The patients orthodontistreferred her to the hospital dental service, believingthat orthognathic surgery might be necessary. Athorough examination revealed face height and liplength to be within normal range; a combination ofdelayed passive eruption and gingival enlargement

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Fig. 2. Delayed passive eruption and gingival enlargementwere determined to be the cause of excessive gingival dis-play.

Fig. 3. Gingival architecture before (A) and 6 months after(B) surgical crown lengthening in the maxillary anteriorsextant

were determined to be responsible for the excessivegingival display (Fig. 2). Surgical crown lengtheningwas performed in the maxillary anterior sextantunder local anesthesia; weekly follow-up visits forthe first month and biweekly visits for the next 5months ensured that meticulous plaque control was

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Fig. 4. One year following crown lengthening, the patientcontinues to maintain the health, function and aestheticsof the periodontium.

Fig. 5. 26-year-old woman with chief complaint of agummy smile

Fig. 6. Poorly contoured restorations, gingival inflam-mation and loss of interdental papillae

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Fig. 7. Existing restorations were impinging upon the bio-logical width of the periodontium.

Fig. 8. Diagnostic wax-up (A) and surgical guide (B) dem-onstrating the location of future restoration margins

maintained and optimum healing occurred (Fig. 3).Subsequent recall visits at 3-month intervals duringthe next year revealed that the patient continued toperform highly effective plaque control, and wasvery pleased with the aesthetic result (Fig. 4).

Case 2

A 26-year-old woman presented to the advancedperiodontology department of our school of den-

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Fig. 9. Before (A) and after (B) ostectomy and osteoplasty

Fig. 10. Stable gingival contours 6 months after surgicalcrown lengthening: buccal (A) and palatal (B) views

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Fig. 11. Final restorations (A); periodontal health and idealgingival display have been accomplished (B). Courtesy ofKian Kar and James Kim.

tistry with a chief complaint of a gummy smile(Fig. 5). The patient was in excellent general healthwith no known allergies, took no medication and de-nied use of tobacco. Examination revealed poorlycontoured ceramometal restorations, gingival in-flammation and loss of interdental papillae (Fig. 6).Existing restorations were violating the biologicalwidth of the periodontium (Fig. 7), a factor whichcontributed to chronic inflammation. A diagnosticwax-up was performed to establish the desired endresult of periodontal and restorative treatment (Fig.8a). Using this wax-up, a surgical guide was fabri-cated to facilitate the crown-lengthening procedure(Fig. 8b). Use of the surgical guide is essential incases where provisional restorations are not pre-pared prior to crown lengthening so that the surgeoncan accurately identify the future location of the res-toration margins and ensure that at least 3 mm ofclearance exits between the margin and the crest ofalveolar bone (Fig. 9). After allowing at least 6months for healing and stabilization of gingival mar-gins (Fig. 10), final restorations were placed, provid-ing a remarkable improvement in periodontal healthand aesthetics (Fig. 11).

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Case 3

An 18-year-old woman presented to the restorativedepartment of our dental school with a defective res-toration margin on tooth 9 (Fig. 12a) that had re-ceived prior endodontic therapy (Fig. 12b). The pa-tient was in excellent general health with no knownallergies, took no medication and denied use of to-bacco. In order to establish a sound margin for thenew restoration, it was necessary to extend the prep-aration apically in close proximity to the alveolarcrest. If crown lengthening alone were performed adiscrepancy would result between the height of thegingival margins on teeth 8 and 9. To avoid this out-come, the existing full coverage restoration on tooth9 was removed and reduced in height, a cast postand core was constructed, and the original restora-tion was provisionally cemented. Orthodonticbrackets were then placed, and tooth 9 was extruded

Fig. 12. 18-year-old woman with defective restoration ontooth 9 (A) that has received prior endodontic therapy (B)

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Fig. 13. After placement of a cast post and core, incisalreduction and provisional cementation of the original res-toration, tooth 9 is orthodontically extruded and retainedfor 5 months.

1 mm per week for 3 weeks and then stabilized for 5months (Fig. 13). Surgical crown lengthening wasthen performed, consisting of full-thickness muco-periosteal flap reflection (Fig. 14a), ostectomy in or-der to provide harmony with adjacent teeth and atleast 3 mm clearance between the final restorationmargin and the alveolar crest (Fig. 14b). Palatal andinterproximal soft tissue was not manipulated in or-der to preserve the interdental papillae. Ostectomyand osteoplasty in interdental areas were performedusing a tunneling technique. The buccal flap was re-placed with interrupted sutures (Fig. 15); after 2months the preparation was refined and a new pro-visional restoration constructed, which remained foran additional 4 months (Fig. 16) prior to placementof the final restoration. Gingival health, comfort andoptimum aesthetics were achieved and maintained(Fig. 17).

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Case 4

A 28-year-old woman presented for periodic exami-nation. The patient was in excellent general healthwith no known allergies, did not take medication anddenied tobacco use. Clinical, radiographic and micro-biological data were used to arrive at a diagnosis ofearly-onset periodontitis (Fig. 18). Oral hygiene in-struction, scaling and root planing, antimicrobialtherapy and periodontal surgery were performed to

Fig. 14. Mucoperiosteal flap reflected, pre-ostectomy (A)and post-ostectomy (B)

Fig. 15. Flap sutured

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Fig. 16. Healing at 6 months with new provisional restora-tion: buccal (A) and palatal (B) views

Fig. 17. Final restoration 18 months after crown length-ening

reduce inflammation and allow for healing and repairof osseous defects. Resulting soft tissue contours wereless than ideal from an aesthetic perspective (Fig. 19).Orthodontic extrusion was performed on tooth 8 (Fig.20), using gentle forces in order to bring the periodon-tium coronally with the tooth (Fig. 21). Tooth positionwas stabilized for 6 months prior to fabrication of anew restoration on tooth 8, resulting in an aestheticlong-term result (Fig. 22).

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Fig. 18. Radiographic findings consistent with early-onsetperiodontitis

Fig. 19. Following definitive periodontal treatment, thegingival margin of tooth 8 is apical to the gingival marginof tooth 9.

Fig. 20. Orthodontic extrusion is performed on tooth 8.

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Fig. 21. Following extrusion, gingival margins of teeth 8and 9 are in harmony.

Fig. 22. Final restoration on tooth 8 after 2 years

Fig. 23. 32-year-old woman with loss of interdental papil-lae and chronic gingival inflammation

Case 5

A 32-year-old woman presented for periodontal con-sultation following extensive restorative treatmentwith an unsatisfactory aesthetic result. The patient

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was in excellent general health with no known aller-gies, took no medication and denied use of tobacco.Loss of interdental papillae and chronic gingival in-flammation were noted (Fig. 23). Treatment con-sisted of a combination of orthodontic extrusion, tobring the periodontium coronally and help restorelost interdental papilla height, and surgical crownlengthening, to establish proper biological width andoptimal gingival contours. Eight months followingsurgical treatment, final restorations were placed,providing the patient with a highly aesthetic result.Effective daily plaque control performed by the pa-tient and periodic recall appointments ensure con-tinued periodontal health, comfort and aesthetics(Fig. 24).

Case 6

A 40-year-old woman presented for periodontal con-sultation with a chief complaint of gummy smile

Fig. 24. A combination of orthodontic extrusion and surgi-cal crown lengthening produced a stable, functional andaesthetic result, shown here 18 months following place-ment of final restorations.

Fig. 25. 40-year-old woman with a chief complaint ofgummy smile

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Fig. 26. The condition was diagnosed as delayed passiveeruption.

Fig. 27. Crestal bone was at the level of the cemento-enamel junctions (A) and was subsequently recontoured(B) to permit healing of the dentogingival junction withan optimum display of the clinical crowns.

(Fig. 25). The patient was in excellent general health,took no medication and denied use of tobacco. Afterclinical and radiographic examination a diagnosis ofdelayed passive eruption was determined (Fig. 26).Mucoperiosteal flap reflection from the buccal as-pect revealed alveolar bone to the level of thecementoenamel junctions (Fig. 27a). Neither palatal

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nor interdental soft tissue was reflected in order toensure maintenance of interdental papillae. Osseousrecontouring was performed on the buccal aspect tolocate the alveolar crest 3 mm apical to the cemento-enamel junction (Fig. 27b). This allowed the dento-gingival junction to heal with the gingival margin atthe level of the cementoenamel junction. A stable,aesthetic result is seen 18 months following thecrown-lengthening procedure (Fig. 28).

Case 7

A 30-year-old woman presented for routine periodicexamination. The patient was in excellent health,took no medications and denied use of tobacco.Radiographic examination revealed extensive carieson the distal aspect of tooth 12, which had been pre-viously treated endodontically (Fig. 29). In order toachieve harmony of the periodontium with the ad-jacent teeth without performing osseous resectionon the cuspid and second bicuspid, tooth 12 was or-thodontically extruded approximately 1 millimeterper week for 4 weeks (Fig. 30). By moving the tooth

Fig. 28. A stable, aesthetic result is seen intraorally (A) andextraorally (B) 18 months following the crown-lengthen-ing procedure.

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Fig. 29. Endodontically treated maxillary first bicuspidwith extensive caries on the distal aspect

Fig. 30. Orthodontic extrusion is performed so that crownlengthening can be performed only on tooth 12, therebypreserving aesthetics.

Fig. 31. After 4 mm of extrusion and 4 months of stabiliza-tion, orthodontic brackets are removed.

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closer to the occlusal plane, the overall length of thetooth was reduced, resulting in a more favorablecrownroot ratio. After 4 months of stabilization, thebrackets were removed (Fig. 31). After post-and-corecementation and provisionalization, mucoperiostealflaps were reflected (Fig. 32a) and osseous recon-touring was performed resulting in adequate biologi-

Fig. 32. Mucoperiosteal flaps were reflected (A) and oss-eous recontouring was performed (B).

Fig. 33. Clinical appearance 1 year following crownlengthening

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cal width while preserving aesthetics (Fig. 32b). Thefinal restoration was placed 6 months later and isseen here clinically (Fig. 33) 1 year following thecrown-lengthening procedure.

Summary and conclusions

Contemporary dental treatment must result in trueoral health, incorporating comfort, function and aes-thetics. The key to a successful outcome with long-term stability is the establishment of an accurate di-agnosis and subsequent development of a compre-hensive treatment plan. The astute clinician will rec-ognize underlying skeletal variations that may not becorrected by periodontal and restorative proceduresalone. Understanding the cause of the condition tobe treated will facilitate selecting and sequencingprocedures that will produce a stable result. Atten-tion should be given to facial symmetry, face height,lip anatomy, profile and smile line when performingthe extraoral examination. Intraorally, importantconsiderations include condition and dimensions ofthe teeth; height of the anatomic crowns versusheight of the clinical crowns; thickness, width, posi-tion and contour of gingival tissue; root anatomy;and topography of the alveolar bone. The integrityof the dentogingival junction must be observed byensuring adequate biological width. Harmony mustexist between soft and hard tissue and between theperiodontium of adjacent teeth. Often a combi-nation of orthodontic extrusion and surgical crownlengthening can be employed to minimize the needfor resective therapy on adjacent teeth, improve thecrownroot ratio and facilitate a more aesthetic out-come. Orthodontic extrusion is also invaluable as ameans to regain lost height of interdental papillae.Margin placement during tooth preparation for fullcoverage restorations should be guided by the posi-tion of the cementoenamel junction; hence, inter-proximal margins, particularly on anterior teeth, willbe more coronal than buccal and lingual margins.This will help ensure adequate biological width andmaintenance of healthy, intact interproximal papil-lae. When periodontal surgical procedures are per-formed in anterior areas, it is necessary to deferplacement of final full coverage restorations for ap-proximately 6 months in order for the level of thegingival margin to stabilize. In patients with particu-larly thin buccal alveolar bone and gingiva, it maybe prudent to monitor maturation of the healingtissue for a longer period of time, and in patientswith relatively thick buccal alveolar bone and gingiva

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it may be reasonable to place final restorations lessthan 6 months following periodontal surgery. Effec-tive daily plaque control and periodic recall are es-sential to maintain long-term stability. By followingthe guidelines outlined in this chapter, the clinicianwill promote a stable, comfortable and functionalperiodontium and provide the patient with an opti-mal aesthetic result.

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