TARRSON FAMILY ENDOWED CHAIR IN PERIODONTICS

UCLA SCHOOL OF DENTISTRY

PresentsPresentsDr. E. Barrie KenneyProfessor & ChairmanSection 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.

Professor and Chairman Division of Associated Clinical Specialties

UCLA School of Dentistry

ESTHETIC SURGICAL PROCEDURES FORCROWN LENGTHENING

1. Gingivectomy

2. Flap surgery for osseous recontouring

Choice depends on

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.

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

1mm.

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