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Combined Periodontal and Esthetic Approach in Restorative Crown Lengthening1Garima Singh, 2Shankar T Gokhale, 3Sidharth Shankar, 4Kausar Parwez Khan, 5Priya Saxena

ABSTRACTFew of the conditions like deep subgingivally located carious lesions, crown and root fractures, pre-existing deep preparation margins are unfavorable for successful restorative procedures. In such situations, surgical lengthening of the clinical crown will improve the anatomical conditions and facilitate restorative proce dures. Gingivectomy with ostectomy/osteoplasty pro-cedure enables the positioning of the alveolar crest at a distance upto 2 to 3 mm from the future reconstruction margin and leads to stable periodontal tissue levels over a period of 6 months. When combined with frenotomy meets at relocating the frenal attachment so as to create a zone of attached gingiva between the gingival margin and the frenum.

Keywords: Crown lengthening, Frenectomy/Frenotomy, Gingi-vec tomy, Ostectomy/Osteoblasty.

How to cite this article: Singh G, Gokhale ST, Shankar S, Khan KP, Saxena P. Combined Periodontal and Esthetic Approach in Restorative Crown Lengthening. J Dent Sci Oral Rehab 2014;5(3):168-172.

Source of support: Nil

Conflict of interest: None

INTRODUCTION

Crown lengthening involves the surgical removal of hard and soft periodontal tissues to gain supracrestal tooth length, allowing for longer clinical crowns1 and maintenance of bio-logical width.2 Crown lengthening procedures are required to solve problems, such as (1) inadequate amount of tooth structure for proper restorative therapy, (2) sub gin gival and subcrestal location of fracture lines, and (3) sub gin gival loca-tion of carious lesions. The techniques used to accomplish crown lengthening include (1) apically posi tioned flap pro-cedure including osteoplasty and ostectomy, and (2) forced tooth eruption with or without fiberotomy.3

The interplay of periodontics and restorative dentistry is present at many fronts including the response of the gingival tissue to the restorative preparations. Dental restorations and periodontal health are inseparably interrelated.4

CASE REPORT

1,3-5Postgraduate Student, 2Professor1-5Department of Periodontology, Institute of Dental Sciences Bareilly, Uttar Pradesh, India

Corresponding Author: Garima Singh, Postgraduate Student Department of Periodontology, Institute of Dental Sciences, Bareilly Uttar Pradesh, India, e-mail: garimasngh5@gmail.com

10.5005/jp-journals-10039-1038

With the increasing popularity of esthetic-oriented treat ment, an understanding of the therapeutic synergies brought about a multidisciplinary approach has developed. As a result, crown lengthening procedures have become an integral component of the esthetic armamentarium and are utilized with increasing frequency to enhance the appearance of restorations placed within the esthetic zone.5

A frenum is a fold of mucous membrane, usually with enclosed muscle fibers, that attaches the lips and cheeks to the alveolar mucosa and/or gingiva and underlying periosteum. A frenum becomes a problem if the attachment is too close to the marginal gingiva. Problems associated with aberrant frenum may create tension on the gingival margin (frenal pull) concomitant with or without gingival recession. This condi tion may be conducive to plaque accumulation and inhibit proper brushing of the teeth.6

A stable, healthy gingival margin and adequate expo-sure of the clinical crown is mandatory prior to crown pre-paration. This is necessary to prevent the exposure of the crown margin and root surface after the crown is placed.6 To deal with these aspects there are many innovative forms of therapies of periodontal minor surgeries which may be used to improve the crown stabilization, to stabilize the results and enhance the esthetics.

Crown lengthening procedures enable the dentist perfor-ming the restoration to develop an adequate area for crown retention without extending the crown margins deep into the periodontal tissues, referred to as the biologic width. The term biologic width is used to describe the junctional epithe lium and connective tissue that attach to the root sur face. Studies have indicated that the average lengths of the connective tissue attachment and junctional epithelium are 1.07 and 0.97 mm, respectively. Therefore the average length of the biologic width is about 2 mm. If the restorative margin is placed into this area, the crestal bone will be lost to re-establish the biologic width.6

Clinical crown-lengthening procedures include gingi-vectomy, an apically positioned flap (APF), an APF with osseous reduction, forced eruption combined with surgery, and forced eruption combined with fiberotomy.6

A gingivectomy technique can be used to eliminate the tissue that forms the pocket or sulcus wall; such tissue may be overgrown (gingival pocket) and may interfere with the intended restorative procedures. Removal of the tooth-

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supporting bone (Ostectomy) is accomplished to lengthen the clinical crown. It is essential that there be at least 3 mm between the most apical extension of the restoration margin and the alveolar bone crest. This space allows sufficient room for the supracrestal collagen fibers that are part of the periodontal support mechanism, as well as providing a gingival crevice of 2 to 3 mm. If this guideline is used, the margin of the crown is finally positioned at its correct level, approximately halfway down the gingival crevice. 6

Gingivectomy is indicated only for teeth with more than 3 to 4 mm of attached gingiva.7

The technique of frenectomy and frenotomy have been introduced for coping with the problems associated with the aberrant frenum. Frenectomy is complete removal of the frenum, including its attachment to underlying bone, and may be required in the correction of an abnormal diastema between maxillary central incisors. Frenotomy is the incision of the frenum. Both procedures are used, but frenotomy generally suffices for periodontal purposes-that is, relocating the frenal attachment so as to create a zone of attached gingiva between the gingival margin and the frenum.6

The purpose of this paper is to present a case with inade-quate amount of tooth structure for prosthetic crown place-ment with high frenum attachment. This case was treated by gingivectomy with ostectomy and frenotomy.

CASE REPORT

A 19-year-old female patient referred to the department of periodontology in need of crown lengthening of right maxillary central incisors. Patient gave history of having sustained fractured maxillary central incisor 1 month back following road traffic accident, for which she had to undergo root canal treatment immediately.

The patient’s medical history was nonsignificant for major conditions or allergies and free of contributory

factors (e.g. systemic disease), making her an ideal surgical candidate. After discussion with the restorative dentist, esthetic crown-lengthening was recommended to allow a healthy, optimal relationship between the teeth and the periodontium.

Intraoral examination (Figs 1A and B) and radiograph (Fig. 2) revealed that the Ellis class III fracture of tooth 11, had been treated endodontically. Periodontal examination revealed good oral hygiene with minimal plaque and calculus deposits. The gingiva was pink and firm, and the papillae were intact. Clinical examination revealed shallow probing depths, no mobility, inadequate amount of keratinized attached gingival of 11 on the buccal aspect and palatal aspect and tension on the gingival margin due to high labial freanum attachment.

To start, thorough scaling was done followed by oral hygiene instructions. After 3 to 4 weeks of initial therapy patient was recalled for next phase of surgical procedure aiming to do crown lengthening. On the labial side an inverse bevel incision was given on 11 and extending out to 21 (Figs 3A and B) to maintain symmetry of gingival margins among the central incisors, by using Bard Parker blade (No.15), thereby considering the esthetic value of the smile.

On the palatal aspect inverse bevel incision was given limiting its extent to 11 and at the same time an effort was made to retain scalloped margin using a Bard-Parker blade (No. 15). A full thickness mucoperiosteal flap including palatal gingiva and alveolar mucosa was raised by means of a mucoperiosteal elevator. The marginal collar of tissue, including pocket epithelium and granulation tissue, was removed with curettes, and the exposed root surfaces are carefully scaled and planed (Fig. 4).

The alveolar bone crest was recontoured (ostectomy) with the objective of recapturing the normal form of the alveolar process, i.e. positive architecture but at a more

Figs 1A and B: Preoperative view: (A) labially and (B) palatally

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apical level. The osseous surgery was performed labially, palatally and interproximally using carbide burs with external irrigant and every effort was made to meet the requirement of biologic width (Figs 5A and B). Following careful adjustment, the labial and palatal flap was sutured to the level of the newly recontoured alveolar bone crest (Fig. 6).

A frenotomy scissor incision was given over the labial freanum (Fig. 6). Finally sutures were given at the freanum to prevent relocating of the fibers (Fig. 7). And over that a periodontal dressing (Coe-Pak®) was placed (Fig. 8). Antibiotics (amoxicillin 500 mg tid for 5 days) and analgesics (Diclofenac sodium 50 mg bid for 3 days) were prescribed. After 24 hours 10 ml chlorhexidine gluconate

Fig. 2: IOPAR in relation to 11 Fig. 4: Removal of marginal collar of tissue

rinse 0.2% bid was advised for 2 weeks, and the patient was given appropriate postoperative instructions.

The sutures were removed after 7 days and the surgical site was irrigated with saline. The healing of the surgical site was quite uneventful and satisfactory (Fig. 9). After 3 months, the apical displacement of the free gingival margin was 3 mm (Figs 10A and B).

Final preparation of the teeth began a half year later, to confirm the final position of gingival margin following postsurgical recession. Care was taken to ensure that the margins of the temporary crown were smooth and closely adapted to ensure gingival health. Final cementation of the crowns was performed after 6 months.

Figs 3A and B: Internal bevel gingivectomy incision: (A) labially i.r.t 11 and 21 and (B) palatally i.r.t 11

Figs 5A and B: After ostectomy: (A) labial view and (B) palatal view

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DISCUSSION

There is a significant relationship between restorative den tis try and periodontal health. Deeper subgingival mar-gins, especially those encroaching the junctional epi the-lium, and placed near alveolar bone cause the gingival inflammation, loss of connective tissue and bone resorption. Thus, periodontal surgery is recommended to support restorative dentistry for allowing long clinical crowns and re-establishment of biological width.

The concept of the biological width stems from histo-logic description of the dentogingival complex by Gragiulo et al (1961). He concluded the mean total length of the dento-gingival complex was 2.73 mm.8 Rosenberg et al (1980) com bined epithelial and connective tissue attachment of 2 mm with 1 to 2 mm for the restorative finish line, resulting in a recommendation of 3.5 to 4.0 mm. Wagenberg et al. 1989 suggested that at least 5.0 to 5.25 mm of tooth structure should be above the osseous crest.9

There is significant marginal tissue rebound following crown lengthening surgery that has not fully stabilized by 6 months. The amount of coronal rebound appears to be related to the position of flap related to the alveolar crest at suturing. These findings support the premise that clinicians should establish proper crown height during surgery without

Fig. 6: Frenotomy incision

Fig. 7: Suturing-labial view

Fig. 8: Periodontal dressing

Fig. 9: Postoperative 1 week

Figs 10A and B: Postoperative 3 months: (A) labial view and (B) palatal view

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over reliance on flap placement at the osseous crest to gain necessary crown length.10

After the surgical clinical crown-lengthening procedure, the provisional restoration must be readapted. A waiting period of 12 weeks has been suggested prior to starting the final restoration, although Bragger et al reported no change in attachment levels or probing depths after 6 weeks of healing. However, due to the possibility of recession, Bragger et al (1992) recommended a waiting period of 6 months for areas that held esthetic concerns.11

Alveolar bone loss caused by inflammatory periodontal disease often results in an uneven outline of the bone crest. The purpose of osteoplasty is to create a physiologic form of the alveolar bone without removing any ‘supporting’ bone. Osteoplasty therefore is a technique analogous to apically positioned flap surgery. Patients not receiving adjunctive antibiotic therapy, apically positioned flap surgery with osseous recontouring is more effective than apically posi-tioned flap surgery without osseous recontouring in reducing periodontal pocket depth and levels of major periodontal pathogens.12

Crown lengthening involves the surgical removal of hard and soft periodontal tissues to gain supracrestal tooth length allowing for longer clinical crowns and re- establishment of the biological width. A human study to evaluate the positional changes of biologic width, following surgical crown lengthening, showed that biological width was reestablished to its original vertical dimension by 6 months.13

CONCLUSION

There is a significant relationship between restorative den tistry and periodontal health. Periodontal surgery is recommended to support restorative dentistry, maintaining esthetics and improve long-term prognosis. Surgical crown lengthening should be the most immediate and common approach, since, it will expose the sound tooth structure immediately after surgery.

Surgical crown lengthening done with gingivectomy, the bone level can be lowered to allow for the placement of the prosthetic margin. This surgical approach accomplishes the goal of re-establishment of the biological width with a perma nent apical shift of the alveolar crest and the gingival margin. Crown lengthening with frenotomy improved patient compliance by avoiding a second surgical exposure. Thus, stable margins are achieved exposing tooth structure for restorative therapy.

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