S68

Clinical Comparison of Desired

Versus Actual Amount of Surgical
Crown Lengthening
F. Herrero,* J.B. Scott* P.S. Maropis,* and RA. Yukna"'

The actual length of clinically exposed tooth structure between planned resto-
ration margin and alveolar crest ("biologic width") obtained during surgical crown
elongation procedures was compared to the textbook goal of 3.0 mm. Sixteen (16)
patients with 21 teeth requiring surgical crown lengthening for restoration placement
participated. Oral hygiene instructions were given and optimal plaque control was
mandatory. At each clinician's discretion, surgical techniques consisted of either gin-
givectomy or an apically positioned flap with and without osseous resection. Utilizing
a reference stent, measurements were obtained at the facial, mesial-facial, lingual, and

distal-lingual of the treated teeth both before and after osseous reduction. Parameters
evaluated were gingival margin position, probing depth, mucogingival junction posi-
tion, alveolar crest location, mobility, plaque index, and gingival index. These mea-
surements were again recorded 8 weeks after surgery with the exception of alveolar
crest. Statistical analysis with the paired i-test and linear correlation showed no sig-
nificant change from baseline or among operators with varying experience in any of
these parameters. Overall the results showed that the default objective of 3 mm be-
tween planned restoration margin and alveolar crest was not routinely achieved (mean
2.4 ± 1.4 mm). The post-treatment distance from the planned restoration margin to
the alveolar crest was greatest at the facial aspect of the teeth (mean 2.6 ± 1.2 mm)
and least at the distal-lingual (mean 2.2 ± 1.7 mm). In addition, although more ex-
perienced periodontists removed a larger amount of bone, the amount of root surface
exposed was still short of the initially desired biologic width. Within the limits of this
clinical study a 3 mm biologic width was not routinely achieved during surgical crown
elongation. / Periodontol 1995;66:568-571.
Key Words: Biologic width; gingiva/anatomy and histology; tooth/surgery; bone and
bones/surgery; tooth/anatomy and histology.

Surgical crown lengthening is often necessary as a result
of subgingival or subcrestal extension of tooth fractures,
carious lesions or previously placed restoration margins.1-3
According to several authors,4-5 2 mm constitutes the "bi-
ologic width," with 1 mm occupied by junctional epithe-
lium and another 1 mm occupied by connective tissue
attachment. Palomo and Kopczyk2 stated that a minimum
"biologic width" of only 1.0 mm is necessary. They fur-
ther stated that creation of a normal gingival sulcus fol-
lowing surgical crown lengthening would require an ad-
ditional 1 to 2 mm of exposed root coronal to the alveolar
crest, for a total of 2.5 to 3.5 mm of tooth length from
the finished restoration margin to the crest of alveolar
bone. Ingber et al.6 recommend that 3 mm of supracrestal
tooth structure be present following surgical crown
lengthening.
Although the findings and concepts reported in the
above mentioned studies have been adopted as a basis for
surgical crown lengthening procedures, relatively few of
the reported experiments involved human subjects in spe-
cific need of surgical crown lengthening. In addition,
there are no known studies in the current literature which
deal directly with surgical clinicians' immediate postsur-

*Periodontics Department, School of Dental Medicine, University of

gical results of crown lengthening procedures and the
Pittsburgh, Pittsburgh, PA.
"biologic width" or amount of tooth exposure obtained
as a result of the surgery. There is some question as to
Department of Periodontics, Louisiana State University School of Den-
tistry, New Orleans, LA. whether the treatment objectives of 3 mm of "biologic
Volume 66
Number 7
width" areroutinely obtained following surgical crown
lengthening procedures.
The purpose of this study was to compare the actual
amount of supracrestal tooth length obtained during sur-
gical crown lengthening procedures with the presurgically
desired amount. In addition, the clinical effectiveness in
achieving this goal by periodontists of varying degrees of
experience was evaluated.
MATERIALS AND METHODS
Subject Sample
Patients were interviewed for possible participation in this
study based on the diagnosis of insufficient clinical crown
for proper restoration placement and a treatment plan that
included the need for surgical crown lengthening. Written
informed consent as approved by the Institutional Review
Board, University of Pittsburgh, School of Dental Medi-
cine was obtained from adult patients referred to Graduate
Periodontics, Department of Periodontics, School of Den-
tal Medicine, University of Pittsburgh. Patients were in-
structed in oral hygiene prior to periodontal treatment and
demonstrated effective plaque control on the involved
teeth prior to entry into the study.
A default goal of 3 mm of supracrestal tooth exposure
apical to the planned restoration margin was established
based on the existing clinical philosophy of the restorative
and periodontics departments involved in the project. The
operators were not advised of a specific clinical goal dur-
ing the procedure, but were asked to perform the indi-
cated crown elongation according to their clinical judg-
ment. Premarginai and postsurgical measurements were
made by an independent investigator.
No further modification of the tooth preparation or al-
teration in the existing temporary or other restoration was
allowed during the eight weeks of the study in order to
preserve the reference points for measurement.
Surgical Technique
The actual surgical technique utilized was determined by
the individual operating surgeon. A gingivectomy or api-
cally positioned flap with or without osseous recontouring
was utilized to achieve the treatment goals. The surgeons
(who were blinded as to the exact purpose of the study)
exercised their own clinical discretion as to their having
achieved sufficient biologic width (supposedly at least 3
mm of root exposure apical to the planned restoration
margin). When they felt that they were finished, the
"post-osseous" documentation was obtained. The sur-
geons (4 first year and 4 second year graduate students
and 4 faculty) were not advised as to the nature of the
study nor of the measurements that were being made. All
measurements were taken along the stent grooves with a
calibrated manual probe to the nearest 1 mm by one of
the authors not involved in the surgery without the sur-
HERRERO, SCOTT, MAROPIS, YUKNA 569
geon present. Repeat measurements were taken at random
times to test for intra-examiner reliability.
Following completion of the surgery and suturing when
flaps were used, the choice to apply dressing or not was
left to the clinician. Patients were provided with 0.12%
Chlorhexidine gluconate* and cotton-tipped applicators for
local plaque control postsurgically. The patients were
scheduled at one week postsurgically for dressing and/or
suture removal, and at 2, 4, 6, and 8 weeks for observa-
tion, plaque removal, and review of plaque control.
Clinical Evaluation
Measurements were obtained preoperatively, during sur-
gery, and 8 weeks postoperatively.
At a presurgical appointment, impressions were taken
for. the fabrication of a measurement stent for each area
to be evaluated. The measurement stent was grooved ver-
tically at the mesiofacial, facial, distolingual, and lingual
surfaces of each study tooth. Oral hygiene review and
necessary prescriptions were completed.
At the surgical appointment preoperative and postop-
erative instructions were reviewed. Mobility,5 tissue bio-
type (narrow, average, wide), gingival index (Löe and Sil-
ness),7 and plaque index (O'Leary)8 were recorded. A
mark was placed with a Vi round bur at the free gingival
margin of the treated teeth presurgically and at the
planned restoration margin during surgery. Measurements
were made from the stent to the free gingival margin; base
of the pocket; planned restoration margins; and mucogin-
gival junction of the mesiofacial, facial, distolingual, and
lingual surfaces of the teeth to be treated. Mobility and
clinical measurements of stent to alveolar crest were made
after the gingivectomy was completed or flaps were re-
flected both before and after osseous corrections. All data
were collected again 8 weeks postsurgery. The zone of
attached gingiva was calculated by subtracting the mea-
surement of the stent to the mucogingival line from that
of stent to the base of the pocket.
RESULTS
Twenty-one (21) teeth were treated in 16 patients. Teeth
were used the unit (n
as 21) for statistical analysis by
=
the paired i-test and linear correlation comparing obtained
results to baseline and the surgical objective. Surgical
bone removal was evaluated by subtracting the distance
from the stent to the alveolar crest both before and after
osseous reduction. The biologic width achieved was de-
termined by subtracting the distance of alveolar crest
postosseous reduction from the planned restoration mar-
gin mark. Table 1 illustrates the mean bone removal and
mean biologic width obtained during surgery. The great-
est amount of both mean bone removal and biologic width
:Peridex, Procter & Gamble, Cincinnati, OH.
8Periotest, Siemens Dental, Charlotte, NC.
 J Periodontol
570 SURGICAL CROWN LENGTHENING PROCEDURES July 1995

Table 1. Mean Bone Removal (mean mm ± standard error) and

Obtained Mean "Biologic Width" (mean mm ± standard error)
eters or among operator experience levels. Intraexaminer
reliability within ±1.0 mm was 94%.
Facial Mesiofacial Distolingual Lingual
Mean bone re- DISCUSSION
moval 0.8 ± 0.9 0.7 ± 1.2 0.6 ± 1.4 0.4 ± 1.0 The goal of surgical crown lengthening is to provide the
Mean "biologic
width" 2.6 ± 1.2 2.4 ± 1.0 2.2 ± 1.7 2.3 ± 1.5
restorative dentist with sufficient clinical crown to permit
optimum restoration of a tooth. The "biologic width" is
of prime concern during surgical crown lengthening and
Table 2. Mean Bone Removal (mean mm ± standard deviation)
to Clinician Experience
the minimum desired distance achieved immediately post-
According
surgically from the crest of alveolar bone to the margin
Second Year First Year of the planned restoration has been proposed to be at least
Graduate Graduate
Experience Level Faculty Students Students 3 mm. This study attempted to determine whether peri-
Mean bone removal 1.1 ±0.6 0.8 ± 0.5 0.0 ± 0.7
odontists routinely achieve 3 mm of "biologic width"
Mean biologic width following crown lengthening procedures. If proper crown
obtained facial 1.7 ± 0.7 3.2 ± 1.3 2.7 ± 0.8 length is not obtained routinely, then other educational
and clinical guidelines may need to be developed in order
Table 3. Mean Bone Removal (mean mm) Still Required to Obtain to improve the surgical results. As seen in Table 1, the
a 3 mm "Biologic Width" greatest mean amount of bone removal occurred on the
Mesio- Disto- facial and mesiofacial with the lingual and distolingual
Tooth Surface Facial facial lingual Lingual sites demonstrating the least amounts of ostectomy. These
Mean required varying numbers might be expected due to the difference
bone removal 0.4 0.6 0.8 0.7 in ease of accessibility of the facial compared to the lin-
gual aspects. The mean distance from planned restoration
Table 4. Change in Facial Attached Gingiva Following Surgical/ margin to alveolar crest achieved in this study did not
Crown Elongation meet the minimum 3 mm requirement used as the default

Presurgical 8 Weeks
Mean mm 2.5 ± 1.2
Range mm 0-4
was found on the mid-facial surface of the treated teeth.
Other surfaces had lower figures for both parameters.
Overall, a mean biologic width of 2.4 ± 1.4 mm was
achieved.
The more experienced periodontists removed more
bone (mean 1.1 ± 0.6 mm) than either the second year
graduate students (0.8 ± 0.5 mm) or the first year grad-
uate students (0.0 ± 0.7 mm) (Table 2).
The mean amount of bone removal still required to
obtain a minimum 3 mm biologic width is presented in
Table 3. Statistically, no significant correlation was ob-
tained between experience level and mean obtained bio-
logical width (Table 2).
The amount of facial attached gingiva before surgery
was compared to the amount present after 8 weeks of
healing (Table 4). Seven (7) of the teeth showed an in-
crease; 6 a decrease; and 8 showed no change in attached
gingiva. In no instance was the amount of attached gin-
giva totally eliminated as a result of the surgical proce-
dure. Although mobility of the surgically treated teeth
was recorded in this study, due to measurement error and
technical inconsistency, results are not reported.
None of the statistical analyses demonstrated statistical
Postsurgical objective in this study and generally proposed in the lit-
2.3 ± 1.3 erature. Table 1 also shows that the mean obtained dis-
0.5-5 tance from the planned restoration margin and alveolar
crest was greatest at the facial (2.6 mm) and least at the
distolingual (2.2 mm). Therefore, an additional 0.4 mm
and 0.8 mm of tooth exposure at the facial and distolin-
gual, respectively, would be needed to achieve a 3 mm
"biologic width" (Table 3).
The amount of bone removal paralleled the experience
level of the clinicians. Experienced periodontists achieved
the greatest amount of bone removal (1.1 mm), compared
to second year graduate students (0.8 mm), or first year
graduate students (0.0 mm) (Table 2). However, no sig-
nificant correlation was found between experience level
and resultant "biologic width." This pattern of increased
effectiveness with increased experience has been shown
in other clinical studies.9-"
When dealing with restored teeth and subgingival mar-
gins that can be plaque traps, data tend to indicate that
the presence of attached gingival tissue is more cru-
cial.12'3 In all of the sites treated in this study, some at-
tached gingival tissue was maintained enabling a more
favorable prognosis and possibly less future recession.
However, several sites were left with a minimal zone of
attached gingiva.
Among the recognized limitations of this study are the
lack of standardization of the clinical area treated, the
surgical technique used, and the operators. However, it
was felt that the format used reflected general clinical

significance from baseline for any of the clinical param- situations.

Volume 66
Number 7
The purpose of this trial was to determine whether 3
mm of "biologic width" was routinely achieved follow-
ing surgical crown lengthening procedures. Within the
limits of this study, it is suggested that such an anatomic
dimension is not routinely achieved even by experienced
clinicians. Therefore, if the objective of surgical crown
lengthening is to provide at least 3 mm of tooth structure
between the planned restoration margin and the alveolar
crest, clinicians may need to be more aggressive in their
surgical procedure and take intermittent measurements
during treatment to provide the optimal distance for a
healthy gingival unit around restored teeth.
Conclusion
Overall the proposed minimum desired 3 mm distance
from planned restoration margin to alveolar crest, the "bi-
ologic width," was "not routinely achieved in this study.
Clinicians may need to be more aggressive during sur-
gical crown lengthening procedures to achieve the pro-
posed goal of a 3 mm biologic width.
Acknowledgments
The manuscript preparation efforts of Sharon Holman and
the LSU Word Processing Center are appreciated and rec-
ognized. This study was supported in part by the L.D.
Caulk and Equipment Divisions of Dentsply, York, PA
and Siemens Dental, Charlotte, NC.
HERRERO, SCOTT, MAROPIS, YUKNA 571
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Send reprint requests to Dr. J. Brent Scott, Periodontics, Box 138,
Louisiana State University School of Dentistry, 1100 Florida Avenue,
New Orleans, LA 70119.
Accepted for publication December 19, 1994.