Periodontology

Geoffrey J Bateman

Naveen Karir and Shuva Saha

Principles of Crown Lengthening

Surgery
Abstract: Crown lengthening is an invaluable tool for the restorative dentist in the management of short clinical crown heights. This
procedure, as an adjunct to a holistic restorative treatment plan, can produce predictable results, whilst ensuring good aesthetics and
maintaining periodontal health. Crown lengthening procedures are invaluable where toothwear or lack of supragingival tooth substance
would render full coverage restoration difficult. Gaining access to subgingival caries for strategic abutments can also be achieved in
this way. In certain instances, excessive gingival show or inharmonious gingival margin levels can be aesthetically managed with crown
lengthening procedures.
Clinical Relevance: Knowledge of crown lengthening techniques, and where these might be prescribed, may be a useful addition to
practitioners’ treatment planning options, or to decide when referral may be more appropriate.
Dent Update 2009; 36: 181-185

Restorative dentistry implies a multi-

disciplinary approach to the provision
of dental care and has advanced
tremendously in recent times. Modern
trends see a shift towards implant-retained
restorations and adhesive/resin-bonded
techniques to replace missing tooth tissue.
Recent advances in adhesive dentistry
make the restoration of worn teeth
using these techniques an alternative
predictable treatment option. There are,
however, clinical situations where adoption
of traditional techniques, namely full-
coverage restorations, is necessary. For
many of these techniques, the importance
of retention and resistance form to the

Geoffrey J Bateman, BDS, MFDS

RCS(Ed), MMedEd, MRD RCS(Eng),
FDS(Rest Dent) RCS(Ed), Consultant in
Restorative Dentistry, Naveen Karir,
BDS, MFDS RCS(Eng), Specialist Registrar
in Restorative Dentistry and Shuva
Saha, BDS, MFDS RCS(Eng), MFDS
RCS(Ed), DipConSed, Specialist Registrar
in Restorative Dentistry, Birmingham
Dental Hospital, St Chad’s Queensway,
Figure 1. Dimensions of the biologic width.
Birmingham B4 6NN, UK.
April 2009 DentalUpdate 181
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pg181-185 Principles of Crown Lengthening.indd 1 30/3/09 11:30:56

 Periodontology
Figure 2. Gold and composite temporary crowns
encroaching on biologic width.
success and longevity of restorations,
and thus the need to have adequate
supragingival tooth tissue, is critical. The
need for healthy periodontal tissues to
support these restorations also cannot be
overstated. Crown lengthening surgery
is underpinned by our understanding of
the relationship of restorative margins to
these periodontal tissues.
Biologic width
The term ‘biologic width’
was originally coined by Gargiulo et
al1 in 1961. The original research was
based on scientific measurements of
the relationship and dimensions of the
dentogingival junction in cadaveric
specimens. Functionally, the supracrestal
attachment can be divided into two
parts: the connective tissue attachment
and the epithelial attachment (Figure
1). In this study, connective tissue
attachment measurements were
fairly constant, whereas the epithelial
attachment (junctional and sulcular)
was highly variable. The mean values
of the connective tissue and epithelial
attachments were 1.07mm and 1.66mm,
respectively (junctional epithelium
0.97mm and sulcular epithelium 0.69
mm). The biologic width is defined as ‘the
width of the junctional epithelium and
supracrestal connective tissues that lie
between the base of the gingival sulcus
and the alveolar crest’ and represents the
area of attachment of the periodontal
soft tissues to the tooth. The average
dimension of biologic width has been
shown to be 2.04mm.
Understanding and application
182 DentalUpdate
pg181-185 Principles of Crown Lengthening.indd 2
soft tissue margin occlusally to the incisal/
cusp tip. Crown lengthening is therefore
indicated where insufficient crown length
exists to allow predictable restoration of
the teeth. It may also be indicated to gain
access to subgingival caries or to improve
gingival aesthetics.
Figure 3. Full arch wax-up.
Contra-indications for crown
lengthening
There are few absolute contra-
indications to crown lengthening and
these include medical issues that might
preclude other oral surgical procedures. A
selection of some of the more important
relative contra-indications include:
„ Smoking;
„ Thin periodontal tissue biotype;
„ Narrow-band of attached gingivae;
„ Where a furcation on the tooth or an
Figure 4. Stent fabricated on waxed-up model and adjacent tooth may be exposed;
used during surgery. „ Surgery in the aesthetic zone;
„ Concurrent endodontic/periodontal
disease;
„ Presence and extent of caries.
of the concepts of the biologic width
is of key importance when planning
placement of margins of restorations as
Assessment of treatment
impingement into this critical space has
options
Crown lengthening is a
been associated with plaque accumulation,
surgical procedure and a degree of post-
gingival inflammation, attachment loss
operative discomfort and morbidity is to
and crestal bone loss.2 It has therefore
be expected. It is therefore incumbent on
been suggested that restoration margins
a practitioner to consider other potential
should not be placed more than 0.5–1.0
treatment options as part of the consent
mm subgingivally, and that there should
process.
be at least a 3 mm distance between
Alternative treatment options
the restoration and the alveolar crest to
prevent encroachment on to the biologic
width.3,4 The biologic width concept is also
relevant to dental implants. Some studies
have suggested a certain width of peri-
implant mucosa is necessary to ensure
stability of the soft tissue framework and,
where this is insufficient, then physiological
bone resorption takes place until this
dimension is secure.5,6
Indications for crown
lengthening
There are many factors to
consider before planning restorative
treatment and one of the most
fundamental is crown length, especially in
cases involving non-carious tooth tissue
loss. Crown length may be defined as the
Figure 5. Split rubber dam.
portion of tooth that extends from the
April 2009
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1/4/09 15:23:10
 Periodontology
Figure 6. Simple crown lengthening with gingivectomy.
Figure 7. Apically-repositioned flap surgery.
may include:
„ Orthodontic extrusion of teeth +/-
crown lengthening;
„ Overdenture in cases of extreme
toothwear;
„ Extraction and tooth replacement.
Case preparation
Tooth preparation
Where possible, the
provisional restoration of teeth that
are planned for crown lengthening will
simplify further management. Caries
should be removed, as far as possible,
initially. This will allow an assessment
of the remaining tooth substance and
restorability. Existing crown restorations
should be removed and replaced with
provisional restorations. Provisional
crowns can provide a clear guide to the
surgeon of encroachment on biologic
184 DentalUpdate
pg181-185 Principles of Crown Lengthening.indd 4
width, and where bone removal may
be a necessary adjunct to crown
lengthening (Figure 2). In addition, well-
fitting margins simplify oral hygiene,
reduce plaque accumulation and
improve post-surgical healing response.
In many cases, crown
lengthening is necessary before teeth
can be restored, for example in severe
tooth surface loss. In such cases,
preparation of a pre-operative diagnostic
wax-up is an invaluable planning aid
(Figure 3). This will provide information
such as how much tooth substance
needs to be exposed for crown retention,
likely post-operative crown-root ratio
and planned aesthetic result. In addition,
a stent constructed on the diagnostic
wax-up may also be used as a surgical
guide for bone removal (Figure 4).
Definitive endodontic
treatment should be carried out prior to
crown lengthening, where appropriate.
Failed attempts at root canal treatment
after crown lengthening surgery may
result in tooth loss and therefore the
patient may have been exposed to
unnecessary surgery. Where isolation
due to short crown height is difficult, a
split dam technique may be used (Figure
5).
Informed consent
Crown lengthening surgery
has similar risks to other forms of
periodontal surgery. In particular, the risk
of an adverse aesthetic impact should be
discussed carefully. Often, this surgery is
in the aesthetic zone. Loss of interdental
papillae and subsequent ‘black triangles’
may be a significant consequence.
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Bone removal around teeth adjacent
to those to be crown lengthened may
compromise their own support. The
risk of exposing a furcation has to
be carefully evaluated. Orthodontic
extrusion of teeth may be valuable in
some instances as the alveolar bone
and gingivae will tend to move with
the tooth. This may help place the
gingival margin in an ideal position and
prevent excessively long clinical crowns.
Exposure of root dentine may also
predispose to dentinal hypersensitivity.
Another, not uncommon,
consequence is relapse of the gingival
margin.7 Bone removal does not come
naturally to restorative dentists and,
where this is inadequate, the gingival
margin will tend to return to pre-
operative levels. The surgeon should
therefore make every effort to ensure
that, where necessary, bone removal
is carried out to allow at least 3 mm
between alveolar crest and restorative
margins. Needless to say, careful clinical
records should be made as part of the
planning process and, where aesthetic
change is intended, clinical photographs
are mandatory. It is important to record
a detailed pocket chart around the
teeth planned for surgery, to ensure:
„ No untreated periodontitis remains
undetected at the planning stage;
„ A detailed record of probing sulcus
depth is available at the time of surgery.
Surgical procedures
There are three main
approaches to surgical crown
lengthening:
„ Gingivectomy;
„ Apically-positioned flap (APF)
surgery;.
„ APF with osseous reduction.
As bone removal is often
necessary to avoided encroaching on
biologic width, the APF with osseous
reduction is probably the most
frequently used approach.
Gingivectomy
Gingivectomy represents
the simplest approach to crown
lengthening. It is generally appropriate
where there is an element of gingival
overgrowth or false pocketing. It is
April 2009
30/3/09 11:31:21

also valuable where there has been
loss of periodontal attachment. In this
respect, a detailed pocket chart will be
invaluable.
Precise changes in
gingival margin location are relatively
straightforward with a gingivectomy
technique. This is in contrast with
the apically repositioned flap, where
location of the gingival margin may be
less predictable and technically more
demanding. On the other hand, the
gingivectomy approach may be less
conservative of attached gingival tissue.
Where this is only present in a thin
band, an apically-positioned flap may
represent a more tissue-conservative
option. Figure 6 demonstrates a case
where simple gingivectomy was used
to effect an increase in crown height.
Apically-positioned flap surgery
Where this flap is
considered, the width of attached
gingivae should be carefully assessed.
Where this width is minimal, the
incision may be intrasulcular to
preserve attached gingivae. Where
there is abundant attached gingivae,
the incision may be relatively scalloped
and submarginal. Local gingival
conditions should be observed and the
flap may incorporate both intrasulcular
and submarginal elements.
The flap design for an
apically repositioned flap should
normally involve two vertical relieving
incisions. This increases flap mobility
and makes apical repositioning more
straightforward. The flap will normally
extend to include adjacent teeth and
thus allow interdental bone removal
and recontouring, as appropriate.
Often, the decision to remove bone
can be made when the flap is raised
and precise measurements may be
made of the distance between alveolar
crest and restoration margins.
The relieving incisions
should be made as vertical as
possible and parallel with each other.
This means that, when the flap is
repositioned apically, there is good
apposition of flap margins at these
relieving incisions.
Figure 7 illustrates a case
April 2009
pg181-185 Principles of Crown Lengthening.indd 5
where an apically repositioned flap was
used to lengthen the clinical crowns of
two central incisor teeth.
When the apically-positioned
flap is sutured, it is convenient initially
to place sutures in the vertical relieving
incisions. The needle penetration in the
flap margin should be relatively more
apical in the bound tissue than the
reflected flap as this will generate apical
rather than coronal tension.
Interdental sutures are
placed to provide soft tissue coverage
of interdental bone. This is done with
minimal tension to avoid coronal
movement of the flap. It is very difficult
to attain perfect closure of an apically
repositioned flap and, in some places,
healing will be by secondary intention. It
is often prudent to place a periodontal
dressing after closure to protect any areas
of denuded bone.
Osseous reduction
Osseous reduction during
crown lengthening is often necessary. A
decision can be made on this when the
flap is raised and measurement of alveolar
crest to restorative margin can be made
with a periodontal probe. Initial bone
removal is accomplished with burs and
copious coolant. An osseous contour is
created to mirror the parabolic interdental
contour and scalloped cervical margins of
the original alveolar bone and, ideally, to
support the gingival tissues.
It is important to avoid
damage to the root surfaces of the teeth
to be lengthened. To this end, a thin
layer of bone is left on the root surfaces.
This may then be removed with hand
instruments, such as a sharp curette or
chisel.
Post-surgical management
Healing is by secondary
intention, in many cases, and periodontal
dressings and sutures are left in place
for around one week, where possible.
Gingival maturation will continue over
time and it is sensible to postpone
definitive restoration of teeth until this
time. In particular, definitive restoration
of teeth in the aesthetic zone should
be carried out at least six months after
surgery.
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Periodontology
Conclusions
Crown-lengthening
surgery represents a useful adjunct
to restorative treatment planning and
may be very useful, particularly where
toothwear necessitates a conventional
approach to restoration. As with many
periodontal surgical procedures, case
selection and planning is paramount.
Crown-lengthening can be technically
demanding and potentially have negative
aesthetic consequences. It is important,
therefore, that practitioners anticipate
these difficulties and refer for treatment
where appropriate.
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DentalUpdate 185
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