Crown Lengthening Procedure 2011 11 8 R 1

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Crown Lengthening Procedure 2011년 11월 8일 치주과 R 1 김동희 KHU Perio

Crown Lengthening Procedure 2011년 11월 8일 치주과 R 1 김동희 KHU Perio

Introduction 5, 22 Crown Lengthening Procedure (CLP) Reestablishment of a healthy periodontium at a

Introduction 5, 22 Crown Lengthening Procedure (CLP) Reestablishment of a healthy periodontium at a more apical level Bensimon(1999) The Surgical Procedure to expose adequate clinical crown to prevent the placement of the crown margin into the area of the biologic width Newman et al (2002) KHU Perio

Introduction 1, 2, 4 Crown Lengthening Procedure (CLP) 1. Access subgingival caries 2. Gain

Introduction 1, 2, 4 Crown Lengthening Procedure (CLP) 1. Access subgingival caries 2. Gain retention in sites with insufficient supracrestal tooth structure necessary for prosthetic treatment 3. Restore tooth without impinging biologic width 4. Esthetic purpose KHU Perio

Introduction Crown Lengthening Procedure (CLP) Gingivectomy with Externally beveled path of incision Gingivectomy with

Introduction Crown Lengthening Procedure (CLP) Gingivectomy with Externally beveled path of incision Gingivectomy with Internally beveled path of incision Apically Positioned Flap including bone resection Forced tooth eruption with fiberotomy mucogingival interceptive therapy KHU Perio

Contents Excessive gingival display Insufficient length of clinical crown Short anatomic crown Vertical maxillary

Contents Excessive gingival display Insufficient length of clinical crown Short anatomic crown Vertical maxillary excess & Long mid-face Exposure of Sound Tooth Structure Apically Positioned Flap including bone resection Forced tooth eruption with fiberotomy Ectopic tooth eruption Double Pedicle Graft Apically Positioned Flap Free Gingival Graft KHU Perio

Crown Lengthening Procedure 2 Excessive gingival display Exposure of Sound Tooth Structure Ectopic tooth

Crown Lengthening Procedure 2 Excessive gingival display Exposure of Sound Tooth Structure Ectopic tooth eruption KHU Perio

Excessive gingival display 1, 2 Lower edge of the upper lip - limits the

Excessive gingival display 1, 2 Lower edge of the upper lip - limits the amount of gingiva that is exposed when person smile Gummy Smile - high lip line expose a broad zone of gingival tissue - form of lip cannot be easily changed Teeth, interdental papillae Gingival margins Incisal edges KHU Dentist Improve dentofacial esthetic Periodontal, Prosthetic treatment Perio

Excessive gingival display 2 Analysis of the dentofacial structures - Facial symmetry - Interpupillary

Excessive gingival display 2 Analysis of the dentofacial structures - Facial symmetry - Interpupillary line : even or uneven - Smile line : low, median, high - Dental midline in relation to facial midline - Gingival display during speech and during broad, relaxed smile - Harmony of gingival margins - Location of gingival margins in relation to the CEJ - Tooth size and proportions / harmony - Incisal plane / occlusal plane KHU Perio

Reason of Excessive gingival display 2 Insufficient length of clinical crown Short anatomic crown

Reason of Excessive gingival display 2 Insufficient length of clinical crown Short anatomic crown Vertical maxillary excess & Long mid-face KHU Perio

Insufficient length of clinical crown 2 Reduce the amount of gingiva exposed to fix

Insufficient length of clinical crown 2 Reduce the amount of gingiva exposed to fix disproportional appearance of the clinical crown (small front teeth) free gingiva > 1 mm Thin biotype full exposure of the anatomic crown ( Gingivectomy / Gingivoplasty ) Bony ledge Thick biotype Apically Positioned Flap ( osseous recontouring ) KHU Perio

Biotype 19, 20 Cook et al (2011) Thick Biotype Thin Biotype Plate thickness ↑

Biotype 19, 20 Cook et al (2011) Thick Biotype Thin Biotype Plate thickness ↑ thickness ↓ Keratinized tissue width ↑ width ↓ CEJ-alveolar crest distance ↓ distance ↑ Gingival architecture flat Scalloped ( thin biotype labial plate thickness ≒ ½ thick biotype )     Characteristics Inflammation Surgery Tooth Extraction Thick Biotype Flat Large attached gingiva   Thick underlying bone Resistant to acute trauma Soft tissue Marginal inflammation Hard tissue Infrabony defects   Predicable Minimal ridge atrophy P<. 001 Significantly More likely to Kao et al (2008) Thin Biotype  Scalloped Minimal attached gingiva Thin underlying bone Gingival recession Rapid bone loss Difficult to predict Ridge resorption Thin Biotype : Gingival recession ↑ Plate thickness ∝ Biotype Thick plate = Thick gingiva KHU Perio

Biotype 19 Probe Visibility - Probe visible through gingival sulcus in thin biotype -

Biotype 19 Probe Visibility - Probe visible through gingival sulcus in thin biotype - Central incisor : most variability in probe visibility Visible KHU Invisible Perio

Insufficient length of clinical crown 2 Regarding the amount and pattern of pigmentation full

Insufficient length of clinical crown 2 Regarding the amount and pattern of pigmentation full exposure of the anatomic crown ( Gingivectomy / Gingivoplasty ) Externally beveled path of incision - remove pigmentation produce pink gingival tissue Internally beveled path of incision - maintain pigmentation KHU Perio

Short anatomic crown 2 More extensive bone recontouring is required Prosthetic measures to increase

Short anatomic crown 2 More extensive bone recontouring is required Prosthetic measures to increase the apico-coronal dimension of the dentition KHU Perio

Vertical maxillary excess & long mid-face 2 teeth & gingival margins is perfectly normal

Vertical maxillary excess & long mid-face 2 teeth & gingival margins is perfectly normal - Size and shape of the teeth & Location of the gingival margins Perfectly normal Major Maxillofacial surgical procedure - Crown lengthening procedures will not suffice - maxillar must be altered Evaluate Risk-benefit & cost-benefit ratio before correct esthetic problem KHU Perio

Crown Lengthening Procedure 2 Excessive gingival display Exposure of of Sound Tooth Structure Ectopic

Crown Lengthening Procedure 2 Excessive gingival display Exposure of of Sound Tooth Structure Ectopic tooth eruption KHU Perio

Subgingival Restoration Margin 2, 4, 9 1. Inadequate crown length - Inadequate amount of

Subgingival Restoration Margin 2, 4, 9 1. Inadequate crown length - Inadequate amount of tooth structure for proper restorative therapy 2. Extensive Caries - Subgingival location of carious lesions 3. Tooth Fracture - Subgingival location of fracture lines 4. Dentinal Hypersensitivity 5. Increased esthetic demands KHU Perio

Exposure of sound tooth structure 2 Apically Positioned Flap Including bone resection Indication crown

Exposure of sound tooth structure 2 Apically Positioned Flap Including bone resection Indication crown lengthening of multiple teeth (quadrant or sextant of dentition) Forced tooth eruption Indication : removal of attachment and bone from adjacent teeth must be avoided Forced tooth eruption with fiberotomy Indication : maintain location of the gingival margin at adjacent teeth unchanged KHU Perio

Exposure of sound tooth structure 2, 5 Apically Positioned Flap Including bone resection Increase

Exposure of sound tooth structure 2, 5 Apically Positioned Flap Including bone resection Increase clinical crown length - maintain the existing attached gingiva - dentogingival unit will be re-formed - plaque control more effectively indication crown lengthening of multiple teeth (quadrant or sextant of dentition) contraindication surgical crown lengthening of single teeth in the esthetic zone KHU Perio

Exposure of sound tooth structure 2, 17, 18 Apically Positioned Flap Including bone resection

Exposure of sound tooth structure 2, 17, 18 Apically Positioned Flap Including bone resection Repositioning of attached gingiva Nabers (1954) - Pocket > MGJ reposition the attached gingiva to farther apically - 1 vertical incision Apically Repositioned Flap Friedman (1962) - entire complex of the soft tissue displaced in apical direction (gingiva & alveolar mucosa) KHU Perio

Exposure of sound tooth structure 2, 18 Apically Positioned Flap Including bone resection Apically

Exposure of sound tooth structure 2, 18 Apically Positioned Flap Including bone resection Apically Repositioned Flap ① ② ③ ④ ⑤ ⑥ ⑦ KHU Friedman (1962) Vertical releasing incision Reverse bevel incision Mucoperiosteal flap is raised Remove tissue collar Osseous surgery Flap is apically repositioned Suture Perio

Exposure of sound tooth structure 5, 21 Apically Positioned Flap Including bone resection Second

Exposure of sound tooth structure 5, 21 Apically Positioned Flap Including bone resection Second Incision Class I : KG more than adequate buccal incision 1 -3 mm from the crest, flap is positioned apically Class II : KG adequate crestal incision Class III : KG inadequate sulcular incision, flap apically positioned 1 -2 mm below crest of bone increase the zone of KG Partial-full thickness flap newly created papillae - Thinned to 1. 5 mm KHU Perio

Exposure of sound tooth structure 2 Apically Positioned Flap Including bone resection Bone resection

Exposure of sound tooth structure 2 Apically Positioned Flap Including bone resection Bone resection must be performed at adjacent teeth - in order to gingival margin at its new and more apical position Gingiva inherent tendency to bridge abrupt changes in the contour of the bone crest Remove bone from adjacent teeth to create gradual rise and fall in the profile of the osseous crest substantial amounts of attachment may have to be sacrificed KHU Perio

Exposure of sound tooth structure 2, 5 Apically Positioned Flap Including bone resection Bone

Exposure of sound tooth structure 2, 5 Apically Positioned Flap Including bone resection Bone resection must be performed at adjacent teeth Tool - round bur - hand chisel KHU Consider factor - Height of the adjacent teeth Amount of root that has to be denuded Crown-to-root ratio Biologic Width Perio

Biologic Width Dentogingival unit 4 Gargiulo et al (1961)    Average Measurement Sulcus Depth

Biologic Width Dentogingival unit 4 Gargiulo et al (1961)    Average Measurement Sulcus Depth (A) 0. 69 mm Length of Epithelial Attachment (B) 0. 97 mm Connective Tissue Attachment (F) 1. 07 mm Total Dentogingival unit (A+B+F) 2. 73 mm Total attachment (B+F) Biologic Width 2. 04 mm KHU Perio

Biologic Width 3, 10 Impinge upon the biologic width - gingival inflammation bleeding periodontal

Biologic Width 3, 10 Impinge upon the biologic width - gingival inflammation bleeding periodontal pocket formation loss of connective tissue attachment with apical migration of the junctional epithelium - bone resorption KHU Perio

Adequate Supracrestal Tooth Length 3, 9, 12 3 mm Nevins(1984), Fugazzotto(1985), Inger(1997) 4 mm

Adequate Supracrestal Tooth Length 3, 9, 12 3 mm Nevins(1984), Fugazzotto(1985), Inger(1997) 4 mm Rosenberg et al. (1980), Potashnick et al(1982), Becker et al(1998) - 2. 73 mm : total length of the dentogingival unit 3 mm of supracrestal tooth structure be obtained during surgical crown lengthening - 2 mm : Epithelial and connective tissue attachment - 1 -2 mm : Restorative finish line minimum of 4 mm above the bone crest to achieve periodontal and prosthetic success 5. 0 – 5. 25 mm Wagenberg et al. (1989) at least 5 to 5. 25 mm of tooth structure should be above the osseous crest KHU Perio

Critical Distance from Furcation No furcation involvement Furcation involvement N 16 10 Mean 5.

Critical Distance from Furcation No furcation involvement Furcation involvement N 16 10 Mean 5. 13 2. 75 12 Dibart et al (2003) SD Range 0. 81 4 to 7 0. 72 2 to 4 Critical Distance from Furcation < 4 mm - chances of furcation involvement in the future is very high Evaluation of the position of the furcation opening - relation to the length of the root trunk - Bite-wing radiographs are extremely helpful Furcation Involvement KHU No Furcation Involvement Perio

Exposure of sound tooth structure 2, 9 Forced tooth eruption Orthodontic tooth movement can

Exposure of sound tooth structure 2, 9 Forced tooth eruption Orthodontic tooth movement can be used to erupt teeth Moderate eruptive force Teeth Move in unison with the tooth entire attachment apparatus indication 1. Removal of attachment and bone from adjacent teeth must be avoided 2. reduce pocket depth at sites with angular bony defects KHU Perio

Exposure of sound tooth structure 2, 9 Forced tooth eruption Level and align gingival

Exposure of sound tooth structure 2, 9 Forced tooth eruption Level and align gingival margins - malpositioned tooth or gingival recession erupted to the level of the normally positioned teeth - entire attachment apparatus and dentogingival junction will follow the root of the tooth as it is moved coronally Bone & soft tissue levels at adjacent teeth remain unchanged Tooth must be extruded equal or slightly longer KHU Perio

Exposure of sound tooth structure 2, 13 Forced tooth eruption Orthodontic brackets and arch

Exposure of sound tooth structure 2, 13 Forced tooth eruption Orthodontic brackets and arch wire Power elastic and arch wire (or bar) - power elastic is tied from the bracket to the arch wire or bar pull the tooth coronally - if most of the crown structure is lost : root canal therapy, post place in the root canal, fit with power elastic KHU Perio

Exposure of sound tooth structure 14, 15 Forced tooth eruption Use Steel ligature or

Exposure of sound tooth structure 14, 15 Forced tooth eruption Use Steel ligature or Elastomeric ring - Numbers of bacteria : Steel ligature < Elastomeric ring Forsberg et al(1991) Use bonded appliances or banded appliances - Complication : Bonded appliances < Banded appliances KHU Boyd et al (1992) Perio

Exposure of sound tooth structure 10 Forced tooth eruption “Funneling” or “Lipping” of alveolar

Exposure of sound tooth structure 10 Forced tooth eruption “Funneling” or “Lipping” of alveolar crestal bone - bone accompany tooth movement - require flap surgery to remove osteoid and osseous tissue Completion of eruptive phase KHU Funneling or Lipping Osseous resection Suture Perio

Exposure of sound tooth structure 2, 10 Forced tooth eruption with fiberotomy Fiberotomy during

Exposure of sound tooth structure 2, 10 Forced tooth eruption with fiberotomy Fiberotomy during the forced tooth eruption - Crestal bone and gingival margin are retained at pre-treatment location - tooth-gingiva interface at adjacent teeth is unaltered indication adjacent teeth gingival margin should be maintain unchanged contraindication fiberotomy should not be used at teeth associated with angular bone defects KHU Perio

Exposure of sound tooth structure 10, 16 Forced tooth eruption with fiberotomy Only alveolar

Exposure of sound tooth structure 10, 16 Forced tooth eruption with fiberotomy Only alveolar bone that was attached to the root via periodontal fibers accompanied the tooth in its movement Polson(1984) Entire alveolar bony housing followed the occlusal movement of the tooth when a uniform light force was used only where the fibers remained attached and uninjured Oppenheim (1940) KHU Perio

Exposure of sound tooth structure 2, 10 Forced tooth eruption with fiberotomy Fiberotomy -

Exposure of sound tooth structure 2, 10 Forced tooth eruption with fiberotomy Fiberotomy - once every 7~10 days during the phase of forced eruption - sever alveolar crestal fibers eliminate tension applied to the alveolar crestal bone prevent crestal bone from following root in coronal direction KHU Perio

Exposure of sound tooth structure 10 Forced tooth eruption with fiberotomy Extrusion with Paritial

Exposure of sound tooth structure 10 Forced tooth eruption with fiberotomy Extrusion with Paritial Fiber Resection Pontoriero (1987) - sulcular fiber resection on mesial surface of root - osseous crest obliquely angled on the distal surface Pretretment KHU Poststabilization Perio

Crown Lengthening Procedure 2 Excessive gingival display Exposure of Sound Tooth Structure Ectopic tooth

Crown Lengthening Procedure 2 Excessive gingival display Exposure of Sound Tooth Structure Ectopic tooth eruption KHU Perio

Ectopic tooth eruption 7, 8 Buccally erupting teeth - restrict or eliminate the keratinized

Ectopic tooth eruption 7, 8 Buccally erupting teeth - restrict or eliminate the keratinized gingiva show reduced dimensions of the gingiva (erupting cusp - deciduous tooth) Orthodontic therapy - Fixed orthodontic appliance allow plaque accumulation alter toothbrushing technique (more traumatic) - if lack of keratinized gingiva potential risk for gingival recession mucogingival interceptive therapy Pini Prato et al (2000) KHU Perio

Ectopic tooth eruption 7 mucogingival interceptive therapy Purpose Save keratinized gingiva by moving entrapped

Ectopic tooth eruption 7 mucogingival interceptive therapy Purpose Save keratinized gingiva by moving entrapped keratinized tissue apically to erupting tooth indication 1. buccally erupting teeth scheduled for orthodontic treatment 2. entrapped gingiva : adequate width and thickness attached via healthy connective fiber to the cementum of decidous KHU Indication Contraindication Perio

Ectopic tooth eruption 2, 7 mucogingival interceptive therapy Double Pedicle Graft Indication : cusp

Ectopic tooth eruption 2, 7 mucogingival interceptive therapy Double Pedicle Graft Indication : cusp tip in keratinized gingiva close to MGJ Apically Positioned Flap Indication : cusp tip in alveolar mucosa slightly apical to MGJ Free Gingival Graft Indication : cusp tip in alveolar mucosa very apically to MGJ KHU Perio

Ectopic tooth eruption 2, 7 Double Pedicle Graft Indication : cusp tip in keratinized

Ectopic tooth eruption 2, 7 Double Pedicle Graft Indication : cusp tip in keratinized gingiva close to MGJ incision Parallel to long axis of tooth PPD : 1 mm KHU suture apically to erupting cusp 7 years Perio

Ectopic tooth eruption 2, 7 Apically Positioned Flap Indication : cusp tip in alveolar

Ectopic tooth eruption 2, 7 Apically Positioned Flap Indication : cusp tip in alveolar mucosa slightly apical to MGJ vertical lateral releasing incision partial thickness flap elevate 3 months KHU suture apically to erupting cusp 7 years Perio

Ectopic tooth eruption 2, 7 Free Gingival Graft Indication : cusp tip in alveolar

Ectopic tooth eruption 2, 7 Free Gingival Graft Indication : cusp tip in alveolar mucosa very apically to MGJ Split incision on entrapped gingiva detach entrapped gingiva suture apically to erupting cusp 3 months KHU Perio

Ectopic tooth eruption 7, 8 mucogingival interceptive therapy Keratinized Tissue  Surgical Technique Double pedicle

Ectopic tooth eruption 7, 8 mucogingival interceptive therapy Keratinized Tissue  Surgical Technique Double pedicle flap Apically positioned flap Free gingival graft Pini prato et al (2000) N Cases Baseline   3 months 8 3. 19 3. 06 10 2. 87 2. 82 11 3. 82 3. 18 Control Site Test Site KHU  7 years 3. 25 2. 75 3. 32  N = 8 Baseline 3 months 2 years 3. 07 2. 83 3. 17 Test Site 3. 06 2. 87 2. 93 Control Site  2. 94 1. 12 1. 37  > Perio

Conclusion Crown Lengthening Procedure can improve dentofacial esthetics especially in the case of Excessive

Conclusion Crown Lengthening Procedure can improve dentofacial esthetics especially in the case of Excessive gingival display Apically Positioned Flap including bone resection can be used to provide enough sound tooth structure to restore teeth without impingement on the biologic width Orthodontic tooth movement can be used in CLP with adjacent teeth remain unchanged. Fibrotomy during forced tooth eruption make crestal bone and gingival margin retained at pretreatment location Mucogingival interceptive surgery is an effective approach to conserve the keratinized gingiva of ectopically erupting teeth KHU Perio

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