Esthetic Crown Lengthening for Maxillary Anterior Teeth CE 5

In the maxillary anterior region, the gingival labial margin position Michael Sonick, DMD Abstract: Assistant Clinical Professor of Surgery is an important parameter in the achievement of an ideal smile. The relation- School of Medicine ship between the periodontium and the restoration is critical if gingival health Yale University and esthetics are to be achieved. Periodontal therapy is a necessary and useful New Haven, Connecticut Assistant Clinical Professor of Periodontics adjunct when any anterior restoration is undertaken. Anterior surgical crown School of Dental Medicine lengthening may be undertaken to avoid restorative margin impingement on the University of Connecticut Farmington, Connecticut biologic width. Crown lengthening is also used to alter the gingival labial pro- Private Practice of Periodontics and Dental files. This article discusses the esthetic parameters of ideal gingival labial posi- Implants tions and presents a classification of crown-lengthening procedures and the Fairfield, Connecticut procedure for a two-stage crown-lengthening technique. The two-stage crown- lengthening technique is surgically precise because healing is predictable.

entistry has undergone a significant evolution in the last 2 decades. Learning Objectives: Sophisticated advances in the development of newer restorative mate- After reading this article, the reader D rials and techniques have led to an unprecedented improvement in should be able to: esthetic rehabilitation. It is no longer enough to merely replicate lost tooth • describe the indications for structure. Patients demand and expect anterior rehabilitations to be esthetic. crown lengthening in the There is a tremendous focus on cosmetics today. One has only to gaze through maxillary anterior sextant. magazine advertisements to see the emphasis that is placed on being attractive. • discuss the parameters of Dentists are blessed with the unique ability to not only improve patients’ dental gingival labial rela- health but also enhance their attractiveness. The relationship between a per- tionships to achieve esthet- son’s physical appearance and his or her self-esteem is well documented1,2 ics and harmony. (Psychology Today, November, 119-131, 1973). Studies have shown that a per- • determine how to position son’s face is the prime source of determining physical attractiveness.1 Patients the restorative margin so have stated that their teeth have the greatest impact on improving their phys- the biologic width is not violated. ical appearance, and hence self-esteem. Therefore, dentists play a significant role in helping to improve their patients’ psychological health. • explain the indications for the variety of crown-length- Dentists are called on to provide restorations that are in harmony with the ening techniques available. lips, the face, the adjacent teeth, and a healthy periodontium. Until recently, the scope of esthetic rehabilitation was limited to a close replication of tooth structure on a healthy periodontal foundation. In the past, periodontal therapy was aimed primarily at the elimination of disease, sometimes at the expense of esthetics. However, the scope of periodontal therapy has expanded. The prima- ry goal remains to maintain the dentition with a healthy intact dentogingival unit. However, periodontics has now entered the age of periodontal plastic surgery.3 Many periodontal therapies lead to esthetic amelioration of the denti- tion. These techniques allow for the ability to cover denuded roots, correct localized alveolar defects, regenerate bone, increase the amount of keratinized gingiva, enhance papilla reformation, and alter dental gingival levels. The preservation of a sound periodontium remains the sine qua non of a successful esthetic and functional restoration. A thorough knowledge of the normal anatomy and the interplay between the restoration and the periodon- tium is essential to achieve a predictable successful esthetic rehabilitation of the smile when prosthetics are planned in the maxillary anterior sextant. Communication between the restorative dentist and periodontist is essential in 807 Vol. 18, No. 8 Compendium / August 1997 these cases. Periodontal therapy plays an lengthening exist. These include caries CE 5 important role in the esthetic rehabilitation of removal, increasing crown length for restora- the maxillary anterior segment, especially if tion retention, restoration of the tooth with- periodontal disease is present. If the periodon- out violating the biologic width, and esthetics tium is healthy, the role of periodontics in via an alteration of the gingival labial profile. smile rehabilitation is limited to crown length- This article introduces a two-stage crown- ening and gingival augmentation. lengthening technique. The focus will be on Many indications for clinical crown the maxillary anterior sextant. The esthetic parameters and biologic rationale must first be discussed before the technique is elucidated.

Figure 1—A clinical illustration of peri- Esthetic Parameters of the Periodontium odontal health and The gingival labial position is but one of a ideal esthetic gingi- few factors that can contribute to an esthetic val balance. smile. The evaluation of a smile should include an analysis of the amount of gingival display when the lips are parted. The smile is dynamic and variable and changes with age. Aging leads to a decrease in the amount of maxillary central incisor display when smiling.4 Depending on the relationship of the upper lip Figure 2A—The pre- operative view of to the cervical margin of the maxillary central uneven, dissimilar incisors,5 a smile is one of three types: high lip gingival margins. line, low lip line, and medium lip line. The medium lip line is felt to be the most ideal, harmoniously displaying the dental and gingi- val elements in proportional symmetry (Figure 5H). A low lip line is rarely a problem for the restorative dentist. In fact, it often serves as a drape for imperfect dental relationships and dentistry. A high lip line, which displays a dis- proportionate amount of gingival tissue, can Figure 2B—Post- sometimes be altered if the clinical crowns can operatively, gingival symmetry and a be lengthened. This is possible if there is more esthetic excess gingival display, as in delayed passive appearance are eruption, or if the teeth will be restored and evident. the dental gingival relationships reestablished at the new dental gingival junction. This is dependent on tooth length, incisal edge posi- tion, and the functional occlusion. Healthy, esthetic gingival tissues should be pink in color and firmly bound down to the necks of the teeth. The surface texture of the Figure 3A—The pre- gingival tissues is stippled, with an orange-peel operative view of older anterior crowns. appearance. The interdental papillae extend Note the gingival from the free gingival margin and should be recession and uneven firm and knife-edged. They should fill the gin- gingival margins. The dental gingival gival embrasures to the contact point (Figure position of the cen- 1). Care should be taken to avoid loss of gingi- trals is too incisal. val papillae in all periodontal and restorative The patient’s left and procedures because they are difficult, if not right laterals are more apical in posi- impossible, to re-create after being destroyed. tion than the centrals. The gingival zenith is located distal to the long axis of the tooth on the labial surface of 808 Compendium / August 1997 Vol. 18, No. 8 the maxillary central incisors and canines. In tissue attachment averaged 2.04 mm, and has contrast, the maxillary lateral incisors have a come to be known as the biologic width.15 CE 5 symmetrical gingival height of contour with Numerous articles have discussed the need the gingival zenith at the midline of the labial to maintain a minimum biologic width of tooth surface5-7 (Figure 1). 2 mm relative to the margin of the restora- As stated earlier, the gingival height of tion.16-27 This has become the standard for contour ideally follows the contour of the which numerous crown-lengthening proce- upper lip. Closer inspection reveals that the dures have been performed over the last 3 gingival height of contour of contralateral decades. Clinicians have questioned the need teeth should be symmetrical. The height of for a minimum of 3 mm (2 mm for biologic contour of the central incisors should be sym- metrical and at a level coincident with the maxillary canines. The lateral incisors should Figure 3B—Surgical have a gingival level slightly more incisal view of a one-stage crown-lengthening (about 1.5 mm) than the adjacent centrals and procedure, classifica- canines.5,8 Uneven gingival margins create tion II A 1. Ostectomy visual tension and violate one of the most is performed to alter the gingival position important parameters of esthetics—that of of the central incisors. symmetry (Figures 2A, 3A, 5A, 5B, and 6A). A periodontal probe is The exact amount of attached gingival tis- used to determine the sue required for health varies. However, if a new position of the biologic width and restoration is being considered and a minimum where the crown mar- of attached tissue is present, preprosthetic aug- gin can be placed. mentation is recommended so that teeth will 9-11 not be predisposed to recession. If a minimal Figure 3C—The flap amount of keratinized gingiva exists before is sutured 2 mm from crown lengthening, all of it must be preserved the crest of bone. during the procedure via sulcular incisions. The free gingival margin will form Gingivectomies and external bevel incisions 1 mm incisal to this are contraindicated. position. The papillae In addition to the above periodontal con- have not been violat- ed. Note how far the cepts, some other factors that contribute to the epithelium must trav- restoration of a pleasing esthetic smile are the el to close the surgi- lips, the facial profile and structure, the incisal cal wound margin. edge position, tooth shade, color and hue, the Figure 3D—The incisal embrasures, the incisogingival height of postoperative healing the teeth, tooth contour, texture, alignment, at 1 week. The gingi- va is inflamed, and and the plane of occlusion. no sulcus is evident. The maturation of Biologic Width—A Concept Under Siege gingival sulcus and The dental gingival unit is composed of the final gingival scallop for this two parts—the epithelial attachment, or junc- patient took tional epithelium, and the connective-tissue 6 months. 12,13 attachment. A gingival sulcus is also pres- Figure 3E—The final ent. In the seminal study by Gargulio et al,14 a restoration 10 months proportional relationship was established after crown-length- ening surgery. The between the crest of alveolar bone, the con- central incisors are nective-tissue attachment, the epithelial equal in length and attachment, and the gingival sulcus. Their in proper relation- research presented an average sulcus depth of ship with the laterals and canines. 0.69 mm, an average epithelial attachment of (Restoration by Dr. 0.97 mm, and an average connective-tissue David Wohl, Fairfield, attachment of 1.07 mm. The combined Conn.) dimension of the epithelial and connective- 809 Vol. 18, No. 8 Compendium / August 1997 width and 1 mm for gingival sulcus) of sound attachment from 0.0 mm to 6.25 mm. In 1981, CE 5 tooth structure between the restoration and Ramfjord30 questioned the surgical need for the the crest of alveolar bone in all situations.28,29 creation of a 2-mm to 3-mm biologic width The wisdom of not needing a minimum apical to the proposed restoration margin. He dimension of space between the restoration theorized that it may be better for the body to and the alveolar bone and applying it to all create its own biologic width, as long as the human situations is based on clinical impres- patient maintains adequate oral hygiene. Data sion.28,29 In 1961, Gargulio et al14 reported by others show that this may, in fact, be impos- ranges in sulcus depth from 0.0 mm to sible. The average marginal fit of gold and 5.36 mm, in epithelial attachment from ceramic crowns has been shown to be 20 µm to 0.08 mm to 3.72 mm, and in connective-tissue 57 µm.31,32 Because the average size of a microorganism is between 4 µm and 10 µm, we can assume that even a clinically acceptable Figure 4A—Crown fitting crown would be capable of harboring lengthening, classifi- 33 cation II A 3, is per- dental plaque. Waerhaug postulated that the formed. No restora- inflammatory lesion exerted its influence tive dentistry is 2 mm from the plaque front. Therefore, the planned, so the maxi- mum clinical crown rationale for placing the crown margin 3 mm exposure is the thera- from the alveolar bone might be to eliminate peutic endpoint. A the influence of plaque from the 2.7-mm zone gingivectomy of influence described by Waerhaug. removes a collar of tissue slightly incisal Numerous experimental studies have to the CEJ. shown the potential for attachment loss when restorative tooth margins are placed within Figure 4B—Crown- 2 mm of the alveolar crest.20,22,23,33 It has also lengthening proce- dure postgingivecto- been shown that the placement of my. Note the intracrevicular margins predisposes the tooth increased exposure to recession34 (Figure 3A). Other studies have of the clinical crown. However, if the bone corroborated these observations, noting that is not removed, gin- subgingival crown margins are associated with gival tissues will more inflammation compared to supragingival regenerate incisally margins.17,24 Therefore, placing a crown margin 3 mm from the crest of bone. subgingivally does not guarantee that it will be stable. In the esthetic zone, crown margins must be hidden. Therefore, it is beneficial to Figure 4C—The full- thickness mucoperi- err on the side of caution and maintain at least osteal flap is reflect- 2 mm between the crown margin and the alve- ed after gingivecto- olar bone. Violation of the biologic width can my. This allows 35,36 access for ostectomy. result in recession or inflammation. Depending on the inflammatory state of the gingiva and/or the force of the probe, human variability makes the precise determination of the individual components of the biologic width difficult. The exact histological depth of the gingival sulcus is impossible to determine Figure 4D—After clinically. The probe might penetrate the ostectomy, the flap epithelium or connective-tissue attachment. is sutured to the This is a constant dilemma for the practition- intact papillae with interrupted sutures. er. It has been proposed that the complex be The tissue will usu- renamed the dentogingival complex and that ally maintain itself in its dimension be 3 mm on the direct labial of this position. the maxillary anterior teeth.27 Also, the exact dimension of the various components of the dentogingival complex cannot be determined 810 Compendium / August 1997 Vol. 18, No. 8 clinically. How can the clinician then decide CE 5 Table 1—Classification of Crown- where to place the margin of the restoration if Lengthening Procedures the base of the sulcus cannot be determined? Kois27 has suggested that the position of the I Gingival reduction only—bone removal not osseous crest be used to determine margin required placement. When the patient is under anes- A Gingivectomy thesia, the alveolar crest of bone can be sound- B Gingival flap surgery ed and its position determined. The clinician can then place the crown margin II Mucoperiosteal flap with ostectomy—bone removal required 3 mm from the crest of bone, assuming the pre- A One-stage procedures, which require one of viously discussed concepts of biologic width the following: are understood and agreed on. (1) Flaps, ostectomy, apical positioning (2) Flaps, ostectomy, gingivectomy, Types of Crown-Lengthening Procedures positioning The two indications for maxillary anterior (3) Gingivectomy, flaps, ostectomy, crown-lengthening procedures are: (1) to positioning increase the amount of labial exposure of the B Two-stage procedure, which requires: clinical crown, and (2) to increase the amount Flaps, ostectomy, and repositioning of tooth exposed superior to the bone to prevent 4 to 6 weeks later—gingivectomy impingement of the restoration on the biologic width. Depending on the situation and the ther- apeutic endpoint required, a number of surgical Figure 4E—Gingival procedures are available. A classification of healing 1 year post- these procedures is shown in Table 1. operatively. Tissues have remained stable where they were Gingival Reduction Only sutured. No restora- Rarely are these techniques called for tive dentistry was because bone reduction is usually needed to performed. achieve enough exposure of the clinical crown. However, if bone removal is not neces- sary, it is possible to perform either a gingivec- tomy or gingival flap surgery without ostecto- my. In the case shown here, a gingivectomy alone is done. The preoperative view (Figure Figure 5A—The pre- operative unesthetic 2A) shows uneven, dissimilar margins. The smile. The incisal gingiva is inflamed and in need of plaque con- edges do not follow trol. The clinical crowns are not completely a similar curvature. exposed because of excess gingival display. The The centrals are not in harmony with the distance from the free gingival margin to the anterior dentition. bone is 6 mm. Oral hygiene instructions are given and root planing is completed. After 6 weeks, gin- gival healing is complete and a gingivectomy Figure 5B—With is performed. The postoperative photograph “short” central incisor (Figure 2B) shows gingival symmetry, crowns, the centrals improvement of oral health, and a much more are in balance with each other but are esthetic appearance. This level of improve- not in proper gingival ment is seldom achieved without osseous or incisal relationship surgery. with the canines and laterals. After peri- Mucoperiosteal flaps with ostectomy are odontal treatment, usually required to achieve enough exposure of restorative treatment the clinical crown. Either one-stage or two- will improve the in- cisal and the gingival stage procedures can be done. The three types of labial relationship. one-stage procedures are: (1) flaps, ostectomy, 812 Compendium / August 1997 Vol. 18, No. 8 and apical positioning; (2) flaps, ostectomy, crest of bone7,26,37,38 (Figures 3A through 3E). CE 5 gingivectomy, and positioning; and (3) gin- This technique is useful if the amount of kera- givectomy, flaps, ostectomy, and positioning. tinized gingiva is limited. The advantage of Two of the three one-stage techniques and the this procedure is that all of the keratinized gin- two-stage technique are reviewed here. giva is preserved and a healthy band of attached and free gingiva remains after the One-Stage Surgical Crown-Lengthening surgery. However, if healing is delayed (Figure Techniques 3D), it can take months for the sulcus to re- The technique listed in Table 1 as classifi- form. A minimum of 3 mm from the alveolar cation II A 1 involves raising a mucoperiosteal crest to the restoration margin is necessary to flap, followed by ostectomy and then the api- avoid violation of the biologic width. The final cal positioning of the tissues at or near the position of the free gingival margin is unknown because the tissues may shrink or swell, depending on the individual patient. Figure 5C—Crown The tissue position at the conclusion of peri- lengthening, classifi- odontal surgery may be altered by the healing cation II B, is per- formed. The initial process and may not be stable for months. This incision and a full- delays the final impression and thus delays the thickness mucoperi- completion of the restoration. A second minor osteal flap reflection are shown. Incisions gingivectomy may also be needed to place the are made at the distal free gingival margin at the precise position to labial line angles of achieve a harmonious esthetic balance. the centrals without violating the papillae. The second mucoperiosteal flap with ostectomy technique, classification II A 3, is also a one-stage approach. The indications Figure 5D—Ostecto- my is performed on include an inadequate amount of exposed clin- both central incisors. ical crown and a requirement for bone The zenith of bone removal. The technique begins with an inter- curves slightly to the distal. The new nal bevel gingivectomy, placing the margin of crown margin will be gingival tissues at their final anticipated labial 3 mm from the newly position (Figure 4A), regardless of their rela- created crest of alve- olar bone. The labial tionship to the underlying alveolar bone. An ostectomy is blended adequate amount of keratinized tissue must with the interproxi- remain after the removal of a collar of free mal bone. marginal gingiva (Figure 4B). Less than ade- quate postsurgical keratinized gingiva is a con- Figure 5E—The flap is sutured back in its traindication to this technique. After the gin- original position with givectomy, an incision is made in the new sul- interrupted sutures. cus and a full-thickness mucoperiosteal flap is reflected, exposing the underlying bone (Figure 4C). When restorative dentistry is not planned, removal of 2 mm of bone from the cementoenamel junction (CEJ) is recom- mended to expose the maximum amount of clinical crown without causing recession and possible root exposure. Care is taken to leave Figure 5F—An inter- nal bevel gingivecto- the interdental papillae intact, because loss my is performed would lead to esthetic compromise. Only a 5 weeks postopera- thin labial flap of tissue is raised over the papil- tively. The distance from the free margin- lae to avoid papillary collapse. Labial ostecto- al gingiva to the alve- my is now performed, positioning the labial olar crest was 6 mm. bone at least 3 mm from the newly created Therefore, 3 mm of marginal gingiva facial free gingival margin. The flap is then could be excised. repositioned and sutured to the nonviolated 814 Compendium / August 1997 Vol. 18, No. 8 papillae (Figures 4D and 4E). The advantage from the alveolar bone. However, this does not of this technique is that it is one-stage. take into consideration alveolar bone resorp- CE 5 However, healing is not always predictable, tion, which is possible whenever thin alveolar despite adherence to biologic principles. labial bone is surgically exposed. If this occurs, Alterations in healing occasionally lead to the gingival tissues will re-form in relation to less-than-ideal esthetics, resulting in reentry the alveolar bone and not the CEJ. This can surgery or an additional gingivectomy. For this result in root exposure of a natural tooth. The reason, a two-stage crown-lengthening proce- dure was developed. Figure 5G—Two Two-Stage Surgical Crown-Lengthening weeks postgingivec- tomy, complete heal- Technique ing of the tissues is A two-stage crown-lengthening procedure seen. The patient can is indicated when an increase in clinical crown now have provisional restorations placed. length is necessary and labial bone removal is When stability is required (Figures 5A, 5B, and 6A). The first seen in the provision- procedure involves initial reflection of a full- als, the final impres- thickness mucoperiosteal flap to achieve sions can be taken. access to the facial alveolar bone (Figure 5C). Figure 5H—The The palatal tissues are not included and the final, well-balanced papillae are preserved. In isolated areas, verti- smile 2 weeks after insertion of veneers cal incisions may be useful to minimize flap size on teeth Nos. 6 and to avoid a labial flap reflection over papil- through 11. lae. The vertical incisions are made at the flap (Restoration by Dr. Stephen Guss, margins on the labial line angle of the teeth Fairfield, Conn.) being lengthened (Figures 5C, 5D, and 6C). This avoids the possibility of papilla shrinkage. Figure 6A—A single- Bone removal is then performed after flap tooth implant was placed in the posi- reflection (Figures 5D and 6C). The position tion of the right cen- of the restorative margin must be anticipated tral incisor with the so that the appropriate amount of bone can be anticipation of removed. There must be at least 3 mm of space crown-lengthening the adjacent central between the crown margin and the bone so incisor and placing a that the biologic width will not be impinged labial veneer after on or compromised. Esthetic principles should implant integration. be taken into account during the ostectomy procedure because the gingival tissue follows Figure 6B—Radiograph of the tempo- the bony contour. The zenith of bone over the rized dental implant. Note the depth of labial root surface should mimic the anticipat- the implant placement to move the “dental” gingival junction apically. ed gingival position (Figures 5D and 6C). The height of alveolar contour should be at the midline of the lateral incisors and slightly dis- tal on the centrals and canines.5-8,38-40 The labi- al crest of bone is positioned at least 3 mm from the anticipated position of the restora- tion margin to allow for adequate biologic width (Figures 5D and 6C). If restorations are not contemplated and the procedure is performed solely to expose additional natural clinical crown, the labial alveolar bone margin should be positioned 2 mm from the CEJ. The body will re-form a 2-mm biologic width and a 1-mm sulcus, lead- ing to a free margin of gingival tissue 3 mm 815 Vol. 18, No. 8 Compendium / August 1997 outcome is esthetic compromise in an area patient is seen for the second procedure, an CE 5 being treated for esthetic improvement. After internal bevel gingivectomy (Figures 5F, 6D, the ostectomy procedure, the flap is reposi- and 6E). The alveolar crest is sounded and the tioned at its original position with interrupted millimeters of supra-alveolar gingiva deter- sutures (Figure 5E). Two weeks postoperative- mined. This number minus 3 mm is the ly, gingival healing appears complete (Figure amount of gingiva that can be removed with 6D). Visually, it appears as if no surgery was no change in the free gingival margin. A collar performed because the gingival levels have of gingival tissue is excised, leaving additional remained unaltered. At 4 to 6 weeks postoper- root exposed. To achieve esthetic accuracy, atively, gingival tissues are stable and the calipers or periodontal probes can be used. Complete gingival healing is achieved at 2 weeks (Figure 5G). Figure 6C—Crown- This technique can be combined with lengthening surgery, other procedures. Occasionally, a situation will classification II B, is performed on a cen- arise where gingivectomy is required on some tral incisor. Incisions teeth and ostectomy as well as gingivectomy are made at the on others. As demonstrated, these techniques mesial and distal line angles of the central have many indications, independent of the incisor. Bone is types of dentistry that are being performed. removed 3 mm apical Often they are useful when performing anteri- to the gingival height or reconstruction with dental implants and of contour of the adja- cent central incisor natural teeth. The esthetic principles remain implant. the same—the achievement of an esthetic, Figure 6D—Six harmonious, symmetrical smile. weeks after crown lengthening, calipers are used to measure Conclusion the implant crown Many of today’s dental patients are cos- length. This mea- metically oriented. Many others come into surement will be dental offices unaware of the benefits and exis- transferred to the adjacent central tence of cosmetic dental rehabilitation. An incisor so an accu- important role for dentists is to teach patients rate gingivectomy what is possible and available to them. can be performed. Dentists are fortunate today to be able to com- pletely reconstruct what has been lost. Few dis- ciplines of medicine can make this claim. Figure 6E—The central incisor Periodontal therapy has seen a tremendous immediately after growth in technology, which allows dentists to completion of re-create almost all lost periodontium with caliper-measured gingivectomy. Note predictability. The focus of periodontics has the symmetry of the changed from resective to regenerative and gingival margins. esthetic. Likewise, restorative dentistry has seen a tremendous evolution in the quality of dental materials. Natural-looking restorations are now possible. Dental implants have made a Figure 6F—The final third set of teeth possible for patients. The restoration 2 years knowledge and technology for complete dental postoperatively. A rehabilitation exists. ceramic crown is on the implant on the For all of this to be well orchestrated, how- right central incisor. ever, communication must exist between the A labial veneer is on patient and the dentist. The dentist must be the left central incisor. (Restoration aware of what patients want and need. The by Dr. Keith Rudolph, patient must be knowledgeable as to what is Westport, Conn.) possible, and must understand the costs, risks, and benefits of treatment. Communication 816 Compendium / August 1997 Vol. 18, No. 8 also must exist among dentists. The various dental disciplines must main- tain a dialogue about what is possible in each field. The impact of each dentist’s treatment on the final result must be known by all participating clinicians. Lastly, excellent communication between the dentist and den- tal technician should exist. Total esthetic rehabilitation is a team approach. It is hoped that the crown-lengthening techniques presented will make anterior cosmetic restorations more predictable. With proper treatment planning and communication, a predictable, controlled, esthetic, harmo- nious result can be achieved for many patients. The beneficiaries will be all who participate in the process.

Acknowledgment The author wishes to express his sincere appreciation to Cheryl Lynn Ives for her helpful cooperation and editorial expertise in preparing this manuscript.

References 1. Patzer GL: Understanding the causal relationship between physical attractiveness and self- esteem. J Esthet Dent 3:144-146, 1996. 2. Patzer, GL: Self-esteem and physical attractiveness. J Esthet Dent 7:274-277, 1995. 3. Miller PD: Concept of periodontal plastic surgery. Pract Periodontics Aesthet Dent 5(5):15-20, 1993. 4. Vig RG, Brundoo GC: The kinetics of anterior tooth display. J Prosthet Dent 39:502, 1972. 5. Rufenacht CR: Fundamentals of Esthetics. Chicago, Quintessence Publishing Co, Inc, 1990. 6. Wheeler RC: An Atlas of Tooth Form, ed 4. Philadelphia, WB Saunders Co, 1969. 7. Allen EP: Surgical crown lengthening for function and esthetics. Dent Clin North Am 37(2):163-

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Compendium / August 1997 Vol. 18, No. 8 179, 1993. 29. Mishkin DJ, Gellin RG: Biologic width and crown length- 8. Chiche GJ, Pinault A: Esthetics of Anterior Fixed Prostho- ening (letter to the editor). J Periodontol 64:920-921, 1993. dontics. Chicago, Quintessence Publishing Co, Inc, 1994. 30. Ramfjord SP: Periodontal considerations of operative den- CE 5 9. Studer S, Zellweger U, Scharer P: The aesthetic guidelines tistry. Oper Dent 10:144-159, 1988. of the mucogingival complex for fixed prosthodontics. 31. Holmes JR, Sulik WD, Holland GZ, et al: Marginal fit of Pract Periodontics Aesthet Dent 8(4):333-342, 1996. castable ceramic crowns. J Prosthet Dent 67:594-599, 1992. 10. Maynard JG, Wilson RD: Physiologic dimensions of the 32. Christensen GJ: Marginal fit of gold castings. J Prosthet periodontium significant to the restorative dentist. Dent 16:297-305, 1966. J Periodontol 50:170-174, 1979. 33. Waerhaug J: Subgingival plaque and loss of attachment in 11. Stetler KJ, Bissada NB: Significance of the width of kera- periodontitis as observed in autopsy material. J Periodontol tinized gingiva on the periodontal status of teeth with sub- 47:636-642, 1976. marginal restorations. J Periodontol 58:696, 1987. 34. Tal B, Soldinger M, Dreiangel A, et al: Periodontal 12. Schroeder HE, Listgarten RA: Fine structures of the devel- response to long-term abuse of the gingival attachment by oping epithelial attachment in human teeth. Monographs supracrestal amalgam restorations. J Clin Periodontol in Developmental Biology. Basel, S Kaarger, 1971. 16:650-659, 1989. 13. Sicher H: Changing concepts of the supporting dental 35. Valderhaug J, Birkeland JM: Periodontal conditions in structures. Oral Surg 12:31-35, 1959. patients 5 years following insertion of fixed prostheses. 14. Gargulio AW, Wentz FM, Orban BJ: Dimensions and rela- J Oral Rehabil 3:237-243, 1976. tion of the dentogingival junction in humans. J Periodontol 36. Kois J: The gingival is red around my crowns—a differen- 32:261-267, 1961. tial diagnosis. Dent Econ 101-105, April 1993. 15. Cohen DW: Lecture, Walter Reed Army Medical Center, 37. Wagenburg BD, Eskow RN, Langer B: Exposing adequate June 3, 1962. tooth structure for restorative dentistry. Int J Periodontics 16. Ingber JS, Rose LF, Coslet JG: The “biologic width”—a Restorative Dent 9:23, 1989. concept in periodontics and restorative dentistry. Alpha 38. Allen EP: Use of mucogingival surgical procedures to Omegan 70:62-65, 1977. enhance esthetics. Dent Clin North Am 32(2):307-330, 1988. 17. Sillness J: Fixed prosthodontics and periodontal health. 39. Moskowitz ME, Nayyar A: Determinants of dental esthet- Dent Clin North Am 24:317-329, 1980. ics: a rationale for smile analysis and treatment. Compend 18. Dragoo MR, Williams GB: Periodontal tissue reactions to Contin Educ Dent 16(12):1164-1186, 1995. restorative procedures. Int J Periodontics Restorative Dent 40. Kovich V: Esthetics and anterior tooth position: an ortho- 2(1):9-23, 1982. dontic perspective. Part I: crown length. J Esthet Dent 19. Dragoo MR, Williams GB: Periodontal tissue reactions to 5(1):19-23, 1993. restorative procedures. Part II. Int J Perio- dontics Restorative Dent 2(2):35-45, 1982. 20. Carnevale G, Sterrantino SF, DiFebo G: Soft and hard tissue wound healing following tooth preparation to the alveolar crest. Int J Periodontics Restorative Dent 3(6):37-53, 1983. 21. Nevins M, Skurow HM: The intracrevicular restorative margin, the biologic width, and the maintenance of the gingival margin. Int J Periodontics Restorative Dent 4(3):31, 1984. 22. Pharma-Benfenati S, Fugazzotto PA, Ruben MP: The effect of restorative margins on the postsurgical development and nature of the periodontium. Part I. Int J Periodontics Restorative Dent 5(6):31-52, 1985. 23. Pharma-Benfenati S, Fugazzotto PA, Ferrira PM, et al: The effect of restorative margins on the postsurgical development and nature of the periodontium. Part II. Int J Periodontics Q & B FOODS Restorative Dent 6(1):64-75, 1986. 24. da-Jocoby Lavina F, Ziafiropoulos GG, 1/3 B/W Ciancioa S: The effect of crown margin loca- tion on plaque and periodontal health. Int J Periodontics Restorative Dent 9(3):197-205, 1989. 25. de Waal H, Castellucci G: The importance of restorative margin placement to the biologic width and periodontal health. Part I. Int J Periodontics Restorative Dent 13(5):461-467, 1993. 26. de Waal H, Castellucci G: The importance of restorative margin placement to the biologic width and periodontal health. Part II. Int J Periodontics Restorative Dent 14(1):70-83, 1994. 27. Kois J: Altering gingival levels: the restora- tive connection. Part I: biologic variables. J Esthet Dent 6(1):3-9, 1994. 28. Dello Russo NM: Biologic width and crown lengthening (letter to the editor). J Peri- odontol 64:1993. Circle 29 on Reader Service Card 819 Vol. 18, No. 8 Compendium / August 1997 CE 5 Quiz5

This article provides 1 hour of CE credit from Dental Learning Systems, Co., Inc., in association with the University of Southern California School of Dentistry and the University of Pennsylvania School of Dental Medicine. Record your answers on the enclosed answer sheet or submit them on a separate sheet of paper.

1. Possible indications for crown- zenith is located along the mid- avoided because: lengthening include: line of the labial surface of the: a. it adds time to the procedure. a. increasing crown length for a. central incisors. b. it eliminates papillary reces- restoration retention. b. lateral incisors. sion. b. restoring the tooth without c. canines. c. there is never a need to violating the biologic width. c. lateral and central incisors. lengthen teeth interproximally. c. esthetics via an alteration of d. none of the above the gingival labial profile. 5. A mucoperiosteal flap can be d. all of the above performed when: 9. The restorative tooth-margin a. ostectomy is required. position should be determined 2. Placing the margin of the b. excess gingiva covers the clin- before the first stage of the two- restoration within the biologic ical crown. stage crown-lengthening proce- width can result in: c. a minimal band of keratinized dure so that: a. recession. gingiva exists. a. the appropriate amount of b. chronic inflammation. d. all of the above bone can be removed. c. the re-creation of a newly b. the biologic width will not be positioned dental gingival 6. A gingivectomy for crown compromised later. complex. lengthening is contraindicated c. neither a nor b d. all of the above when: d. both a and b a. excess keratinized gingiva exists. 3. In an ideal esthetic situation, the b. access to bone is not required. 10. At stage 2 surgery, the total marginal gingival height of the c. the margin of the provisional millimeter (mm) amount of gingi- maxillary central incisors relative restoration lies within the va that can be excised without to the maxillary lateral incisors is biologic width. violating the dental gingival located: d. the gingiva is extremely complex is: a. approximately 1.5 mm more fibrotic. a. the distance from the free incisally. gingival margin to the alveo- b. coincident with the central 7. The two-stage crown-lengthening lar crest minus 3 mm. incisors. procedure requires: b. the clinical sulcus depth. c. approximately 1.0 mm more a. a gingivectomy. c. not able to be determined apically. b. increased clinical skill. without performing a d. approximately 4.0 mm more c. crowning of all teeth. mucoperiosteal flap. incisally. d. reflection of a palatal flap. d. the distance from the mucogingival junction to the 4. In the maxilla, the gingival 8. Reflection of the papillae is alveolar crest.

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