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3D-Printed Surgical Guide for Crown Lengthening Based on Cone Beam Computed Tomography Measurements: a Clinical Report with 6 Months Follow Up

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3D-Printed Surgical Guide for Crown Lengthening Based on Cone Beam Computed Tomography Measurements: a Clinical Report with 6 Months Follow Up applied sciences Case Report 3D-Printed Surgical Guide for Crown Lengthening Based on Cone Beam Computed Tomography Measurements: A Clinical Report with 6 Months Follow Up Abdulkareem Alhumaidan 1, Ayed Alqahtani 2 and Faisal al-Qarni 3,* 1 Department of Preventive Dental Sciences, College of Dentistry, Imam Abdulrahman Bin Faisal University, Dammam 31441, Saudi Arabia; [email protected] 2 King Fahad Specialist Hospital, Dammam 32253, Saudi Arabia; [email protected] 3 Department of Substitutive Dental Sciences, College of Dentistry, Imam Abdulrahman Bin Faisal University, Dammam 31441, Saudi Arabia * Correspondence: [email protected] Received: 10 July 2020; Accepted: 11 August 2020; Published: 17 August 2020 Featured Application: When no prosthetic treatment is indicated, esthetic crown lengthening can be facilitated by fabricating a 3D printed surgical guide based on CBCT measurements and an intra oral scan. Abstract: Excessive gingival display is a common clinical presentation that often requires surgical intervention. This report is for a patient for whom esthetic crown lengthening is indicated due to altered passive eruption. Cone beam computed tomography (CBCT) scan and an intraoral scan were used to design and print a single surgical guide which provided a reference for both gingivectomy and osteoectomy. A satisfactory outcome was obtained 6 months after surgery. The present technique provided a simplified method of generating a surgical guide with predictable results by relying on the existing tooth anatomy rather than diagnostic waxing. This technique is particularly useful when crowns or veneers are not indicated. Keywords: crown lengthening; surgical guide; CBCT; CAD/CAM; 3D printing 1. Introduction Excessive gingival display, which can be due to altered passive eruption (APE) or gingival enlargement, results in short clinical crowns; this is a cause of common esthetic concern for many patients. Gingivectomy or esthetic crown lengthening with bone resection is often required to increase the clinical crown length and achieve acceptable esthetic outcomes [1]. The decision whether to perform bone resection is largely dependent on the location of the alveolar bone crest in relation to the cementoenamel junction. If the bone crest is at, or coronal to, the cementoenamel junction, then osseous resective surgery is indicated [2]. In order to locate the bone crest, bone sounding and periapical radiograph assessments are typically performed [3,4] However, these methods may be challenging and could provide inaccurate assessments [5]. Cone beam computed tomography (CBCT) has been suggested as a precise and reliable alternative approach for diagnosing APE [6]. To achieve adequate esthetic results, surgical guides are often utilized, and based on diagnostic waxing, made with acrylic resin or vaccuform transparent shells [7,8]. However, this technique has been reported to be sometimes inaccurate [9]. A recent report described a digital workflow in which Appl. Sci. 2020, 10, 5697; doi:10.3390/app10165697 www.mdpi.com/journal/applsci Appl. Sci. 2020, 10, 5697 2 of 8 Appl. Sci. 2020, 10, x FOR PEER REVIEW 2 of 8 digital waxing was used to design the surgical guideguide for crown lengthening [[10].10]. The use of diagnostic diagnostic waxing is not necessary when no restorative treatmenttreatment isis indicated.indicated. Currently, there are no no known known studie studiess that that have have used used CBCT CBCT to to locate locate the the facial facial bone bone crest crest and and to designto design a digitally a digitally fabricated fabricated guide guide for for crown crown lengthening lengthening surgery. surgery. Therefore, Therefore, this this clinical report presents a patient with altered passive eruption, for whom CBCT was combined with digital scanning to make a single surgical guide for crowncrown lengthening.lengthening. 2. Case Case Report A 22-year-old female patient presented to the College of Dentistry clinics at Imam Abdulrahman Bin Faisal University with complaining of “a gummygummy smile” (Figure1 1).). UponUpon initialinitial examinationexamination thethe patient did not show any gingival tissues at rest, however on full smile, 4 mm of gingival band was shown below the lower border of the maxillary lip. The medical history of the patient did not show any relevant medical issues, while dental history revealed that patient had completedcompleted orthodontic teeth alignment with clear aligneraligner therapy 6 months earlier. Figure 1. PreoperativePreoperative smile smile view showin showingg excessive gingival display. Furthermore, there were no significantsignificant findingsfindings on the extra-oral examination and patient was normally asymmetrical. The The facial facial three three thirds thirds were analyzed and found to bebe normal.normal. A lateral cephalometric analysis confirmed confirmed absence of of vertic verticalal maxillary excess and dentoalveolar extrusion. extrusion. The maxillary lip length was 19 mm, the incisal display at rest was 4 mm, and the lip mobility was also assessed and found to be 6 mm. The clinical crown lengths of central incisors, lateral incisors, and canines teeth were 8 mm, 7 mm, and 8 mm, respectively.respectively. The gingival phenotype was assessed using thethe probe-transparency probe-transparency test4 test4 and and was determinedwas determined to be thick.to be A thick. CBCT scanA CBCT (CS9300; scan Carestream (CS9300; CarestreamHealth Inc., Health Kodak, Inc Rochester,., Kodak, NY, Rochester, USA) was NY, acquired USA) was to acquired analyze the to analyze level of the the level alveolar of the bone alveolar crest bonein relation crest in to relation the cementoenamel to the cementoenamel junction. juncti The radiographicon. The radiographic parameter parameter was set was as 90 set kVp as 90/4 kVp/4 mA/s, with voxel size 200 µm, according to manufacturer’s exposure settings with a field of view 10 5 cm mA/s, with voxel size 200 μm, according to manufacturer’s exposure settings with a field of view× 10 (diameter height). Based on the sagittal cross section of the maxillary anterior sextant, the distance × 5 cm (diameter× × height). Based on the sagittal cross section of the maxillary anterior sextant, the distancebetween between the bone the crest bone and crest the and respective the respective cementoenamel cementoenamel junction junction was at was a maximum at a maximum of 1.5 of mm 1.5 (Figuremm (Figure2). The 2). CBCTThe CBCT scan alsoscan showedalso showed that the that patient the patient had a had thick a buccalthick buccal cortex. cortex. Due to Due the to short the shortclinical clinical crowns crowns presentation, presentation, the squarish the squarish appearance appearance of the teeth,of the and teeth, the and aforementioned the aforementioned clinical clinicalfindings, findings, the patient the waspatient diagnosed was diagnosed with excessive with ex gingivalcessive gingival display display as a result as a of result altered of passivealtered passiveeruption eruption APE type APE 1 withtype a1 lowwith bone a low crest. bone Treatmentcrest. Treatment options options were were discussed discussed with with the patient the patient and andesthetic esthetic crown crown lengthening lengthening with with bone bone resection resection was proposed.was proposed. Appl. Sci. 2020, 10, x FOR PEER REVIEW 3 of 8 Appl. Sci. 2020, 10, 5697 3 of 8 Appl. Sci. 2020, 10, x FOR PEER REVIEW 3 of 8 Figure 2. Distance from cementoenamel junction to facial bone crest as measured on cone beam Figure 2. Distance from cementoenamel junction to facial bone crest as measured on cone beam computedFigure 2. Distancetomography from (CBCT). cementoenamel junction to facial bone crest as measured on cone beam computed tomography (CBCT). computed tomography (CBCT). 2.1. Desgin Desgin and 3D Printing of Surgical Guide 2.1. Desgin and 3D Printing of Surgical Guide An intraoral scanscan (TRIOS;(TRIOS; 3Shape) 3Shape) was was acquired acquired to to aid aid in in fabricating fabricating a surgical a surgical guide guide (Figure (Figure3a). 3a).Digital DigitalAn Imagingintraoral Imaging andscan and Communications(TRIOS; Communications 3Shape) was in in Medicine acquired Medicine (DICOM)to (DICOM) aid in fabricating files files were were a converted convertedsurgical guide toto Standard (Figure Tessellation3a). Digital LanguageImagingLanguage and (STL) (STL) Communications format format and and then thenin superimposed Medicine superimposed (DICOM) with STLwith files files STL were acquired files converted acquired from theto fromStandard intraoral the intraoralscanTessellation using scan coDiagnostiX Language using coDiagnostiX (STL) 9.7 software format 9.7(Dental softwareand then Wings (D suentalperimposed INC, Wings Montreal, INC, with Canada).Montreal, STL files Then Canada). acquired using Then thefrom design using the thesoftwareintraoral design scan (3Shape software using Premium coDiagnostiX(3Shape Dental Premium 9.7 System; software Dental 3Shape), (DSystentalem; the Wings 3Shape), level INC, of thethe Montreal, cementoenamellevel of Canada). the cementoenamel junction Then using was junctionmarkedthe design (Figurewas software marked3b) to (Figure guide(3Shape the 3b) Premium gingivectomy to guide Dental the gingivectomy incision System; line, 3Shape), followed incision the line, by level a followed second of the line by cementoenamel 3a mmsecond apical line to 3 mmthejunction cementoenamel apical was to markedthe cementoenamel junction (Figure line 3b) toto junction
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