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Short Clinical Crowns (SCC) – Treatment Considerations and Techniques

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Short Clinical Crowns (SCC) – Treatment Considerations and Techniques J Clin Exp Dent. 2012;4(4):e230-6. Short clinical crown. Journal section: Clinical and Experimental Dentistry doi:10.4317/jced.50556 Publication Types: Review http://dx.doi.org/10.4317/jced.50556 Short clinical crowns (SCC) – treatment considerations and techniques Ashu Sharma 1, G. R. Rahul 2, Soorya T. Poduval 3, Karunakar Shetty 3, Bhawna Gupta 4. 1 BDS, MDS. Department of Prosthodontics, Bangalore Institute of Dental Sciences and Research Center, 5/3 Hosur Main Road, Opposite Lakkasandra Bus Stop. Wilson Garden, Bangalore, India. 2 BDS, MDS. Professor and Head of Department of Prosthodontics. Bangalore Institute of Dental Sciences and Research Center, 5/3 Hosur Main Road, Opposite Lakkasandra Bus Stop. Wilson Garden, Bangalore, India. 3 BDS, MDS. Professor. Department of Prosthodontics. Bangalore Institute of Dental Sciences and Research Center, 5/3 Hosur Main Road, Opposite Lakkasandra Bus Stop. Wilson Garden, Bangalore, India. 4 BDS. House surgeon. Bangalore Institute of Dental Sciences and Research Center. Bangalore, India. Correspondence: Dept. of Prosthodontics, Bangalore Institute of Dental Sciences and Research Center, 5/3 Hosur Main Road, Opposite Lakkasandra Bus Stop. Wilson Garden, Bangalore 560027. India. email: [email protected] Sharma A, Rahul GR, Poduval ST, Shetty K, Gupta B. Short clinical crowns (SCC) – treatment considerations and techniques. J Clin Exp Dent. 2012;4(4):e230-6. http://www.medicinaoral.com/odo/volumenes/v4i4/jcedv4i4p230.pdf Received: 15/04/2011 Accepted: 19/04/2012 Article Number: 50556 http://www.medicinaoral.com/odo/indice.htm © Medicina Oral S. L. C.I.F. B 96689336 - eISSN: 1989-5488 eMail: [email protected] Indexed in: Scopus DOI® System Abstract When the clinical crowns of teeth are dimensionally inadequate, esthetically and biologically acceptable restoration of these dental units is difficult. Often an acceptable restoration cannot be accomplished without first surgically increasing the length of the existing clinical crowns; therefore, successful management requires an understanding of both the dental and periodontal parameters of treatment. The complications presented by teeth with short clinical crowns demand a comprehensive treatment plan and proper sequencing of therapy to ensure a satisfactory result. Visualization of the desired result is a prerequisite of successful therapy. This review examines the periodontal and restorative factors related to restoring teeth with short clinical crowns. Modes of therapy are usually combined to meet the biologic, restorative, and esthetic requirements imposed by short clinical crowns. In this study various methods for treating short clinical crowns are reviewed, the role that restoration margin location play in the main- tenance of periodontal and dental symbiosis and the effects of violation of the supracrestal gingivae by improper full-coverage restorations has also been discussed. Key words: Short clinical crown, surgical crown lengthening, forced eruption, diagnostic wax up, alveoloplasty, gingivectomy. e230 J Clin Exp Dent. 2012;4(4):e230-6. Short clinical crown. Introduction Causes of short clinical crowns A short clinical crown is defined as any tooth with less Common causes of short clinical crowns (SCC) include than 2 mm of sound, opposing parallel walls remaining (4-9): after occlusal and axial reduction (1). A comprehensive 1. Disease (caries, erosion, tooth malformation). treatment plan and proper sequencing of therapy is nee- 2. Trauma (fractured teeth, attrition). ded to overcome the complications presented by a short 3. Iatrogenic dentistry (excess tooth reduction, large clinicl crown. This paper examines the periodontal and endodontic access openings). restorative factors related to restoring teeth with short 4. Eruption disharmony (insufficient passive eruption, clinical crowns and also various methods available for mesially tipped teeth). treating short clinical crowns are reviewed. 5. Exostosis, and genetic variation in tooth form. When restoring a short clinical crown, the clinician may attempt to gain length by placing a subgingival margin. Restorability assesssment of short clinical However, deep subgingival margins that encroach upon crown the biologic width jeopardize the periodontal tissue and However, before any treatment is initiated on a tooth are therefore not desirable (2,3). The short clinical crown with short clinical crown, restorability must be establis- cannot be evaluated by visual inspection alone. A tho- hed (4). Restorative assessment should include: rough examination that includes clinical examination, 1. Consideration of the arch position of the tooth. radiographic examination, and diagnostic cast analysis 2. Strategic value of the tooth. is essential for successful rehabilitation of severely com- 3. Periodontal considerations. plicated oral dentition. Inadequate diagnosis and impro- 4. Crown-to-root ratio. per treatment plan may not ensure a satisfactory result. 5. Interarch space occlusion. Visualization of the desired result is a prerequisite of 6. Endodontic treatment feasibility. successful therapy. 7. Esthetics (2). Crown retention and resistance form are primarily rela- ted to crown length, total occlusal convergence degree, Subgingical margin placement: A solution or and axial surface area. Secondary retention and resistan- problem to Short clinical crown ce form may be derived from boxes, grooves, or pins When restoring a tooth with a SCC, the clinician may placed in solid tooth structure. The relationship of axial attempt to gain length by placing a subgingival finish wall height to prepared tooth width also greatly influen- line. However, deep subgingival margins that encroach ces crown retention and resistance form. The axial wall upon the biologic periodontal width (10-11) jeopardize height must be great enough to prevent the rotation of the periodontium and are therefore not desirable. The the casting around a point on the opposite margin. A biologic width-approximately 1 mm of epithelial atta- crown on a short tooth preparation has a greater tenden- chment and 1 mm of connective tissue attachment is a cy toward displacement than a crown on a tooth of the physiologic entity that should not be violated. Invading same axial wall height with a smaller diameter. Sound the biologic width during tooth preparation can result tooth structure should provide the principal source of in chronic inflammation, loss of alveolar bone, gingi- retention. Foundation restorations (buildups) should not val recession and periodontal pocket formation. The be relied upon because it is difficult to know how well amount of pathologic response is related to the indivi- the foundation itself is retained. It is important to place dual patient’s susceptibility to periodontal disease (11- the finish line on a sound tooth structure to ensure a fa- 21). The chronic inflammation resulting from violation vorable prognosis for the restoration (2) of the biologic width compromises both esthetics and periodontal health. Subgingival margins make adequa- Search strategy te margin placement difficult, compromise provisional A PubMed search of English literature was conducted up restoration maintenance, complicate impression making to February 2011 using the terms: short clinical crown, procedures and may preclude accurate evaluation of the surgical crown lengthening, forced eruption, diagnostic final restoration and isolation to cementation (14). wax up, alveoloplasty and gingivectomy. Additionally, the bibliographies of 5 previous reviews, their cross refe- Other treatment options for short clinical rences as well as articles published in Periodontol 2000, crowns Compendium Continuing Education of General Dentis- The restoration of teeth with SCC has included the fo- try, Journal of Periodontology, Quintessence Internatio- llowing techniques: nal, Jouranl of American Dental Association, New York 1. Alteration of tooth preparation design and placement State Dental Journal, Journal of Prosthetic Dentistry and of auxillary retention and resistance form features. International Journal of Periodontics Restorative Dentis- 2. Placement of foundation restorations. try were manually searched. 3. Surgical crown lengthening. e231 J Clin Exp Dent. 2012;4(4):e230-6. Short clinical crown. 4. Orthodontic eruption. biologic width (11). When biological width is violated, 5. Endodontic treatment and overlay removable partial as a defense mechanism, inflammatory response trig- dentures (2). gers alveolar bone resorption to provide space for a new 1. Altering tooth preparation design: connective tissue attachment, which results in increased The short clinical crown does not permit the use of routi- pocket depth (22). A recent study by Lanning et al. was ne tooth preparation design. Additional design features carried out on 18 teeth from 18 patients that required are required to compensate for decreased retention and crown lengthening (23). Teeth were checked after sur- resistance form. Retention and resistance factors in too- gery, at three and six months. The authors concluded that th preparation are related primarily to surface area and the preoperative measurement of biological width was height of the preparation, axial wall convergence, tex- re-established after six months from the surgery, and, ture of the prepared surface and secondarily to intraco- at the same time, an average of 3 mm of coronal tooth ronal retentive devices (15-18). The walls of a short cli- structure was gained as a result of the surgery. These nical crown should
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