TARRSON FAMILY ENDOWED CHAIR IN PERIODONTICS

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TARRSON FAMILY ENDOWED CHAIR IN PERIODONTICS
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UCLA SCHOOL OF DENTISTRY
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Presents
Presents
Dr. E. Barrie KenneyProfessor ChairmanSection
of Periodontics
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E. Barrie Kenney B.D.Sc., D.D.S., M.S.,
F.R.A.C.D.S.
Tarrson Family Endowed Chair in Periodontics.
ESTHETIC SURGICAL PROCEDURES FOR CROWN
LENGTHENING
Professor and Chairman Division of Associated
Clinical Specialties UCLA School of Dentistry
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• Choice depends on
• Gingival crevice depth
• Need to maintain minimum of 1 mm connective
  tissue between depth of crevice and bone
• Adequate width of Keratinized gingiva

• Gingivectomy
• Flap surgery for osseous recontouring

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• Need minimum of one millimeter connective tissue
  coronal to bone margin
• Gingival margin will be two millimeters coronal
  to this with 2 mm crevice depth.

• Red line- Gingival margin.Pink area connective
  tissue.
• Black line probe to depth of crevice.

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1mm.
Distance of gingival margin to bone on labial is
3mm.Two mm of this is crevice depth, and 1mm. is
for connective tissue between probable depth and
crest of bone.
2mm
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• Five millimeters of crevice depth with adequate
  band of Keratinized tissue
• Gingivectomy can be used to increase crown length
  by up to 3 mm

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• Advantages of Gingivectomy
• Precise control of gingival contours
• Low risk of inadvertent necrosis of tissue during
  healing

• Advantages of Flap Procedure
• Wide range of suitable cases

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• Crevice depth of five millimeters will allow
  three millimeters of crown lengthening by
  Gingivectomy
• If more than three millimeters needed use Flap
  Surgery

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• Gingivectomy Techniques
• This patient requires 3 mm of crown lengthening
• Sufficient crevice depth and Keratinized tissue

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Gingivectomy completed with surgical scalpels and
knives
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Healing at three weeks
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• Crowns placed twelve weeks after Gingivectomy
• Next slide Before and After

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Gingivectomy to correct lack of symmetry and
short crowns
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• Sufficient crevice depth and Keratinized gingiva
• Frenum correction also needed

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• Scalpel used to establish 10 mm crown length on
  central incisor
• Height of contour of gingiva is distalized

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Kirkland Knife used to refine gingival contours
by gentle scraping
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• Length of central incisor serves as basis for
  lateral incisor and cuspid
• Lateral incisor gingival margin 1 mm coronal to
  central
• Cuspid gingival margin at same level as central

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The lateral incisor also has distalized gingival
margin
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Left central incisor gingival margin shaped for
symmetry with right central
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• Gingivectomy completed with bilateral symmetry
• Right central incisor edge will need shortening

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Initial incision for Frenectomy
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• Removal of wedge of tissue from frenum
• Interdental papilla is untouched

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• Incision made through periosteum to expose bone
• This ensures no muscle pull exists to interdental
  papilla

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Wound closed tightly with 5.0 gut sutures
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• Healing at twelve weeks
• Next Slide Before and After

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Crown Lengthening requires Flap Surgery and
osseous correction
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• Initial Incisions
• Central incisor and cuspid new gingival margins
  at same level
• Sulcular incision used on lateral incisor to make
  it harmonious with central and cuspid
• Interproximal incisions preserve papillae

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• Incisions on left symmetrical with right
• Use new blade for each two teeth to minimize
  tissue trauma

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• Flap carefully dissected with sharp scalpels
• 3 mm of bone crest exposed
• Bone recontouring needed to provide adequate
  connective tissue apical to crevice depth

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Bone Margin has been moved apically of central
incisor and cuspid
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Flap sutured with apical positioning of gingival
margins on central incisors and cuspids
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• Final Result at Twelve Weeks
• Next Slide Before and After

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Short clinical crowns with large gingival display
on smiling
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Insufficient gingival crevice depth for
Gingivectomy
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Premolars are included because of exposure with
smiling
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15 c scalpel used to distalize gingival margin
equally on central incisors
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12 B scalpel begins sharp dissection of full
thickness flap with preservation of interdental
papillae
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Incised gingiva gently removed with sharp back
action hoe
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Flap elevated and bone recontoured
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Flaps sutured with simple 5.0 gut interproximal
sutures
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Central incisors lengthening to 11 mm
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Firm pressure applied to flap for 5 minutes
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• Healing at one week
• No post surgical brushing or flossing
• Chlorhexidine mouth washes three times per day

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• Healing at twelve weeks
• Gingival margins now stable
• Gentle brushing with soft brush and chlorhexidine
  from second week post operative
• Gentle flossing after four weeks healing
• Next slide Before and After

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Short clinical crowns and excessive gingival
display following orthodontic treatment
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• Level of Incisal edge is established
• Central incisor and cuspid incisal edges at same
  level
• Lateral incisal edge 1 mm apical to central
  incisor
• Incisal plane parallels lower lip

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Gingival crevice too shallow for Gingivectomy
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New gingival margins established with incisions
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Central incisor length at 10.50 mm
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Flap elevated to expose bone margin
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Bone recontoured to provide sufficient connective
tissue for Biologic width
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Flaps sutured in final position
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• Healing at twelve weeks
• Next slide Before and After

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Upper and lower incisors, cuspids, and premolars
with asymmetry and small clinical crowns
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Size of clinical crowns too short for facial
dimensions and smile
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Flap elevated to expose bone margins
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• Osseous recontouring to move bone margins apical
• Long anatomical crowns on central incisors

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Flaps sutured with apical position of gingival
margins including premolars
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• Healing at twelve weeks
• Cuspids elongated to give masculine emphasis
• Next two slides Before and After

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• Altered passive eruption
• Short asymmetrical clinical crowns

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Healing at one week
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• Healing at 12 weeks
• Next Slide Before and After

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Gingival and tooth esthetics unacceptable to
patient
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Flaps and osseous recontouring completed
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• Final Restorations completed after 24 weeks of
  healing
• Next Slide Before and After

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ONE WEEK POST SURGERY
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TEN WEEKS POST SURGERY
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• Crown lengthening for esthetics and to provide
  sufficient root volume for crown retention
• Need to establish incisal edge as baseline for
  gingival dimensions

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Provisional acrylic template establishes final
crown dimensions and incisal edge
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Patient can view template and suggest any
necessary changes
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At time of Flap Surgery, gingival margins outline
on tissues
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Incisions made following template dimensions
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Flaps elevated to expose bone margins
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Bone recontoured to mirror final gingival margins
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Position of new gingival margins confirmed with
stent
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Flap positioned with polytetraflurethylene sutures
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Palatal view
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• Healing at 6 weeks
• Lower incisors also treated
• Next Slide Before and After

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If amount of crown lenthening needed will result
in depth of crevice being less than 1mm from bone
margin then flap sugery and bone removal is
required to give adequate BIOLOGICAL WIDTH