Cosmetic Tribune U.S. No. 4, 2011
Two-stage esthetic crown lengthening
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Cosmetic TRIBUNE
The World’s Cosmetic Dentistry Newspaper · U.S. Edition
April 2011
www.dental-tribune.com
Vol. 4, No. 4
Two-stage esthetic crown lengthening
By Michael Sonick, DMD,
Stephen Rothenberg, DMD
and Debby Hwang, DMD
Before
A smile that is perceived as
unattractive mars confidence,
sociability and self-regard. For
some patients, the lack of visual
appeal stems in large part from a
“gummy smile,” which a layperson
begins to consider disharmonious
when there is 3 to 4 mm of gingiva
displayed.1
Management of such a complaint often entails both periodontal and restorative therapy, if not
also orthognathic surgery and
facial plastic procedures.
The following report showcases
two-stage esthetic crown lengthening and prosthetic rehabilitation for the treatment of a gummy
smile.
Patient history
Fig. 4: Surgical guide in place in the
mouth. The ideal tooth contours are
shaded in white.
Fig. 1a: Initial facial presentation of patient, who
exhibits a gummy smile (up
to 7 mm of soft-tissue display) and vertical maxillary
excess.
A medically and periodontally stable 40-year-old female presented
with excessive, asymmetric gingival display of 5 to 7 mm upon
smiling, short clinical crowns and
incisal wear from tooth #4 to #13
(Figs. 1, 2).
Due to attrition and the relationship between the dentition and
periodontal drape, the anterior
teeth appear square-shaped and
“masculine.”
Diagnoses included (1) Coslet
Type IA altered passive eruption,
evidenced by a wider-than-customary dimension of keratinized
gingiva and an alveolar crest at
least 1.5 apical to the cementoenamel junction (CEJ); and (2)
vertical maxillary excess. 2,3 The
patient also shows a thick tissue
biotype.
•
•
•
•
•
•
•
Fig. 5: Initial full-thickness flap reflection at first stage surgery. Note the apical level of the alveolar crest compared
to the cemento-enamel junction.
Fig. 6a: Final bone contours after ostectomy.
Fig. 2:
Excessive keratinized gingiva,
a thick softtissue biotype
and asymmetric
gingival contours exist.
Consult with oral and maxillofacial surgeon regarding
orthognathic surgery
Consult with facial plastic surgeon regarding lip lowering
therapy
Consult with restorative dentist
regarding ideal tooth shape setup and fabrication of surgical
guide
Two-stage
esthetic
crown
lengthening from tooth #4 to
#13
First stage: osseous recontouring
6-week healing period
Second stage: gingivectomy
3-month healing period
g CT page 2C
Fig. 14: Facial view six years
post-treatment.
Fig. 1b:
Initial view of
maxillary anterior teeth upon
smiling. The
clinical crowns
appear short
and demonstrate attrition.
Treatment plan
•
After
Fig. 6b: The final osseous contour lies at
least 3 mm from the anticipated restorative margins, as outlined by the surgical guide.
Fig. 3a:
The maxillary
diagnostic
model.
Fig. 3a
Fig. 3b
Fig. 3b:
Ideal wax-up
created on
the diagnostic
model.
[2] =>
2C Clinical
Cosmetic Tribune | April 2011
f CT page 1C
•
•
Final porcelain veneer restorations for teeth #4
through #13
Delivery of maxillary occlusal bite guard
Treatment plan rationale
Fig. 7: Sling sutures in place after osseous reshaping. Note
the similarity in gingival height and morphology between
pre-surgical and post-surgical views.
Fig. 8: Healing 10 days after first stage crown lengthening. The periodontal level still approximates the initial
presentation.
Fig. 9: Healing six
weeks after first
stage of crown
lengthening.
Ideal treatment for the patient with vertical maxillary excess embraces a host of dental and medical
specialties.
In such a case as this, in which the patient demonstrates up to 7 mm of gingival display, LeFort I
maxillary impaction may further refine results if conventional crown lengthening insufficiently elevates
the periodontal margin, creates an unacceptable
crown-to-root ratio or precludes achievement of a
natural-seeming emergence profile due to exposure
of excessive radicular structure.3
Likewise, neuromuscular relaxation of the upper
lip by botulinum toxin type A (BTX-A) depresses
the lip, and thus masks any mucosal surplus left
after periodontal surgery.4
As the patient declined orthognathic and facial
plastic therapy, the treatment rendered to alleviate
her gummy smile and reestablish tissue and dental
symmetry included a two-stage crown lengthening procedure followed by delivery of porcelain
veneers from tooth #4 to #13.
A biphasic crown lengthening approach minimizes the 1 to 3 mm coronal gingival shifts common after one-stage procedures detected especially in patients with thick soft-tissue biotypes (such
as the patient featured in this report).5
By first reshaping only the osseous crest and
letting healing commence, it is possible to correct
any coronal rebound of the soft tissue seen after
healing at the second, gingivectomy-only, surgery. Once the attachment apparatus fully remodels post-gingivectomy, which takes roughly three
months, final restorations may be cemented.
Restorative consult
From the diagnostic models, the patient’s prosthodontist created an ideal dental wax-up, upon
which a vacuform matrix was applied to generate
a surgical guide (Figs. 3, 4).
Osseous recontouring (first stage)
Fig. 10a: Frontal view immediately after second stage gingivectomy.
The first stage of biphasic crown lengthening of
teeth #4 through #13 involved only osseous resection. The patient took 0.25 mg oral triazolam and
600 mg ibuprofen one hour before surgery.
Anesthesia with 2 percent lidocaine with
1:100,000 epinephrine and 0.5 percent bupivicaine
with 1:200,000 epinephrine was given via local
infiltration.
A buccal sulcular incison was made extending
from tooth #4 to #13, and vertical incisions were
dropped at the mesio-buccal and disto-buccal line
angles of teeth #4 and #13. A full-thickness flap
was elevated (Fig. 5).
Ostectomy was performed using an Ochsenbein
chisel, carbide finishing bur and Neumeyer bur to
position the alveolar crest at least 3 mm from the
anticipated restorative margin at each site, as verified by the surgical guide (Fig. 6).
The bone was gradualized such that no sharp
edges or bulbous areas existed, and positive architecture was preserved. The flaps were replaced
and sutured in sling fashion with 4-0 expanded
polytetrafluoroethylene (ePTFE) (Fig. 7). The gingival height and shape post-surgery appeared similar to that found before surgery, even 10 days after
intervention (Fig. 8).
Gingivectomy (second stage)
Fig. 10b: Positional relationship between the lip and
gingival margin immediately after second stage gingivectomy.
Once the soft tissue resettled six weeks post-ostectomy (Fig. 9), the second stage of biphasic crown
lengthening of teeth #4 through #13 was executed.
The patient was sedated and anesthetized as above.
A definitive external bevel gingivectomy of teeth
#4 through #13 was performed with a #15 scalpel
utilizing the surgical template to delineate the
COSMETIC TRIBUNE
The World’s Dental Newspaper · US Edition
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t.oemus@dental-tribune.com
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d.berland@dental-tribune.com
Managing Editor/Designer
Implant, Endo & Lab Tribunes
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Dental Tribune America, LLC
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Published by Dental Tribune America
© 2011 Dental Tribune America, LLC
All rights reserved.
Cosmetic Tribune strives to maintain
utmost accuracy in its news and clinical reports. If you find a factual error or
content that requires clarification, please
contact Group Editor Robin Goodman at
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Cosmetic Tribune cannot assume responsibility for the validity of product claims
or for typographical errors. The publisher also does not assume responsibility
for product names or statements made
by advertisers. Opinions expressed by
authors are their own and may not reflect
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Tell us what
you think!
Do you have general comments or criticism you would like to share? Is there
a particular topic you would like to see
articles about in Cosmetic Tribune?
Let us know by e-mailing feedback@
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[3] =>
Clinical
Cosmetic Tribune | April 2011
3C
desired tooth contours (Fig. 10).
The papillae were left intact and no sutures
were required. Healing four weeks after the
gingivectomy revealed a harmonious gingival
drape (Fig. 11).
Final prosthetics
Placement of final veneers on teeth #4 through
#13 occurred three months post-gingivectomy
(Fig. 12). An occlusal bite guard was delivered
to protect the restorations.
In order to correct lip line asymmetry and
further diminish gingival display, neuromuscular lip correction (lowering) with BTX-A was
reconsidered, but the patient did not pursue
treatment.
Six years after veneer placement, the patient
remained satisfied with the functional and
esthetic result achieved solely through periodontal surgery and prosthetic rehabilitation
(Figs. 13, 14).
Fig. 12c: Right lateral view of final veneers
(#4 through #8) three months after gingivectomy.
Fig. 11a: Frontal view four weeks after second
stage gingivectomy.
Fig. 12d: Left lateral view of final
veneers (#9 through #13) three months
after gingivectomy.
Postoperative instructions
After each surgical procedure, the patient was
instructed to take 600 mg of ibuprofen every
4–6 hours, hydrocodone 7.5 mg/acetaminophen
750 mg every 4–6 hours as needed for pain and
100 mg of doxycycline a day for 10 days.
The patient was instructed not to brush at
or near the surgical site but instead to rinse
with 0.12 percent chlorhexidine or warm saline
twice daily. The patient was also directed not to
chew in the affected area for at least two weeks.
Suture removal occurred at 10 to 14 days
post-surgery. CT
Fig. 11b: Positional relationship between the lip
and gingival margin four weeks after second
stage gingivectomy.
References
1.
2.
3.
4.
5.
Kokich VO, Kokich VG, Kiyak HA. Perceptions of dental professionals and laypersons
to altered dental esthetics: asymmetric and
symmetric situations. Am J Orthod Dentofacial Orthop 2006;130(2):141–51.
Coslet JG, Vanarsdall R, Weisgold A. Diagnosis and classification of delayed passive
eruption of the dentogingival junction in
the adult. Alpha Omegan 1977;70(3):24–8.
Garber DA, Salama MA. The aesthetic
smile: diagnosis and treatment. Periodontol
2000 1996;11:18–28.
Polo M. Botulinum toxin type A (Botox) for
the neuromuscular correction of excessive gingival display on smiling (gummy
smile). Am J Orthod Dentofacial Orthop
2008;133(2):195–203.
Sonick M. Esthetic crown lengthening for
maxillary anterior teeth. Compend Contin
Educ Dent 1997;18(8):807–12, 14–6, 18–9;
quiz 20.
Fig. 13a: Smile pre-treatment.
Fig. 12a: Frontal view of final veneers (#4
through #13) three months after gingivectomy.
Fig. 13b: Smile six years post-treatment.
After
(All photos provided
by Dr. Michael Sonick)
Fig. 12b: Central view of final veneers (#6 through
#11) three months after gingivectomy.
About the authors
Before
Periodontal surgeon: Michael Sonick, DMD
Restorative dentist: Stephen Rothenberg, DMD
Dr. Michael Sonick is a full-time practicing
periodontist and implant surgeon in Fairfield,
Conn. He is on the editorial boards of many
journals and is co-editor of the textbook,
Implant Site Development.
He is currently a guest lecturer at New York
University School of Dentistry and is director
of Sonick Seminars, in Fairfield, Conn.
Fig. 14: Facial view six years
post-treatment.
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