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  3. 3. Presents Presents Dr. E. Barrie Kenney Professor & Chairman Section of Periodontics
  4. 4. E. Barrie Kenney B.D.Sc., D.D.S., M.S., F.R.A.C.D.S. Tarrson Family Endowed Chair in Periodontics. Professor and Chairman Division of Associated Clinical Specialties UCLA School of Dentistry ESTHETIC SURGICAL PROCEDURES FOR CROWN LENGTHENING
  5. 5. <ul><li>Gingivectomy </li></ul><ul><li>Flap surgery for osseous recontouring </li></ul><ul><li>Choice depends on </li></ul><ul><li>Gingival crevice depth </li></ul><ul><li>Need to maintain minimum of 1 mm connective tissue between depth of crevice and bone </li></ul><ul><li>Adequate width of Keratinized gingiva </li></ul>
  6. 6. <ul><li>Need minimum of one millimeter connective tissue coronal to bone margin </li></ul><ul><li>Gingival margin will be two millimeters coronal to this with 2 mm crevice depth. </li></ul><ul><li>Red line- Gingival margin.Pink area connective tissue. </li></ul><ul><li>Black line probe to depth of crevice. </li></ul>
  7. 7. 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 1mm.
  8. 8. <ul><li>Five millimeters of crevice depth with adequate band of Keratinized tissue </li></ul><ul><li>Gingivectomy can be used to increase crown length by up to 3 mm </li></ul>
  9. 9. <ul><li>Advantages of Gingivectomy </li></ul><ul><li>Precise control of gingival contours </li></ul><ul><li>Low risk of inadvertent necrosis of tissue during healing </li></ul><ul><li>Advantages of Flap Procedure </li></ul><ul><li>Wide range of suitable cases </li></ul>
  10. 10. <ul><li>Crevice depth of five millimeters will allow three millimeters of crown lengthening by Gingivectomy </li></ul><ul><li>If more than three millimeters needed use Flap Surgery </li></ul>
  11. 11. <ul><li>Gingivectomy Techniques </li></ul><ul><li>This patient requires 3 mm of crown lengthening </li></ul><ul><li>Sufficient crevice depth and Keratinized tissue </li></ul>
  12. 12. Gingivectomy completed with surgical scalpels and knives
  13. 13. Healing at three weeks
  14. 14. <ul><li>Crowns placed twelve weeks after Gingivectomy </li></ul><ul><li>Next slide Before and After </li></ul>
  15. 16. Gingivectomy to correct lack of symmetry and short crowns
  16. 17. <ul><li>Sufficient crevice depth and Keratinized gingiva </li></ul><ul><li>Frenum correction also needed </li></ul>
  17. 18. <ul><li>Scalpel used to establish 10 mm crown length on central incisor </li></ul><ul><li>Height of contour of gingiva is distalized </li></ul>
  18. 19. Kirkland Knife used to refine gingival contours by gentle scraping
  19. 20. <ul><li>Length of central incisor serves as basis for lateral incisor and cuspid </li></ul><ul><li>Lateral incisor gingival margin 1 mm coronal to central </li></ul><ul><li>Cuspid gingival margin at same level as central </li></ul>
  20. 21. The lateral incisor also has distalized gingival margin
  21. 22. Left central incisor gingival margin shaped for symmetry with right central
  22. 23. <ul><li>Gingivectomy completed with bilateral symmetry </li></ul><ul><li>Right central incisor edge will need shortening </li></ul>
  23. 24. Initial incision for Frenectomy
  24. 25. <ul><li>Removal of wedge of tissue from frenum </li></ul><ul><li>Interdental papilla is untouched </li></ul>
  25. 26. <ul><li>Incision made through periosteum to expose bone </li></ul><ul><li>This ensures no muscle pull exists to interdental papilla </li></ul>
  26. 27. Wound closed tightly with 5.0 gut sutures
  27. 28. <ul><li>Healing at twelve weeks </li></ul><ul><li>Next Slide Before and After </li></ul>
  28. 30. Crown Lengthening requires Flap Surgery and osseous correction
  29. 31. <ul><li>Initial Incisions </li></ul><ul><li>Central incisor and cuspid new gingival margins at same level </li></ul><ul><li>Sulcular incision used on lateral incisor to make it harmonious with central and cuspid </li></ul><ul><li>Interproximal incisions preserve papillae </li></ul>
  30. 32. <ul><li>Incisions on left symmetrical with right </li></ul><ul><li>Use new blade for each two teeth to minimize tissue trauma </li></ul>
  31. 33. <ul><li>Flap carefully dissected with sharp scalpels </li></ul><ul><li>3 mm of bone crest exposed </li></ul><ul><li>Bone recontouring needed to provide adequate connective tissue apical to crevice depth </li></ul>
  32. 34. Bone Margin has been moved apically of central incisor and cuspid
  33. 35. Flap sutured with apical positioning of gingival margins on central incisors and cuspids
  34. 36. <ul><li>Final Result at Twelve Weeks </li></ul><ul><li>Next Slide Before and After </li></ul>
  35. 38. Short clinical crowns with large gingival display on smiling
  36. 39. Insufficient gingival crevice depth for Gingivectomy
  37. 40. Premolars are included because of exposure with smiling
  38. 41. 15 c scalpel used to distalize gingival margin equally on central incisors
  39. 42. 12 B scalpel begins sharp dissection of full thickness flap with preservation of interdental papillae
  40. 43. Incised gingiva gently removed with sharp back action hoe
  41. 44. Flap elevated and bone recontoured
  42. 45. Flaps sutured with simple 5.0 gut interproximal sutures
  43. 46. Central incisors lengthening to 11 mm
  44. 47. Firm pressure applied to flap for 5 minutes
  45. 48. <ul><li>Healing at one week </li></ul><ul><li>No post surgical brushing or flossing </li></ul><ul><li>Chlorhexidine mouth washes three times per day </li></ul>
  46. 49. <ul><li>Healing at twelve weeks </li></ul><ul><li>Gingival margins now stable </li></ul><ul><li>Gentle brushing with soft brush and chlorhexidine from second week post operative </li></ul><ul><li>Gentle flossing after four weeks healing </li></ul><ul><li>Next slide Before and After </li></ul>
  47. 51. Short clinical crowns and excessive gingival display following orthodontic treatment
  48. 52. <ul><li>Level of Incisal edge is established </li></ul><ul><li>Central incisor and cuspid incisal edges at same level </li></ul><ul><li>Lateral incisal edge 1 mm apical to central incisor </li></ul><ul><li>Incisal plane parallels lower lip </li></ul>
  49. 53. Gingival crevice too shallow for Gingivectomy
  50. 54. New gingival margins established with incisions
  51. 55. Central incisor length at 10.50 mm
  52. 56. Flap elevated to expose bone margin
  53. 57. Bone recontoured to provide sufficient connective tissue for Biologic width
  54. 58. Flaps sutured in final position
  55. 59. <ul><li>Healing at twelve weeks </li></ul><ul><li>Next slide Before and After </li></ul>
  56. 61. Upper and lower incisors, cuspids, and premolars with asymmetry and small clinical crowns
  57. 62. Size of clinical crowns too short for facial dimensions and smile
  58. 63. Flap elevated to expose bone margins
  59. 64. <ul><li>Osseous recontouring to move bone margins apical </li></ul><ul><li>Long anatomical crowns on central incisors </li></ul>
  60. 65. Flaps sutured with apical position of gingival margins including premolars
  61. 66. <ul><li>Healing at twelve weeks </li></ul><ul><li>Cuspids elongated to give masculine emphasis </li></ul><ul><li>Next two slides Before and After </li></ul>
  62. 69. <ul><li>Altered passive eruption </li></ul><ul><li>Short asymmetrical clinical crowns </li></ul>
  63. 70. Healing at one week
  64. 71. <ul><li>Healing at 12 weeks </li></ul><ul><li>Next Slide Before and After </li></ul>
  65. 73. Gingival and tooth esthetics unacceptable to patient
  66. 74. Flaps and osseous recontouring completed
  67. 75. <ul><li>Final Restorations completed after 24 weeks of healing </li></ul><ul><li>Next Slide Before and After </li></ul>
  70. 89. <ul><li>Crown lengthening for esthetics and to provide sufficient root volume for crown retention </li></ul><ul><li>Need to establish incisal edge as baseline for gingival dimensions </li></ul>
  71. 90. Provisional acrylic template establishes final crown dimensions and incisal edge
  72. 91. Patient can view template and suggest any necessary changes
  73. 92. At time of Flap Surgery, gingival margins outline on tissues
  74. 93. Incisions made following template dimensions
  75. 94. Flaps elevated to expose bone margins
  76. 95. Bone recontoured to mirror final gingival margins
  77. 96. Position of new gingival margins confirmed with stent
  78. 97. Flap positioned with polytetraflurethylene sutures
  79. 98. Palatal view
  80. 99. <ul><li>Healing at 6 weeks </li></ul><ul><li>Lower incisors also treated </li></ul><ul><li>Next Slide Before and After </li></ul>
  81. 105. 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