This document discusses crown lengthening procedures. It describes different surgical techniques for crown lengthening including external bevel gingivectomy, internal bevel gingivectomy with or without ostectomy, and apically positioned flap techniques. It discusses factors to consider like the amount of bone removal needed, ideal flap design, and management of soft and hard tissues. Proper biologic width dimensions, flap suturing, and esthetic goals are important considerations for achieving good outcomes with crown lengthening surgery.
This document discusses the history and techniques of free gingival grafts (FGG), a periodontal plastic surgery procedure used to widen attached gingiva. It describes the classic FGG technique which involves preparing the recipient site, obtaining a partial-thickness graft from the palate donor site, suturing the graft into place, and protecting the donor site. Variant techniques like the accordion, strip, and combination methods are also outlined. The healing process of FGG grafts is explained, noting revascularization begins after 2-3 days and integration is largely complete by 10-17 days, though thicker grafts may take longer. FGG procedures aim to enhance plaque removal, improve tooth stability, and provide tissue
1. Osseous surgery involves modifying the alveolar bone support of teeth and includes techniques like osteoplasty and ostectomy. It aims to eliminate pockets and correct unphysiological bone architecture.
2. Factors in selecting a technique include the amount and location of bone loss, root trunk length, and anatomical limitations. Techniques range from non-resective procedures like osteoplasty to resective procedures like ostectomy.
3. Outcomes of osseous surgery generally include pocket elimination and establishment of physiological bone contours and architecture, though some bone loss from remodeling is expected in the range of 0.06mm to 1.2mm.
A 40-year-old female presented with an inability to eat properly due to a fractured crown. Upon examination, the remaining tooth structure was below the gumline and not accessible. The procedure involves adjusting the gum tissue and bone around the tooth to provide better access and ensure a proper restoration fit. Biologic width and ferrule effect must be considered to prevent inflammation, bone loss, and future issues. Complications can include an unaesthetic appearance, sensitivity, and loss of bone or papilla.
This document discusses the historical background and various methods of root biomodification, which involves chemically or mechanically modifying the root surface to promote periodontal regeneration. It describes how citric acid, tetracycline, fibronectin, and EDTA work to demineralize and detoxify the root surface in order to remove the smear layer and expose collagen fibers, making the surface more biocompatible and conducive to new attachment of periodontal tissues. Register and Burdick's 1975 technique using citric acid application for 2-3 minutes is outlined, along with modifications by Miller. The mechanisms and benefits of different agents are explained.
This document discusses different types of periodontal flaps used in periodontal surgery. It defines a periodontal flap as a section of gingiva and/or mucosa surgically separated from underlying tissues to provide access to bone and roots. It describes various classifications of flaps based on bone exposure, flap placement, papilla management, and indications for specific flap types like modified Widman flap and apically displaced flap. Distal molar surgery flaps like triangular and linear wedge designs are also summarized. The document provides detailed procedures and pre/post operative views for different flap techniques.
This document discusses crown lengthening procedures in the esthetic zone. It defines crown lengthening as a periodontal procedure that reshapes gingival and supporting tissues to expose more tooth structure. Indications include gingival asymmetries, excessive gingival display, and exposure of sound tooth structure for restorative needs. The document describes different types of crown lengthening procedures including gingivectomy and flap surgery with osseous resection. It emphasizes the importance of maintaining biologic width and provides case examples to illustrate crown lengthening treatments.
Crown lengthening therapy aims to expose more tooth structure for restorative or aesthetic purposes. A 2010 review summarizes key aspects of the procedure, including maintaining at least 3mm of biological width and 1.5mm of ferrule length for improved force distribution and reduced attachment loss. Soft and hard tissue management is also discussed. Osseous resection may take 3-6 months to establish biological width, so impressions and final preparations should wait at least 6 months to allow for stable tissue healing.
This document provides an overview of guided tissue regeneration (GTR). It begins with definitions of periodontal regeneration and GTR. It then discusses the history and development of GTR from the 1970s onwards. The core concept of GTR is explained, which is based on Melcher's hypothesis that only periodontal ligament cells can regenerate the periodontal attachment apparatus. Indications, contraindications, design criteria and objectives of GTR barriers are covered. The document classifies and compares advantages and disadvantages of absorbable versus non-absorbable membranes. Key factors affecting GTR outcomes are discussed. Surgical techniques and the healing of GTR-treated defects are described. The document concludes with additional considerations like complications and the
This document discusses the history and techniques of free gingival grafts (FGG), a periodontal plastic surgery procedure used to widen attached gingiva. It describes the classic FGG technique which involves preparing the recipient site, obtaining a partial-thickness graft from the palate donor site, suturing the graft into place, and protecting the donor site. Variant techniques like the accordion, strip, and combination methods are also outlined. The healing process of FGG grafts is explained, noting revascularization begins after 2-3 days and integration is largely complete by 10-17 days, though thicker grafts may take longer. FGG procedures aim to enhance plaque removal, improve tooth stability, and provide tissue
1. Osseous surgery involves modifying the alveolar bone support of teeth and includes techniques like osteoplasty and ostectomy. It aims to eliminate pockets and correct unphysiological bone architecture.
2. Factors in selecting a technique include the amount and location of bone loss, root trunk length, and anatomical limitations. Techniques range from non-resective procedures like osteoplasty to resective procedures like ostectomy.
3. Outcomes of osseous surgery generally include pocket elimination and establishment of physiological bone contours and architecture, though some bone loss from remodeling is expected in the range of 0.06mm to 1.2mm.
A 40-year-old female presented with an inability to eat properly due to a fractured crown. Upon examination, the remaining tooth structure was below the gumline and not accessible. The procedure involves adjusting the gum tissue and bone around the tooth to provide better access and ensure a proper restoration fit. Biologic width and ferrule effect must be considered to prevent inflammation, bone loss, and future issues. Complications can include an unaesthetic appearance, sensitivity, and loss of bone or papilla.
This document discusses the historical background and various methods of root biomodification, which involves chemically or mechanically modifying the root surface to promote periodontal regeneration. It describes how citric acid, tetracycline, fibronectin, and EDTA work to demineralize and detoxify the root surface in order to remove the smear layer and expose collagen fibers, making the surface more biocompatible and conducive to new attachment of periodontal tissues. Register and Burdick's 1975 technique using citric acid application for 2-3 minutes is outlined, along with modifications by Miller. The mechanisms and benefits of different agents are explained.
This document discusses different types of periodontal flaps used in periodontal surgery. It defines a periodontal flap as a section of gingiva and/or mucosa surgically separated from underlying tissues to provide access to bone and roots. It describes various classifications of flaps based on bone exposure, flap placement, papilla management, and indications for specific flap types like modified Widman flap and apically displaced flap. Distal molar surgery flaps like triangular and linear wedge designs are also summarized. The document provides detailed procedures and pre/post operative views for different flap techniques.
This document discusses crown lengthening procedures in the esthetic zone. It defines crown lengthening as a periodontal procedure that reshapes gingival and supporting tissues to expose more tooth structure. Indications include gingival asymmetries, excessive gingival display, and exposure of sound tooth structure for restorative needs. The document describes different types of crown lengthening procedures including gingivectomy and flap surgery with osseous resection. It emphasizes the importance of maintaining biologic width and provides case examples to illustrate crown lengthening treatments.
Crown lengthening therapy aims to expose more tooth structure for restorative or aesthetic purposes. A 2010 review summarizes key aspects of the procedure, including maintaining at least 3mm of biological width and 1.5mm of ferrule length for improved force distribution and reduced attachment loss. Soft and hard tissue management is also discussed. Osseous resection may take 3-6 months to establish biological width, so impressions and final preparations should wait at least 6 months to allow for stable tissue healing.
This document provides an overview of guided tissue regeneration (GTR). It begins with definitions of periodontal regeneration and GTR. It then discusses the history and development of GTR from the 1970s onwards. The core concept of GTR is explained, which is based on Melcher's hypothesis that only periodontal ligament cells can regenerate the periodontal attachment apparatus. Indications, contraindications, design criteria and objectives of GTR barriers are covered. The document classifies and compares advantages and disadvantages of absorbable versus non-absorbable membranes. Key factors affecting GTR outcomes are discussed. Surgical techniques and the healing of GTR-treated defects are described. The document concludes with additional considerations like complications and the
Periodontitis is a complex infection initiated by bacteria –tissue destruction.
Host: the organism from which a parasite obtains its nourishment/ an individual who receives a graft
Modulation: the alteration of function or status of something in response to a stimulus or an altered physical or chemical environment
Guided tissue regeneration (GTR) involves placing barriers over defects to separate gingival tissues and allow regeneration of periodontal ligament and bone. Animal and human studies show that excluding epithelium and allowing repopulation of defects by periodontal ligament cells leads to new attachment. Both resorbable and non-resorbable membrane barriers have been used for GTR with the goal of preventing epithelial migration and promoting regeneration. GTR has been shown to be predictable for treating intra-bony defects and grade II furcations.
Vestibuloplasty is a surgical procedure to deepen the oral vestibule by changing the attachments of the soft tissue. There are several types of vestibuloplasty procedures, including mucosal advancement, secondary epithelization, and grafting. Mucosal advancement involves undermining and advancing the oral mucosa, while secondary epithelization uses the oral mucosa to line one side and allows the other side to heal through epithelization. Grafting can use skin, mucosa, or dermis grafts to line the extended vestibule. The document discusses techniques for each type of vestibuloplasty procedure.
This document discusses crown lengthening procedures and biological width. It defines biological width as the natural distance between the base of the gingival sulcus and alveolar bone, which is typically 2mm. Crown lengthening surgically exposes more tooth structure above the bone to avoid violating the biological width and prevent inflammation. The document outlines different types of crown lengthening procedures based on the available soft and hard tissue dimensions, as well as factors to consider like gingival biotype and restoration design. Maintaining at least 3mm of tooth structure above bone is recommended to allow for proper restorative margins and healing.
It restore alveolar bone to the level existing at the time of surgery or slightly more apical to this level. Aim is to achieve positive bony architecture.
STEPS INCLUDE:
1.VERTICAL GROOVING
2. RADICULAR BLENDING
3. FLATTENING INTERPROXIMAL BONE
4. GRADUALIZING MARGINAL BONE
PREFERRED TREATMENT FOR ONE WALLED PERIODONTAL BONE DEFECTS (HEMISEPTUM)
Indirect Sinus Lift
A sinus lift procedure is essentially done to increase bone height and density in the posterior maxilla.
Extremely effective in increasing bone height. for more details visit our website https://www.implantdentistindia.com/i...
Direct Sinus Lift
The direct sinus lift or the lateral window sinus elevation is a widely used technique when resorption of the alveolar bone which leads to insufficient bone height (No bone to place implant). for more details please visit https://www.implantdentistindia.com/d...
We will assure you of the best treatment in this area.
Experienced Implantologist -Dr. Sudhakar Reddy, a Maxillofacial surgeon by specialization has vast experience with such a surgical procedures and can make this surgery very simple.
Book an appointment now
Surgical gingivectomy involves removing the pocket wall and smoothing root surfaces to eliminate suprabony pockets and provide access for calculus removal. This creates a favorable environment for gingival healing and restoration of a healthy contour. Indications include deep pockets where bone defects cannot be corrected or aesthetic concerns. Contraindications include pockets below the mucogingival junction. The procedure involves exploring each pocket with a probe, removing the pocket wall and granulation tissue, then covering with a surgical pack. Healing occurs over 1-2 months as granulation tissue forms and epithelium migrates over it.
This document discusses various root coverage procedures for treating gingival recession. It begins by defining gingival recession and classifying types. Nonsurgical treatments including monitoring, desensitizing agents, and restorations are outlined. Surgical options such as laterally positioned flaps, double papilla flaps, coronally positioned flaps, free gingival grafts, and subepithelial connective tissue grafts are described in detail. Factors in selecting a procedure and modifications to techniques are also summarized. The document concludes that careful case selection and surgical management are key to achieving successful root coverage outcomes.
The document discusses Minimally Invasive Surgical Techniques (MIST) in periodontal surgery. It provides an overview of the history and rationale for MIPS, describing key features such as smaller incisions, limited flap elevation using sharp dissection only, use of microscopes and microinstruments, and microsuturing techniques. MIPS has advantages like reduced trauma, improved wound stability and closure, and less post-operative discomfort. The document reviews studies supporting the efficacy and effectiveness of MIPS and recent developments in the approach, including use of a videoscope and potential future applications of robot-assisted surgery.
Gingivectomy and gingivoplasty are procedures to remove gum tissue and reshape the gum line. Gingivectomy removes gum tissue from deep pockets, while gingivoplasty contours gum tissue without eliminating pockets. The document outlines the indications, contraindications, techniques, and healing process for gingivectomy. Surgical gingivectomy uses knives and curettes to remove gum tissue in pockets and reshape the gum line. Healing occurs through granulation tissue formation and re-epithelialization over 1-2 weeks. Other techniques include electrosurgery, laser gingivectomy, and chemo surgery.
Biologic width - Importance in Periodontal and Restorative DentistryDr.Shraddha Kode
The document discusses the biologic width, which refers to the dimensions of the soft tissue attached to the tooth coronal to the alveolar bone crest. It consists of the junctional epithelium, connective tissue attachment, and the sulcular depth, totaling approximately 2-3 mm. Violation of the biologic width by placing restorative margins too far subgingivally can lead to bone resorption, gingival recession, or hyperplasia. The document outlines techniques for assessing biologic width dimensions and various surgical or orthodontic procedures to correct violations. Maintaining at least 3 mm of distance from the restorative margin to alveolar bone is important for periodontal health.
This document discusses periodontal regeneration and the various factors involved. It begins by defining key terminology related to grafting and regeneration. It then discusses the biology and objectives of periodontal regeneration, including the ideal outcome of new attachment formation and factors that can influence outcomes. The document outlines various techniques for periodontal regeneration including non-graft associated approaches involving removal of epithelium and surgical techniques, as well as graft-associated approaches using various graft materials. Requirements for predictable regeneration and assessment methods are also summarized.
Gingivectomy is the surgical excision of gingiva to remove diseased pocket walls and expose tooth surfaces. It is indicated for conditions like suprabonny pockets, fibrous enlargement, and crown lengthening. There are several types of gingivectomy including surgical, chemosurgery, electrosurgery, cryosurgery, and laser gingivectomy. The surgical procedure involves marking pockets, making internal beveled incisions, removing diseased tissue and calculus, and placing a periodontal pack. Post-operative healing occurs through clot formation, granulation tissue growth, and epithelialization over 2-3 weeks.
Lasers and its application in periodonticsShilpa Shiv
The document discusses different types of lasers used in periodontology, including their properties, mechanisms of interaction with tissue, safety classifications, and clinical applications. It provides details on lasers such as the argon, diode, Nd:YAG, Er:YAG, and CO2 lasers, covering their wavelengths, active mediums, delivery systems, absorption characteristics, and periodontal uses. The document also examines laser tissue interactions, safety considerations, and the theoretical zones of tissue change caused by laser exposure.
This document summarizes the process of using free gingival grafts for root coverage. Free gingival grafts are soft tissue grafts that are disconnected from their blood supply when harvested. For survival, they rely on nutrients from the graft bed. To promote survival over avascular root surfaces, the graft bed is extended in size and the graft is made thick to provide capillary channels to transport nutrients to the center. Case examples show grafts harvested from the palate and sutured over denuded root surfaces, with subsequent healing resulting in root coverage and attachment.
The modified Widman flap is a periodontal surgical technique used to obtain access to the root surface and allow for intimate postoperative adaptation of healthy connective tissue and epithelium to the root surface. Key aspects include:
1. Incisions are made internally and intracrevicularly to minimize tissue loss and gingival shrinkage. Vertical releasing incisions are usually not used.
2. The goal is access for root debridement rather than pocket elimination. Minimal flap elevation of 1-2mm is done to access root surfaces.
3. It is indicated for mild to moderate periodontitis with pocket depths up to 6mm and minimal inflammation. Primary intention healing occurs.
- The document discusses bone harvesting techniques for various donor sites including the chin, mandibular ramus, maxillary tuberosity, and intraoral vs extraoral sites. Key details are provided on indications, anatomy, harvesting procedure, complications, and principles of autogenous bone graft healing for each donor site. Autogenous grafts are considered the gold standard due to their osteogenic, osteoinductive and osteconductive properties.
This document provides an overview of endodontic surgery. It begins with a brief history of endodontic surgery dating back over 1500 years. It then discusses the definition, rationale, objectives, and indications for endodontic surgery. The document outlines the classification of endodontic surgery and describes various surgical procedures like periradicular surgery, root-end resection, and root-end filling. It provides details on surgical instruments, treatment planning considerations, and techniques for achieving profound local anesthesia. In summary, the document provides a comprehensive review of the principles and procedures involved in endodontic surgery.
Split ridge and expansion techniques are effective for the correction of moderately resorbed edentulous ridges in selected cases.
Transverse expansion is based on osseous plasticity obtained by corticotomy. It progressively allows for an adequate transversal intercortical diameter large enough to insert one or several dental implants.
The gap created by sagittal osteotomy expansion undergoes spontaneous ossification, following a mechanism similar to that occurring in fractures.
Periodontitis is a complex infection initiated by bacteria –tissue destruction.
Host: the organism from which a parasite obtains its nourishment/ an individual who receives a graft
Modulation: the alteration of function or status of something in response to a stimulus or an altered physical or chemical environment
Guided tissue regeneration (GTR) involves placing barriers over defects to separate gingival tissues and allow regeneration of periodontal ligament and bone. Animal and human studies show that excluding epithelium and allowing repopulation of defects by periodontal ligament cells leads to new attachment. Both resorbable and non-resorbable membrane barriers have been used for GTR with the goal of preventing epithelial migration and promoting regeneration. GTR has been shown to be predictable for treating intra-bony defects and grade II furcations.
Vestibuloplasty is a surgical procedure to deepen the oral vestibule by changing the attachments of the soft tissue. There are several types of vestibuloplasty procedures, including mucosal advancement, secondary epithelization, and grafting. Mucosal advancement involves undermining and advancing the oral mucosa, while secondary epithelization uses the oral mucosa to line one side and allows the other side to heal through epithelization. Grafting can use skin, mucosa, or dermis grafts to line the extended vestibule. The document discusses techniques for each type of vestibuloplasty procedure.
This document discusses crown lengthening procedures and biological width. It defines biological width as the natural distance between the base of the gingival sulcus and alveolar bone, which is typically 2mm. Crown lengthening surgically exposes more tooth structure above the bone to avoid violating the biological width and prevent inflammation. The document outlines different types of crown lengthening procedures based on the available soft and hard tissue dimensions, as well as factors to consider like gingival biotype and restoration design. Maintaining at least 3mm of tooth structure above bone is recommended to allow for proper restorative margins and healing.
It restore alveolar bone to the level existing at the time of surgery or slightly more apical to this level. Aim is to achieve positive bony architecture.
STEPS INCLUDE:
1.VERTICAL GROOVING
2. RADICULAR BLENDING
3. FLATTENING INTERPROXIMAL BONE
4. GRADUALIZING MARGINAL BONE
PREFERRED TREATMENT FOR ONE WALLED PERIODONTAL BONE DEFECTS (HEMISEPTUM)
Indirect Sinus Lift
A sinus lift procedure is essentially done to increase bone height and density in the posterior maxilla.
Extremely effective in increasing bone height. for more details visit our website https://www.implantdentistindia.com/i...
Direct Sinus Lift
The direct sinus lift or the lateral window sinus elevation is a widely used technique when resorption of the alveolar bone which leads to insufficient bone height (No bone to place implant). for more details please visit https://www.implantdentistindia.com/d...
We will assure you of the best treatment in this area.
Experienced Implantologist -Dr. Sudhakar Reddy, a Maxillofacial surgeon by specialization has vast experience with such a surgical procedures and can make this surgery very simple.
Book an appointment now
Surgical gingivectomy involves removing the pocket wall and smoothing root surfaces to eliminate suprabony pockets and provide access for calculus removal. This creates a favorable environment for gingival healing and restoration of a healthy contour. Indications include deep pockets where bone defects cannot be corrected or aesthetic concerns. Contraindications include pockets below the mucogingival junction. The procedure involves exploring each pocket with a probe, removing the pocket wall and granulation tissue, then covering with a surgical pack. Healing occurs over 1-2 months as granulation tissue forms and epithelium migrates over it.
This document discusses various root coverage procedures for treating gingival recession. It begins by defining gingival recession and classifying types. Nonsurgical treatments including monitoring, desensitizing agents, and restorations are outlined. Surgical options such as laterally positioned flaps, double papilla flaps, coronally positioned flaps, free gingival grafts, and subepithelial connective tissue grafts are described in detail. Factors in selecting a procedure and modifications to techniques are also summarized. The document concludes that careful case selection and surgical management are key to achieving successful root coverage outcomes.
The document discusses Minimally Invasive Surgical Techniques (MIST) in periodontal surgery. It provides an overview of the history and rationale for MIPS, describing key features such as smaller incisions, limited flap elevation using sharp dissection only, use of microscopes and microinstruments, and microsuturing techniques. MIPS has advantages like reduced trauma, improved wound stability and closure, and less post-operative discomfort. The document reviews studies supporting the efficacy and effectiveness of MIPS and recent developments in the approach, including use of a videoscope and potential future applications of robot-assisted surgery.
Gingivectomy and gingivoplasty are procedures to remove gum tissue and reshape the gum line. Gingivectomy removes gum tissue from deep pockets, while gingivoplasty contours gum tissue without eliminating pockets. The document outlines the indications, contraindications, techniques, and healing process for gingivectomy. Surgical gingivectomy uses knives and curettes to remove gum tissue in pockets and reshape the gum line. Healing occurs through granulation tissue formation and re-epithelialization over 1-2 weeks. Other techniques include electrosurgery, laser gingivectomy, and chemo surgery.
Biologic width - Importance in Periodontal and Restorative DentistryDr.Shraddha Kode
The document discusses the biologic width, which refers to the dimensions of the soft tissue attached to the tooth coronal to the alveolar bone crest. It consists of the junctional epithelium, connective tissue attachment, and the sulcular depth, totaling approximately 2-3 mm. Violation of the biologic width by placing restorative margins too far subgingivally can lead to bone resorption, gingival recession, or hyperplasia. The document outlines techniques for assessing biologic width dimensions and various surgical or orthodontic procedures to correct violations. Maintaining at least 3 mm of distance from the restorative margin to alveolar bone is important for periodontal health.
This document discusses periodontal regeneration and the various factors involved. It begins by defining key terminology related to grafting and regeneration. It then discusses the biology and objectives of periodontal regeneration, including the ideal outcome of new attachment formation and factors that can influence outcomes. The document outlines various techniques for periodontal regeneration including non-graft associated approaches involving removal of epithelium and surgical techniques, as well as graft-associated approaches using various graft materials. Requirements for predictable regeneration and assessment methods are also summarized.
Gingivectomy is the surgical excision of gingiva to remove diseased pocket walls and expose tooth surfaces. It is indicated for conditions like suprabonny pockets, fibrous enlargement, and crown lengthening. There are several types of gingivectomy including surgical, chemosurgery, electrosurgery, cryosurgery, and laser gingivectomy. The surgical procedure involves marking pockets, making internal beveled incisions, removing diseased tissue and calculus, and placing a periodontal pack. Post-operative healing occurs through clot formation, granulation tissue growth, and epithelialization over 2-3 weeks.
Lasers and its application in periodonticsShilpa Shiv
The document discusses different types of lasers used in periodontology, including their properties, mechanisms of interaction with tissue, safety classifications, and clinical applications. It provides details on lasers such as the argon, diode, Nd:YAG, Er:YAG, and CO2 lasers, covering their wavelengths, active mediums, delivery systems, absorption characteristics, and periodontal uses. The document also examines laser tissue interactions, safety considerations, and the theoretical zones of tissue change caused by laser exposure.
This document summarizes the process of using free gingival grafts for root coverage. Free gingival grafts are soft tissue grafts that are disconnected from their blood supply when harvested. For survival, they rely on nutrients from the graft bed. To promote survival over avascular root surfaces, the graft bed is extended in size and the graft is made thick to provide capillary channels to transport nutrients to the center. Case examples show grafts harvested from the palate and sutured over denuded root surfaces, with subsequent healing resulting in root coverage and attachment.
The modified Widman flap is a periodontal surgical technique used to obtain access to the root surface and allow for intimate postoperative adaptation of healthy connective tissue and epithelium to the root surface. Key aspects include:
1. Incisions are made internally and intracrevicularly to minimize tissue loss and gingival shrinkage. Vertical releasing incisions are usually not used.
2. The goal is access for root debridement rather than pocket elimination. Minimal flap elevation of 1-2mm is done to access root surfaces.
3. It is indicated for mild to moderate periodontitis with pocket depths up to 6mm and minimal inflammation. Primary intention healing occurs.
- The document discusses bone harvesting techniques for various donor sites including the chin, mandibular ramus, maxillary tuberosity, and intraoral vs extraoral sites. Key details are provided on indications, anatomy, harvesting procedure, complications, and principles of autogenous bone graft healing for each donor site. Autogenous grafts are considered the gold standard due to their osteogenic, osteoinductive and osteconductive properties.
This document provides an overview of endodontic surgery. It begins with a brief history of endodontic surgery dating back over 1500 years. It then discusses the definition, rationale, objectives, and indications for endodontic surgery. The document outlines the classification of endodontic surgery and describes various surgical procedures like periradicular surgery, root-end resection, and root-end filling. It provides details on surgical instruments, treatment planning considerations, and techniques for achieving profound local anesthesia. In summary, the document provides a comprehensive review of the principles and procedures involved in endodontic surgery.
Split ridge and expansion techniques are effective for the correction of moderately resorbed edentulous ridges in selected cases.
Transverse expansion is based on osseous plasticity obtained by corticotomy. It progressively allows for an adequate transversal intercortical diameter large enough to insert one or several dental implants.
The gap created by sagittal osteotomy expansion undergoes spontaneous ossification, following a mechanism similar to that occurring in fractures.
This case series evaluated a protocol for selecting the implant diameter during immediate implant placement in fresh extraction sockets. 20 patients received immediate implants in the maxillary anterior region. Implant diameter was selected based on preoperative CBCT measurements to maintain a 3mm gap between the implant and buccal bone wall. Autogenous bone graft was used to fill the gap. Postoperative CBCTs found no significant changes in socket dimensions and minimal buccal bone resorption up to a mean follow up of 35 months, indicating the protocol helped preserve buccal bone stability.
The biological width is defined as the dimension of soft tissue attached to the tooth coronal to the alveolar bone crest, including the sulcus depth, epithelial attachment, and connective tissue attachment. It typically measures around 2.04 mm. Violation of the biological width can occur when restorations are placed too far subgingivally and can lead to inflammation and bone loss. Surgical crown lengthening and orthodontic extrusion are techniques used to correct biological width violations. Maintaining the biological width is important for peri-implant health as well.
JOURNAL CLUB ON THE OUTCOME OF ORAL IMPLANTS PLACED IN BONE WITH LIMITED BU...Shilpa Shiv
This document summarizes a study that evaluated the outcomes of oral implants placed in bone with limited bucco-oral dimensions over a 3-year period. 100 implants were placed in 28 patients. The study found that the implants had a 100% survival rate over 3 years and that the marginal bone levels around the implants remained stable. The results indicate that implants can successfully be placed in sites with up to 4.5mm of bucco-oral bone width without the need for bone grafting, providing patients maintain good oral hygiene.
The document discusses pre-prosthetic surgery, which aims to modify the oral environment to better support prosthetic appliances. The goals are to provide a broad, flat ridge with height and a firm mucosal covering. Objectives include eliminating disease, conserving structures, and providing support to withstand forces. The document describes various basic surgical procedures like alveoloplasty, tori removal, and soft tissue procedures to reshape ridges and remove excess tissue in preparation for dentures.
This document discusses various biological considerations related to dental restorations and periodontal health. It covers topics such as biologic width, margin placement, overhangs, and correcting biologic width violations. Key points include that supragingival margins have the least impact on the periodontium, biologic width violations can lead to inflammation and bone loss, and overhangs increase plaque and pathogens if placed subgingivally. The document provides guidelines for proper margin placement based on sulcular depth to avoid future recession. It also discusses procedures for tissue retraction and electrosurgery when placing subgingival margins.
This presentation of mine is a brief overview of surgical management of root canal treatment failure . The non surgical approach is already explained in other presentation.
The biological width refers to the dimensions of the junctional epithelium and connective tissue attachment above the alveolar crest, which averages 2.04mm. Placement of restoration margins within 1mm of the gingival sulcus is ideal to preserve this biological width, while subgingival placement can lead to inflammation, recession, or bone loss by violating the biological width. When a violation occurs, it can be corrected by surgery to remove bone away from the margin by the ideal biological width distance, or by orthodontic extrusion. Maintaining the biological width is essential for periodontal health.
mucogingival surgery or plastic surgery of muco-gingival tissue is a surgical procedure targeted to correct and eliminate anatomic, developmental and traumatic alterations of gingiva.
Periodontally Accelerated Osteogenic Orthodontics with Piezoelectric Surgery...Abu-Hussein Muhamad
Piezosurgery has been applied in dentistry for many years. This paper reviews specifically the treatment applications that have been used in surgically assisted orthodontic treatment since the last decade. Periodontally Accelerated Osteogenic Orthodontics (PAOO) is a surgical technique which results in an increase in alveolar bone width, shorter treatment time, increase post-treatment stability, and decrease amount of apical root resorption. The aim of this case report is to compare the use of micro-motor and piezoelectric surgery unit during decortication in Periodontally Accelerated Osteogenic Orthodontics technique.
Key words: Piezoelectric surgery, piezosurgery, Periodontal regeneration , accelerated tooth movement
Prosthesis is one of the most important component of an implant. There are various prosthetic factors that must be considered for a successful implant. Few of them include prosthesis type and material, the connection between abutment and prosthesis, occlusal factors, etc.
REFERENCES TAKEN FROM CARRANZA'S TEXTBOOK OF CLINICAL PERIODONTOLOGY AND LINDHE'S TEXTBOOK OF CLINICAL PERIODONTOLOGY AND IMPLANT DENTISTRY. CONTAINS ENOUGH AND MORE DETAILS OF THIS TOPIC FOR BDS STUDENTS.HOPE THIS PRESENTATION WILL HELP U GAIN SOME KNOWLEDGE ABOUT PERIODONTAL PLASTIC AND ESTHETIC DENTISTRY.
This document discusses periodontal plastic surgery techniques. It begins by defining periodontal plastic surgery and outlining its goals of correcting anatomical deformities, increasing attached gingiva, and deepening shallow vestibules. It then describes various techniques for widening attached gingiva including free gingival grafts, free connective tissue grafts, and apically positioned flaps. Criteria for selecting mucogingival techniques include ensuring the surgical site is plaque-free and has adequate blood supply. The objectives of periodontal plastic surgery are to address problems associated with lack of attached gingiva and shallow vestibules. Key techniques are described for augmenting gingiva both apical and coronal to a ging
Periodontal plastic surgery is defined as the surgical procedures performed to correct deformities of the gingiva or alveolar mucosa. It includes widening of attached gingiva,
deepening of shallow vestibules, resection of the aberrant frena, depigmentation of gingiva.In all of these procedures, blood supply is the most significant concern and must be the underlying issue for all decisions regarding the individual surgical procedure.
This document discusses secondary pre-prosthetic surgical procedures. It describes ideal ridge form for denture wearing and secondary procedures to modify ridges through augmentation or altering relationships. Ridge augmentation aims to recreate ridges compatible with dentures through autografts, homografts, or alloplastic materials. Ridge relationship procedures correct arch discrepancies through maxillary advancement or mandibular advancement surgeries. Secondary soft tissue procedures further modify ridges after hard tissue alterations.
This document provides an overview of dental implants, including:
- Dental implants are artificial tooth roots placed in the jaw to hold replacement teeth. There are three main types: endosseous, subperiosteal, and transosteal implants.
- Implants are typically made of titanium and fuse with the jawbone through osseointegration. Placement involves raising soft tissue flaps, drilling pilot holes, widening the holes, placing the implant, and adapting the soft tissue around it.
- Risks include injury to nearby structures during surgery and post-operative infection or bleeding. Success rates depend on patient health and bone quality. With proper planning and placement, implants can successfully replace missing
Similar to Crown lengthening and restorative procedures in the esthetic zone (20)
8 Surprising Reasons To Meditate 40 Minutes A Day That Can Change Your Life.pptxHolistified Wellness
We’re talking about Vedic Meditation, a form of meditation that has been around for at least 5,000 years. Back then, the people who lived in the Indus Valley, now known as India and Pakistan, practised meditation as a fundamental part of daily life. This knowledge that has given us yoga and Ayurveda, was known as Veda, hence the name Vedic. And though there are some written records, the practice has been passed down verbally from generation to generation.
Cell Therapy Expansion and Challenges in Autoimmune DiseaseHealth Advances
There is increasing confidence that cell therapies will soon play a role in the treatment of autoimmune disorders, but the extent of this impact remains to be seen. Early readouts on autologous CAR-Ts in lupus are encouraging, but manufacturing and cost limitations are likely to restrict access to highly refractory patients. Allogeneic CAR-Ts have the potential to broaden access to earlier lines of treatment due to their inherent cost benefits, however they will need to demonstrate comparable or improved efficacy to established modalities.
In addition to infrastructure and capacity constraints, CAR-Ts face a very different risk-benefit dynamic in autoimmune compared to oncology, highlighting the need for tolerable therapies with low adverse event risk. CAR-NK and Treg-based therapies are also being developed in certain autoimmune disorders and may demonstrate favorable safety profiles. Several novel non-cell therapies such as bispecific antibodies, nanobodies, and RNAi drugs, may also offer future alternative competitive solutions with variable value propositions.
Widespread adoption of cell therapies will not only require strong efficacy and safety data, but also adapted pricing and access strategies. At oncology-based price points, CAR-Ts are unlikely to achieve broad market access in autoimmune disorders, with eligible patient populations that are potentially orders of magnitude greater than the number of currently addressable cancer patients. Developers have made strides towards reducing cell therapy COGS while improving manufacturing efficiency, but payors will inevitably restrict access until more sustainable pricing is achieved.
Despite these headwinds, industry leaders and investors remain confident that cell therapies are poised to address significant unmet need in patients suffering from autoimmune disorders. However, the extent of this impact on the treatment landscape remains to be seen, as the industry rapidly approaches an inflection point.
share - Lions, tigers, AI and health misinformation, oh my!.pptxTina Purnat
• Pitfalls and pivots needed to use AI effectively in public health
• Evidence-based strategies to address health misinformation effectively
• Building trust with communities online and offline
• Equipping health professionals to address questions, concerns and health misinformation
• Assessing risk and mitigating harm from adverse health narratives in communities, health workforce and health system
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Osteoporosis - Definition , Evaluation and Management .pdfJim Jacob Roy
Osteoporosis is an increasing cause of morbidity among the elderly.
In this document , a brief outline of osteoporosis is given , including the risk factors of osteoporosis fractures , the indications for testing bone mineral density and the management of osteoporosis
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
Histololgy of Female Reproductive System.pptxAyeshaZaid1
Dive into an in-depth exploration of the histological structure of female reproductive system with this comprehensive lecture. Presented by Dr. Ayesha Irfan, Assistant Professor of Anatomy, this presentation covers the Gross anatomy and functional histology of the female reproductive organs. Ideal for students, educators, and anyone interested in medical science, this lecture provides clear explanations, detailed diagrams, and valuable insights into female reproductive system. Enhance your knowledge and understanding of this essential aspect of human biology.
Here is the updated list of Top Best Ayurvedic medicine for Gas and Indigestion and those are Gas-O-Go Syp for Dyspepsia | Lavizyme Syrup for Acidity | Yumzyme Hepatoprotective Capsules etc
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Basavarajeeyam is a Sreshta Sangraha grantha (Compiled book ), written by Neelkanta kotturu Basavaraja Virachita. It contains 25 Prakaranas, First 24 Chapters related to Rogas& 25th to Rasadravyas.
Crown lengthening and restorative procedures in the esthetic zone
1. In the name of God
By Seyedeh Marzieh Hashemi Nejad
2.
3. Crown lengthening is one of the most common surgical procedures in
periodontal practice. A recent American Academy of Periodontology
survey reported that approximately 10% of all periodontal surgical
procedures are performed in order to achieve gain in crown length (1).
The main indications of crown-lengthening surgical procedure include
treatment of subgingival caries, crown or root fractures, altered passive
eruption, cervical root resorption and short clinical abutment. The
rationale of crown lengthening is to reestablish the biologic width (e.g.
the natural distance between the base of the gingival sulcus and the
height of the alveolar bone) in a more apical position to avoid a violation
that may result in bone resorption, gingival recession, inflammation or
hypertrophy.
4. The concept of biologic width stems from the classic
histologic study by Gargiulo et al. (13), who measured
the average dimension of the epithelial junction (0.97
mm) and connective tissue attachment (1.07 mm) in
humans. These values were summed to provide the
biologic width, yielding an average dimension of 2.04
mm. A recent systematic review (22) found similar
mean values of biologic width (2.15–2.30 mm),
although considerable intra- and interindividual
variances were reported (subject sample range: 0.20–
6.73 mm).
5. The integrity of the biologic width is considered a necessary step, in
restorative and prosthetic rehabilitations, to obtain and maintain
healthy soft tissues. While crown-lengthening procedures in
posterior areas have been investigated in detail, crown lengthening
performed for esthetic reasons in anterior areas is still a matter of
debate.
A literature search on PubMed for ‘esthetic crown lengthening’
returned a list of 250 articles. Among these articles, there are no
systematic reviews and only a few controlled clinical trials (3, 5, 14,
16, 20).
Moreover, anterior crown lengthening is often described as part of a
multidisciplinary orthodontic and restorative treatment plan. For
these reasons, although a number of surgical procedures are
described, an evidence-based technique is not available and many
questions still remain unanswered.
6. The purpose of this paper is to focus on the description
of the surgical and restorative phases in the esthetic
crown-lengthening procedure by answering the
following questions:
what is the ideal surgical flap design?
how much supporting bone should be removed?
how should the position of the flap margin relate to
the alveolar bone at surgical closure?
and how should the healing phase be managed in
relation to the timing and the position of the
provisional restoration with respect to the gingival
margin?
8. Flap design (vestibular aspect)
The flap is designed by creating submarginal parabolic
incisions, starting from the angular lines of the adjacent
teeth and crossing at the level of the interdental papillae,
thereby reproducing the natural scalloping of a patient’s
gingival margin. Correct placement of the primary incision
is based on the probing depth and on the amount of
keratinized tissue available (4, 7).
In a patient with an ‘adequate’ dimension of keratinized
tissue, the distance of the primary incision from the gingival
margin is proportional to the differences in probing depth of
the adjacent teeth (6). If the amount of keratinized tissue is
‘inadequate’, the primary incision should be intrasulcular.
9. it is recommended that there be at least
3.0 mm between the gingival margin and
bone crest
In the case of caries or tooth fracture, to
ensure margin placement on sound tooth
structure and retention form, the surgery
should provide at least 4 mm from the
apical extent of the caries or fracture to
the bone crest
10. Treatment Options For Crown Lengthening Procedures
1) Surgical
A) Gingivectomy
Conventional ( Scalpel or Kirkland knife)
Laser
Electrocautery
B) Internal Bevel Gingivectomy with or without ostectomy (also referred as flap surgery with
or without osseous surgery)
C) Apical positioning of flap with or without ostectomy
2) Combined (SURGICAL & NON SURGICAL) - Orthodontic Treatment
Crown Lengthening Procedures- A Review
Article
11. Clinical Procedures in Margin Placement
The first step in using sulcus depth as a guide in margin placement is to manage
gingival health. Once the tissue is healthy, the following three rules can be used to
place intracrevicular margins:
Rule 1: If the sulcus probes 1.5 mm or less, place the restorationmargin 0.5 mm below
the gingival tissue crest. This is especially important on the facial aspect and will
prevent a biologic width violation in a patient who is at high risk in that regard.
Rule 2: If the sulcus probes more than 1.5 mm, place the margin half the depth of the
sulcus below the tissue crest. This places the margin far enough below tissue, so that it
will still be covered if the patient is at higher risk of recession.
Rule 3: If a sulcus greater than 2 mm is found, especially on the facial aspect of the
tooth, evaluate to see if a gingivectomy could be performed to lengthen the teeth
and create a 1.5-mm sulcus. Then the patient can be treated using Rule 1.
12. A- Crown Lengthening Surgery Using
External Bevel Gingivectomy
This technique is generally performed when there is sufficient sulcular depth and
keratinized tissue so that the incision does not violate the biologic width or cause
exposure of the bone. It can be performed with the help of scalpel or a Kirkland
knife (conventional), lasers or electrocautery.
Reduction of soft tissue alone is indicated if there is adequate attached gingiva and
more than 3 mm of tissue coronal to the bone crest This may be accomplished by
either gingivectomy or flap technique.
Crown Lengthening Procedures- A Review Article
13. Crown Lengthening Surgery Using Internal Bevel
Gingivectomy With Or Without Ostectomy
(Undisplaced Flap)
The initial or inverse bevel incision is made depending upon that how much crown
exposure is required. Then the second or the crevicular incision is made from the
bottom of the sulcus to the bone to detach the connective tissue from the bone.
The flap is then raised and third incision is given to remove the tissue tags. After
complete scaling and root planning flap is then sutured back in position.
Crown Lengthening Procedures- A Review Article
14. General Tissue Assessment Before Under taking Cls
Soft Tissue Assessment
Situation1- If width of attached gingiva adequate-(>3mm)-external bevel gingivectomy or
internal bevel gingivectomy
Situation 2- If width of attached gingiva inadequate (<3mm)- apically positioned flap (If
soft-tissue excision via a gingivectomy would result in a postoperative gingival width of less
than 3 mm, one should consider the apically positioned flap as an alternative to a simple
gingivectomy.)
Hard Tissue Assessment
Situation1- If bone crest is low i.e. more apically – no ostectomy
Situation 2- If bone crest is high i.e. more coronal- ostectomy performe
Crown Lengthening Procedures- A Review Article
15. Flap elevation is a controversial issue. The literature describes full-
thickness (3, 19), split-thickness (2) and split-full-split-thickness
approaches (4, 18, 25). The rationale of the split-thickness elevation is
to preserve the periostium in order to minimize postsurgical bone
resorption and to facilitate the apical suturing of the flap. The full-
thickness approach has the advantages of being easier to perform and
of gaining direct access to the bone than the split-fullsplit-thickness
and full-thickness approaches. The split-full-split-thickness approach
merges the positive aspects of both techniques: the papillae area is
elevated split-thickness in order to obtain a precise postsurgical
adaptation, while, apically, a full-thickness elevation is made in order to
gain access to the bone and to preserve the periosteum, which would
otherwise be lost during osteoplasty, at the inner aspect of the flap.
Once an adequate amount of bone has been exposed, a split-thickness
dissection can be performed to facilitate the apical anchorage of the
flap in the desired position (4, 7, 25).
16. full-thickness
Periosteum is reflected to expose the underlying bone
Indicated in resective osseous surgery
Contraindications:
•Area where treatment for osseous defect with mucogingival problem is not required.
•Thin periodontal tissue with probable osseous dehiscence and osseous fenestration.
•Area where alveolar bone is thin
17. split-thickness
•Periosteum covers the bone.
•Indicated when the flap has to be positioned apically.
•When the operator does not desire to expose the bone.
18. split-full-split-thickness
The resulting trapezoidal-shaped flap was elevated with a split–full–split approach in the coronal–apical direction: the surgical
papillae comprised between the horizontal incisions and the probeable sulcular area apical to the root exposure were elevated
split thickness keeping the blade almost parallel to the root, and the soft tissue apical to the root exposure was elevated full
thickness inserting a small periostium elevator in to the probeable sulcus and proceeding in the apical direction up to exposing
3–4mm of bone apical to the bone dehiscence. This was done in order to include the periostium in the thickness of that central
portion of the flap covering the avascular root exposure. The releasing vertical incisions were elevated split thickness keeping the
blade parallel to the bone plane, thus leaving the periostium to protect the underlying bone in the lateral areas of the flap. Apical
to bone exposure flap elevation continued split thickness and finished when it was possible to move.
19. Flap design (palatal aspect)
The palatal flap is raised using the thinned palatal flap approach (9). As the palatal flap cannot be moved
apically, the position of the primary incision must anticipate the future configuration of the crestal
bone and depends on the amount of crown lengthening required and on the palatal vault anatomy.
In the presence of a shallow palatal vault the distance of the incision from the gingival margin is
exclusively related to the amount of crown lengthening required.
In the presence of a deep palatal vault, the soft-tissue thickness has to be taken into consideration, with
thicker soft tissues necessitating a greater amount of tissue removal with the secondary palatal flap and
more pronounced apical repositioning of the flap.
Hence, if the deep palatal vault has thick soft tissue, the primary incision should be less para-marginal
than if the deep palatal vault has thin tissues. Otherwise, there is a risk of incomplete coverage of the
palatal bone. In order to avoid excessive exposure of palatal bone, great care must be taken not to make
the incision too far from the gingival margin, especially in the case of a shallow vault or a deep palatal
vault with thick soft tissue.
After vestibular and palatal flap reflection, the soft tissue delimited with the primary incisions is removed
using manual and ultrasonic devices.
23. Ostectomy
Ostectomy consists of the removal of supporting bone (bone connected
to the root surface with periodontal ligament), and the amount of bone
resected is determined by the extent of the crown lengthening required.
Many authors have proposed a range of values (3 mm to > 5 mm) for
the amount of tooth structure to be exposed during crown-lengthening
procedures (12, 15–17, 21, 23). These ‘numbers’ are derived from the
histologic description of the dentogingival complex by Gargiulo et al.
(13). Although considerable variations were reported, the dimension of
the supra-osseous soft tissue was, on average, 2.73 mm.
24. Other authors (16, 18) proposed a method to measure the
individual biologic width dimension using presurgical,
transmucosal probing. In particular, Lanning et al. (16)
reported a biologic width average of 2.26 ±0.13 mm, while
Perez et al. (18) measured a mean supra-osseous gingiva of
3.63 ± 0.64 (range: 2.67–5.00) mm. Although the mean values
of biologic width found in these studies are similar, the
significant range variability observed between patients makes
it reasonable to carry out presurgical biologic width or supra-
osseous gingiva measurements in order to personalize the
extent of bone removal.
25. Osteoplasty
Osteoplasty consists of the removal of nonsupporting bone and aims
to thin the vestibular and lingual/ palatal aspects of alveolar bone
and to eliminate any osseous ledges or exostosis. It includes
techniques of vertical grooving and radicular blending aimed at
establishing physiologic osseous morphology and root prominence
(4, 6). The amount of bone required to be removed has not been
quantified in the literature, and whether osteoplasty is needed
requires a subjective clinical judgment. However, bone reduction
could be considered as complete when the flap can be precisely
adapted over the underlying bone.
26. Instrumentation
Bone is removed by high-speed drilling under copious irrigation
with sterile water. Aggressive, multitapered drills can be used
initially, followed by the use of diamond burs and handheld
chisels to refine the bone surface. Care must be taken to remove
all interproximal bone remnants (i.e. widow’s peaks) and to
prevent inadvertent trauma to the teeth. Root planing of the
exposed root surface is carried out using ultrasonic and hand
instruments to create a hard, smooth and clean root surface.
27. Flap suturing and positioning
The flap is sutured with vertical mattress sutures
anchored to the periosteum with the rationale of
obtaining a tight adaption of the flap to the
underlying tissues at the desired apical position.
28. Esthetic considerations
The goal of esthetic surgery is to mimic, as much as possible, the natural
aspect of soft tissues and to give a harmonious aspect to the surgical area.
The presurgical and surgical variables to be considered to achieve these
objectives are:
The position of the vestibular incision. As the vestibular flap can be
precisely adapted to the bone crest and sutured at the desired position,
the vestibular incision should be mostly guided by considering the final
position of the mucogingival line after flap suturing, with the purpose of
obtaining a uniform band of keratinized tissue around the anterior teeth.
Interdental soft tissues. The interdental soft tissues should be left in
place if no interproximal crown lengthening is required. This is the case if
a patient is affected by buccal passive altered eruption requiring
restorative rehabilitation.
29. Ostectomy (Fig. 1). The tooth that will have the buccal bone crest
most apically displaced after ostectomy (for a restorative, ferrule
effect, or esthetic or periodontal reasons) has to be considered as
the ‘guiding tooth’. Once the guiding tooth is identified, the extent
of the ostectomy on the adjacent teeth should respect the following
esthetic proportion parameters: the apicocoronal position of the
bone crest should be at the same level of homologous contralateral
elements; the position of the bone crest of the central incisors
should be at the same level or more coronal to the bone crest of
the canines; and the position of the bone crest of the lateral incisors
should be more coronal to the bone crest of the central incisors and
canines.
30. Osteoplasty. The osteoplasty must be performed
accurately in order to establish physiologic and
harmonious vestibular bone morphology. How the
bone thickness is managed has a direct influence on
the appearance and rebound of soft tissues and the
tooth-emergence profiles.
31.
32. Soft-tissue rebound
The regrowth of soft tissue after the crown-lengthening procedure has been investigated
in detail.
Bragger et al. (5), performed a study on 25 patients to assess changes in the soft-tissue
level after a crown-lengthening procedure with a 6-month follow-up. Immediately after
suturing, the surgical procedure resulted in apical displacement of the soft-tissue margin
by an average distance of 1.32 mm. At 6 months, stable periodontal tissues with minimal
changes in the gingival margin levels were reported. These data were partially confirmed
by Lanning et al. (16),
in a study on 18 patients. These authors observed no significant change in the position of
the free gingival margin between 3- and 6-month time points (7.64 ± 0.32 and 7.90 ±
0.30 mm, respectively). As no postsurgical measures of the free gingival margin were
provided, a comparison between baseline (after flap suturing) and 3- to 6-month time
points is not possible.
33. .
Conversely, Pontoriero & Carnevale (20), in a study on 30 patients, found
significant alterations of the marginal periodontal tissues from the
immediate postsurgical level (4.8 ± 1.7 mm interproximally and 5.7 ± 2.4
mm buccolingually) over a 12-month healing period (1.6 ± 1.4 mm
interproximally and 2.8 ± 2.6 mm buccolingually), indicating significant
coronal displacement of the newly formed soft-tissue margin.
Moreover, a different pattern in the healing response between different
tissue biotypes was observed, with the coronal regrowth at interproximal
and buccal/lingual sites being significantly more pronounced in patients
with a thick tissue biotype than in patients with a thin tissue biotype.
34. The tendency for a coronal shift of the soft-tissue margin during healing
was also confirmed by Perez et al. (18), Arora et al. (3), and Deas et al.
(10), on studies with 6 months of follow-up.
In particular, Arora et al. (3) and Deas et al. (10) related the tissue
rebound to the postsurgical flap position, observing greater growth when
flaps were positioned closer to the alveolar crest.
These findings underline the importance of a presurgical evaluation by
the clinician, and the extent of the ostectomy should be considered
according to the tissue biotype. Also, the clinician should be aware that
the position of the flap directly influences the soft-tissue rebound and
accordingly should choose an appropriate suture technique.
35. Wound healing
Research has shown that when the clinician creates an apically positioned flap with
an osseous resection procedure, the biological width reestablishes itself at an
apical level.
Researchers have observed that if the margin of the flap is positioned at the level
of the osseous crest, a postoperative vertical gain or rebound in supracrestal soft
tissues occurs that averages 3 mm.
If the flap margin is placed at a level more coronal to the newly established
osseous crest, less vertical gain or rebound in supracrestal soft tissues has been
observed.
Contemporary crown-lengthening therapy
36. A simple excision of tissue probably would result in regrowth of soft tissue if the
osseous crest is less than 3 mm apical to the existing free gingival margin.
If reverse architecture remains after a tooth with a surrounding healthy
periodontium has undergone crown lengthening, excess gingival tissue may
rebound in the healing phase.
Reduction of osseous ledging or an exostosis via osteoplasty was recommended
originally by Schluger32 in 1949 and subsequently by Friedman33 in 1955. It is our
opinion that reduction of alveolar bone enlargements reduces the risk of
postoperative rebound of soft tissue.
Contemporary crown-lengthening therapy
37. There was a significant inverse correlation between the distance from flap to bony
crest at the time of suturing and the amount of tissue rebound, indicating a greater
rebound when the flap margin was positioned closer to the bony crest. Flaps that
were sutured within 1 mm of the alveolar crest experienced the greatest coronal tissue
rebound.
The amount of coronal tissue rebound decreased as the flaps were sutured more
coronally.
Rebound was not observed when the flaps were sutured at a distance >4 mm
coronally.
ESTHETIC CROWN LENGTHENING:
GUIDELINES FOR ACHIEVING IDEAL GINGIVAL ARCHITECTURE AND STABILITY
38. Many factors seem to contribute to the maintenance of tooth structure gained
through surgical crown lengthening procedures. Individual patient healing
characteristics, reformation of the biologic width, adequacy of positive osseous
architecture created during surgery, timing of restorative procedures,different tissue
biotype, and post-operative plaque control may be among these factors. another
factor may be the position of the flap margin after surgery, which was examined in
the present study.
It is possible that earlier marginal tissue stability can be achieved if the gingival
margin is placed at the time of suturing in a position that accounts for the
reformation of the biologic width.
39. Provisional and definitive prosthetic
management
Management of the provisional prosthetic restoration is a fundamental step in the
esthetic rehabilitation process that often troubles both the clinician and the patient. Three
procedures can be adopted based on the time point when the teeth are prepared and
on the position of the margins of the prosthesis with respect to the gingival margin:
(i) intra-operative tooth preparation and relining of the provisional restoration;
(ii) early tooth preparation and relining of the provisional restoration; and
(iii) delayed tooth preparation and relining of the provisional restoration.
40. Intra-operative tooth preparation and
provisional relining
In this approach,
tooth preparation is carried out during surgery, after ostectomy and osteoplasty, usually with the use of diamond
burs.
Abutments are prepared with knife-edge margins at the bone crest level.
The intra-operative preparation offers the following advantages:
1) elimination of undercuts;
2) root proximity correction;
3) and smoothing and cleansing of root surfaces by removing calculus and necrotic cement remnants.
After preparation of abutments the provisional restoration can be relined during surgery or immediately after
suturing.
Prosthetic margins should be positioned at a distance of at least 1 mm from the gingival level and constantly
monitored in order not to interfere with the healing of soft tissue.
The frequency with which the provisional restoration is modified is related to the expected soft-tissue rebound (i.e. the
position of the flap at time of suturing and the gingival biotype) (6).
The final prosthesis can be delivered when soft-tissue stability is observed.
41. Early tooth preparation and provisional relining
In this approach
tooth preparation occurs after 3 weeks from the surgery (25). During this period, the presurgical
provisional restoration is left in place.
The rationale for this approach is to manage the provisional prosthetic steps after the initial healing
has taken place and following restoration of the connective tissue attachment (i.e. the re-
establishment of the biologic width and during the maturation phase of the soft tissues).
In the first 3 weeks after surgery, approximately 1 mm of bone surrounding the teeth involved in the
surgery resorbs and leaves a portion of healthy root cementum available for connective tissue
attachment to re-form, in a more apical position (24).
The area previously occupied by the connective tissue attachment, where intra-operative root planing
was performed, is now a hard, smooth and clean surface onto which the junctional epithelium can
adhere (8).
Three weeks after surgery, the probing depth is zero and the sulcus and the interdental papillae are
still absent. From a clinical point of view, the tooth structure that, after the soft-tissue maturation, will
become subgingival is now still supragingival, thus facilitating management of the provisional
prosthetic restoration.
42. The abutment preparation is now performed at, or close to, the gingival level with a knife-
edge margin and using the healed soft-tissue margin as a guide.
A new provisional restoration is relined at the same level.
The early tooth preparation offers the following advantages (25):
1) less aggressive abutment preparation;
2) the provisional prosthetic phase does not interfere with the re-establishment of the biologic
width;
3) no need for provisional relining at the end of surgery;
4) easy supragingival knife-edge preparation using the healed soft-tissue margin as a guide;
5) easy supragingival relining of the provisional restoration in a rested patient with no
bleeding;
6) conditioning of the soft tissues during the maximal regrowth period;
7) and no need for retraction cords during abutment preparation and relining of the
provisional restoration (necessary in the case of delayed tooth preparation and provisional
relining).
43. The provisional restorations are modified further only in the interdental aspect, thus
avoiding unesthetic exposure of tooth structure during the entire healing phase. This also
minimizes hypersensitivity.
The contact point is initially positioned at a distance of 3 mm from the interdental soft
tissues and is progressively shifted in a more coronal position, a millimeter at a time, as
the interdental space is filled by the soft-tissue regrowth.
Also, the convergence of the provisional interproximal surfaces is gradually augmented,
to maximize the regrowth of the interdental papillae. The frequency of the provisional
modifications is related to the expected soft-tissue rebound.
The time for the final impression is specifically chosen in each patient when, at the last
control visit, there is no further growth of the interdental papillae with respect to the
last contact point of the temporary crowns (25). An example of esthetic crown
lengthening limited to the buccal aspect and early restorative phase is shown in Figs 2–8.
An example of esthetic crown lengthening and early restorative phase is shown in Figs 9–
14.
44. Delayed tooth preparation and provisional
relining
This approach is based on the concept of not interfering with
healing of the soft tissues (11). After the crown-lengthening
procedure, the margins of the provisional restoration are
maintained at the presurgical level until soft-tissue stability is
achieved (9–12 months). At this point, the final abutment
preparation is performed and the final prosthesis is delivered.
45.
46.
47.
48.
49.
50.
51.
52.
53.
54. Conclusions
Despite the fact that crown lengthening in esthetic areas is a widely used clinical procedure,
there is a lack of evidence in the literature regarding the description of both surgical and
prosthetic procedures. However, some indications can be summarized:
The objective of resective surgery is to obtain an increase in the clinical crown length. To
achieve this, hard and soft tissues must be thinned as much as possible in order to minimize
the amount of supporting bone removal (ostectomy):
1) The surgical papillae should be elevated in a split-thickness manner.
2) The palatal flap should be elevated using the ‘thinned palatal flap approach’.
3) The nonsupportive bone should be thinned to obtain a precise flap adaptation.
4) The buccal ostectomy should be performed, after choosing the guiding tooth, following the
esthetic proportion parameters.
55. Regrowth of soft tissue after the crown-lengthening procedure is dependent on
individual patient factors and the timing of the placement of the final restoration
should be chosen accordingly.
The provisional prosthetic restoration phase should start 3 weeks after the surgery
in order not to interfere with the re-establishment of the biologic width and to
condition the soft tissues during the period of maximal regrowth. Figure 15
summarizes the staging of crown-lengthening prosthetic procedures.