preparations while respecting the biological width concept.1 If not respected the
desirable effect is neither healthy nor cosmetically pleasing (Fig.1). Periodontal
surgery in general requires removal of healthy supporting alveolar bone resulting
in soft tissue gaps between teeth (Fig 2). Although the resultant soft tissue
component is a major determinant of the cosmetic appearance of the treatment
outcome its dimensions and contours depend on the thickness of the tissue and the
position of its supporting underlining bone. Since gingival recession/bone loss
occurs after elevation of a full gingival flap, often, the resultant soft tissue is
deficient resulting in unfavourable appearance. Unlike at non-cosmetic sites, such
outcome is very undesirable when the surgery involves readily visible are of the
mouth. The author has used a modification technique described in this article for
many years with excellent results.
Medical and dental histories are taken as before any dento-alveolar surgery and
lead to appropriate protocols for surgical management. Since the impact of these
histories are no different from any periodontal surgeries I will not detailed them
in this paper. Yet, its omission in this paper would give a false impression of
their importance.
2. Assign to what extent each item on the list could be rectified by the surgery,
improved but not eliminated or not addressed at all. This is integral part of the
treatment planning process done by the operator. Not all cosmetic concerns can be
addressed because of technical and biological limitations. It is best to address
each of the items on the list individually so that false expectations could be
avoided. This process is part of the case presentation and is best done by
illustrating it on a good quality monitor.
3. Discussion with the patient outlining what can be achieved, to what extent and
at that level of predictability. This is best done in front of the monitor
preferably with the help of electronic simulations. It is desirable that the final
simulation is given to the patient, either by print or later sent via Email, so
that time is allowed for full understanding of the treatment plan, its objectives,
its limitations and the level of predictability of the planned outcome.
This method of preparation will strengthen the process of informed consent while it
is not legally binding the operator because it is a plan only, one that is
ultimately modulated by individual variations in healing and post-surgical
management. An example of this process is depicted in Figures 4 and 5. Surgical
templates, marked diagnostic models and diagnostic wax-ups can guide the surgeon
during the procedure (Figures 6 and 7).
The three determinants of the surgical procedure, are outlined in differed colours
in (Fig. 12 and13). They are: 1. Gingival margin, 2. The imagined margins of the
planned restoration, 3. The crestal bone. In these figures the fourth line is the
margin of the provisional crown that is not identical with the margins of the
planned restoration.
The elevator is used to retract the mini-flap and allow access to the bone with a
round bur (Fig. 14) While protecting the soft tissue from trauma from the high
speed bur. The same can be accomplished with an end-cutting bur with a higher
degree of protection of the root surface and the soft tissue.
Before the osteoplasty is initiated measurements are made from the CEJ to the
crestal bone and the gingival margin (Fig15) allowing the surgeon to make the final
decision as to how much bone to remove. The osteoplasty will then commence with the
aim to create the desired domains, as dictated by the biological width concept,
necessary for the proper healing. The novelty of the procedure described in this
paper is in flap management rather than in how these parameters are managed in
classical crown-lengthening procedures. By not fully raising the flap, as in the
conventional crown lengthening procedure bone loss attributed to large flap
exposures is prevented. If brief the distance from the planned crown margin to the
crestal bone is about 3-4 mm respecting the biological width concept and allowing
for the ferrule to be established in case full crown preparations were planned.
After completion of the osteoplasty and copious irrigation with sterile saline the
surgical wound is close wither by a tissue adhesive (Fig.16), sutures (Fig.17) or
combination of both (Fig.18). Post-surgical care is similar to the classic crown
lengthening procedures.
The same approach can be applied to cases where additional crown length is deemed
necessary after the preparations were completed and the preps were critically
reviewed. In this case after the provisional restorations were in place the preps
were deemed inadequate for retention and hence crown lengthening procedure was
requested (Figures 24 and 2.5).
Conclusion