Surgical lengthening of U. Bragger, D.

Lauchenauer and
N. R Lang
University of Berne, School of Dental
Medicine, Berne, Switzeriand
the clinical crown
Bragger U, Lauchenauer D and Lang NP: Surgical lengthening of the clinical
crown: J Clin Periodontol 1992: 19: 58-63.

Abstract. The aim of the present study was to assess the changes in the perio-
dontal tissue levels as an immediate result of the surgical crown lengthening
procedure and over a 6-months healing period. 25 patients ranging between 20 to
81 years of age were included in the study. A total of 85 teeth (43 test and 42
control teeth not exposed to surgery) were evaluated over 6 months. After initial
therapy, the indication for crown lengthening comprised need for increased reten-
tion and accessibility to deep subgingival preparation margins hampering im-
pression taking. During surgery, the alveolar crest was reduced, thereby creating
a distance of 3 mm to the future reconstruction margin. The results of this study
demonstrated that the mean probeable changes in the levels of the periodontal
tissues from those defined after surgery were minimal, resulting in changes compar-
able to the shifts observed at control teeth not exposed to any surgical procedures.
Frequency analysis of the number of sites with dislocation of the free gingival
margin demonstrated that 12% of the sites with crown lengthening procedure
showed 2-4 mm recession of the free gingival margin between 6 vi'eeks and 6
months postoperatively. In esthetically critical, visible areas of the dentition, Key words: periodontal flap; crown lengthen-
recessions must be closely observed in the healing period after surgical crown ing; perioprosthetics.
lengthening, when prosthetic reconstructions are planned on such teeth. Accepted for publication 13 November 1990

In addition to favorable periodontal
and endodontic conditions, the amount
of remaining supracrestal healthy tooth
substance might determine the restorab-
ility of a tooth or a root. Technical re-
storative procedures require a well-de-
fined preparation margin that can be
recognized during impression taking.
Conditions which allow for optimal
control of the marginal fit of a recon-
struction and optimal access for daily
plaque control by the patient are also
necessities. Furthermore, sufficient
length of the clinical crown is required
for optimal retention of the planned re-
constructions.
In some clinical situations, however,
conditions are unfavorable for success-
ful restorative procedures. These in-
clude; deep subgingivally-located cari-
ous lesions, crown and root fractures,
preexisting deep preparation margins,
perforations during endodontic therapy
and root resorptions. In such situations,
surgical lengthening of the chnical
crown will improve the anatomical con-
ditions and facilitate restorative pro-
cedures. This may provide the necessary
gain of retention or render the tooth or
the root restorable at all.
In case reports, crown lengthening
has been described as a procedure simi-
lar to an apically repositioned flap with
ostectomy/osteoplasty (Ingber et al.
1977, Palomo & Kopczyk 1978, Kahl-
dahl et al. 1984, Baima 1986, Davis et
al. 1987). Some reports point out the
importance of a thorough root planing
after the ostectomy in order to avoid
reattachment of the surgically separated
fibres at a level which would he too
coronal, thus positioning the level of the
connective tissue attachment deliberate-
ly and predictably at a more apical level
(Levine & Stahl 1972, Tal & Diaz 1985,
Bragger & Lang 1988).
There are, however, few reports on
controlled studies of the periodontal
changes in the healing phase after surgi-
cal procedures aimed at lengthening the
clinical crown.
The aim of the present study was to
assess the changes in the periodontal
tissue levels as an immediate result of
the surgical crown lengthening pro-
cedure and over a 6-months healing
period.
Material and Methods
Informed consent for participation in
this study was obtained from 25 patients
ranging between 20 and 81 years of age,
receiving comprehensive dental care. All
the patients were subjected to initial
periodontal therapy including a case
presentation, instructions for homecare,
as well as scaling/rootplaning and re-
moval of marginal irritants.
The indications for crown lengthen-
ing included in this study, comprised
gain of retention and accessibility to
deep subgingival preparation margins
hampering impression taking. Briefiy,
the fiap procedure and the ostectomy/
osteoplasty were performed according
to Ingber's (Ingber et al. 1977) recom-
mendations, i.e. the positioning of the
alveolar crest at a distance of at least
3 mm from the future reconstruction
margin. Close fiap adaption and chemi-
cal plaque control with Chlorhexidine
0.1% rinses for two weeks favoured
healing of the soft tissues. After 3 weeks,
reconstructive work was continued and
most of the test teeth included in this
report were crowned during the obser-
vation period.
In a situation which required inter-
dental tissue reduction including ostec-
tomy at 2 neighbouring teeth, both teeth
were considered as test teeth. Corre-
sponding control teeth were chosen in
 Surgical crown lengthening 59

Initial therapy indication for after flap reflection after ostectomy/ after suturing ; 6 weeks 6 monhts
crown lengthening before ostectomy/ osteoplasty exam. exam.
osteoplasty
baseline exam.

Pll
i PI) Pll
Gl 61 Gl
FGM FGM FGM FGM
AL AL AL
BL BL
Fig. I

the contralateral quadrant which were soft tissue levels due to the surgery, and istically significant changes from base-
not exposed to any surgical procedure. in order to assess the clinical changes line to 6 months were noted at either
A total of 85 teeth (43 test and 42 in the periodontal tissue levels over 6 the test or at the control sites. Similarly,
controls) were evaluated over 6 months. months after the surgery. there were no significant changes in the
The test teeth included 7 incisors, 8 can- GI, which ranged between 0.78 and
ines, 20 bicuspids and 8 molars. 0.92.
Statistical analyses
The following clinical parameters
were assessed at 6 sites (mesiobuccal, Differences in the nonparametric indi-
Bone level reduction during crown
buccal, distobuccal, distolingual, lin- ces (Pll and GI) between test teeth and
lengthening
gual, mesiolingual) on each test tooth control teeth and between different test
exposed to the surgical lengthening of and control sites, and at baseline com- At 68 sites (32%), 1 mm of crestal al-
the clinical crown, and from each homo- pared to 6 weeks and 6 months, were veolar bone was removed during the
logous control tooth. statistically analyzed using the Mann- crown lengthening procedure (Table 1).
Plaque index (Pll) according to Whitney-t/-test (Siegel 1956). Paired The bone reduction amounted to 2 mm
Silness & Loe (1964) and unpaired t-tests (Chilton 1967) were at 43 sites (21%) and 3-4 mm at 9 sites
Gingival index (GI) according to applied for assessment of statistically (4%). Due to the limited extent of
Loe & Silness (1963) significant differences in the distances ostectomy/osteoplasty which did not al-
Distance from a reference mark on splint-free gingival margin (FGM) and ways include all of the sites of a tooth
the splint to the free gingival margin splint-base of the pocket (AL). This evaluated, no change was observed at
(FGM) analysis was performed using both the 79 sites (38%). At 11 sites (5%) a coronal
Distance from a reference mark on tooth and the site as the statistical unit. displacement of the bone level was
the splint to the probeable base of the In addition, all the probing parameters noted, reflecting the error ofthe method
pocket (AL) were subjected to frequency analyses. (Table 1).
Distance from a reference mark on The distribution of the number of test
the splint to the alveolar bone (BL) and control sites with different changes
in the probing parameters were com- Changes in the position of the free gingival
In order to standardize localization
pared by means of the Kolmogorov- margin
and direction ofthe probing procedures,
grooves were drilled in a prefabricated Smirnov test (Siegel 1956). The mean distances from the reference
hot-cured acrylic splint. By subtracting splint mark to the free gingival margin,
FGM from AL the probing pocket at the test and control teeth, are listed
Results
depths (PD) were calculated. in Table 2. After suturing, the crown
Pll and Gl
In Fig. 1, the exact sequences of the lengthening procedure resulted in an im-
different scorings are presented. The At test and control teeth, the mean Pll mediate mean apical displacement of
scorings were chosen in order to reveal ranged between 0. 27 to 0.52 and no stat- the soft tissue margin of 1.32 mm.
the changes in the bone and periodontal
Table 2. Mean distances between the reference splint marks and the free gingival margin
(FGM) and the probeable base of the pocket (AL) as well as the pocket depths (PD) for test
Table I. Distribution of the number of sites (T) and control (C) teeth at the various time points of scorings
with different changes in the alveolar bone Baseline
level as an immediate result of crown length- presurgically After suturing 6 weeks 6 months
ening
X S.D. X S.D. X S.D. X S.D.
Change (mm) No. sites
FGM T 6.02 2.39 7.34* 2.30 7.49 * 2.46 7.39 * 2.00
-1-1 11 5% 5.83 2.15 6.05 1.93 6.01 1.93
C
0 79 38% 8.25 2.29 9.65 * 2.39 9.61 * 2.09
AL T
_J 68 32% 8.24 2.11 8.52 2.23 8.47 2.03
C
-2 43 21% 1.89 1.67 2.13 0.79 2.24 0.10
PD T
-3 6 3% 2.07 1.67 2.51 0.91 2.59 0.97
C
-4 3 1%
S.D.: standard deviation.
total 210 100% * Refers to statistically significantly different from controls as well as from baseline (p^
60 Bragger et al.
Table 3. Number of test and control sites exhibiting different variations of the free gingival
margin from baseline to 6 weeks and from immediate postoperative (2nd FGM) to 6 weeks
Change in the location
of the FGM (mm)
+3
+ 2 " '
+1
0 41 20.0%
-1
z.
-3
-4
total
level of
significance
+ indicates coronal displacement of the FGM.
indicates apical displacement of the FGM.
When the location of the soft tissue
margin defined after suturing was com-
pared to the position at 6 weeks and 6
months, no statistically significant dif-
ferences between mean values were
noted. At the control teeth which were
not exposed to surgery, practically no
changes in the position of the free gin-
gival margin were observed.
Frequency analyses of the changes in
the location of the soft tissue margin
at test sites from baseline to 6 weeks
revealed no change in 20.0%, apical dis-
placement from 1 to 4 mm in 77.5%
and coronal displacement of ] mm in
2.5% of the sites (Table 3). Between
baseline and 6 weeks, 27% of the con-
trol sites revealed no change, 44% an
apical displacement from 1-4 mm and
29% a 1 mm coronal displacement of
the free gingival margin (Table 3). Fre-
quency analysis of the changes in the
FGM occurring from immediate to 6
weeks postsurgically revealed no change
in 47%, apical displacement from 1-4
Table 4. Number of test and control sites exhibiting different changes in the location of the
free gingival margin between 6 weeks and 6 months after crown lengthening
Change in the location of
the FGM (mm)
+3
+2
+1
0 69 38%
1 vealed apical displacement of the peri-
'' - 2
1
- ^ - - 3
total
level of significance
+ indicates coronal displacement of the FGM.
indicates apical displacement of the FGM.
Comparison of the frequency distri-
butions of the changes revealed no stat-
Test sited Test sites Control sites istically significant difference between
baseline - 6 weeks 2nd FGM - 6 weeks baseline - 6 weeks test and control sites.
0 2 0
0 2.5% 6 20% 0 29% Changes in the probing attachment levei
: . " . 5 26 39
79 47% 36 27% In Table 1, the mean distances from the
71 43 53 splint mark to the probeable base of the
62 33% 4 44% pocket are listed for test and control
23 3 1 sites. Due to the surgical lengthening of
2 1 the clinical crown, the mean probing
207 169 134 attachment level at test teeth was statis-
tically significantly reduced but revealed
p<0.00\- no statistically significant changes be-
tween 6 weeks and 6 months postsurgi-
cally. At the control sites, no significant
changes were observed between baseline
and 6 months. Between baseline and 6
weeks the apical displacement of the
mm in 33% and coronal displacement probing attachment level ranged be-
from 1-3 mm in 20% (Table 3). The tween 1 and 4 mm at 81% of the test
distribution of the number of test sites sites, whereas a reduction from 1-4 mm
with different changes in the location of was observed at 30% of the control sites
the FGM from baseline to 6 weeks was (Table 5). The distribution of the num-
statistically significantly different from ber of test and control sites with differ-
the changes observed at the control ent changes in the attachment level be-
sites. However, when the changes from tween 6 weeks and 6 months was not
the immediate postsurgical FGM to 6 statistically significantly different (Table
weeks at the test sites were compared 6).
to the changes occurring at the control
sites, no statistically significant differ-
ences were observed. Changes in the probing pocket depth
In the time periods 6 weeks to 6
months postsurgically, the test sites The mean probing pocket depth at test
demonstrated no change in the level of teeth was 1.89+ 1.67 at baseline, 2.51
the FGM in 38%, apical displacement 0.91 mm at 6 weeks and 2.59 + 0.97 mm
from 1-4 mm in 29%) and coronal dis- at 6 months. There were no statistically
placement from 1-3 mm in 33% (Table significant differences between the mean
4). The corresponding changes at con- probing pocket depth measurements at
trol sites between 6 weeks and 6 months test and control sites nor over time in
postsurgically were no change in 50%, any of the two groups (Table 2).
apical displacement between 1 and 3
mm in 23% and coronal displacement
between 1-3 mm in 26% (Table 4), Discussion
The results of this study demonstrated
that once defined by surgery the mean
changes of the level of the FGM were
minimal and were comparable to the
Test sites Control sites shifts in the FGM level occuring at the
6 weeks - 6 months 6 weeks - 6 momths
control teeth.
1 0 Comparison of the levels of the free
5 33% 3 26% gingival margin and the probeable
53 42 attachment pre- and postsurgically re-
88 50%
311 37
18 29% 1 23% odontal tissues from the crown length-
3 1 ening procedure. This resulted in a
1 0 mean apical displacement of the free
gingival margin immediately postsurgi-
181 172
cally of 1.3 mm, of 1.5 mm at 6 weeks
and of 1.4 mm at 6 months.
The mean changes in the level of the
free gingival margin give the impression

Table 5. Number of test and control sites with changes in the probing attachment level between
baseline and 6 weeks after crown lengthening
Test sites Control sites
Changes of the AL (mm) baseline - 6 weeks baseline - 6 weeks
+2 1 \ 2% 71 15%
+1 231
0 36 17% 108 55%
-1 49)
-2 47 81% 30%
25
6 0.6-1.1 mm was measured, varying with
total 206 198
level of significance
indicates coronal shift in the probing attachment level,
indicates apical shift in the probing attachment level.
that the surgical placement of the soft procedure were pocket elimination, cre-
tissues predictably defines the future po- ation of optimal bone and soft tissue
sition of the free gingival margin. The contours as well as open debridement of
frequency analyses, however revealed the roots in patients with periodontitis.
that between 6 weeks and 6 months Caton & Nyman (1981) investigated
there was no change or a change within the effect of the surgical elimination of
+1 mm at 85% of the sites. At 18 sites, osseous walls of angular defects on the
a reduction of 2mm, at 3 sites of 3 mm levels of the different periodontal
and at one site of 4 mm was measured, tissues. The surgical treatment resulted
whereas 5 sites showed a coronal dis- in a mean apical displacement of the
placement of the FGM of 2 mm and FGM of 1.46 mm at test sites, whereas
one site of 3 mm. the FGM was located at the CEJ at
The fact that 12% of these sites control sites. The connective tissue
showed an apical displacement of the attachment level and the alveolar crest
free gingival margin of more than 1 mm height at test sites were located 0.5 mm
has to be taken into consideration when more apically compared to the control
crown and bridgework is performed sites. The procedure also resulted in a
after surgical crown lengthening in es- reduction of the probing pocket depth
thetically critical and visible areas. at the test sites of 1 mm compared to
the controls.
A few controlled clinical studies re-
ported on the alterations in the perio- In a report by Lindhe & Nyman
dontal tissues using similar indications (1980), alterations in the position of the
for the crown lengthening procedure as marginal soft tissue following perio-
well as surgical technique. In several dontal surgery were assessed. The posi-
studies however, changes in the perio- tion of the free gingival margin in re-
dontal tissue levels following apically lation to the CEJ was measured at buc-
repositioned flaps were observed. In cal aspects of incisors, premolars and
these studies the aims for the surgical molars, presurgically and at 2 months
Table 6. Number of test and control sites with changes in the probing attachment levels
between 6 weeks and 6 months after crown lengthening
Test sites Control sites
Change of the AL (mm) 6 weeks - 6 months 6 weeks - 6 monhts
+3 1 of the postsurgical remodelling resulted
+2 27% 7 26%
+1 37
0 40% 86 50%
-1 341
2 33% 7 24%
-3
total 177 173
level of significance ns
+ indicates coronal shift in the probing attachment level.
indicates apical shift in the probing attachment level.
Surgical crown lengthening 61
postsurgically as well as after 10-11
years of regular maintenance. In these
43 patients, the aim of the periodontal
surgical procedure was to eliminate
pockets > 3 mm and to eliminate bony
defects. During active treatment, the po-
sition of the mean FGM shifted from 3
to 5.5 mm in relation to the CEJ. Dur-
ing the 10-11 years of recall, a coronal
displacement of the FGM ranging from
the tooth type and presence or absence
of keratinized gingiva.
Whereas the studies mentioned above
have been concerned mostly with the
changes in the periodontal soft tissue
levels, other experiments have been con-
centrating on the histologic remodelling
of alveolar bone following periodontal
surgical procedures. Exposure of al-
veolar bone by flap elevation and instru-
mentation on root surfaces and on bone
resulted in resorption of alveolar bone
(Wilderman et al. 1960, Wilderman
1963, Caffesse et al. 1968, Costich &
Ramfjord 1968, RamQord & Costich
1968, Horton et al. 1975). This resorp-
tive phase was followed by a phase of
repair defined as "bone fill" in defects
(Wilderman et al. 1960, Caton &
Zander 1976) and increased bone den-
sity at the crest due to the formation of
a e new cortical plate (Wilderman 1963,
Caffesse et al. 1968, Ramfjord & Cos-
tich 1968).
In re-entry operations, Pennel et al.
(1967) found a mean loss of crestal bone
height of 0.63 mm 14-44 days after oss-
eous surgery. By means of computer-
assisted - densitometric - image - analysis
(CADIA), Bragger et al. (1988) assessed
the interdental alveolar bone remodel-
ling activity after periodontal fiap pro-
cedures. Part of the patients included
in that study were patients exposed to
crown lengthening procedures. Similar
to the histological studies mentioned
above the resorptive phase could also
be documented by means of CADIA.
In 82% of the sites examined a phase of
repair was observed between one and
six months postsurgically. The activity
in 32% of the sites in a net loss of density
six months postsurgically compared to
the immediate postsurgical situation.
Similarly, in the present report, in 12%
of the sites a further recession of the
free gingival margin was observed be-
tween one and six months postsurgi-
cally.
In order to avoid the preparation of
a fullthickness fiap, gingivectomy may
62 Bragger et al.
also be considered for lengthening the
clinical crown.
In a study by Monefeldt & Zachris-
son (1977), the effect of gingivectomies
on the clinical facial crown height was
assessed on study models from first bi-
cuspids scheduled for extraction for or-
thodontic reasons. In addition, this pro-
cedure was used for esthetic corrections
when lateral incisors were moved ortho-
dontically to the position of central inci-
sors. It was observed that the mean clin-
ical crown height increased 1 mm,
whereas the mean probing pocket depth
was reduced 1 mm. In the histologic
analyses, no apical migration of the epi-
thelium beyond the cemento enamel
juncfion was observed. This led to the
conclusion that gingivectomy resulted
in a reduction of pseudo pockets and
did not displace the connective tissue
attachment level apically. Therefore,
gingivectomies cannot be recommended
for the controlled apical dislocation of
the alveolar bone crest, the free gingival
margin and connective tissue attach-
ment level.
An alternative technique for gaining
clinical crown height by means of ortho-
dontic forced eruption in combination
with gingival fiberotomy was described
by Pontoriero et al. (1987). Document-
ing four clinical cases, Kozlovsky et al.
(1988) reported that this technique re-
sulted in root exposures ranging from
1.5-5 mm. This technique has the ad-
vantage that root exposure can be per-
formed without the need for a fiap pro-
cedure in combination with osseous
surgery, possibly affecting the perio-
dontal tissues of a neighbouring tooth.
However, this technique cantiot be ap-
plied in all situations which require
lengthening of the clinical crown, such
as prosthetic reconstruction in den-
titions with severe attrition. In such in-
stances, sufficient retention and interoc-
clusal space for the reconstruction are
created by crown lengthening all the re-
maining teeth of the maxilla and/or the
mandible and by increasing the vertical
dimension. Several sessions in which
fiberotomies are performed are required
in order to prevent that the periodontal
tissues are pulled coronally together
with the orthodontically moved root. A
retention period of about 4 weeks is
advocated to prevent relaps of the root.
Therefore, it seems that the orthodontic
forced eruption in combination with
fiberotomies represents a rather con-
servative approach for the periodontal
tissues of neighbouring teeth. However,
this procedure is certainly much more
cumbersome compared to the surgical
lengthening of the clinical crown.
It may be concluded, that creating a
distance of 3 mm from the alveolar
crestal bone level to the future recon-
struction margin during surgical length-
ening of the clinical crown leads to
stable periodontal tissue levels over a
period of 6 months. In esthetically im-
portant, visible areas, recessions of the
free gingival margin must be closely ob-
served during the healing period after
crown lengthening procedures, when
prosthetic reconstructions are planned
on such teeth.
Acknowledgement
This report has been supported by the
Swiss National Foundation for Scien-
tific Research, grant No. 3.922-0.87 and
by the Clinical Research Foundation
(CRF), University of Berne, Switzer-
land.
Zusammenfassung
Die chirurgische Verlangerung der klinischen
Krone
Mit der hier vorliegenden Studie wurde beab-
sichtigt, die Veranderungen der parodontalen
Gewebeniveaus als unmittelbare Folge chi-
riirgischer Verlangerung der klinischen Kro-
ne, und wahrend einer 6 monatlichen Hei-
lungsperiode zu beurteilen, 25 Patienten im
Alter von 20 bis 81 Jahren nahmen an dieser
Studie teil, Insgesamt 85 Zahne (43 Test- und
42 nicht chirurgisch behandelte Kontrollzah-
ne) wurden 6 Monate lang beobachtet, Nach
der initialen Therapie ergab sich die Indika-
tion zur Verlangerung der klinischen Krone
durch die Notwendigkeit einer Retentions-
verbesserung und zur Freilegung von tieflie-
genden, die Abformung erschwerenden Pra-
parationsgrenzen, Um einen Abstand von 3
mm zum Rand der zukiinftigen Rekonstruk-
tion zu erreichen, wurde die alveolare Kno-
chenleiste reduziert. Die Resultate dieser Stu-
die zeigten nur geringfugige sondierbare Un-
terschiede zwischen den mittleren Niveaus
der parodontalen Gewebe vor und nach der
chirurgischen Behandlung, was den Verande-
rungen entsprach, die bei nicht chirurgisch
behandelten Kontrollzahne beobachtet wur-
den, Analysen der Vorkommenshaufigkeit
von Steilen mit disloziertem freien Gingival-
rand zeigten, dass wahrend der postoperati-
ven Beobachtungszeit zwischen 6 Wochen
und 6 Monaten, bei 12% der Steilen an Zah-
nen mit verlangerten klinischen Kronen, Re-
zessionen des freien Randes der Gingiva von
2-4 mm vorlagen. Asthetisch kritische, sicht-
bare Gebissregionen mussen wahrend der
Heilungsperiode nach chirurgischer Verlan-
gerung der klinischen Krone genau beobach-
tet werden, wenn solche Zahne mit prothe-
tischen Rekonstruktionen versehen werden
sollen.
Resume
Elongation chirurgicale de la couronne clinique
Le but de l'etude presente a ete d'evaluer les
variations de niveau des tissus parodontaux
immediatement apres la chirurgie d'elonga-
tion de la couronne ainsi que pendant les six
mois suivants, Vingt-cinq patients ages de 20
a 81 ans ont participe a cette etude avec un
nombre total de 85 dents: 43 tests et 42
controles n'ayant subi aucune chirurgie, L'e-
longation de la couronne etait indiquee lors-
qu'il y avait un besoin accru de retention
et d'acces a des preparations sous-gingivales
profondes rendant la prise d'empreinte tres
compliquee. Pendant la chirurgie, le rebord
alveolaire' a ete reduit creant un espace de 3
mm par rapport au bord de la construction
future, Les resultats de cette etude ont de-
montre que les variations moyennes au son-
dage des niveaux des tissus parodontaux
apres chirurgie etaient minimales et compara-
bles a celles des sites controles, L'analyse de
frequence du nombre de sites avec variation
de la hauteur de la gencive marginale a de-
montre que 12% des sites operes subissaient
une recession de 2 a 4 mm de la gencive libre
entre six semaines et six mois apres l'opera-
tion, Dans les zones oii l'esthetique joue un
role important les recessions post-operatoires
doivent done etre suivies minutieusement.
References
Baima, R, F, (1986) Extension of clinical
crown length. Journal of Prosthetic Den-
tistry 5S, 547-551,
Bragger, U,, Pasquali, L, & Kornman, K, S.
(1988) Remodelhng of interdental alveolar
bone after periodontal flap procedures as-
sessed by means of computer assisted-den-
sitometric-image-analysis. Journal of Clin-
ical Periodontology 15, 558-564.
Bragger, U, & Lang, N, P (1988) Chirugische
Verlangerung der klinischen Krone,
Schweizerische Monatsschrift filr Zahn-
medizin 98, 644-651,
Caffesse, R. G., Ramfjord, S, P & Nasjletti,
C. E, (1968) Reverse bevel periodontal
flaps in monkeys. Journal of Periodontolo-
gy 39, 2\9-235.
Caton, J. & Nyman, S, (1981) Histometric
evaluation of periodontal surgery (III),
The effect of bone resection on the connec-
tive tissue attachment level. Journal of
Periodontology 52, 405-409,
Caton, J, & Zander, H, A. (1976) Osseous
repair of an infrabony pocket without new
attachment of connective tissue. Journal of
Clinical Periodontology 3, 54-58.
Chilton, N, W. (1967) Design and analysis in
dental and oral research, pp. 69-73, J. B.
Lippincott company, Philadelphia & To-
ronto.
Costich, E. R. & RamQord, S. P. (1968) Heal-

ing after partial denudation of the alveolar
process. Journal of Periodontology 39,
127-134.
Davis, J. W., Fry, R., Krill, D. B. & Rostock,
M. (1987) Periodontal surgery as an ad-
junct to endodontics, prosthodontics and
restorative dentistry. JADA 115, 271-275.
Horton, J. E., Tarpley Jr., T. M, & Wood, L.
D. (1975) The healing of surgical defects
on alveolar bone produced with ultrasonic
instrumentation, chisel and rotary bur.
Oral Surgery, Oral Medicine, Oral Pathol-
ogy 39, 536-546.
Ingber, F. J, S., Rose, L. F, & Coslet, J. G.
(1977) The "Biologic Width" - A concept
in periodontics and restorative dentistry,
Alpha-Omegan 10, 62-65,
Kahldahl, W. B., Becher, C, M. & Wentz, F.
M, (1984) Periodontal surgical preparation
for specific problems in restorative den-
tistry. Journal of Prosthetic Dentistry 51,
36-41.
Kozlovsky, A,, Tal, H. & Lieberman, M,
(1988) Forced eruption combined with gin-
gival fiberotomy. Journal of Clinical Perio-
dontology 15, 534-538.
Levine, H. L. & Stahl, S. S. (1972) Repair
following periodontal flap surgery with the
retention of gingival fibers. Journal of
Periodontology 43, 99-103.
Lindhe, J. & Nyman, S. (1980) Alterations
of the position of the marginal soft tissue
following periodontal surgery. Journal of
Clinical Periodontology 7, 525-530.
Loe, H. & Silness, J. (1963) Periodontal dis-
ease in pregnancy (I). Prevalence and sev-
erity. Acta Odontologica Scandinavica 21,
533-551,
Monefeld, I. & Zachrisson, B. (1977) Adjust-
ment of clinical crown height by gingivec-
tomy following orthodontic space closure.
Angle Orthodontics 47, 256-264.
Palomo, F. & Kopczyk, R. A. (1978) Ration-
ale and methods for crown lengthening,
JADA 96, 257-260,
Pennel, B. M,, King, K, O., Wilderman, M,
N. & Baron, J, M. (1967) Repair of the
alveolar process following osseous surgery.
Journal of Periodontology 38, 426-431.
Pontoriero, R., Celenza, F , Ricci, G, & Car-
nevale, G. (1987) Rapid extrusion with fib-
er resection: A combined orthodontic -
periodontic treatment modality. The Inter-
national Journal of Periodontics and Re-
storative Dentistry 5, 31^3,
Ramfjord S, P & Costich, E, R, (1968) Heal-
ing after exposure of periosteum on the
Surgical crown lengthening 63
alveolar process. Journal of Periodontology
39, 199-207.
Siegel, S. (1956) Non-parametric statistics for
the behavioral sciences. McGraw-Hill Book
Company, New York, Toronto, London.
Silness, J. & Loe, H. (1964) Periodontal dis-
ease in pregnancy (II). Correlation be-
tween oral hgiene and periodontal con-
dition. Acta Odontologica Scandinavica 24,
747-759,
Tal, H. & Diaz, M. L, (1985) Crown length-
ening procedures: an overview. Journal of
Dental Medicine 3, 3-7.
Wilderman, M. N., Wentz, F, M, & Orban,
B, J, (1960) Histogenesis of repair after
mucogingival surgery. Journal of Perio-
dontology 31, 283-299,
Wilderman, M. N, (1963) Repair after a peri-
osteal retention procedure. Journal of
Periodontology 34, 487-503,
Address:
Urs Bragger
University of Berne
School of Dental Medicine
Freiburgstrasse 7
CH-3010 Berne
Switzerland