A Multidisciplinary Approach to Esthetic Dentistry

Journal of Dental Sciences and Oral Rehabilitation, July-September 2014;5(3):161-164 161

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A Multidisciplinary Approach to Esthetic Dentistry1Anuraag Gurtu, 2Anurag Singhal, 3KK Dixit, 4Kunal Agnihotri, 5Ridhi Bansal

CASE REPORT

1,3Professor, 2Professor and Head, 4,5Postgraduate Student1-5Department of Conservative Dentistry and Endodontics Institute of Dental Sciences, Bareilly, Uttar Pradesh, India

Corresponding Author: Anuraag Gurtu, Professor, Department of Conservative Dentistry and Endodontics, Institute of Dental Sciences, Bareilly, Uttar Pradesh, India, Phone: +91-9897571589 e-mail: anuraggurtu@yahoo.com

10.5005/jp-journals-10039-1036

ABSTRACTThe appearance of the gingival tissues surrounding the teeth plays an important role in the esthetics of the anterior maxillary region of the mouth. Abnormalities in symmetry and contour can significantly affect the harmonious appearance of the natural or prosthetic dentition. As well nowadays, patients have a greater desire for more esthetic results which may influence treatment choice. When restoring teeth that have subgingival caries or fractures below the gingival attachment, a clinical crown-leng-thening procedure is needed to establish the biologic width.

Keywords: Crown-lengthening, Esthetics, Subgingival caries, Biologic width.

How to cite this article: Gurtu A, Singhal A, Dixit KK, Agnihotri K, Bansal R. A Multidisciplinary Approach to Esthetic Dentistry. J Dent Sci Oral Rehab 2014;5(3):161-164.

Source of support: Nil

Conflict of interest: None

INTRODUCTION

An ideal anterior appearance necessitates healthy and inflammation-free periodontal tissues. Garguilo1 described various components of the periodontium, giving mean dimensions of 1.07 mm for the connective tissue, 0.97 mm for the epithelial attachment and 0.69 mm for the sulcus depth. These measurements are known today as the biologic width. Ingber et al2 observed that the presence of caries or restorations in close proximity to the alveolar crest may lead to inflammation and bone loss due to violation of the biologic width. Hence, they recommended that the restorative margin be a minimum of 3 mm coronal to the alveolar crest, suggesting that this margin could be achieved through a surgical intervention known as crown-lengthening surgery.

Crown-lengthening has been traditionally utilized as an adjunct to restorative dentistry, typically in situations where subgingival caries or fractures require the exposure of sound tooth structure and re-establishment of the biologic width space. Additionally, chronic gingivitis secondary to the placement of restorations that impinge on the biologic width may also be treated with crown-lengthening procedures.3

Clinical crown-lengthening is performed to achieve margins on sound tooth structure, maintenance of the bio-logic width, access for impression techniques and esthetics.10 Clinical crown-lengthening procedures include gingi-vectomy, an apically positioned flap (APF), an APF with osseous reduction, forced eruption combined with surgery, and forced eruption combined with fibrotomy.

RATIONALE FOR SURGICAL CROWN-LENGTHENING

Esthetic and Functional Concerns

The indications for crown-lengthening surgery include esthetic enhancement, exposure of subgingival caries, exposure of a fracture or some combination of these. Crown-lengthening surgery has been categorized as esthetic or functional. The term ‘functional’ relates to exposure of subgingival caries, exposure of a fracture or both. Often, the discussion of crown-lengthening in the anterior sextants is presented in the context of esthetic surgery. Excess gingival display can occur when passive eruption has been delayed. The result is the appearance of short clinical crowns. In the presence of a medium or a high lip line, this condition is more noticeable. If the patient desires an anterior dentition that is more normal in tooth length, resective treatment that exposes the anatomical crowns may be warranted.6,7

In an esthetically important area in which the free gin-gival margin may be located significantly coronal to the cementoenamel junctions (CEJs) of the dentition, resection of these excess tissues may not pose a high risk of developing a problematic situation. This is true, even if full-coverage restorations are not planned, as long as the interdental tissues are not involved in the process of resection.8 Moreover, an altered morphology of the anterior dentition’s interdental papillae after healing also is a concern. Black triangles may develop if the postresection distance between the contact area and the interdental osseous crest is greater than 5 millimeters.9

Unlike scenarios where the exposure of sound tooth struc ture is the main goal, the success of esthetic crown-lengthening is determined by the ultimate restorative margin position and the postoperative appearance of the gingival tissues. Conventional protocols require a waiting period of 4 to 6 weeks for sufficient healing of the attachment apparatus prior to initiating restorative endeavors.4

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CASE REPORT

A 23-year-old female patient reported to the Department of Conservative Dentistry and Endodontics with a chief complaint of esthetic correction for her upper and lower front teeth (Fig. 1). Past dental history revealed patient got composite restoration in the proximal area with respect to 11, 21 one year back. Her medical history was noncontributory. Clinical examination revealed subgingival caries with respect to 21 and proximal caries with respect to 32, 31 and 41 in addition there was localized spacing with respect to 32, 31 and 41, none of these teeth had sensitivity. Radiographic examination showed no periapical pathology. Electric pulp test result showed vital 11, 21, 32, 31 and 41.

The treatment phase was divided into 3 phases:• 1st phase: Caries removal, esthetic correction and mid

line closer of lower anterior teeth: In phase 1 of treatment proximal caries with respect to 32, 31 and 41 was removed following which esthetic recontouring of 32 and mid-line diastema closure was performed with respect to 31 and 41 (Fig. 2) with use of light cure composite (Z350 3m ESPE).

• 2nd phase: Surgical crown-lengthening and caries removal: In the 2nd phase envelop flap was raised exten ding from distal aspect of 12 to distal aspect of 22 (Fig. 3). After raising the flap it was evident that there was subgingival caries with respect to 11 as well. Hence

Fig. 1: Preoperative photograph Fig. 2: Esthetic correction and mid line diastema closer with respect to 31 and 41

Fig. 3: Envelop flap raised Fig. 4: Caries excavation

Fig. 5: Composite restoration Fig. 6: Crown-lengthening with respect to 12, 11, 21, 22

A Multidisciplinary Approach to Esthetic Dentistry

Journal of Dental Sciences and Oral Rehabilitation, July-September 2014;5(3):161-164 163

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Fig. 7: Healing after 8 weeks/2 months Fig. 8: Removal of caries and old composite restoration

Fig. 9: After final restoration

Table 1: Classification system for esthetic crown-lengthening procedures3

Classification Characteristics Advantages DisadvantagesType I Sufficient soft tissue allows

gingival exposure of the alveolar crest or violation of biologic width

May be performed by the restorative dentist.Provisional restorations of the desired length may be placed immediately

Type II Sufficient soft tissue allows gingival excision without exposure of the alveolar crest but in violation of the biologic width

Will tolerate a temporary violation of the biologic width?Allows staging of the gingivectomy and osseous contouring procedures.Provisional restorations of the desired length may be placed immediately

Requires osseous contouring.May require a surgical referral.

Type III Gingival excision to the desired clinical crown length will expose the alveolar crest

Requires osseous contouringMay require a surgical referralLimited flexibility

Type IV Gingival excision will result in inadequate band of attached gingival

Limited surgical optionNo flexibility

caries was removed (Fig. 4) and composite restoration was placed in the defect (Fig. 5). Further crown-lengthening proce dure was performed with respect to 12, 11, 21, 22 in order to increase the clinical height of the crown (Fig. 6). Postoperative photograph (Fig. 7) after 2 months shows proper adaptation of gingival margin.

• 3rd phase: Esthetic correction of 11 and 21: In 3rd phase of treatment, previous proximal composite filling and secondary caries on 11 and 12 were removed (Fig. 8) which was followed by esthetic recontouring of 11 and 12 (Fig. 9) with use of light cure composite (Z350 3M ESPE).

DISCUSSION

In regions of the mouth where esthetics are important, wound-healing after crown-lengthening surgery must be allowed to proceed to completion if optimal results are to be achieved. Any disruption of the wound-healing process can lead to undesirable consequences. After crown-lengthening surgery, the periodontium continues to remodel and mature. Bragger et al5 reported that gingival recession can occur between 6 weeks and 6 months after the surgery. Hence, if prosthetic reconstructions are planned, recessions must be closely observed during the healing phase. Tem porary crowns should be retained until the wounds are completely

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healed (possibly up to 6 months), after which final crown preparation and insertion can be accomplished. If these guide lines are followed, gingival recession should not occur. Supporting this a classification as proposed by Ernesto3 has been given for esthetic crown-lengthening procedures (Table 1).

CONCLUSION

With the increasing popularity of esthetic-oriented treatment, an understanding of the therapeutic synergies brought about by an interdisciplinary approach has developed. As a result, crown-lengthening procedures have become an integral component of the esthetic armamentarium and are utilized with increasing frequency to enhance the appearance of restorations placed within the esthetic zone.

REFERENCES

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2. Ingber JS, Rose LF, Coslet JG. The ‘biologic width’—a concept in perio dontics and restorative dentistry. Alpha Omegan 1977;70(3):62-65.

3. Ernesto A. Aesthetic crown lengthening: classification, biologic rational and treatment planning considerations. Pract Proced Aesthet Dent 2004;16(10):769-778.

4. Chu SJ. A biometric approach to esthetic crown lengthening. Pract Proced Aesthetic Dent 2007;19(10):1-24.

5. Bragger U, Lauchenauer D, Lang NP. Surgical lengthening of the clinical crown. J Clin Periodontol 1992;19(1):58-63.

6. Allen EP. Surgical crown lengthening for function and aesthetics.Dent Clin North Am 1993;37(2):163-179.

7. McGuire MK. Periodontal plastic surgery. Dent Clin North Am 1998;42(3):411-465.

8. Hempton TJ, Esrason F. Crown lengthening to facilitate restorative treatment in the presence of incomplete passive eruption. J Calif Dent Assoc 2000;28(4):290-291.

9. Tarnow DP, Magner AW, Fletcher P. The effect of the distance from the contact point to the crest of bone on the presence or absence of the interproximal dental papilla. J Periodontol 1992; 63(12):995-996.

10. Becker W, Ochsenbein C, Becker BE. Crown lengthening: The periodontal-restorative connection. Compend Contin Educ Dent 1998;19(3):239-246.