Maximise treatment outcomes
Featured Products Promotional FeaturesPosted by: Dental Design 16th May 2022
Crown lengthening has various indications, from supporting crown placement to enhancing smile aesthetics. However, like all dental procedures, crown lengthening requires careful planning and consideration of the patient’s oral health and anatomy to maximise the potential for successful treatment outcomes.
It’s in the details
An ‘attractive’ smile is thought to be comprised of the upper lip position, the proportion and colour of the teeth and the amount of gingiva that is displayed.[i] Excessive gingival display (EGD), or a ‘gummy’ smile, can cause extensive aesthetic concerns for the patient. It has been reputed that a smile with a gingival display of 1 to 2mm is adequate for an attractive smile.[ii] There may be several possible aetiologies for EGD; gingivitis, gingival hyperplasia, altered passive eruption (APE) or tooth wear.i Ascertaining the cause of the patient’s excessive gingival display will aid in devising a suitable treatment plan, and thus securing a desirable outcome.
Depending on the cause, EGD can be remedied with certain therapies such as lip repositioning surgery, botulin toxin injections, hyaluronic acid injections or crown lengthening. Where indicated, crown lengthening has been shown to be an ideal treatment pathway for patients with APE,[iii] however, as with all dental procedures, careful planning and analysis of the patient’s oral health and anatomical morphology is paramount for optimal outcomes.[iv] [v] A study[vi] noted that problems encountered during treatment can be directly traced to factors overlooked prior to surgery, in the examination and planning stages. So, balancing the anatomical considerations with the desires of the patient will help the clinician to formulate the best course of action, as well as ensure that all possible risks and challenges are reduced.
Things to consider
The biologic width is an important consideration when planning for crown lengthening therapy. It has been noted that biologic width is essential for the preservation of periodontal health. Poor management of the biologic width can cause bleeding, inflammation and/or recession of the gingival tissue, formation of pockets between the gingivae and teeth and the loss of alveolar bone. In restorative dentistry, biologic width violation can also impact the prostheses and thus the outcome of the treatment.[vii] [viii] Gingival biotype can similarly impact treatment outcomes.
Gingival biotypes are usually categorised into ‘thick’ and ‘thin’ types; thick periodontal biotypes have been noted to be related to good periodontal health, although it has likewise been noted that inflammation of these tissues can result in increased pocket formation in thick biotypes and gingival recession in thin biotypes.[ix] Therefore, the identification of the gingival biotype is important due to the various responses it can have to trauma, and the subsequent effects these responses can have on the outcomes of restorative and regenerative therapies.[x] [xi] Gingival biotype thickness can be ascertained through various methods, such as periodontal probing or with digital methods such as computed tomography scanning (CTS).[xii]
In the patient’s hands
As part of the treatment planning, patients must be made fully aware of their role in the aftercare. Providing them with all the relevant information and guidance will ensure that they fully comprehend how they can best support their gingivae throughout the healing period. Alongside patient co-operation, regular maintenance visits play an integral role in the success of the treatment, and will motivate patients to maintain their periodontal health appropriately.[xiii]
Patients who seek treatment for aesthetic reasons must have their expectations managed, as their desired final look may not always be possible, depending on the condition of their oral health, and soft and hard tissues. Therefore, to avoid dissatisfaction, employing a more patient-centric approach during the treatment planning stage can increase patient satisfaction.[xiv] Researchxiii has shown that implementing additional communication methods, such as digital tools, can further enhance patient satisfaction with treatment outcomes, improve quality of care and establish a more positive patient-dentist relationship.
Before and after – gummy smile treatment
The more you know…
For clinicians looking to discover more on the topic, the Surgical Crown Lengthening Hands-on course with BPI Dental Education & Training provides an exceptional opportunity to delve into the topic and learn more about surgical techniques, aesthetic considerations, treatment planning and much more. This one-day course also provides clinicians with a chance to get hands-on, so they can put what they have learned into practice.
A successful outcome relies upon a synergy between the treatment planning, patient assessment, the surgery and aftercare. By executing each step correctly, other treatments that affect the gingival tissues, such as those orthodontic in nature, will be enhanced and improved.
For more information or to book upcoming courses, please visit https://bpieducation.co.uk/dental-courses/surgical-crown-lengthening/
[i] Van der Geld, P., Oosterveld, P., Van Heck, G. and Kuijpers-Jagtman, A.M. (2007). Smile Attractiveness. The Angle Orthodontist, [online] Available at: https://meridian.allenpress.com/angle-orthodontist/article/77/5/759/57949/Smile-AttractivenessSelf-perception-and-Influence [Accessed 8 Feb. 2022].
[ii] Brizuela, M. and Ines, D. (2022). Excessive Gingival Display. [online] PubMed. Available at: https://www.ncbi.nlm.nih.gov/books/NBK470437/ [Accessed 7 Feb. 2022].
[iii] Cairo, F., Graziani, F., Franchi, L., Defraia, E. and Pini Prato, G.P. (2012). Periodontal Plastic Surgery to Improve Aesthetics in Patients with Altered Passive Eruption/Gummy Smile: A Case Series Study. International Journal of Dentistry, [online] Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3465986/ [Accessed 7 Feb. 2022].
[iv] Izwan Omar, N. and Mohd, N. (2021). Esthetic Management of Gummy Smile with Maxillary Bone Protuberance and Altered Passive Position of Teeth. Journal of International Dental and Medical Research. [online] Available at: https://www.researchgate.net/publication/355174990_Esthetic_Management_of_Gummy_Smile_with_Maxillary_Bone_Protuberance_and_Altered_Passive_Position_of_Teeth [Accessed 7 Feb. 2022].
[v] Xenoudi, P. and Karydis, A. (2019). Crown Lengthening Procedures for Functional and Esthetic Purposes. Current Oral Health Reports, [online] Available at: https://link.springer.com/article/10.1007/s40496-019-00229-2 [Accessed 7 Feb. 2022].
[vi] Sivakumar, A., Thangaswamy, V. and Ravi, V. (2012). Treatment planning in conservative dentistry. Journal of Pharmacy and Bioallied Sciences, [online] Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3467905/ [Accessed 7 Feb. 2022].
[vii] Saathvika Ramani, V. (2020). A Review On Biologic Width: The Key To Restorative And Periodontal Interrelationships. Annals of the Romanian Society for Cell Biology, [online] Available at: https://www.annalsofrscb.ro/index.php/journal/article/view/9646 [Accessed 7 Feb. 2022].
[viii] Aishwarya, M. and Sivaram, G. (2015). Biologic width: Concept and violation. SRM Journal of Research in Dental Sciences, [online] Available at: https://www.srmjrds.in/article.asp?issn=0976-433X;year=2015;volume=6;issue=4;spage=250;epage=256;aulast=Aishwarya [Accessed 7 Feb. 2022].
[ix] Rana, A. (2015). Gingival Biotype Assessment in a Healthy Periodontium: Transgingival Probing Method. JOURNAL OF CLINICAL AND DIAGNOSTIC RESEARCH. [online] Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4484158/#b8 [Accessed 7 Feb. 2022].
[x] Abraham, S., Deepak, K.T., Ambili, R., Preeja, C. and Archana, V. (2014). Gingival biotype and its clinical significance – A review. The Saudi Journal for Dental Research, [online] Available at: https://www.sciencedirect.com/science/article/pii/S221081571300019X [Accessed 7 Feb. 2022].
[xi] Shah, R., Sowmya, N.K., Thomas, R. and Mehta, D.S. (2016). Periodontal biotype: Basics and clinical considerations. Journal of Interdisciplinary Dentistry, [online] Available at: http://www.jidonline.com/text.asp?2016/6/1/44/188172 [Accessed 7 Feb. 2022].
[xii] Alves, P.H.M., Alves, T.C.L.P., Pegoraro, T.A., Costa, Y.M., Bonfante, E.A. and de Almeida, A.L.P.F. (2018). Measurement properties of gingival biotype evaluation methods. Clinical Implant Dentistry and Related Research, [online] Available at: https://onlinelibrary.wiley.com/doi/abs/10.1111/cid.12583 [Accessed 7 Feb. 2022].
[xiii] Razi, M.A., Debnath, S., Chandra, S. and Hazra, A. (2019c). Biologic Width – Considering Periodontium in Restorative Dentistry. International Journal of Contemporary Medical Research [IJCMR], [online] Available at: https://pesquisa.bvsalud.org/portal/resource/pt/sea-202268 [Accessed 7 Feb. 2022].
[xiv] Touati, R., Sailer, I., Marchand, L., Ducret, M. and Strasding, M. (2021). Communication tools and patient satisfaction: A scoping review. Journal of Esthetic and Restorative Dentistry. [online] Available at: https://onlinelibrary.wiley.com/doi/full/10.1111/jerd.12854 [Accessed 7 Feb. 2022].
