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Flapless aesthetic crown lengthening: A new therapeutic approach

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Caso clínico
Vol. 2 Núm. 3 Sep-Dic 2011

Flapless aesthetic crown lengthening: A new

therapeutic approach
Julio Cesar Joly,* Paulo Fernando Mesquita de Carvalho,** Robert Carvalho da Silva ***
Abstract

Aesthetic crown lengthening is one important chapter in contemporary periodontology. Traditionally, this procedure is
performed using a flap elevation to a full exposure of the underling bone to allow for osteotomy/osteoplasty. However, in
well-indicated cases, it is possible to meet that purpose using a flapless approach; i.e. without a flap elevation, in which
the osteotomy is performed through the gingival sulcus using proper micro-chisels. To do this, it is important to have an
adequate width of keratinized tissue and a bone crest not considered thick (thin and intermediate tissue biotypes). Among
the benefits of this breaking-through procedure are low morbidity with no sutures, less bleeding, greater patient acceptan-
ce, and immediate outcome. As long as the indications are respected and the learning curve is left behind, predictable
outcomes are expected. Flapless aesthetic crown lengthening is one alternative minimally invasive approach which, when
indicated, offers realistic clinical benefits to our patients.

Key words: Gummy smile, periodontal plastic surgery, aesthetic, flapless crown lengthening.

Resumen

El alargamiento coronario estético es un concepto importante en la periodontología contemporánea. Tradicionalmente, en

este procedimiento se hace elevación de colgajos para poder realizar osteomía/osteoplastia en el hueso subyacente. Sin em-
bargo, en casos específicos este propósito es alcanzado utilizado un abordaje sin elevación de colgajos (Flap-less approach).
La osteotomía es realizada a través del surco gingival utilizando microcinceles. Para efectuar esta técnica es importante contar
con un adecuado ancho de tejido queratinizado y una cresta delgada o intermedia evitando las crestas gruesas). Entre los ben-
eficios de este procedimiento de ruptura a través del surdo gingival están la baja morbilidad, el prescindir de suturas, un menor
sangrado, una mayor aceptación del paciente y los resultados son inmediatos. Siempre y cuando se respeten las indicaciones
y la curva de aprendizaje quede atrás, los resultados predecibles son esperados.

Palabras clave: Sonrisa gingival, cirugía plástica periodontal, cirugía estética periodontal, cirugía sin colgajo.

* Coordenador do Curso de Mestrado em Periodontia-CPO/São Leopoldo Mandic–Campinas. Coordenador dos Cursos de Especiali-
www.medigraphic.org.mx
zação em Periodontia e Implantodontia-APCD–Piracicaba. Professor do Curso Avançado de Reconstrução Tecidual em Áreas Estéti-
cas-CETAO-São Paulo.
** Professor dos Cursos de Especialização em Periodontia e Implantodontia-APCD–Piracicaba. Professor do Curso Avançado de Recons-
trução Tecidual em Áreas Estéticas-CETAO-São Paulo.
*** Coordenador do Curso de Especialização em Periodontia-EBO/SLM–Brasília. Professor do Curso de Mestrado em Periodontia-CPO/
SLM–Campinas. Professor dos Cursos de Especialização em Periodontia e Implantdontia-APCD–Piracicaba. Professor do Curso
Avançado de Reconstrução Tecidual em Áreas Estéticas-CETAO-São Paulo.

Este artículo puede ser consultado en versión completa en http://www.medigraphic.com/periodontologia

103
 Joly JC, Mesquita CPF, Carvalho SR

INTRODUCTION The precise indication calling for intervention by a pe-

riodontist is the altered passive eruption.5 In these cases,
It seems that there is no «ideal recipe» for an attractive the facial proportions and length/motility of the upper lips
and beautiful smile. However, the harmony and symme- are normal; however, there is an extensive exposure of the
try of its elements (facial, labial and dental elements) are gingiva and short clinical crowns. Tooth eruption is deter-
very important.1 Several factors should be evaluated in mined by the crown emerging from the bony housing, and
the esthetic planning towards smile optimization, parti- is finished when teeth reach the occlusal plane and occlu-
cularly those periodontal aspects related to tissue color, de. During this process, the soft tissues are also moved in
contour, symmetry, zenith and position of the gingival the coronal direction and start to physiologically recede
margins.2 in the apical direction to the level of the cement-enamel
During a spontaneous smile, the position of the inferior junction –CEJ– (passive eruption). When for any reason
border of the upper lip determines three different condi- the soft tissues don’t migrate apically, it is called altered
tions of exposure of the teeth and gingival tissues (high, passive eruption, and is characterized by excess of coverage
average and low lip-lines).3 In this moment, it is very of the crown by the soft tissues. It can be sub-classified re-
important to distinguish two frequent terms that are very lated to the position of the CEJ and the bony crest (BC).5,6
used in clinical practice that can sometimes cause confu-
sion: gummy smile and high lip-line. Gummy smile refers TECHNIQUE DESCRIPTION
to conditions when patients expose 3.0 mm or more of gin-
giva during speech or smile;4 so while every patient har- In flapless aesthetic crown lengthening, it is imperative to
boring a gummy smile appearance has a high lip-line, the meet the precise indications to fully benefit the patients:
contrary is not necessarily true. Understanding the correct abundant keratinized tissue and thin bone (thin or interme-
diagnosis of gummy smile is essential to indicate proper diate biotypes). The incision is positioned on the CEJ level
treatment.5,6 It can be related to vertical bone excess, den- when pristine teeth are treated (intact, without restorati-
to-alveolar extrusion, labial muscle hypermobility, altered ve needs) (Figures 1 a-k), or at the desired gingival margin
passive eruption, and combinations of these. when restorative procedures are indicated (Figures 2 a-m).

1a

1c

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1d 1b

Figures 1 (a-d). a-c. Different views of a patient with excessive gingival display associated with smile disharmony; observe
the great amount of keratinized tissue and an intermediate biotype. d. Probing to identify the sulcus depth, CEJ and bone crest.

104 Revista Mexicana de Periodontología 2011; 2(3): 103-108

 Flapless aesthetic crown lengthening: A new therapeutic approach

1e

1i
1f

1j

1g

1h
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1k

Figures 1 (e-k). e. Gingival recontour using an internal besel. f. Osteotomy without flap elevation using the micro-chisel. g-h. Gingival
outline refinement, using a curved micro-scizor. i-k. Clinical appearance 3 years after surgery, in which can be observed a good balance of
the zenith of the teeth and gingival arquitecture and less exposure of the tissues during smile.

Revista Mexicana de Periodontología 2011; 2(3): 103-108 105

 Joly JC, Mesquita CPF, Carvalho SR

2a 2f

2b 2g

Este documento es elaborado por Medigraphic

2c 2h

2d 2i

2e www.medigraphic.org.mx 2j

Figures 2 (a-m). a-b. Gummy smile appearance associated to passive aleterd eruption and short/hipermobile upper lip (combined
ethiology). c-d. Mock-up in place suggesting case resolution, observe in figure d the comparison between the sides with and without
the resin suggesting the clinical improvement of both crown lengthening and restaurations. e. Internal besel incision performed.
f. Bone sounding. g. It defines the necessity to do an osteotomy. h. Clinical view 4 months after the surgery depicting soft tissue
maturation and allowing for the phrosthetic rehabilitation. i-j. Tooth preparation for venners and provisionals’ delivery.

106 Revista Mexicana de Periodontología 2011; 2(3): 103-108

 Flapless aesthetic crown lengthening: A new therapeutic approach

an osteotomy, on the other hand if the distance found is

greater than or equal to 2.0 mm; in most the cases the gin-
gival margin is stable in that position following healing. Of
course, in cases with restorative needs, the CEJ is not used
as a reference for the incision and landmark for the even-
tual need for osteotomy. In those instances, our referen-
ce is the future prosthetic margin. The osteotomy, when
indicated, is performed through the gingival sulcus using
proper and delicate micro-chisels in small movements to
2k
establish the vertical distance to accommodate the struc-
tures of that biologic width. We accept 2.0-3.0 mm as
an ideal distance between the bone crest and CJE/future
prosthetic margin. In those cases, since the indication is
strictly for thin or moderate tissue biotypes, the bone is
generally thin and there is no need for any osteoplasty.
During all the procedures, a thorough irrigation using cold
saline solution is performed, and at the end of the surgery
gauze compression is done to stop any bleeding. No sutures
or dressing are necessary.

DISCUSSION

2l The treatment planning for aesthetic crown lengthening

has to take into account the necessity or otherwise of asso-
ciated prosthetic rehabilitation. In clinical situations, where
veneers or crowns are anticipated, the determination of the
future prosthetic margin should match the gingival margin
contours and will eventually orient the extent of osteotomy.
In these cases, exposure of the roots is not a problem since
restorations will cover those areas. There should be suffi-
cient time for healing of the soft tissues before the final too-
th preparation and impression. The gingival sulcus seems
to be completely established after 3 months, but complete
healing of the tissues can take up to a year depending of cha-
2m racteristics of the initial surgery;7 i.e., the amount of osteo-
tomy and osteoplasty. When no restorations are anticipated
the reference for eventual osteotomy is the CEJ.
k-m. Clinical aspect of the condition 9 months after the surgery and In clinical situations related to altered passive eruption,
the crown/venners in position. Observe the harmony and simetry of the amount of keratinized tissue determines what inci-
the patient smile improving the overall appearance. sion should be performed; i.e., if there is a good amount of
tissue, an internal bezel can be easily used. On the other
hand, if minimal keratinized tissues are observed, an in-
Following incision, the tissue collar is removed using re- trasucular incision is generally performed associated with
gular scalers and contours of the gingival margin are re- an apically positioned flap.8 This is important because
www.medigraphic.org.mx
fined using curved micro-scissors. The next step is the
bone sounding, in which a periodontal probe is positioned
although there is no minimum amount of tissues conside-
red adequate for establishing health, the keratinized tissue
parallel to the crown through the gingival sulcus until it is considered a nobel structure related to esthetics and to
stops at the bone crest. On average, the biologic width stabilization of the gingival sulcus. For this reason, we be-
(disregarding the gingival sulcus) is around 2.0 mm; i.e., lieve that we should always maintain at least 3.0 mm of
the vertical distance necessary to establish the biological keratinized tissue.
seal at the supra-bony area and below the CEJ. When that The distance between the CEJ and bone crest determines
distance is less than 2.0 mm it means we have to promote the need or otherwise for osteotomies to establish the spa-

Revista Mexicana de Periodontología 2011; 2(3): 103-108 107

 Joly JC, Mesquita CPF, Carvalho SR

ce for the adaptation of the periodontal structures of the 6. Levine RA, McGuire M. The diagnosis and treatment of
biologic seal (biologic width). Traditionally, osteotomy the gummy smile. Compend Contin Educ Dent 1997; 18:
and osteoplasty are performed after a flap elevation for full 757-62, 764; quiz 766.
exposure of the bone. In our understanding, this is valid 7. Pontoriero R, Carnevale G. Surgical crown lengthening:
A 12-month clinical wound healing study. J Periodontol
for thick tissue biotype in which osteoplasty (thickness re-
2001; 72: 841-8.
moval) is recommended to improve the bone architecture 8. Joly JC, Da Silva RC, Carvalho PFM. Reconstrução teci-
and the adaptation of the tissues.8 dual estética - Procedimentos plásticos e regenerativos
In our practice, we have seen more cases of thin and inter- periodontais e peri-implantares. São Paulo: Artes Médi-
mediate tissue biotypes, especially in the pre-maxilla and cas 2009: 253-309.
therefore, in most clinical situations, osteoplasty is not 9. Januário AL, Duarte WR, Barriviera M, Mesti JC, Araújo
necessary.9 This means flap elevation in such cases is not MG, Lindhe J. Dimension of the facial bone wall in the
strictly necessary. Obviously, the so-called flapless proce- anterior maxilla: A cone-beam computed tomography
dure is technically sensitive, so a course of learning is ne- study. Clin Oral Implants Res 2011.
cessary to master it without tearing the soft tissues. Besides
this, without elevating the flap it is more difficult to orient
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108 Revista Mexicana de Periodontología 2011; 2(3): 103-108

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