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\def\RunningAuthor{Deepika Masurkar et al.}
\firstPage{2926}
\articleType{Case Report}
\receivedDate{06 Nov 2020}
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\title{\textbf{Crown Lengthening Procedure: Report of Two Cases}}
\author{Deepika~Masurkar\textsuperscript{*},  
            Priyanka~Jaiswal, 
            Diksha~Agrawal~\\[5pt]{Department of Periodontics, Sharad Pawar Dental College, Datta Meghe Institute of Medical Sciences, Sawangi (Meghe), Wardha - 442004, Maharashtra, India}}

\begin{abstract}
Crown lengthening is a surgical procedure designed to increase the extent of the supragingival tooth structure, so that the clinician can restore the tooth. Crown lengthening procedure is done to maintain normal biologic width and increase crown length for retention of prosthesis. Various techniques have been proposed to perform CLP, such as gingivectomy, undisplaced flap with or without osseous reduction, apically repositioned flap with or without bone reduction, and orthodontic forced eruption with or without fibrotomy. Selection of one of this CLP technique depends upon esthetics, clinical ratio of crown to root, structure of root, location of furcation, position of tooth and the capacity of the tooth to be restored. This case report illustrate two different methods of doing crown lengthening procedure the selection of case depends upon various soft tissue and hard tissue parameters. Owing to the various advantages, disadvantages and associated limitation with different methods, we opted for surgical CLP with scalpel method. Uneventful healing was observed in both our cases. No post-operative complications was observed in both cases. Thus to conclude success rate of CLP is high but appropriate selection of case is required. In our case report both the methods of CLP shows significant result in increasing the crown length and maintaining the biological width.  
\end{abstract}\def\keywordstitle{Keywords}

\begin{keywords}Crown Lengthening,\newline Gingivectomy,\newline Osseous reduction
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\makeatletter{\raggedright\textsuperscript{*}Corresponding Author\par Name:\ Deepika~Masurkar~\\ Phone:\ 7758016390~\\  Email:\ dipika.masurkar@gmail.com
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\section{Introduction}
American Academy of Periodontology Practice Profile Survey in 2003 said that crown lengthening procedure (CLP) is one of the most commonly performed periodontal surgery.\unskip~\citep{991589:21302674}  In CLP it is often essential to gain both adequate resistance and retention form by achieving supracrestal tooth length\unskip~\citep{991589:21302677,991589:21302676,991589:21302682,991589:21302683}. Re-establishment of the biologic width is achieved  to avoid impingement of restoration margins on the attachment apparatus.\unskip~\citep{991589:21302681,991589:21302678} Various techniques have been proposed to perform CLP, such as gingivectomy, undisplaced flap with or without osseous reduction, apically repositioned flap with or without bone reduction, and orthodontic forced eruption with or without fibrotomy. Selection of one of this CLP technique depends upon esthetics, clinical ratio of crown to root, structure of root, location of furcation, position of tooth and the capacity of the tooth to be restored.\unskip~\citep{991589:21302670}

\unskip~\citep{991589:21302675} described the biologic width as ``the zone of the root surface coronal to the alveolar crest to which the junctional epithelium and connective tissue are attached'' which is approximately 2.04 mm. The dimension of the biologic width can vary based on the position of a tooth, from tooth to tooth, and from surface to surface on the same tooth. Crown margins which are located below gingiva can cause inflammation of gingiva leading to damage of biologic width, whereas crown margins present supra-gingivally did not cause gingival inflammation.\unskip~\citep{991589:21302669}

Thus, CLP must be done so as to allow easy restorative treatment of the teeth which have short crown length. CLP also results in access for appropriate restorative measures having deep subgingival pathologies by giving adequate retention form. 

This case report describes two methods of crown lengthening procedures in which normal biologic width is maintained and crown length is increased for retention of prosthesis.

\textbf{Case 1}

A 24-year-old systemically healthy male patient was referred to the department of Periodontics for crown lengthening procedure with \#46. Patient had undergone endodontic treatment with \#46 in department of Conservative dentistry, 1 week prior. Tooth had 1{\textendash}2 mm PPD on mid-lingual surface and 2-3 mm in mid-mesial, mid-distal and mid-buccal region. CAL was 1{\textendash}2 mm on mid-lingual surface and 2-3 mm in mid-mesial, mid-distal and mid-buccal region. Tooth was firm with no involvement of furcation area. Clinical crown length was 2 mm on the lingual side (Figure~\ref{f-4f3a4e6a8f6f}) and on mesial, distal and buccal side it is 4-5mm. IOPA showed a normal interproximal bone level (Figure~\ref{f-036458019b17}), and adequate root length. On the bases of CAL and radiograph, the amount of bone present was estimated to be 85\% {\textendash} 90 \%. Prognosis of tooth \# 46 was determined to be fair. Overall prognosis was good with mild chronic gingival inflammation. Oral prophylaxis was done including scaling and polishing. Patient was instructed for proper oral hygiene measures and further, patient was appointed for CLP.


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\caption{\boldmath {Incision given.}}
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\caption{\boldmath {Follow up after 7 days.}}
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\caption{\boldmath {Different instruments by which CLP is done their advantage and disadvantage.} }
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\tblmidrule 
\multicolumn{1}{p{\dimexpr(.19509999999999998\linewidth-2\tabcolsep)}}{\multirow{2}{\linewidth}{Scalpel}} &
  Readily available &
  Time consuming\\
 &
  Easy Handling &
  Bleeding during and after surgery.\\
\multicolumn{1}{p{\dimexpr(.19509999999999998\linewidth-2\tabcolsep)}}{\multirow{3}{\linewidth}{Electrocautery}} &
  Less time consuming &
  If cautery touches bone it can cause damage to root and bone\\
 &
  Less bleeding &
  expensive equipment\\
 &
   &
   Skilled professionals.\\
\multicolumn{1}{p{\dimexpr(.19509999999999998\linewidth-2\tabcolsep)}}{\multirow{5}{\linewidth}{Laser}} &
  Less postoperative complications &
  Need for additional education (especially in physics).\\
 &
   Less discomfort  &
  Expensive equipment\\
 &
  \multicolumn{1}{p{\dimexpr(.31959999999999997\linewidth-2\tabcolsep)}}{\multirow{3}{\linewidth}{}} &
  Not readily available in market\\
 &
   &
  Do not eliminate the need for anaesthesia.\\
 &
   &
  Implementation of safety measures\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}
\textbf{Surgical procedure}

Under local anesthesia\unskip~\citep{991589:21302668,991589:21302673}  a crevicular incision was made on the buccal and the lingual side of tooth \# 46. Full thickness flap reflection was done on both sides (Figure~\ref{f-eca357bf7588}). To maintain a biologic width post-operatively (during crown placement), 3{\textendash}4 mm osseous reduction on the lingual side was made with the help of micromotor and round carbide bur with 0.23 mm diameter (HM1T-023) under copious irrigation of normal saline (Figure~\ref{f-0b756a515b78}). Following the procedure, desirable crown length was achieved. After attaining heamostasis, flaps were positioned apically using interrupted and periosteal sutures at apical end (Figure~\ref{f-63a622fb73bb}). The periodontal pack was placed. 

Periodontal pack and suture removal was done after 7 days of surgery (Figure~\ref{f-fd6915b12cdf}). Post-operative evaluation after 7 days revealed uneventful healing and 4 mm of desirable crown length with tooth \# 46, sufficient for crown placement. Patient's re-evaluation was done after 21 days to check for complete healing. Furthermore, patient was referred to department of Prosthodontics after 12 weeks\unskip~\citep{991589:21302678,991589:21302672} for placement of PFM crown with 46.

\textbf{Case 2 }

A 25-year-old male patient was referred to the department of Periodontics for crown lengthening procedure with \#16. On intra-oral examination, it was observed that endodontic treatment was performed with tooth \#16. Tooth had 3-4 mm PPD on the mid-palatal surface (Figure~\ref{f-a6f2baf7204d}) and 2-3 mm in mid-mesial, mid-distal and mid-buccal region. Tooth was firm with no involvement of furcation area. CAL was 1{\textendash}2 mm on mid-palatal surface and 2-3 mm in mid-mesial, mid-distal and mid-buccal region. Clinical crown length was 2 mm on the palatal side (Figure~\ref{f-4f3a4e6a8f6f}) and on mesial, distal and buccal side it is 4-5mm.

Reduction of only soft tissue was indicated in this case as there was adequate attached gingiva and more than 3 mm of the soft tissue was present above the crest of the bone.

Under local anesthesia the pocket on palatal side was marked with the help of pocket marker (Figure~\ref{f-561e4962442d}). Incision with blade no \# 15 was given starting 1 mm apical to the marking and is directed coronally to the point between the base of the pocket to the crest of the alveolar bone (Figure~\ref{f-043ab518441e}). The incision given was close to the crest of bone but did not expose it (Figure~\ref{f-963b68d9da7d}). Soft tissue above the bone was removed. Adequate crown length for prosthetic replacement, considering the biologic width was achieved. Periodontal pack was given to protect the raw wound (Figure~\ref{f-758cae39de32}). 

Periodontal pack removal was done 7 days after surgery. Post operative evaluation after 7 days (Figure~\ref{f-af57ab313a54}) reveled uneventful healing and 4 mm of desirable crown length with tooth \# 16. Patient's re-evaluation was done after 21 days to check for complete healing. Furthermore, patient was referred to the department of Prosthodontics 12 weeks post-operatively for placement of PFM crown with \# 16.\unskip~\citep{991589:21302678}
    
\section{Discussion}
The concept of CLP was given by  D.W. Cohen (1962).\unskip~\citep{991589:21302673} The purpose of CLP is to avoid the violation of biologic width that may occur due to placement of subgingival margin of crown in order to get adequate retention form in short clinical crown cases. Violation of biologic width results into injury to the periodontium, leading to inflammation of gingiva, loss of attachment level and resorption of bone.\unskip~\citep{991589:21302672}

The objective of CLP is to provide sufficient clinical crown for tooth restoration. The indications of CLP are subgingival fracture, naturally short clinical crown due to non-exposure of anatomic crown, teeth shortened by extensive caries or fracture and subgingival/ root caries.\unskip~\citep{991589:21302684}

In a clinical and radiographic study, it was seen that surgical extrusion technique have few advantages over the other conventional CLP techniques like preservation of the position of gingival margin and interproximal papilla.\unskip~\citep{991589:21302680}\ensuremath{^{}} However, \unskip~\citep{991589:21302679} reported that surgical extrusion\ensuremath{^{}} can cause marginal bone loss and apical root resorption. 

CLP can be carried out by various instruments such as scalpels, cautery and lasers which have their own advantages, disadvantages (Table~\ref{tw-cc593c0727b8}).\unskip~\citep{991589:21302667,991589:21302671}

Owing to the above mentioned advantages, disadvantages and associated limitation with different methods, we opted for surgical CLP with scalpel method. Uneventful healing was observed in both our cases. No post-operative complications was observed in both cases.
    
\section{Conclusions}
When a crown placement is to be done, the maintenance of an intact, healthy periodontium and appropriate crown length is necessary to maintain the tooth. CLP is practical to perform which facilitate restorative therapy and improves the esthetic appearance. Success rate of CLP is high but appropriate selection of case is required. In our case reports, both the cases showed significant result in increasing the clinical crown length while maintaining the biological width post crown placement. 

\textbf{Conflict of interest}

The authors declare that they have no conflict of interest for this study.

\textbf{Funding support}

The authors declare that they have no funding support for this study.
    

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