Effects of the GingivalStat approach on early gingival margin remodeling following esthetic clinical crown lengthening: A case series.

OBJECTIVES: The aim of this case series is to present the potential applications of the GingivalStat approach, that is, the use of temporary gingival stabilizers, to favor early gingival margin remodeling and prevent the occurrence of gingival rebound following esthetic clinical crown lengthening. CLINICAL CONSIDERATIONS: Four patients requiring clinical crown lengthening were treated for esthetical and functional reasons. The surgical approach included: (a) gingival margin recontouring; (b) full-thickness flap elevation; (c) osteotomy (to achieve an adequate dimension between the alveolar bone crest and the CEJ) and osteoplasty (to reduce the bone thickness and improve the buccal bone anatomic profile, where indicated); (d) temporary gingival stabilizer placement using a block-out resin or a composite (the GingivalStat approach); and (e) flap repositioning, adaptation, and suture. One- to five-year follow-ups, reported in the different case scenarios, show evidence of clinically stable gingival margins around the treated teeth. CONCLUSIONS: Within the limits of this case series, it can be concluded that the GingivalStat approach appears as a further maneuver to cope with clinical crown lengthening procedures at esthetic sites. GingivalStat seems to favor gingival margin contour remodeling during the early phase of healing as well as prevent the occurrence of gingival rebound. CLINICAL SIGNIFICANCE: GingivalStat approach may guide gingival margin remodeling and prevent gingival rebound after wound healing of sites submitted to esthetic clinical crown lengthening.

Evaluation of minimally invasive esthetic crown lengthening using an open flap versus flapless surgical approach: A randomized controlled clinical trial.

OBJECTIVES: Esthetic crown lengthening (ECL) is commonly advocated to treat patients with altered passive eruption (APE). Since the introduction of the minimally invasive surgical concept, a limited number of studies have investigated this technique in a standardized manner, with further studies required to verify the validity and predictability of the minimally invasive FL-technique. The current randomized trial compares a minimally invasive (ECL), using piezosurgery with flapless-approach (FL), versus an open-flap (OF) approach in the management of patients with APE Type 1B. MATERIALS AND METHODS: Twenty-four patients diagnosed with APE Type 1B were randomly assigned into test (FL) with tunneling approach or control (OF) group with minimally invasive flap reflection (n = 12/group). Postoperative pain was assessed during the first 48 h. Gingival margin (GM) level relative to a custom-made stent (rGM) and patient satisfaction were assessed preoperative, immediately after surgery, at 3 and 6 months postsurgically. Postoperative swelling was reported for the first week postsurgically. Plaque index (PI), bleeding on probing (BoP), clinical attachment level (CAL), pocket depth (PD) and pink esthetic score (PES), were evaluated at baseline and 6 months. Linear regression analysis was conducted for pain. RESULTS: OF-group reported significantly higher pain and swelling scores than FL-group during the first 48 h (p < 0.05). FL-group showed no significant differences regarding rGM between 3 and 6 months, in contrast to OF-group, where a significant decrease in rGM was notable (p < 0.05). No significant differences in PI, BoP, CAL, PD, PES, and patient satisfaction scores were evident between groups (p > 0.05). Regression analysis demonstrated that treatment and gender were significant predictors for pain (p < 0.05). CONCLUSIONS: Within the current study's limitations, piezo-surgical ECL with FL-approach presented significantly lower postoperative pain, swelling, and early GM stability compared to OF-approach. CLINICAL SIGNIFICANCE: Piezosurgical ECL with a FL-approach can be considered a predictable technique with advantages over the OF-approach in the management of patients with APE Type1B.

Use of both the diode and Er: YAG lasers in esthetic crown lengthening with the aid of digitally guided dual technique: 3 years follow-up.

OBJECTIVE: To explore the feasibility of the usage of digital guides in combination with low- and high-power lasers for the treatment of excessive gingival display, also known as "gummy smile". CLINICAL CONSIDERATIONS: Excessive gingival display due to altered passive eruption can affect patient's perception of their own esthetics and consequently have an impact on self-confidence. Therefore, the management of this condition should offer a predictable and stable long-lasting solution. To attain these objectives, digital planning emerges as a tool in optimizing the outcomes of crown lengthening surgery for this condition by enhancing precision through the use of surgical guides. Additionally, the usage of high- and low-powered lasers can provide a safe approach because of their tissue selective removal properties. CONCLUSIONS: The technique described showed satisfactory clinical results in the short- and long-term follow-up, leading to an improvement in patients' self-esteem. This approach integrates digital and laser technologies to deliver a surgical treatment characterized by precision, efficiency, and safety. CLINICAL SIGNIFICANCE: Digital dentistry has contributed to innovative dental procedures, as personalizing surgical guides for patients, assisting and guiding incisions of the gingival margins, as well as the extension of the osteotomy, during the procedures for increasing the clinical crown. Furthermore, smile esthetics are directly related to an individual's improved emotional and social quality of life.

Full-mouth rehabilitation with lithium disilicate ceramic crowns in hypoplastic amelogenesis imperfecta: a case report and review of literature.

BACKGROUND: Amelogenesis imperfecta (AI) is a group of genetic disorders characterized by tooth discoloration and enamel defects. Patients with AI always exhibit generalized attrition and defective tooth structure, leading to the loss of occlusal vertical dimension (OVD). Appropriate rehabilitation is challenging and essential to improve patients' aesthetics and function. CASE PRESENTATION: This case report presents a comprehensive management of a 30-year-old woman with hypoplastic AI. A 52-month follow-up revealed satisfactory full-mouth rehabilitation performances of lithium disilicate ceramic crowns after clinical crown lengthening, with increased vertical dimension. CONCLUSIONS: Patients with severe hypoplastic AI require proper full-mouth rehabilitation. Using full-crown lithium disilicate restorations to increase the OVD by 2‒4 mm is a safe and predictable recommendation for such cases. In addition, patients with AI require complex and comprehensive management. The long-term effects of full-mouth rehabilitation with lithium disilicate ceramic crowns still necessitate further follow-ups.

A comparative study of the use of digital technology in the anterior smile experience.

OBJECTIVES: this study aims to compare the clinical outcomes of traditional and digital crown extension guides in the aesthetic restoration of anterior teeth. Additionally, the study will analyze the differences in the results of various digital crown extension guides in anterior aesthetic restorations. METHODS: Sixty-two patients who required aesthetic restoration of their anterior teeth were selected for this study. The patients had a total of 230 anterior teeth and were randomly divided into three groups: a control group of 22 cases who received diagnostic wax-up with pressure film, an experimental group 1 of 20 cases who received 3D printed digital models with pressure film, and an experimental group 2 of 20 patients who received digital dual-positioning guides. The control group had a total of 84 anterior teeth, experimental group 1 had 72 anterior teeth, and experimental group 2 had 74 anterior teeth. The study compared three methods for fabricating crown extension guides: the control group used the diagnostic wax-up plus compression film method, while experimental group 1 used compression film on 3D printed models and experimental group 2 used 3D printed digital dual-positioning crown extension guides. After the crown lengthening surgery, the control group patients wore DMG resin temporary crown material for gingival contouring, while the experimental group patients wore 3D printed resin temporary crowns for the same purpose. The patients were followed up in the outpatient clinic after wearing temporary crowns for 1 month, 3 months, and 6 months, respectively. The clinical results were evaluated in terms of marginal fit, red aesthetic index, and white aesthetic index. RESULTS: Based on the statistical analysis, the experimental group required significantly fewer follow-up visits and less time for guide design and fabrication compared to the control group. Additionally, the surgical time for the experimental group was significantly shorter than that of the control group. During the postoperative period between the 1st and 3rd month, the PES index scores for the marginal gingival level, proximal, and distal mesiodistal gingival papillae of the experimental group showed a trend of superiority over those of the control group. By the 6th month, the marginal gingival level exhibited a significant difference between the experimental and control groups. The experimental group demonstrated superior results to the control group in terms of shape, contour, and volume of the teeth, color, surface texture, and transparency of the restorations, and features during the 1st and 3rd postoperative months. In the 6th month, the comparative results indicated that the experimental group continued to exhibit superior outcomes to the control group in terms of the shape, color, surface texture, and transparency of the restorations, as well as the characteristics of the teeth. Additionally, the experimental group demonstrated significantly fewer gingival alterations than the control group at 1 month, 3 months, and 6 months post-procedure, with this difference being statistically significant. Furthermore, the combination of 3D printing technology and restorative techniques was utilized, resulting in consistent patient satisfaction. CONCLUSION: Digitalisation plays an important role in anterior aesthetic restorations. The use of digital technology to manage the entire process of anterior cosmetic restorations can improve restorative results, reduce the number of follow-up appointments, shorten consultation time, and achieve better patient satisfaction.

Digital planning and guided dual technique in esthetic crown lengthening: a randomized controlled clinical trial.

OBJECTIVES: The present study aimed to compare the guided dual technique with the conventional technique in esthetic crown lengthening (ECL). MATERIALS AND METHODS: The trial registration number is NCT04922086. Twenty-four participants diagnosed with altered passive eruption (APE) type I subcategory B were selected and allocated into two groups. In the control group (n = 12), the ECL procedure was planned by clinical examination and transgingival probing; in the test group (n = 12), the ECL procedure was carried out using digital planning and a double guide. Clinical parameters were assessed at baseline, immediately after the intervention (IAI), and at 4, 8, and 12 months of follow-up. RESULTS: The clinical crown length (CCL) mean at baseline was 8.09 mm (± 0.77) and increased significantly to 9.92 mm (± 0.62) IAI, with minimal significant reduction after 12 months (9.47 mm [± 0.60]) in the control group. Similarly, in the test group, the mean CCL at baseline was 8.04 mm (± 0.69) and increased significantly to 9.94 mm (± 0.57) IAI, with minimal reduction after 12 months (9.35 mm [± 0.80]). No differences were found between the mean CCL determined in the digital planning and after 12 months. No correlation was found between gingival thickness and gingival margin stability. High esthetic satisfaction was demonstrated by participants/specialists without differences between groups. CONCLUSIONS: In conclusion, the guided dual technique was as effective as the conventional technique for treatment of APE, with stable results after 12 months of follow-up. CLINICAL RELEVANCE: The guided dual technique aims to transfer both the gingival and bone resection planned position to facilitate the ECL surgical procedure and increase treatment predictability.

The crown lengthening double guide and the digital Perio analysis.

OBJECTIVE: This article describes a surgical crown lengthening double guide, which was digitally obtained to improve diagnosis, treatment outcome, and follow-up. CLINICAL CONSIDERATIONS: The rehabilitation of anterior dental esthetics should involve interdisciplinary and facially driven planning for achieving pleasant long-term outcomes. Surgical crown lengthening is one of the most common periodontal surgery, which can be assisted by digital tools to improve surgical planning and follow-up. CONCLUSION: The double guide for surgical crown lengthening allows the proper management of hard and soft tissues for achieving a predefined goal based on biological requirements and facially driven planning. In addition, the digital quality control allows the follow-up compared with the pre-operative condition and planned treatment plan. CLINICAL SIGNIFICANCE: The use of digital tools allow the clinician to develop a facially driven planning with proper communication with the team and patient, leading to a shorter, more predictable, and less invasive surgical technique, reducing postoperative inflammation and increasing patient comfort.

Digitally planned surgical crown lengthening in the esthetic zone.

Surgical crown lengthening is one of the most common surgical procedures in periodontal practice. It is divided into functional and esthetic surgical crown lengthening. In general, surgical crown lengthening is a predictable periodontal surgical procedure. Its most common complication is excessive regression of the dentoalveolar complex coronally. Esthetic surgical crown lengthening can be performed predictably through prior digital planning, minimizing the risk of potential complications such as excessive regression of the dentoalveolar complex coronally. The present study reported in this article is a clinical case of surgical crown lengthening with digital planning to derive practical recommendations.

[How long does a tooth last after a surgical crown lengthening?] / Hoe lang gaat een gebitselement mee na een chirurgische kroonverlenging?

The presence of subgingival pathology, such as a deep secondary caries lesion, a fracture, an already existing restoration that needs to be replaced or the presence of a resorption defect, can constitute a difficult starting situation for the preservation of a tooth. How to deal with such a situation has been a topic of discussion for years. Surgical crown lengthening is one of the first and classic treatment options that is often chosen in such cases. Crown lengthening is a periodontal surgical technique to obtain extra supra crestal clinical crown length. The question is, what is the long-term prognosis of teeth after surgical crown lengthening. To answer this question, a review of the literature was carried out looking for clinical studies examining survival. Four studies with a follow-up of at least 5 years were included. The factors that adversely affect survival of the tooth after the crown lengthening are an unfavourable crown-root ratio, insufficient plaque control and moderate ability to keep the restoration clean.

The use of diode laser in esthetic crown lengthening: a randomized controlled clinical trial.

This clinical trial assessed patient comfort, satisfaction, and the achievement and maintenance of ideal gingival margin levels using laser compared to conventional surgery in sculpting the soft tissues during esthetic crown lengthening. Eighteen patients with altered passive eruption were treated in a randomized split-mouth design by laser or scalpel crown-lengthening surgery. Patients were evaluated for intra- and postoperative pain and bleeding at 3 and 7 days. Clinical parameters including clinical crown length, probing depth, plaque index, bleeding on probing, and clinical attachment level were recorded at baseline, 3 and 6 months postoperatively. A gradual reduction in postoperative pain was recorded for both sides with no statistically significant difference at 3 (scalpel: 4.4 ± 1.33, laser: 4.8 ± 1.34; p = 0.088) and 7 days (scalpel: 1.8 ± 0.94, laser: 1.8 ± 1.10; p = 0.655). A statistically significant gain of coronal tooth structure was observed at 1, 3, and 6 months. Stability in the post-crown-lengthening level of the gingival margin was achieved one month following the procedure with no significant changes in the following months. All patients reflected acceptable results based on clinical evaluation and patient-reported outcomes. The diode laser can be used effectively as an alternative to the scalpel for the management of altered gingival contour. CLINICAL SIGNIFICANCE : This study demonstrated that a diode laser is an effective tool for the management of cases with altered passive eruption. In addition, it gives insight to practitioners regarding the timing of esthetic restorative procedures and emphasizes the preservation of the gingival complex dimensions.

Diagnostic Mock-Up as a Surgical Reduction Guide for Crown Lengthening: Technique Description and Case Report.

Background and Objectives: The report describes a technique using a diagnostic mock-up as a crown-lengthening surgical guide to improve the gingival architecture. Materials and Methods: The patient's primary concern was improving her smile due to her "gummy smile" and short clinical crowns. After clinical evaluation, surgical crown lengthening accompanied by maxillary central full-coverage single-unit prostheses and lateral incisor veneers was recommended. The diagnostic mock-up was placed in the patient's maxillary anterior region and used as a soft tissue reduction guide for the gingivectomy. Once the planned gingival architecture was achieved, a flap was reflected to proceed with ostectomy in order to obtain an appropriate alveolar bone crest level using the overlay. After six months, all-ceramic crowns and porcelain veneers were provided as permanent restorations. Results: A diagnostic mock-up fabricated with a putty guide directly from the diagnostic wax-up can be an adequate surgical guide for crown-lengthening procedures. The diagnostic wax-up was used to fabricate the diagnostic mock-up. These results suggested that it can be used as a crown-lengthening surgical guide to modify the gingival architecture. Several advantages of the overlay used in the aesthetic complex case include: (1) providing a preview of potential restorative outcomes, (2) allowing for the appropriate positioning of gingival margins and the desired alveolar bone crest level for the crown-lengthening procedure, and (3) serving as a provisional restoration after surgery. Conclusions: The use of a diagnostic mock-up, which was based on a diagnostic wax-up, as the surgical guide resulted in successful crown lengthening and provisional restorations. Thus, a diagnostic overlay can be a viable option as a surgical guide for crown lengthening.

Does Surgical Crown Lengthening Procedure Produce Stable Clinical Outcomes for Restorative Treatment? A Meta-Analysis.

PURPOSE: The present systematic review was designed to assess whether surgical crown lengthening (SCL) procedure produces stable clinical outcomes for restorative treatment. METHODS: Based on the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines, a specific PICO question was constructed: "Does the SCL procedure produce stable clinical outcomes for restorative treatment?" Electronic databases (MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and Cochrane Oral Health Group Trials Register) were searched up to December 2017. The risk of bias was assessed based on the revised recommendations of the Consolidated Standards of Reporting Trials (CONSORT) statement. Forest plots were computed reporting weighted mean difference (WMD) of outcomes and 95% confidence intervals (CI) for crown length (CL), position of gingival margin (PGM), biological width (BW), and bone level changes. RESULTS: Five studies were included. The risk of bias was considered high in all studies. A high degree of heterogeneity was noticed for CL, PGM, and BW. The overall mean difference for CL (WMD = -1.84, 95% CI = -0.103 to 2.05, p = 0.076), PGM (WMD = 0.87, 95% CI = 0.12 to 1.62, p = 0.02), and BW (WMD = -0.11, 95% CI = -2.21 to 1.99, p = 0.91) were not significant at follow-up. The overall mean difference for bone level changes was significant (WMD = 1.64, 95% CI = 1.26 to 2.03, p < 0.001) at follow-up. CONCLUSION: It remains debatable whether SCL produces gingival rebound, or re-establishes BW and changes in clinical attachment level; however, further studies with low risk of bias randomized CCTs and long-term follow-up are recommended to reliably assess the restorative outcomes of SCL.

Crown lengthening and restorative procedures in the esthetic zone.

Crown lengthening is one of the most common surgical procedures in periodontal practice. Its indications include subgingival caries, crown or root fractures, altered passive eruption, cervical root resorption and short clinical abutment, and its aim is to re-establish the biologic width in a more apical position. While the procedure in posterior areas of the dentition has been thoroughly investigated, crown lengthening performed for esthetic reasons in the anterior areas is still a matter of debate and an evidence-based technique is not available. This paper provides accurate descriptions of the surgical and restorative phases of the esthetic crown-lengthening procedure by answering the following questions: what is the ideal surgical flap design? how much supporting bone should be removed? how should the position of the flap margin relate to the alveolar bone at surgical closure? and how should the healing phase be managed in relation to the timing and the position of the provisional restoration with respect to the gingival margin?

A digitally guided dual technique for both gingival and bone resection during crown lengthening surgery.

This paper presents a digitally guided dual technique that provides references for gingival and bone resection during crown lengthening surgery. The architecture of the teeth, gingiva, and alveolar bone is scanned and registered to design dual guides consisting of a gingivectomy guide and an alveolectomy guide that are used in periodontal surgery for esthetic rehabilitation.

Periodontal status of anterior teeth following clinical crown lengthening by minimally traumatic controlled surgical extrusion.

BACKGROUND/AIMS: The number of fractured anterior teeth following trauma has been increasing while not every patient is able to afford a dental implant instead of maintaining the injured tooth. Thus, a tooth conservation solution is required to place an aesthetic and functional restoration without biologic width violation. The aim of this study was to evaluate the effectiveness of minimally traumatic controlled surgical extrusion in fractured anterior teeth crown lengthening by assessing the periodontal status through clinical examination and radiographs. METHODS: This longitudinal observational study investigated a group of 18 patients (six males and 12 females) at the Department of Periodontology, National Hospital of Odonto-stomatology, Ho Chi Minh City, Vietnam. Following pre-surgery procedures and examination, minimally traumatic controlled surgical extrusion was carried out using a periotome. Patients were examined at four follow-up appointments after 1 week, 1, 3 and 6 months to record the following experimental variables: periodontal parameters including the gingival index (GI), pocket depth (PD), bleeding on probing (BOP), mobility, marginal gingiva position, alveolar ridge resorption, periapical osteogenesis, tooth resorption and ankylosis. RESULTS: All periodontal parameters were significantly decreased at 3 and 6 months post-procedure (P < 0.001). Tooth mobility decreased gradually following surgery, and at 6 months, all teeth became normal at level 0. Periapical osteogenesis changes were significantly increased at 1, 3 and 6 months in comparison with pre-surgery (P < 0.001). Marginal gingiva position and alveolar ridge resorption were not significantly different between pre-surgery and 1, 3 and 6 months post-surgery. No cases of root resorption or ankylosis were observed at 6 months post-surgery. CONCLUSION: A minimally traumatic controlled surgical extrusion technique for clinical crown lengthening yielded highly successful results in both aesthetic and functional aspects, and no cases had unfavourable outcomes during the 6-month follow-up period.

Increased and correlated expression of connective tissue growth factor and transforming growth factor beta 1 in surgically removed periodontal tissues with chronic periodontitis.

BACKGROUND AND OBJECTIVE: Both gingival tissue destruction and regeneration are associated with chronic periodontitis, although the former overwhelms the latter. Studies have shown that transforming growth factor beta 1 (TGF-ß1), a growth factor largely involved in tissue regeneration and remodeling, is upregulated in chronic periodontitis. However, the gingival expression of connective tissue growth factor (CTGF or CCN2), a TGF-ß1-upregulated gene, in patients with periodontitis remains undetermined. Although both CTGF/CCN2 and TGF-b1 increase the production of extracellular matrix, they have many different biological functions. Therefore, it is important to delineate the impact of periodontitis on gingival CTGF/CCN2 expression. MATERIAL AND METHODS: Periodontal tissue specimens were collected from seven individuals without periodontitis (group 1) and from 14 with periodontitis (group 2). The expression of CTGF and TGFß1 mRNAs were quantified using real-time PCR. RESULTS: Analysis using the nonparametric Mann-Whitney U-test showed that the levels of expression of both CTGF/CCN2 and TGFß1 mRNAs were significantly increased in individuals with periodontitis compared with individuals without periodontitis. Furthermore, analysis using a nonparametric correlation (Spearman r) test showed a positive correlation between TGFß1 and CTGF/CCN2 mRNAs. CONCLUSION: The gingival expression levels of CTGF/CCN2 and TGFß1 mRNAs in individuals with periodontitis are upregulated and correlated.

Interactions of hard tissues, soft tissues, and growth over time, and their impact on orthodontic diagnosis and treatment planning.

The approach to orthodontic diagnosis has changed gradually but steadily over the past 2 decades. The shift away from diagnosis based entirely on hard tissue evaluations has been a result of a broadened recognition of the importance of facial and smile appearance to our patients, and how they change over time. The purpose of this article is to describe and illustrate the integration of the new soft tissue paradigm into long-term treatment planning, with a focus on the esthetic goals of treatment.

Semidirect Restorations in Multidisciplinary Treatment: Viable Option for Children and Teenagers.

Due to the esthetic necessity required nowadays, the multidisciplinary treatment became a fundamental step in the restoration success. When the patient exhibits dental agenesis of one or more elements, he can show difficulty in social interactions. The age of the patient is a limiting factor to esthetic procedures, however, it should be evaluated as a real indicative with each case. The utilization of semi-direct restorations is a viable option due the cost, esthetic and improvement of physical and mechanical properties. The purpose of this paper is to present a case detailing the confection and cementation of anterior semi-direct restorations aimed at an anatomic reestablishment associated with integrated treatment with periodontics and orthodontics.

Periodontal considerations in veneer cases.

Porcelain veneers are a minimally invasive technique to enhance patients' smiles. A crucial component in these cases is the supporting periodontal apparatus and its interaction with the restorations. This article addresses basic concepts such as biologic width, altered eruption patterns, appropriate gingival contouring and smile design to give practitioners the tools to diagnose, evaluate and treat cases successfully and predictably.

Aesthetic Treatment Related to Clinical Need--An Illustrated Case Report.

Aesthetic treatment may be patient driven and usually by a 'want', rather than a 'need'. This paper describes the management of a patient who presented with aesthetic wants and clinical needs, both of which were caused as a result of unsuccessful aesthetic treatment which the patient had received previously. The diagnostic process, discussion of the treatment plan and clinical procedures, which produced a satisfactory result, are described and illustrated. Clinical Relevance: This case demonstrates that aesthetic treatment may commit the patient to future dental treatment needs, particularly if treatment provided is poorly planned and carried out to an unsatisfactory standard.