What are the steps in the hard tissue crown lengthening procedure?
Treatment technique is varied from the method of which the tissue is removed. They are:
- regular blade
- reposition flap more apically
The best way to approach crown lengthening is first the crow should be prep such that the new crown margin is visuallized. Then the patient can undergo crown lengthening procedure.
We always anesthetized our patient for our hard tissue crown lengthening procedure . Regular blade provides speed and clean steril cut. Electrosurgery provides hemostasis while maintaining the speed efficiency. Laser provides excellent hemostasis, excellent post-operative healing, and excellent tissue control in term of thinning or contouring. However, laser cutting can be very slow and time consuming. Very often I use all three tools with judgement based on the amount of gingiva and the number of teeth involved. Finally, I always combine the removal of gingival tissue with flap reposition more apically as to deepen the vestibule (in many case it help to facilitate oral hygiene effort), to preserve attached gingiva (good protection from localized trauma and bacterial invasion), allow to visualize the alveolar bone crest and determine the need for bone contouring or removal. REMEMBER, tissue growth always followed bone support.
After the tissue is trim and removed to the level of the future crown margin (read about the location of crown margin in the column above), we always reflect the flap to recontour the bone crest. A small round bur should be used and make sure we have adequate water cooling during bone removal (to avoid dehiscence of bone, the cutting temperature should be under 47 degree Celsius). The bone should be removed such that the bone crest is located about 3-4mm from the new crown margin as to satisfy the requirement of biological width. Next the flap is reposition and allow for adaptation at the new gingival crest.. The gingival crest should not demonstrated any pulling movement . In doing so, the flap should be released and readapted prior to suture.
Finally, we suture with either goretex suture or gut suture. I always avoid silk suture because even though it is inexpensive, it always attracted plaque and bacteria harboring to the surgical site. Goretex suture is nonresorbable, very expensive but they are very hygienic, ease of handling, and very strong. Gut suture is weaker but resorbable. Broken suture may lead to reattachment of gingiva at the less optimal location, healing with secondary intention, and subclinical infection due to food/bacteria penetrates the surgical site. I preferred gut suture in this the procedure of hard tissue crown lengthening. Patient will be post-op 1 days, 14 days (tissue heals clinically), and 28 days (tissue heals microscopically). At the end of 28 days, impression of the crown can be made.
These are the protocol of which Dr. Bui follows in his periodontal therapy. It is not necessary the same or equivalent with other operator. Our method may be different, but the final result should be toward achieving that esthetic smile which everyone deserves.
Does the tissue grow back in time?
As mention above, more often we removed or recontour the bone crest as to ensure the biological width is NOT violated and thus the gingival crest will stay where it is placed as long as no other pathological process such as crown margin overhang or periodontal disease occurred. Patient will only have to maintain good oral hygiene with periodic cleaning every six months.
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