What are the steps involved in Functional Crown Lengthening?
Which scenarios/teeth are best for this type of surgery?
What is biologic width and why should we care?
Is Bone sounding a diagnostic test, or just a genre of music?
The answer to these questions and a lot more can be found in this packed episode with Dr Hiten Halai. We cover the right protocols when crown lengthening and understand the difference between aesthetic and functional crown lengthening.
https://youtu.be/KRlEtz16I8cWatch PDP207 on YoutubeProtrusive Dental Pearl – Bone Sounding
Using a periodontal probe, go into the depth of the sulcus, pushing deeply until you hit bone, all while recording the measurement with the probe. This measurement will then guide you on how to carry out your crown lengthening procedure. Push hard to pass the connective tissue and ensure you are touching the bone.
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Need to Read it? Check out the Full Episode Transcript below!
Highlights of this Episode:03:19 Protrusive Dental Pearl06:10 Introduction – Dr Hiten Halai12:56 Functional Crown Lengthening15:41 Understanding Crown Lengthening Types18:42 University of Dental Instagram22:38 Biologic Width aka Supra-crestal Tissue Attachment25:51 Functional Crown Lengthening: Practical Considerations31:09 Assessments & Keratinised Tissue35:47 Understanding Tissue Phenotypes39:16 Case Study: Premolar Treatment43:17 Bone Sounding and Biologic Width46:58 Shape of Gingivectomy50:31 Flap Designs52:37 Burs for Crown Lengthening56:13 Healing and Restoration Timelines58:31 Learning and Training Opportunities
Key Takeaways:
This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance.
This episode meets GDC Outcome C.
ADG Code: 490 PERIODONTICS (Mucogingival management)
Aim: To enhance knowledge and practical understanding of crown lengthening procedures, with a focus on distinguishing between aesthetic and functional crown lengthening, and the importance of biologic width in achieving predictable clinical outcomes.
Learning Outcomes:
If you liked this episode, check out: PDP079 – Crown Lengthening
Click below for full episode transcript:Teaser: Despite what the University of Instagram tells you, all cases cannot be treated by laser gingivectomy. And that is the truth. Four or five years down the line, when there has been enough time for that tissue to relapse, what happens is they'll come back with that persistent inflammation. And actually the management of it is much more complex now.
Teaser:If you’re going to remove an extensive amount of bone and you might even cause mobility, that is probably not indicated in that situation. If your alveolar bone all of a sudden grows from incidental peaks to a really low trough on the mid palatal, the soft tissues will not be able to follow that margin there, okay? And if you cut them to that, post surgically, there will be rebound. It’s kind of like, the way I describe it, it’s like-
Jaz’s Introduction:When you think of crown lengthening, what do you first think of? Do you perhaps think of aesthetic crown lengthening? That’s when we’re trying to make the gingival levels match up. For example, a lateral incisor, we want that gum to go a little bit higher. So that’s aesthetic crown lengthening. We’re lengthening how much tooth we’re showing for the primary benefit of aesthetics.
The other type of crown lengthening, which I personally have more experience with, is functional crown lengthening. Think of an upper premolar, which is the example we use deeper in this episode today. And this premolar, it’s got good amount of buccal tissue, but palatally, it’s got very little tissue. It might even be broken sub gingivally. And yes, in this world of implants, there is a place for titanium therapy, but I like to save teeth where possible.
And if the general endodontic prognosis is good, A good way to improve the restorative prognosis is by doing functional crown lengthening. And so this would be necessary because, yes, you’ve got good tissue buccally and you get good ferrule. Ferrule is like that tooth structure that the crown can grab onto.
Now, if you haven’t got any structure palatally, and your palatal tooth structure is broken subgingivally, how is the crown supposed to grip that tooth structure? We need at least two millimeters 360 degrees, maybe 1. 5 millimeters with care, but two millimeters is ideal in the literature. So if we can get rid of some gum palatally and a bit of bone, and then now everything heals so that you can now grab on to two millimeters of tooth structure, you have lengthened how much crown you have available of the tooth to be able to restore.
Hello, Protruserati, I’m Jaz Gulati, and welcome back to your favorite dental podcast. I’m joined by specialist periodontist Dr. Hiten Halai, and you’ll find out the funny way which Hiten had a big role to play in the birth of this podcast many years ago. Now we discussed everything from indications and contraindications and actually came to guide us through the technique step by step from assessment, bone sounding, the incision, and the bone removal down to which burs you should use for the bone removal.
And if you’re a Student or a young clinician who’s never done this before then this should inspire you to seek out more education and learn more. Pick up those books or go on a course. But it’ll give you a really sound understanding. And if you have a bit more experience under your belt, with a little bit of mentorship, I think you could do this.
I think functional crown lengthening, if you pick your case as well, like an upper premolar, and you’ll see why an upper premolar is ideal for this. This is fun dentistry. This is fun. You get to breathe new life into a tooth, which was otherwise of poor restorative prognosis. And once in a blue moon, when I get to do this, I quite enjoy it.
Dental PearlNow, Protrusive Dental Pearl Time. As you know, every PDP episode, I give you a pearl. And if you think back to a few episodes ago, I told you about accessing through a molar before you do your sectioning of that molar for extraction to give you more practice of accessing molars for endo. So the more you access, the more you improve with your access cavity.
Now in a similar vein, in the perio crown lengthening field, one skill that we talk about in this podcast is bone sounding. Now, I’ve talked about bone sounding on this episode four. That episode of Dr. Jason Smithson on Ovate Pontics, absolutely brilliant. Do check it out if you haven’t already. And I talked about the edentulous site and how to bone sound there.
Actually, bone sounding can happen around any tooth. You want to figure out where is that bone relative to that gingival margin? And don’t worry if it’s not quite making sense of why you do this, that’s all to come later in this episode. But essentially you want to get a perioprobe, you want to go into the depth of the sulcus, and then you want to go really hard until you hit bone.
And that measurement will guide you in terms of how to do your crown lengthening. And if you’ve never done this before, you want to get like a feel of what it feels like to actually hit bone. Because sometimes you get to the connective tissue and you think, ah, I’m there. But actually, if you really push a bit more, you’ll sink in another millimeter or two more.
And that’s when you’ve truly done bone sounding. So how can you practice bone sounding without doing it for no reason at all? Okay. So if you’re doing an extraction, then I kind of regularly bone sound for extraction because it’s one of the ways I check that the patient is sufficiently numb. So whenever I’m doing an extraction, I will probe really hard with a sharp probe.
Buccal, mesial, distal, lingual, to make sure that the patient is fully anesthetized. And actually what I’m doing is very often I’m getting down to the bone. And so I have ...