Volume 7, Issue 5, May – 2022 International Journal of Innovative Science and Research Technology

ISSN No:-2456-2165

Crown Lengthening: A Comprehensive Review

Dr. JAYALAKSHMI PA1 , Dr. SWATHI AMIN2
Post graduate1, Reader2
Department of Conservative Dentistry and Endodontics
AJ Institute Of Dental Sciences, Mangalore Rajiv Gandhi
University Of Health Sciences, Karnataka, India

Abstract:- Crown lengthening (CL) is a surgical CL procedures were classified as either cosmetic or
treatment that allows the clinician to rebuild the tooth by functional according on the clinical state 7. In the "aesthetic
extending the supragingival tooth structure. Surgical crown lengthening" category, young patients with gummy
crown lengthening can make it easier to restore worn smiles and short clinical crowns due to altered passive
teeth. It improves the look and makes dental preparation eruption that necessitate an increase in the length of the
easier. The amount of height that can be gained by tooth structure were discussed 7. In this case, crown
surgery may be limited by anatomical factors. Lasers are lengthening is limited to the anterior aesthetic zone and aids
the greatest option for crown lengthening because they in improving an individual's aesthetic look, whereas CL
offer precision, faster wound healing, less discomfort, designed to expose subgingival cavities or a fractured tooth
and superior aesthetics. To attain satisfactory results, is referred to as "restorative / functional crown lengthening"
cases suggested for crown lengthening in the aesthetic ( Hempton and Rosenberg, 2010) 7. In some clinical
zone require unique considerations. The employment of situations, cosmetic and functional crown 7.
appropriate diagnostic methods, surgical and
restorative criteria, and lasers increases the procedure's Crown lengthening can be done with a scalpel,
certainity and achievement. This review article will go electrocautery, or, more recently, lasers 7. Lasers have an
through different aspects of crown lengthening, surgical advantage over the scalpel in functional crown lengthening
crown lengthening methods, indications and treatments due to advantages such as little discomfort, quick
contraindications, role of orthodontics in crown hemostasis, and immediate placement of restoration,
lengthening as a multidisciplinary approach, and however literature to support the same is sparse. (1993,
prosthesis placement of margings for prosthetic cases. Pick)7.
The functional and aesthetic requirements of laser aided
crown lengthening, as well as surgical vs laser assisted A. INDICATION
crown lengthening methods, are discussed in this article. Indications for the crown lengthening can be subdivided
into 3 subgroups
Keywords:- Crown lengthening, Biological width , Laser  PROSTHETIC1
assisted-crown lengthening , Laser vs surgery.  To increase the crown length
 To create ferrule effect
I. INTRODUCTION  To reposition the borders of restoration impinging
the biological width
Dentists see highly disfigured or highly mutilated teeth
on a daily basis in today's dentistry1. This complicates
clinical decision-making when determining whether the  ASTHETIC1
tooth or teeth should be removed or restored1. Modern  Changed passive eruption
dentistry is primarily concerned with patient safety and  In Gummy smile cases
minimally invasive procedures2. New instruments and  In cases of short teeth
materials have been created to achieve this 2. This is the age  Teeth with uneven gingival contour
of dental implants, an era in which efforts to save severely
damaged teeth are dwindling1.  RESTORATIVE 1
 For correction of subgingival caries
Clinical Crown Lengthening procedure is an important  Analyze perforation in coronal third of root
alternative in almost all the specialties of dentistry 3. The  In cervical root resorption.
term Crown Lengthening (CL) was first coined by DW
Cohen in the year of 1962 4. It's a surgery that involves a B. CONTRA-INDICATIONS8
blending of hard tissue and soft tissue reduction, as well as  Insufficient Crown to Root ratio
orthodontic tooth exposure (with or without braces)5.  Unrestorability of caries or root fracture
According to the definition of the American Academy of  When it affects esthetic appearence
Periodontology ,CL is a “ Surgical procedure designed to  High furcation
increase the extend of the supragingival tooth structure for  Inappropriate predictability
the restoration or esthetic purposes by apically positioning  Tooth arch relationship inaccuracy
the gingival margin , removing supporting bone or both 5.  Compromised adjacent periodontium or esthetic
Various clinical conditions may need CL such as irregular  Improper restorative space
smile line , gummy smile , mutilated or fractured teeth ,  Unable to maintain.
worn out teeth by parafunctional habits( eg: bruxism) 6

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Volume 7, Issue 5, May – 2022 International Journal of Innovative Science and Research Technology
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C. BIOLOGIC WIDTH9 be an average of 2.04 mm in areas with periodontal health,
The notion of biologic with was initially introduced by with the junctional epithelium occupying around 0.97 mm
Gargialo, Wentz, and Orban, who used cadaver specimens and connective tissue attachment to the root surface
to measure the distance between the apical end of the occupying 1.07 mm.2. The physiologic location of biologic
gingival sulcus and the crest of the alveolar bone10. That width might alter with age , tooth migration due to loss of
distance, now known as the biologic width, was observed to arch or occlusal integrity or orthodontic treatment.2

Biologic width ( Fig 1 , Fig 2 )

II. VIOLATION OF BIOLOGIC WIDTH ANALYSIS

A. CLINICAL METHOD proximal aspects, and also for cosmetic crown lengthening
When a periodontal probe is used to check the procedures22. Bone sounding is used to determine the
restoration margin levels and the patient experiences tissue thickness of soft tissue layer and proximity of the alveolar
irritation, it signifies the margin has extended into the bone during the planning stages of various surgical
attachment and a biologic width infringement has occurred. procedures22 .
Chronic escalating gingival inflammation near the
restoration, bleeding on probing, localised gingival C. EVALUATION BY RADIOGRAPHS
hyperplasia with minor bone loss, gingival recession, pocket The interproximal breach of biologic width can be
formation, clinical attachment loss, and alveolar bone loss distinguished using a radiographic approach. Because of
are all signs of biologic width breach. Alternate passive dental superimposition, radiographs are not useful on the
eruption and subgingivally positioned restoration borders mesiofacial and distofacial line angles of teeth 28. Sushama
are the most common sites for gingival hyperplasia. 26. and Gouri introduced a new parallel profile radiography
(PPR) approach for determining the size of the
B. BONE SOUNDING dentogingival unit (DGU). Because it is easy, rapid, non-
Under local anaesthetic, probe to the bone level (called invasive, and repeatable, the authors conclude that the PPR
"sounding to bone") and subtract the sulcus depth from the technique can be used to precisely measure both the length
resultant measurement to get the biologic width. A diagnosis and thickness of the DGU, as well as to eliminate individual
of biologic width violation can be validated if the distance and location variance29.
obtained is less than 2 mm at one or more places. To ensure
accuracy and reduce individual and location variance, this
measurement should be conducted on teeth with healthy
gingival tissues and repeated on several teeth 27. It is used to
decide the placement of the alveolar crest on the labial and

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 To avoid biologic width violations, there are groups of  Patient with a high crest
biologic width and margin position guidelines. High Crest is a strange natural phenomenon that occurs
Based on total attachment measurement and sulcus depth only about 2% of the time. There is one location where
following bone sounding dimensions, Kois proposed three High Crest is particularly noticeable: on a proximal
biologic width classifications: There are three types of surface near an edentulous area. The mid-facial dimension
crests: normal, high, and low 30,31. [Fig 2] 2nd Figure is less than 3.0 mm, and the proximal dimension is less
than 3.0 mm in the High Crest patient [Figure 2]b. In this
 Patient with a normal crest situation, an intracrevicular margin is unlikely to be placed
The mid-facial dimension of a Normal Crest patient is 3.0 since it would be too close to the alveolar bone, causing
mm, while the proximal dimension ranges from 3.0 mm to biologic width impingement and persistent inflammation.
4.5 mm. [Fig 2] a. Normal Crest occurs around 85 percent
of the time. The gingival tissue in these circumstances is  Patient with a low crest
likely to remain stable for a long time. The crown's edge In the Low Crest patient group, the mid-facial dimension is
must be no closer than 2.5 mm from the alveolar bone. As greater than 3.0 mm, and the proximal dimension is greater
a result, in the Normal Crest patient, a crown margin that than 4.5 mm. [fig 2] c About 13% of the time, there is a
is 0.5 mm subgingivally is expected to be well-tolerated Low Crest. The Low Crest patient has been demonstrated
by the gingiva and stable over time. to be more prone to recession due to the implantation of an
intracrevicular crown margin. Attachment apparatus is
harmed when a retraction cord is installed during crown
preparation. As the offended attachment heals, it returns to
its original place of the Normal Crest, causing gingival
recession.

Fig.3: (a) Normal crest showing biologic width on labial and interproximal site, (b) High crest showing biologic width on labial
and interproximal site. (c) Low crest showing biologic width on labial and interproximal site, (d) Pateint ALow crest unstable;
and, Pateint B-. Low crest stable

D. ORDER OF TREATMENT (ALLEN 1993)11  Endodontic therapy:

Clinical and radiographic assessment :  To be performed before surgery
 Caries has to be managed  Monitoring of gingival inflammation
 Removal of faulty restorations is to be performed  Plaque control
 provisional restorations has to be placed  Scaling and root planning.
 Inflammation has to be reduced
 Superior evaluation of crown lengthening needed  Re-assessment for:
 Enhanced surgical access, mainly interproximally  Orthodontic therapy
 Better placement of margin post surgically  Surgical therapy

 Surgery

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E. CROWN LENTHENING CLASSIFICATION1 gingival edge without exposing the osseous crest. Later,
Type I crown lengthening is distinguished by adequate after the gingival excision, osseous correction is required to
gingival tissue coronal to the alveolar crest, allowing the recontour the alveolar crest to a level where the biologic
surgical alteration of the gingival margin levels without the width is replaced.
need for osseos recontouring. A gingivectomy or
gingivoplasty method is usually operated to avoid biological Bone sounds for Type III crown lengthening may show
width violation by creating a suitable gingival margin. a condition where moving the gingival edge may expose the
osseous crest. Type IV crown lengthening is used for
Soft tissue measures distinguish Type II crown situations in where an excessive amount of connected
lengthening, which allows surgical adjustment of the gingiva compromises the degree of gingival resection 5.

Table 1: CROWN LENTHENING CLASSIFICATION

F. PRESURGICAL ASSESSMENT  Osseous scallop

Smukler and Chibi (1997)10 put forward the following  Gingival form
presurgical clinical analysis prior to crown lengthening
procedures: III. GENERAL TISSUE ASSESSMENT BEFORE
 To locate the finish line before surgery UNDETAKING CROWN LENTHENING
 If it cannot be located , it should be anticipated
A. Soft Tissue Assessment
 Transcrevicular circumferential probing is done before
the surgery for locating the biologic width (Bone  Situation 1 : If the width of the attached gingiva
Sounding) appropriate -(>3mm) - external bevel gingivectomy or
internal bevel gingivectomy
 Surgical site
 Contralateral site  Situation 2 : If the width of attached gingiva
inappropriate (<3mm) - apically positioned flap
 The amount of alveolar bone removal will be
B. Hard Tissue Assessment (Figure 3)
determined by the biologic width requirements.
 Situation 1 :If the bone crest level is apically or low
 The overall amount of tooth structure that required to
be exposed is determined by a combination of biologic then there is no need for ostectomy.
width and prosthetic requirements.  Situation 2 : If the bone crest level is more coronal or
high then ostectomy is performed.
 The topography, architecture, and curvature of the
tooth structure are determined for the following:

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Fig. 4: Hard Tissue Assessment

C. TREATMENT METHODS 1
 External bevel gingivectomy
 Scalpel
 Laser
 Electrocautery
 Chemosurgery
 Cryosurgery
 Internal bevel gingivectomy
 Apically displaced flap with or without bone resection
 Rapid Orthodontic Extrusion
 Combined technique (Surgical and Orthodontic)

IV. EXTERNAL BEVELGINGIVECTOMY

Fig. 5: INCISION GIVEN IN EXTERNAL BEVEL
A. SCALPEL GINGIVECTOMY
External bevel gingivectomy with scalpel is commonly
performed when there is sufficient sulcular depth and F. INSTRUMENTS REQUIRED:
keratinized tissue to ensure that the incision does not breach  Diagnostic instruments: Mouth mirror, periodontal
the biological breadth and when low bony forms do not probe.
necessitate osseous resection. Goldman first introduced this  Periodontal pocket markers
approach in 195132.  Bard-Parker blade with blade holders.
 Periodontal Knives, scissors, and nippers:
B. CONTRAINDICATIONS:33
 Kirkland gingivectomy knife.
 When crown lengthening requires bone surgery or a
 Orban’s interdental knife.
detailed assessment of the anatomy and morphology of
 Goldman fox periodontal scissors.
the bones.
 Goldman fox nippers.
 When the pocket's bottom is apically positioned near
 Gingivoplasty diamond burs.
the mucogingival junction.Situations that necessitate
aesthetics, such as in the anterior maxilla.  Curettes
G. PROCEDURE
C. MERITS:
 Flap elevation is not necessary  Marking the pockets: either with periodontal pocket
marker or with periodontal probe. Each pocket at
 It is very easy to do several areas to outline the course on the surface.
 It helps to practice in a easy manner
H. External bevel incision:
D. DEMERITS  The incision is started apical to the points marked and
 Surgical area will be exposed. is directed coronally to a point between the base of the
 Increased postoperative pain. pocket and the crest of the bone.
 Healing of the tissues will be delayed  The incision should be bevelled approximately 45
degrees to the tooth surface and is primarily directed
E. INDICATIONS coronally.
 Elimination of suprabony pockets, regardless of their  Clinically the angulation of the external bevel incision
depth, if the pocket wall is fibrous and firm. is dictated by the volume of the keratinized gingiva,
 Elimination of gingival enlargements. the volume of crest of the alveolar bone and the
 Elimination of suprabony periodontal abscesses. position of the base of the pocket.
 The incision can be continuous or discontinuous.
 Recreation of normal festooning is mandatory.

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 Remove the excised pocket wall. N. OSSEOUS CROWN LENGTHENING USING ERBIUM
 Remove granulation and clean the root surface. LASERS
 Periodontal pack if necessary. The Erbium laser allows dentists to offer patients a less
intrusive option to osseous crown lengthening, reducing the
I. LASER PRINCIPLES 5 negative side effects of traditional treatment 23. The
Laser-assisted crown lengthening operations have shown wavelength of Er; Cr:YSGG is 2.78 metres. It is absorbed
to be more accurate. The laser technique varies depending by water and hydroxyapatite, which make up the majority of
on the device and the wavelength of the laser used12. The bone and dentin, and the ensuing reactions cause bone tissue
more the ablation of the tissue, the greater the absorption of and tooth ablation65. To reduce edoema and the requirement
laser energy in the target tissue. Selection of laser mainly for sutures, this type of treatment demands little tissue
depends on the effect of laser on the adjacent tissues. Lasers displacement, resulting in less pain and edema 21. The
should be carefully used to avoid contact with non – target Erbium laser allows dentists to offer patients a less intrusive
areas. Carbon dioxide (CO2) and Nd:YAG, Argon lasers option to osseous crown lengthening, reducing the negative
with wavelengths of 10,600nm and 1064nm, respectively, side effects of traditional treatment.
are the most often utilised soft tissue lasers in dentistry.
O. LASER ASSISTED-CROWN LENGTHENING IN
J. MERITS: ESTHETIC ZONE
 Dry operating field can be achieved The rationale for crown lengthening procedures has
 Reduced chances of bacterimia due to instant become more esthetic driven due to the increasing
sterilization of the operating field popularity of smile enhancement therapy. It is essential for
 Improved healing. the clinicians to understand the diagnostic criteria, treatment
 Decreased post-operative edema and scar formation planning process and biological parameters involved to
determine the appropriate indications, as well as the surgical
 Decreased post-operative pain and discomfort.
and restorative protocols that are available to improve the
K. DEMERITS: potential for predictable outcomes in the esthetic zone. Key
 It is very expensive. diagnostic factors in analyzing the amount of gingival
 Laser safety precautions must be maintained. excision and bone removal are:22

P. IN THE ESTHETIC ZONE, LASER ASSISTED CROWN

L. LASER TECHNIQUES 5
LENGTHENING
The fact that laser therapy is bloodless improves the
As smile improvement therapy has increased in
clinician's ability to see tissue shapes and characteristics
during surgical treatment. This considerably lessens the popularity, the motivation for crown lengthening surgeries
has shifted from function to aesthetics. To improve the
anxiety of both the patient and the clinician. In a soft tissue
chance of predictable outcomes in the aesthetic area,
crown lengthening surgery, there are two primary
approaches that can be performed. The amount of tissue to practitioners must understand the diagnostic criteria,
treatment planning process, and biological aspects involved,
be removed13 usually determines which approach is optimal
as well as the surgical and restorative treatments available.
for removing tissue. When a considerable amount of tissue
When calculating the quantity of gingival excision and bone
needs to be removed, an excisional approach is performed,
removal, the following diagnostic factors should be
in which the laser is wielded like a knife to remove a huge
considered:
amount of tissue. When only a little quantity of tissue needs
to be removed, ablation is usually the best option. The laser  Identifying the position of the incisal edge
light is delivered in a back-and-forth motion to ablate  Determining an appropriate clinical crown length
(vapourize) the tissue in small areas during this  Creating the postsurgical gingival margin borders.
procedure..14.
Q. LASER VS SURGERY
M. DIODE In traditional dental therapy, lasers are utilised for
A diode laser is a solid-state semiconductor laser made gingivectomy and gingivoplasty. The use of lasers results in
up of Gallium, Arsenide, and other elements such as low or no bleeding, as well as proper tooth exposure. Lasers
Aluminum and Indium. Its wavelength varies between 810 can modify the oral soft tissue more easily than a scalpel,
and 980 nanometers. Reflection, transmission, dispersion, with less bleeding and no need for suturing15. When a laser
and absorption are only few of the ways tissue interacts with is utilised instead of a traditional scalpel, there is less wound
laser radiant energy. 20 The tissue is warmed (37°C to contraction and scarring16. If a surgical procedure with a
60°C), welded (70°C to 900°C), vaporised (100°C to scalpel17 is required, the area around the teeth that will be
150°C), and carbonised (200°C) when heat is provided to it subjected to the process must be appropriately sedated. The
via a laser beam. It causes fast cell vaporisation, resulting in transgingival probing method is used to assess the initial
the loss of intracellular fluid, chemical mediators, and probing depth and calculate the biological breadth using
intracellular material, as well as protein denaturation, William's periodontal probe18. The amount of gingival tissue
resulting in a weakened local inflammatory response. to be removed is noted once the biological width is
calculated19.

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Because the laser-assisted soft tissue crown  Chemically treated gingival wounds require longer to
lengthening surgery is a minimally invasive procedure, a heal than scalpel wounds for gingival epithelization,
topical anaesthetic gel was applied to the area prior to the junctional epithelium reformation, and reestablishment
procedure. Safety precautions were taken by both the doctor of the alveolar crest fibre system.
and the patient, including the use of safety glasses. After
enough anaesthetic has been obtained, a diode laser with a VII. CRYOSURGERY44:
wavelength of roughly 940nms can be employed. The laser
equipment was used in a continuous mode with paintbrush- Cryosurgery is the surgical application of cryoablation,
like strokes that went slowly to remove gingival tissue and which involves intense cold in surgery to eliminate aberrant
expose enough dental structure. It had a 400-meter or pathological tissue.
disposable tip. To achieve physiologic gingival form, the tip
A. MERITS:
is examined for debris on a regular basis and cleaned with
 It is possible to achieve a bloodless field of labour.
sterile moist gauze. The procedure emphasises the value of
lasers. 5.  Vascular gingival enlargements can be treated with it.
 There is no pain as a result of the inhibition of
V. ELECTROCAUTERY neuronal transmission.
 There are no signs of a secondary infection.
Flocken first proposed this approach in 198034.  It is cost-effective.
Surgical diathermy is another name for it. It is the division
of tissue caused by a high-frequency electrical current B. DEMERITS:
administered with a metal tool or needle . It works with 1.5-  The action's depth cannot be regulated.
7.5 million cycles per second high-frequency current.  Healing is slow and painful, necessitating the use of
packs for prolonged periods of time.
There are three types of electrodes used: single wire
electrodes for incising and excising, loop electrodes for VIII. INTERNAL BEVEL GINGIVECTOMY WITH OR
tissue planning, and single wire electrodes for incising and WITHOUT OSTECTOMY (UNDISPLACED FLAP)45
excising.For coagulation procedures, heavier, bulkier
electrodes are used. It's a procedure for people with low and high bone
morphologies who may or may not need osteoplasty and
A. MERITS:35,36 osteotomy. It's known as a periodontal flap procedure. The
 It enables for proper tissue shaping underlying fibrous tissue and pocket epithelium are removed
 It aids in the prevention of bleeding. by lifting a partial thickness flap. Scaling, root planing, and
osseous surgery are performed as needed.
B. DEMERITS:37,38,39,40
 If it comes into contact with a bone, it may cause
irreversible harm.
 If the electrode comes into contact with the root, it
causes sections of cementum to burn.

VI. CHEMOSURGERY

Commonly used materials are :Potassium hydroxide41, 5%

paraformaldehyde 42

A. MERITS:43
 Non-anesthetic tissue removal.
 Tissue removal without discomfort
 Tissue removal without causing haemorrhage
B. DEMERITS:43 Fig. 6: Diagram of the internal bevel incision (first incision)
 The action of paraformaldehyde is confined to a depth to reflect a full-thickness (mucoperiosteal) flap. The incision
of around 1mm. ends on the bone to allow for the reflection of the entire flap.
 Packing must be repeated here.
 Leaving a pack on for an extended period of time will Most periodontal flap operations start with an internal
cause healing to be delayed. bevel incision. The flap is mirrored from this incision to
 If the pack is held below the bone edge, bone necrosis expose the underlying bone and root. The internal bevel
can ensue. incision achieves three important goals:
 Abscess development is a possibility. • It removes the pocket lining;
 The action's depth is uncontrollable. • It preserves the relatively uninvolved outer surface of the
 It is impossible to obtain effective gingival gingiva, which becomes attached gingiva when apically
remodelling. positioned; and
• It creates a sharp, thin flap margin for adaptation to the
bone-tooth junction.

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This incision is also known as the first incision since it A. INDICATION:52
is the first incision in the creation of a periodontal flap, and When there isn't enough gingiva for reduction, the bony
it is also known as the reverse bevel incision because its contour is too high, or the gingiva isn't connected
bevel is in the opposite direction as the gingivectomy enough.The crowns of many teeth in a quadrant or sextant of
incision. The #15C or #15 surgical blade is the most the dentition are extended.
commonly used.
B. CONTRAINDICATION
• In the cosmetic zone, surgical crown lengthening of
single teeth is not recommended.

C. MERITS:49
• In the linked gingiva's enlarged zone.
• By primary goal, close proximity of the flap
encourages healing.
• The bone provided is completely covered by the flap's
viable tissue, eliminating macroscopic sequestration
and likely decreasing chronic alveolar crest loss.
• When the amount of gingiva in the postoperative
period can be accurately managed.
Fig. 7: Position of knife in performing internal bevel • The surgeon is able to build a functionally appropriate
incision. investing unit by keeping the mucogingival complex
and transferring it apically.
A. SURGERY WITHOUT OSTECTOMY X. RAPID ORTHODONTIC EXTRUSION
Ensure that adequate linked gingiva remains after the
incisions are made to avoid a mucogingival issue. To Orthodontic extrusion is also known as forced eruption
guarantee that the tooth height is maintained at a minimum therapy (FET). FET is based on the biologic concept that
of 3 to 5 mm over the whole circle, the final bone level orthodontically erupted root segments are accompanied
should be carefully measured in all areas surrounding the coronally by their respective gingiva and supporting
tooth. structures53, and it is used to treat solitary non-restorable
teeth as defined by Ingber. According to Reitan and others,
B. MERITS: 27 eruptive tooth motions stretch gingival and periodontal
• The pocket liner is removed. fibres, causing gingiva and bone to shift coronally54,55.
• It protects the gingiva's comparatively unaffected outer
surface. Circumferential Supracrestal Fiberotomy (CSF) is the
• It results in a razor-sharp, narrow flap margin that cutting of the connective tissue attachment (through
adapts to the bone-tooth interface. fiberotomy), which prevents tensile forces from reaching the
• There are no exposed bare surfaces. periodontium and hinders osseous remodelling at a level
• Healing with a major goal in mind. coronal to the remaining intact fibre attachment.
INDICATIONS:
C. DEMERITS:28 Rapid orthodontic extrusion with CSF is performed when
• If flap elevation is performed, it may result in crestal there is an adequate root crown ratio with associated
bone loss. gingival to improve clinical crown length60.

IX. APICALLY DISPLACED FLAP WITH OR CONTRAINDICATIONS: 61,62

WITHOUT OSSEOUS RESECTION  Tooth with a short root length ratio and poor root shape,
resulting in an insufficient crown/root ratio after extrusion.
Nabers (1954)48 was the first to describe a strategy for  It should not be done on a tooth that is infected with
preserving the gingiva following surgery. Friedman coined periodontal disease.
the term "apically relocated flap" in 1962 to better
accurately characterise Nabers49's surgical approach. MERITS
 Supracrestal fiberotomy is all that is needed.
To expose the sound tooth structure, an apically
positioned flap approach with bone recontouring (resection)
DEMERITS
may be employed. At the time of surgery, a minimum of
 It has the potential to cause root resorption, ankylosis, and
4mm of sound tooth structure must be revealed. During the
movement.
healing process, supracrestal soft tissues will extend
coronally, covering 2-3 mm of the root and leaving just 1-2 Post insertion in an RCT-treated tooth (Fig. 1), wire
mm of supragingivally located sound tooth structure, as well attachment with composite and e chain (Fig. 3), orthodontic
as broadening the attached gingiva zone, allowing crown extrusion with button and e chain, and orelasticextrusion are
lengthening in patients with reduced attached gingiva50,51. all examples of FET. (Fig 4).

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Fig. 8: Radiograph demonstrating post placement 6mm within alveolar bone prior to eruption

Fig. 9: 2mm distance between the serated post and 0.022x0.025 stainless steel rectangular wire

Fig. 10: Orthodontic extrusion with wire attachment by composite and e-chain

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Fig. 11: Orthodontic extrusion with button and e-chain or elastic

XI. COMBINED TECHNIQUE (SURGICAL AND REFERENCES

ORTHODONTIC)
[1.] Contemporary crown-lengthening therapy: A review-
Using a combination of surgical and orthodontic Timothy J. Hempton. JADA, Vol. 141,2010
extrusion, the bone attachment and diameter of the [2.] Peters MC, McLean ME. Minimally invasive
connected gingiva can be increased. First, Forced Eruption operative care. II. Contemporary techniques and
Therapy is performed, followed by surgical excision of soft materials: an overview. J Adhes Dent. 2001;3(1):17-
tissue to expose the teeth. 31.
[3.] Milavec.S, Craspire B. Case report: Clinical crown
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