40 Minute Crown Lengthening Tutorial with Reena Wadia – PDP079

Does Biological Width, apparently now known as ‘Supra-crestal tissue attachment’ confuse you? Or would you like an introduction or a refresher on the clinical stages of Crown Lengthening? Fear not, I twisted specialist Periodontist Reena Wadia’s arm and finally got her on the show to teach us!

Check out this full episode on YouTube

Need to Read it? Check out the Full Episode Transcript below!

Protrusive Dental Pearl: How to find out what kind of biotype you’re dealing with: Use a ball ended Perio probe and use the ball-end/tip (sometimes it’s coloured) and probe in to the sulcus – if you can see the tip of the probe shining through the gingiva then that’s a THIN biotype. and if you can’t see the tip of the probe then that is a THICK biotype.

“Don’t complicate things, if something works in your hands and you’re doing it well, keep things simple, don’t have too many variations because then it just starts getting unpredictable. So test everything out, go on courses, and then see what works in your hand and then stick with that.” – Dr. Reena Wadia

In this episode, we discussed:

  • Bone sounding (10:35)
  • Aesthetic crown lengthening (13:06) and Functional crown lengthening (18:02)
  • Altered passive eruption and active eruption (14:21)
  • Fundamental difference between the two types of crown lengthening (20:06)
  • Biology of keratinised tissue (24:13)
  • Steps involved in crown lengthening surgery (26:32)
  • Using dental stents as a guide (29:44)
  • Post-op management for flaps (30:35)
  • Pre- and Post-operative care (33:05)
  • Ideal case for beginner Dentists (35:19)
  • Placement of sutures (36:28)

Check out Dr.Reeda Wadia’s Perio School

Check out Reena’s Crown Lengthening Live course on a Sunday in London!

If you liked this episode, you might also enjoy How to Save ‘Hopeless’ Teeth with the Surgical Extrusion Technique 

Click here for Full Episode Transcription:

Opening Snippet: When you start taking on more complex restorative cases or you start doing smile design cases. These kind of cases you tend to appreciate that there are two other types of disciplines or too hard skills that really benefit a lot of these patients.

Jaz’s Introduction: 
Number one is orthodontics like a lot of my restorative patients, they will really benefit from pre restorative orthodontics and that makes sense. Okay?

With ortho you can actually intrude teeth get the gingival levels even you can actually make your dentistry less invasive, less prep by getting the teeth in the right position. But the second one is actually soft tissue related more and more and more to get the gum lines even or what we call aesthetic crown lengthening. There is a huge role in the Perio.

So, this episode is focusing on that THIS with Reena Wadia. Reena Wadia is someone who has really inspired me so many years and when I was a dental student, she qualified, and she’s always been a mentor to me. In fact, I’ve mentioned Reena’s name in the previous episodes as you know what Reena taught me this or Reena taught me that. So, she’s such a great giving clinician, she’s a specialist periodontist.

I know you will love her, and today’s episode is talking about just CROWN LENGTHENING SURGERY where it comes to aesthetic crown lengthening. i.e. doing some sort of surgery to make the gum lines or gingival zeniths more even and presentable or functional crown lengthening. This is when you’re actually doing crown lengthening to allow you to get more of a Ferrule so you can actually restore a tooth. We’re going to talk differences how to plan for each one. What’s a post op advice to give and many more gems.

Protrusive Dental Pearl:
The Protrusive Dental Pearl I have for you is how to find out what KIND of BIO TYPE you’re dealing with. And the classic way to do is use a ball ended perio probe and use the perio probe has like a black ball, right? So, it’s like a black painted ball, and then you put it inside the sulcus. Okay?

And if you can see the black or the probe shining through the gingiva then you know, you’ve got someone with a thin bio type and you write your notes, okay, diagnosis, thin bio type. If you can’t see the probe or if you can’t see the ball end, then that is a thick bio type and that’s a good little technique that I learned, which is very relevant to this episode. We’ll also be talking a bit later this episode about HOW TO DO BONE SOUNDING.

Okay, what is bone sounding and how to do it and how it’s relevant to your planning for crown lengthening surgery. So, if you don’t know what your altered passive eruption is to your alter active eruption, then this episode will sort you right OUT. Let’s join Reena now, the main podcast and I’ll catch you in the outro.

Main Episode:
Your ears must be burning because I know you’re super busy and stuff, you probably haven’t had time to listen to podcasts, like for commutes and stuff, but your ears must be burning because I talk about you now and again on the podcast, I say, you know what? Reena taught me this many years ago, you know Reena once taught me this. So it is so nice, Reena Wadia to have you on the podcast today. How are you?

Yes, really good. Thank you. Thanks for having me on the show. Congratulations on such a successful podcast and delighted to you.

Thank you, so it’s down to the Protruserati. So those who listen to the podcast are called the Protruserati and it’s all down to them. All over the world who listens. So it’s really nice and we’re going to cover the theme of crown lengthening surgery. And you are someone who has taught me so much more than just perio stuff back in the day.

You taught me about life, you taught me about communication skills, you taught me about how to navigate this difficult minefield of dentistry. So, I’m sure some of those nuggets, I might just say now and get a remember that time, you taught me this, whatever, so we might just like, you know, take lots of different directions, but for those very few people out there who don’t know who you are, Reena. Just give us a quick little intro of yourself and what you do.

Sure. So, yeah, I’m Reena, I’m a specialist periodontist and based in London. So, most of my week I’m at the clinic at 75 Harley Street where we’ve got a specialist clinic with me and a few hygienist as well, which I really love and enjoy. We recently moved to our new clinic, which has been exciting. And then once we come in the hospital as well at King’s and then the rest of the week I’m teaching, doing podcasts like these, and enjoying myself as well. So, it’s a really nice balance.

Do you still do your Instagram lives? Remember once you’re doing loads? Nice to enjoy catching them. Do you still get time for much of that?

I’m trying to keep that going. I think I had more time during the lockdown to do all that, but I think its technology is amazing. I mean things like this, things like Instagram live, it’s a great way to connect with people and share knowledge and information. So, I’m hoping to do more of that going forward and now that the practice has settled down.

You need to because your presence on camera, your teaching ability is something I model. I’m like, ‘How can I be more like Reena when I’m communicating something because something I’ve admired for many years.’ But today we’re going to really have something really well, which is crown lengthening surgery, which we’re going to start the very basics because over the last six months to a year or so, a lot more dental students have started to listen to a podcast from all over the world. So, let’s just even start with the very basics like WHAT IS CROWN LENGTHENING SURGERY?

Actually don’t underestimate the basics because with things like crown lengthening often if you don’t get those basics, that’s when things go wrong, which I’m sure will go into later. But it’s always great to start off with a definition. So, crown lengthening is basically what it says.

Essentially, it’s removal of usually soft and hard tissue to gain supragingival crown height basically. It usually involves removal of bone. Sometimes it doesn’t, but essentially, you’re creating more tooth crown of structure above the gum line and you’re recreating usually what we call the biologic width, which is now called supracrestal tissue attachment. According to the new classification.

Wow, I had no idea actually. This is new to me. So now it’s called supracrestal tissue attachments and no longer we’re going to be using biologic width.

Yeah, I do like the word biologic width have to say. I think I still kind of use it, but if you want to be perfect and textbook according to the new classification, it’s supracrestal tissue attachment.

Okay, fine, Fair enough. Let’s go with supracrestal tissue attachment. Now, I think for the basis of this podcast, that’s not going to stick with me. So, if I say biological width I mean supracrestal tissue attachment. Okay. Right.

Well one of the most basic things that I got exposed to crown lengthening early on was when I saw some cases on social media where else, right? Where someone had just come and like on one side like upper right canine to upper right central. They just started to use the blade to cut away tissue. And it looked amazing. It’s like WOW this right side revealing the true clinical crown of that tooth compared to whether the tissue was overgrown on the left. It looked amazing, right?

And then I thought this is great, RIGHT? Let’s go to Monday morning practice. And the biggest mistake someone could make now, and we will discuss this very, very much detail now is you can just make a huge mistake by just cutting away the gum and then that’s it. It’s not as simple as that because you alluded to it already. You all seem to consider hard tissue bone removal. So, the most basic question, I think the most fundamental question everyone should be thinking is okay at what point is it can you get away with?

Because I have in a few cases, got away with it. when can you get away with just simple soft tissue removal? Maybe you’re trying just improve the gingival zenith, which is the highest point of the tooth of a central just to match it before you do your crown. When can we get away with that? And then when can we not get away with that? And then we have to consider raising a flap, bone removal, sutures, blood like the T-shirt I’m wearing, that kind of stuff.

So, this is such a fundamental question and I think this is if you don’t understand the principles, this is where you’ll get it wrong and this is where when you do it, it might look nice for like a week or two and then the patient will come back and it’s an absolute disaster. So, it’s all about the biologic width.

So, with crown lengthening, what you’re trying to do is recreate the biologic width. Now the biologic width is something very special or should I call it supracrestal Issue attachment. You have to respect it. If you respect it, it will respect you. That’s what I always say.

So that biologic width, but first let’s define what it is. So, it’s the junction epithelium plus your connective tissue. According to Gargiulo, which is a person who 1961. Long time ago defined it. It’s two millimeters approximately. Now, practically if you include the Sulcus depth, we say it’s sort of 3 millimeters So the number for you to remember is 3 millimeters.

Now, what you have to always check is, do you have that three millimeters? So, when you’re looking at your tissue margin or whichever your reference point is to the bone level, if you have the Crestal bone level-

Can we make this really specific and tangible? So, let’s talk about the upper right central incisor and the upper left central incisor. Let’s say that the upper left one is just more gummy, right? And you want to check with the upper left one, how would you do it?

So, you firstly find your reference point which is going to be the same as the other one, right? So, you want to match it. So, if from that point to the alveolar crest, you’ve got three millimeters. Guess what? Great.

You’ve got your biologic width. You don’t need to worry. If you don’t have three between your reference point and your bone, you will need to recreate it, which is normally the case. And if you need to recreate it, you recreate it by removing bones so you can shift that space up.

So, the point is, if you’re probing or you’ve got a radiograph and your bone sounding and you’ve actually got three millimeters. Once you cut the gum, you’ve cut the gums where you want it, then you’ve got three millimeters. Till the Everquest, you’ll find great, you’ve already got your biologic width or your supracrestal tissue attachment. If you don’t, you then need to raise a flat and remove bone so that you then create that three millimeters. Does that make sense?

Makes perfect sense. And please don’t try this at home unless you’ve actually done a course or something like that and we’ll talk about that in the end. But you mentioned bone sounding. Please explain what is bone sounding and how to do it. I’m familiar with it. I’ve done it.

But maybe based on your description, I might realize, hey, maybe I’ve done it wrong a few times. So, what is the best way to do bone sounding? So, we’ve got the central incisor. You want to check is my bone three millimeters away or not? That’s called bone sounding. But tell us how to do it.

Bone sound is an interesting one. It’s a way of determining where the bone level is. So, you know, if you need to remove bone or not and you know if you need to raise a flap. Now there’s other ways also of determining where the bone level is like your radiographs or like actually just raising a flap anyway and seeing where the bone is.

That’s the safest way of doing it. But bone sounding is a technique which you can use during your planning phase to get a bit more of an idea of this. And what you do is literally what it says. You could usually numb the patient up if you’re nice and then you literally get a probe, and you just push it right down until you feel the bone.

It’s quite not like normal probing right down and when you feel that hard bone, that’s where you measure, and you say okay that’s where my bone level is. So that’s bone sounding. I have to say I don’t often bone sound; my kind of technique is I’ve pretty much always raise a flap unless it’s extremely obvious that you don’t need to remove bone because you don’t really know until you physically see the bone exactly what this, not just where the bone level is but the structure of the bone. Sometimes in crown lengthening, you’ve got this bulbous bone, right?

And you want to actually recontour the bone as well. It’s not just about ostectomy, it’s about osteoplasty as well. So, there are many benefits of raising a flap. So, I always advocate usually unless it’s super obvious that you don’t need to being safer doing it properly the first time rather than making your patient go through surgery again, if it doesn’t work.

I think we did an agreement as a special periodontist I think you know, you’re so comfortable raising flaps, you know, so that makes sense and how you do that and then you can control all the outcomes. Like you said, a real pearl you gave that is that sometimes periodontists when they’re doing the surgery, they have to remove the thickness of bone as well, which is something that people don’t appreciate.

Sometimes that’s a really good tip there as well. With the bone sounding, like me is more restorative background. I’m more likely to do bone sounding than the number of the flaps I will raise in a year is way less than you. So, I am doing more bone sounding.

That one thing that I might want to say, and you correct me if I’m wrong is sometimes when you’re starting bone sounding, you go in and you think you’re there, but you’re probably just at the connective tissue, you actually need to really go a little bit more and then you hit the bone. Is that something that you might find a beginner might make a mistake like that?

Definitely don’t be too gentle and you know, they’re numb so it’s not going to hurt. So definitely going to be a little bit aggressive with it.

Okay, so let’s talk about the difference between for I know there’s two types of crowns lengthening I think there might be more, but as a general dentist there’s aesthetic crown lengthening and functional crown lengthening. Is there anymore? And can you just go over a little bit about each one? The differences.

So yeah, you’re right. So, there’s two major types of crown lengthening, aesthetic, and restorative. aesthetic is becoming more and more popular, I have to say. Looks like getting lots of patients interested in what they call the gum lift, which I find really funny. I like to call it.

I think there’s a bit more than a gum lift. It’s quite like gum sculpting more than anything. But anyway, aesthetic lengthening, it’s getting more popular and it’s a great skill to have as a general dentist as well because if you’re doing all these beautiful smile cases, it just adds that extra bit at the end and I think you can’t forget about soft issues.

The pink is part is really important if you put all that work into doing Invisalign and all the other bonding, whitening and everything else. if your gingival margin isn’t quite right, it’s going to affect the final result. So aesthetic crown lengthening is what it says essentially is to improve the aesthetics. So it could be, for example, like you described earlier, uneven gingival contours, RIGHT?

So, one is slightly higher than the other and that slight difference can make every difference of the smile so small but significant impact. Other ones sometimes just generally gummy smiles and conditions such as altered passive eruption CAN CAUSE.

I totally want to talk about THAT. So, you can just go into what that means. When I first came across that like two years at dent school it was just completely confused me. Now I’ve got some clarity on it, but I think this would be such a fundamental thing to cover.

Yeah. So, you want me to talk about that now in terms of also passive eruption show?

Yeah. Let’s do that.

Yeah, sure. So altered passive eruption So this is quite surprisingly a lot of people don’t know about it and it’s one of the most common reasons for a gummy smile. And I have to admit I actually didn’t know about until I did my specialist training. So, it’s not something that’s really touched upon or usually at undergraduate dental school.

So going back to basics basically you have active eruption which is when the teeth come out of the jaw was essentially in the most simplistic terms. And passive eruption is when your gingiva retract around the tooth and there’s an it’s four stages for you with the details, but there’s four stages as to how the gingiva you retract and that’s passive eruptions.

Active eruption, passive eruption, altered passive eruption is when that process doesn’t go quite a plan and when the gingiva doesn’t quite retract to the level of the CeJ where it should be. So, what happens is your gingival margin is coronal to your C.E. J. And biology hasn’t quite finished its job. So, with crown lengthening, what you’re doing is almost recreating where it should, where the gingival margin should be. So, the CeJ is underneath the gingival margin and there’s different types of altered passive eruption.

You get four different four types 1A, 1B, 2A. And 2B. And if you look at the classification, it depends on where the bone level is and the amount of keratinised tissue that you have attached gingiva that you have as well. So, you can then divide it up. But I think it’s extremely common. The incidences like 11-12%. So, it’s not uncommon and you might find that most of the cases that you see that gummy smiles are actually altered passive eruption cases.

Reena because it’s altered passive eruption. So, no one has explained to me like active eruption, passive eruption. Cause I love that. So, with the altered passive eruption, because it really helps you to explain it because it’s a passive part that’s had an issue and not the active part. So, is active more like bone and passive more like gum, right?

Yeah, but active is exactly the tooth and the bone and then exactly. The passive eruption is a gingival part of it essentially.

So, does that mean that someone who’s got altered passive eruption might be someone who gets away more with just the gingivectomy without the bone removal? Or is that not the case?

No. So, I would probably say that the passive side are just focus on gums and I would actually say periodontium structure. So, the bone in passive eruption might be at the right level. It might not be. So, there’s two different types and one type is at the right level. One type, it isn’t.

So, depending on what type it is. So, if it’s, you have, I’ll just go through it, 1 A Is basically osseous crest is apical to the CeJ. And then 1B Is osseous crest at the Cej so for 1A, you would do a gingivectomy whereas for 1B, you would do a gingivectomy plus osteo surgery. So active eruption, I would say is the teeth and then passive eruption is gums and periodontium basically, I was just going to say it’s just good to know about it because personally.

I think before doing any type of treatment, you need a diagnosis as to why you’re doing that treatment. It’s just important to highlight that you do need a diagnosis before you then do treatment i.e crown lengthening. So, knowing about altered passive eruption that could be your diagnosis, or a fractured crown, might be your diagnosis, but you need to know you have to have a diagnosis before you prescribe treatments. I think it is important to know about its condition.

Great. And we were just touching on the difference between aesthetic crown lengthening, which how ape tied in so nicely with. But now can you just touch a bit on functional crown lengthening and then we might do that. And which is the most common tooth that you get referred for functional crown lengthening?

So functional crown lengthening, also called restorative crown lengthening is basically when you have inadequate tooth structure. it’s a strategic tooth You’re trying to say that, but you just don’t have two-millimeter ferrule. And by doing restorative crown lengthening, essentially creating that so you can restore the tooth. it could be that you’ve got a fracture, you’ve got a perforation, ended perforation in the coronal third.

That’s key. You’re not going to do if it’s like in the apical third so something in the coronal 3rd and you’re trying to save that tooth, or an important point is if you’re trying to relocate the crown margin when it’s been impinged. Ie someone’s not respected the biologic width guess what, you’re now going to have to do crown lengthening to recreate it. So that’s actually really common and seeing it more and more.

I said the most common the few times I’ve done, I have done it to get more Ferrule so that I can now make a tooth that was previously unrestorable. More restorable give it a better prognosis, which is the most common tooth that you get referred for this?

It’s usually a lower molar. From my experience, that’s what I’ve had so far. It’s usually like a strategic tooth they’ve lost already. Lost another molar behind it. Patients are really keen to save it and do everything they can. And don’t want to jump straight into implants and that’s usually the most common thing. I always say to the patient, you know, everything has a lifespan in dentistry. And so, if you’re going to jump to an implant, guess what?

That implant also might have a lifespan. So, the longer you can keep your own tooth the better. And I’m not saying to do heroics, like if it’s a tooth which is completely broken down, has got like a 10-millimeter perio pocket, terrible endo. Yes, it may be better to extract that you have to be sensible, but usually nothing is better than your own tooth In my experience.

Fantastic. What people really resonate with what dentistry resonate with when they listen to podcast is there’s little sayings, there’s ways that we communicate with patients. So that’s awesome. So yeah, you said lower molars are the most common that you found. I can see the rationale behind that. And I love what you say to the patients. Now, what is a fundamental difference between the aesthetic crown lengthening and the restorative crown lengthening? In terms of the surgeon when you’re doing the procedure.

So, in terms of the differences between the two, firstly, the similarities are that the principles are the same. So, you’re in both scenarios, you’re trying to recreate the biologic width and you’re using a reference point. Now, the differences are the reference point. So usually for aesthetic crown lengthening, it’s usually your CEJ, especially in altered passive eruption cases. Whereas for restorative crown lengthening or functional crown lengthening, it might be a certain crown margin, it might be that amount of sound tooth tissue that you need. So, it varies.

The actual technique itself again, the principles are the same. I.e., we’re going to a little bit more detail but you remove the gum, raise the flap, remove the bone. stitched back up. However, for aesthetic crown lengthening, usually it’s just buccal because it’s you know, you don’t see the palatal or lingual, so it’s usually just buccal. Whereas for restorative it’s usually is 360 across the tooth. For restorative crown lengthening usually if it’s at the back of the mouth especially, I wouldn’t be worried about doing vertical releasing incisions. You know, not that bothered about it.

Whereas anteriorly, I really would avoid it because you don’t want any scarring because you know, doing it for aesthetic reasons. So, we try to minimize and usually you don’t need it to be honest for aesthetic. You sometimes it’s usually a Kind of 4-4 case or 3-3 you’ve got enough access without doing a relieving incision. Often as well for your end goal is also different between the two while you’re actually doing it.

But often for aesthetic crown lengthening I would also consent them for what I call it a revision surgery because when we go to the restorative phase, often these patients that they want a little tweak before the final restorations to make everything perfect. Or if you get gingival overgrow again, then you might need to do a bit more surgery. So that’s less important for restorative cases. So, I would consent for revision surgery for aesthetic crown lengthening as well.

And I guess the other differences with the healing. I often use things like coe- pak for restorative crown lengthening because it really keeps the tissues down or as for aesthetic, I would not be putting coe-pak at the front of mouth. Coe-pak, just to explain is a dressing that you can use periodontal dressing. It looks a bit like pink chewing gum, feels like chewing gum and you just press it on the tissues and essentially just keeps the tissues in place. And then two weeks later, you remove it and take the stitches out it works beautifully but it’s not something you’re going to paste across someone’s from in front of their mouths.

So anterior cases, those aesthetic ones. you’re not using a coe-pak, but you just letting nature do its job.

Yeah. You need to suture. You always need to suture. If you raise the flap, you have to suture. But apart from that, yeah, the gums will just heal, and suturing is really important. I mean, everyone focuses on the first few stages of removing the gum and bone. But your suture is where your tissue is going to end up, right? So, spend time on suturing as well and doing it well.

Amazing. Good few pearls in that. I’m going to go really geeky now and ask you a geeky question which always bothered me about this subject, right? And I just can’t get my head around it. So now that I have you on the show, I’m going to be very selfish. Ask a question. I’m hoping it’ll help others who are thinking the same thing. Right? So, you mentioned about the similarity between aesthetic crown lengthening and restorative crown lengthening i.e you have to cut some gum away.

You raise a flap, you remove the bone etc. You suture back which is so important. Now that scenario where you actually cut the gum away. Okay let’s talk simplistic terms, Right? the gingivectomy You cut the gum away. And yes, you got different goals. You know the CEJ being one and the other one just revealing more tooth structure.

But everyone’s got a defined and finite amount of keratinised tissue. Right? So, let’s say you know, you’ve got some patients, right? And they’ve got like miles of keratinised tissue like thick meaty. I’d love to do crown I think in a case like that. But then you got someone who’s just got two millimeters of keratinised tissue. Right?

So, what if for that patient who you’re doing let’s say a restorative crown lengthening on the lower molar they’ve got let’s say four millimeters keratinised tissue. And then you cut away three millimeters and then you do your crown lengthening and then you suture it back. What happens, right? Does it just stay as one-millimeter keratinised tissue for the rest of that patient’s life? Or does the apical part of it suddenly become keratinised? What happened? What the biology about that?

Yeah, that’s a really good question. So, I think the first important point is keratinised tIssue is important. It helps patients to comfortably clean around the gingiva, so it maintains health. So keratinised tissue, if there’s not tons of it, you need to be careful basically. So, in most cases you have enough to be able to do a gingivectomy, raise a flap remove bones, stitch it back up.

But in the rare cases where you don’t have sufficient keratinised tissue and you know, by then cutting it away essentially there’s going to be hardly anything left. You need to change your technique. So, in this case you actually need to preserve the keratinised tissue. You need to raise the flap, right past the mucogingival junction and actually after you remove the bone apically repositioned flap.

So, it’s a different technique for those types of cases. I have to be honest; I can’t remember the last time I did that. So, in most cases you will have sufficient keratinised tissue. But you are right to be on red alert if that happens, preserve the keratinised. And I’m biased as a periodontist saying that, but honestly is really important to have it there.

So essentially, that’s the difference than therefore between what we call receptive crown lengthening surgery. Is it apically positioned? Is that the correct term?

Right, apically positioned. Using a different approach. Exactly.

That’s the one that I’ve never done. Apically repositioned. Is that something you teach on your course?

It is, yeah, it’s something that I teach, but it’s so like so rare that you probably won’t need to, if you were starting out for the first time, I wouldn’t advise that as your first case. You want one with stacks of keratinised tissue as you said, so it’s more tricky for sure.

Okay, Reena we’re taking like a little geeky detour covering all the wonderful things that you answered. My fault because I ask you, is geeky questions about altered active eruption stuff, but really I want to hear because I think what people find useful this podcast is hearing the steps, the little steps and what you taught me many years ago, Reena was micro steps. You taught me that the term micro steps out, and these are the difference between success and failure is not the big success but little micro steps you take. So, within the remit of the podcast episode, let’s cover a couple of minutes of what are the steps involved in crown lengthening surgery?

Yeah, micro steps. It’s so important. Honestly, some of the best clinicians, it’s not just about the macro steps, it’s about the tiny detail and doing it consistently every single time. So, it’s good to remember that. So, the first step I would say is assessment to plan your approach. And it’s all about planning, crown lengthening, the actual procedure, the surgical side of things is actually not that difficult.

It’s the planning stage, as with anything in dentistry. So, you’ve got to plan a couple of things. So firstly you need to look at your periodontal health and I know I’m biased, but I’ve seen too many cases where someone’s got Periodontitis and they start hacking away and doing aesthetic, crown lengthening.

It’s not appropriate. Cutting tissues that are inflamed and plus plaque everywhere. It’s going to be messy. It’s not going to heal well you could make it worse. So, step by step. Get the periodontal health super healthy patient. Plaque control needs to be optimal. Look at all the restorative factors. You know, do you need to redo the endo? Is there anything else you need to do restoratively before you then start your crown lengthening? Also determine your reference point.

What is your reference point? Is that the CEJ That’s what is it? Because that’s going to be what you’re going to measuring from and you’re going to remember that three millimeter rule essentially. If you’re doing aesthetic crown lengthening, you need to plan your gingival aesthetics. So, know the gold standard, where’s that zenith meant to be on the canine? Where’s that zenith meant to be on the central? Is it meant to match? etcetera. So, you need to plan that out. I quite like what I’ve started doing now. I have my iPad and then I import the patient’s photo and I’ve got a little pen and I draw on and then I show that to the patient as well. I’m using iPad. It’s quite fun.

Quite therapeutic. And then also looking at the amount of keratinised tissue that we discussed as well earlier and also where your bone level is. So, they’re all your kind of key components when you’re planning your case. The next thing is then your flap design and your incisions. Give yourself more room than you might think, especially with restorative crown lengthening. Don’t be too conservative. You’ve got to go one tooth either side of the tooth you’re treating to get enough access to the bone. So, flap design incisions.

If you’re doing aesthetic crown lengthening, I teach that. The flap designs where you’re not going through the actually raising a papilla because you don’t want to risk having black triangle. So, there’s all these little nitty gritty things to be aware of. We then remove the excess gingival tissue, and you raise your flap and throughout all of this, you know you’ve got to have the right instruments don’t underestimate.

As with anything in dentistry, good quality surgical instruments are critical. It’s all about micro surgical now as well. So, I’ve got a nice set of micro surgical instruments. Because perio is very delicate. It’s not like oral surgery, you’ve got to be very detailed and delicate. A completely different approach which applies in crown lengthening as well.

Anyway, as I was saying you raise the flap and then you see where the bone is and you do your osseous management. So, at this point you remove the bone whether that’s using slow hand piece with water and a round bur. I started using a Piezo as well. You can actually get a Piezo which removes bone which is quite nice. So, I’ve been using that. Once you’ve got your bone levels sorted you then suture.

I’m going to stop you there Reena, because you talk about the bone removal and talk about suture. But I’ve seen before when I was at Guy’s doing my D.C.T. Post that sometimes you get these like Essix retainers that was lab made to guide you. Do you use those?

Yeah, I used to quite a lot depends on who I’m working with. Often the cases are referred by dentists who gone to the effort of making a wax-up and sending a stent It can be helpful to give you a general idea and there’s different stents. Some stents just show you where to cut the gum essentially.

You still need to use your own clinical skills to make sure you get it perfect. But it gives you a guide, it’s a guide. Some stents are very sophisticated. It also shows you where to remove the bone up to. So, it’s it depends. It can I think if you’re starting off, it’s worth doing.

I’m trying to envision like doing a bigger case and you know, because you’re so experienced in this now is like, imagine you’ve done your gingivectomy. You raise the flap, you remove the bone. But then because the gum now behaves differently. Once you raise the flap, it becomes flappy, right? So, when you’re trying to approximate it back, just kind of measure. Okay. Have you, will it look, okay? Any advice on eyeballing that?

Yeah. What I’m generally do is quite simple. You just put the flap back, push your elevator against the flat and put your probe underneath and you just keep doing that basically. And that’s how I generally do so which works quite well. Yes. And then you suture. So, there’s different types of suture.

I have to just say whatever works in your hands. I use vicryl usually five or six. So, but you know whatever works in your hands or whatever technique you can even just do simple interrupted. It’s just going to be good suture and get the soft tissue in the correct place. mattress sutures are good as well. And then if you need to put a dressing on, if it’s restorative crown lengthening you might want to use some coe-pak and then you let everything heal. And usually, it’s two weeks that then you then review them, remove the stitches.

I usually get a Cotton pledget it dip it in Corsodyl I don’t like using the C WORD. It’s the only time I like using [cortisol] is after surgery where I literally wiped the gingiva and remove the sutures and then you just let it heal. And I guess timing wise in terms of cases. you’re looking at restorative cases that you need to wait three months prior to putting your definitive restoration on. You can put your provisional AFTER sutures out.

You can go straight to provisional, but you need to wait ideally three months for aesthetic cases. The textbook answer. You actually have to wait six months, I have to say. So, me and my referrals, we wait 4-5 months and were usually okay. But what you need to be aware of is the gingival margin can continue to slightly change up to six months?

So if you want to do it properly, get some good provisionals on possibly lab made provisionals, just let them be essentially for six months, once everything’s perfect, then go into your final ones because the last thing you want is you’ve got your finals and then like a month later gingiva ever so slightly higher up and the patients not happy and have to redo everything. So that’s your overall steps. So, you assess flap design incisions, raise the flap, remove the excess gingival first raise the flap, remove the bone. stitch up, let it heal and then move on to your restorative phase. If there is one.

If you’re doing any revision surgery then does that reset the clock for six months?

Usually not depending on what it is. If it’s such as it’s usually the tiniest amount. So, I think it doesn’t really count unless it’s extensive then yes, reset the clock unfortunately.

Got you. So, you’ve done your crown lengthening surgery with those lovely steps to talk through. What’s the post op care looking like for a patient? You mentioned about how long to wait for restorative, which is one of my next question. That’s awesome. So, we know that six months for aesthetic cases. Perfect. But post op wise, what do you say to a patient?

Yeah. So, in terms of any surgical procedure, they’re going to be on Chlorhexidine usually for two weeks. No brushing of the area because it’s technically a wound. So, if you can’t brush it, it’s a delicate area. Brushing the rest of the mouth as normal. soft foods, ideally for as long as possible, but ideally a week or so. Just be sensible. Nothing would like seeds and crusty things that’s going to affect the healing. And then just in terms of two weeks after once you remove the stitches, they then can start brushing the area.

And crown lengthening is unique in the fact that unlike other periodontal surgeries, you can start brushing quite quickly and you kind of need to, so the gum doesn’t try to go back to where it was. So, with other types of periodontal surgery, sometimes for months they don’t brush. So, it’s quite different with crown lengthening. So, and of course after any surgical procedure, patients need to take it easy. No major exercise.

I think that painkillers, regular painkillers are fine. I also include an ice pack that they can just put on their face, especially between a big case. The thing is give them everything they need. The last thing you want is you put your patients through a massive surgery and then they have to go to like boots to buy all this stuff on the way home.

It’s Not Fun. give them a goody bag with everything they need ice pack, painkillers, straws whatever else they need mouthwash, gauze. So, they’re ready to go straight home. I think that preparation side is really important. I also send them an email the week before telling how to prepare.

So, get your food’s ready. Soft foods, food replacement drinks, you’re really good, all those kind of things, get them painkillers, all of that. So, they feel prepared otherwise. They’re just, you know, they don’t feel prepared to get more anxious and everything goes wrong. You need a calm patient. If you’re doing these types of cases.

That was brilliant. I really love the fuel reference, which I never thought of that, but I guess that’s something new. Right? We can start having these meal replacements. It makes so much sense. And also having a goody bag. You’re so right. You made it really clear that you don’t want this patient just had this surgery numb lips to go to boots to buy something. You’re so right.

We should totally make a goody bag. Last question, last couple questions that clinically orientated I want to ask about which is the ideal case? Like imagine, you know, this is something you teach. What do you tell your students? Right, okay. When you go out Monday morning find a case which has which takes these boxes.

Yeah. So, when you’re starting off, I would say a restorative crown lengthening is good as the first case because it’s the back of the mouth. Something goes not wrong, but it’s not beautiful. It’s not going to be the end of the world. Lots of keratinised tissue, possibly minimal bone removal. So, you just kept practice on raising a flap and doing some minimal bone removal.

Once you’ve got the hang of that, then you can move on to a bit more complex and possibly anterior cases with lots of keratinised tissue. But I get minimal bone removal. So, start off easy. Get your confidence because the last thing you want is you do a case, and it goes wrong and you know what it’s like. You just don’t want to do anymore. So, you’ve got to have an easy first case.

Pick someone with a very low lip line and you do aesthetic crown lengthening on them. That’s the best person, which I don’t see the point of you see it down on the ground sometimes.

Yeah. And a nice, a nice, easy patient. Like not one that’s like, ridiculously nervous and difficult. If you see what I mean. Fidgety. Yeah.

Geeky little, tiny questions. Now sutures facing buccal or facing palatal. Let’s say you doing some upper crown lengthening aesthetic. They’re not facing buccal or they’re not facing PALATAL or does it not matter?

It probably doesn’t matter too much. I always do buccal. I think it irritates some more when it’s palatally on the tongue and keep playing around with it. So, I stick to buccal knots.

Okay, sweet. And then always the cold blade. Or is there a place for laser?

I absolutely love, I’m very traditional. I love the blade. But there is a place for laser, I have to say, I don’t use it, but if you’re doing simple gingivectomy cases you can use it is and it’s great because it stops the bleeding as well.

So if you’re doing an overgrowth cases, actually, technically for removing the bulk, that is a type, I should never said, actually, that’s a type of crown lengthening technically if you want to be geeky, which you are, I am as well, so that is a kind of thing. And for those types of cases we can get a lot of bleeding. The laser might be really useful.

Talking about this amlodipine induced gingival-

Technically removing that bulk, you’re actually crown lengthening, so that is technically the third type. But anyway, I mean it’s whatever works in your hands, I think at this stage it’s worth possibly starting off with a blade because it’s traditional thing to use and then exploring other systems. And why one thing I would say is don’t complicate things.

Like if something works in your hands and you’re doing it well, keep things simple. Don’t have too many variations in what I call your micro steps or building blocks because then it just things start getting unpredictable. So, test everything out, go on courses and then see what works in your hands and then stick with that.

Well at least you nicely to. Because I’ve seen so many good reviews on your course. Video testimonials, your videos that you may have been so crisp. Tell us about, I mean is it purely online? Is it a hands on as well? I mean how does that work with your course?

Yeah. So all of our courses are under perio school which I set up during the lockdown, which is really exciting. And originally perio schools all online because it happened because of the lockdown so I had to cancel my courses basically made everything online. Which has been amazing because people from all over the world have been access. We’ve got a massive community now which is really exciting. So, there’s lots of courses online.

The crown lengthening one is hands on because there’s no way I think you can just learn it from watching a video. You need to come in person. We’ve got special models that we ordered from the U.S where you can remove the gum. It’s very cool. We’ve got pig’s heads obviously to get the experience of removing gum bone stitching all those kind of things. And so, the key crown lengthening course is a hands on course. It’s a one-day course usually on a Sunday.

You’re such a geek. I love that.

Because, you know, you don’t have to give up a day of work, which is nice. And the next one’s on the 18th of July. And if you go to www.perio.school.

And that’s on a Sunday? That was the Sunday, RIGHT?

Yeah, that’s Sunday.

That’s good. That sounds so enticing. Okay. I will definitely take a look at that. Is that one just purely hands on? That is an online component as well?

It’s purely hands on and we literally go step by step. I mean we’ve had like new grads on that and it’s for anyone really. We’ve had people 20 years’ experience, people have just qualified. And what we do, there’s electric component and we’ll show you the bit and then you do basically explain it.

Then I show you and then you do it on the pig’s head. So it’s step by step and at the end of the day you should be quite confident. Be able to go. My whole point is you go out into practice, and you can actually do a crown lengthening case. That’s the whole point. I have to say as well though there is mentoring after that as well.

I was just going to ask about that, do you have like a secret group or something that you can post to?

Yeah, it’s just 1 to 1 to basically whenever you get case we’ll talk through it, we’ll do a quick video call, we’ll talk through the steps. Then we’ll talk about how it went after you take some pictures.

It’s just till you get the confidence because the whole point of course is for me is I want the satisfaction for me is for me to you will say to me, you know, I’ve gone out and done my first case and then it’s like, yeah, I don’t want to say, oh, that was a good course and then that’s it. You want to be able to apply it. So yeah, it would be great to have anyone who’s interested on. Then if you want to go any questions just get in touch.

I will definitely put the link on the website ASAP. So, guys check that out on a Sunday. That sounds amazing in London. And I totally echo what you said about try and get delegates through their first case ASAP and supporting them is the same with the splint course, which I set up and I just love our little community and every time someone posts a splint that are done and the color in a parafunctional analysis and stuff, it makes me so happy.

And then now everyone’s taking videos of the patients saying, you know what, my headaches are gone or whatever. So, the same with you, I guess when patients send you, when dentist send you photos of their patients who they are and crown lengthening said, you must feel so proud and have that warm, fuzzy feeling inside.

It’s amazing. Makes me really happy. But also in the patients when you hear that, as you said, their reviews. Things like crown lengthening can be life changing. Don’t underestimate the value of it, whether it’s aesthetic or even restorative. You managed to save someone’s tooth.

You know, the value of a tooth is huge. So, if you can have this skill, which I think is great for anyone in practice, you know, whatever specialty you and whether your general practice or it’s literally a key skill for everyone. So, it’s worth knowing about.

We’re recording right now is June. And do you have any spaces available for July so I can message my community?

Yes, we do. We’ve got around six spaces left so it’s going to be a small group of 10. so, we’ve got a couple more spaces.

Brilliant. I’ll get that out to everyone. I’m sure we’ll see some Protruserati on there. Reena, thank you so much for covering crown lengthening in such a great way. It’s always nice connecting with you. It’s lovely to see you there for a long while and thank you for giving up your time. We appreciate it.

Thank you so much. It’s been a pleasure.

Jaz’s Outro: 
Well, there we are, Protruserati. I hope you enjoyed that episode with Reena all about crown lengthening. I hope you’re now able to assess your patients better and look at them with a different lens in terms of when you see someone with short clinical crowns got small teeth. Well, is it really that they have small teeth or is it that their gum never matured?

Okay, so it’s a different way to look at someone. And then from there, when you make that diagnosis, some patients may actually desire, once you communicate the value of it to them, an aesthetic improvement in terms of crown lengthening or you may plan some functional crown lengthening to help improve your restorative prognosis. So, I hope you enjoyed that very much.

And I’ll catch you in the next episode. As usual, please do check us out on Instagram and of course our telegram, Our special little family on telegram. It’s protrusive.co.uk/telegram to join our telegram group. Protruserati only. I’ll catch you in the next episode. Same time, same place.

Hosted by
Jaz Gulati

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