CASE REPORT

Intentional Gingival Retraction With Provisional Direct Restoration:A Novel Approach to Facial Crown Lengthening

Takeshi Nozawa* and Koichi Ito†

Introduction: Achieving a harmonious marginal gingiva is an important factor in esthetic dentistry. However, surgicalcrown lengthening of single teeth risks asymmetry of the gingival outline in the esthetic zone. In restorative dentistry, exces-sive gingival retractionor deepsubgingival preparation cancause facial gingival recession. This case report describesanovelapproach for facial crown lengthening of single teeth using intentional gingival retraction and provisional direct restoration.

Case Presentation: After administration of anesthesia, facial bone sounding was performed. Gingival retractioncords were pressed into the connective tissue attachment from the mesial to the distal line angle. A provisional direct res-toration was then performed. These procedures were repeated until an ideal gingival outline was achieved.

Conclusion: Intentional gingival retraction with provisional direct restoration appears to be useful for facial crownlengthening of single teeth in periodontal biotypes with thin bone. Clin Adv Periodontics 2012;2:98-104.

Key Words: Crown lengthening; gingival recession.

BackgroundCrown lengthening procedures are performed to improveexcessive gingival display and to expose sound toothstructures. Inadequate tooth structures, subgingival frac-ture lines, and subgingival carious and non-carious cervicallesions are indications for exposure of sound tooth struc-tures.1 Forced eruption with fiberotomy is performed inthe coronal direction.2 The apically positioned flap pro-cedure with osseous resection is performed in the apicaldirection. After this surgery, hard- and soft-tissue remodel-ing results in long-term free gingival growth.3,4 During a12-month wound-healing period, facial and interdental

marginal gingiva change at different rates.5 It is thusdifficult to determine the correct timing of subgingivalcrown placement.6

The supra-alveolar fibers in the facial free gingiva mainlyconsist of dentogingival fiber groups, which extend from anapical connective tissue attachment, and circular and semi-circular fiber groups, which connect with horizontal fibers.7

When a retraction cord is inserted into the gingival sulcusand the subgingival crown contour is temporarily increased,free gingiva spreads horizontally, and the marginal gingivashifts apically. When the retraction cord is removed, themarginal gingiva returns by soft-tissue rebound. Some re-ports have shown that root flattening using repeated scalingand root planing caused soft-tissue remodeling in thecoronal direction.8,9 Conversely, Allen10 stated that simplesoft-tissue excision results in crown lengthening in thin peri-odontal biotypes but that such lengthening is lost as the softtissue rebounds in thick periodontal biotypes.11 Recently,Nozawa et al.3 showed the relationship between the gingivalzenith position and the interdental gingival midpoint line in

* Private practice, Niigata, Japan.

† Department of Periodontology, Nihon University School of Dentistry,Tokyo, Japan.

Submitted April 20, 2011; accepted for publication July 8, 2011

doi: 10.1902/cap.2012.110042

98 Clinical Advances in Periodontics, Vol. 2, No. 2, May 2012

FIGURE 1 Case 1. 1a Initial examination revealed a subgingival non-cariouscervical lesion in the mandibular left first premolar. The width of KG was 4mm. 1b Four months after the first IGP, the width of KG was 3 mm, and thesubgingival non-carious cervical lesion persisted. 1c When five cords werepressed into the connective-tissue attachment, the inferior border wasidentified. 1d Immediately after provisional direct restoration, the width of KGbecame 1.5 mm. 1e Twelve months later, the width of KG was 2 mm. Thebone sounding value was 2 mm. 1f Another 8 months later (24 months afterthe first IGP), the width of KG was 2 mm. A supragingival non-carious cervicallesion was evident. 1g One week after performing direct restoration andocclusal adjustment.

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the maxillary anterior dentition. In summary, soft-tissue re-modeling caused by the strain of supra-alveolar fibers mayinfluence the position of marginal gingiva.

The non-surgical gingival displacement technique is usu-ally used to treat subgingival caries and to take subgingivalimpressions without damaging periodontal tissue.12 Thereare two kinds of retraction cord methods: single-string anddouble-string techniques. The single-string technique is thesimplest and least traumaticmethod.13However, Loe and Sil-ness14 pointed out that the retraction cord is pressed into theconnective-tissue attachment. The double-string techniqueallows predictable impression taking because of the abilityto control bleeding andmaintain thewidthof the gingival sul-cus. However, this technique is associated with a greater po-tential for gingival recessionbecause thepackingof twocordsinto the facial sulcus in the anterior dentition may separateconnective-tissue attachments from the root.13 Furthermore,Tarnow et al.15 showed that deep subgingival margins causefacial gingival recession. The present article describes inten-tional gingival retraction with provisional direct restoration(IGP) for facial crown lengthening in single teeth.

Clinical Presentation, Management,and OutcomesCase 1A 40-year-old male patient requested treatment for a sub-gingival non-carious cervical lesion on the mandibular leftfirst premolar. Before treatment, the presence of a wearfacet on the cusp was observed. Occlusal adjustment waspossible in the treatment phase.16 Periodontal parameterswere examined per 0.5mmusing a periodontal probe.‡ Fol-lowing a study by Ainamo et al.,17 the width of keratinizedgingiva (KG) was measured to compare the increase incrown length. Probing depths (PDs) were 1 mm on the me-sial surface, 2 mm on the buccal surface, and 1 mm on thedistal surface. The width of KGwas 4mm (Fig. 1a). In con-sideration of the thin periodontal biotype, 4-0 black silksuturex (0.15 mm diameter) was used as a retraction cord.After administration of anesthesia, two cords were pressedinto the connective-tissue attachment from the mesial tothe distal line angle. A provisional direct restorationk{

was then performed. The sense of incongruity of gingivadisappeared in 2 or 3 days. A subgingival operative treat-ment was scheduled to be performed at the time of the nextperiodontal maintenance.

Four months later, the subgingival non-carious cervicallesion persisted, and mesial, buccal, and distal PDs were1 mm. The width of KG was 3 mm (Fig. 1b). After admin-istration of anesthesia, five cordswere pressed into the con-nective-tissue attachment. The inferior border was thenidentified (Fig. 1c). A provisional direct restoration wasperformed, and the width of KG became 1.5 mm (Fig.1d). Twelvemonths later, all PDswere 1mm, and thewidthof KG was 2 mm. The buccal bone sounding value was2 mm (Fig. 1e). The tooth length from the incisal edge tothe gingivalmarginwasmeasured on the studymodel usingdigital slide calipers.# The distance was 8.38 mm. Direct

restoration was proposed at this time, but the patient re-fused the treatment. Another 8 months later, all PDs were1 mm, and the width of KG was 2 mm. The bone soundingvalue was 2 mm. A supragingival non-carious cervicallesion was evident (Fig. 1f). Direct restoration**††‡‡ andocclusal adjustment were then performed (Fig. 1g). Thetooth length on the study model was 7.82 mm.

Case 2A 65-year-old female patient requested esthetic improve-ment of a fractured maxillary left central incisor and canine.Initial examination revealed subgingival caries on the leftcentral incisor and asymmetric marginal gingiva betweenthe central incisors. PDs were 1 mm, and the width of KGwas 5 mm (Fig. 2a). All bone sounding values were 3 mm.The tooth length on the studymodelwas 9.55mm.After ini-tial periodontal therapy, the first IGP was performed. Afteradministration of anesthesia, a #3 retraction cordxx (1.2 mmdiameter) was pressed into the connective-tissue attachment.A provisional direct restoration was then performed (Fig.2b). The gingival sense of incongruity lasted 2 weeks.

Three weeks after the first IGP, all PDs were 1 mm, andthe width of KGwas 4mm.Mesial, buccal, and distal bonesounding values were 3, 2.5, and 2.5mm, respectively (Fig.2c). The tooth length on the study model was 10.41 mm.Another 3 weeks later, composite laminate veneer (secondIGP) was performed using a #0 retraction cordkk (0.6 mmdiameter) (Fig. 2d). One week thereafter, PDs were 1 mm,and the width of KG was 3.5 mm. The bone soundingvalues were 3, 2.5, and 2.5 mm (Fig. 2e). The tooth lengthon the study model was 10.82 mm. The provisional re-storations{{ had been in place for 5 months (Fig. 2f). A freegingival impression was performed using provisionalizedtransfer copings for duplicating free gingival form.18 Zirco-nia crowns## were manufactured and placed. One monththereafter, PDs were 1 mm, and the width of KG was<3.5mm (Fig. 2g). Twomonths after zirconia crownplace-ment, the interdental papilla was filled, and coronal gingi-val rebound was observed (Fig. 2h; Table 1).

DiscussionThe apically positioned flap procedure with osseous resec-tion is usually performed to reconstruct dentogingival units.However, this surgery has some problems. The first is that,when a gingival flap is displaced to the apical position, quitea bit of soft-tissue reboundoccurs, and themarginal gingival

‡ PCP-UNC 15, Hu-Friedy, Chicago, IL.x Nesco suture, Alfresa Pharma, Tokyo, Japan.k CLEARFIL SE BOND, Kuraray Medical, Tokyo, Japan.{ ESTELITE + QUICK, Tokuyama, Tokyo, Japan.# NTD12-15PMX, Mitutoyo, Kawasaki, Japan.**CLEARFIL SE BOND, Kuraray Medical.†† ESTELITE + QUICK, Tokuyama.‡‡ CLEARFIL PORCELAIN BOND ACTIVATOR, Kuraray Medical.xx Ultrapak Cord, Ultradent Products, South Jordan, UT.kk Ultrapak Cord, Ultradent Products.{{ Provista, Sun Medical, Shiga, Japan.## KATANA Zirconia Block, Kuraray Medical.

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100 Clinical Advances in Periodontics, Vol. 2, No. 2, May 2012 A Novel Approach to Facial Crown Lengthening

FIGURE 2 Case 2. 2a Initial examination revealed asymmetric marginal gingiva between the maxillary central incisors. Thick facial gingiva was evident at theleft central incisor. The width of KG was 5 mm. 2b After administration of anesthesia, a #3 retraction cord was pressed into the connective-tissue attachment.2c Three weeks later, the width of KG was 4 mm. 2d Another 3 weeks later, composite laminate veneer was performed using a #0 retraction cord. 2e One weeklater, the marginal gingiva was almost symmetrical. The width of KG was 3.5 mm. 2f Provisional restorations had been in place for 5 months. 2g One monthafter zirconia crown placement, the width of KG was <3.5 mm. 2h Two months after zirconia crown placement, the interdental papilla was filled, and coronalgingival rebound was observed.

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positionwill not stabilized forz1 year.4,5 Second, the differ-ent rates of gingival growth between facial and interdentalareas cause changes in crown form.3,5 It is thus difficult todetermine the correct timing of subgingival crown place-ment.6 Third, root surfaces are immediately exposed to sa-liva and plaque after this surgery. Contamination of the rootsurface is the biggest problem of this surgery. Finally, thissurgery results in attachment loss (AL) of adjacent teeth.Thus, surgical crown lengthening of single teeth in the es-thetic zone is a contraindication for this surgery.1

Forced eruption with fiberotomy causes supracrestalAL and exposure of sound tooth structures.2 Repeatedfiberotomy using intentional gingival retraction separatessupracrestal attachment.2,13,14 Deep subgingival crownplacement causes the reformation of the gingival unitthrough marginal recession in combination with apicaland lateral migration of the junctional epithelium to thelevel of remaining cementum inserted fibers.15 In thesetwo cases, provisional direct restoration was performedto prevent soft-tissue rebound, and it may cause reforma-tion of the dentogingival unit.19

IGP has several advantages in the surgical lengthening ofsingle tooth crowns. The first advantage is the nonsurgicalnature of the treatment. IGP does not cause gingival scar-ring after vertical incision, making it more acceptableto patients who require treatment in the esthetic zone.20

Second, bleeding, gingival crevicular fluid, and saliva arecontrollable.13 Therefore, this procedure may be used si-multaneously with provisional direct restoration. Third,provisional direct restoration is precise in three dimensionswithout an overhang and can be performed because suffi-cient gingival retraction is performed. Some disadvantagesare also associated with IGP. The first disadvantage is that

the application of IGP is difficult in thick facial bone. Be-cause intrabony defects are readily caused in thick bone,osseous surgery is necessary in the interdental area andfor patients with thick facial bone.21 The primary indica-tion for IGP is thin facial bone.22 When thick facial boneis present, a two-stage approach using IGP may be desir-able.10,11,23 The second disadvantage is thatz1 mm exten-sion was achieved in each procedure. If a greater degreeof crown lengthening is required, a greater number ofIGP procedures is necessary. The third disadvantage is thepostoperative sense of incongruity. In the case of thick peri-odontal biotypes, this sense of incongruity may persist.Therefore, the time interval may depend on the periodontalbiotype and the postoperative sense of incongruity. Thefourth disadvantage is postoperative gingival rebound.24

Especially when the gingiva is thick, rebound occursreadily.

Deas et al.25 showed that when a gingival flap was dis-placed in the apical position, the soft-tissue rebound oc-curred in the coronal direction.5 Conversely, gingivalrecession was seen when a gingival flap was maintained inthe coronal position.25 Also in the second case, soft-tissue re-bound was observed in the postoperative course. Soft-tissuerebound seems to occur by the constancy of the diameter ofbiologicwidth after crown lengthening.5,19,24,25 Additionally,soft-tissue remodeling caused by the strain of free gingivais considered to be a cause of soft-tissue rebound.3,10,11 Fur-thermore, brushing pressure may be related.3,8,9 For thesereasons, the position of the marginal gingiva will be stabi-lized. In terms of prosthetic treatment, the period and quan-tity of soft-tissue rebound should be considered in theesthetic zone.5,6 Additional studies are necessary to investi-gate the details of soft-tissue rebound in IGP. n

TABLE 1 Periodontal Parameters of the Buccal Surface

Case and Time PD (mm) KG (mm) TL Increase (mm) TL Increase (%) BS (mm)

Case 1

Baseline 2 4 0 0 N/A

4 months after first IGP 1 3 1 40 N/A

Second IGP N/A 1.5 2.5 100 N/A

16 months after first IGP 1 2 2 80 2

24 months after first IGP 1 2 2 80 2

Case 2

Baseline 1 5 0 0 3

3 weeks after first IGP 1 4 1 66.7 2.5

7 weeks after first IGP 1 3.5 1.5 100 2.5

8 months after first IGP 1 <3.5 <1.5 <100 N/A

9 months after first IGP 1 <3.5 <1.5 <100 N/A

TL ¼ tooth length; BS ¼ bone sounding value.

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Summary

Why is this case report newinformation?

j IGP is a novel approach to facial crown lengthening of single teeth.

What are the keys to successfulmanagement of these cases?

j Confirm the morphologic characteristics of the bone using bonesounding.

j Press gingival retraction cords into the connective-tissue attachmentfrom the mesial to the distal line angle.

j Use small cords when the marginal gingiva approaches an ideal line.

What are the primary limitations tosuccess in these cases?

j The primary indication for IGP is thin facial bone. Postoperative soft-tissue rebound may occur. Thick facial bone and interdental alveolarbone are contraindications for this technique.

AcknowledgmentsThe authors thank Prof. HideoMatsumura (Department ofFixed Prosthodontics,NihonUniversity School ofDentistry,Tokyo, Japan) for his advice and Mr. Shunzo Tsurumaki(Masters, Niigata, Japan) for porcelain work. The authorsreport no conflicts of interest related to this case report.

CORRESPONDENCE:Dr. Takeshi Nozawa, Nozawa Dental Office, 9-7 Sakae-cho, Ojiya-shi,Niigata-Ken, 947-0011, Japan. E-mail: nozawa.perio.implant@world.ocn.ne.jp.

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