Step by Step Functional Crown Lengthening – PDP207

Protrusive Dental Podcast

What are the steps involved in Functional Crown Lengthening?

Which scenarios/teeth are best for this type of surgery?

What is biologic width and why should we care?

Is Bone sounding a diagnostic test, or just a genre of music?

The answer to these questions and a lot more can be found in this packed episode with Dr Hiten Halai. We cover the right protocols when crown lengthening and understand the difference between aesthetic and functional crown lengthening.

https://youtu.be/KRlEtz16I8c

Watch PDP207 on Youtube

Protrusive Dental Pearl – Bone Sounding

Using a periodontal probe, go into the depth of the sulcus, pushing deeply until you hit bone, all while recording the measurement with the probe. This measurement will then guide you on how to carry out your crown lengthening procedure. Push hard to pass the connective tissue and ensure you are touching the bone.

Not using AI to write your notes and letters for you yet? Save hours every day and save money using this affiliate link for DigitalTCO: Click Here

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

Highlights of this Episode:
03:19 Protrusive Dental Pearl
06:10 Introduction – Dr Hiten Halai
12:56 Functional Crown Lengthening
15:41 Understanding Crown Lengthening Types
18:42 University of Dental Instagram
22:38 Biologic Width aka Supra-crestal Tissue Attachment
25:51 Functional Crown Lengthening: Practical Considerations
31:09 Assessments & Keratinised Tissue
35:47 Understanding Tissue Phenotypes
39:16 Case Study: Premolar Treatment
43:17 Bone Sounding and Biologic Width
46:58 Shape of Gingivectomy
50:31 Flap Designs
52:37 Burs for Crown Lengthening
56:13 Healing and Restoration Timelines
58:31 Learning and Training Opportunities

Key Takeaways:

• Hiten’s journey began with a passion for periodontics during dental school.
• Managing time effectively is crucial for specialists with busy schedules.
• Functional crown lengthening is often underutilized in practice.
• Aesthetic crown lengthening can lead to complications if not done correctly.
• Understanding biologic width is essential for successful crown lengthening procedures.
• Preoperative assessments are critical for determining candidacy for crown lengthening.
• The type of gingival tissue affects surgical outcomes and healing.
• Proper surgical techniques can prevent complications and ensure better healing.
• Postoperative care is vital for achieving desired aesthetic results.
• Continuous education and mentorship are important for dental professionals.

This episode is eligible for 1 CE credit via the quiz on Protrusive Guidance.

This episode meets GDC Outcome C.

ADG Code: 490 PERIODONTICS (Mucogingival management)

Aim: To enhance knowledge and practical understanding of crown lengthening procedures, with a focus on distinguishing between aesthetic and functional crown lengthening, and the importance of biologic width in achieving predictable clinical outcomes.

Learning Outcomes:

1. Identify the key differences between aesthetic and functional crown lengthening and the clinical scenarios in which each is most appropriate.
2. Demonstrate an understanding of biologic width and its significance in the success of crown lengthening procedures, including the impact on long-term periodontal health.
3. Apply the principles of bone sounding to accurately assess the need for crown lengthening and ensure optimal restoration outcomes, minimising risks such as gingival recession and bone loss.

If you liked this episode, check out: PDP079 – Crown Lengthening

Click below for full episode transcript:

Teaser: Despite what the University of Instagram tells you, all cases cannot be treated by laser gingivectomy. And that is the truth. Four or five years down the line, when there has been enough time for that tissue to relapse, what happens is they'll come back with that persistent inflammation. And actually the management of it is much more complex now.

Teaser:
If you’re going to remove an extensive amount of bone and you might even cause mobility, that is probably not indicated in that situation. If your alveolar bone all of a sudden grows from incidental peaks to a really low trough on the mid palatal, the soft tissues will not be able to follow that margin there, okay? And if you cut them to that, post surgically, there will be rebound. It’s kind of like, the way I describe it, it’s like-

Jaz’s Introduction:
When you think of crown lengthening, what do you first think of? Do you perhaps think of aesthetic crown lengthening? That’s when we’re trying to make the gingival levels match up. For example, a lateral incisor, we want that gum to go a little bit higher. So that’s aesthetic crown lengthening. We’re lengthening how much tooth we’re showing for the primary benefit of aesthetics.

The other type of crown lengthening, which I personally have more experience with, is functional crown lengthening. Think of an upper premolar, which is the example we use deeper in this episode today. And this premolar, it’s got good amount of buccal tissue, but palatally, it’s got very little tissue. It might even be broken sub gingivally. And yes, in this world of implants, there is a place for titanium therapy, but I like to save teeth where possible.

And if the general endodontic prognosis is good, A good way to improve the restorative prognosis is by doing functional crown lengthening. And so this would be necessary because, yes, you’ve got good tissue buccally and you get good ferrule. Ferrule is like that tooth structure that the crown can grab onto.

Now, if you haven’t got any structure palatally, and your palatal tooth structure is broken subgingivally, how is the crown supposed to grip that tooth structure? We need at least two millimeters 360 degrees, maybe 1. 5 millimeters with care, but two millimeters is ideal in the literature. So if we can get rid of some gum palatally and a bit of bone, and then now everything heals so that you can now grab on to two millimeters of tooth structure, you have lengthened how much crown you have available of the tooth to be able to restore.

Hello, Protruserati, I’m Jaz Gulati, and welcome back to your favorite dental podcast. I’m joined by specialist periodontist Dr. Hiten Halai, and you’ll find out the funny way which Hiten had a big role to play in the birth of this podcast many years ago. Now we discussed everything from indications and contraindications and actually came to guide us through the technique step by step from assessment, bone sounding, the incision, and the bone removal down to which burs you should use for the bone removal.

And if you’re a Student or a young clinician who’s never done this before then this should inspire you to seek out more education and learn more. Pick up those books or go on a course. But it’ll give you a really sound understanding. And if you have a bit more experience under your belt, with a little bit of mentorship, I think you could do this.

I think functional crown lengthening, if you pick your case as well, like an upper premolar, and you’ll see why an upper premolar is ideal for this. This is fun dentistry. This is fun. You get to breathe new life into a tooth, which was otherwise of poor restorative prognosis. And once in a blue moon, when I get to do this, I quite enjoy it.

Dental Pearl
Now, Protrusive Dental Pearl Time. As you know, every PDP episode, I give you a pearl. And if you think back to a few episodes ago, I told you about accessing through a molar before you do your sectioning of that molar for extraction to give you more practice of accessing molars for endo. So the more you access, the more you improve with your access cavity.

Now in a similar vein, in the perio crown lengthening field, one skill that we talk about in this podcast is bone sounding. Now, I’ve talked about bone sounding on this episode four. That episode of Dr. Jason Smithson on Ovate Pontics, absolutely brilliant. Do check it out if you haven’t already. And I talked about the edentulous site and how to bone sound there.

Actually, bone sounding can happen around any tooth. You want to figure out where is that bone relative to that gingival margin? And don’t worry if it’s not quite making sense of why you do this, that’s all to come later in this episode. But essentially you want to get a perioprobe, you want to go into the depth of the sulcus, and then you want to go really hard until you hit bone.

And that measurement will guide you in terms of how to do your crown lengthening. And if you’ve never done this before, you want to get like a feel of what it feels like to actually hit bone. Because sometimes you get to the connective tissue and you think, ah, I’m there. But actually, if you really push a bit more, you’ll sink in another millimeter or two more.

And that’s when you’ve truly done bone sounding. So how can you practice bone sounding without doing it for no reason at all? Okay. So if you’re doing an extraction, then I kind of regularly bone sound for extraction because it’s one of the ways I check that the patient is sufficiently numb. So whenever I’m doing an extraction, I will probe really hard with a sharp probe.

Buccal, mesial, distal, lingual, to make sure that the patient is fully anesthetized. And actually what I’m doing is very often I’m getting down to the bone. And so I have just done some bone sounding. So two benefits here. One, it gives you practice of bone sounding. If it’s not something that you’re used to, it gives you that skill.

It gives you that tactile feel or what it feels like to feel bones. So when you do a future case of functional crown lengthening, you are more likely to get accurate measurement. And two, it’s a great way to check that you’ve got objective anesthesia from the tooth you’re extracting. For those who are watching this on the Protrusive Guidance, YouTube, etc, then you would have seen a visual.

For those listening, I’m hoping I described it well enough that you can actually implement this if you have an extraction today if you’re heading into work right now. As always, everything I discuss will go in the show notes. Now, very often with my guests, we explore a topic so well and the notes that are generated, the premium notes that we create, are a lovely summary, a cheat sheet, if you like, of the entire episode.

So if you’re a Protrusive Guidance member, you can get that from the Protrusive Vault or under the episode in the paid section of the app. The premium notes are a paid benefit of being a Protrusive member and you support the podcast. So me and the team can keep creating wonderful content for you. So if you ever wanted to access that PDF, cause maybe you’re driving, maybe you’re running and you want to revisit and refresh everything.

Then that’s why we create the PDF summaries. A lot of work actually goes into this. So head over to protrusive.app or download the Protrusive Guidance app and check that out. This episode is eligible for CPD or one CE credit and we are a PACE approved provider. Now it’s time to enjoy the episode. I’ll catch you in the outro.

Main Episode:
Dr. Hiten Halai, welcome to the Protrusive Dental Podcast. Before we get into today’s topic, did you know, Hiten, right, and we didn’t talk about this before I hit the record button, did you know that you may be single handedly responsible for this podcast?

[Hiten]
What you mean?

[Jaz]
Okay. Let me explain how, okay. Remember those, at that time, many, many years ago, I messaged you on Facebook. Right? And this must have been like, I don’t know, eight, nine years ago. Seven or a significant time ago, right? Like a significant, a lifetime ago to ask you about advice about you being in Singapore. I was in England, you were in Singapore and you were one of the guys along with Surinda who helped me to come to Singapore, gave me everything I needed to know, and then just as I was coming, you were leaving. right? So never got-

[Hiten]
Never really crossed. Yeah.

[Jaz]
Literally like the opposite planes, right. Anyway, so ever so thankful for all the help you gave me, right? And then anyway, fast forward like two years, I come back to England and just like you got bombarded by everyone asking you about Singapore and stuff, right?

I felt like I was getting bombarded like daily, right? And I was on the phone call on my commute from London to Oxford, asking, answering the same questions that you used to answer. How much do you earn? Do you need to pass the exam? Do you speak English? You remember those questions, right?

[Hiten]
Yeah, yeah, yeah. All the usual stuff.

[Jaz]
The same things I ask you basically, right? Anyway, so that led me to create the podcast. Cause episode one was like, okay, how can I get my message out there? So people stop asking me so I can get back to this and listen to my audio books. So episode one was a Surinda at expat dentists in Singapore.

[Hiten]
Yeah.

[Jaz]
So there we are. You created this podcast.

[Hiten]
Yeah, strong word, but no, I’m glad to be an inspiration to you. I guess.

[Jaz]
A hundred percent, my friend. And you’ve been doing great inspiring things. You’re obviously you’ve been a specialist for a while now. But Hiten, tell us about yourself, man. Tell us about you, your journey and how you ended up as a PerioBot.

[Hiten]
Yeah. So, I think, well, it started at dental school. Like when I was doing my undergrad training, I really actually enjoyed Perio, which is a surprise to a lot of people because at undergrad level, it tends to be what people think quite boring, but I made it a point to go and kind of learn more about than just bog standard non surgical treatment and oral hygiene and get into a bit more depth about what actual perio is and what life looks like as a perio specialist. And it is a lot more than just kind of non surgical treatments.

[Jaz]
Exactly. As you were saying that, Hiten, you were saying, you enjoyed it. And all I was thinking was you enjoyed sticking the scaler a few millimeters deeper than earlier. And then that’s it really. I mean, but then obviously you’ve done your research, you are far ahead of your time. So what does an average week look like? Tell us, what is it that you do now that you wanted to emulate and what you got a dose of as a student?

[Hiten]
Yeah, my week is different every week. I’m usually five days clinical, which is quite a lot. I know, but I love-

[Jaz]
Five days a week is crazy. I don’t know how you do it. I mean, it reminds me of, I think the Singapore time when I message you, I think you also give a crazy answer then it’s all like six days or something. How many days are you working in Singapore?

[Hiten]
As I was working six days and I was doing eight to eight, I was going to work after dinner, which is not what someone should be doing. And at that point I started considering my life, thinking, I don’t know how long I could do this. And-

[Jaz]
Well, you obviously had, you’re coasting now. Now you’re just working five days normal hours, nine to five. So this is your vacation. You’re on vacation, man.

[Hiten]
Yeah, this is nothing. I mean, and as cliche as it sounds, like actually when you enjoy what you do, like it, it really, like the time flies, like the week goes by and it’s Friday already and of course I love my weekends and that’s great. I have my weekends to myself. I don’t do any work on the weekends. I make that a rule and that’s my family time, but five days a week.

I say I’m five days clinical, but actually in an average month, I’m probably away a week and a bit, I do a fair amount of traveling and also lecturing now as well, so, I mean, as I do more and more of it. Webinars, podcasts, DFT lectures, running our own courses, those kinds of things. So then that kind of takes up some time as well, doing some corporate stuff, working with Bupa and things like that. So as that increases-

[Jaz]
What about the admin though? Like patient letters, because being a specialist, that’s what you expect to do, right? Writing back to referring dentists, writing comprehensive letters to your patients. How do you squeeze that in? I mean, have you got any admin time, like, blocked out?

[Hiten]
At the beginning, I used to come home and past five o’clock, I’ll be here at home for another two hours, just finishing off the admin, the letters for that day. And I thought to myself, this is not how I can go on. Like, this is not the way to continue with my life. And it’s just eating into my time, which is, should be my own time.

So I just basically made it a point to put systems in place at the places that I work at to make sure that there’s a very effective, like a workflow whereby, as soon as the patient’s seen me for a consultation, that letter is pretty much ready to go and whether that means my nurse has already loaded up the letter for me, has filled in all the template bits and bobs, and then the practice manager is already au fait with how I like my letters to be done, dots the i’s, crosses the t’s, if I’ll do a final check, sign off.

Off it goes basically. What it means now is, I’ll have an hour for a consultation these days. Be done in 45 minutes. 15 minutes is just for me to do a bit of admin, let us get sorted. And then at least by five o’clock, I’m done. I don’t have any other bits and bobs to do. So it takes time and you need good team members and good practices, which are running really well, but putting in that effort from the beginning saves you so much time in the long run.

[Jaz]
It’s a lot of pain creating that system, work, teaching those around you to work to it. But once it’s done, you front loaded all the hard work. Now, have you embraced the power of AI yet?

[Hiten]
Not yet. You know.

[Jaz]
Dude, you need to get Digital TCO right away, man. Like, I’ve been speaking to Azim, right? I got him onto it, right? Azim, Azim loves it. Thankfully. Okay. Honestly, mate, like literally you just stick the microphone on, right? And you press play and it’ll write a letter for you. Like the full thing. You’ll write a notes for you. You just have to check it. So, trust me, you will love it.

[Hiten]
He’s every time I see him, he’s like, mate, how have you not got on TCO yet? And he keeps showing me and I’m like, yeah, yeah. Do you know, I need to, I need to. It’s just laziness. I’m going to be honest.

[Jaz]
It’s because you’ve already got your system. You’ve already got your system. To change a system takes energy.

[Hiten]
Yeah, and for me at the moment, if it’s not broken, I don’t know.

[Jaz]
Yes. Totally understand. It works for most dentists. The system is broken. The most dentist system is broken and that’s why it comes in. So, mate, your journey went to Singapore. You came back to the UK, you did your specialist training and you described kind of like your week. You got some variety in there. Yeah. Let’s talk about the topic of functional crown lengthening.

Okay. Before we define what it is and stuff, what percentage of your month? I mean, I don’t even know like how much this is a required service, how many referrals one gets for this compared to other work like implants, soft tissue stuff. How many referrals do you have? What percentage of your work does functional crown lengthening actually make up nowadays?

[Hiten]
Yeah, actually, it’s actually quite little, it’s actually quite little if I’m honest. I think one is people, maybe not having the ability to know what can be achieved with heavily broken down teeth. And secondly as well, I think in the day of implants, there’s always that conversation of going through surgical procedure, which costs X.

May or may need root treatment, may or may need a crown, whatever. At that point, the cost of all that, are we better off extraction and implant, you know? So that often has a role to play. The aesthetic side of crown lengthening, as more and more people do Invisalign, more and more people appreciate soft tissue work.

I think that’s where I get more of the work from. Honestly speaking, I will maybe do one or two cases a month, something like that, of crown lengthening, whether that’s functional or aesthetic. Again, and it varies from periodontist to periodontist, I know a lot of periodontists do several cases a week, I know others that don’t do any, yeah.

And I think also it’s, even in periodontics, people will have their own subspecialties as well, people will be, heavily non surgical people with surgical people will be exclusively implants now and not do any perio treatment right? For me honestly-

[Jaz]
It’s a niche within a niche, you can make your specialty what exactly what you want.

[Hiten]
Yeah and for me my niche is soft tissue work we could do all work. I will do five, six cases a week, averaging one a day of muco gingival work. So that’s where my passion is and where my interest is.

[Jaz]
When you say muco gingival work, is that recession coverage?

[Hiten]
Not just recession coverage. It’s basically augmentation of gingival tissues of any kind, not just management of recession. It’s for gaining or keratinized tissue. It’s for development of keratinized tissue around implants.

It’s around bulking pontic sites. It’s getting ready for bridges, those kind of things. It’s a whole host of sort of procedures, basically, but all to some degree involve augmentation of soft tissue in one way or the other. But yeah, functional crown lengthening, lengthening in general is something that we learn quite extensively in our perio training.

And even though maybe I don’t do as many as I don’t do many on a day to day basis, it’s still something that I have a, good amount of knowledge on and have had experience in managing and even complex cases and things like that.

[Jaz]
So for the students that are listening and the younger colleagues, what are the different types of crown lengthening? What is it? Just the bare bones, like you’re talking to someone who’s very early in their career, just describe in simple terms, what is crown lengthening? What are the different types?

[Hiten]
Yeah, yeah. So basically crown lengthening is a procedure. It’s a surgical procedure that is carried out and it involves augmentation of the gingival tissues and also the alveolar bone. And in that process, what we’re trying to do is expose more of the tooth structure, essentially to move it more supergingivally.

And that will take many different forms. Either it involves cutting away tissue, moving tissue down. It may just involve removing gum. It may just involve removing bone or it may remove involve a combination of both basically, but essentially it involves augmentation of either or both of those tissues to increase the crown height essentially.

[Jaz]
And you’re doing it for aesthetics versus function two different concepts, right?

[Hiten]
Yeah, so when we talk about functional crown lengthening, it specifically relates to doing it for a functional purpose that may be like-

[Jaz]
Which is always improving restorability, surely, right? Is there any other functional purpose?

[Hiten]
Yeah, yeah, essentially, yeah. It’s in the sense that you want to gain clinical crown height of some degree, either that’s to increase retention of it in direct restoration. You need to create a ferrule of some sort, or you don’t have enough crown height to get a ferrule. If you’ve already got, or if you’ve got a cavity basically, and it’s quite subgingival, and you can’t get isolation there, you could carry out crown lengthening there to make the margin supra gingival to make it one easier for you to restore and then long term easier for the patient to manage and maintain so they can access that margin to clean it.

Yeah. Also rarer things like, if you’ve got cervical resorptions, root resorptions, just apical to the CEJ, you can crown link from that site in order for you to restore it with a biocompatible material. And then put the tissues back over that area basically. So that in itself is some form of crown lengthening.

It’s different to aesthetic crown lengthening. And just like that, aesthetics is it’s all about kind of improving the appearance of the smile. And most commonly it’s reducing the appearance of a gummy smile or what we’d call a gingival excess. Tends to be patients post ortho who then want to have kind of the gingival tissues re contoured in order to get a good amount of clinical crown height so that when they’re smiling they show a sort of, let’s say, harmonious amount of tooth and also soft tissue as well.

[Jaz]
And get that nicer gingival symmetry going as well basically. And you know what I’m seeing more of, and I mean you kind of alluded to it right, in some instances. It may involve removal of bone or sometimes just soft tissue. Now, if you go down that approach now, I know we’re supposed to be talking about functional crown and thing, but just for a brief second on aesthetic we see on Instagram, oh, I just lasered the gingiva a bit.

And then it is some edge bonding. And we see that all the time that every case, oh yeah, I just lasered about a millimeter of gum. Should it be as prevalent as it is? Basically cause I don’t know. I just feel as though from my prior knowledge and understanding, that there’s very few patients that will fall into a category that are amenable to that. But you explain your view when you see that.

[Hiten]
Yeah. I teach these courses very, very regularly on crown lengthening, right? And we have one slide that relates exactly that. And it says, despite what the university of Instagram tells you, all cases cannot be treated by laser gingivectomy. And that is the truth.

There will be 5 percent of cases, which will be okay if you take one or two millimeters of gingival tissue off and you put a composite margin there, right? The reality is the problem with that is over time, if left long enough, it will relapse. And in the best case scenario, it will relapse with maybe a minor aesthetic issue and you’d have to cut it back again and redo it.

In worst case, if you encroach on biologic width by you cutting away tissue and you’re now placing a restorative margin in an area where it shouldn’t be, you’re going to invade something called the biologic width. Which we’ll talk about in a little while when we talk about how to assess for crown lengthening.

But if you’re doing that, essentially over time, that patient is going to get persistent inflammation. If that’s left, you’re going to get pocket formation, bone loss, and eventually affect the prognosis of that tooth. So, you know-

[Jaz]
Do you see this in the clinic? Like patients coming in where they’ve been subject to this and they had these veneers placed and you’re having to correct the crown lengthening. Tell us about these kind of cases that you might have seen.

[Hiten]
Yeah, so exactly that, like often what you see is with the laser gingivectomy, you’ll see an immediate post op where it looks all nice and clean, the laser or the electrosurgery, let’s call it, because it’s not actually lasers people are using, it’s electro curettage, they’ll give you hemostasis, so you can put a beautiful composite restoration there, right up to the gingival margin, but the reality is four or five years down the line, when there has been enough time for that tissue to relapse, what happens is they’ll come back with that persistent inflammation.

And actually the management of it is much more complex now because they’d have to go through a retrospective crown lengthening procedure. And at that point, I can’t guarantee that, let’s say those margins, which were supposed to be just sub or equi, are now not going to be exposed. And in this case, where you’ve got high smile line, where it’s really aesthetically an issue, patients have to be warned of the risk that not only will they need a surgical crown lengthening, they may also need to have all their crowns and veneers replaced.

Because as much as we try to kind of control where the final tissues will sit after crown lengthening. We don’t know what’s going to happen with the biology, and there’s always this risk that it will inadvertently expose a margin of restoration, which then will need to be replaced. And if someone spent a good amount of money getting it all done just a few years ago, you can imagine they’re not best pleased to hear that they now got to go for all this corrective work to have it done.

[Jaz]
Now, you said that about 5% of cases aren’t amenable to that. Describe the ideal 5% scenario, whereby we should double tap it on Instagram and this is valid.

[Hiten]
Yeah. So let’s say when we are assessing a tooth for crown lengthening now, right? There are quite a few things that we need to look at. The first thing is where is the soft tissue at the moment? Do we need to expose more of the crown or like when we’re talking about crown, right? So essentially the issue is that you’ve got a short crown for whatever reason. Can you get away with adding composite to the edge at the bottom of the tooth.

Is that going to give you the outcome that you need? Is that going to give you the appearance of the crown height? If not, then you need to be taking it away from the gingival margin, yeah? And if you’re going to plan to take away tissue from the gingival margin, you need to know where the bone is sitting underneath there, okay? And this is where this concept of biologic width comes into it. All right. So biologic-

[Jaz]
Like a supracrestal tissue attachment. Are you proud of me?

[Hiten]
Yes. That’s the one. Yes. You know it. You know it boy. So biologic width. It’s a term that gets banded about everywhere. Oh my God. You invaded the biologic width.

But let’s talk about what biologic width is here. Just so everyone understands. Biologic width is a fixed number. It is basically the sum or the height of the soft tissue attachment that sits above the crest of the bone. So you have your alveolar bone here, you’ll have a little bit of connective tissue that will sit and attach onto the root of the tooth.

And then above that, you’ll have a bit of epithelial tissue, which will sit partly on root, traverse the CEJ and then partly on the crown of the tooth there as well. The total of the connective tissue and epithelial attachment on average is about one millimetre each. So then your biologic width in an average patient is two millimeters.

So essentially, if you have two millimeters of biologic width, and let’s say you have a sulcus, gingival sulcus of one millimeter in depth, it means that from any gingival margin that you have, the bone needs to sit at least three millimeters away. And let’s say you’ve just done a gingivectomy.

So you’ve taken away, let’s say the sulcus depth, you’ve taken one millimetre away, so now you don’t have any sulcus. You’re left with just the biologic width element of it, okay? If your bone is just two millimetres away, your body’s going to want to recreate a new biologic width. Because the biologic width is a protective mechanism.

It protects any bacterial ingress so it doesn’t go on directly onto the bone. And so if you cut away a bit of gingival margin, what will happen is your body will be like, hang about, this is not right, we need to re establish a biologic width. So it will do what it needs to, it will resorb that bone, create 1mm space so that that biologic width can be shifted down 1mm and allow space for a new gingival sulcus to form.

[Jaz]
So essentially some perio will happen in that scenario to reestablish three millimeters away from the gingival margin.

[Hiten]
Correct. Now the problem with that is you can’t control, you’re not in control of how much bone that’s going to be changed by. So if you’re lucky, it might not be that significant, and it might not impact your overall outcome, okay?

But the chances are, what will probably happen is over time, you will get inflammation, because in the body’s attempt to try and recreate that biologic weight. If it can’t do so, it will respond by getting inflamed, and it will respond by creating pockets and moving that bone down. Over time, you’ll get recession, it will expose the margin there as well.

[Jaz]
Okay, at the very best scenario, I guess what would happen is that the gingiva will just creep down and relapse, like you said, and If it’s just an edge bonding case, that restorative material wasn’t placed there. It’s all that happens that you lose the final smile. You made the tooth longer and it looked amazing and symmetrical, but then a year later, the gums crept down and all your moments of work are gone.

[Hiten]
Correct. You get relapsed basically of that, right? That’s best case scenario. Worst case scenario, you’ve got a margin that’s stopping that tissue from rebounding. So that essentially, it’s always going to be an issue unless that restorative margin is removed.

[Jaz]
So moving on to functional, if you don’t mind, I want to know the differences, the nuances, and if you assess it the same way for functional, but then also about which teeth that we mentioned, we’ll get to it, which teeth are amenable to it.

[Hiten]
Yes. So generally teeth that are amenable to functional crown lengthening, all these, generally speaking, you can do crown lengthening on molars, anteriors, premolars and stuff. But there are certain things that we need to consider, which are like kind of contraindications to doing crown lengthening.

So let’s say basically you need to look at a couple of things. You need to look at whether at the end of your treatment, you’re going to have enough root length left in the alveolar bone. What I’m alluding to here is, are you going to end up with a favorable crown to root ratio by the end of the crown lengthening procedure?

If you’re going to remove an extensive amount of bone, if you’re going to have a very little bit of root left, that the progress of that tooth, and you might even cause mobility in that tooth is probably not indicated in that situation. The other thing is root proximity. So in, particularly in posterior teeth, if you’ve got two molar roots which are very, very close together, this is a practical contraindication.

In functional crown lengthening, it requires you to remove interdental bone. And if you haven’t got enough space between roots to get even a Piezon or a bur or even the smallest rose head through there, you’re going to cause iatrogenic damage to those roots. Yeah, again, it’s going to affect the prognosis of those teeth.

So, you just practically can’t do it in those situations. Another big thing in molars is furcation exposure. Now, in the molars, furcation entrances, so the fornix of furcations, can be as shallow as one to two millimeters away from the CEJ. So that doesn’t really give you much scope to crown lengthening.

And in an ideal situation, you want to keep one millimeter of bone above the fornix of any furcation. So the reality of it is, very few teeth actually meet the ideal, let’s say, indication for crown lengthening. All right. So essentially, some teeth that you crown lengthen, it may lead to a furcation exposure.

But as long as you understand that that’s what is going to happen, you understand the implications of that, and your patient is consented of that. Because essentially, if you’ve got a furcation exposure, yes, it will impact the progression of that tooth long term. The patient will have to maintain that site. You will have to continually check that area as well. But the alternative could be an extraction of that tooth, which the patient may not be wanting.

[Jaz]
But, going back to your previous point, if you’re getting into a scenario where a crown lengthening a molar for functional reasons so that you can restore it, likely, again, this tooth already has or will need a root canal, need a temporary crown, a crown, just like you said before, you’re getting into implant territory.

It’s something that I can see why molars are, anatomical complexities, access, and the cost. It’s not something that I’ve ever done. I’ve done premolars. It’s the only time I’ve ever done crown lengthening is premolars. I just tend to get premolars that I think, alright, I fancy, improving the prognosis of this tooth.

Because even with like, and incisors, actually. I had a patient who had canine to canine wear that was more on the palatal and that had enough ferrule labially but didn’t have enough ferrule palatally, right? And so by getting more palatal tooth structure, I was able to get a ferrule 360. So those are two scenarios I’ve done it. Is that what you’re suggesting as well is the more common way to go?

[Hiten]
Yeah, I mean, like another common thing is like when you’ve got substantial fractures, let’s say premolars, right, and you’ve got cuspal fractures, those are kind of good candidates for crown lengthening, which you’ll see palatal cusp fracture.

I mean, palatal, actually crown lengthening palatally is much easier than to do buccally, which is doesn’t, you think, okay, axis wise, it’s easier buccally, but actually palatally, you have ample alveolar bone, you have ample keratinised tissue and keratinised tissue, another big factor that we need to talk about, but when you are first starting out, those are the kind of ones that are a bit more easier to do and a bit more forgiving because-

[Jaz]
Which is why I cherry pick those. All the tough ones that send them guys like you.

[Hiten]
So, when we talk about it, when you boil down to it, actually very few teeth are the ideal candidate for crown lengthening, yeah? And before you get to that point, yeah, a lot of molar teeth, you’ll be having that conversation already. It’s like, okay, well, by the time you add the cost of the crown lengthening surgery, the crown, potential root canal, that might be necessary. Are you already in the point of, should we think about extraction and implant at that point there?

[Jaz]
Do you mind asking, if you were to crown lengthen a molar, right? Obviously we charge by time. How long will it take you? What’s the London rate or England rate in terms of, okay, a crown length thing for a molar, for example. The reason I’m only bringing it out is because that dentists who may never been subjected to this, they can actually involve in their calculations, have an informed discussion with their patient.

[Hiten]
Yeah, yeah. Like to be honest, it varies from place to place. Typically, I will take about an hour or so to do that procedure. It can vary from 700 to 900 pounds, typically for a crown linked film procedure.

[Jaz]
Okay, so we can factor that in and very quickly with the root canal for the specialist, 12, 13 hundred pounds. Then the crown, yeah, it’s easy getting into implant territory, basically, so that just validates that.

So those teeth, like such, for example, pre molars and whatnot, when you are doing a crown lengthening there, functional crown lengthening, what are you assessing for to make sure that, okay, you said already about the proximity to the adjacent tooth, about whether there’s enough root there as well. What else are you doing before we then actually think, okay, I’m going to pick up the scalpel.

[Hiten]
Right, yes. So, as I said, first I need to know, the most important thing is, where is my margin going to be? Like, where is my proposed gingival margin? Where am I going to plan to restore to? You have to work backwards, so you’ve got to say, look, this is where I envisage my new CEJ, my new gingival margin will be.

If I cut my gingival tissue to this much, based on my biologic width measurement, I’m going to need to move my bone margin by this much. All right. And then you’ll know, okay, you’ll be able to assess, okay, look, will I be in a good crown to root ratio or not that you can look at, right? So yeah, it’s basically you’re working backwards.

You start with the final prosthesis or restoration, and then you’re going to calculate backwards, kind of how much soft tissue you need to remove, how much bone you’re going to remove as well. Okay. When you’re doing that preoperative assessment, one of the other things that is quite important and we’ll talk about is, is keratinised tissue.

Okay. So, keratinised tissue until recently, it’s been something that as periodontists is quite, I don’t want to say controversial. It’s not controversial. It’s kind of like heavily debated about how much cratonized tissue you need around a tooth. Okay. It wasn’t only till 2017 when the classification guidelines came out that it’s been agreed that you need two millimetres of cratinized tissue and one millimetre of attached tissue around the tooth for it to be stable and for you to minimize the risk of further gingival recession or periodontal disease occurring.

[Jaz]
What do you mean by a keratinised ensemble? What do you mean by keratinised and attached?

[Hiten]
Attached, right. So, essentially, if you think about the formation of a sulcus, yeah, a sulcus is not attached, it’s free gingiva. When you put your probe into it, it moves. Okay. Beyond that, the tissue beyond that is attached to the alveolar bone underneath.

Okay. Understood. So that is basically tissue that is attached by periosteum to the alveolar bone underneath, okay? And that is not mobile. You don’t always have that. Let’s say, for example, commonplace, you don’t have that is lower incisor labial. If teeth are really moved out of the alveolus and there’s no attached in your mouth means when you pull the lip down, all that tissue moves with it.

Okay. And that’s not attached. So one, there has to be characterization there. Yeah, and two, not only has to be keratinised, at least a millimeter of it has to be attached onto the, basically the bed or the periosteum underneath that, okay? So that’s why those two things have to be met. And when you’re crown lengthening, remember, we’re essentially planning to cut away tissue here, okay?

That’s what crown lengthening is, you’re cutting away tissue to expose more clinical crown height. If you don’t have two millimetres of keratinised tissue. You can’t afford to cut it away.

[Jaz]
Which is why I favoured those cases. Just like you said, lately, where I didn’t have to worry about that. I had enough labelling, which is why I cherry picked those cases.

[Hiten]
Cut where you want. Cut where you want in pilot. There’s keratinised tissue everywhere. But yes, luckily, if you don’t have two millimeters of keratinised tissue, you can’t cut it away, unfortunately. And therefore you get into more complex territory, which means you’re going to have to think about trying to move that whole band of keratinised tissue that you do have apically.

So here we’re talking about apically. We position flaps, you’re getting into specialist territory, complex crown lengthening. Honestly, luckily, 9 times out of 10, a tooth that you’re crown lengthening, because it’s associated with a thicker phenotype, will have a decent band of keratinised tissue that you can cut away.

[Jaz]
So you can sacrifice and you don’t have to do apical repositioning, you can do excisive? What’s it called?

[Hiten]
Gingivectomy?

[Jaz]
Receptive. Receptive.

[Hiten]
Receptive surgery. You do a receptive or gingivectomy in that area, basically. Okay. I mean, worst case scenario is if you don’t have any keratinised tissue, essentially what you have to do is you have to put a graft there. To create keratinised first. And then cut it away or move it apically, basically. Yeah.

[Jaz]
Sounds like a lot of work, isn’t it?

[Hiten]
It’s a lot of work, right? And that’s why you can see very few people have it done.

[Jaz]
This is why they call it gum gardening. There we are. It all makes sense now. So that’s why it gets quite complex.

[Hiten]
But honestly speaking, 9 times out of 10 you’ll have a straightforward type of case with, because interestingly, the other thing, so we’re talking about just coming back to the main thing, which is where we’re talking about preoperative assessments, right? So one thing is keratinised tissue. The other thing as well is tissue thickness.

Or the gingival phenotype. You’ll have two types. You’ll have a thin phenotype or a thick phenotype. People are somewhere in the mid middle. But broadly speaking, if you’re a thinner phenotype. It’s very unlikely you’re going to be suffering from gummy smiles and things like that, okay? Often what happens in those situations is the tissues will recede over time.

So thinner tissues, they just tend to recede, okay? So most often, let’s say specifically for gummy smile treatment, you’re going to have the thicker phenotype, yeah? And the thicker phenotype is also associated with more keratinised tissue.

[Jaz]
But the outcome is better healing, less risk of recession and unpredictable healing, right?

[Hiten]
Okay. I mean, we say about better healing. Each of them have the nuances as well. So with a thicker phenotype, your patient is more, more prone to rebound.

[Jaz]
More relapse.

[Hiten]
Yeah, exactly. Because the tissues will relapse. They’re not going to recede. So if anything, what’s going to happen is once you do your crown lengthening, I’m already thinking, okay, this patient’s a thicker phenotype.

So when I’ve done my biologic with measurement, say that my biologic with measurement is two milimetres, usually I will allow three millimeters from the gingival margin. I may allow three to four millimeters to allow for a bit of rebound to occur in the thicker phenotype. Whereas, and I may cut away a little bit more tissue than I need to knowing that there will be some rebound of that tissue in a thick phenotype.

[Jaz]
In contrast, when we’re talking about a thinner phenotype, you’re going to be much more conservative. So you’re going to cut away a little bit less because there’ll be some postoperative recession. Even with the alveolar bone, you cut a little bit less away because you know that as you get post surgical inflammation, that will probably take away a little bit of that alveolar bone height as well.

So you’re not going to go to the full three, four millimeters. You may be shy away a little bit and allow the body to do a little bit of it as well. So, that again is a nuance. Like, so you’re looking first at keratinised tissue. Have you got enough? If you do, fantastic. Cut it. No problems. If you don’t, you’re going to be needing to do some kind of apical repositioning surgery.

Or you’re going to need to be doing grafting. Bit too complex I would say. Probably needs to go to a specialist at that point. But gingivectomy, with someone who’s got training at a general dental practice level. it’s more than capable of doing that. And then you’ve got to look at the tissue thickness, have we got a thicker or thin phenotype?

That’s going to dictate how we carry out the surgery. And also, I mean, without going into too much detail of it, the way that your blade is inclined, because you may have heard of terms of inverse and external bevel incisions, okay, internal and external bevel incisions, right? So internal bevels are designed to thin thick tissues. External bevels are designed to make thinner tissues thicker. So those little nuances, they’ll come into play when you kind of try to plan the actual sort of the nuances of the surgical treatment.

[Hiten]
I’ve heard of those incisions, but it’s nice to know the sort of role they play. And the nice little nuance to consider.

[Jaz]
In the interest of making it tangible for the GDPs that are listening here, everything makes so much sense so far. Let’s talk about, I think sometimes when you talk about, cause you can’t cover everything background and that’s not the point. It’s about to give people a flavor. When can it can be used indications, contradications, suitability.

Have you done that already? So let’s talk about a specific scenario and we’ll just talk about one specific scenario and we can learn a lot more and go deeper basically. So let’s talk about the pre molars that I’ve treated, for example. I remember treating these premolars and on the upper right, and I treated both these premolar because the kind of fracture they had was that I was really lacking palatal tooth structure.

Okay. But I had a buccal wall that was decent. So, because I was lacking palatal tooth structure and I knew that, okay, keratinised tissue was important and I didn’t know how, I still dunno how to do an Apical repositioning. I was like, okay, this is a great candidate for me as a GDP.

The patient can afford the endo and the restoration stuff. So in that scenario, talk us through the sort of procedural element of the functional crown lengthening.

[Hiten]
Right. Okay. First, you’ve got to decide how much crown height you want to gain.

[Jaz]
Okay. All right. So let’s say we’re going for, we want to be able to, so right now, if you want to put crown margin there, you don’t have any ferrule. And we want at least a two millimetre ferrule. So we want to gain two millimetres of tooth stress. You want plus two on the palatal.

[Hiten]
Okay, fine. So we’re aiming to, we have a restorative margin, two millimetres of where your current tooth clinical crown ends at the moment. So now we know that, okay, let’s say palatally, palatally, you’re going to have a thicker phenotype.

9 times a 10, it’s going to be thicker. So what we need to do now is from your restorative margin, you’re going to want to take away at least two millimeters. So you can get that clinical crown. I would say go three millimeters. So actually what we’re going to plan is a gingivectomy.

Three millimeters from where your current crown height is, okay? That will allow for a little bit of relapse, okay? And it’ll also allow for the formation of a gingival sulcus in that area, okay? It’s not so crucial on the palatal because where the margin is, ideally you want it a little bit supra gingival Anyway, because it’s cleansable, it’s not really an aesthetic site. But yeah, we’re talking about three millimeters of gingivectomy that we’re going to perform.

[Jaz]
So this is a scalpel, an electrocautery, use whatever you want basically, right?

[Hiten]
You can use either, you can use three, you can use laser, you can use electrosurgery, you can use a blade, yeah, to do that gingivectomy. Now, but before you do that, we’re going to be doing a pocket chart. We’re going to basically do bone sounding on the palatal aspect. The purpose of the bone sounding is to determine the biologic width. So let’s we figured out the biologic width is two millimeters. So what that means is from our gingival margin, the new gingival margin that we’ve created, the bone has to sit two millimeters. Which is going to be the biological width. Plus one millimetre for the gingival sulcus. So the bone has to sit three millimetres away from the new gingival margin that you’ve created.

[Jaz]
So therefore compared to where it is now, right, you’re going to go to this one. I’m kind of working out for everyone here compared to where the tooth is broken down. Now, the bone should end up being five millimetres away from that.

[Hiten]
Exactly. Yeah.

[Jaz]
And it can use stents and stuff, right?

[Hiten]
Yeah. Well, you don’t have to use stents. You didn’t have to use stents.

[Jaz]
I don’t, I haven’t.

[Hiten]
No, so the time you will need to use a stent is if you’re planning usually aesthetic sites when you’re doing your anterior aesthetics, because that’s when it’s really key, right? But even like just for aesthetic crown lengthening, where there’s no cosmetic work planned, or even just small edge bonding, I won’t use a stent. If we’re talking about full veneers, full composite bonding, then yes, we’ll be using a stent. Okay, based on the definitive prosthesis. But in these cases, palatals, it’s not necessary. Okay. Because in your mind’s eye, you already know where you’re proposing to have your gingival margin there.

[Jaz]
You can check with your perioprobe, put it right against the bone and see where the margin is. And you do that calculation of, okay, when the biological width reestablishes, how much true structure will that give you?

So it’s like a game of maths, like you said before, as well. The only thing that I want to check on in terms of nuances, because younger colleagues are thinking about bone sounding. I’ve covered it before in a podcast, but people don’t listen to everything. So just cover in that upper premolar area, palatal, what does bone sounding look like when you do it?

[Hiten]
Okay. So what’s going to happen? You need to do it under anaesthetic because it’s quite uncomfortable otherwise. So what happens is you’re trying to determine what the biologic width is. That’s what bone sounding is. And if you remember, the biologic width is the sum or the height of the epithelial attachment and the connective tissue attachment.

It doesn’t include the gingival margin value, okay? Because that varies from site to site, okay? So what we’re going to do, we’re going to get our perioprobe and we’re going to insert it into the pocket, okay? That’s going to give us a measure of the gingival margin, yeah?

[Jaz]
The sulcus.

[Hiten]
The sulcus, sorry, the sulcus depth, yeah. So let’s say we’re talking, we’ve got two millimeters of a sulcus at that point. Your probe is going to measure two on the band, okay? From there, we’re going to basically pierce through the soft tissue until we hit a bony stop, okay? You will definitely feel, if you go along the root surface, you will hit the alveolar bone and your probe won’t go any further, okay?

So now you’ve reached the crest of the bone. So let’s say that measurement is now 4,okay? So from your gingival margin measurement, your sulcus measurement, sorry, your probe has traveled two millimeters further down to hit the bone, okay? So that two millimeters that your probe has traveled, that’s your biologic width because you’ve now paced through connective tissue and epithelial tissue to get to the height of the aveolar bone. So that’s what you’re finding.

[Jaz]
And in some individuals this could be more, this could be three, for example, right? In some individuals, like, there could be, it’s an individual thing, like you said at the beginning, some people might miss that. So, from reading Kois’ work, you know, high crest, low crest, we won’t get into that, but some people have a variation basically. So it’s good to measure each individual’s actual biological width, like you said.

[Hiten]
It will vary from site to site. It will vary from tooth to tooth. It will vary from person to person. When we look at studies, it varies on humans from between one to six millimeters on average per patient. Look, you don’t need to be so facetious about it, about measuring every single site and doing a biologic width measurement and then going to do that on the sixth point.

But as long as you get a rough idea of what that biologic measurement of that patient is, that’s pretty good. So I would set an average value of what the biologic width measurement is on that tooth, let’s say. And like I said, typically, it’s going to be around two millimeters on average, most here where there is about two millimeters is the average measurement of a biological width.

[Jaz]
Here’s a geeky question, right? So we go that scenario where we’re going to plan to remove in this patient then remove two millimeters of bone. And to reestablish that but then we also counted for the one millimeter sulcus. But if someone started with the two millimeter sulcus, should we be planning for them to have a two millimeter sulcus at the end or should we still aim for one millimeter sulcus?

[Hiten]
I mean, it’s neither here nor there. It doesn’t really matter because again-

[Jaz]
Yeah, it’s one of those things.

[Hiten]
Yeah. Cause the sulcus is again, variable. The sulcus depth. What I would say to you, as long as you’ve got one millimeter room for a sulcus, that’s good. If you want to give two, give two, it’s fine. Because the sulcus will be two millimeters. It’s fine. It’s not the end of the world. But at least you need at least one millimeter is what I would say.

[Jaz]
Okay. So you’ve done the gingivectomy there before you’d done the gingivectomy, you did the bone sounding, you know your measurement, you’ve done the gingivectomy, and then-

[Hiten]
Just come back to the gingivectomy. Now the shape of the gingivectomy is also quite important as well. So when we’re talking about function crown lengthening, it’s very rare that it just involves, just, let’s say the palatal, the wall of of the tooth. We have to also include the essential spaces. So it can’t be a case where the incision is just done like a little C shape.

[Jaz]
U shape. Yeah.

[Hiten]
Or U shape. No, it has to gradate, it has to taper and to include the papilla. So it’s what we call like a crisscross design. So you’re basically from the midpoint of the palatal aspect of that tooth, you’re going to go and include the papilla on one side. And the same on the other side, okay?

So what that means is when that flap is elevated, and you go and remove the bone, not just on the palatal aspect, but also in the incidental space, when the papilla sits back down, you’ll have created crown height in the incidental area as well. You can’t just do it in isolation, okay? And again, the other thing with that is, you have to end up with what is called positive architecture. And this is more important for incidental chronic things. Actually, let’s leave that aside for a second. Let’s just kind of focus in on what we’re talking about here.

[Jaz]
Because yeah, you’re a specialist, man. You’re like every little nuance detail, which I love it. It can definitely see that.

[Hiten]
I need to tell you about a negative and positive architecture, but you told me to keep it simple. So let’s keep it simple. Let’s go back to where we were. We were talking about the incision, which has to not only be palatal, it has to include the papilla. So that’s what my-

[Jaz]
Very useful, very useful. And the take home point there is don’t neglect the interproximal because even if you, let’s say, even if you don’t need mesial and distal ferrule, let’s say you have that by chance and you just only happen to have like the palatal, mid palatal portion, for example, rare, obviously, but even still.

You need to account for some bone removal mesial and distal, because you can’t just have like a crater, which is what I think we’re trying to get to, you can’t have a crater in the middle, and then you need to have a nice transition. So this is what I learned when I was doing my first few cases, I was learning about this, of making sure that the bone is smooth and flowing.

And from memory, it was like, there was a certain number of degrees, was it 15 degrees or something like that? Like, it shouldn’t be like a too acute. It shouldn’t be like a step.

[Hiten]
Yeah, 15 degrees roughly. But what we’re saying here essentially is soft tissue do not like sort of very steep curves and very quick changes in its architecture underneath. So if your alveolar bone all of a sudden grows from incidental peaks to a really low trough on the mid palatal, the soft tissues will not be able to follow that margin there. And even if you cut them to that, post surgically, there will be rebound. It’s kind of like, the way I describe it is like kind of two curtain poles, right, or two tent poles, right?

If you’ve got two tent poles hanging really tall, yeah, and you’re draping a fabric over it, that fabric is not going to sit with a big deep V in the middle there, okay? It’s going to sit up there. Okay. You’re not going to get that shape, that deep U shape that you’ve cut away. It will just rebound and it will be held up by those incidental bone peaks.

So that’s part of the reason why you have to remove those incidental bone peaks to some degree in order for you to get that undulating pattern of the soft tissue to stay where it is at the position that you cut it to. Basically on the incidental, on that portion.

[Jaz]
Yeah. Brilliant. So that’s a little clinical tip there to bear in mind when you’re thinking and planning in your head as well. So once you’ve done the gingivectomy, the kind of flaps I’ve done in the past, rightly or wrongly, have been an envelope. Like I just lifted away. I didn’t do any like relieving incisions or anything because palatally I just didn’t feel I need to. Is that how you do it as well?

[Hiten]
Yeah. The only time you’ll need to do a relieving incision is if you’re going to do an apically repositioning of that flap. When I teach these things and we do the practical element, people will say, have I extended it too far? Have I raised the flap enough? So my answer is, why have you raised that flap in the first place? And the answer is, well, you’ve raised that flap because you want to access the bone.

Because otherwise you’d have ended up the gingivectomy. That’s all you would have had to do. The sole purpose now of raising a flap is to access the bone underneath, so you can adjust it, okay? And if that was the purpose of what you intended to raise that flap, can you do your job? Can you get an instrument in there? Can you see the site that you need to remove the bone from? And can you do it safely? And if the answer to that is no, then you haven’t raised your flap enough.

[Jaz]
It’s all about access.

[Hiten]
Yeah, because you can’t access it. And that’s the only reason you raise the flap now. And so in order to get more access, you have to extend the flap laterally. So increase the envelope. So it may mean you have to include them, the neighboring papilla on either side. You very, very rarely. In fact, you’ll never need to do a vertical incision there. You just extend it laterally. It’s better to do that because you’ll get better healing. Not only better healing, as soon as you start dropping vertical incisions on flaps, you completely lose the mobility. But you increase the mobility dramatically, let’s say, so you completely lose the stability of the flap.

[Jaz]
Okay, I knew that this is why I felt comfortable with GDP with some experience and some prior homework or whatnot to do these procedures because I felt okay, I’m in a safe area where I don’t need to do any relieving incisions and that worked well.

So once you’ve got your envelope flap, you can see the bone. I remember many years ago when I did this. I didn’t, I picked up the phone to Dhru Shah and the periodontist said, Drew, what kind of burs can I use on the bone? And he said, dude, just use carbide, use diamond, use what you want. I was like, really? Is there a special bone bur? Like, as a GDP, I didn’t know. So tell us about the kind of burs you’re using.

[Hiten]
So I would just use a sterile rose head. Straightforward. Yeah. You’re going to have some kind of irrigation through it cause you’re going to, it has to be cooling. But, it doesn’t have to be anything fancy, man.

Like honestly speaking, it’s not unknown that I will use an ultrasonic to remove alveolar bone on a higher setting. If the bone is so thin, you can chip away at it with it with an ultrasonic and then get a curette just to scrape it off. If it’s thicker, you just use it a slow speed rose head, fine, not an issue.

You can use lasers. Yeah, you can use peons and things like that, but in general practice, if you’ve not got access to those things. Slow speed with some kind of irrigation. Even if you don’t have irrigation, you’ll need to have your nurse kind of doing saline through it. That’s absolutely fine.

Usually on our courses, we teach people to use ultrasonics to chip away because when you’re talking about aesthetic sites, yeah. The bone’s a little bit thinner, so you can get away of actually with marking out where you need to be with ultrasonic, and then actually if you use ultrasonic on alveolar bone, it creates like this kind of mushy kind of texture, which you can then just scrape away with a curette. I should get a decent amount of control with an ultrasonic. So sometimes I’ll just ultrasonic, but yeah, rose head’s absolutely fine. That’s what I tend to use in most cases.

[Jaz]
To help the beginners out there, when I did this, having some mentoring with Drew or Amit Patel, who was helping me at the time. Once you remove the height of the bone, like at two millimeters, it’s really important then to make sure, you smooth that step, right? So if you’ve gone down vertically, if you feel with your glove finger, you’ll feel like a step bone again, your point earlier, as you said, everything needs to be smooth and flowing. So again, is that something that you would use the bur for or some sort of specialized chisels and stuff?

[Hiten]
Again, you can either use a chisel, you can use a bone curette, or you can just use the rose head again. All you’re trying to achieve is so, like, to liken it to a crown prep, you’re trying to go from a shoulder to a chamfer, basically, yeah?

Because, again, it comes down to the fact that the soft tissue does not like those steep changes in, or acute changes in the underlying bone architecture, okay? So, if you were to leave this little ledge there, essentially, or the shoulder, you’ll end up with this weird, like, kind of trough or pocket. It’ll form into a pocket, basically, and the soft tissue won’t be able to adapt itself well into that area, okay?

And, at worst, it’ll leave a pocket, but in anterior site, essentially, you’d have a weird aesthetic result. You won’t have a nice emergence profile of your tooth from the gingiva, because it’ll have this little bulky appearance, and then the tooth will come out from there. So you do kind of like a chamfer, you kind of gradate that in a horizontal direction as well. So that the soft tissues can adapt better into that area.

[Jaz]
Brilliant. Now in the interest of time and obviously there’s only so much we can discuss and I’d encourage everyone to attend your courses attend some period training. It’s always good to add these skill sets your GDP, you know skill sets. It gives you an appreciation of the surgical techniques and also be able to restore teeth that you may not have been able to restore before It’s a great little thing.

I’ve got a case coming up In a few weeks time, again, premolar, palatal side. It’s like, okay, I’ve been here before. Yeah, I’m a great, I’m a great, you know, best thing about being a GDP. It’s in the ability to cherry pick. And I think case selection is everything and you must hate that, but, now you’re on the other side.

But in the interest of time, look, we’re not going to go into the suturing, we’re not going to go into this. The main question I want to answer now, because I want them to learn more and get inspired to learn more, but the main question is how long to wait before you can actually put your definitive restorations?

[Hiten]
Restorations. Okay. So generally speaking, let’s just first talk about evidence here. Okay. So, 80% to 90% of the healing will occur within the first two months. So what’s happening here is you’re getting epithelial and the connective tissues reforming, periosteum is reforming, and you’re going to get maturation of the tissue just starting at the two months phase.

So basically what that means is 80% to 90% of the stability is there at two months. But after that, you can get some minor changes. So the gingival margin may creep up a little bit or go down a little bit. We’re talking maybe half a millimeter here with that. So what I would say is that a posterior site where the final gingival margin, if it’s gone up half a mil, one mil max, it’s not going to make that much of a difference, three months.

Anterior sites, where you’re talking, we’re talking really highly aesthetic work and gingival margin has to be spot on. I would say wait at least six months before you go in and do your definitive restorations. So during that time, patient will be in temporaries and as the soft tissues change, you can probably be, you need good lab made long term temporaries and you can be adding composite onto the margins as and when you need to, but definitely plan and consent your patient to accept the temporaries for at least six months.

And also when you’re doing your planning, that’s what you want to be doing. If you want to get a nice stable, result and a good aesthetic outcome for your patients.

[Jaz]
So in our scenario of the example, pre molar, it’s like three months would be fine for that because the palatal genital margin moving here and there is not so crucial.

[Hiten]
No, yeah, even two months, like.

[Jaz]
Yeah, two months.

[Hiten]
Yeah, two, three months, I would be fine on the palatal aspect because like I said, the main aim there was to get enough clinical crown height there, yeah? And you pretty be sure, you know, like. If you’re going to keep your margins quite super gingival, which you probably will do in a palatal, if they creep up by one millimeter, it’s not the end of the world.

Yeah, yeah. Because you still pretty much will be supra gingival. But in a aesthetic site that one millimeter could be a massive difference.

[Jaz]
Absolutely.

[Hiten]
So that could be the difference between an an exposed margin and and a hidden margin. So yeah.

[Jaz]
Very true. Each case on its merit, and it’s all, like you said, it’s all in the planning. Hiten, thanks so much for giving us this tour. We reached a one hour point now of, time goes fast, doesn’t it? Time flies when you’re having fun. Functional crown lengthening. We talked a little bit about the aesthetic crown lengthening in the beginning, how be careful with that, quote unquote, laser gingivectomy.

And we talked about the biological width, therefore, then we talked about these scenarios of doing functional crown lengthening, the nuances of it. We almost got super duper geeky and talked about all these positive, negative stuff, but I really backed in, and we covered it quite nicely there. Yes, we didn’t talk about suturing.

Yes, we didn’t talk about post op care protocols, but this is all to inspire you guys to learn more, to gain your CPD for this podcast, which is great, but also just to, you get a higher level of understanding and hopefully we made these, this topic a bit more tangible for the dentists. Now, how can we learn more from you? I know there’s some training that you do. Tell us where to find out more.

[Hiten]
Yeah, basically I’m involved with an academy, Edudent, and we run courses for GDPs, not just GDPs, we also run courses for hygienists and therapists as well. But on the basis of this, if you are interested in learning more background lengthening, if you want to learn about when and when not you can be doing the gingivectomies, to doing the more complex types of cases and aesthetic cases, and you want to know the proper protocol that we as specialists follow to get predictable outcomes, then you can sign up to our course and you can find our details which is Edudent UK that’s E D U D E N T U K on Instagram, or you can go to www. edudent. co. uk.

Also, if any of you guys want to know a bit more about crown lengthening, about getting started, feel free to drop me a message. You can contact me on @hh_periodontics, which is my Instagram as well, or you can email me [e-mail].

[Jaz]
The Instagram, follow him. It’s how I think it must have been Facebook, Messenger back in the day when I was messaging you is how you helped me with my Singapore move, which led to this podcast being created. So there’s good things that can come if you need some perio advice and hit into your guy.

[Hiten]
Yeah, yeah, I’m happy to give you guys, you know, even if you just want a second opinion on anything, even if it’s not crown lengthening, just drop me a message you want to know about referrals, whatever it may be. I’m approachable.

[Jaz]
And where do you work? London, yeah?

[Hiten]
I work all around. I work in London and I work in Berkshire and in Hertford, Hertfordshire.

[Jaz]
Whereabouts in Berkshire?

[Hiten]
I work in Windsor, in Burnham and in Chalfont Saint peter.

[Jaz]
You sound like endodontist man, you’re everywhere.

[Hiten]
I know man. Yeah, I’ve got to keep myself on my toes, isn’t it?

[Jaz]
Have you ever turned up, one of our guests once, Ameer Alloybocus , has he turned up at the wrong, because you worked at so many clinics, you turned up at the wrong clinic on the wrong day. Has that happened to you?

[Hiten]
Once. Once. I can’t believe I did that. I’m usually so organised, but once I rocked up to clinic, and they were like, hey, you’re not meant to be here, and I was like, and I quickly, luckily it was between Burnham and Windsor and it’s 20 minutes away. So it was fine. But yeah, imagine I was on Harley street and I needed to get into Windsor. So half a minute, but thankfully it’s not happened that much.

[Jaz]
I always wondered how you guys managed it. Well, there we are. It’s nice to get a glimpse into specialist life as well. Hiten, thank you so much for all those years ago is helping me, but also today helping make functional crown and think tangible. And we gain a lot from that. So thanks so much, my friend.

[Hiten]
No worries. Absolute pleasure, Jaz.

Jaz’s Outro:
Well, there we have it guys. Thank you so much for listening all the way to the end. As you went on, we made it more and more tangible so you can really visualize what a functional crown lengthening looks like, even if you’ve never done one before, never seen one before.

Thanks again to my guest Dr. Hiten Halai for both inspiring the birth of the podcast, if you like, and also talking us through functional crown lengthening. Now, if you’ve never done anything like this before, you’ve never actually made an incision, then please go and source all perio training, read a book about perio, see some videos on YouTube, do what you like.

That always inspired me before surgery. And maybe if you’ve got a few more years under your belt, you’re confident with sectioning and elevating, and you’ve got a nice case, then with a few questions, and maybe you can post on the Protrusive Guidance app, send us a radiograph, send some photos, and ask questions.

Whilst it’s not one to one mentorship, we are group mentorship on Protrusive Guidance. It’s absolutely brilliant. We have some real superstars on there, some lovely, kind, geeky dentists that are so generous with their knowledge. And I’m so proud to have created this community. So if you’re not already part of the community, do join us.

The website is protrusive. app. And if it’s one thing you do today, if you’re not already a member, please join us. It’s a bit of a selection process. We are approving. We have to verify that you are a dental professional, because this is how we keep our platform secure and nice and geeky and allow ourselves to be vulnerable.

Because when we do that, we unlock so much more learning. Thank you so much once again, everyone. I’ll catch you same time, same place next week. Bye for now.