Hi and welcome, or welcome back. You are listening to the Perio Patient Podcast, a podcast for my patients and anyone else who cares to listen. My name is Dr. Ben Young and I am a periodontist in private practice in San Antonio, Texas. This is episode 100 and the title is What is a Crown Lengthening Procedure?
I hope you are doing well.
Today I would like to talk about a particular procedure known as the Crown Lengthening Procedure.
It is a confusing name and I wish I could change it, but it is imbedded into the insurance procedure codes so the best I can do is to help you understand what it is. Perhaps a better descriptor rather than lengthening, because we are not stretching the tooth or making it longer in that way, would be to describe it as exposing. We are exposing more crown.
There are essentially two reasons we would want to do this and neither have to do with periodontal disease per se. In fact, these procedures imply periodontal health. And because this is the case, it is important first to rule out periodontal disease in order to correctly submit for insurance reimbursement.
The first reason to perform a crown lengthening procedure is for esthetic reasons. If the teeth involved in the smile are covered by the gums so that the entire crown is not exposed, then the procedure would be to expose them. When we do this there is an immediate result of a bigger smile. These procedures are usually performed on young people, sometimes at the completion of orthodontics.
Sometimes, when attempting to treat this gummy smile problem, dentists will attempt to remove the gums only to expose the crowns and not address the position of where the bone is relative to these crowns. This often results in a relapse. The gums either grow back to where they were before, or they might show some improvement, but not as much as initially expected. Again, this is because often the bone under the gums is in the wrong position relative to the crowns. When this is the case, the gums will always heal in a way to protect the bone. We call this protective distance the Biologic Width. In other words, bone is designed never to be exposed, it is healthy and protected by the skin – which in the mouth we call the gums or gingiva. The soft tissue protects the bone from bacteria and also nourishes it. When bone is exposed, say at the time of the extraction of a tooth, the gums, as part of the healing phase, quickly grow over the exposed areas through cell replication.
Applying this understanding back to the gummy smile where the crowns are hidden by gums, it is usually necessary not only to reshape the gums but to also reshape the bone to provide this biological width necessary so the gums will recover in a new position that will both enable the crowns of the teeth to show but also the bone surrounding the teeth to be adequately protected.
The second type of crown lengthening is not for esthetics. This does not mean, however, that the esthetic upper front teeth are excluded from requiring crown lengthening for this second reason.
Why this distinction is important for you the patient to understand has to do with dental insurance. Usually, if the reason for crown lengthening is for esthetics, the insurance company will possibly reject the claim. This does not mean that the procedure is unnecessary, it might be because the gums failed to grow to the correct positions in the first place, but this will be a narrative fight with insurance. This means it is wise to obtain a preauthorization for crown lengthening procedures anytime the front teeth are involved.
The second type of crown lengthening is needed when there is not enough crown of the tooth left to restore. This is due usually to earlier fillings or crowns needing to be replaced, but now, once crowns or fillings have been removed, there is little tooth structure above the gums remaining. Now the crown portion, which may involve part of the upper root of the tooth as well needs to be exposed. This means, just like the esthetic crown lengthening, the gums, and bone will need to be reshaped so they will heal in a position that allows the restoring dentist access to enough tooth structure to build upon.
Here is what you need to know about this second type of crown lengthening procedure.
Usually, it will only work once.
What I mean by this is that it is usually not in the best interest of the patient to lengthen beyond what was achieved the first time. This is because our backdoor, should this tooth be lost, is to preserve enough bone in order to place a dental implant. But even if a dental implant is not desired, the preservation of bone and gums are still important even if a bridge is to be placed. Also, the second crown lengthening may not result in enough good tooth structure to even work well. Teeth are only so large, to begin with.
So here is when a crown lengthening or exposing procedure is useful. If you have enough tooth structure to place a crown that will last at least five or more years, then it is usually a good option to consider. It means you are choosing to keep this tooth longer rather than replace it. This gives you the opportunity to prepare for its replacement sometime in the future. It is buying you time.
This is an important principle you as a patient do well to understand when becoming involved with these types of advanced surgical and restorative procedures. It is this. The more complicated the dentistry necessary, the more possibilities of failure – or a shorter life span until the next restoration. If you can get five years out of something like this, then it is an excellent option, but don’t believe that this fixes these types of problems permanently. They might and they might not.
This brings me to my final point, and one useful for everyone listening, is whether or not you ever need a crown lengthening procedure.
Prevention of problems is always the most economical approach to dental care.
It is especially important for those who have a history of tooth decay, extensive restorative work, or periodontal disease. Continuing to return to have teeth and fillings checked and pockets around teeth measured is incredibly valuable because it can keep dental work down to its minimal necessary requirements.
Remember, most disease processes in the mouth are for the most part silent.
I had a patient recently who stated what many unfortunately believe. “Well, it doesn’t hurt so it can’t be that bad.”
Yes, it most definitely can be bad even when it doesn’t give the individual any warnings through pain. Many live with low-level pain as well, simply believing that the fact the pain is low level the problem is small as well. Pain and the severity of a problem may not be connected at all. Self-diagnosing dental problems based on how the teeth and mouth feel can delay seeking care until the problems are big and much more expensive. Best to see dentists and dental hygienists on a regular routine basis.
Well, that’s it for today. I hope you have found this helpful. If I have left you with a few questions, please let me know.
You have been listening to the Perio Patient Podcast and I am still Dr. Ben Young. Thank you, as always for listening. Bye for now.
My dad, unfortunately, passed away when we couldn’t remember his blood type… His last words to us were, “Be positive!”