Rather than start yet another thread on closed crown lengthening, I decided to resurrect a former one.

I posted this in the laser forum on DT as well, but wanted to share this little story with my LDF friends as well …

***********************

Here’s an update on the topic of closed crown lengthening …

This morning I did what I was challenged to do by Danny — perform a closed CL with the laser and open it up and see what things looked like.

First, a disclaimer: This was my first attempt at ANY perio surgery, so you guys who do this stuff all the time, gimme a break.

Another disclaimer: You guys who do closed CL all the time and get great results will just say that I didn’t do it right, and you’d probably be right. However, I’m like most other laser purchasers and went at it with all the training I’ve received and a knowledge of what I’ve learned from months of discussions here on this forum.

One last disclaimer: You periodontists out there — please don’t gloat. It’s because of your input that I was at least curious enough to see what I’d done with the laser under the tissues.

Female patient, deep DO amlagam on #29, fractured lingual cusp. After presenting her with options, we mutually agreed upon the following treatment plan:

1) Root canal therapy
2) Crown lengthening
3) Post and core, crown

Today I had her in, explained the procedure to her and why we were doing things the way we did. I took pictures along the way to document the case, but because it was virtually impossible for me to hold everything where I wanted and still take the pictures, they all turned out blurry. Guess I need to train an assistant to use the camera.

Anyway, I reduced the gingival height to accomodate where I wanted my margin to be, which left me with less than 1mm of sulcus.

I used the Er:YAG laser at 30Hz, 150mJ with water to reduce the bone enough to allow for new attachment below the proposed crown margin. Using a perio probe, I tried to feel my way around the bone and extend the bone reduction laterally to make a smooth transition and avoid the formation of a trough in the bone. I thought I’d done a pretty decent job. Were it not for Danny’s challenge to lay a flap and see what it looked like, I’d have merrily prepped the tooth and taken an impression.

I made a mini-flap on the lingual only (the bony reduction was primarily on the lingual, with the reduction feathering across the interproximal crest. I was more than a little surprised to see a rather significant, boxy trough in the bone, from the root surface outward. Needless to say, I was surprised and disappointed.

I spent a few long seconds contemplating how I might have been able to get a smooth reduction of bone in that area and concluded that, without having visual access, there’s no way. Maybe YOU could do it, but I couldn’t. The bone thickness on the lingual was much thicker than I’d expected.

I used the laser to smooth out the defect and form a smooth transition to the surrounding bone, took a couple of worthless, blurry pictures, then sutured the flap in position with a couple of 5-O chromic sutures and gave post-op instructions. I should end up with at least 2mm of attachment and supragingival margins.

I’m sorry I can’t show you pictures. I’m sure it would only open the floodgates of criticism, but it would demonstrate how, at least in THIS case, closed CL would have been courting disaster. I really don’t see how I could’ve angled the tip of the laser enough lingually to keep from forming negative bony architechture.

I’ll certainly follow the case and report back. I’m planning on at least 8 weeks of healing, followed by the P/C and crown prep, which shouldn’t affect the attachment.

I realize that this doesn’t settle a thing in the ongoing argument pro/con closed CL, but am hoping that someone might benefit from my experience.

Again, please be kind in your critiques. I collect guns and know how to use them. 🙂

— Don

Don and Al,

I concur. The closed crown lengthening is elegant and needs to be reserved for very narrow boney alveolus, which is not much of the mouth.

I would like to find some information on conservative perio flap techniques. Especially ones which involve reflecting both buccal and lingual flaps but conserve papillas. The only ones I was schooled on involve multiple teeth, ramping and tapering over several teeth and was intended for treating the boney defects of disease.

My take on the state of the world of gums and bones.
I’m glad you brought this up.

Lee