Article Type : Research Article
Authors : Mauricio Andrés Tinajero Aroni, Allison Jazmín Ortiz Miranda, Mauricio Tinajero Camacho and Edgar Pantoja
Keywords : Periodontics; Aesthetic treatment; Altered passive eruption
Supracrestal insertion measurements to achieve proportions in the smile that harmonize with the face. Excessive gummy display, also known as a "gummy smile," is a common cosmetic concern among dental patients. Excessive gingival exposure when smiling has been largely seen as unsightly, leading many patients to seek some type of treatment to address this problem. The etiology involved in the gummy smile is usually multifactorial, so an accurate diagnosis is essential before any surgical treatment. Potential causes for a gummy smile are: Short lips, Hypermobile/hyperactive lip activity, Short clinical crown, Dentoalveolar extrusion, and altered passive eruption, Vertical maxillary excess, and gingival hyperplasia. The case in this regard: A 22-year-old female patient attended the consultation with the main complaint of excessive gums when smiling, with no relevant history. A diagnosis is made, which results in altered passive eruption and as a treatment, aesthetic crown lengthening is performed to alleviate the patient's problem.
Altered Passive Eruption (APE) is a
genetic or developmental condition characterized by coronal positioning of the
gingival margin on the enamel, resulting in short clinical crowns . According
to the glossary of periodontal terms, the American Association of Periodontics
defines Altered Passive Eruption as: Exposure of the tooth secondary to apical
migration of the gingival margin to a location at or slightly coronal to the
cementoenamel junction (CEJ) .
Although Altered Passive Eruption
(APE) leads to cosmetic deterioration, this situation is a normal variation and
is not necessarily pathological. APE was described as a genetic or
developmental condition . The most widely accepted classification for APE
was published by Coslet et al. in 1977 . This classification involves
considerations about the amount of keratinized gingiva:
Type I: Wide
Type II: Thin
And the distance from the CEJ to the
alveolar crest and the CEJ ratio corresponds to the distance of 1.5 mm accepted
Subgroups B: When
the alveolar crest is at the level of the CEJ.
Chan, in his article
"Predictability in the treatment of gummy smile with altered passive
eruption", in 2015 mentions: A key element to reach a diagnosis is to
observe the location of the cemento-enamel junction (CEJ) in the gingival
sulcus. The CEJ normally resides just apical to the free gingival margin of the
crown. In contrast, CEJ may reside up to 10 mm apical to the free gingival
margin in altered passive eruption. If CEJ can be detected in the sulcus and
all other etiologies have been ruled out, a diagnosis of altered passive
eruption can be made .
A cosmetic crown lengthening
procedure is required to treat APE. One of the most important parameters to
evaluate before performing an aesthetic crown lengthening procedure is the
location of the cemento-enamel junction (CEJ), which ultimately determines the
clinical length of the crown. Furthermore, the location of the alveolar ridge
and its thickness determine whether a gingivectomy procedure should be
performed with or without bone resection surgery. Another critical factor is
understanding the interaction between the position of the gingival margin and
the CEJ in relation to the alveolar ridge. Failure to establish the optimal
distances between the CEJ and the alveolar crest could result in potential relapse
or unwanted exposure of the root surfaces .
Materials and Methods
A 22-year-old female patient attended the San Francisco de Quito University (USFQ) Dental Clinic, with the main complaint: “when I smile, my gums are visible a lot”. He has no significant personal or family history. Routine periodontal examinations (Periodontal Spreening and Recording (PSR), Oral Hygiene Index (OHI), Periodontogram begin to be carried out (Figure 1).Clinical evaluations
CEJ: This is
visualized directly when there is gingival recession, however, it can be
located subgingivally using the periodontal probe or an explorer.
Direct bone level (DBL) measurement obtained after reflection of the surgical
flap is considered the most accurate method and the gold standard for detecting
the location of the alveolar crest. However, it is an invasive procedure that
causes discomfort to patients and may not always be applicable in the pre-surgical
planning and diagnosis phases.
The series of extraoral and intraoral
pre-surgical photographs is taken of the patient:
at rest (Figure 2), Frontal with a wide smile (Figure 3), Lateral right and
Lateral left (Figure 4).
(Figure 5), Upper Occlusal and Lower Occlusal (Figure 6), Right Lateral and
Left Lateral (Figure 7).
For this clinical case, it was
decided to opt for the modified classification of Ragghianti, in 2016 (7).
Where the altered passive eruption is accompanied by the altered active
eruption, complementing the Colset classification.
Where the thickness of the gingiva is
maintained in Type I and Type II, it is classified as altered passive eruption
alone or is supplemented by altered active eruption. Highlighting as follows:
gingiva >2mm with a distance of 1.5mm from the cemento-enamel junction (CEJ)
to the alveolar crest. (Type I, altered passive eruption alone).
gingiva ?2mm with a distance of 1.5mm from the cemento-enamel junction (CEJ) to
the alveolar crest. (Type II, altered passive eruption alone).
gingiva >2mm with insufficient distance from the cemento-enamel junction
(CEJ) to the alveolar crest. (Type I, altered passive eruption accompanied by
altered active eruption).
gingiva ?2mm with insufficient distance from the cemento-enamel junction (CEJ)
to the alveolar crest. (Type II, altered passive eruption accompanied by
altered active eruption).
Classifying the patient as: Keratinized
gingiva >2mm (Figure 8) with insufficient distance from the cemento-enamel
junction (CEJ) to the alveolar crest. (Type I, altered passive eruption
accompanied by altered active eruption). It was decided to make internal bevel
incisions modifying the future gingival contour plus bone resective surgery to
restore the measurements of the supracrestal insertions.
Bleeding Points (Bone Probing): The
esthetic crown lengthening procedure has traditionally been guided on the basis
of clinical evaluation of parameters by direct visual assessment and bone
probing . We perforated the gingival tissues, at the zenith according to the
dental piece, with a periodontal probe (Hu-Friedy /CP15), thus creating
bleeding points (Figure 9). It was performed with a periodontal probe
(Hu-Friedy /CP15) and the points were connected in a scalloped form (15c
These points are then connected in a
scalloped form (15c scalpel) to represent the future gingival contour of all
the teeth to be treated (pz # 15 to 25) (Figure 10). The internal bevel
technique at 45° of the scalpel blade was used, subsequently, the soft tissue
was removed with a universal curette (Hu-Friedy), all this preserving the
Intrasulcular incisions were made to
raise a full-thickness flap, without exceeding the mucogingival line, using a
2-9 molt curette (Supremo) (Figure 11).
To preshape bone recontouring
(ostectomy and osteoplasty), leaving the bone crest 2 to 3 mm from the newly
outlined gingival margins and thus limiting the amount of gingival rebound. The
amount of bone resection should be gradually reduced with a high powered turbine
and burs intended for gingival lengthening, towards the line angles to avoid
loss of interdental bonding and black triangles (Figure 12).
We finished the surgery by
repositioning the flap and making sutures. A vertical mattress was placed on
the interdental papilla of the incisors, while suspensory stitches were made in
the other areas (Nylon 5.0 suture thread) (Figure 13).
Post-surgical measures: The patient
was prescribed 0.12% chlorhexidine (Encident) as a rinse for 15 days until the
stitches were removed. Suspension of tooth brushing in the area. A
non-steroidal anti-inflammatory drug (sodium naproxen, 550mg, every 12h x 3
days) and an analgesic (paracetamol, 1g, every 12h x 3 days) were also
Stitches were removed 15 days after surgery
without incident (Figure 14). The last photograph of the post-surgical patient
was taken, evidencing the change and improving the proportion of the dental
pieces (Figure 15).
APE was once classified as a typical
variation and not necessarily pathologic, but it is often associated with a
“gummy smile” and requires surgical intervention to correct . The diagnosis
of APE is the first step in therapy, there are multiple clinical and imaging
techniques described to help the dentist. Coslet et al. in 1977  described
the location of the CEJ that was used to determine if the anatomical crown is
really short. This author suggests that the CEJ should be located around 1.5mm
from the distance between the alveolar crest and the connective junction. The
location of this structure is more challenging when the bony crest is close to
or coincides with the CEJ.
In addition, the periodontal biotype
must be understood by clinicians for their surgical practice. A flat-thick
periodontium means: the presence of thick, fibrotic soft tissue, significant
amounts of keratinized gingiva, thick, short papilla, and thicker, flatter
bone. In contrast, a thin-scalloped periodontium has thin soft tissue and
keratinized gingiva with long narrow papillae on comparatively thin-skinned
The most predictable APE treatment
protocol can only be indicated by a careful diagnosis and treatment plan.
Transgingival probing (Tp) is the most common method used to determine the
clinical dimensions of the crown, which is used to detect subgingival CEJ. The
soft tissue height can be measured with a periodontal probe in the alveolar
bone, which can be used to guide the amount of bone to be removed. Studies
comparing Tp with direct bone level measurements immediately after flap
reflection indicate that both methods are accurate in determining alveolar bone
In type I, due to the amount of
keratinized gingiva, a marginal band of gingiva can be removed through an
external or internal beveled incision. In type II, the keratinized gingiva is
narrow and requires an intrasulcular incision with an apically repositioned
flap. In cases where removal of the gingival collar may result in less than 2
mm of keratinized gingiva remaining, at least 2 mm of keratinized gingiva
should be maintained on the flap and associated with apical repositioning to
preserve its proper height.
Type I is where most variations of
the technique are found and requires identification of a specific periodontal
biotype to plan the incision. If AAE is not related to APE, gingivectomy is the
recommended course of action. In this situation, osseous approaches are not
required. Cases associated with APE with AAE may require flap resection and
internal bevel incisions. When the periodontal biotype is thick, it is
important to alter the height and thickness of the gingival tissue while
aligning the angulation of the scalpel for the internal bevel incision
approximately 45 degrees to the long axis of the tooth. Type I cases may
present a thin periodontium and extensive keratinized gingiva at the same time.
To avoid loss of gingival height, the incision must have a 90 degree angle with
respect to the long axis of the tooth .
The esthetic crown lengthening
procedure has been found to result in less soft tissue rebound when the
postoperative gingival margin is placed 3 mm coronal to the surgically reduced
alveolar bone, based on clinical studies . Full-thickness flaps are
necessary to allow access to the bone when bone resection is suspected. If
apical repositioning is indicated, you should use a mixed (full and partial
thickness) flap to create flap anchorage to the periosteum. Vertical incisions
may be indicated for the apical flap, depending on operator preference. When a
minimal ostectomy of the marginal ridge is necessary, but not enough to remove
the bulk by osteoplasty, flapless techniques are used. When dealing with a thin
gingival margin, it is important to use Mini- Ochsenbein chisels. Flaps are
usually repositioned with a mattress pad or simple sutures, depending on the
stability of the gingival margin near the CEJ. To achieve predictable and reliable
results, it is essential to carefully design and evaluate all technical steps .
“Gold standard” aesthetic proportion
determines that the width of the maxillary central incisors should be
approximately 80% of their length, with an accepted variation between 65 and
85%; while the upper lateral incisors present around 70% .
Surgical procedure involving gingivectomy, full-thickness flap, and bone resection is an expected protocol to reduce APE related “gummy smiles.” Thus improving the dental proportion, harmonizing the face of the patient.
of Periodontology (4 Ed.) Chicago, IL. Glossaries of periodontal terms. 2001.