Periodontal Plastic Surgery for the Management of Altered is characterized by an excessive amount of attached CASE DESCRIPTION Passive Eruption: 5 Months Follow-Up Case Report gingiva, while type2 is associated with a normal gingival A 20-year-old systemically healthy female, was referred dimension. Two possible subclasses were also suggested. to the department of periodontology of the faculty In subcategory A, the distance Osseous Crest - CEJ is of dental medicine of Monastir (Tunisia) with a chief Safa BEN TANFOUS - DDS greater than 1mm, while in subcategory B the bone complaint of an unacceptable aesthetic result following 1 Resident, Department of Periodontology, Faculty of Dental Medicine of Monastir | Tunisia | [email protected] crest is in the CEJ. However, several authors criticized orthodontic treatment. the fact that this classifcation did not take into account Rym MASMOUDI - DDS the altered active eruption (AAE).10 The latter physiologic Resident, Department of Dentistry, Military Hospital of Tunis | Tunisia The patient was unhappy with her smile. She was variation, characterized by the proximity or coincidence especially uncomfortable with gingival display when 10,11 Omar MAROUANE - DDS of the alveolar crest to the CEJ, was described as the smiling. Moreover, she didn’t like “The black hole” Resident, Restorative Dentistry, Dental Surgery Department, University Hospital Sahloul, Sousse | Tunisia subgroup B of the APE. Moreover, the possible association between teeth 11 and 21. Omar HALOUAN - DDS between APE and AAE was not well described. Recently, Resident, Department of Periodontology, Faculty of Dental Medicine of Monastir | Tunisia a modifcation of the previous classifcation based on The clinical examination revealed short and square in 10 eruptive and biological concepts has been suggested. shape clinical crown appearance. The “black hole” Marwa M’BAREK - DDS Firstly, This modifed classifcation preserved APE Type I Resident, Department of Periodontology, Faculty of Dental Medicine of Monastir | Tunisia between teeth 11 and 21 was effectively present. In and Type II according to amount of keratinized gingiva, addition, transgingival probing revealed that the bone Leila GUEZGUEZ - DDS, PhD but values were added to facilitate diagnosis (Type I- > crest was situated 3mm apically to the CEJ. Finally, 12 Professor, Department of Periodontology, Faculty of Dental Medicine of Monastir | Tunisia 2mm of keratinized tissue/ Type II- ≤ 2mm). Secondly, gingival overlapping was noted when smiling, especially the subgroups A, B were excluded while categories of APE in regards to teeth 12 and 22. (Figure 1a-b) alone or APE associated with AAE were included.10 ABSTRACT Regarding these clinical parameters this patient was Except its esthetic consequences, several authors diagnosed with type I APE, according to the classifcation Background: Altered passive eruption (APE) is defned as the situation in which “the gingival margin in the adult consider that APE is a risk situation for the periodontal of Ragghianti.10 is located incisal to the cervical convexity of the crown and removed from the cemento enamel junction (CEJ) of the health. Indeed, diffculties in oral hygiene and narrow tooth. Clinical features of APE include excessive display of gingiva upon smiling associated to short clinical crown connective attachment are both highlighted.4 It is The treatment protocol included an initial periodontal appearance, since the gingival margin overlaps the anatomical crown. This condition may create esthetic concerns. In particularly important for APE-I-AAE, APE-II associated or therapy whose objective is to reduce gingival fact, teeth seem to be hidden, clinical crowns appear square in shape, and the gingival festooning is fattened. not to AAE.1 Moreover, for Volchansky3 there is a positive infammation. Then, periodontal surgery aiming the Case Report: This case present the management of a case of APE type I diagnosed in a 20-year-old systemically correlation between APE and acute necrotizing ulcerative enhancement of the smile by establishing the proper healthy female. The patient was unhappy with her smile. In fact, she was especially uncomfortable with gingival gingivitis. From this point of view, APE should be treated tooth proportion was performed. display when smiling and with “The black hole” between teeth 11 and 21. Initial periodontal therapy (IPT) was even if patient has not esthetic demand. applied including oral hygiene instructions and scaling. Then, an external bevel gingivectomy was performed followed The conventional non-surgical therapy consisted in a by the frenectomy of the upper labial frenum. Gingival healing was uneventful. The gingival line steel stable 5 months Periodontal surgery leads to improving the esthetic full mouth scaling. In addition, the patient was advised postoperative, and the papilla between teeth 11 and 21 flled the whole interproximal space. aspect of the lower third of the face by establishing the to perform and maintain her oral hygiene by brushing proper tooth proportion and by placing the gingival Conclusions: The proper treatment of APE may enhance the smile. From this point of view, external bevel 3 times a day and to use a chlorhexidine mouth rinse of margin in a suitable position relative to the lip.10,11,13 The gingivectomy is an effective procedure in case of APE type 1. In some cases, frenectomy may improve the aesthetic 0.2% twice daily. type of treatment proposed for each one of the different result. These techniques, lead to stable results. clinical situations of APE is based on its classifcation.10 The surgical therapy comprised an external bevel gingivectomy concerning only the 4 maxillary incisors; KEYWORDS The aim of this paper is to present the management of associated with frenectomy of the upper labial frenum. Altered passive eruption, Gummy smile, External bevel gingivectomy, Gingival overgrowth. a case of APE type I with an external bevel gingivectomy First, the pockets were probed and bleeding points associated to frenectomy and its 5-month follow-up. produced. Then, the primary incision was made with

INTRODUCTION Altered passive eruption (APE) was frst defned by Coslet or slightly coronal to the CEJ.6 This variation in habitual et al. in 1977.1 It is the situation in which “the gingival morphology is considered as a physiological situations margin in the adult is located incisal to the cervical and in any case as a pathological one.4 convexity of the crown and removed from the cemento enamel junction (CEJ) of the tooth”.2 “Retarded passive Clinical features of APE include excessive display of eruption” or “delayed passive eruption” have been also gingiva upon smiling associated to short clinical crown proposed to defne this periodontal status.3 appearance, since the gingival margin overlaps the anatomical crown.1,7 This condition may create esthetic The term APE refers to the mechanism underlying concerns. In fact, teeth seem to be hidden, clinical production of this morphological variant. Indeed, it is crowns appear square in shape,4,8 and the gingival attributed to failure in concluding the passive eruption festooning is fattened.4 a b phase.4,5 The Glossary of Periodontal terms of The 1 American Academy of Periodontology defned this The classifcation proposed by Coslet et al. is the most (Fig. 1) a) Pretreatment view of upper anterior teeth. Note the short and square in shape clinical crown appearance eruption stage as the tooth exposure secondarily to frequently cited in the literature. According to which, b) Photography of the pre-treatment smile showing gingival overlapping when smiling apical migration of the gingival margin to a location at APE has been divided into two main types.3,9 The Type1

| 22 | Smile Dental Journal | Volume 12, Issue 3 - 2017 Smile Dental Journal | Volume 12, Issue 3 - 2017 | 23 | Kirkland knife; while the secondary one was made with frenectomy. We insisted on removing the fbrous attachment Following surgical operation, paracetamol 2x3 for DISCUSSION ® Orban knife. After removing carefully the incised tissues on the bone by a periodontal curette. Finally, the edges of 5 days (Adol 500mg, SAIPH,˙Tunis, Tunisia) and The etiology of APE remains unclear.4,8 Several factors have ® with a 15 blade, the gingival contour was corrected by the mucosal slope of the diamond shaped wound were chlorhexidine oral rinse 1x2 for 10 days (Eludril 90mL been evoked, such as interocclusal interference on the soft gingivoplasty using a fne pair of gingival scissors. Once sutured with interrupted sutures; while the gingival wound SIMED, Tunis, Tunisia) were prescribed. The pack and the tissues during the eruptive phase.4 The periodontal biotype gingivectomy realized, we performed maxillary labial was covered with a periodontal pack. (Figure 2a-h) sutures were removed 1 week post-operatively. was, also, cited. As a matter of fact, the thick and fbrotic gingival tissue tend to migrate more slowly during the 1 week after surgery, healing was uneventful and the passive phase than fne gums.4 Whatever, few studies have gingival margin was situated in the CEJ with a scalloped related such mechanisms to the morphology of the coronal gingival architecture. The gingival line steel stable 5 periodontium.5,8 The hereditary factor was incriminated months postoperative, and the papilla between teeth too, and it seems to be confrmed. Indeed, According to 11 and 21 flled the whole interproximal space (Figure a recent preliminary study: 65% of patients diagnosed 3a-b). Moreover, the smile was enhanced and the patient with APE had at least one family member showing the was satisfed of the fnal clinical outcomes (Figure 4). same condition, and 15% had the whole family group with altered passive eruption.4,14

To diagnose APE, clinicians must take in account the a b patient age. Nevertheless, there is controversy surrounding the life time at which a diagnosis of APE can be made. In fact, all authors13,15-17 agreed to say that we can speak of an APE only when the passive phase of the eruption remains incomplete after the patient has completed his growth, it is rather the age at which the passive eruption ends which creates disagreement. Evian CI15 believed that the anterior teeth typically undergo passive eruption 13 a in the early teen years. On the other hand, Zucchelli G. stated that passive eruption continuous until patients had completed their growth i.e.18 to 20 years for the woman c d and 20 to 22 years for man. However, Volchansky A.16 Indicated that by the age of 20 years passive eruption had 17 (Fig. 2) not yet ceased in the anterior teeth. Weinberg M. agreed and stated that no study had investigated what happens a) The pockets are probed past 20 years of age. and bleeding points produced b) The primary incision made with Kirkland knife To establish a diagnosis of APE we have to proceed of c) The secondary incision elimination. Etiology of gingival display while smiling, made with Orban knife other than APE, must be excluded: d) The incised tissues are b 1. Vertical maxillary excess (VME): A visual diagnosis of carefully removed VME is made when the lower third of the face is longer e e) The gingival contour is (Fig. 3) a) Soft tissue healing 1 week after surgery than the remaining thirds;18 cephalometric analysis can corrected f) X-ray b) clinical photography 5 months post-operative. be, also, useful.19 In this case, the lower third of the g) labial frenectomy Note the stability of the gingival line and that the papilla face was proportionate to the remaining thirds. h) sutures of the edges of the between teeth 11 and 21 flled the whole interproximal space f diamond shaped wound 2. Hypermobile upper lip (HUL): during smiling there was 8mm of lip rising. Thus, the diagnosis of hyperactive upper lip was excluded. In fact, according to Garber et Salama20 the normal shift of the upper lip during smiling is 6 to 8mm and it is 1.5 to 2 time higher in cases of hyperactivity of the upper lip. 3. A short upper lip: measured from the subnasale to the inferior border of the upper lip, the length of the upper lip of our patient was 21,5mm which is in the normal rang of the maxillary lip length i.e. 20 to 22mm in young adult females.21 4. Incisal Attrition with compensatory eruption: was also excluded since there is no generalized tooth surface (Fig. 4) Photography of the fnal patient smile after healing. loss.11 Note that the papilla flled the hole interproximal space g h 5. Gingival overgrowth: since CEJ was not detectable in between teeth 21 and 11 the sulcus this etiology was discarded too.22

| 24 | Smile Dental Journal | Volume 12, Issue 3 - 2017 Smile Dental Journal | Volume 12, Issue 3 - 2017 | 25 | 15. Evian CI, Cutler SA, Rosenberg ES, Shah RK. Altered passive eruption: the undiagnosed entity. The Journal of the American Dental Association. 1993;124(10):107-10. 6. Regarding these parameters, only APE could explain CONCLUSION 16. Volchansky A, Cleaton-Jones P, Fatti L. A 3-year longitudinal 24. De Rouck T, Eghbali R, Collys K, De Bruyn H, Cosyn J. The the gingival display while smiling. Moreover, teeth study of the position of the gingival margin in man. Journal of gingival biotype revisited: transparency of the periodontal APE is an uncommon physiologic variation of the probe through the gingival margin as a method to discriminate seem to be hidden, clinical crowns appeared square in morphology of the dentogingival unit. Although, it clinical periodontology. 1979;6(4):231-7. 4,8 4 17. Weinberg M, Eskow R. An overview of delayed passive eruption. thin from thick gingiva. Journal of clinical periodontology. shape, and the gingival festooning was fattened. This implies very important esthetic concerns and it is, also, 2009;36(5):428-33. effectively corresponds to the clinical aspect of APE.1 Compendium of continuing education in dentistry (Jamesburg, considered as a risk factor for periodontium. Thus, the NJ: 1995). 2000;21(6):511-4,6,8 passim; quiz 22. 25. Galgali SR, Gontiya G. Evaluation of an innovative treatment of APE should be undertaken even if patient 18. Robbins JW. DIFFERENTIAL DIAGNOSIS AND TREATMENT or radiographic technique-parallel profle radiography-to determine the dimensions of dentogingival unit. Indian journal The second step is to verify if AAE was associated to doesn’t express esthetic demand. Excess GINGIVAL DISPLAY. 1999. APE.10 In fact, the crestal bone, landmarked by bone 19. Humayun N, Kolhatkar S, Souiyas J, Bhola M. Mucosal of dental research. 2011;22(2):237. coronally positioned fap for the management of excessive 26. Moshref A, editor Altered passive eruption. The Journal of the sounding, was 3mm apically to the CEJ which was The proper treatment of APE may enhance the smile. Western Society of Periodontology/Periodontal abstracts; 1999. enough to the connective tissue attachment and junction gingival display in the presence of hypermobility of the upper From this point of view, external bevel gingivectomy is lip and vertical maxillary excess: A case report. Journal of 27. Mirko P, Miroslav S, Lubor M. Signifcance of the labial frenum epithelium. The biologic width was also verifed by an effective procedure in case of APE type 1. In some periodontology. 2010;81(12):1858-63. attachment in periodontal disease in man. Part 1. Classifcation X-ray.22-24 Whatever, radiographic interpretations are cases, frenectomy may improve the aesthetic result. 20. Garber DA, Salama MA. The aesthetic smile: diagnosis and and epidemiology of the labial frenum attachment. Journal of only diagnostic on the interproximal area. On the facial These techniques, lead to stable results. treatment. Periodontology 2000. 1996;11(1):18-28. periodontology. 1974;45(12):891-4. 21. Peck S, Peck L, Kataja M. The gingival smile line. The Angle 28. Dewel B. The labial frenum, midline diastema, and palatine aspect of teeth they cannot identify the violations of papilla: a clinical analysis. Dental clinics of North America. biologic width because of tooth superimposition.25 Thus ACKNOWLEDGMENTS orthodontist. 1992;62(2):91-100. 22. Dolt AH, Robbins JW. Altered passive eruption: an etiology 1966:175-84. AAE was excluded. The authors acknowledge Research Laboratory of Oral of short clinical crowns. Quintessence International-English 29. Díaz-Pizán ME, Lagravère MO, Villena R. Midline diastema Health and Orofacial Rehabilitation LR12 ES11, Faculty Edition- 1997;28:363-74. and frenum morphology in the primary dentition. Journal of dentistry for children. 2006;73(1):11-4. Regarding all these clinical data, our patient was of Dental Medicine, Monastir University, Tunisia. 23. Levine R, McGuire M. The diagnosis and treatment of the gummy smile. Compendium of continuing education in dentistry 30. Armitage GC. Development of a classifcation system for diagnosed with type I APE, according to the classifcation periodontal diseases and conditions. Annals of periodontology. 10 (Jamesburg, NJ: 1995). 1997;18(8):757-62,64; quiz 66. of Ragghianti. In fact, a wide band of keratinized gingiva CONFLICTS OF INTEREST 1999;4(1):1-6. (>2mm) in the buccal aspect of incisors was noted. The authors declare that there is no confict of interest regarding the publication of this paper. After the conventional non-surgical therapy, treatment protocol includes the surgical phase. It comprised, as REFERENCES 10,20 suggested by several authors, a gingivectomy to 1. Coslet J, Vanarsdall R, Weisgold A. Diagnosis and classifcation آفاق جديدة في طب السنان السريري expose the hidden clinical crown. In this case, regarding of delayed passive eruption of the dentogingival junction in the the important amount of attached gingiva, we proceeded adult. The Alpha Omegan. 1977;70(3):24. to an external bevel gingivectomty. Indeed, festooning of 2. Goldman HM, Cohen DW. Periodontal therapy: CV Mosby Co.; the gingiva and reestablishing gingival physiology are St. Louis, Mo, 1973. الؤتر الردني الامس والعشرون لطب السنان Volchansky A, Cleaton-Jones P. Delayed passive eruption-A .3 much better mastered with external bevel gingivectomy predisposing factor to Vincent’s Infection? Journal of the dental than with internal bevel one. It is to highlight that apically association of South Africa. 1974;29(5):291-294. positioning fap cannot be indicated in this case; it is only 4. Alpiste-Illueca F. Altered passive eruption (APE): a little- The 25th Jordanian International Dental Conference reserved to APE-II.10,20 Regarding osseous resection, it known clinical situation. Med Oral Patol Oral Cir Bucal. was unnecessary since AAE was excluded.1,10,11,26 2011;16(1):100-4. October 3 - 6, 2017 5. Alpiste-Illueca F. Morphology and dimensions of the dentogingival unit in the altered passive eruption. Medicina Amman - Jordan 27 The upper labial frenum had a papillary attachment. oral, patologia oral y cirugia bucal. 2012;17(5):814. [email protected] This type of insertion was mainly associated with 6. Periodontology AAo. Glossary of periodontal terms: American papillary loss and recession.28,29 In our case study, Academy of Periodontology; 2001. it was concluded that the “The black hole” resulting 7. Gottlieb B, Orban B. Active and passive continuous eruptions of teeth. J Dent Res. 1933;13:214. from the papilla apical displacement was caused by 8. Nart J, Carrió N, Valles C, Solís-Moreno C, Nart M, Reñé R, tension exercised by frenum fber on the interdental et al. Prevalence of altered passive eruption in orthodontically papilla between teeth 11 and 21. The loss of the treated and untreated patients. Journal of periodontology. involved papilla cannot be the result of periodontitis. 2014;85(11):348-53. In fact, probing depth did not exceed 3mm at all teeth, 9. Hoelscher BC. Passive eruption patterns in frst molars: The University of Iowa. MS (Master of Science) thesis, University of especially in the mesial aspect of teeth 11 and 21. Iowa, 2011. http://ir.uiowa.edu/etd/982 Whatever, bleeding in probing was present. Moreover, 10. Ragghianti Zangrando MS, Veronesi GF, Cardoso MV, Michel no bone loss was noted in the radiographic (figure RC, Damante CA, Sant’Ana AC, et al. Altered Active and 2f). Our patient was diagnosed with a plaque induced Passive Eruption: A Modifed Classifcation. Clinical Advances gingivitis which don’t involve deep periodontium.30 Thus, in Periodontics. 2016(0):1-28. 11. Chu SJ, Karabin S, Mistry S. Short tooth syndrome: diagnosis, frenectomy was performed during which the greatest etiology, and treatment management. CDA J. 2004;32(2):143-52. attention was given to the elimination of frenum fbers 12. Lang NP, Löe H. The relationship between the width inserted in the papilla. of keratinized gingiva and gingival health. Journal of periodontology. 1972;43(10):623-7. 5 months post-operative, the gingival margin steel stable 13. Zucchelli G, Gori G. Mucogingival esthetic surgery: Quintessenza Edizioni; 2013. and the smile was enhanced. The papilla between teeth 14. Rossi R, Brunelli G, Piras V, Pilloni A. Altered passive eruption 11 and 21 flled the whole interproximal space. Moreover, and familial trait: A preliminary investigation. International the patient was satisfed of the fnal clinical outcomes. journal of dentistry. 2014.

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