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Periodontal Plastic Surgery for the Management of Altered Passive

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Periodontal Plastic Surgery for the Management of Altered Passive 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.
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