Altered Passive Eruption (APE) and Active Secondary Eruption (ASE): Differential Diagnosis and Management

CLINICAL RESEARCH

Altered passive eruption (APE) and active secondary eruption (ASE): differential diagnosis and management

Irfan Ahmad, #%4 Consultant Prosthodontist, Department of Substitutive Dental Sciences, College of Dentistry, University of Dammam, Kingdom of Saudi Arabia

Correspondence to:*SGBO"INBE #%4

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Abstract more, the differential diagnosis between the two, and that between other mirror- The process of tooth eruption consists of ing conditions, is essential for arriving two phases, active and passive. While at a deﬁnite diagnosis and correct treat- the distinction is unequivocal, the mech- ment strategies, which may be similar anism is ambiguous. This article com- but have different consequences. This pares and contrasts altered passive article concludes with two case studies eruption (APE) and active secondary that show the management of APE and eruption (ASE). Although these phases ASE, highlighting the treatment similari- present with similar clinical manifesta- ties and differences that are dependent tions, each has its own etiology, physio- on the speciﬁc etiology. genesis, and pathogenesis. Further- (Int J Esthet Dent 2017;12:352–376)

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Introduction medication, or a coronal location of the gingival margin due to erratic eruption &YDFTTJWF NBYJMMBSZ HJOHJWBM EJTQMBZ patterns. In addition, numerous mirror- colloquially referred to as a “gummy ing conditions, unrelated to dental and/ smile,” detracts from pleasing anterior or gingival factors, also manifest as a pink esthetics.1 People who have this XJEFCBOEPGNBYJMMBSZHJOHJWB"TXFMM esthetic aberration often suffer from so- as detracting from anterior pink esthet- cial stigma, ridicule, and sarcasm, and JDT FYDFTTJWFNBYJMMBSZHJOHJWBMEJTQMBZ are erroneously judged by others in can impact on oral health and the lon- terms of their intellect, trustworthiness, gevity of the dentition. The correction friendliness, and self-confidence.2 The of these anomalies is often not straight- EFHSFF PG NBYJMMBSZ HJOHJWBM FYQPTVSF forward, and its success frequently de- in patients with a gummy smile has at- pends on correct diagnosis and subse- tracted much attention in the dental quent appropriate treatment. Treatment literature. The accepted norm among may involve surgical, restorative, pros- clinicians for anterior pink esthetics is thetic or orthodontic treatment, muscu- NNBNFBTVSFNFOUUIBUJTFOEPSTFE lature taming, or a combination of these CZ JOOVNFSBCMF UFYUT BOE TVSWFZT PO modalities. the subject.However, it should be re- membered that opinions are subjective. Surveys of populations in different coun- Definitions tries with disparate esthetic values and differing education levels, social mores, #FGPSFFNCBSLJOHPOUIJTEJTDVTTJPO JU and religious taboos will have different is important to avoid ambiguity by defin- outcomes. So while surveys can serve ing some basic dentogingival anatomi- as a general guide, there are instances, cal terminology (Fig 1). GPSFYBNQMF XIFSFEJTDFSOJOHQBUJFOUT The cervicoincisal height of the NBZSFHBSEBOZBNPVOUPGHJOHJWBMFY- crowns of natural teeth is classified into posure or any minor gingival zenith dis- three categories: clinical length, ana- parity as detrimental to their smile and tomical length, and biological length. general appearance. Therefore, in order Clinical crown length is the visible height to avoid treatment failure, it is essential measured from the incisal edge to the to take heed of patients’ wishes, irre- most coronal aspect of the free gingival spective of the clinical and laboratory margin (FGM). The anatomical crown prowess.7 length, which may or may not be clini- 5IF DMJOJDBM BQQFBSBODF PG FYDFT- cally visible, is the distance from the in- sive gingival display is usually concur- cisal edge to the cementoenamel junc- rent with short clinical crowns relating to tion (CEJ). Lastly, the biological crown dental or gingival factors. Dental causes length, which is invisible and determined include acute trauma, rampant decay, or either through radiography, tactile bone attrition due to tooth surface loss (TSL), sounding, or by raising a mucogingi- while gingival causes include gingival val flap, is the distance from the incisal hypertrophy due to systemic illness or edge to the midfacial alveolar bone crest

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Keratinized gingiva (FGM Mucogingival junction – red to mucogingival junction)

Biologic width (epithelial attachment to alveolar bone crest)

Sulcus depth (FGM to Alveolar bone crest – yellow epithelial attachment)

CEJ (cementoenamel junction) – blue Clinical crown length (incisal edge to FGM) FGM (free gingival margin ) – pink

Anatomical crown length (incisal edge to CEJ)

Biologic crown length (incisal edge to bone crest)

Fig 1 Dentogingival terminology.

(clinical crown length + sulcus depth + primary eruption, from when the tooth biologic width). emerges into the oral cavity until it reach- Other terminologies include the vis- es its antagonist counterpart. This is fol- ible width of keratinized gingiva, which lowed by passive eruption, which results is measured from the coronal aspect in apical migration of the gingiva to fully of the FGM to the mucogingival junc- FYQPTFUIFDMJOJDBMDSPXO"MUIPVHIUIF tion; and the invisible biologic width, active phase (active primary eruption) which is the linear measurement from predominates during the juvenile and the epithelial attachment to the alveolar puberty phases of development,10 it CPOFDSFTU DPOTJTUJOHPGBQQSPYJNBUFMZ can nevertheless be triggered through- 1 mm of connective tissue and 1 mm out life11 as active secondary eruption of epithelial attachment, and which is (ASE) when a tooth is unopposed by its a prerequisite for periodontal integrity antagonist. Situations causing interoc- and health. DMVTBMDMFBSBODFJODMVEFNJTTJOHPSFY- tracted teeth, loss of tooth substrate following trauma, caries, TSL (tooth wear), Physiogenesis of tooth periodontal disease or intentional space eruption creation to stimulate this process, eg, the Dahl concept.12 The physiogenesis of tooth eruption Passive eruption is histologically di- consists of two distinct phases: active vided into four stages:

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1. The epithelium attachment of the den- ever, in APE (also known as delayed UPHJOHJWBM DPNQMFY %($ JT FOUJSFMZ passive eruption or retarded passive located on enamel, coronal to the CEJ. eruption), the FGM is located more incis- 2. The epithelium attachment is partly ally or coronally over the enamel, result- on enamel and partly on cementum. ing in short clinical crown lengths and a 5IFFQJUIFMJVNBUUBDINFOUJTFOUJSFMZ so-called gummy smile. PODFNFOUVN XJUIJUTDPSPOBMBQFYBU 5IF FYDFTTJWF HJOHJWBM DPWFSBHF the CEJ. of the anatomical crown seen in APE 5IFFQJUIFMJVNBUUBDINFOUBOE'(. is caused by retardation of the pas- are apical to the CEJ (gingival reces- sive eruption phase of tooth eruption. sion). There are two morphological types of APE (Type 1 and 2), each with two fur- The prevalence of altered passive erup- UIFS TVCEJWJTJPOT 4VCUZQF " BOE # tion (APE) is around 12% in the popu- (Fig 2). In both types, the FGM is in a lation.4UBHFTUPBSFSFHBSEFEBT more coronal position. normal physiological processes, while The distinguishing feature of Type 1 UIF MBTU TUBHF DIBSBDUFSJ[FE CZ FYQP- is a wide band of keratinized attached sure of cementum, is considered path- gingiva with a grossly apical location ological and is caused by sequelae to of the mucogingival junction in relation QFSJPEPOUBMEJTFBTFPS5ZQF"4& FY- to the alveolar crest. In subtype 1A, the plained below). distance from the CEJ to the bone crest JTXJUIJOUIFOPSNPGøUPNN XIJMF JOTVCUZQF# UIF$&+JTBMNPTUDPJODJ- Etiology dent with the alveolar crest. In Type 2, the keratinized gingiva is Altered passive eruption (APE) narrower and the mucogingival junction closer to the CEJ, which could be at- In normal circumstances, the DGC is lo- tributed to a failure of active or passive cated near the CEJ, with the FGM slightly eruption. In subtype 2A, the distance concealing the anatomical crown. How- between the CEJ and the alveolar bone is normal (accommodating the normal CJPMPHJDXJEUI XIJMFJOTVCUZQF# UIF $&+ BMNPTU BQQSPYJNBUFT UIF BMWFPMBS crest, allowing little space for the epithelium and connective tissue attachments. 5ZQFT#BOE#BSFDPNNPOJOBEP- lescence but rare in adulthood, ie, they are a transitionary phase to the second- BSZEFOUJUJPO*OBEEJUJPO 5ZQF#JTUIF Type 1A Type 1B Type 2A Type 2B most commonly encountered, and has been termed altered active eruption,

Fig 2 Coslet’s altered passive eruption (APE) which is a failure in the active eruption classiﬁcation. phase. This interruption, or diapause, in

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Occlusal plane

Initial position: Final location: Initial position: Final location: Initial position: Final location: eg, tooth wear, level to oc- eg, unop- beyond oc- eg, unop- root exposure presence of clusal plane posed tooth clusal plane – posed tooth – long clinical opposing – short clinical or antagonist normal clinical or antagonist crown length antagonist crown length tooth wear crown length tooth wear

Type 1 Type 2 Type 3

Alveolar compensation Overeruption with PG Extrusion (overeruption with PG coronal to occlusal plane (overeruption without PG level with occlusal plane) coronal to occlusal plane)

PG = periodontal growth

Fig 3 Active secondary eruption (ASE) classiﬁ cation.

the tooth eruption process is attributed teeth during mastication. However, with- to a variety of causes, including genetic out this periodic stimulation, the erup- predisposition, unfavorable environ- tion process is once again activated. mental and systemic factors such as ASE occurs when interocclusal space occlusal interferences, root ankylosis, is created, either by a variety of unwant- incomplete root formation, space limita- ed causes such as missing antagonist tions, thick periodontal biotypes, cardio- teeth, TSL, dental caries, acute traumas, facial spacial relationship of the jaws, chronic periodontitis, mesial tilting of op- and metabolic disruption (hormones posing teeth, or intentional orthodontic and growth factors).17 Whether a single space creation. factor or multiple factors are responsible Three types of ASE are described remains an enigma, since physiogene- 'JH *O5ZQF UIFUPPUITVGGFST54- sis of tooth eruption is still unresolved, and over-erupts to meet its antagonist and further research is required for elu- counterpart in order to maintain oc- DJEBUJOHUIJTDPNQMFYQIFOPNFOPO clusal vertical dimension (OVD) or face height, also known as dentoalveolar Active secondary eruption (ASE) compensation. This is achieved by periodontal growth and the concomitant The occlusion of the dentition is main- migration of the alveolar housing and tained in a state of equilibrium due to periodontal ligament toward the occlusal intermittent stimulation by antagonist plane, resulting in a short clinical crown

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recession), where the tooth maintains its occlusal position while the FGM recedes apically. In addition, depending on tooth conﬁguration in the arch, ASE can also be accompanied by mesial drifting and tilting caused by missing teeth, tooth wear, or loss/fracture of dental restorations/prostheses. As mentioned earlier, ASE can also be intentionally activated for correcting certain hard and soft tissue anomalies Fig 4 &YDFTTJWF NBYJMMBSZ HJOHJWBM EJTQMBZ OPU CZNFBOTPGPSUIPEPOUJDFYUSVTJPO NPW- caused by APE or ASE. ing the DGC in a coronal direction to line up erratic gingival zeniths, leveling arches, creating a favorable crown/root length and disparate gingival zeniths.20 ratio, increasing bone volume prior to It is important to realize that dentoal- implant placement, and raising the OVD veolar compensation is a reaction to an for compensating TSL using the Dahl event (interocclusal space and lack of principle. intermittent stimulation), while the action of compensation is accomplished by triggering ASE with periodontal growth. Differential diagnosis and Type 2 is also characterized by peri- mirroring conditions odontal growth, but is initiated by a missing antagonist tooth or antagonist tooth Differential diagnosis between APE, wear. In this scenario, the tooth over- ASE, and other mirroring conditions in- erupts coronal to the occlusal plane, volves four diagnostic stages. maintaining its original crown length but The ﬁrst diagnostic stage is visual with disparity of the gingival zeniths, as assessment, determining the degree the tooth is more coronal compared with PG NBYJMMBSZ HJOHJWBM FYQPTVSF BOE UIF adjacent teeth. MFOHUIPGUIFUFFUIJOUIFNBYJMMBSZBOUFS- -BTUMZ 5ZQF BMTPLOPXOBTFYUSV- JPS TFYUBOU EVSJOH TNJMF EZOBNJDT SF- sion) involves unilateral overeruption of QPTFBOEMBVHIUFS *GFYDFTTJWFHJOHJWBM the tooth in a coronal direction, beyond FYQPTVSFJTFWJEFOU CVUUIFUFFUIIBWF the occlusal plane, leaving the FGM in an average width/length (w/l) ratio in the JUT PSJHJOBM MPDBUJPO BOE UIFSFGPSF FY- SFHJPOPG 22 with the length of the posing the dentin and cementum of the DFOUSBMJODJTPSTBQQSPYJNBUFMZNN root surface, resulting in a long clinical and there are no signs of tooth wear, then crown length. If the tooth is unopposed, the patient does not have APE or ASE it will continue erupting until reaching 'JH *OUIFTFDJSDVNTUBODFT UIFXJEF the antagonist alveolar ridge.21 This CBOEPGNBYJMMBSZHJOHJWBMEJTQMBZDPVME type of movement is distinguished from be attributed to other mirroring condi- UIBUPDDVSSJOHJOTUBHFPG"1& HJOHJWBM tions such as Angle Class II, division II;

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Angle Class III; a short upper lip (aver- USBOTQBSFODZ FYQPTFE EFOUJO age female lip is 21 mm, and male lip 5IJTJTBTJNQMJTUJDJOEFY TJODFUPEBUF JTNN hypertonicity of the orofa- there is no single internationally recog- DJBM NVTDMFT EFOUPBMWFPMBS FYUSVTJPO OJ[FE JOEFY PG 54- GPS DMJOJDBM BOE SF- QSPUSVTJPOPGUIFQSFNBYJMMBJODSFBTFE search applications that encompasses WFSUJDBMEJNFOTJPOPGUIFNBYJMMBDBOU- etiology, morphology, prevalence, ter- JOHPGUIFJODJTBMQMBOFBOEPSNBYJMMB minology, pathogenesis, monitoring, or or a combination of these anomalies. management of this insidious condi- If any of these are suspected, crown tion. lengthening is futile, as creating long The second diagnostic stage is the clinical crown lengths will deteriorate location of the CEJ by periodontal prob- white esthe tics and further compound ing. If TSL is evident, with the CEJ situat- the already compromised pink esthet- ed within the sulcus near the FGM, and ics. Therefore, other treatment options the measurement from the CEJ to the should be considered, depending on incisal edge (anatomical crown length) the etiology, including orthodontics, JTNN UIFEJGGFSFOUJBMEJBHOPTJT orthognathic surgery, local muscle re- is ASE. In the absence of tooth wear, MBYBOUT MJQ FMPOHBUJPOT XJUI SIJOPQMBT- reduced clinical crown length, and the ties, lip muscle detachments, myoto- CEJ not situated within the sulcus or mies, surgical lip repositioning,27 or a near the FGM, the diagnosis is APE (see combination of these modalities. Hence, 'JH differential diagnosis is quintessential The third diagnostic stage is bone for informing patients of available thera- sounding for ascertaining the type of pies, and most importantly, for ensuring APE. If the periodontal probe measure- SFBMJTUJDPVUDPNFTBOEFYQFDUBUJPOT ment from the FGM to the alveolar crest *O UIF QSFTFODF PG FYDFTTJWF NBYJM- JT NN XJUIBOBQJDBMMPDBUJPOPGUIF lary gingival display and reduced clinic- mucogingival junction, then the diagno- al crown length, the differential diagnosis is APE Type 1A, and with a normal lo- sis is either APE or ASE. APE is clinically cation of the mucogingival junction, the diagnosed as short clinical crowns with diagnosis is Type 2A. However, when PSNPSFDPWFSBHFPGUIFBOBUPNJDBM the measurement from the FGM to the al- crown by the overlying gingiva, which WFPMBSDSFTUBQQSPYJNBUFTNNPSMFTT is flattened and festooned, with the in- and the mucogingival junction is apical UFSQSPYJNBM QBQJMMB CBTF XJEFS UIBO JUT PSOPSNBM UIFEJBHOPTJTJT5ZQF#BOE DPSPOBMBQFYIFJHIU0OUIFPUIFSIBOE 5ZQF# SFTQFDUJWFMZ 'JH short clinical crowns with apparent tooth The fourth diagnostic stage is radio- wear are diagnosed as ASE, usually by graphic evaluation, either by parallel pro- attrition at the incisal edges. The wear at mMFSBEJPHSBQIZ 113Y or cone beam the incisal edges is classified according DPNQVUFEUPNPHSBQIZ $#$5 con- UPUIF4NJUIBOE,OJHIU5PPUI8FBS*OEFY firming the thickening of both the crestal (TWI) for attrition as follows: 0 = intact in- alveolar bone and the connective tissue cisal edge; 1 = non-visualization of the attachment, as well as the location of the enamel lobes; 2 = the dentin is seen by CEJ.5ZQJDBMMZ "1&5ZQFT#BOE#

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Table 1 Differential diagnosis of APE and ASE

APE ASE

Short clinical Yes Yes (Type 1) crown length

Long clinical No :FT 5ZQF crown length

Tooth wear No Yes

Missing antago- No :FT 5ZQFTPS nist tooth/teeth

CEJ location to Apical to FGM Normal parameters to FGM (Types 1 FGM and 2) or $PSPOBMUP'(. 5ZQF

Alveolar crest /FBSFS$&+ 5ZQFT#BOE# PS Nearer occlusal plane (Types 1 and 2) or location to CEJ/ Normal parameters to CEJ (Types 1A Normal parameters to occlusal plane occlusal plane and 2A) 5ZQF

Keratinized gingi- 8JEF 5ZQFT"BOE# PS Wide (Types 1 and 2) or val width /PSNBMQBSBNFUFST 5ZQFT"BOE# /PSNBMQBSBNFUFST 5ZQF

Mucogingival "QJDBM 5ZQFT"BOE# PS Normal parameters location /PSNBMQBSBNFUFST 5ZQFT"BOE#

APE - altered passive eruption ASE - active secondary eruption

are diagnosed when there are smaller Management of APE biologic widths (ie, a smaller distance and ASE from the CEJ to the crestal bone, leaving little space for the connective tissue and The implications of APE to oral heath are epithelial attachments), while in Types possible risk to periodontal pathosis, in- 1A and 2A, the relationship of the CEJ cluding chronic inﬂammation, acute ne- and alveolar crest is normal, around crotizing ulcerative gingivitis or gingival øUPNN hyperplasia. However, the salient is- Finally, the sulcus depth can be within sues are either compromised pink es- normal parameters (1 mm), and hence thetics, which prompts patients to seek its depth is an unreliable diagnostic in- professional help, or when restorative dication of APE, and in the presence of treatment is contemplated on the affect- short clinical crowns, bone sounding ed tooth/teeth. If uncorrected, and the is a better diagnostic assessment tool restorative margins are placed supra- (Table 1). or equigingivally, the esthetic anomalies

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include short wide crowns with a large gingivectomy alone suffices, leaving XM SBUJP FYQPTVSF BOEPS TUBJOJOH PG NNGSPNUIF'(.UPUIFBMWFPMBSDSFTU the restoration finish line, persistence for maintaining the biologic width and PGFYDFTTJWFHJOHJWBMEJTQMBZPSHVNNZ HJOHJWBMTVMDVT$POWFSTFMZ JO5ZQFT# smile, and festooned flattened gingiva. BOE# HJOHJWFDUPNZQMVTPTTFPVTSF- All of these compromise the dentofacial cession by ostectomy and osteoplasty esthetic composition or attractiveness of are indicated for removing crestal bone the smile. Conversely, subgingival mar- BOEDSFBUJOHUIFOFDFTTBSZNNTQBDF gins can violate the biologic width, caus- from the FGM (2 mm for biologic width, ing periodontal insult, again resulting in and 1 mm for sulcus). However, depend- unsightly and unhealthy pink esthetics. ing on the location of the mucogingival The clinical implications of ASE can be junction, the flap design and reposition- short or long capriciously shaped clin- ing may require modification for ensur- ical crowns, depending on the type of ing an adequate band of keratinized gin- active eruption; unsightly uneven incisal giva for periodontal health. The incisions edges; erratic gingival zenith margins; and tissue resection (soft and hard) are BOEEFOUJOFYQPTVSFBUUIFJODJTBMFEHFT limited to the facial aspect, and involve and/or root surfaces, causing sensitivity reestablishing the correct gingival scal- and discoloration, combined with accel- lops for mimicking underlying osseous erated tooth substrate loss with possible architecture. In addition, gingivectomy fracture and/or endodontic involvement. incisions are confined within the facial Following precise diagnosis, a man- line angles for creating the correct gin- agement strategy is planned. This gival scallop, without resecting the in- strategy may simply involve restorative UFSQSPYJNBM QBQJMMBF UP BWPJE DSFBUJOH corrections, or it may necessitate perio- unwanted gingival embrasures causing plastic surgery, orthodontics, orthog- so-called “black triangles.” The soft tis- nathic surgery, systemic or local muscle sue healing process is erratic, at times SFMBYBOUT PSBDPNCJOBUJPOPGUIFTFEJT- with postsurgical recession or a coronal ciplines. rebound of the FGM. Furthermore, the If the diagnosis is limited to APE, there healing period is variable, from a few is only one option: periodontal plastic weeks to several years, depending on surgery for crown lengthening, either surgical protocols, as well as patient gingivectomy alone or gingivectomy with constitutional and systemic factors. osseous resection,depending on the For patients with high lip lines, minor relationship of the alveolar crest to the gingival zenith aberrations after healing CEJ, and the width of keratinized gingi- can be corrected with judicial incisions va. The outcomes of these procedures with scalpel blades or diode lasers. are predictable, with a high degree of Correcting asymmetrical gingival patient satisfaction. The significance margins for ASE is also accomplished of bone sounding is in determining with perioplastic surgery, or alternatively which crown-lengthening procedure is by orthodontic intrusion, usually in com- required. With Types 1A and 2A, and bination with restorative or prosthetic assuming adequate keratinized tissue, modalities for replacing the lost enam-

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el and dentin, depending on wheth- left central incisor, necessitating a full- er the etiology is TSL or unopposed coverage crown. The right central inci- BOUBHPOJTU T 8IJMFGPS"1& FYDFTTUJT- sor escaped major trauma but incurred sue removal establishes correct gingival minor incisal edge damage, which was [FOJUITBOEFYQPTFTUIFDMJOJDBMDSPXO repaired with a resin-based composite to its proper w/l ratio, a similar protocol restoration. Although unable to fully ar- GPS"4&SFTVMUTJOFMFDUJWFFYQPTVSFPG ticulate her esthetic anomalies, she was the tooth root surface, which may re- generally unhappy with the appearance quire desensitizing agents or restorative of her smile, and described her anterior coverage for protecting the vulnerable teeth as “short and fat.” Esthetic analys- FYQPTFEEFOUJO5IFTFDPOEPQUJPOGPS is revealed a lack of tooth display dur- correcting ASE is orthodontic intrusion JOHUIFIBCJUVBMMJQQPTJUJPO 'JH BSF- for reestablishing correct gingival zenith versed smile line during repose smiling heights, plus either resin-based compos- and laughter; a small median diastema; ite or porcelain restorations for replacing eschewed dental midline; and incisal TSL. Furthermore, the etiological causes plane canting to the left, an anomaly should be addressed, missing teeth re- generally regarded as one of the most placed, counseling given for mitigating displeasing features of a smile 'JH TSL, and nightguards provided to curb Further scrutiny established short clin- and minimize occlusal parafunctional ical crown lengths of the canines and activities. Finally, it is prudent to foresee central incisors, lack of dominance of UIFDPOTFRVFODFTPGFYUSBDUJPOTGPSQSF- the central incisors, and a defective venting ASE, and patient counseling is bulbous crown on the left central incisor essential to limit future unnecessary and causing bruising of the gingival margin. costly treatment. In addition, the left lateral incisor sagged The following two case studies il- coronal to the incisal plane, while the left lustrate the correction of APE and ASE canine displayed a distofacial rotation, using a combination of perioplastic both of which disrupted the pleasing surgery and restorative/prosthetic ap- distal incisal embrasure progression proaches for the restitution of pink and 'JH 5IFHJOHJWBM[FOJUITPGUIFNBY- white anterior esthetics. They highlight JMMBSZTFYUBOUXFSFFSSBUJD DBVTFECZUIF the similarities and differences in treat- short clinical crown lengths of the ca- ment modalities for short clinical crowns nines and central incisors. This resulted with different etiologies. JO FYDFTTJWF HJOHJWBM FYQPTVSF FTQF- cially on the left. In addition, a wide band of keratinized attached gingiva was evi- Case study 1: APE dent apical to the anterior teeth, and the canine gingival zeniths were coronal to "ZFBSPMEGFNBMFXBTSFGFSSFEUPUIF that of the central incisors, creating a dental hospital with a request for improv- gingival esthetic line (GAL) Class IV on ing her anterior dental esthetics. Coun- both sides. TFMJOHSFWFBMFEUIBUBOBDDJEFOUZFBST The provisional diagnosis was APE before had caused the fracture of her Type 1A on the central incisors and left

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Fig 5 Dentofacial preoperative view of the ha- Fig 6 Dentofacial preoperative view during smil- CJUVBMMJQQPTJUJPOTIPXJOHMBDLPGBOUFSJPSNBYJMMBSZ ing showing a reversed smile line, median diastema, tooth display. slanted dental midline, and incisal plane canting to the left.

Fig 7 Dental preoperative view showing lack of Fig 8 %JBHOPTUJD XBYVQ PG UIF DFOUSBM JODJTPST dominance of the central incisors, short clinical for increasing the length of the porcelain laminate crowns of the central incisors and canines, and dis- veneer (PLV) on tooth 11, and the all-ceramic crown ruptive distoincisal embrasure progression on the POUPPUI XJUIBDPSSFTQPOEJOHTJMJDPOFJOEFYGPS MFGUTJEFPGUIFNBYJMMBSZTFYUBOU an intraoral mock-up and temporization.

MBUFSBMJODJTPS BOE5ZQF#POUIFDB- NNNN JODSFBTJOH OJOFT#POFTPVOEJOHFTUBCMJTIFEUIBU UIFJS MFOHUI GSPN UP NN UP BM- surgical crown lengthening would be MPX HSFBUFS UPPUI FYQPTVSF EVSJOH UIF necessary, involving gingivectomy alone habitual lip position, which is regarded for teeth 11, 21, and 22, and gingivec- as a prerequisite for a youthful appear- tomy with osseous recession for teeth ance. BOEUPDSFBUFTQBDFGPSUIFCJP- 'PMMPXJOH QSPQIZMBYJT UIF PGGFOEJOH MPHJDXJEUI"EJBHOPTUJDXBYVQ 'JH crown on the left central incisor was re- was utilized for simulating the correct moved, revealing circumferential inﬂam- XM SBUJP PG UIF DFOUSBM JODJTPST UP NBUJPO PG UIF HJOHJWBM NBSHJOT 'JHT

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Fig 9 Facial view after removing the defective Fig 10 Occlusal view after removing the defec- horizontally overcontoured crown on the left central tive horizontally overcontoured crown on left central incisor, showing circumferential inﬂammation of the incisor, showing circumferential inﬂammation of the gingival margins. gingival margins.

Fig 11 Periodontal probe showing the proposed Fig 12 Periodontal probe showing the proposed GAL Class I on the right side. GAL Class I on the left side.

and 10). A chairside, correctly ﬁtting acrylic temporary restoration was fabri- cated for promoting gingival health. The subsequent stage was esthetic crown lengthening of the canines and left lateral incisor for creating a GAL Class I on both the right and left sides of UIFNBYJMMBSZTFYUBOU 'JHTBOE After bone sounding under local anes- thesia, bleeding points were placed for guiding the ensuing surgical proced- Fig 13 #MFFEJOHQPJOUUPHVJEFUIFHJOHJWFDUPNZ VSFT 'JH 5IF JOJUJBM TUFQ XBT DBS- incision. rying out a gingivectomy by incising

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Fig 14 (JOHJWFDUPNZPOUFFUIBOEQSJPSUP Fig 15 (JOHJWFDUPNZPOUPPUIUPJODSFBTFUIF EJTDBSEJOHUIFFYDFTTHJOHJWBMUJTTVF clinical crown length for establishing the correct w/l SBUJPPG

Fig 16 Papillae preservation incisions followed Fig 17 *OUFSSVQUFE TVUVSFT OPOSFTPSCBCMF CZnBQFMFWBUJPOUPFYQPTFPTTFPVTCPOFDSFTUBQ- securing the ﬂap around the left canine following QSPYJNBUJOHUIF$&+ DPOTJTUFOUXJUI"1&5ZQF# ostectomy and osteoplasty.

Fig 18 Ten-day healing prior to suture removal. Fig 19 Five-week healing showing establishment of GAL Class I on the right and left sides (compare with Fig 7).

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Fig 20 Facial view showing gingival health around Fig 21 Occlusal view showing gingival health MFGUDFOUSBMJODJTPSQSFQBSBUJPO DPNQBSFXJUI'JH around left central incisor preparation (compare with Fig 10).

Fig 22 Minimally invasive tooth preparation for Fig 23 Isolation with gingival retraction cord, a a PLV on the right central incisor, conﬁned to the wooden wedge, and polytetraﬂuoroethylene (PTFE) enamel layer to enhance adhesive bonding with a tape during the adhesive cementation protocol. resin-based cement.

FYDFTTUJTTVF UP UIF DPSSFDU HJOHJWBM sulcus from the gingivectomy margin to [FOJUIIFJHIUTVTJOHB/PDTDBMQFM the midfacial osseous crest. A similar blade, guided by the bleeding points procedure was performed on the right QMBDFECFGPSFIBOE 'JHTBOE " canine, but using a flapless approach. full-thickness mucoperiosteal flap was Since the left lateral incisor was an APE SBJTFEBSPVOEUIFMFGUDBOJOFUPFYQPTF Type 1A, surgery was limited to a gin- the osseous crest, which was adjacent givectomy without osseous contouring. to the CEJ, confirming the provisional The crown lengthening was completed EJBHOPTJTPG"1&5ZQF# 'JH "O by suturing the flap around the left ca- ostectomy and osteoplasty were per- OJOFXJUIOPOSFTPSCBCMFJOUFSSVQUFE formed around the left canine, creating sutures (Fig 17). Uneventful healing BNNTQBDFGPSUIFCJPMPHJDXJEUIBOE JT TIPXO JO 'JHVSFT BOE BGUFS

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EBZTBOE XFFLT SFTQFDUJWFMZ "U sive protocol. The teeth were isolated a later date, crown lengthening, limited with gingival retraction cord, a wood- to gingivectomy, was carried out for the en wedge, and polytetrafluoroethylene central incisors for establishing a more (PTFE) tape during the cementation pro- apical position of the gingival zeniths. DFEVSF 'JH "SFTJOCBTFEDFNFOU A further 2 months was allowed for (Variolink Veneer, Ivoclar Vivadent) with the tissues to mature and gingival ze- BEFOUJOCPOEJOHBHFOU 0QUJ#POE953 niths to stabilize before proceeding Kerr) adhered the ceramic restorations with tooth preparations for the central with a hermetic seal at the margins. Fi- incisors. During this healing phase, the nally, judicial esthetic contouring was patient bleached her teeth to improve carried out on the left lateral incisor and the shade prior to delivery of the de- canine to harmonize the distal incisal finitive restorations. The preparation for embrasure progression. The postopera- the full-coverage all-ceramic crown on tive results show integration of the indi- the left central incisor was refined, and rect ceramic restorations with the soft the acrylic temporary crown relined un- tissue, dominance of the central inci- til gingival health was evident (Figs 20 sors, increased crown lengths of the ca- and 21). On the right central incisor, the nines and central incisors with the cor- porcelain laminate veneer (PLV) prep- rect w/l ratios, elimination of the incisal aration was minimal, confined to the cant on the left, and GAL Class I on both enamel layer, and defining the cervical, TJEFT 'JHTø UPø 5IF EFOUPGBDJBM JOUFSQSPYJNBM BOE QBMBUBM mOJTI MJOFT WJFXTIPXTBDDFQUBCMFNBYJMMBSZHJOHJ- (Fig 22). Following the fabrication of WBMFYQPTVSFEVSJOHBSFMBYFETNJMF B the feldspathic PLV and all-ceramic IPS smile line coincident with the curvature FNBY *WPDMBS 7JWBEFOU DSPXO JO UIF PGUIFMPXFSMJQ BOEJODSFBTFEUPPUIFY- dental laboratory, the latter was bonded posure during the habitual lip position to the tooth substrate using an adhe- 'JHTøBOEø

Fig 24 Postoperative view in centric occlusion Fig 25 Postoperative anterior view showing GAL showing increased clinical crown lengths of the $MBTT*POUIFSJHIUBOEMFGUNBYJMMBSZTFYUBOU/PUJDF NBYJMMBSZDBOJOFTBOEDFOUSBMJODJTPST UPHFUIFSXJUI the esthetic contouring by enameloplasty on the left increased anterior overbite of the latter, and impec- lateral incisor and canine to establish correct distal cable gingival health (compare with Fig 7). progression of the incisal embrasures.

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Fig 26 Postoperative right lateral view showing Fig 27 Postoperative left lateral view showing GAL GAL Class I and correct w/l ratios of the right canine Class I and correct w/l ratios of the left canine and cen- and central incisor following esthetic crown length- tral incisor. Notice the esthetic contouring by enamelo- ening. plasty on the left lateral incisor and canine to establish correct distal progression of the incisal embrasures.

Fig 28 Dentofacial postoperative view during a Fig 29 Dentofacial postoperative view showing SFMBYFE TNJMF TIPXJOH DPJODJEFODF PG UIF JODJTBM NBYJMMBSZJODJTPSEJTQMBZEVSJOHUIFIBCJUVBMMJQQPT- plane with the curvature of the lower lip, acceptable JUJPO DPNQBSFXJUI'JH NBYJMMBSZ HJOHJWBM FYQPTVSF QFSQFOEJDVMBS EFOUBM midline, and elimination of the cant on the left (com- QBSFXJUI'JH

Case study 2: ASE line, lack of dominance of the central in- DJTPST BOE FYDFTTJWF HJOHJWBM EJTQMBZ "ZFBSPMEXPNBOBUUFOEFEUIFTQF- BQJDBMUPUIFDBOJOFT 'JH *OUSBPSBM cialty clinic of the dental hospital com- FYBNJOBUJPOmOEJOHTJODMVEFETIPSUDMJO- plaining of a “crooked smile” and gaps ical crown length of the canines, consid- between her teeth. The dentofacial com- erable TSL on the facial surfaces of the position revealed a substantial median NBYJMMBSZBOUFSJPSUFFUIEVFUPBCSBTJPO NBYJMMBSZEJBTUFNB 54- BSFWFSTFETNJMF and serrated incisal edges caused by

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attrition. In addition, cervical decay was evident on the right canine, as well as a defective composite veneer on the right MBUFSBMJODJTPS 'JH 5IFHJOHJWBM[F- niths of the canines on both sides were coronal to that of the central incisors, consistent with a GAL Class IV gingival TDBMMPQJOHPGUIFNBYJMMBSZTFYUBOU5IF occlusal view confirmed tooth wear with EFOUJOFYQPTVSF TDBMF BDDPSEJOHUP the Smith and Knight TWI classification 'JH 0UIFSEFOUBMJTTVFTTVDIBTBO Fig 30 Dentofacial preoperative view during a - anterior mandibular diastema, defective SFMBYFETNJMFTIPXJOHBSFWFSTFETNJMFMJOF NBYJM lary median diastema, TSL, serrated and abraded mYFEQBSUJBMEFOUVSFT BOENJTTJOHNBO- JODJTBMFEHFT BOEFYDFTTJWFHJOHJWBMEJTQMBZBQJDBM dibular teeth also required addressing to the canines. at a later date. The diagnosis for the short clinical crowns of the canines was ASE Type I, caused by attrition and subsequent dentoalveolar compensation moving the gingival zeniths (and dentogingival DPNQMFY DMPTFSUPUIFPDDMVTBMQMBOF 5IFUSFBUNFOUQMBOGPSUIFNBYJMMBSZTFY- tant was, firstly, esthetic crown lengthening to increase the clinical crown lengths of the canines and thereby reduce gin- HJWBMFYQPTVSFEVSJOHTNJMJOH4FDPOEMZ prepless direct composite restorations Fig 31 Frontal preoperative view showing cervical decay on the right canine, defective composite to establish correct w/l ratios of the cen- veneer on the right lateral incisor, and TSL caused tral incisors, eliminate the median dias- by abrasion and attrition. tema, replace the defective filling on the right lateral incisor, remove the cervical decay on the right canine, and replace the facial surface enamel loss caused by abrasion. "GUFS QSPQIZMBYJT B EJBHOPTUJD XBY VQXJUIBTJMJDPOFJOEFYXBTGBCSJDBUFE and used as a framework for guiding the esthetic crown lengthening and resin- CBTFEDPNQPTJUFSFTUPSBUJPOT 'JH To achieve correct proportion for the left

DBOJOF UIFFYJTUJOHDMJOJDBMDSPXOMFOHUI Fig 32 Occlusal preoperative view showing tooth PGNN 'JH SFRVJSFEJODSFBTJOHUP XFBSXJUIEFOUJOFYQPTVSF 4NJUIBOE,OJHIU58*

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Fig 33 %JBHOPTUJDXBYVQBOETJMJDPOFJOEFYGPS Fig 34 &YJTUJOHDMJOJDBMDSPXOMFOHUIPGMFGUDBOJOF guiding crown lengthening and composite ﬁllings. PGNN

Fig 35 Proposed clinical crown length of left ca- Fig 36 #POFTPVOEJOHPGNNGSPNUIF'(.UP OJOFPGNN the midfacial osseous crest.

Fig 37 (JOHJWFDUPNZ VTJOH B /PD TDBMQFM Fig 38 5IFNNPGJODJTFEHJOHJWBJTSFNPWFE blade. with a periodontal curette.

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Fig 39 Periodontal probe showing coincidence Fig 40 Creating a new biologic crown length of of the central incisor and canine gingival zeniths, NNPOUIFMFGUDBOJOF with a 1-mm coronal lateral incisor gingival zenith, which is consistent with a GAL Class I.

NN 'JH 5IFCPOFTPVOEJOHPG for stabilization of the gingival zeniths; in NN 'JH NFBOUUIBUUPMFOHUIFO the interim period, the patient opted for UIF DMJOJDBM DSPXO MFOHUI UP NN home bleaching prior to the restorative would require ostectomy for creating a QIBTF 'JH CJPMPHJDBMDSPXOMFOHUIPGBQQSPYJNBUF- The restorative stage commenced by MZ ø UP NN XJUI B UP NN using a transparent composite shade space for the new biologic width. The in- (Empress Direct, Ivoclar Vivadent) for itial step was a gingivectomy to remove building up the incisal edges of the cen- NNPGHJOHJWBUPDSFBUFB("-$MBTT tral incisors, aided by the previously * 'JHTø UPø 4VCTFRVFOUMZ B GVMM GBCSJDBUFETJMJDPOFJOEFYGSPNUIFEJBH- thickness ﬂap was elevated following OPTUJD XBYVQ 'JH "MM DPNQPTJUF JOUFSQSPYJNBMBOETVMDVMBSJODJTJPOT BOE restorations were performed according vertical and horizontal ostectomy and osteoplasty were carried out using end- cutting and cylindrical burs, respective- ly, under copious irrigation with sterile TBMJOF'JHVSFTIPXTUIFOFXCJPMPHJD DSPXOMFOHUIPGUIFDBOJOFPGBQQSPYJ- NBUFMZ NN " TJNJMBS QSPDFEVSF was performed on the right canine, and the ﬂaps were sutured. Uneventful healing after 10 days shows a more cervical location of the gingival zeniths around CPUIDBOJOFT 'JH /PUFIPXUIFJO- creased clinical crown lengths of the ca-

OJOFTBSFBUUIFFYQFOTFPGSPPUFYQP- Fig 41 Ten-day healing showing longer clinical TVSF"GVSUIFSNPOUITXBTBMMPXFE DSPXOTPGCPUINBYJMMBSZDBOJOFT

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Fig 42 "GUFS NPOUIT PG IFBMJOH BOE QPTU Fig 43 Incisal edge build-up of the central inci- CMFBDIJOH DPNQBSFXJUI'JH sors with a transparent shade resin-based compos- JUFVTJOHUIFTJMJDPOFJOEFYPGUIFEJBHOPTUJDXBYVQ TIPXOJO'JHVSF

Fig 44 Postoperative result showing the restitu- Fig 45 Postoperative result showing GAL Class tion of pink and white anterior dental esthetics by *POUIFSJHIUBOEMFGUTJEFTPGUIFNBYJMMBSZTFYUBOU esthetic crown lengthening and prepless composite DPNQBSFXJUI'JH SFTUPSBUJPOT SFTQFDUJWFMZ DPNQBSFXJUI'JH

Fig 46 Postoperative dentofacial view showing BDDFQUBCMFNBYJMMBSZHJOHJWBMFYQPTVSFBOEBTNJMF line coincident with curvature of the lower lip (com- QBSFXJUI'JH

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Differential diagnoses of short clinical crown length – location of the CEJ to FGM

Fig 47 Differential diagnosis of APE and ASE by location of the CEJ relative to the FGM. In APE, the CEJ is located apical to the FGM, ASE Type 1 APE Type 1A & 1B while in ASE, the CEJ (active secondary eruption) (altered passive eruption) BQQSPYJNBUFTUIF'(.

to strict prepless and adhesive proto- crowns with compromised pink esthet- cols, relying on micromechanical and ics, and while the treatments in both cas- chemical adhesion of a dentin bonding es were similar and involved perioplastic BHFOU 0QUJ#POE953 5IFQPTUPQFSB- surgery, the etiology – and hence future tive result shows the correct w/l ratio of management – was different. In the first the central incisors, median diastema case (APE), the crown lengthening itself closure, and replacement of the lost was a fait accompli, while in the second enamel and dentin due to the previously case (ASE), the patient required dietary NFOUJPOFE 54- 'JHT BOE 5IF advice, nightguards, and future period- dentofacial view during repose smil- ic reviews for monitoring parafunctional JOH TIPXT SFEVDFE HJOHJWBM FYQPTVSF activity for the cessation and mitigation BSPVOEUIFNBYJMMBSZDBOJOFT ("-$MBTT of TSL. *POUIFSJHIUBOEMFGUTJEFTPGUIFNBYJM- One of the defining features for the MBSZTFYUBOU 'JH EPNJOBODFPGUIF differential diagnosis of both APE and central incisors, and a smile line parallel ASE is the location of the CEJ. In the UPUIFDVSWBUVSFPGUIFMPXFSMJQ 'JH first case (APE), the location of the CEJ Finally, the patient was counseled about was apical to the FGM, while in the sec- diet and oral hygiene procedures, and POEDBTF "4& UIF$&+BQQSPYJNBUFE provided with nightguards to mitigate UIF $&+ 'JH 5IFSFGPSF BDIJFWJOH tooth wear and protect the composite the correct clinical crown lengths for the restorations. "4&QBUJFOUOFDFTTJUBUFEFYQPTJOHUIF root surface, which in itself could cause future problems that would require de- Discussion sensitizing agents and/or protecting the FYQPTFE EFOUJO XJUI SFTUPSBUJWF NBUFS- In the two case studies discussed here, ials. In addition, the ASE case showed the esthetic anomaly was short clinical TSL at the incisal edges of the canine,

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while in the APE case, the canines were tions, the dental and gingival causes of pristine and unworn. Furthermore, the short clinical crowns are APE or ASE, keratinized band of tissue in the APE and differential diagnosis of the two is patient was wide, which is consistent essential for arriving at correct man- with APE Type 1, while in the ASE case agement strategies of these conditions, study, this width was within the norm due which compromise anterior dental es- to dentoalveolar compensation. Finally, thetics. The two case studies presented since soft tissue healing is erratic, pe- in this article show striking clinical simi- riodic monitoring is essential for both larities, but with different etiologies and cases to ensure long-term periodontal diagnoses. Although the initial treatment health and the maintenance of both pink may be similar, the long-term manage- and white esthetics. ment differs, and careful counseling and monitoring is essential for ongoing oral health, function, and esthetics. Conclusion

This discussion has focused on short Acknowledgment DMJOJDBM DSPXOT DPODVSSFOU XJUI FYDFT- TJWF NBYJMMBSZ HJOHJWBM EJTQMBZ EVF UP The author would like to thank Professor various soft and hard tissue anomalies. Khalid Almas for his participation in the Apart from numerous mirroring condi- APE clinical case study.

References

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