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

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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 %FQBSUNFOUPG4VCTUJUVUJWF%FOUBM4DJFODFT $PMMFHFPG%FOUJTUSZ 6OJWFSTJUZPG%BNNBN 10#PY %BNNBN ,JOHEPNPG4BVEJ"SBCJB5FM&NBJMJBINBECET!BPMDPN JBINBE!VPEFEVTB 352 THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY 70-6.&t/6.#&3tAUTUMN 2017 AHMAD 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) 353 THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY 70-6.&t/6.#&3tAUTUMN 2017 CLINICAL RESEARCH 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 354 THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY 70-6.&t/6.#&3tAUTUMN 2017 AHMAD 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 fol- lowing 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: 355 THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY 70-6.&t/6.#&3tAUTUMN 2017 CLINICAL RESEARCH 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 epithe- lium 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 356 THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY 70-6.&t/6.#&3tAUTUMN 2017 AHMAD 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
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