Esthetic Crown Lengthening in the Treatment of Gummy Smile

CASE REPORT

Esthetic crown lengthening in the treatment of gummy smile

Mauricio Andrés Tinajero Aroni, MSc Diagnosis and Surgery, UNESP, São Paulo State University, Brazil

Suzane Cristina Pigossi, PhD Clinics and Surgery, Federal University of Alfenas, Brazil

Elton Carlos Pichotano, PhD Diagnosis and Surgery, UNESP, São Paulo State University, Brazil

Guilherme José Pimentel Lopes de Oliveira, PhD Periodontia e Implantodontia, Universidade Federal de Uberlândia, Brazil

Rosemary Adriana Chierici Marcantonio, PhD Diagnosis and Surgery, UNESP, São Paulo State University, Brazil

Correspondence to: Prof Suzane Pigossi Clinics and Surgery, Federal University of Alfenas, Gabriel Monteiro da Silva St, 700 Alfenas Minas Gerais 37130-001, Brazil; Tel: +55 35 3701-9000; Email: [email protected]

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Abstract gery. Moreover, a lip repositioning procedure was also performed in one case to complement the periodon- The aim of this article was to evaluate 1 year after sur- tal therapy. Compared with baseline, an increase of gery a surgical protocol that included gingivectomy 1.6 mm in the mean tooth crown height was ob- and an apically positioned ﬂap plus osseous resective served in the photographic analysis at 12 months. A surgery to correct excessive gingival display (EGD) in minimal difference was observed between the mean patients with altered passive eruption (APE) of the tooth crown height immediate postoperative and at maxillary anterior teeth. Six female patients aged 18 to 12 months, which indicates stability of the gingival 22 years were diagnosed with APE type 1B. Surgical margin. In conclusion, the surgical protocol outlined crown lengthening with ﬂap surgery and bone recon- in this article describing esthetic crown lengthening touring was performed to achieve the biologic width. for the treatment of APE/gummy smile resulted in pre- Photographic images were analyzed to evaluate the dictable outcomes and stability of the gingival margin stable improvement of crown length before the pro- 1 year after surgery. cedure (baseline), immediately after surgery (immediate postoperative), and at 3 and 12 months postsur- (Int J Esthet Dent 2019;14:370–382)

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Case 1 Case 2 Case 3

a a a

b b b

c c c

d d d

Fig 1 Changes in tooth dimensions and gingival display of cases 1 to 6 from baseline (a), immediate postoperative (b), 3 months (c), and 12 months (d) after the crown lengthening surgery.

Introduction tion,4 affecting people (predominantly females) of 20 to 30 years of age.5 A harmonious smile is considered a symbol Possible etiologic factors for EGD in- of beauty in modern society.1 A multifacet- clude plaque or drug-induced gingival en- ed scenario, including tooth form and posi- largement or overgrowth, altered passive tion, gingival tissue levels, and lip position eruption (APE), short clinical crowns, verti- determine smile esthetics, which has been a cal maxillary excess, hyperactive or short focus of dental treatment.1,2 There has been upper lip presence or a combination of particular interest in the treatment of exces- these clinical conditions.6,7 From the clinical sive gingival display (EGD), commonly perspective, APE is associated with in- termed gummy smile, and periodontal plas- creased gingival band width and gingival ex- tic surgery techniques have been used to posure during smiling.8 In a normal eruption improve smile esthetics.1 EGD is character- phase, the gum tissue migrates apically, ized by an overexposure of the maxillary with gradual exposure of the tooth crown gingiva during smiling or speaking.3 This stabilizing at the cervical level.9 Thus, mostly condition occurs in 10.57% of the popula- due to developmental or genetic factors,

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Case 4 Case 5 Case 6

a a a

b b b

c c c

d d d

the alteration in APE may lead to the per- quate space for the insertion of a connec- sistence of an excessive amount of soft tis- tive tissue attachment to the root surface. In sue over the enamel surface, resulting in an subcategory B, this space is minimal and excessive quantity of gingival tissue at the does not allow for a correct biologic maxillary anterior teeth during smiling.1 width.1,11 Depending on the classification, In addition, APE has been subclassified different possible treatments are indicated. into two types:10 type 1 is characterized by The treatment plan for APE type 1B should an excessive amount of attached gingiva include the management of the periodontal with shorter crowns, while type 2 is a gum- tissue and incorporate gingivectomy and my smile associated with a normal gingival apically positioned flap plus osseous resec- dimension. In addition, two possible sub- tive surgery (esthetic crown lengthening classes (A and B) have been suggested, de- surgery).12 However, APE type 2 showing ex- pending on the relationship of the bone cessive growth of the maxillary process crest (BC) to the cementoenamel junction generally requires a multidisciplinary treat- (CEJ) of the tooth (BC–CEJ). In subcategory ment plan, including orthognathic surgery A, the BC–CEJ is > 1.5 mm, allowing ade- and orthodontic treatment.13 It is empha-

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sized that APE type 1 treatment is a chal- the clinical intraoral examinations, the pa- lenge and is risky because excessive bone tients’ oral cavities were examined under resection on the maxillary anterior teeth natural light using sterile instruments to re- may lead to residual gingival recession.1,12 cord the plaque index (PI) and the gingival On the other hand, a limited resection may index (GI) using the criteria proposed by Sil- result in coronal regrowth of the gingival ness and Loe.17 Only patients with a PI and margin, reducing the length of the postsur- GI of < 20% were included in the study.1 gical clinical crowns.1 Therefore, an ade- Moreover, all patients presented inadequate quately planned surgical procedure its es- tooth width and height proportions in the sential to guarantee proper treatment of superior anterior maxilla. These parameters APE and satisfy patients’ expectations. were detected using a specific probe (Chu’s In some cases, where the EGD is caused Aesthetic Gauges; Hu-Friedy). Transgingival by the combined etiology of a hyperactive probing (TP) using a conventional periodon- upper lip and APE, other techniques are as- tal probe (Hu-Friedy) detected a BC–CEJ sociated with crown lengthening surgery to distance of < 1.5 mm in the superior anter- resolve the EGD. In these cases, procedures ior teeth. Based on this, the patients were such as botulinum toxin injection14 or lip re- diagnosed with APE type 1B, and surgical positioning15 have been proposed. The lip crown lengthening with flap surgery and repositioning technique is accomplished by bone recontouring was the indicated treat- a single partial-thickness elliptical incision in ment (Figs 1a and 2a). the depth of the anterior maxillary vestibule. Then, the lip mucosa is sutured to the mu- Esthetic crown lengthening and cogingival line.15 This technique was de- frenectomy surgery signed to be shorter in duration and less ag- gressive than orthognathic surgery, and also Local anesthesia was induced using a 4% ar- causes fewer postoperative complications.16 ticaine solution with epinephrine 1:100,000 The aim of this case series was to evalu- (Nova DFL). The surgical procedure was ini- ate the efficiency of a surgical protocol con- tiated with gingival demarcation on the mid- sisting of gingivectomy and an apically re- buccal aspect of the teeth using a specific positioned flap combined with osseous probe (Chu’s Aesthetic Gauges) (Fig 2b and c). resective surgery to correct EGD in patients After the gingival demarcation, the CEJ pos- with APE at the maxillary anterior teeth. The itions were checked with a conventional gingival margin stability obtained with the periodontal probe (Hu-Friedy). An internal crown lengthening procedure was evaluat- bevel incision was made following the CEJ ed at 3- and 12-months postsurgery. anatomy using a No. 15 C blade at each tooth (teeth 13 to 23), preserving the inter- Case description dental papillae (Fig 2d). The removal of the marginal gingival strip was made with a Inclusion criteria perio dontal curette (Hu-Friedy) (Fig 2e). The gingival contour was delineated using a Six periodontally and systemically healthy Goldman Fox microscale (Quinelato) to- female patients aged 18 to 22 years who gether with delicate Goldman Fox pliers to were non-smokers sought treatment. They reduce the gingival volume (Fig 2f). were dissatisfied with their smile esthetics An intrasulcular incision was made, and a due to the overexposure of the maxillary conservative full-thickness flap to the level gingiva during smiling or speaking. During of the mucogingival junction (MGJ) was

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ab c

de f

gh i

jk l

Fig 2 Representative case illustrating the esthetic crown lengthening surgical procedure (case 6). (a) Pretreatment view of the maxillary anterior teeth. (b) Gingival margin measurement using a specific tip. (c) Gingival demarcation on midbuccal aspect. (d) External bevel incision following the CEJ anatomy. (e) Gingival margin removal with a periodontal curette. (f) Gingival contour finalization using a Goldman Fox microscale and pliers. (g) Full-thickness flap elevation. (h) Ostectomy and osteoplasty using carbide steel burs. (i) Ostectomy and osteoplasty, final aspect. (j) Single interrupted sutures. (k) Labial frenectomy. (l) Immediate postoperative, final aspect. raised on the buccal aspect, including teeth incisions were placed on the upper and un- 13 to 23 (Fig 2g). Teeth 14 and 24 were also derneath surfaces of the tweezer using a affected by the APE and included in the flap. No. 15 C blade. The triangular resected por- The BC–CEJ distance was measured on the tion of the frenum was removed, and a blunt midbuccal aspect, then carbide steel burs dissection was performed on the bone to and hand chisels were used for ostectomy relieve the frenum attachment. The edges of and osteoplasty, aiming to attain a 2-mm the wound were sutured with single inter- BC–CEJ distance (Fig 2h and i). No interrupted sutures (Cytoplast PTFE sutures, proximal crestal bone was removed. PERIO USP, 4/0) (Fig 2l). The flap was repositioned, and single in- The patients were prescribed 0.12% terrupted sutures (Cytoplast PTFE sutures, chlorhexidine gluconate (Periogard; Col- PERIO USP, 4/0) were used to stabilize the gate) and instructed to rinse gently twice flap (Fig 2j). In all cases, the labial frenum was daily for 15 days. Tooth brushing was to be closely attached to the gingival margin in the discontinued in the surgical area during this superior incisive region. Then, a frenectomy time. An antibiotic (Azithromycin, 500 mg, was made (Fig 2k) to complete the removal once daily) was prescribed for 3 days to pre- of the frenum using the conventional tech- vent possible postoperative infection. A nique described by Devishree et al.18 The fre- nonsteroidal anti-inflammatory (Nimesulide, num was engaged with a hemostat tweezer 100 mg, 12/12 h) and an analgesic (Dipy- inserted into the depth of the vestibule, and rone, 500 mg, 6/6 h) were also prescribed.

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abc

Fig 3 Scheme of image measurement standardization. (a) Digital ruler calibration using an initial photograph of the teeth with a millimeter probe. (b) Dental crown width measurement in the initial photograph (baseline to preoperative) using a digital ruler. (c) Dental crown height measurement in the initial photograph (baseline to preoperative) using a digital ruler.

Table 1 Dental crown height mean length (millimeters) obtained in each case at Postsurgical follow-up baseline, immediate postoperative, 3 months, and 12 months The 7-day postoperative healing was un- Immediate Baseline 3 months 12 months postoperative eventful and the sutures were removed. For Case 1 8.6 10.1 9.6 9.6 case 1, a restorative phase was carried out 3 months after the surgical crown length- Case 2 5.8 7.0 6.9 8.2 ening procedure to close the diastema be- Case 3 7.0 7.0 7.1 7.1 tween teeth 11 and 21 using composite res- Case 4 7.3 9.2 9.3 8.9 in (Fig 1d). Patient photographs were taken Case 5 6.0 6.8 6.3 6.2 before the surgery (baseline), immediately Case 6 6.5 9.0 8.2 8.6 after the surgery (immediate postoperative), after 3 months, and after 12 months (Fig 1a Final 6.8 8.0 7.7 8.4 mean to d). The photographs were analyzed to evaluate the stability of the results of the The distortion ratio was calculated by dividing the average width obtained in the ﬁnal photograph (immediately postoperative, 3 months or 12 months) by the width obtained in crown lengthening procedure. Distortions the initial photograph (baseline). between the photographs were adjusted using mathematic calculations following the modiﬁed sequence proposed by Teren- Table 2 Dental crown height mean length (millimeters) obtained in each case at zi et al19. The reference structures (dental immediate postoperative and 12 months crown width) were measured with the digital ruler of the digital smile design (DSD) Immediate postoperative 12 months program, using millimeters as the unit of Case 1 9.3 8.7 measurement (Fig 3). First, the digital ruler Case 2 9.0 9.2 was cali brated to a real measurement using an initial photograph of the teeth with a Case 3 7.2 7.2 millimeter probe in each case. The dental Case 4 9.3 8.9 crown width of two teeth (superior central Case 5 6.3 5.7 incisors) in the initial photograph (baseline Case 6 10.0 9.6 – preoperative) was obtained. In the same way, the widths of the same teeth were Final 9.1 8.8 mean measured in the immediate postoperative and 3- and 12-month follow-up photo- The distortion ratio was calculated by dividing the average width obtained in the photograph at 12 months by the width obtained in the photograph at 3 months. graphs. An average of the two measure-

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Case 1 Case 2 Case 3

a a a

b b b

Case 4 Case 5 Case 6

a a a

b b b

Fig 4 Changes in smile appearance in cases 1 to 6 from baseline (a) to 12 months (b) after the crown lengthening procedure. ments was obtained for each photograph. ate postoperative photograph. This distor- A distortion ratio was calculated by dividing tion ratio was used to compare the crown the mean width obtained in the ﬁnal pho- length obtained in the immediate postoper- tograph (immediate postoperative, 3 or ative photograph with that obtained in the 12 months) by the width obtained in the ini- 12-month one (Table 2). tial photograph (baseline). This distortion The smile photographs 1 year after the ratio was used to normalize the measure- crown lengthening procedure (Fig 4) show ments of crown length utilized to compare a reduction in the gingival smile and a cor- the crown length after immediate postop- rection of the gingival zenith. Table 1 shows erative, 3 and 12 months, with the crown a 1.2 mm increase in the average crown length obtained from the baseline photo- length after the surgical procedure (differ- graph ( Table 1). Moreover, a distortion ratio ence between immediate postoperative was also calculated by dividing the mean and baseline). After 12 months, the average width obtained in the 12-month photo- crown length remained 1.6 mm higher than graph by the width obtained in the immedi- at baseline (difference between 12 months

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Fig 5 Lip repositioning procedure (case 6). (a to c) Measurement of keratinized gingiva. (d and e) Elliptical incision demarcation using a marking pencil. (f to i) Single a bc partial-thickness elliptical incision. (j) Simple interrupted suture in the medium, canine, and molar regions. (k) Immediate postoperative, ﬁnal aspect.

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abc

Fig 6 Changes in smile appearance in case 6 from baseline (a), to 12 months after the crown lengthening surgery (b), and 3 months after the lip repositioning surgery (c). postoperative and baseline). Moreover, A single partial-thickness elliptical incision Table 2 shows a minimal difference (0.3 mm) was created with a No. 15 C blade, removing between the average crown length in the the epithelium but keeping the underlying immediate postoperative measurement and connective tissue intact (Fig 5f and i). Care 12 months after the procedure; in other was taken to avoid damage to the minor sal- words, the gingiva rebound 12 months after ivary glands in the submucosa. The area of the surgical procedure was only 0.3 mm, frenectomy was approximated with a simple indicating gingival margin stability after interrupted suture (polyglycolic resorbable 12 months of follow-up. 5/0 suture, Vicryl; Ethicon/Johnson & John- son) to ensure symmetry and proper midline Lip repositioning technique placement. Other key sutures were made bilaterally in the canine and molar regions One patient (case 6) was dissatisfied with the (Fig 5j). Then, multiple interrupted sutures degree of gingival exposure during smile were made between the initial key suture even after the crown lengthening proce- placement areas to complete the wound dure. In this case, the EGD occurred due to closure (Fig 5k). The same postoperative the combination of APE with a hyperactive protocol described above was followed, upper lip. Therefore, lip repositioning was and the patient was instructed to minimize performed according to the technique pro- lip movements when smiling or talking for posed by Rosenblatt and Simon20 to com- 2 weeks after the surgery. The sutures were plement the gummy smile treatment. The removed at the 2-week follow-up appoint- preoperative protocol described above was ment. Postoperative healing was uneventful. followed. The location of the mucogingival A minor scar formed on the suture lines but junction and the keratinized gingiva size remained invisible during smiling. The were determined using a periodontal probe 3-month follow-up showed a reduction of (Fig 5a to c). A marking pencil was used to gingival display, and the patient was satisfied outline the borders of the elliptical incision with the final treatment result (Fig 6). (Fig 5d and e). The lower incision coincided with the mucogingival line in order to avoid Discussion any loss of attached gingiva, and was ex- tended from the mesial aspect of the first A careful diagnosis and treatment plan are premolars bilaterally. The distance between essential to indicate the most predictable the superior and inferior borders was APE treatment protocol.15 The most com- 1.5 mm, which was the length of the repos- mon diagnostic method is TP, which is used itioning desired in the patient’s smile as de- to detect the CEJ subgingivally and to cal- termined by the preoperative measurement. culate the real clinical crown dimension.21

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The soft tissue height is measured with a Clinical studies evaluating the esthetic periodontal probe down to the BC, and this crown lengthening procedure have shown dimension can also be used to guide the that less soft tissue rebound occurs when amount of osseous resection to be ful- the postoperative gingival margin is posi- filled.22 Studies comparing TP with direct tioned 3 mm coronal to the surgically re- bone-level measurements immediately af- duced BC, compared with flaps reposi- ter flap reflection suggest that TP is an accu- tioned at or below it.6,18 In these case reports, rate method of determining BC levels.23,24 the BC was placed 2 mm apical to the CEJ, However, although transgingival bone prob- and the flap 1 mm coronally, to allow for a ing measurements seem to be very close to proper biologic width and to ensure the sta- the histometric bone level,25 the use of cone bility of crown height gained over time. In beam computed tomography (CBCT) has these case reports, a clinically insignificant also been proposed, which allows for the gingival rebound of 0.01 mm was observed three-dimensional (3D) visualization of the between 3 and 12 months. On the other alveolar bone/soft tissue as well as accurate hand, according to a review by Marzadori et and precise measurements.26 A retrospec- al,30 a buccal ostectomy should be per- tive study by Batista et al27 showed that formed after choosing the guiding tooth, CBCT enabled a precise diagnostic of the following the esthetic proportion para- reduced distance between the CEJ and the meters. Thus, for these authors, the bone BC as well as the precise determination of reduction could be considered complete the anatomical crown length, a key refer- when the flap was precisely adapted over ence for APE surgical treatment.27 However, the underlying bone.30 The tissue biotype TP alone was used to diagnose and select might also significantly influence the gingi- all APE type 1B cases treated in this case se- val tissue rebound, as previous studies have ries due to the unavailability of the patients shown that the mean tissue regrowth in pa- to undergo CBCT scanning during the sur- tients with a thick biotype was significantly gical planning period. greater than those with a thin one.31,32 There- In this case series, Chu’s Aesthetic Gaug- fore, the identification of tissue biotype is es were successfully used to guide the ex- necessary before crown lengthening sur- cess gingival tissue removal and correct the gery, since the presence of a thick biotype tooth size proportion. These measurement will require greater bone reduction to avoid tips include Chu’s Proportion Gauge, which tissue rebound.31 represents an objective mathematic ap- The photographic analysis performed in praisal of tooth size ranges.28 Additionally, a the present case series suggests that the full-thickness flap was performed to access crown lengthening procedure described in the BC and restore the biologic width, as- this article was successful in increasing the suring the stability of the long-term clinical clinical crown length and maintaining it for results. Ribeiro et al29 suggested another 12 months (average crown length 1.6 mm method to treat APE, ie, a minimally invasive higher than at baseline). The average crown flapless esthetic crown lengthening proced- length values observed in these case reports ure using micro chisels, via incision without was 6.8 mm (baseline), 8.0 mm (immediate flap elevation. However, in their randomized postoperative), 7.7 mm (3-month follow-up), controlled trial, the esthetic crown length- and 8.4 mm (12-month follow-up) (Table 1). ening, with or without flap elevation, Using the same surgical protocol, Silva et showed similar and stable clinical results for al33 observed values of 8.5 mm (baseline), up to 12 months. 10.3 mm (immediate postoperative) and

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9.9 mm (6-month follow-up). Cairo et al1 cases of several vertical maxillary excesses, also observed average crown length values where an interdisciplinary approach is re- of 8.5 mm (baseline), 10.2 mm (immediate commended.36 postoperative), and 10.1 mm (6-month fol- In a modified lip repositioning technique, low-up). Moreover, certain clinical studies the maxillary labial frenulum is maintained, have shown some gingival rebound ranging and two mucosal strips (one at each side of from 0.1 to 0.2 mm over the time period.1,29 the frenulum) are removed.16 In this modifi- However, in these case reports, a clinically cation, the frenulum helps to maintain the insignificant gingival rebound of 0.3 mm position of the labial midline and prevents was observed between the immediate post- changes in lip symmetry. However, the fren- operative measurement and the one taken ulum maintenance can limit the correction at 12 months (Table 2). of the EGD in the region of the maxillary The case 6 patient was dissatisfied with central incisors during lip repositioning.15 A the degree of gingival exposure during smile recent clinical study showed that the modi- even after the crown lengthening proce- fied lip repositioning technique shows less dure. In this case, the EGD occurred due to relapse after surgery as well as excellent the combination of the APE with a hyperac- cosmesis. Moreover, compared with the tive upper lip. The less-invasive options for conventional technique, it shows greater hyperactive upper lip treatment are botuli- sustainability after 6 months.37 In case 6 in num toxin injection14 or lip repositioning.16 the present case series, the frenulum was Injecting overactive muscles with measured removed during the crown lengthening quantities of botulinum toxin results in a re- procedure due to its insertion near to the duction of muscle activity, a relaxing of the gingival margin. For this reason, in this case lip muscles, and a decrease of the upward the conventional lip repositioning technique pull on the lip.34,35 Although the botulinum was utilized. toxin injection is the least-invasive treat- The methodological limitations of the ment, the results are temporary and only present case series include a relatively low last for a period of 3 to 6 months before number of participants and the absence of slowly fading.35 Due to this, lip repositioning any clinical analysis of the periodontal was successfully indicated for the hyperac- parameters to confirm the photographic tive upper lip treatment in this case. A recent analysis described in this article. Therefore, systematic review published by Tawfik et al35 additional controlled clinical studies are showed that lip repositioning successfully necessary to evaluate the long-term out- reduced the EGD by 3.4 mm. Faus-Matoses comes of the procedure here described et al15 showed in three case reports that lip with a larger sample size. repositioning can produce stable results In conclusion, the surgical protocol in- 1 year after the procedure. Thus, lip repos- cluding gingivectomy and apically posi- itioning is indicated for patients with minor tioned flap plus osseous resective surgery discrepancies as well as for those who de- could be considered a predictable protocol sire a treatment that is less invasive than or- for the reduction of EGD associated with thognathic surgery but which has a more APE. immediate (and long-term) result compared with orthodontics or botulinum toxin injec- Disclaimer tion treatment.35 However, this technique is contraindicated in the presence of a mini- The authors declare that there are no con- mal zone of attached gingiva as well as in flicts of interest.

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References

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382 | The International Journal of Esthetic Dentistry | Volume 14 | Number 4 | Winter 2019