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] 370 | The International Journal of Esthetic Dentistry | Volume 14 | Number 4 | Winter 2019 ARONI ET AL 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 (immedi- ate postoperative), and at 3 and 12 months postsur- (Int J Esthet Dent 2019;14:370–382) The International Journal of Esthetic Dentistry | Volume 14 | Number 4 | Winter 2019 | 371 CASE REPORT 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, 372 | The International Journal of Esthetic Dentistry | Volume 14 | Number 4 | Winter 2019 ARONI ET AL 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- The International Journal of Esthetic Dentistry | Volume 14 | Number 4 | Winter 2019 | 373 CASE REPORT 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 374 | The International Journal of Esthetic Dentistry | Volume 14 | Number 4 | Winter 2019 ARONI ET AL 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).