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Key points
Suggests ways to expedite healing. Suggests ways to improve patient comfort. Suggests a minimal intervention perio-restorative
approach for improving anterior dental aesthetics.
The rehabilitation of anterior dental aesthetics involves a multitude of disciplines, each with its own methodologies for
achieving a predefined goal. The literature is awash with different techniques for a given predicament, based on both
scientific credence, as well as empirical clinical judgements. An example is crown lengthening for correcting uneven gingival
zeniths, increasing clinical crown lengths, and therefore, reducing the amount of maxillary gingival display that detracts from
pleasing pink aesthetics. Many procedures have been advocated for rectifying gingival anomalies depending on prevailing
clinical scenarios and aetiology. This paper presents a minimally invasive technique for crown lengthening for short clinical
crowns concurrent with excessive maxillary gingival display, which is expedient, maintaining the inter-proximal papilla,
mitigating morbidity, reducing post-operative inflammation, and increasing patient comfort. In addition, with a similar ethos,
a minimally invasive tooth preparation approach is presented for achieving optimal white aesthetics.
Introduction greater intervention later for correcting altered passive eruption (APE),5 or a combi-
unwanted eventualities. nation of these causes. The most frequently
In an era of medical and dental minimal An excessive amount of maxillary gingival encountered dentogingival phenomenon
intervention protocols, the professions are display, concomitant with short clinical manifests as an excessive amount of gingiva
perpetually seeking modalities that reduce crowns, is generally regarded as unpleasing covering the clinical crown of the tooth,
trauma, morbidity, accelerate healing and during smiling, having a negative personal resulting in pronounced gingival display. The
reduce clinical treatment time with predict- and social impact.1,2 However, relatively simple most common aetiology is altered passive
able and long-lasting results. This tendency is periodontal crown lengthening surgery, with eruption (APE), a failure of the passive stage
prevalent across all dental disciplines, where or without a restorative adjunct, can yield of tooth eruption, leaving the gingival margin
patient demands for expediency are fuelling remarkably satisfying aesthetic results for in a more coronal location.6 APE is classified
treatments for producing ‘immediate results’ boosting patient confidence and satisfac- into two types with two further subdivisions
accompanied by minimal discomfort. Many tion.3 The management of unwanted gingival in each type,7 depending on the position of the
dental therapies are promoting procedures display varies according to aetiology and mucogingival junction and alveolar bone crest.
with prefixes such as ‘short’, ‘less’, ‘rapid’ and includes crown lengthening, local muscle In Type 1, a wide band of keratinised tissue
‘minimal’. Many of these modalities have sound relaxants, orthodontics, and dentoalveolar or is evident (apical location of mucogingival
scientific platforms, but others lack long-term orthognathic surgery.4 Therefore, differential junction), and in subtype A, the alveolar bone
data. The principle of minimal intervention diagnosis is crucial for arriving at a precise crest is within the norm with adequate space
and instancy is laudable, but unless evidence- diagnosis, and subsequent treatment planning for the biological width. In Type 1B, the bone
based and predictable, the resultant treatment that is realistic and feasible. crest approximates the cemento-enamel
is futile and often detrimental, requiring junction (CEJ), leaving little room for the
Aetiology connective tissue and epithelial attachments
(biologic width). In Type 2, the mucogin-
1
Imam Abdulrahman Bin Faisal University, Dammam, An excessive gingival display, or ‘gummy gival junction is within the norm, and in
Dammam 31441, Saudi Arabia, Department of Substitutive
Dental Sciences, College of Dentistry smile’, has its origins from skeletal, muscular subtype A, the alveolar crest at a normal
*Correspondence to: Dr Irfan Ahmad or dentogingival abnormalities including location to accommodate the biologic width,
Email: iahmadbds@aol.com
elongated maxillae, short and/or hypertonic while in subtype B, the bone is close to the
Refereed Paper. Accepted 24 October 2017 maxillary lips, dentoalveolar compensation, CEJ, with reduced space for the biologic
DOI: 10.1038/sj.bdj.2018.121
Angle’s Class II (ii) or Class III occlusions, width (Fig. 1).
was evident, especially on the right side, with Diagnosis and treatment planning
a smile line not coincident with the curvature The wide band of keratinised gingiva with
of the mandibular lip (Fig. 2). In addition, the short clinical crowns is consistent with APE
maxillary anterior teeth were abraded due to Type 1. The latter is also the cause of excessive
attrition with worn and serrated edges resulting gingival display due to erratic passive tooth
in a lack of increasing anterior-posterior incisal eruption patterns. In addition, the tooth
angle embrasures. Evaluation during an exag- wear exposing dentine is classified as scale 3,
gerated smile, especially during speech and according to the Smith and Knight Tooth Wear
laughter, showed excessive gingival display Index (TWI).16 The attrition had also caused a Fig. 5 Pre-operative study cast showing
and erratic gingival zeniths of the anterior loss of occlusal vertical dimension (OVD). The short clinical crown lengths and large width/
maxillary sextant. dual diagnosis of APE and TSL necessitated a length ratios of the incisors and canines
Intra-oral examination confirmed a severely perio-restorative approach for rectifying both
worn maxillary dentition, flattening of the man- pink and white aesthetics for reducing gingival and tooth whitening, a diagnostic wax-up
dibular anterior teeth, and a coronally located display and increasing length of the teeth in was fabricated with correct proportions of the
maxillary frenal attachment with a maxillary the maxillary anterior sextant for correcting maxillary anterior teeth. The wax-up was then
median diastema measuring 1 mm. The capricious tooth proportions. In addition, duplicated in plaster for creating a vacuum
short clinical crown lengths of the maxillary rehabilitation of white aesthetics necessitated stent for an intra-oral surgical guide for
incisors and canines, combined with a wide closing the median diastema, reinstating assessing the amount of tooth display during
band of keratinised gingiva (with melanin pig- incisal embrasure angles, and establishing the habitual (‘rest’) lip position, and parallelism
mentation) resulted in the excessive gingival a pleasing anterior-posterior distal width of the smile line in relation to the curvature
exposure mentioned above. Also, a defective progression from the central incisors to the of the mandibular lip during a repose smile,
composite restoration was present on the canines. speech and laughter. Since treatment involved
right lateral incisor, impinging on the gingival The dual modality perio-restorative both periodontal and restorative rehabilitation,
margin (Fig. 3). Tooth surface loss (TSL) was treatment plan involved two distinct phases; the guide served as a reference for guiding the
substantial, exposing the underlying dentine first, perioplastic aesthetic crown lengthening extent of crown lengthening, in combination
strata at the incisal edges of both maxillary for correcting pink aesthetics, followed by a with increasing the clinical crown length for
and mandibular anterior teeth (Fig. 4). The restorative phase for replacing the lost tooth achieving a satisfactory incisal edge position
patient divulged stress-related bruxism and substrate for restitution of white aesthetics. of the maxillary teeth, accompanied by an
had previously been prescribed a nocturnal Following supportive prophylaxis therapy
night-guard for mitigating her grinding habit.
In addition, measurements of the maxillary
anterior teeth revealed disproportionately large
width/length (w/l) ratios of the incisors and
canines. For example, the width of the right
maxillary central was 8 mm, with a length of
6 mm, correlating to a w/l ratio of 1.3 (Fig. 5),
compared to the acceptable average w/l ratio
of 0.78.14 The inter-tooth relationship also
Fig. 7 Diagnostic wax-up showing the
required correction for achieving a pleasing
Fig. 6 Analysis of existing and proposed proposed increased clinical crown lengths of
anterior-posterior distal width progression
width/length ratio of the left central incisor the maxillary anterior teeth
from the central incisor to the canines.15
Fig. 8 The intra-oral surgical guide as a Fig. 9 Gingivectomy using external bevel Fig. 10 The incised gingival tissue is
reference for determining the amount of incisions placed within the facial line angles removed with a curette
crown lengthening, and increasing the of the incisors and canines for preserving
length of the maxillary anterior teeth, for the interdental papilla
example, for tooth #11, the existing clinical line angles of the incisors and canines for
crown length is 6 mm, and the proposed preserving the interdental papilla (Fig. 9).
clinical crown length is approximately Since the primary objective of the perioplastic
10.5 mm. To achieve this objective requires the patient’s approval before commencing surgery was rehabilitation of pink aesthetics,
crown lengthening of around 2.5 mm, plus treatment. It is important to note that the crown lengthening was confined to the facial
2 mm increase in incisal length
surgical stent acts as a guide for facilitating aspects of the teeth without involving the
treatment, and should not be regarded as a palatal surfaces. The incised superfluous tissue
increase of the anterior vertical overbite. facsimile of the final aesthetic result, which is was subsequently removed with a curette for
This would open the bite anteriorly by 2 mm often modified as treatment progresses. The visualising the newly established position of
for re-establishing the OVD using the Dahl remaining treatment would be provided at the free gingival margin (FGM)(Figs 10 and
concept,17 allowing intentional over-eruption a later date including frenectomy, replacing 11). Using a periodontal probe, bone sounding
of the posterior teeth. For example, the existing lost tooth substrate at the incisal edges of the was measured from the FGM to the mid-facial
length of the left maxillary central incisor is anterior mandibular teeth with direct resin- alveolar crest for determining the extent of
6 mm, and proposed clinical crown length is based composite restorations, addressing the osseous recession necessary for establishing
about 10.5 mm (Fig. 6). In order to achieve posterior restorations and missing teeth, and the new biological width. Since the bone
an acceptable w/l requires crown lengthening providing the patient with a new night-guard crest was almost approximated the CEJ, the
of around 2.5 mm, plus increasing the incisal for mitigating attrition. diagnosis of APE Type 1B was confirmed,
length by 2 mm. In addition, to close the and therefore, 2 mm ostectomy from the CEJ
maxillary median diastema, the width of the Rehabilitating pink aesthetics was necessary. The microsurgery approach
centrals needed to be increased by 0.5 mm, The minimally invasive perioplastic micro- involved intra-sulcular reflection of the FGM
from 8 mm to 8.5 mm. With these new dimen- surgery for aesthetic crown lengthening was with a Zekrya gingival retractor for gaining
sions, the w/l ratio of the central incisors would performed as follows. Initially, using the intra- access to the alveolar crest, as well as protect-
be restored to within acceptable normal limits: oral surgical guide (Fig. 8), bleeding points ing the gingival tissues during the ostectomy,
Existing w/l ratio of tooth #21: were placed for determining the position of which was performed with a diamond coated
8 mm/6 mm = 1.3 the gingival zeniths of the incisors and canines. piezo-surgery tip under copious saline irri-
Proposed w/l ratio of tooth #21: Since an adequate width of keratinised gingiva gation (Fig. 12). The completed surgical
8.5 mm/10.5 mm = 0.8 was present, external bevel gingivectomy procedure created the correct GAL on both
Furthermore, incisal embrasures angles, incisions were used, located within the facial the right and left side of the maxillary sextant
gingival aesthetic line (GAL),18 and satisfactory (Fig. 13).
distal width progression were evaluated with
the diagnostic wax-up (Fig. 7), and gaining
procedures. A recent study concludes that later by gingivectomy to compensate for thick bone biotypes, extensive ostectomy
although the local levels of receptor activator of unpredictable soft tissue healing. Another may be required, necessitating an open flap
nuclear factor-κB ligand (RANKL) and osteo- method is deliberately violating the biologic approach. In these situations, complete bone
protegerin (OPG) were increased for an open width by locating the restorative margins sub- visualisation is essential for adequate access for
flap approach at three months, but the gingival gingivally, either into the epithelial, or con- osseous contouring without traumatising the
margin stability was similar for both open flap nective tissue attachment and then waiting overlying gingival tissues.
and flapless approaches after 12 months.21 for the reestablishment of the biologic width. Finally, consideration of the degree of free
The ubiquitously quoted 3 mm alveolar The rationale for the latter is that biologic gingival margin (FGM) rebound is crucial for
reduction emanates from the premise that the width violation is commonplace during ensuring long-term stability of the gingival
average biologic width is 2 mm, plus a mean restorative procedures without deleterious architecture and profile. The amount of
sulcus depth of 1 mm. However, to date, there effects, and natural healing does re-establish rebound is estimated to be between 1 mm to
is no unequivocal dimension for the biologic a new biologic width by osseous remodel- 3 mm following a period of six months to one
width in humans, varying on the tooth type, ling. However, if healing is not as anticipated, year healing.31 Therefore, the initial gain in
tooth site, periodontal disease, and post-sur- osseous contouring may be necessary at a clinical crown length may be reduced over a
gical healing after procedures such as crown later date for creating the requisite space for period of a year, negating the initial gain.32,33
lengthening.22 Nevertheless, assuming perio- the biologic width.28 Some studies report that the amount of FGM
dontal health is evident, the general consensus Due to the minimal initial trauma of a rebound depends on the positioning of the
for clinical objectives of the biological width microsurgical approach shown in this case flap margin to the alveolar crest after osseous
is 2 mm. study, the primary tissue healing and subse- resection; the closer the flap is to the alveolar
If restorations are planned, the time for quent maturation is expedited, and therefore, crest (less than 1 mm), the greater the degree
delivery of these is also a matter of conten- potentially reduces the time before delivery of of FGM rebound for creating space for a
tion. Some authorities believe that a period the definitive restorations.29 In addition, since new biologic width.34 Also, the degree and
of six months to a year is allowed for stability the interproximal papillae are excluded from incidence of FGM rebound are greater with
after surgery. However, others believe that surgery trauma, gingival embrasure recession thick compared to thin periodontal biotypes.
soft tissue stability is evidenced 8–12 weeks or formation of the so-called ‘black triangles’ are Another factor affecting long-term stability is
post-surgically, and although the final res- obviated. Furthermore, a microsurgical protocol the amount of bone removal during ostectomy
torations can be contemplated at this time,23 for crown lengthening has similar outcomes for achieving the desired 3 mm from the FGM
remodelling of the supracrestal tissues of the to open flap surgery after 12 months,30 and to the alveolar crest, and it has been suggested
biological width takes much longer at around therefore, may be indicated for thin or interme- that at least 3 mm of bone be resected if the
six months.24 Also, the alveolar crest level diate bone biotypes when minimal ostectomy initial gain in clinical crown length is to be
(normal, low or high) should be ascertained and osteoplasty are anticipated, whereas, with maintained over time. Hence, the amount
before deciding where to place the restorative
margins in relation to the FGM (supragingi-
val, equigingival or subgingival),25 and closely
monitored for post-operative recession in
aesthetically sensitive areas.26 Finally, the
implications of clinical changes to adjacent
and non-adjacent sites compared to treated
sites should be considered, especially when
crown lengthening is performed solely for
aesthetic reasons.27
Fig. 20 Post-operative incisal view showing Fig. 21 Post-operative frontal view showing
The two-stage crown lengthening procedure impeccable gingival health surrounding the
replacement of the TSL (compare with Fig. 4)
involves an initial osseous resection, followed crown and PLVs (compare with Fig. 3)
Fig. 22 Post-operative right lateral view Fig. 23 Post-operative left lateral view Fig. 24 Post-operative dento-facial view
showing reestablishment of pink aesthetic, showing reestablishment of pink aesthetic showing restitution of both pink and white
with a GAL Class I with a GAL Class I aesthetics (compare with Fig. 2)
of bone removal takes precedence to the 3. Silva C O, Soumaille J M, Marson F C, Progiante P S, 20. Ribeiro, Hirata, Reis et al. Open-flap versus flapless
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