Rossi Gummy Smile

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Roberto Rossi, DDS, MScD Private Practice Genoa, Italy Remo Benedetti, MD, DDS Private Practice Genoa, Italy Regina Isabel Santos-Morales, DMD Private Practice Makati City, Philippines CASE REPORT THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY VOLUME 3 • NUMBER 3 • AUTUMN 2008 212 Treatment of Altered Passive Eruption: Periodontal Plastic Surgery of the Dentogingival Junction Correspondence to: Dr Roberto Rossi Torre San Vincenzo 2, 16121 Genova, Italy; phone: 39 010 5958853; fax: 39 010 3460429; e-mail: [email protected] C o p y r i g h t b y N o t f o r Q u i n t e s s e n c e Not for Publication

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Transcript of Rossi Gummy Smile

Page 1: Rossi Gummy Smile

Roberto Rossi, DDS, MScD

Private Practice

Genoa, Italy

Remo Benedetti, MD, DDS

Private Practice

Genoa, Italy

Regina Isabel Santos-Morales, DMD

Private Practice

Makati City, Philippines

CASE REPORT

THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY

VOLUME 3 • NUMBER 3 • AUTUMN 2008

212

Treatment of Altered Passive

Eruption: Periodontal Plastic Surgery

of the Dentogingival Junction

Correspondence to: Dr Roberto Rossi

Torre San Vincenzo 2, 16121 Genova, Italy;

phone: 39 010 5958853; fax: 39 010 3460429; e-mail: [email protected]

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ROSSI ET AL

dentogingival unit. This article describes

how periodontal plastic surgery can re-

model the attachment apparatus, reestab-

lish the correct biologic width, eliminate

the excessive show of gingiva, and ex-

pose the correct dimensions of teeth. Api-

cally repositioned flaps with osseous re-

contouring can restore gingival health and

the esthetic parameters of the smile line.

(Eur J Esthet Dent 2008;3:212–223.)

Abstract

Excessive gingival display, frequently seen

in adults and resulting in short clinical

crowns, has been described in the literature

by several authors as “altered passive erup-

tion.” It is defined as a dentogingival rela-

tionship wherein the gingival margin is po-

sitioned coronally on the anatomic crown

and does not approximate the cemento-

enamel junction due to the disruption in the

development and eruptive patterns of the

213THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY

VOLUME 3 • NUMBER 3 • AUTUMN 2008

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CASE REPORT

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214

the epithelial attachment.8

Biologic width

has also been defined by Ingber et al as the

actual measurement between the bottom

of the gingival sulcus and the alveolar bone

crest.9

They found that in healthy normal

gingiva, the distance from the CEJ to the

crest of the alveolar bone is on average

1.55 mm. They claim that this space is nec-

essary for a healthy and stable attachment

apparatus. This value should be under-

stood as a theoretical mean as there have

been no studies to show the variability of

this value in humans.

There have been several studies to de-

termine the accuracy of dentogingival

measurements. Using cadaver jaws,

Vacek et al support the concept that the

connective tissue attachment is less vari-

able than the epithelial attachment.10

Their

mean measurements were 1.14 mm and

0.77 mm for epithelial and connective tis-

sue attachments, respectively, and these

were different from the previous paper.

Another paper, by Boyle et al, investigat-

ed the interproximal bone crest levels in

clinically healthy patients ranging in age

from 11 to 70 years using bitewing radi-

ographs.11

Measurements taken from the

CEJ to the alveolar bone crest ranged be-

tween 0.2 mm and 2.15 mm, with a mean

distance of 1.24 mm. They found a graph-

ic expression of regression of CEJ–alveo-

lar bone crest distance with age. One of

the conclusions of this study was that the

normal CEJ–alveolar bone crest distance

of 1.5 mm described by Gargiulo et al7has

large variations, and may often be as little

as 0.2 mm. A more recent study, by

Alpiste-Illueca, using a reproducible radi-

ographic technique, found values of

2.05 mm for the CEJ–alveolar bone crest

distance and 2.0 mm for biologic width.12

These results corroborate the notion that

The periodontal literature has described

delayed or altered passive eruption as the

condition in which the patient presents with

an excessive show of gingiva upon smiling

and when the gingival margin overlaps the

anatomical crown resulting in short clinical

crowns.1–4

This display of excessive pink

soft tissue is also referred to as “gummy

smile.”5

Anatomical consideration

In a normal situation, an adult dentate pa-

tient should display a dentogingival rela-

tionship where the gingival margin is locat-

ed on the enamel approximately 0.5 to

2 mm coronally to the cementoenamel

junction (CEJ).2

The gingival margin is lo-

cated on the enamel whereas the junction-

al epithelium is located between the base

of the sulcus and the CEJ. The connective

tissue attachment apparatus has its fibers

embedded into the cementum and is locat-

ed between the alveolar bone and the CEJ.

The mucogingival junction is located api-

cal to the crest of bone. The histologic re-

lationships of the dentogingival junction

were studied by Sicher in 1959.6It is com-

posed of, first, the connective tissue fiber at-

tachment of the gingiva, and second, the

epithelial attachment.6

In 1961, Gargiulo et

al studied these dimensions using human

cadaver teeth.7

They found the distance

from the base of the epithelial attachment

to the crest of alveolar bone (connective tis-

sue attachment) to be constant. The mean

average length in all stages of eruption was

1.07 mm. The epithelial attachment was

variable and averaged 0.97 mm.7“Biolog-

ic width” was defined by Cohen in 1962 as

the space provided on the root surface for

the attachment of the connective tissue and

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ROSSI ET AL

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Case reports

Clinical case 1 (Figs 1 to 5)

This is the case of a 30-year-old female

complaining of excessive gingival display

and short clinical crowns. The patient

showed poor oral hygiene and sponta-

neous bleeding in several sites (Fig 1).

After initial therapy consisting of oral hy-

giene instruction, scaling, and root planing,

the gingival condition improved. However,

the gingival margin remained on the

enamel coronal to the CEJ (Fig 2). Debride-

ment reduced inflammation, allowing ac-

curate evaluation of the extent of altered

passive eruption. This case was diagnosed

as delayed passive eruption of type II, sub-

types A and B, depending on the sites. Ra-

diographic examination revealed no bone

loss, and some areas showed bone close-

ly approximating the CEJs of the teeth.

Probing depth was 3 to 4 mm, revealing the

presence of pseudopockets. Bone sound-

ing was carried out to determine the level

the dimensions of the dentogingival unit

are highly variable.

The biologic width becomes significant

when maintaining gingival health of tissues

for restorative, orthodontic, periodontal, and

esthetic concerns.

Coslet et al have classified altered pas-

sive eruption in adult patients as follows.1

� Gingival/anatomic crown relationship:

Type I – gingival margin incisal to the

CEJ, where there is a noticeably wider

gingival dimension from the margin to

the mucogingival junction.

Type II – dimension from the gingival

margin to the mucogingival junction

which appears to be within the normal

mean width, as described by Bowers3

and Ainamo and Loe.2

� Alveolar crest–CEJ relationship:

Subtype A – the alveolar crest–CEJ dis-

tance is approximately 1.5 mm. This al-

lows for normal attachment of the gingi-

val fibers into cementum.

Subtype B – the alveolar crest is at the

level of the CEJ.

Fig 1 (a and b) Initial presentation.

a b

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Fig 2 Reevaluation

stage after initial therapy.

Fig 3 (a, b and c) Intraoral views showing osseous contours upon flap reflection. Both central incisors (b) do

not have room for the connective tissue and the epithelial attachment (2.0 mm) as the osseous crest is <1 mm

from the CEJ.

Fig 4 (a, b and c) After osseous resective surgery, the interproximal bone has been shaped to accommo-

date the soft tissue contours and the alveolar crest has been scalloped to provide room for the biologic width.

a b c

a b c

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terproximal areas. During a recall visit of

the patient 5 years after the procedure, the

established dentogingival unit appeared

stable (Fig 5). In summary, by reducing soft

tissue inflammation, apical repositioning of

gingival flaps, and establishing a new bio-

logic width (2.0 mm) through osseous re-

sective surgery, the chief complaint of the

patient was met with an esthetic outcome.

Clinical case 2 (Figs 6 to 20)

This is the case of a 27-year-old female

complaining of gummy smile and short

clinical crowns (Figs 6 to 9). The patient was

tall and her short clinical crowns were dis-

proportionate to her face and her smile. The

patient exhibited adequate oral hygiene.

Radiographs showed very limited biologic

width on all the teeth of the upper arch

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217

of buccal bone and the position of the CEJ

in relation to the gingival margin.

After local anesthesia was administered,

marginal incisions were performed. Full-

thickness flaps were reflected buccally and

palatally to expose the underlying bone.

The height and thickness of the bone

showed biologic width was minimal

(0.5 mm) on the two maxillary central inci-

sors and 1.5 mm on the lateral incisors

(Fig 3). In some areas, such as the maxil-

lary left bicuspids, the alveolar bone was at

the CEJ, thus impinging the biologic width.

An osseous resective procedure provid-

ed biologic width of 2 mm in all teeth, thus

creating more space for the soft tissue to

be repositioned approximately at the CEJ

(Fig 4). Scalloping of the gingiva was then

performed using a no. 15c blade. The flaps

were sutured back with vertical mattress

sutures to reposition the papillae in the in-

Fig 5 Five-year follow-

up shows stability of the

established dentogingi-

val interface.

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Fig 6 The smile at rest position during the consulta-

tion visit.

Fig 7 The “gummy smile” at the consultation visit.

Fig 8 (a, b and c) Preoperative smile line.

Fig 9 (a, b and c) Preoperative clinical view.

a b c

a b c

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(Fig 10). The diagnosis was altered passive

eruption type I subtype B. The treatment

plan was to remove the excessive soft tis-

sue to expose the teeth fully to their natural

length and to remove osseous structure to

give room for a biologic width of at least

2 mm. In some areas, one-third of the clin-

ical crowns were covered with gingiva. The

clinical crown of the central incisor was

only 8 mm. However, the radiographic

length measured 12 mm (Figs 11 and 12).

The extent of soft tissue removal for each Fig 10 Radiograph showing the limited biologic

width; the osseous crest is close to cementoenamel

junction level.

Fig 11 Central incisor:

the anatomical crown

length was 12 mm.

Fig 12 Central incisor: the clinical crown length was

only 8 mm.

Fig 13 Initial scalloping of the soft tissues, through

submarginal incisions.

Fig 14 Removal of excessive soft tissue showing the

correct clinical crown exposure.

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After local anesthesia was administered,

scalloped incisions were made using a no.

15c blade to mark the extent of soft tissue

removal (Fig 13). Soft tissues were removed

and the true lengths of the clinical crowns

were exposed (Fig 14). Full mucoperiosteal

flaps were elevated buccally and palatally to

expose the thick, bulbous bony architecture

(Fig 15). Osseous crests were found ap-

proximating the level of the CEJ, thus not

allowing for the proper biologic width. Os-

seous recontouring provided at least 2 mm

space between the CEJ and the crest of the

alveolar bone from teeth 15 to 25, eliminat-

ing the thick bony ledges (Fig 16). The flap

was repositioned apically using single inter-

rupted resorbable sutures (Fig 17).

At the 6-month recall the patient showed

a marked improvement in soft tissue qual-

ity (Figs 18 to 20). The smile line showed

the full length of the teeth, with remarkable

esthetic enhancement of the smile.

CASE REPORT

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VOLUME 3 • NUMBER 3 • AUTUMN 2008

220

tooth was measured clinically and radi-

ographically prior to the procedure. The

surgical planning anticipated the removal

of at least 1 mm of alveolar bone at all the

sites to restore the correct minimum biolog-

ic width and to allow correct bone remod-

eling in order to provide adequate scallop-

ing and architecture (Fig 13).

Fig 15 Thick, bulbous osseous contours upon flap elevation, situated at almost the cementoenamel junction

level.

a b c

Fig 16 (a and b) Frontal view following osseous plastic surgery to provide space for the biologic width.

a

Fig 17 Single interrupted sutures in place.

b

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Discussion

Altered passive eruption is an uncommon

occurrence that is only diagnosed upon

clinical observation. It is defined as a dento-

gingival relationship wherein the margin of

the gingiva is positioned incisally/occlusal-

ly on the anatomic crown in adulthood and

does not approximate the cementoenamel

junction.13

This means that the crowns of

the teeth appear very short and thus proj-

ect a gummy smile. The incidence of this

condition has not been fully studied in

adults, although Volchansky and Cleaton-

Jones, in a study in children aged between

6 and 16 years, found the incidence to be

12%.14

In this study, they also observed that

clinical crown height increases with in-

creasing age. Thus, tooth eruption and for-

mation of the dentogingival junction should

be clearly understood prior to any treat-

ment.

Fig 18 (a, b and c) Healing at 6 months, showing healthy gingiva and proper exposure of enamel.

a b c

Fig 20 The new smile shows overall enhanced facial

esthetics.

Fig 19 The new smile line displays the appropriate amount of teeth and soft tissue, eliminating the “gummy

smile”.

a b

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Esthetic considerations

The dental practitioner can influence the

smile by correcting tooth length problems,

as in altered passive eruption cases. This

should be considered in relation to the lip

line of the patient. Tooth length has been

studied in the literature; Townsend report-

ed that canines and central incisors should

be at the same length, and the lateral inci-

sor should be 1 to 2 mm shorter.19

There

should be an interdental papilla of 4.5 to

5 mm from the tip of the papilla to the

depth of the marginal scallop, and the

most apical part of the gingival scallop

should reflect the angle of the long axis of

the tooth. The author also mentioned that

the mean crown length for a maxillary cen-

tral incisor is 13.5 mm; for a maxillary later-

al incisor, 12 mm; and for a maxillary ca-

nine, 13 mm. Wheeler’s textbook20

also

reported on tooth sizes, giving average

lengths for maxillary anterior clinical

crowns measured on extracted teeth. The

values given were 10.5 mm for maxillary

incisors, 9 mm for lateral incisors, and

10 mm for canines. These values should

serve as guides and should be regarded

as one important aspect of esthetic treat-

ment. Gingivectomy procedures can be

performed using these values, while also

keeping in mind Loe and Ainamo’s de-

scription of the ideal clinical crown size for

a particular patient (Fig 13).2

In normal dentition, teeth and their alveoli

actively erupt from their crypts. They con-

tinue to erupt through the gingiva until they

make occlusal contact with the teeth in the

opposing arch.15

Orban and Kohler in 1924

described the various stages of eruption of

teeth.16

In stage 1, the epithelial attachment

is situated along the enamel surface im-

mediately above the CEJ. In stage 2, the

epithelial attachment is situated along both

the enamel above the CEJ and the cemen-

tum surface of the root of the tooth. In stage

3, the epithelial attachment is situated on-

ly on the cementum, immediately below

the CEJ. Stages 1 to 3 are physiologic in

nature. Finally, in stage 4 the epithelial at-

tachment migrates apically due to peri-

odontal disease or other pathologic condi-

tions.

Variations in the height of the gingival

margin on the anatomic crown have been

observed in adults at various ages.

Volchansky and Cleaton-Jones found that

in a study in children aged between 6 and

16 years, 12.1% of the 1,025 evaluated pa-

tients exhibited delayed passive eruption.17

The same study found that eruption of

teeth was completed by the age of 12

years for the maxillary central incisors and

canines, and the maxillary lateral incisors

continued to demonstrate minor changes

in gingival margin position up to 16 years

of age. However, Morrow et al suggest that

passive eruption, resulting in increased

clinical crown length, seems to continue

throughout the teenage years, until the age

of 19.18

It is, therefore, imperative that age is

also considered before treating altered

passive eruption cases.

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Conclusions

This paper provides clinical and biologic

presentations on the treatment of altered

passive eruption, using periodontal plastic

procedures such as esthetic crown length-

ening. Altered passive eruption occurs on

patients who exhibit unesthetic short clinical

crowns with gummy smiles. The dento-

gingival dimensions are taken into consid-

eration in careful diagnosis and treatment

planning of the cases. Clinical and radio-

graphic examinations dictate the necessary

removal of soft and hard tissues to achieve

the desired result. The reestablishment of a

new and correct biologic width and the ex-

posure of the correct length of the clinical

crown leads to excellent clinical, biologic,

and esthetic outcomes.

Resective procedure

Once the level of the gingiva has been es-

tablished, selective osseous recontouring

can be achieved by performing submar-

ginal incisions to the desired height of the

clinical crown.20

A biologic width of at least

2 mm between the alveolar crest and the

CEJ should be attained to ensure the

health of the attachment apparatus

(Fig 16). The thickness of the gingiva

should also be taken into consideration

when the flaps are replaced, and mainte-

nance of a good zone of attached gingiva

should also be addressed.

14. Volchansky A, Cleaton-Jones

P. The position of the gingival

margin as expressed by clini-

cal crown height in children in

ages 6–16 years. J Dent Assoc

S Africa 1975;4:116–122.

15. Evian CI, Cutler SA, Rosen-

berg ES, Shah RK. Altered

passive eruption: The undiag-

nosed entity. J Am Dent Assoc

1993;124:107–110.

16. Orban B, Kohler, J. The physi-

ologic gingival sulcus. Z Stom-

atol 1924;22:353.

17. Volchansky A, Cleaton-Jones P.

Clinical crown height (length) –

a review of published meas-

urements. J Clin Periodontol

2001;28:1085–1090.

18. Morrow LA, Robbins JW, Jones

DL, Wilson NHF. Clinical crown

length changes from age

12–19: A longitudinal study. J

Dent 2000;28:469–473.

19. Townsend CL. Resective sur-

gery: An esthetic application.

Quintessence Int

1993;24:535–542.

20.Wheeler RC (ed). Wheeler’s

atlas of tooth form, ed 5.

Philadelphia: WB Saunders,

1984:136–138.

8. Cohen DW. Pathogenesis of

Periodontal Disease and its

Treatment. Washington, DC:

Walter Reed Army Medical

Center, 1962.

9. Ingber JS, Rose LF, Coslet JG.

The “biologic width”: A con-

cept in periodontics and

restorative dentistry. Alpha

Omegan 1977;70:62–65.

10. Vacek JS, Gher ME, Assad DA,

Richardson AC, Giambarresi

LI. The dimensions of the

human dentogingival junction.

Int J Periodontics Restorative

Dent 1994;14:155–165.

11. Boyle W, Via F, McFall W. Radi-

ographic analysis of alveolar

crest height and age. J Peri-

odontol 1973;44:236–243.

12. Alpiste-Illueca F. Dimensions

of the dentogingival unit in the

maxillary anterior teeth: A new

exploration technique (parallel

profile radiograph). Int J Peri-

odontics Restorative Dent

2004;24:386–396.

13. Volchansky A, Cleaton-Jones

P. Delayed passive eruption –

a predisposing factor to Vin-

cent’s infection. J Dent Assoc

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