DISCUSSION

This study compares, for the first time, the clinical effects of conventional OF
and minimally invasive FL crown-lengthening techniques for the treatment of
EGD. Both surgical modalities displayed successful clinical outcomes up to 12
months, with slight morbidity and suitable patient satisfaction. There- fore, the
hypothesis that the FL surgery for ECL would yield similar clinical results to
the OF technique was accepted. The choice for a surgical technique for crown
lengthening depends on a number of factors, including the proportion of the
attached gingiva area. All patients included presented an adequate zone of
KGH that would remain even after the removal of the required gingival tissue
(Table 3). Therefore, both surgical procedures were fully indicated for the
selected patients. The FL technique would be contraindicated in cases in which
the KGH is limited. In addition, the FL technique requires scalloped incisions
that could create mu- cogingival problems when the KG is inadequate, whereas
the OF technique allows preservation of the preexisting keratinized tissue and
its replacement in an apical position.
Both the OF and FL approaches produced sig- nificant reductions in the
excessive gingival tissue, as observed by the increase in the rGM and rCAL
levels and decrease in the PD and KGH measurements over time, compared
with baseline (Table 3). Further- more, this study assesses the alterations in the
GM as an immediate outcome of surgical crown lengthening and over a 12month healing period. The OF and FL procedures resulted in a post-surgical
immediate mean apical removal of the gingival tissue of 1.3 and 1.1 mm,
respectively, considering all buccal sites. At 6 and 12 months post-surgery, the
GM reduction achieved was 1.0 mm for both groups (Table 4). This finding
shows that, once the level of the GM was defined by both surgical procedures,
its changes were minimal up to 12 months. At 3 months post-surgery, the midbuccal GM of the OF group (6.8 mm) dis- played a higher distance from the
reference point compared with the FL group (6.5 mm). This negligible
difference is probably just a consequence of flap elevation in the OF group,
which may place the GM more coronally during short-term healing. Likewise, a
slightly higher level of BOP was observed in the interproximal buccal sites of
the OF group at 3 months compared with the FL group. This finding is possibly
a result of the tissue trauma/healing in the interproximal areas due to papilla
elevation and suture.
These clinical results are in agreement with a previous investigation18
demonstrating that the changes in the GM from those defined after a
conventional OF crown lengthening were minimal at 6 months. Conversely,
these findings are in contrast to those from an earlier report that observed a
tendency for the GM to grow coronally from the immediate post-surgical level
up to 12 months following crown-lengthening surgery.19 However, those
authors performed an apically positioned
flap technique with bone

recontouring, where the GM was positioned subcrestally at interproximal sites

and at the bone crest at the buccal/ lingual sites. Deas et al.20 demonstrated
that a greater coronal rebound of the gingival tissue occurred when the GM was
positioned closer to the bone crest during the crown-lengthening surgery.
However, a minor rebound occurred at 6 months when the GM was sutured at 3
mm from the bone. In the present study, the GM was positioned at the level of
the CEJ and at 3 mm from the bone crest during the OF and FL surgeries,
providing a minimal distance for the biologic width.17,21,22 Using microchisels, the FL approach allowed bone recontouring in an apical direction, via
incisions, when the bone crest was located at or close to the CEJ. As the access
to bone in the FL surgery is blind, the amount of bone removal was guided
by means of probing. This infers that a tactile sensitivity is needed to blindly
locate the bone level in relation to CEJ during the FL procedure, while the OF
approach benefits from the full visualization of the bone level and removal. The
minimally invasive FL technique evaluated herein is not a mere gingivectomy,
as an alternative to the full-thick- ness flap, because it includes bone crest
remodeling when necessary. The simple excision of the gingival tissue without
bone remodeling would probably result in coronal tissue regrowth during
healing, if the bone crest was <3 mm apical to the post-surgical position of the
GM.7,19 Thus, the similar stability of the GM of the FL group to that of the OF
group is attributed to the creation of a distance of 3 mm from the alveolar bone
crest to the GM.
The comparable stability of the GM, up to 12 months, after the OF and FL
surgeries was reinforced by the MLR analysis. No surgical modality predicted
the non-appearance of the creeping at- tachment of the GM in a coronal
direction at 12 months from the position defined during surgery. Interestingly,
among the characteristics of the periodontal tissues obtained by tomography, a
lower BT plus GT distance was the only significant predictor for the nonappearance of creeping attachment. It has been suggested that the periodontal
biotype may influence the extent of tissue alteration after crown lengthening. A
previous investigation has demonstrated that the coronal regrowth of the soft
tissue margin was more pronounced in patients with thick tissue biotype.18 It is
important to note that the patients included in this study presented a mean BT
of 0.9 0.3 and 0.9 0.4 mm for the OF and FL sides, which probably
contributed to the long-term success of the crown lengthening. The FL is a
technique sensitive to bone thickness, since the reduction of bone in the
buccal-palatal direction in cases of thick bone is not possible using this noninvasive approach because the flap is not elevated to completely access the
bone tissue. Therefore, it is supposed that OF with osteoplasty/ostectomy
would be indicated in cases of thick periodontal biotype to better predict the
final position of the GM and reduce the chances of tissue rebounding.
Studies have attributed a critical role to RANK, its ligand RANKL, and OPG in
regulating osteoclastogenesis and bone remodeling.23,24 In the present study,

the levels of OPG and RANKL are assessed in an attempt to verify the impact of
OF and FL approaches on short-term bone remodeling. Results demonstrate an
increase in the RANKL and OPG concentrations at 3 months after OF surgery. In
addition, the concentration of OPG was significantly higher in the OF than the
FL groups at 3 months. Therefore, as expected, it seems that flap elevation
may induce an intensified bone remodeling process. However, these molecular
events may not result in any clinical consequences in relation to the success of
crown lengthening over time.
Compared with the traditional OF, the minimally invasive FL approach is
expected to present advantages with regard to duration of surgery, blood
supply, tissue manipulation and trauma, technical complexity, wound stability,
gingival architecture preservation, and patient discomfort and morbidity.
Regarding duration of surgery, the FL surgery resulted in a 25% reduction in
surgical time compared with OF. Considering patient morbidity, both techniques
resulted in minor discomfort (Table 1). However, it is important to note that
there was a tendency toward higher mean VAS score for pain on the OF side
that was probably related to the tissue reflection and consequent higher
surgical trauma. Regardless of patients perceptions, the authors observed
that the FL approach permitted faster healing and lower tis- sue inflammation
at 7 days, compared with the OF approach, especially in the papilla areas (Fig.
1J), where small remaining scars were noticed in the papilla area of the OF
sides up to 3 months (Fig. 1K). A gummy smile can have an adverse effect on
the perception of a patients attractiveness, friendliness, trustworthiness,
intelligence, and self-confidence.16 Therefore, the correction of EGD is an
important element not only in the esthetics of the smile, but also in patient selfesteem. In this study, patients reported high satisfaction with esthetic
appearance at 7 days after both surgical approaches. These high levels of
esthetic appearance satisfaction were also maintained at 3 months postsurgery for both the OF and FL techniques, probably as result of the minimal
gingival regrowth over time.