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212
THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 3 • NUMBER 3 • AUTUMN 2008
ROSSI ET AL
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Abstract
Excessive gingival display, frequently seen dentogingival unit. This article describes
in adults and resulting in short clinical how periodontal plastic surgery can re-
crowns, has been described in the literature model the attachment apparatus, reestab-
by several authors as “altered passive erup- lish the correct biologic width, eliminate
tion.” It is defined as a dentogingival rela- the excessive show of gingiva, and ex-
tionship wherein the gingival margin is po- pose the correct dimensions of teeth. Api-
sitioned coronally on the anatomic crown cally repositioned flaps with osseous re-
and does not approximate the cemento- contouring can restore gingival health and
enamel junction due to the disruption in the the esthetic parameters of the smile line.
development and eruptive patterns of the (Eur J Esthet Dent 2008;3:212–223.)
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CASE REPORT
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The periodontal literature has described the epithelial attachment.8 Biologic width
delayed or altered passive eruption as the has also been defined by Ingber et al as the
condition in which the patient presents with actual measurement between the bottom
an excessive show of gingiva upon smiling of the gingival sulcus and the alveolar bone
and when the gingival margin overlaps the crest.9 They found that in healthy normal
anatomical crown resulting in short clinical gingiva, the distance from the CEJ to the
1–4
crowns. This display of excessive pink crest of the alveolar bone is on average
soft tissue is also referred to as “gummy 1.55 mm. They claim that this space is nec-
5
smile.” essary for a healthy and stable attachment
apparatus. This value should be under-
stood as a theoretical mean as there have
Anatomical consideration been no studies to show the variability of
this value in humans.
In a normal situation, an adult dentate pa- There have been several studies to de-
tient should display a dentogingival rela- termine the accuracy of dentogingival
tionship where the gingival margin is locat- measurements. Using cadaver jaws,
ed on the enamel approximately 0.5 to Vacek et al support the concept that the
2 mm coronally to the cementoenamel connective tissue attachment is less vari-
2
junction (CEJ). The gingival margin is lo- able than the epithelial attachment.10 Their
cated on the enamel whereas the junction- mean measurements were 1.14 mm and
al epithelium is located between the base 0.77 mm for epithelial and connective tis-
of the sulcus and the CEJ. The connective sue attachments, respectively, and these
tissue attachment apparatus has its fibers were different from the previous paper.
embedded into the cementum and is locat- Another paper, by Boyle et al, investigat-
ed between the alveolar bone and the CEJ. ed the interproximal bone crest levels in
The mucogingival junction is located api- clinically healthy patients ranging in age
cal to the crest of bone. The histologic re- from 11 to 70 years using bitewing radi-
lationships of the dentogingival junction ographs.11 Measurements taken from the
were studied by Sicher in 1959.6 It is com- CEJ to the alveolar bone crest ranged be-
posed of, first, the connective tissue fiber at- tween 0.2 mm and 2.15 mm, with a mean
tachment of the gingiva, and second, the distance of 1.24 mm. They found a graph-
epithelial attachment.6 In 1961, Gargiulo et ic expression of regression of CEJ–alveo-
al studied these dimensions using human lar bone crest distance with age. One of
cadaver teeth.7 They found the distance the conclusions of this study was that the
from the base of the epithelial attachment normal CEJ–alveolar bone crest distance
to the crest of alveolar bone (connective tis- of 1.5 mm described by Gargiulo et al7 has
sue attachment) to be constant. The mean large variations, and may often be as little
average length in all stages of eruption was as 0.2 mm. A more recent study, by
1.07 mm. The epithelial attachment was Alpiste-Illueca, using a reproducible radi-
variable and averaged 0.97 mm.7 “Biolog- ographic technique, found values of
ic width” was defined by Cohen in 1962 as 2.05 mm for the CEJ–alveolar bone crest
the space provided on the root surface for distance and 2.0 mm for biologic width.12
the attachment of the connective tissue and These results corroborate the notion that
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ROSSI ET AL
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THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 3 • NUMBER 3 • AUTUMN 2008
CASE REPORT
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Fig 2 Reevaluation
stage after initial therapy.
a b c
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.
a b c
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.
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of buccal bone and the position of the CEJ terproximal areas. During a recall visit of
in relation to the gingival margin. the patient 5 years after the procedure, the
After local anesthesia was administered, established dentogingival unit appeared
marginal incisions were performed. Full- stable (Fig 5). In summary, by reducing soft
thickness flaps were reflected buccally and tissue inflammation, apical repositioning of
palatally to expose the underlying bone. gingival flaps, and establishing a new bio-
The height and thickness of the bone logic width (2.0 mm) through osseous re-
showed biologic width was minimal sective surgery, the chief complaint of the
(0.5 mm) on the two maxillary central inci- patient was met with an esthetic outcome.
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 Clinical case 2 (Figs 6 to 20)
the CEJ, thus impinging the biologic width.
An osseous resective procedure provid- This is the case of a 27-year-old female
ed biologic width of 2 mm in all teeth, thus complaining of gummy smile and short
creating more space for the soft tissue to clinical crowns (Figs 6 to 9). The patient was
be repositioned approximately at the CEJ tall and her short clinical crowns were dis-
(Fig 4). Scalloping of the gingiva was then proportionate to her face and her smile. The
performed using a no. 15c blade. The flaps patient exhibited adequate oral hygiene.
were sutured back with vertical mattress Radiographs showed very limited biologic
sutures to reposition the papillae in the in- width on all the teeth of the upper arch
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Fig 6 The smile at rest position during the consulta- Fig 7 The “gummy smile” at the consultation visit.
tion visit.
a b c
a b c
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Fig 13 Initial scalloping of the soft tissues, through Fig 14 Removal of excessive soft tissue showing the
submarginal incisions. correct clinical crown exposure.
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a b c
Fig 15 Thick, bulbous osseous contours upon flap elevation, situated at almost the cementoenamel junction
level.
a b
Fig 16 (a and b) Frontal view following osseous plastic surgery to provide space for the biologic width.
tooth was measured clinically and radi- After local anesthesia was administered,
ographically prior to the procedure. The scalloped incisions were made using a no.
surgical planning anticipated the removal 15c blade to mark the extent of soft tissue
of at least 1 mm of alveolar bone at all the removal (Fig 13). Soft tissues were removed
sites to restore the correct minimum biolog- and the true lengths of the clinical crowns
ic width and to allow correct bone remod- were exposed (Fig 14). Full mucoperiosteal
eling in order to provide adequate scallop- flaps were elevated buccally and palatally to
ing and architecture (Fig 13). 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
Fig 17 Single interrupted sutures in place. the full length of the teeth, with remarkable
esthetic enhancement of the smile.
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a b c
Fig 18 (a, b and c) Healing at 6 months, showing healthy gingiva and proper exposure of enamel.
a b
Fig 19 The new smile line displays the appropriate amount of teeth and soft tissue, eliminating the “gummy
smile”.
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- Fig 20 The new smile shows overall enhanced facial
ment. esthetics.
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