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Altered Active and Passive Eruption: A Modified Classification

Article · June 2016

DOI: 10.1902/cap.2016.160025

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PRACTICAL APPLICATIONS

Altered Active and Passive Eruption: A Modified Classification

Mariana S. Ragghianti Zangrando,* Giovana F. Veronesi,* Matheus V. Cardoso,* Raphaella C. Michel,* Carla A. Damante,*
Adriana C.P. Sant’Ana,* Maria L.R. de Rezende,* and Sebastião L.A. Greghi*

Focused Clinical Question: How should cases of altered passive and active eruption be diagnosed, classified,
and treated?
Summary: Frequently, a “gummy smile” contributes to esthetic problems and is caused by several factors such as
vertical maxillary growth, dentoalveolar extrusion, short upper lip, upper lip hyperactivity, altered passive eruption (APE),
or a combination of these factors. APE is a genetic or developmental condition characterized by coronal positioning of
the gingival margin over enamel, resulting in short clinical crowns. Active eruption is defined as tooth movement in the oc-
clusal direction as the tooth erupts from its osseous crypt. Altered active eruption (AAE) occurs when teeth achieve the op-
posite relationship to the occlusal plane prematurely and the osseous crest is on or very close to the cemento-enamel
junction. Thus, correct understanding of biologic events related to APE and AAE should be considered in the classification
of a gummy smile. This article proposes a modification of a previous clinical classification and provides a surgical guide for
treatment planning of cases involving APE and/or AAE. Periodontal biotypes are also taken into consideration.
Conclusions: This article proposes modification of a previous classification dealing with two eruptive processes
known as AAE and APE. Clinical cases and schemes enable understanding and treatment planning of different conditions.
Clin Adv Periodontics 2017;7:51-56.
Key Words: Clinical protocols; crown lengthening; esthetics, dental; periodontics; surgical flaps.

Background very close to, the cemento-enamel junction (CEJ), deter-

Esthetic dental therapy related to a “perfect smile” has
become very important in contemporary clinical den-
tistry.1 Among smile disharmonies, excessive gingival
tissue, frequently called a “gummy smile,” can be asso-
ciated with vertical maxillary growth, dentoalveolar
extrusion, short upper lip, upper lip hyperactivity, al-
tered passive eruption (APE), or a combination of these
factors.2
According to the Glossary of Periodontal Terms of the
American Academy of Periodontology,3 passive eruption
is defined as: “tooth exposure secondary to apical migra-
tion of the gingival margin to a location at or slightly cor-
onal to the cemento-enamel junction.” Active eruption is
“the process by which a tooth moves from its germinative
position to its functional position in occlusion with the
opposing arch.”3
In 1933, Gottlieb and Orban4 aimed to describe dental
eruption phases and divided them into active and passive
dental eruption. Eruptive processes initiate with active
dental eruption, characterized by tooth eruption from
the osseous crypt, disruption of the oral epithelium, and
establishment of occlusal contact with the antagonist
tooth.4,5 Passive dental eruption is defined as apical mi-
gration of gingival tissue until accommodation on, or
* Department of Prosthodontics, Discipline of Periodontics, Bauru School
of Dentistry, University of São Paulo, Bauru, São Paulo, Brazil.
Submitted March 24, 2016; accepted for publication June 2, 2016
doi: 10.1902/cap.2016.160025
mining gingival margin (GM) position.6,7 After disrup-
tion of the oral epithelium, both processes continue
simultaneously. These events are part of the determina-
tion of dentogingival union and the establishment of bio-
logic width.4
Although APE leads to esthetic impairment, this situa-
tion is a normal variation and not necessarily pathologic.8
APE was described as a genetic or developmental con-
dition, frequently associated with excessive gingival
display.6 This condition is characterized by a coronal po-
sition of gingival tissue over enamel, resulting in the ap-
pearance of short clinical crowns.9 This alteration has
also been described as a delayed passive eruption.8 Alter-
ed active eruption (AAE) is characterized by proximity
or coincidence of the alveolar crest to the CEJ.10
The most accepted classification for APE was pub-
lished by Coslet et al. 11 This classification involves
considerations about the amount of keratinized gingiva
(Type I: wide gingiva; Type II: thin gingiva) and the dis-
tance from the CEJ to the alveolar crest (subgroup A:
alveolar crest and CEJ relationship corresponds to the
1.5-mm distance accepted as normal; subgroup B: alve-
olar crest is at the level of the CEJ).11 The type of treat-
ment proposed for each clinical situation of APE is
based on its classification.11 However, important bio-
logic principles, such as association with AAE, are not
well described.
This paper presents a modification of a previous classi-
fication and provides a guide for diagnosis and surgical
treatment planning through case series and methods.

Clinical Advances in Periodontics, Vol. 7, No. 1, February 2017 51

P R A C T I C A L A P P L I C A T I O N S
Decision Process: Proposal of a
Modified Classification and a
Surgical Guide
Although the classification proposed by Coslet et al. 11 is
the most frequently cited in the literature, these authors
did not describe an important biologic event, the pro-
cess of AAE. This condition of proximity from the
CEJ to the alveolar crest is described as an APE sub-
group (subgroup B). Despite simultaneous occurrence,
AAE and APE are different events that may or may
not be associated with each other. Based on findings
from the cases presented below, a modification of the
current classification 11 is suggested based on eruptive
and biologic concepts.
This modified classification preserves APE Type I and
Type II according to the amount of keratinized gingiva,
but values were inserted to facilitate a diagnosis (Type I:
>2 mm of keratinized tissue; Type II: £2 mm).12 Another
important modification is the exclusion of subgroups A
and B and the inclusion of categories APE alone or APE
associated with AAE (Fig. 1).
To provide a surgical guide, aspects related to peri-
odontal biotypes and the extension of AAE are important
features to be evaluated for incision design and bone re-
section, respectively. Not only gingival width but also gin-
gival thickness should be assessed to better guide incision
angulation.13 AAE can also be categorized as localized
(only a few teeth) or generalized (by sextants) in determin-
ing necessity and extent of ostectomy and osteoplasty.
FIGURE 1 Modified classification of APE and AAE. 1a APE-I: Keratinized gingiva >2 mm with distance of 1.5 mm
from the CEJ to alveolar crest. 1b APE-II: Keratinized gingiva £2 mm with distance of 1.5 mm from the CEJ to
alveolar crest. 1c APE-I-AAE: Keratinized gingiva >2 mm with insufficient distance from the CEJ to alveolar crest. thickness14 was z2.5 mm. After an-
1d APE-II-AAE: Keratinized gingiva £2 mm with insufficient distance from the CEJ to alveolar crest.
52 Clinical Advances in Periodontics, Vol. 7, No. 1, February 2017
Clinical Scenarios
All patients were referred to Bauru School of Dentistry (Peri-
odontics), University of São Paulo, São Paulo, Brazil from
2013 to 2015 and provided written informed consent for
treatment. Case 1 presents a healthy 22-year-old female
who complained about her “child appearance” due to short
clinical crowns of teeth #4 through #13 (Fig. 2a). Awide band
of keratinized gingiva (>2 mm) was present, and gingival
thickness was z1 mm (Fig. 2b). Demarcation of the CEJ po-
sition on the mid-buccal aspect of all teeth was made to guide
the GM incision. Due to thin gingival thickness, the incision
was made perpendicular to the long axis of teeth (Figs. 2c and
2d). A full-thickness flap was elevated, and the distance be-
tween the alveolar crest and CEJ was z1 mm. AAE was pres-
ent in the majority of teeth (generalized) (Fig. 2e). This patient
was classified as APE-I-AAE. Ostectomy and osteoplasty
were performed to reestablish a distance of z2 mm from
the CEJ to the alveolar crest (Fig. 2f). The GM was stabilized
with single sutures (Fig. 2g). After 6 months, tooth dimen-
sions and gingival display were reestablished (Figs. 2h and 2i).
Case 2 describes a 28-year-old healthy female with
concerns about the esthetics of her anterior teeth due
to short clinical crowns from teeth #5 through #13. This
patient presented with poor plaque control and gingival
inflammation. After scaling and root planing sessions
and oral hygiene instructions, esthetic crown lengthen-
ing was performed. A wide band of keratinized gingiva
(>2 mm) was present, and gingival thickness was
z2 mm. A clinical measurement of gingival thickness
was performed 2 mm apical to the free GM by transgin-
gival sounding.14 Based on position
of the CEJ and gingival thickness,
an internal bevel incision with a
45-degree angulation was performed.
After flap elevation, the distance
between the alveolar crest and
CEJ was z1 mm in relation to all
teeth (generalized). This patient was
classified as APE-I-AAE, which re-
quired ostectomy and osteoplasty.
Final positioning of the flap was
established with mattress sutures.
After 9 months, gingival position
was adequate. However, the gin-
giva was again inflamed between
teeth #8 and #9, due to poor oral
hygiene (supplementary Fig. 1).
In Case 3, a 25-year-old healthy
female requested gingival treatment
to improve the esthetics of her
“gummy smile” (Fig. 3a). She pre-
sented with short clinical crowns
from teeth #6 through #11 (Fig. 3b).
A wide band of keratinized gingiva
(>2 mm) was present, and gingival
esthesia, the position of the alveolar
Modified Classification of Altered Active and Passive Eruption
 P R A C T I C A L A P P L I C A T I O N S

FIGURE 2 Case 1. 2a Initial presentation representing a “gummy smile” with short clinical crowns. 2b Intraoral view of APE, demonstrating wide keratinized
gingiva. 2c Internal bevel incision with angulation of 90 degrees in relation to the tooth long axis, preserving interdental papillae. 2d Gingival contour after
gingival collar removal. 2e Distance of 1 mm between the alveolar crest and CEJ after full-thickness flap elevation. Case was classified as APE-I-AAE.
2f Osseous resection reestablishing distance of z2 mm from the CEJ to alveolar crest. 2g GM stabilized with single sutures. 2h Final appearance of smile after
6 months. 2i Intraoral view after 6 months.

FIGURE 3 Case 3 (courtesy of Drs. Rodrigo Carlos Nahás de Castro Pinto and Allisson Rebelo, Brazilian Association of Dentistry). 3a Initial presentation
representing a “gummy smile” with short clinical crowns. 3b Intraoral view of APE, demonstrating wide keratinized gingiva. 3c Reference points based on PD.
Case was classified as APE-I. 3d Kirkland knife positioning for primary incision. 3e Orban knife positioning for interproximal incision. 3f External bevel incision
and reshaping of GM. 3g Harmonious smile contours after 6 months. 3h Intraoral final aspect demonstrating GM stability after 6 months.

crest was evaluated using a periodontal probe inserted
into the gingival sulcus to measure the distance to the
CEJ (z2 mm in all teeth). This patient was classified as
APE-I. The periodontal procedure performed was a gingi-
voplasty for surgical reshaping of gingiva without osseous
access. Delineation of probing depths (PDs) was repro-
duced on the buccal aspect of the gingival tissue to guide
a scalloped external bevel incision (Fig. 3c). This marginal
incision was accomplished with a Kirkland knife (Fig. 3d),
and release of interproximal tissue was achieved using
an Orban knife (Fig. 3e). After excision of gingival tissue,
festooning of gingiva to obtain interdental vertical grooves
and reshaping of the GM are important to reestablish
gingival physiology (Fig. 3f).15 A harmonious smile ap-
pearance and healthy gingival contours were noted
6 months postoperatively (Figs. 3g and 3h).
Discussion
Classification systems have arisen allowing clinicians
to identify diseases in relation to etiology, pathogen-
esis, and treatment.16 Despite the fact that APE was
considered a normal variation and not necessarily a patho-
logic situation,8 this condition is frequently associated
with a “gummy smile” and requires surgical approaches
to correct it.11 The first important step in therapy is the
diagnosis of APE and AAE. There are several clinical and
imaging methods to help the clinician. Coslet et al.11
identify whether the anatomic crown is, in fact, short
through the CEJ localization. According to Coslet
et al.,11 the CEJ should be located z1.5 mm distant from
the alveolar crest; this distance corresponds to the cor-
rect space for connective attachment.11 In cases where
the osseous crest is very close to, or coincident with
the CEJ, localization of this structure is more difficult.11
In a previous study6 the clinical method used to diagnose
AAE was a comparison between periapical radiographs
and periodontal probing, demonstrating the distance be-
tween the alveolar crest and the CEJ. Another technique
that may be used is transulcus periodontal probing.17,18
After local anesthesia, a periodontal probe is inserted in-
side the gingival sulcus until it reaches the osseous crest.
The distance between the alveolar crest and the CEJ is

Ragghianti Zangrando, Veronesi, Cardoso, et al. Clinical Advances in Periodontics, Vol. 7, No. 1, February 2017 53
P R A C T I C A L A P P L I C A T I O N S
TABLE 1 Surgical Guide for Treatment Decision-Making Process Based on Modified Classification
APE Type I (>2 mm)
Alone External bevel incision or internal bevel incision
With AAE Internal bevel incision and osseous resective surgery
measured.17,18 To better visualize the dimensions of gin-
gival tissue and its relationship to bone, Januário et al.19
proposed the use of tomography evaluation using a labial
retractor. This technique allows a more precise localiza-
tion of the osseous crest and gingival tissue thickness, es-
sential in diagnosis of APE and AAE.
In addition, clinicians should be aware of periodontal
biotype for surgical planning. A thick-flat periodontium
indicates the presence of dense and fibrotic soft tissue,
a large amount of keratinized gingiva, thick and short pa-
pilla, and thick and flat underlying bone.13 On the other
hand, a thin-scalloped periodontium has thin soft tissue
and a small amount of keratinized gingiva with long
and narrow papillae over thin-scalloped bone.13 Gener-
ally, APE prevalence was more common in individuals
with a thick gingival biotype.20 However, data regarding
the prevalence of APE or AAE in adults is scarce. Age is
a fundamental factor for a correct diagnosis, as eruptive
processes achieve balance around 20 years of age.8,20,21
To obtain adequate and predictable results from surgical
treatment of APE and AAE, technical details specific to each
classification must be evaluated. In Type I, due to the amount
of keratinized gingiva, a marginal band of gingiva can be re-
moved through an external or internal bevel incision. In Type
II, the keratinized gingiva is narrow, requiring an intrasulc-
ular incision with an apically repositioned flap (Table 1). In
cases where gingival collar removal might result in <2 mm of
remaining keratinized gingiva, at least 2 mm of keratinized
gingiva should be maintained in the flap and associated with
apical repositioning to preserve its adequate height.
The majority of technique variations occur in Type I,
and identification of periodontal biotype is essential for
incision planning. Gingivoplasty is indicated when APE
is not associated with AAE. Here, osseous approaches
are unnecessary.11 Internal bevel incisions and flap resec-
tion are indicated in cases of APE associated with AAE.
In cases of thick periodontal biotypes, the height and
thickness of gingival tissue must be altered, and blade
angulation for an internal bevel incision must be at
z45 degrees to the long axis of the tooth. Some cases
of Type I can demonstrate a thin periodontium, but with
a sufficient height of keratinized gingiva. Here, the inci-
sion can be angulated at 90 degrees in relationship to the
tooth long axis to remove minimal gingival thickness,
thus avoiding posterior height loss of the GM (Fig. 4).
Gingival thickness can be assessed with a periodontal
probe inserted into the facial aspect of the gingiva sulcus.22
Periodontal biotype is categorized as “thin” if the outline
of the underlying periodontal probe can be seen through
54 Clinical Advances in Periodontics, Vol. 7, No. 1, February 2017
Type II (£2 mm)
Internal bevel incision and apically positioned flap
Internal bevel incision, apically positioned flap, and osseous resective surgery
FIGURE 4a Internal bevel incision with 90-degree angulation for thin
gingival tissue. 4b Internal bevel incision with 45-degree angulation for
thick gingival tissue.
the gingiva, and “thick” if the probe cannot be seen.22
Kan et al.14 compared the evaluation of probe visibility with
clinical measurement of gingival thickness 2 mm apical
to the free GM by transgingival sounding. Values >1 mm
are considered thick gingiva and £1 mm, thin gingiva.14
When the papilla is wide and short, common in square-
shaped teeth, incisions can involve the interproximal re-
gion to reduce and better adapt the volume of papillae in
interdental space. Areas with long and narrow interden-
tal papillae, common in triangular-shaped teeth, should
be preserved without resection of interproximal gingival
tissue, thus avoiding undesirable black spaces (Fig. 5).
When APE is associated with AAE, further treatment
of soft tissue, in conjunction with resection, becomes
essential to prevent treatment relapse with possible gin-
gival overgrowth (Table 1). Generally, quantity of os-
tectomy is based on a distance of z2 mm from the
CEJ to the new position of the marginal crest. Thick fa-
cial bone requires osteoplasty to remove thickness and
provide adequate osseous contour.
When osseous approaches are indicated, full-thickness
flaps are necessary to enable access to bone. However, when
apical repositioning is indicated, a mixed (full- and partial-
thickness) flap (Type II) is needed to create flap anchorage
to the periosteum. Depending upon operator preference,
vertical incisions can also be indicated for apical flap
positioning. “Flapless” techniques are indicated when
minimal ostectomy of the marginal crest is necessary,
without volume removal by osteoplasty. 23 In cases of
thin gingiva, care must be taken when handling the
GM and using mini-Ochsenbein chisels.23 Flaps nor-
mally are repositioned by mattress or single sutures
Modified Classification of Altered Active and Passive Eruption

FIGURE 5a In cases with long and narrow papillae, the incision should
preserve the interproximal region. 5b In cases with wide and short papillae,
the incision can involve the interproximal region.
depending upon the stability achieved by the GM near the
CEJ.24 All technical steps should be carefully evaluated
and designed to achieve predictable and reliable outcomes.
Ragghianti Zangrando, Veronesi, Cardoso, et al.
P R A C T I C A L A P P L I C A T I O N S
Conclusions
A modified classification for APE and AAE conditions
that emphasizes the importance of periodontal biotype
for proper diagnosis and surgical planning is presented.
Respecting the indications of each case and using this
classification as a source for the clinical decision-making
process, surgical treatment outcomes can be more pre-
dictable and reliable. n
Acknowledgments
The authors thank Drs. Rodrigo Carlos Nahás de Castro
Pinto and Allisson Rebelo, Brazilian Association of Den-
tistry (Santos, Sao Paulo, Brazil) for clinical case number
3. The authors report no conflicts of interest related to
this study.
CORRESPONDENCE:
Prof. Mariana Schutzer Ragghianti Zangrando, Al. Octavio Pinheiro
Brisolla 9-75, 17012-901, Bauru-SP, Brazil. E-mail: mariana@fob.usp.br.
Clinical Advances in Periodontics, Vol. 7, No. 1, February 2017 55
P R A C T I C A L A P P L I C A T I O N S

13. Olsson M, Lindhe J, Marinello CP. On the relationship between crown

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56 Clinical Advances in Periodontics, Vol. 7, No. 1, February 2017 Modified Classification of Altered Active and Passive Eruption
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