Periodontology 2000, Vol. 0, 2018, 1–19 © 2018 John Wiley & Sons A/S.
Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Printed in Singapore. All rights reserved
Esthetic treatment of altered
passive eruption
MONICA MELE, PIETRO FELICE, PRAVEEN SHARMA, CLAUDIO MAZZOTTI,
PIETRO BELLONE & GIOVANNI ZUCCHELLI
Gingival excess has been recognized by the American
Academy of Periodontology as a mucogingival defor-
mity around teeth (6). Several conditions may result
in the excessive display of gingiva, including pseu-
dopockets caused by gingivitis, drug-induced gingival
enlargement and altered passive eruption of teeth.
These clinical presentations may lead patients to seek
treatment to address esthetic and/or functional con-
cerns. Excessive gingival display may also result from
altered passive eruption of the maxillary dentition, a
high lip line, a hypermobile upper lip or vertical max-
illary excess (49), and the management of excess gin-
gival display is dictated by its etiology. The aim of this
article is to present a narrative review of the etiology,
classification and management of altered passive
eruption.
Tooth eruption: active and passive
eruption phases
Tooth eruption comprises two phases: an active erup-
tion phase in which the tooth emerges into the oral
cavity; and a passive eruption phase that is character-
ized by apical migration of the soft tissue covering the
crown of the tooth (Fig. 1).
Active eruption phase
According to Steedle & Proffit (55) the active eruption
phase can be subdivided into six distinct phases:
three prefunctional phases (follicular growth, pre-
emergence and post-emergence eruptive outbreak)
and three post-functional phases (juvenile occlusal
equilibrium, pubertal eruptive outbreak and adult
occlusal equilibrium). Some studies have shown that
in its final stages, tooth eruption is regulated not only
PERIODONTOLOGY 2000
by occlusal contact but also by the periodontal
ligament and supracrestal fiber complex (30, 53).
Anthropometric studies have shown that continuous
tooth eruption can compensate for incisal tooth wear,
in severe cases by up to 60%, without affecting the
lower face height. This is seen more readily in
younger patients, who are more likely to exhibit con-
tinued eruption of teeth without occlusal contact,
compared with older patients.
Passive eruption phase
Passive eruption, a term coined by Gottlieb & Orban
in 1933 (28), is a gradual process by which the epithe-
lial attachment of the gingival tissues migrates api-
cally from the coronal enamel to a stable position just
coronal to the cemento–enamel junction with a
fibrous connective tissue attachment forming at the
base of the gingival sulcus (25). This phase can be sub-
divided into four phases depending on the location of
the dentogingival junction relative to the cemento–
enamel junction (25). The dentogingival junction may
be located on enamel alone, on enamel and cemen-
tum or on cementum alone, or both the dentogingival
junction and the gingival margin may be apical to the
cemento–enamel junction. The first phase of passive
eruption is considered to be physiological, while the
remaining three phases are a consequence of patho-
logical periodontal destruction. If passive eruption
does not progress, the gingival margin retains a more
coronal position covering more tooth enamel.
Altered passive eruption
Goldman & Cohen (27) defined altered or retarded
passive eruption as a situation in which ‘the
1
Mele et al.
A B
Fig. 1. Mandibular anterior sextant in a 13-year-old male
patient. (A) Note the active and passive phases of tooth
eruption. The mandibular central incisors have completed
both phases while the other teeth have not. As a result,
their gingival margin is still coronal to the cemento–
gingival margin in the adult is located incisal to
the cervical convexity of the crown and removed
from the cemento–enamel junction of the tooth’.
In the literature, this condition is also referred to
as ‘delayed passive eruption’ (59) and results from
failure of the passive eruption phase to conclude.
In investigating a cohort of over 1,000 adult
patients, with a mean age of 24 years, the preva-
lence of altered passive eruption was reported to
be approximately 12% (59). Coslet et al. (16) classi-
fied altered passive eruption into two types based
on the location of the mucogingival junction in
relation to the alveolar bone crest, and further
classified these into two subgroups based on the
position of the alveolar bone crest in relation to
the cemento–enamel junction. The different types
and subgroups of altered passive eruption are
shown in Fig. 2.
Fig. 2. Schematic drawing summarizing the types and
subgroups of altered passive eruption (courtesy of Guido
Gori). (A) Type 1 subgroup A: the mucogingival junction is
located apically with respect to the cemento–enamel junc-
tion and the buccal bone crest. The distance between the
cemento–enamel junction and the bone crest is physiologi-
cal for connective tissue fiber attachment. (B) Type 2 sub-
group A: the mucogingival junction is located at the level
of, or coronal to, the cemento–enamel junction. The dis-
tance between the cemento–enamel junction and the bone
crest is physiological for connective tissue fiber
2
enamel junction. (B) A lateral view of these teeth shows
the amount of apical gingival migration required before
the buccal soft tissue of the mandibular right lateral inci-
sor reaches maturation.
Relationship between the mucogingival
junction and the alveolar bone crest
Type 1 altered passive eruption is defined by the
gingival margin being incisal or occlusal to the
cemento–enamel junction where there is a noticeably
wider band of attached gingiva from the gingival mar-
gin to the mucogingival junction than the generally
accepted mean width of 3.0–4.2 mm in the maxilla
and 2.5–2.6 mm in the mandible (2, 12). The
mucogingival junction is usually apical to the alveolar
crest in these cases.
Type 2 altered passive eruption is defined by the
presence of a band of attached gingiva from the gingi-
val margin to the mucogingival junction which
appears to fall within the normal mean width as spec-
ified above (2, 12). However, in this type of altered
passive eruption, all the attached gingiva is located
attachment. (C) Type 1 subgroup B: the mucogingival
junction is located apically with respect to the cemento–
enamel junction and buccal bone crest. The bone crest is
located at the level of, or coronal to, the cemento–enamel
junction and there is no physiological space for connective
tissue fiber attachment. (D) Type 2 subgroup B: the
mucogingival junction is located at the level of, or coronal
to, the cemento–enamel junction. The bone crest is located
at the level of, or coronal to, the cemento–enamel junction
and there is no physiological space for connective tissue
fiber attachment. MGJ, mucogingival junction.

on the anatomic crown with the mucogingival junc-
tion located at the level of the cemento–enamel junc-
tion.
Relationship between the alveolar bone
crest and the cemento–enamel junction
In altered passive eruption subgroup A, the alveolar
crest is the normal distance (1–2 mm apical) from the
cemento–enamel junction, thus allowing the gingival
fiber apparatus to be inserted as normal onto cemen-
tum.
In altered passive eruption subgroup B, the alveolar
crest is at the level of or coronal to the cemento–
enamel junction, thereby impinging on the space for
connective tissue fiber attachment. This relationship
is frequently observed during the active eruption
phase of the transitional dentition.
As it is difficult to pinpoint when the physiological
movement of passive eruption ends, controversy
exists regarding the age at which a diagnosis of
altered passive eruption can be made. According to
Coslet et al. (16), by the age of 18–20 years, the
majority of individuals have a mature dentogingival
relationship with a distance between the cemento–
enamel junction and the gingival margin of 0.5–
2 mm (2). Several studies have investigated the
changing position of the gingival margin in different
age groups by measuring the clinical crown height.
In a cross-sectional study conducted in a Caucasian
population of 6- to 16-year-old subjects, the position
of the gingival margin, and therefore the clinical
crown height, was recorded using orthodontic study
models (60, 61). There was a significant difference in
the clinical crown height, between the age groups,
for all teeth except for the second lower molars. The
same authors subsequently conducted a longitudinal
study on subjects 18 years of age (62). The clinical
crown height of the incisor and canine teeth was
measured using standardized photographic tech-
niques, in 30 dental students, over a 3-year period.
There was a progressive increase in mean clinical
height during this period, similar to that observed in
the previous cross-sectional study, suggesting that
continual passive eruption of the teeth occurs until
the age of 20 years.
Morrow et al. (42) investigated the relationship
between age, gender and clinical crown height in a
longitudinal study in which 456 sets of study models
were examined. Each set of models corresponded to
a subject at three different ages: 11–12, 14–15 and
18–19 years. The clinical crown height of the right
maxillary central incisor, right maxillary canine, left
Esthetic treatment of altered passive eruption
maxillary lateral incisor and left mandibular central
incisor was measured from the gingival margin to
the incisal edge using digital calipers. Analysis of the
data obtained showed a significant relationship
between age and crown height for all four teeth
studied. A significant relationship was found with
gender whereby the upper right central incisor,
upper canines teeth, and upper left lateral incisor
were longer in men than in women. Such a relation-
ship was not found with the lower left central inci-
sor. The data in this study indicate that passive
eruption continues at least until age 18–19 years for
both male and female subjects. As it was not possible
to determine whether or not the gingival levels are
stable at this age, the authors made a comparison of
the clinical crown heights reported in their study
with those reported by Gillen et al. (26). It appeared
that in the female patient population, passive erup-
tion was essentially complete by the age of 18–
19 years. Evian et al. (22) compared anterior and
posterior teeth and found that for the former, gingi-
val stability was achieved by 20 years of age, while
for the latter, gingival maturation could continue
into the third decade. Robbins, in 1999 (49), sug-
gested that it may not be prudent to diagnose altered
passive eruption until growth is complete but did
not specify at which age this should be.
Etiopathogenesis of altered passive
eruption
According to some authors, the position of the alveo-
lar bone crest adjacent to the cemento–enamel junc-
tion could impede gingival migration during the
passive eruption phase (25), thereby providing a dis-
tinguishing feature between altered passive eruption
and altered active eruption. The hypothesis has been
proposed that two mechanisms play a part in altered
passive eruption, giving rise to two different morpho-
logical patterns at the level of the dentogingival
junction.
Type 1 altered passive eruption may be caused by
failure of the passive eruption phase, giving rise to
excessive overlap of gingiva and the anatomical
crown of the tooth, but the distance from the bone
crest to the cemento–enamel junction is normal. On
the other hand, type 2 altered passive eruption may
be caused by failure of the active eruption phase and,
as a result, the tooth does not emerge sufficiently
from the alveolar bone, thereby leaving the cemento–
enamel junction positioned in proximity to the alveo-
lar bone crest. This situation, in turn, may prevent
3
Mele et al.

the apical migration of gingiva during the passive
eruption phase.
Few studies have postulated possible causes of
altered passive eruption and several factors have
been proposed. These include occlusal interference
by soft tissues during the eruptive phase, the pres-
ence of thick and fibrotic gums that tend to migrate
more slowly during the passive phase, genetic
causes, the presence of thick bone that might pre-
vent the apical migration of soft tissue, orthodontic
trauma and endocrine conditions (4). Zucchelli (66)
indicated that the presence of thick buccal bone
was a common observation in surgically managed
cases of altered passive eruption, regardless of the
subgroup (A or B; Figs 3 and 4) and that surgical
reduction of this thick bone was essential in the
management of such cases (Fig. 5). The increased
bone thickness might be a consequence of the lack
of gingival retraction. Rossi et al. (51) investigated
the genetic component of altered passive eruption
in a study which aimed to understand whether or
not patients with altered passive eruption have sib-
lings or parents presenting with similar dental char-
acteristics. Immediate family members of 20
patients (10 male and 10 female) with altered pas-
sive eruption were evaluated and the results showed
that family members of patients with altered passive
eruption had a higher-than-average incidence of
altered passive eruption. In this small study, more
than 50% of patients had one family member show-
ing signs of altered passive eruption, and for 15% of
patients, all family members showed signs of altered
passive eruption. The type of passive eruption
within family members was not reported. Orthodon-
tic trauma may also be a causative factor in altered
passive eruption (Fig. 6). A cross-sectional study by
Nart et al. (43) determined the prevalence of altered
passive eruption following orthodontic treatment
using maxillary and mandibular fixed appliances,
and a comparison was made with the prevalence of
altered passive eruption in patients who had never
received orthodontic treatment. The prevalence of
altered passive eruption in patients who had
received orthodontic treatment was higher than in
those who had not received orthodontic treatment,
although the results were not statistically significant
(43). This is in agreement with the clinical impres-
sion of some authors who reported that orthodontic
treatment often gives rise to a gummy smile (31, 33).
Nart et al. (43) also showed a statistically significant
association between altered passive eruption and
gingival biotype, categorized into thin-scalloped,

A B

Fig. 3. Increased thickness of the buccal bone in a patient with altered passive eruption and with physiological distance
between the cemento–enamel junction and the bone crest (subgroup A). (A) Lateral view. (B) Occlusal view.

A B

Fig. 4. Increased thickness of the buccal bone in patients with altered passive eruption. (A) Frontal view: some teeth (cani-
nes) have normal, physiological distance between the cemento–enamel junction and the bone crest, while in others (lateral
and central incisors) the bone crest reaches or covers the cemento–enamel junction (subgroup B). (B) Lateral view.

4

A B
Fig. 5. Increased buccal bone thickness of the patient in
Figs 13 and 21 with altered passive eruption and a gummy
smile. (A) Lateral view showing the increase in thickness of
the buccal bone. (B) Reduction of bone thickness (osteo-
plasty) to treat altered passive eruption.
Fig. 6. Altered passive eruption and gummy smile after
orthodontic therapy in an 18-year-old female patient.
thick-flat or thick-scalloped (19), while age, sex and
the duration of orthodontic treatment were not
associated with altered passive eruption. Many
authors have investigated the causes and mecha-
nisms that may lead to tooth eruption failure (46).
Piattelli et al. (46) used the term ‘primary failure of
eruption’ for those cases with no apparent mechani-
cal cause of failure of tooth eruption, such as root
ankylosis, the presence of supernumerary teeth,
odontogenic tumors, cyst, soft tissues interposed
between teeth and deformities of the crown or root
of the teeth. The authors suggested altered metabo-
lism or blood flow in the periodontal ligament as
the etiological mechanism for this primary failure of
eruption. Certain endocrine alterations, such as
hypopituitarism and hypogonadism, are also related
to a delay in tooth eruption. In a study by Barberi
et al. (7), the authors reported that children who
had a deficiency of growth hormone also presented
a delay in dental and bone age. As early as 1968,
Esthetic treatment of altered passive eruption
Goldman & Cohen (27) reported that the association
between hypothyroidism and the presence of altered
passive eruption was not infrequent. We now have a
clearer understanding of the possible role of hor-
mones, such as growth hormone, insulin-like growth
factors I and II (10), thyroid hormones and epider-
mal growth factor (65), in the eruption process.
Altered passive eruption and
periodontal health
Studies have related altered passive eruption to peri-
odontal health, including altered passive eruption
being a potential risk factor for development of peri-
odontal disease. Coslet et al. (16) indicated that in
altered passive eruption type 2A, the gingiva is unsup-
ported by connective tissue fibers, is frequently of a
thin tissue type and appears to be susceptible to peri-
odontal breakdown. In altered passive eruption type
1B and type 2B, the absence of collage bundles of the
gingival apparatus may predispose to gingival patho-
sis. Prichard (47) postulated that an incisally placed
gingival margin is more prone to trauma from oral
function and is more susceptible to periodontal
pathoses. Factors such as trauma, movement of food
and other debris may contribute to chronic inflam-
mation of a bulbous marginal gingiva.
In altered passive eruption, as the gingiva does not
recede to its normal position and remains on the con-
vex surface of the crown, it is at risk from repeated
trauma. In some cases, excess gingival tissue may also
interfere with adequate oral hygiene and the resultant
accumulation of plaque may give rise to marginal gin-
gival inflammation (Fig. 7) (4). Moreover, restorations
and orthodontic appliances (Fig. 8) placed in close
proximity to the gingival margin may cause an
inflammatory response resulting in gingivitis and
attachment loss in periodontally susceptible patients
Fig. 7. Altered passive eruption and periodontal health.
The excess of gingival tissue may interfere with oral
hygiene practices, and plaque accumulation may give rise
to marginal gingival inflammation.
5
Mele et al.
A
B
(22). Weinberg & Eskow (64) suggested that in the
presence of pseudopockets which develop as a result
of excessive keratinized mucosa (Fig. 9), increased
plaque accumulation and an inflammatory response
may not be esthetically pleasing to the patients. Vol-
chanky & Cleaton-Jones (59) reported a relationship
between the presence of altered passive eruption and
acute necrotizing ulcerative gingivitis, arguing that a
deep gingival sulcus creates the necessary anaerobic
conditions for the development of this infection
(Fig. 10). Although such pathoses may occur in rare
instances, the gingiva of the patient with altered pas-
sive eruption, like all patients, is generally healthy in
the absence of plaque deposits.
Altered passive eruption and
restorative requirements
Altered passive eruption can make restoration of
teeth challenging and the restorative treatment plan
should be formulated before gingival surgery.
Although it is preferable, where possible, to place
restorative margins supragingivally, for esthetic rea-
sons it may sometimes be necessary to place subgin-
gival restorative margins. If restorations with
subgingival margins are prepared in teeth with
altered passive eruption, the margin is likely to be
6
Fig. 8. Altered passive eruption and
periodontal health. (A) Orthodontic
appliances and (B) restorations may
cause an aggravated inflammatory
response in patients with altered
passive eruption.
placed on the enamel with unprepared enamel apical
to the finish line. At a later date, the restorative mar-
gin may become visible if passive eruption continues,
presenting possible esthetic complications (20, 44, 63)
(Fig. 11).
It is also necessary to re-create an adequate bio-
logic width in order to maintain gingival health, to
allow sufficient space between the restorative margin
and the alveolar crest and to prevent an inflammatory
lesion from developing that may result in loss of
attachment (20, 44). A common restorative error,
made when patients with altered passive eruption are
treated, is the placement of margins at what would be
‘normal’ anatomic levels. Such marginal placement
may impinge on the biologic width because of the
increased alveolar bone height, resulting in compro-
mised esthetics as the biologic width re-establishes
itself (21). According to Evian et al. (22), in multi-
rooted teeth, excess soft tissue can interfere with the
interproximal placement of restorations. Eliminating
the excess tissue allows improved access and makes
plaque control easier for the patient. Anteriorly,
altered passive eruption can result in short-looking
teeth, and crown and bridgework can be used to
improve esthetics. However, incorrect placement of
crown margins can cause an inflammatory response,
worsening the appearance of the teeth in the long
term (22).
Fig. 9. Altered passive eruption and
periodontal health. Pseudopocket in
patient affected by altered passive
eruption.
Fig. 10. Altered passive eruption and
periodontal health. Altered passive
eruption associated with necrotizing
periodontal disease.
 Esthetic treatment of altered passive eruption

A C

B D

Fig. 11. Restorative challenges with altered passive erup-
tion. (A,B) Patient with altered passive eruption affecting
the maxillary left central incisor where the margin of the
restoration was probably subgingival at the time of place-
ment. With continuation of passive eruption, this margin
is now supragingival and presents an esthetic challenge.
(C,D) Surgical treatment of altered passive eruption allows
optimal delivery of restorative treatment and achievement
of a more esthetic outcome.

Altered passive eruption and Peck et al. (45) describe three classes of smile line.
A ‘normal’ smile line is one in which the upper ante-
esthetics: gummy smile
rior teeth are completely visible and the lower border
of the upper lip reveals 1–2 mm of gingiva. A ‘low’
For dentists, improvement in esthetics is one of the
smile line is described as one in which the lower bor-
main reasons for the delivery of clinical treatment,
der of the upper lip covers 25% of the upper anterior
and esthetic concerns frequently pose a challenge to
teeth. A ‘high’ smile line, also known as a ‘gummy
the periodontist. Such concerns often relate to gingi-
smile’, is described as one having more than 2 mm of
val margin misalignment or excessive tooth length as
maxillary gingival display (Fig. 12). The prevalence of
a result of gingival recession or excessive gingival
excessive gingival display has been estimated at 10%
exposure when the patient smiles or speaks. The
of 20- to 30-year-old subjects, and it is more common
characteristics of an esthetic smile include:
 A straight dental midline. in women (14%) than in men (7%) (57). Excessive dis-
 A smile line that follows the convexity of the lower play of gingiva can have an adverse effect on the
patient’s perception of attractiveness, friendliness,
lip.
 Symmetric central incisors. trustworthiness, intelligence and self-confidence (39)
 Incisal embrasures that gradually deepen from (Fig. 13). There are different possible etiologic factors
for this clinical presentation, one of which is altered
central incisors to canines.
 Teeth that are straight or mesially inclined. passive eruption (24). If the origin of the excessive
 A width-to-length ratio of the central incisors of gingival display is a skeletal abnormality, then orthog-
nathic surgery and orthodontic treatment should be
75–80% (17).
considered. If there is a dental reason for the exces-
There are also other factors influencing the esthet-
sive gingival display, then correction of the gingival
ics of a smile, including incisor and gingival display
and osseous architecture is indicated.
(23, 58). In fact, maxillary anterior teeth, along with
Malkinson et al. (39) performed a study to demon-
the position of the gingival zenith and balance of the
strate how a major determinant of the esthetics of a
gingival levels, are considered to be the key elements
smile is the amount of gingival display, which can be
of a pleasant smile (38, 52).

A B

Fig. 12. High smile line or gummy smile (pre- and postsurgical correction). (A) Gummy smile as a result of altered passive
eruption. (B) Surgical treatment of altered passive eruption modifies the Peck classification of this smile from a high smile
line to a normal smile line.

7
Mele et al.
A B
excessive in cases of altered passive eruption. The
aims of this research were twofold: first, to investigate
differences in people’s perceptions of the aforemen-
tioned social parameters, when looking at simulated
before- and after-treatment photographs of gummy
smiles; and, second, to investigate differences in these
perceptions between senior dental students and
laypeople. The authors demonstrated that excessive
gingival display negatively affected how attractive a
person’s smile was judged to be, and lay people were
just as sensitive to these differences as senior dental
students (39). Furthermore, research shows that a
patient’s smile can influence his or her perceived
beauty (23, 32). Therefore, the correction of excessive
gingival display may be an important element, not
only in terms of smile esthetics but also in terms of
patients’ self-esteem. In a study by Ribeiro et al. (48),
patients reported high satisfaction with their esthetic
appearance both at 7 days and at 6 months after sur-
gical correction of a gummy smile. In a similar man-
ner, Cairo et al. (13) reported that patients rated the
final outcome of surgical intervention as satisfactory
at the 6-month time-point.
In addition to the presentation of a gummy smile,
altered passive eruption can compromise esthetics in
other ways, such as the short appearance of teeth, or
gingival or tooth-length asymmetry when contralat-
eral teeth have different positions of the gingival mar-
gin (Fig. 14). In fact, the beauty of the human body is
represented by the right–left symmetry and the har-
mony of tissues in terms of color and quality. Kokich
et al., in 1999 (34), evaluated the perception of lay
people and dental professionals (orthodontists and
general dentists), to symmetric alteration of anterior
dental esthetics. Smiling photographs were intention-
ally altered with one of eight common anterior
A B
8
Fig. 13. Altered passive eruption and
gummy smile. (A) Gummy smile as a
result of altered passive eruption. (B)
Patient’s attractiveness improves fol-
lowing periodontal surgery to
improve the dental and gingival
show.
esthetic discrepancies in varying degrees of deviation,
including variations in crown length, crown width,
incisor crown angulation, position of the midline,
open gingival embrasure, gingival margin, incisal
plane and gingiva-to-lip distance. The results of this
study showed that lay people, general dentists, and,
in particular, orthodontists detect specific dental
esthetic discrepancies at varying degrees of deviation.
Using a similar study deign, Kokich et al., in 2006
(35), found that asymmetric esthetic discrepancies
were more perceptible than symmetric ones. In gen-
eral, asymmetric alterations make teeth more
unattractive, not only to dental professionals but also
to the lay public. Symmetric alterations might appear
unattractive to dental professionals but the lay group
often did not recognize such alterations.
Diagnosis of altered passive
eruption
The lack of clear diagnostic criteria for altered passive
eruption has hampered studies in evaluating the
prevalence of altered passive eruption in the adult
population. Most of the literature references a study
by Volchansky & Cleaton-Jones from 1974 (59) that
reported a prevalence of altered passive eruption of
12.1%. Recently, Nart et al. (43) reported a higher
prevalence, of 35.8% (29.5% in the control group and
42.1% in the orthodontic therapy group), of altered
passive eruption. One possible explanation for this
could be the heterogeneity in diagnostic criteria used
to define altered passive eruption. Volchansky and
Cleaton-Jones (59) included only those teeth with a
gingival margin positioned 3 to 4 mm over the
cemento-enamel junction while in the last study (43)
Fig. 14. (A) Altered passive eruption,
gummy smile and gingival margin
asymmetry between the central inci-
sors. (B) In measuring the clinical
crown height of the central incisors,
7 mm for the maxillary right central
incisor, which has a clinical crown,
can described as ‘short’.

a diagnosis of altered passive eruption was estab-
lished if the distance from the gingival margin to the
cemento-enamel junction was ≥3mm. The literature
describes various procedures used to diagnose altered
passive eruption, including clinical observation, clini-
cal investigation of the cemento–enamel junction and
alveolar bone crest and radiographic analyses. These
will be explored individually in more detail below.
Clinical observation and investigations
The extra-oral examination includes an evaluation of
facial symmetry and height, lip or smile line, lip
length and mobility. First of all, the patient is
observed at rest and with a natural smile. If there is
an excessive display of gingiva during smiling, further
diagnostic measurements are required. During this
process, first of all the length and activity of the max-
illary lip at rest from the base of the nose to the wet
border of the maxillary lip is measured. This is usually
20–22 mm in female patients and 22–24 mm in male
patients. If the excessive gingival display is caused
solely by a shorter lip or lip hyperactivity, no treat-
ment is indicated (21).
Once the maxillary lip measurements are made, the
next step is to measure the clinical crowns to assess
their dimensions to determine if teeth have short clin-
ical crowns (Fig. 14). In the literature, several articles
report analysis of the dimensions of clinical crowns in
the permanent dentition. Sterrett et al. (56) gathered
this data using orthodontic study models from Cau-
casian patients. Digital calipers were used to measure
the widest mesiodistal length (perpendicular to the
long axis) and the longest apicocoronal length (paral-
lel to the long axis) of the test teeth on each cast. The
results of the study indicate that the mean width and
length of the clinical crowns is significantly greater in
male patients compared with female patients. The
mean mesiodistal tooth widths for male and female
patients were, respectively, 8.59 and 8.06 mm for the
central incisor, 6.59 and 6.13 mm for the lateral inci-
sor and 7.64 and 7.15 mm for the canine. The mean
apicocoronal tooth lengths for male and female
patients, respectively, were 10.19 and 9.39 mm for the
central incisor, 8.70 and 7.79 mm for the lateral inci-
sor and 10.06 and 8.89 mm for the canine. The mean
coronal tooth width/length ratios for male and female
patients were, respectively, 0.85 and 0.86 for the cen-
tral incisor, 0.76 and 0.79 for the lateral incisor and
0.77 and 0.81 for the canine (56). The study by Gillen
et al. (26) was designed and conducted in a similar
manner to determine the average dimensions of the
six maxillary anterior teeth in 18- to 35-year-old
Esthetic treatment of altered passive eruption
patients and to evaluate the relationships between
intertooth and intratooth dimensions. The results
were comparable with those of the previous study by
Sterrett et al. (56). Monaco et al. (41) indicated the
value of 11  2 mm for the clinical crown of the cen-
tral incisor. If the value was under 8 mm then it was
defined as short. In 1999, Robbins (49) defined ‘short’
clinical crown as one that was under 9 mm in length.
From data extrapolated from the literature, some
authors used the value of 10.5 mm for the length of
the central incisor (21, 47).
In a study by Alpiste-Illueca (5), 123 subjects with
upper anterior teeth presenting clinical evidence of
altered passive eruption were enrolled. Two subjec-
tive criteria were employed for the clinical diagnosis
of altered passive eruption: first, excessively flattened
gingival festooning; and, second, a disproportionate
papilla base width in relation to the height reached
by the tip. Altered passive eruption was diagnosed
when these criteria were met in the context of a
patient with a clinically evident short dental crowns,
considering probing depth, width of keratinized gin-
gival, mucogingival line, length of the clinical crown
and occlusal attrition of the teeth (54). Some authors
(21, 33) indicated that gingival sulcus probe depth is
important for the diagnosis of altered passive erup-
tion and claim that depths of over 3 mm without con-
comitant pathological signs are suggestive of altered
passive eruption. In the study by Alpiste-Illueca (5)
no such relationship was observed because no
patient had a probing depth in excess of 3 mm, the
most frequent value being 1.5 mm. In a study by Dolt
& Robbins, (21) the first step in the diagnostic process
of altered passive eruption is to detect the cemento–
enamel junction subgingivally using an explorer. If
the cemento–enamel junction is located in a normal
position in the gingival sulcus, the patient does not
have altered passive eruption. When the cemento–
enamel junction is not detectable in the sulcus, a
diagnosis of altered passive eruption may be made
and crestal ‘bone sounding’ is then performed. The
gingiva is anesthetized and the periodontal probing
depth is recorded. The probe is then pushed through
the base of the sulcus until the alveolar crest is
engaged and this measurement is recorded. As it is
common for the cemento–enamel junction to be
located approximately at the base of the sulcus, these
measurements can be used to determine the relation-
ship between the cemento–enamel junction and the
alveolar crest, as an aid to surgical treatment plan-
ning. Zucchelli (66) highlighted some challenges with
this approach as establishing the position of the
cemento–enamel junction through ‘sounding’ is not
9
Mele et al.
easy in patients with altered passive eruption, for two
reasons: first, the buccal gingiva is almost always
tightly attached, with a long junctional epithelium
along the enamel surface, making probing difficult;
and, second, teeth with altered passive eruption are
often associated with a buccal bone crest at, or coro-
nal to, the cemento–enamel junction, thereby pre-
venting detection of the cemento–enamel junction,
even in the presence of pseudopockets.
‘Bone sounding’, under anesthesia, is the tradi-
tional technique used to distinguish between altered
passive eruption subtypes A and B. If transgingival
probing reveals the cemento–enamel junction sub-
gingivally, a diagnosis of altered passive eruption sub-
type A can be made. If the alveolar bone crest is
palpated by the probe without the cemento–enamel
junction being detected, a diagnosis of altered passive
eruption subtype B can be made. According to Zuc-
chelli (66), ‘sounding’ is only effective in rare cases as
in the vast majority of cases only one interruption is
felt during subgingival probing and it is difficult to
distinguish the cemento–enamel junction from the
bone crest. Additionally, even if two subgingival inter-
ruptions are detected it can be very difficult to deter-
mine whether the distance between them is
physiologic (1–2 mm) or otherwise (66).
Radiographic analysis
A useful contribution in the diagnosis of altered pas-
sive eruption comes from dental radiography. Paral-
lel profile radiography, as described by Alpiste-
Illeuca (3), was used to determine the dimensions of
the dentogingival unit components, so it was possi-
ble to measure discrepancies and the degree of over-
lap characterizing altered passive eruption. This
radiograph was obtained using radio-opaque gutta-
percha inserted into the base of the sulcus and a
self-sticking lead plate positioned over the kera-
tinized gingival surface. In this way the author could
correlate the clinical and radiographic diagnoses. It
10
was concluded that a gingival overlap of over 19% of
the anatomical crown height is equivalent to the
clinical diagnosis of altered passive eruption. Levine
& McGuire (37) proposed that periapical radiography
should be used with the long-cone parallel tech-
nique to obtain information on the cemento–enamel
junction and bone crest. Many authors use radio-
graphic measures to obtain clinical measures for use
as a guide during surgical treatment (1, 13, 29, 40,
50, 51, 63, 64, 66). For example, Zucchelli (66) com-
pared the clinical and radiographic lengths of the
crown (Fig. 15) with the objective being to correct
the magnification created in the X-ray image in
order to calculate measurements precisely, particu-
larly the distance between the gingival margin and
the cemento–enamel junction and between the
cemento–enamel junction and the bone crest
(Fig. 16). When a significant difference (≥ 3 mm) is
found between clinical crown length (occlusal/incisal
edge to gingival margin) and the radiographic crown
length (occlusal/incisal edge to cemento–enamel
junction), a diagnosis of altered passive eruption is
confirmed. Furthermore, when two distinct lines,
one more coronal for the cemento–enamel junction
and one more apical for the bone crest, can be dis-
tinguished in the radiograph, the diagnosis of sub-
type A can be made and the measurement of the
distance between the cemento–enamel junction and
the bone crest can be recorded (Figs 16 and 17).
Nevertheless, the periapical radiographs do not
always readily distinguish between altered passive
eruption of subtypes A and B as, in some cases, it is
difficult to distinguish the buccal bone crest from
the cemento–enamel junction (66) or whether the
more apical line on the radiograph corresponds to
the buccal or the palatal bone crest (Fig. 18). Batista
et al. (8) suggested the use of cone beam computed
tomography to diagnose and characterize the hard-
and soft-tissue anatomic features of altered passive
eruption-affected teeth and to present a novel, com-
bined surgical approach to its correction based on
Fig. 15. Radiographic diagnosis of
altered passive eruption using a
long-cone periapical radiographic
technique. A gutta-percha cone is
placed buccally to the gingival mar-
gin, thereby highlighting the clinical
crown length. The use of a cotton
wool roll between the teeth and the
X-ray holder prevents displacement
of the gutta-percha cone.

A B
Fig. 16. Periapical radiograph with gutta-percha cone
identifying the gingival margin (GM). (A) The true length
of the gutta-percha cone is compared with its radiographic
length (dashed vertical white line) to correct for image
magnification. Once the cemento–enamel junction (CEJ) is
identified on the radiograph (solid horizontal red line), it is
possible to calculate the precise distance between the gin-
gival margin (GM) and the cemento–enamel junction
(dashed vertical red line) and the true length of the
anatomical crown (solid black vertical line). (B) High mag-
nification of the radiograph, together with the distance
between the gingival margin and the cemento–enamel
junction (GM-CEJ) makes it possible to calculate the dis-
tance between the cemento–enamel junction and the bone
crest (BC). This leads to a diagnosis of altered passive erup-
tion subgroup A.
the biometric information obtained using cone beam
computed tomography.
Treatment of altered passive
eruption
Treatments of altered passive eruption described in
the literature are mainly surgical; there are no data on
nonsurgical treatment of altered passive eruption.
A B
Esthetic treatment of altered passive eruption
Presurgical treatment phase
Most studies on the treatment of altered passive
eruption report that initial therapy consists of oral
hygiene instruction, scaling and ‘root’ planing (22). It
is clear that ‘root’ planing cannot be performed in
order to reduce the pseudopocket because the tissue
beneath the pseudopocket is enamel and not cemen-
tum or root dentine. On the other hand, the uninten-
tional curettage of the soft-tissue wall of the
pseudopocket might induce some marginal soft-tis-
sue shrinkage, which could be considered, by the
patient, as unesthetic ‘gingival recession’ as a result
of the elongated appearance of the tooth with a pseu-
dopocket when compared with the adjacent teeth.
Rossi et al. (50) observed that after initial therapy, the
gingival margin remained on the enamel coronal to
the cemento–enamel junction. Debridement reduced
inflammation, allowing accurate evaluation of the
extent of altered passive eruption, in the absence of
pseudopockets (50). The presurgical treatment phase
should precede any surgical treatment.
Surgical treatment phase
In periodontal health, the width of keratinized gin-
giva, the position of the gingival margins, the location
of the buccal alveolar crest, the location of the
mucogingival junction and the likelihood of concomi-
tant restorative therapy are all factors that collectively
determine the crown-lengthening treatment
approach. Garber & Salama (24) suggested that there
are only two treatment options for cases of altered
passive eruption: first, a simple gingivectomy to
expose the hidden anatomy in cases of altered passive
eruption type 1A; and, second, an apically reposi-
tioned full-thickness flap, with or without osseous
Fig. 17. (A) Periapical radiograph
with gutta-percha cone identifying
the gingival margin. Two different
lines (one more coronal for the
cemento–enamel junction and one
more apical for the bone crest) can
be distinguished in the radiograph;
the diagnosis of altered passive erup-
tion subtype A is confirmed. (B)
Intra-operative photograph confirm-
ing altered passive eruption subtype
A.
11
Mele et al.

A B

Fig. 18. (A) Periapical radiograph

with gutta-percha cone identifying
the gingival margin. It is difficult to
establish the buccal bone crest posi-
tion in relation to the cemento–
enamel junction, but as this line is
more than 3 mm apical to the refer-
ence cone, it is possible to make a
diagnosis of altered passive erup-
tion. (B) Intra-operative photograph
showing altered passive eruption
subtype B.

resective surgery, in other cases of altered passive A

eruption.

Type 1 subgroup A: gingivectomy/

gingivoplasty
When it is determined that the osseous level is appro-
priate, such that there is more than 1 mm separating
the buccal bone crest from the cemento–enamel B
junction, and that an adequate height of attached
gingiva will remain after surgery (type 1A), a simple
gingivectomy is indicated (64) (Figs 19 and 20). The
initial incision should be precise, symmetric and
reflect the normal gingival architecture, so that the
gingival zenith is slightly distal to the midline of the
tooth. To aid this precision, the initial incision is
lightly scored on the gingiva at the level of the C
cemento–enamel junction. Dolt & Robbins (21) claim
that it is difficult to make the initial scoring incision
accurately while sitting behind the patient and sug-
gested sitting in front of the patient and using an
acrylic resin or resin composite stent as a surgical
guide. Kurtzman & Silverstein (36) propose the use of
a black permanent marker guide line for the initial
incision, along with a surgical template. The dentist Fig. 19. Altered passive eruption type 1A treated with gin-
can then return to sitting behind the patient and givectomy. (A) Presurgical view. (B) Minimal gingival cor-
rections not involving bone removal. (C) Postsurgical view.
complete the beveled, full-thickness gingivectomy
incision. A second incision is made in the sulcus of
each tooth, which leaves a gingival collar that is contour, including scalpel, electrosurgery or carbon
excised with a periodontal curette. The tissue should dioxide laser (1, 9, 64). A bipolar electrosurgery pen
be removed cervically so as to not compromise the can be used under copious irrigation for the gin-
interdental papillae, which should be left undisturbed givectomy, then a gingivoplasty pen can be used to
except for minor blending into the gingivectomy inci- plane back the bulky tissue at the papilla and pro-
sion. vide a more natural contour. Finally, a coagulation
The literature suggests that a variety of instru- ball pen can be used in the bipolar unit on coagu-
ments can be used to expose the cemento–enamel lation mode to seal any bleeding over the gingivo-
junction and to obtain a more physiologic gingival plasty surface (36).

12

A B
Fig. 20. Esthetic improvement of the smile sometimes requires minor surgical soft-tissue changes. (A) Patient’s smile
before surgery (case shown in Fig. 19). (B) Patient’s smile 1 year after gingivectomy (case shown in Fig. 19).
Type 2 subgroup A: apically positioned
flap
In type 2A the width of the keratinized band of gin-
giva is relatively normal, and so a convectional gin-
givectomy might eliminate too much of the
keratinized gingiva, leaving the patient with nonideal
alveolar mucosa at the crown margin. The ideal man-
agement of patients with type 2A involves apical
repositioning of the band of keratinized gingiva to a
point at, or near, the cemento–enamel junction.
According to Zucchelli (66), apically positioned flap is
the treatment of choice in the vast majority of the
patients affected by altered passive eruption with an
increased thickness of the buccal bone, necessitating
osteoplasty.
Types 1 and 2 subgroup B: apically
positioned flap with osseous resective
surgery
When the diagnostic procedures reveal osseous levels
approximating the level of the cemento–enamel junc-
tion, ostectomy is indicated. This procedure is often
associated with an apically positioned flap, even if
some authors suggest a flapless esthetic crown-
lengthening procedure (48). The initial incision either
can be carried out as described for the gingivectomy
procedure, with or without a surgical template, or can
be made as a sulcular incision. The position of the
incision depends on a number of factors, including
the width of the buccal keratinized tissues, with
greater keratinized tissue width indicating a more
paramarginal incision; the cemento–enamel junc-
tion/buccal bone crest position, for which the more
apical the cemento–enamel junction/bone crest from
the gingival margin, the more submarginal is the inci-
sion; and dental esthetic proportion criteria, which
dictate that the gingival margins of the lateral incisors
should be coronal to the margins of the canines and
central incisors (Rufenacht gingival class 1) (52).
As a general rule, the incision should be made as
submarginal and as scalloped as possible. This allows
the incision to reproduce the scalloped outline of the
Esthetic treatment of altered passive eruption
cemento–enamel junction and allows wound healing
by primary intention at the level of the interdental
space. A variable-thickness flap is elevated, being split
thickness at the surgical papillae and full thickness at
the buccal aspect of the incision, with the aim of pro-
viding a uniform thickness of the surgical flap. The
incisions cut across the buccal surface of each papilla,
leaving the papilla totally intact interproximally
(Fig. 21). This flap design preserves papillae height
and provides fixed tissue for flap stabilization during
suturing. In fact, because no biologic requirement
exists for the removal of interproximal bone, the buc-
cal interdental papilla are not reflected with the flap.
Therefore, it is prudent to elevate a buccal flap, leav-
ing the interproximal papillae and the palatal tissue
intact so as to not compromise the blood supply to
those tissues, thereby decreasing the probability of
tissue shrinkage. A full-thickness flap is reflected
beyond the mucogingival junction, and the positions
of the cemento–enamel junction and bone crest are
verified visually. Osteoplasty is performed to reduce
bone thickness, while ostectomy is performed to
establish the correct distance between the cemento–
enamel junction and the bone crest. The buccal flap
reflection stops 3–5 mm apical of the buccal bone
crest and is governed by the extent of the osteoplasty
– for example, if the buccal bone is particularly thick,
more osteoplasty is indicated and the margins of the
full-thickness flap are more apical. The osteoplasty is
carried out using a high-speed rotary instrument,
such as a diamond or carbide round bur. According
to Zucchelli (66), most of the osteoplasty is performed
at the interradicular areas, where concave surfaces
are created (Figs 5, 21 and 22) for subsequent reposi-
tioning of the thinned surgical papillae in order to
minimize rebound of the interdental soft tissue.
Disagreement among authors exists in the amount
of octectomy that is needed in order to establish the
correct distance between the cemento–enamel junc-
tion and the buccal bone crest. Some authors suggest
1 mm (13, 66), while others suggest 2 mm (14, 18, 50),
2–2.5 mm (21, 49) or 3.0 mm (8, 11). Camargo et al.
(14) suggested measuring the dimension of the bio-
logical width on the teeth not affected by altered
13
Mele et al.
A B
C D
E F
Fig. 21. Surgical treatment of altered passive eruption
with apically positioned flap and osseous resective sur-
gery. (A) The clinical crowns of the maxillary canines
and lateral incisors are very short. Note the increased
volume of buccal bone. (B) Submarginal incisions are
cut across the buccal surface of each papilla, leaving the
papilla totally intact interproximally. The buccal flap is
elevated using a split full-thickness approach. (C) After
removal of the marginal issue and de-epithelization of
the anatomical papillae, the increased bone thickness is
evident. No physiological distance exists between the
cemento–enamel junction and the bone crest, for
passive eruption. In cases where altered passive erup-
tion affects all teeth, the authors suggest making an
empirical decision as to the extent of the ostectomy
to be performed, indicating that a 2 mm distance
between the cemento–enamel junction and the bone
crest is adequate in the majority of cases. Further-
more, the same authors advocate the additional
removal of bone in the thick biotype to reduce soft-
tissue regrowth and to ensure a stable long-term
result (14). Other authors do not indicate any specific
value, sometimes using terms such as ‘correct anat-
omy’ or ‘adequate ostectomy’ (22, 51, 64). Some
authors use the margin of the flap as a reference
instead of the cemento–enamel junction and osseous
resection can be carried out such that there is at least
3 mm between the osseous crest and the newly cre-
ated free gingival margin (1, 15, 37) (Table 1). In spite
of difference in the extent of the ostectomies, all
authors claim that the purpose of the ostectomy is to
allow space to accommodate the ‘biologic width’.
Chu & Karabin (18) discuss, in detail, scalloping bone,
with the parabolic form of the osseous crest over the
radicular surface mimicking the original osseous
14
connective tissue attachment (subgroup B). (D) Osteo-
plasty (to reduce bone thickness) and ostectomy (to re-
establish space for connective tissue attachment) were
performed. A view of the osteoplasty is shown in Fig. 5.
(E) The flap is positioned at, or 1 mm coronal to, the
cemento–enamel junction and secured with interrupted
sutures, anchoring the surgical papillae to the interdental
de-epithelized anatomical papillae. (F) After 6 months of
healing, clinical crown lengthening, harmonious kera-
tinized height over the teeth treated and correct esthetic
proportion criteria are observed. The smile of the patient
before and after treatment is shown in Fig. 13.
architecture that is thick-flat or thin-scalloped,
depending on the periodontal biotype present (18).
As the bony architecture should reflect the desired
soft-tissue architecture, Cairo et al. (13) and Zucchelli
(66) suggested shaping the osseous crest parallel to
the cemento–enamel junction (Figs 21 and 22).
Ostectomy may be carried out with hand instru-
ments, such as Oschenbein or Weidelstadt chisels.
The majority of authors advise against scaling or root
planing the denuded root surfaces after ostectomy.
This recommendation not to damage or remove the
root cementum relies on the fact that performing
scaling or root planing could produce additional,
unpredictable attachment and bone loss with poten-
tial impact on the esthetic outcome for patients. On
the other hand, in the procedure suggested by Ribeiro
et al. (48) and Cairo et al. (13), the exposed root sur-
faces are carefully planned using curettes.
Similarly, no agreement exists on the flap position-
ing at the end of the surgery, with some authors sug-
gesting suturing the flap at the cemento–enamel
junction (21, 48) and others suggesting that the sutur-
ing should be slightly coronal to the cemento–enamel
 Esthetic treatment of altered passive eruption

A B

C D

E F

Fig. 22. Surgical treatment of altered passive eruption
with apically positioned flap and osseous resective sur-
gery. (A) The clinical crowns of the teeth are short and
asymmetrical at the level of the lateral incisors. (B) Flap
elevation and de-epithelization of the anatomical papil-
lae. No physiological distance exists between the
cemento–enamel junction and the bone crest for attach-
ment of connective tissue in any of the teeth included in
the surgical area (subgroup B). (C) Osteoplasty (to reduce
bone thickness) and ostectomy (to re-establish the cor-
rect space for connective tissue attachment) were per-
formed. (D) The flap is positioned at, or 1 mm coronal
to, the cemento–enamel junction and is secured with
interrupted sutures anchoring the surgical papillae to the
interdental de-epithelialized anatomical papillae. (E) At
the time of suture removal (14 days) the soft-tissue mar-
gins are localized almost at the same level of the end of
the surgery. (F) One year after surgical treatment. The
length of the teeth did not change significantly with
respect to the time of suture removal. Note clinical
crown lengthening with respect to the baseline situation
and the harmonious keratinized tissue height over the
treated teeth. Both of these factors contribute to enhanc-
ing the esthetic outcome.

Table 1. Suggested distance post-ostectomy between the bone crest and cemento–enamel junction or gingival margin
to re-establish biological width

Authors Suggested distance between the bone crest and cemento–enamel

junction or gingival margin to re-establish biological width

Cairo et al. 2012 (13) Bone crest to cemento–enamel junction, 1 mm

Zucchelli 2012 (66) Bone crest to cemento–enamel junction, 1 mm

Camargo et al. 2007 (14) Bone crest to cemento–enamel junction, 2 mm

Rossi et al. 2008 (50) Bone crest to cemento–enamel junction, 2 mm

Dolt & Robbins 1997 (21) Bone crest to cemento–enamel junction, 2–2.5 mm

Robbins 1999 (49) Bone crest to cemento–enamel junction, 2–2.5 mm

Batista et al. 2012 (8) Bone crest to cemento–enamel junction, 3 mm

Ribeiro et al. 2014 (48) Bone crest to cemento–enamel junction, 3 mm

Levine & McGuire 1997 (37) Bone crest to gingival margin, ≥ 3 mm

Claman et al. 2003 (15) Bone crest to gingival margin, ≥ 3 mm

Abou-Aray & Souccar 2013 (1) Bone crest to gingival margin, ≥ 3 mm

15
Mele et al.
A B
C D
junction (13, 49). Zucchelli (66) suggested de-epithe-
lialization of the most coronal aspect of the interden-
tal papillae with microsurgical scissors and
repositioning the flap at, or 1 mm coronal to, the
cemento–enamel junction (Figs 21 and 22) with the
aim of giving the patient the final tooth length imme-
diately after surgery with no further significant post-
operative changes (Fig. 22). If clinical crown
lengthening is indicated on the palatal aspect, the
surgical procedure should be ideally performed on a
separate occasion, leaving the buccal and interproxi-
mal tissue undisturbed (Fig. 23).
Flapless procedure with osseous resective
surgery
Ribeiro et al. (48) suggested a minimally invasive flap-
less esthetic crown-lengthening procedure for the
treatment of altered passive eruption. The alveolar
bone is removed and recontoured using microchisels,
via incision, without flap elevation. In this split-mouth,
randomized controlled trial, esthetic crown lengthen-
ing, with or without flap elevation, was found to have
similar and stable clinical results up to 12 months. The
authors suggest using the flapless procedure because
it seems to be a feasible, predictable and time-saving
(31  12 min vs. 41  14 min) method for treatment
of gummy smile caused by altered passive eruption
compared with flap elevation (48). However, this tech-
nique is not applicable in cases of type 2B altered pas-
sive eruption.
Discussion and conclusions
Passive eruption is a complex process that lasts for at
least 20 years in the anterior sextant, in keeping with
changes related to the development of the rest of the
16
Fig. 23. Surgical treatment of altered
passive eruption in the palatal
aspect. (A) Baseline situation with
the soft tissue covering the palatal
cingulum. (B) Flap elevation, ostec-
tomy and osteoplasty. (C) Apically
positioned flap. (D) One-year out-
come with longer clinical crowns.
body. Many unanswered questions remain regarding
the diagnosis, etiopathogenesis, treatment indica-
tions and therapy of altered passive eruption. Most
studies investigating aspects of altered passive erup-
tion are preliminary studies characterized by small
sample sizes, and as there are no studies evaluating
changes in clinical crown length in subjects older
than 20 years of age, no conclusions regarding the
diagnosis, etiopathogenesis and surgical treatment
need for altered passive eruption can be made. The
clinical diagnosis of altered passive eruption also
remains uncertain because of the difficulty in distin-
guishing between the cemento–enamel junction and
the buccal bone crest during probing or ‘bone sound-
ing’. Long-cone periapical radiographs, even when
improved with radiopaque reference points, do not
always provide unequivocal information regarding
the positions of the cemento–enamel junction and
the buccal bone crest because of the similarity in their
radiopacities. Frequently, clinical observation, even if
not supported by data, reveals thick buccal bone in
patients affected by altered passive eruption. This
could explain the lack of gingival retraction, at least in
patients with a normal, physiologic relationship
between the cemento–enamel junction and bone
crest (subgroup A).
There are no data in the literature reporting how to
perform nonsurgical treatment and maintenance
therapy in patients affected by altered passive erup-
tion and pseudopockets. One limitation is because it
is impossible to perform the equivalent of ‘root plan-
ing’ on enamel in order to reduce the depth of the
pseudopockets. A second limitation derives from the
risk of inducing gingival shrinkage as the conse-
quence of trauma to the inner soft-tissue wall of the
pseudopockets during instrumentation, which can
create an unesthetic and unpredictable alignment of
the soft-tissue margins between adjacent teeth.

The difficulties in selecting an appropriate surgical
technique for the management of altered passive
eruption partly spring from difficulties in arriving at
an accurate diagnosis of altered passive eruption. In
particular, the difficulties in distinguishing between
subgroup A or subgroup B, along with the additional
challenge of the presence of different subgroups of
altered passive eruption among teeth in the same sur-
gical area, complicate surgical treatment planning. If
there is a lack of need for osteotomy or ostectomy, as
in the case of minor disharmonies of the soft-tissue
margin, then simple gingivectomy is the treatment of
choice. However, most cases of altered passive erup-
tion have a need for ostectomy or osteoplasty as a
result of excess bone volume, necessitating an api-
cally repositioned flap with bone recountouring as
part of their surgical management. The main dis-
agreement among the authors relates to the correct
distance between the bone crest and the cemento–
enamel junction (ranging from 1 to 3 mm) in patients
with altered passive eruption subgroup B. This dis-
tance is critical in determining the amount of ostec-
tomy to be performed during surgery. The confusion
is probably caused by the high variability in the width
of the human dentogingival junction. However,
because this distance should reflect the area occupied
by the connective tissue attachment only, it should
not be greater than 1–1.5 mm. This area should not
be instrumented (root planed) during surgery as this
could lead to further, unpredictable bone and attach-
ment loss.
Surgical treatment of altered passive eruption
results in an esthetic change in the patient’s appear-
ance and smile, and despite this there are a lack of
studies evaluating how often patients request treat-
ment of altered passive eruption for esthetic reasons,
as well as a lack of studies evaluating patients’ satis-
faction with the surgical treatment outcome. It is
clear that not all ‘concerns’ that the clinician per-
ceives will be noticed by most of the lay public and
hence they should not necessarily be corrected in the
name of esthetics.
References
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