Periodontal Plastic Surgery for the Management of Altered

is characterized by an excessive amount of attached CASE DESCRIPTION

Passive Eruption: 5 Months Follow-Up Case Report gingiva, while type2 is associated with a normal gingival
dimension. Two possible subclasses were also suggested.
In subcategory A, the distance Osseous Crest - CEJ is
Safa BEN TANFOUS - DDS greater than 1mm, while in subcategory B the bone
Resident, Department of Periodontology, Faculty of Dental Medicine of Monastir | Tunisia | safabentanfous1987@gmail.com crest is in the CEJ.1 However, several authors criticized
the fact that this classification did not take into account
Rym MASMOUDI - DDS
the altered active eruption (AAE).10 The latter physiologic
Resident, Department of Dentistry, Military Hospital of Tunis | Tunisia
variation, characterized by the proximity or coincidence
Omar MAROUANE - DDS of the alveolar crest to the CEJ,10,11 was described as the
Resident, Restorative Dentistry, Dental Surgery Department, University Hospital Sahloul, Sousse | Tunisia subgroup B of the APE. Moreover, the possible association
Omar HALOUAN - DDS between APE and AAE was not well described. Recently,
Resident, Department of Periodontology, Faculty of Dental Medicine of Monastir | Tunisia a modification of the previous classification based on
eruptive and biological concepts has been suggested.10
Marwa M’BAREK - DDS
Firstly, This modified classification preserved APE Type I
Resident, Department of Periodontology, Faculty of Dental Medicine of Monastir | Tunisia
and Type II according to amount of keratinized gingiva,
Leila GUEZGUEZ - DDS, PhD but values were added to facilitate diagnosis (Type I- >
Professor, Department of Periodontology, Faculty of Dental Medicine of Monastir | Tunisia 2mm of keratinized tissue/ Type II- ≤ 2mm).12 Secondly,
the subgroups A, B were excluded while categories of APE
alone or APE associated with AAE were included.10
ABSTRACT
Except its esthetic consequences, several authors
Background: Altered passive eruption (APE) is defined as the situation in which “the gingival margin in the adult consider that APE is a risk situation for the periodontal
is located incisal to the cervical convexity of the crown and removed from the cemento enamel junction (CEJ) of the health. Indeed, difficulties in oral hygiene and narrow
tooth. Clinical features of APE include excessive display of gingiva upon smiling associated to short clinical crown connective attachment are both highlighted.4 It is
appearance, since the gingival margin overlaps the anatomical crown. This condition may create esthetic concerns. In particularly important for APE-I-AAE, APE-II associated or
fact, teeth seem to be hidden, clinical crowns appear square in shape, and the gingival festooning is flattened. not to AAE.1 Moreover, for Volchansky3 there is a positive
Case Report: This case present the management of a case of APE type I diagnosed in a 20-year-old systemically correlation between APE and acute necrotizing ulcerative
healthy female. The patient was unhappy with her smile. In fact, she was especially uncomfortable with gingival gingivitis. From this point of view, APE should be treated
display when smiling and with “The black hole” between teeth 11 and 21. Initial periodontal therapy (IPT) was even if patient has not esthetic demand.
applied including oral hygiene instructions and scaling. Then, an external bevel gingivectomy was performed followed
by the frenectomy of the upper labial frenum. Gingival healing was uneventful. The gingival line steel stable 5 months Periodontal surgery leads to improving the esthetic
postoperative, and the papilla between teeth 11 and 21 filled the whole interproximal space. aspect of the lower third of the face by establishing the
proper tooth proportion and by placing the gingival
Conclusions: The proper treatment of APE may enhance the smile. From this point of view, external bevel
margin in a suitable position relative to the lip.10,11,13 The
gingivectomy is an effective procedure in case of APE type 1. In some cases, frenectomy may improve the aesthetic
type of treatment proposed for each one of the different
result. These techniques, lead to stable results.
clinical situations of APE is based on its classification.10
KEYWORDS
The aim of this paper is to present the management of
Altered passive eruption, Gummy smile, External bevel gingivectomy, Gingival overgrowth. a case of APE type I with an external bevel gingivectomy
associated to frenectomy and its 5-month follow-up.
A 20-year-old systemically healthy female, was referred
to the department of periodontology of the faculty
of dental medicine of Monastir (Tunisia) with a chief
complaint of an unacceptable aesthetic result following
orthodontic treatment.
The patient was unhappy with her smile. She was
especially uncomfortable with gingival display when
smiling. Moreover, she didn’t like “The black hole”
between teeth 11 and 21.
The clinical examination revealed short and square in
shape clinical crown appearance. The “black hole”
between teeth 11 and 21 was effectively present. In
addition, transgingival probing revealed that the bone
crest was situated 3mm apically to the CEJ. Finally,
gingival overlapping was noted when smiling, especially
in regards to teeth 12 and 22. (Figure 1a-b)
Regarding these clinical parameters this patient was
diagnosed with type I APE, according to the classification
of Ragghianti.10
The treatment protocol included an initial periodontal
therapy whose objective is to reduce gingival
inflammation. Then, periodontal surgery aiming the
enhancement of the smile by establishing the proper
tooth proportion was performed.
The conventional non-surgical therapy consisted in a
full mouth scaling. In addition, the patient was advised
to perform and maintain her oral hygiene by brushing
3 times a day and to use a chlorhexidine mouth rinse of
0.2% twice daily.
The surgical therapy comprised an external bevel
gingivectomy concerning only the 4 maxillary incisors;
associated with frenectomy of the upper labial frenum.
First, the pockets were probed and bleeding points
produced. Then, the primary incision was made with

INTRODUCTION
Altered passive eruption (APE) was first defined by Coslet
et al. in 1977.1 It is the situation in which “the gingival
margin in the adult is located incisal to the cervical
convexity of the crown and removed from the cemento
enamel junction (CEJ) of the tooth”.2 “Retarded passive
eruption” or “delayed passive eruption” have been also
proposed to define this periodontal status.3
The term APE refers to the mechanism underlying
production of this morphological variant. Indeed, it is
attributed to failure in concluding the passive eruption
phase.4,5 The Glossary of Periodontal terms of The
American Academy of Periodontology defined this
eruption stage as the tooth exposure secondarily to
apical migration of the gingival margin to a location at
or slightly coronal to the CEJ.6 This variation in habitual
morphology is considered as a physiological situations
and in any case as a pathological one.4
Clinical features of APE include excessive display of
gingiva upon smiling associated to short clinical crown
appearance, since the gingival margin overlaps the
anatomical crown.1,7 This condition may create esthetic
concerns. In fact, teeth seem to be hidden, clinical
crowns appear square in shape,4,8 and the gingival
festooning is flattened.4
a b
The classification proposed by Coslet et al.1 is the most (Fig. 1) a) Pretreatment view of upper anterior teeth. Note the short and square in shape clinical crown appearance
frequently cited in the literature. According to which, b) Photography of the pre-treatment smile showing gingival overlapping when smiling
APE has been divided into two main types.3,9 The Type1

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 Kirkland knife; while the secondary one was made with
Orban knife. After removing carefully the incised tissues
with a 15 blade, the gingival contour was corrected by
gingivoplasty using a fine pair of gingival scissors. Once
gingivectomy realized, we performed maxillary labial
a b
c d
e e) The gingival contour is
g h
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frenectomy. We insisted on removing the fibrous attachment
on the bone by a periodontal curette. Finally, the edges of
the mucosal slope of the diamond shaped wound were
sutured with interrupted sutures; while the gingival wound
was covered with a periodontal pack. (Figure 2a-h)
(Fig. 2)
a) The pockets are probed
and bleeding points produced
b) The primary incision made
with Kirkland knife
c) The secondary incision
made with Orban knife
d) The incised tissues are
carefully removed
corrected f) X-ray
g) labial frenectomy
h) sutures of the edges of the
f diamond shaped wound
Following surgical operation, paracetamol 2x3 for
5 days (Adol® 500mg, SAIPH,˙Tunis, Tunisia) and
chlorhexidine oral rinse 1x2 for 10 days (Eludril® 90mL
SIMED, Tunis, Tunisia) were prescribed. The pack and the
sutures were removed 1 week post-operatively.
1 week after surgery, healing was uneventful and the
gingival margin was situated in the CEJ with a scalloped
gingival architecture. The gingival line steel stable 5
months postoperative, and the papilla between teeth
11 and 21 filled the whole interproximal space (Figure
3a-b). Moreover, the smile was enhanced and the patient
was satisfied of the final clinical outcomes (Figure 4).
a in the early teen years. On the other hand, Zucchelli G.13
b 1. Vertical maxillary excess (VME):
(Fig. 3) a) Soft tissue healing 1 week after surgery
b) clinical photography 5 months post-operative.
Note the stability of the gingival line and that the papilla
between teeth 11 and 21 filled the whole interproximal space
(Fig. 4) Photography of the final patient smile after healing.
Note that the papilla filled the hole interproximal space
between teeth 21 and 11
DISCUSSION
The etiology of APE remains unclear.4,8 Several factors have
been evoked, such as interocclusal interference on the soft
tissues during the eruptive phase.4 The periodontal biotype
was, also, cited. As a matter of fact, the thick and fibrotic
gingival tissue tend to migrate more slowly during the
passive phase than fine gums.4 Whatever, few studies have
related such mechanisms to the morphology of the coronal
periodontium.5,8 The hereditary factor was incriminated
too, and it seems to be confirmed. Indeed, According to
a recent preliminary study: 65% of patients diagnosed
with APE had at least one family member showing the
same condition, and 15% had the whole family group with
altered passive eruption.4,14
To diagnose APE, clinicians must take in account the
patient age. Nevertheless, there is controversy surrounding
the life time at which a diagnosis of APE can be made.
In fact, all authors13,15-17 agreed to say that we can speak
of an APE only when the passive phase of the eruption
remains incomplete after the patient has completed his
growth, it is rather the age at which the passive eruption
ends which creates disagreement. Evian CI15 believed
that the anterior teeth typically undergo passive eruption
stated that passive eruption continuous until patients had
completed their growth i.e.18 to 20 years for the woman
and 20 to 22 years for man. However, Volchansky A.16
Indicated that by the age of 20 years passive eruption had
not yet ceased in the anterior teeth. Weinberg M.17 agreed
and stated that no study had investigated what happens
past 20 years of age.
To establish a diagnosis of APE we have to proceed of
elimination. Etiology of gingival display while smiling,
other than APE, must be excluded:
A visual diagnosis of
VME is made when the lower third of the face is longer
than the remaining thirds;18 cephalometric analysis can
be, also, useful.19 In this case, the lower third of the
face was proportionate to the remaining thirds.
2. Hypermobile upper lip (HUL): during smiling there was
8mm of lip rising. Thus, the diagnosis of hyperactive
upper lip was excluded. In fact, according to Garber
et Salama20 the normal shift of the upper lip during
smiling is 6 to 8mm and it is 1.5 to 2 time higher in
cases of hyperactivity of the upper lip.
3. A short upper lip:measured from the subnasale to the
inferior border of the upper lip, the length of the upper
lip of our patient was 21,5mm which is in the normal
rang of the maxillary lip length i.e. 20 to 22mm in
young adult females.21
was also
4. Incisal Attrition with compensatory eruption:
excluded since there is no generalized tooth surface
loss.11
5. Gingival overgrowth: since CEJ was not detectable in
the sulcus this etiology was discarded too.22
Smile Dental Journal | Volume 12, Issue 3 - 2017 | 27 |
 6. Regarding these parameters, only APE could explain
the gingival display while smiling. Moreover, teeth
seem to be hidden, clinical crowns appeared square in
shape,4,8 and the gingival festooning was flattened.4 This
effectively corresponds to the clinical aspect of APE.1
The second step is to verify if AAE was associated to
APE.10 In fact, the crestal bone, landmarked by bone
sounding, was 3mm apically to the CEJ which was
enough to the connective tissue attachment and junction
epithelium. The biologic width was also verified by
X-ray.22-24 Whatever, radiographic interpretations are
only diagnostic on the interproximal area. On the facial
aspect of teeth they cannot identify the violations of
biologic width because of tooth superimposition.25 Thus
AAE was excluded.
Regarding all these clinical data, our patient was
diagnosed with type I APE, according to the classification
of Ragghianti.10 In fact, a wide band of keratinized gingiva
(>2mm) in the buccal aspect of incisors was noted.
After the conventional non-surgical therapy, treatment
protocol includes the surgical phase. It comprised, as
suggested by several authors,10,20 a gingivectomy to
expose the hidden clinical crown. In this case, regarding
the important amount of attached gingiva, we proceeded
to an external bevel gingivectomty. Indeed, festooning of
the gingiva and reestablishing gingival physiology are
much better mastered with external bevel gingivectomy
than with internal bevel one. It is to highlight that apically
positioning flap cannot be indicated in this case; it is only
reserved to APE-II.10,20 Regarding osseous resection, it
was unnecessary since AAE was excluded.1,10,11,26
The upper labial frenum had a papillary attachment.27
This type of insertion was mainly associated with
papillary loss and recession.28,29 In our case study,
it was concluded that the “The black hole” resulting
from the papilla apical displacement was caused by
tension exercised by frenum fiber on the interdental
papilla between teeth 11 and 21. The loss of the
involved papilla cannot be the result of periodontitis.
In fact, probing depth did not exceed 3mm at all teeth,
especially in the mesial aspect of teeth 11 and 21.
Whatever, bleeding in probing was present. Moreover,
no bone loss was noted in the radiographic (figure
2f). Our patient was diagnosed with a plaque induced
gingivitis which don’t involve deep periodontium.30 Thus,
frenectomy was performed during which the greatest
attention was given to the elimination of frenum fibers
inserted in the papilla.
5 months post-operative, the gingival margin steel stable
and the smile was enhanced. The papilla between teeth
11 and 21 filled the whole interproximal space. Moreover,
the patient was satisfied of the final clinical outcomes.
| 28 | Smile Dental Journal | Volume 12, Issue 3 - 2017
CONCLUSION
APE is an uncommon physiologic variation of the
morphology of the dentogingival unit. Although, it
implies very important esthetic concerns and it is, also,
considered as a risk factor for periodontium. Thus, the
treatment of APE should be undertaken even if patient
doesn’t express esthetic demand.
The proper treatment of APE may enhance the smile.
From this point of view, external bevel gingivectomy is
an effective procedure in case of APE type 1. In some
cases, frenectomy may improve the aesthetic result.
These techniques, lead to stable results.
ACKNOWLEDGMENTS
The authors acknowledge Research Laboratory of Oral
Health and Orofacial Rehabilitation LR12 ES11, Faculty
of Dental Medicine, Monastir University, Tunisia.
CONFLICTS OF INTEREST
The authors declare that there is no conflict of interest
regarding the publication of this paper.
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