Esthetic crown lengthening with ostectomy and frenotomy for treatment of gummy smile: A case report from Prof. Soedomo Dental Hospital, Yogyakarta-Indonesia

To clinically evaluate the effect of the application of a Zirconia biovolume combined with surgical crown lengthening in patients with altered passive eruption, vertical maxillary excess, and excessive gingival display. Three systemically healthy patients (two female, one male) presenting altered passive eruption (APE) Type 1 Subtype B with vertical maxillary excess (VME) and gingival display > 5 mm were treated with a protocol consisting in the preparation of a Zirconia biovolume to be applied in the anterior maxilla at the same time of surgical crown lengthening. Intra and extra oral scans were taken, as well as CBCT and printing of stereolithographic models in order to study the cases, plan the fabrication of the biovolume, and plan the surgical crown lengthening. Patients were followed for up to 12 months. Healing was uneventful in all three cases, and all patients were satisfied with the esthetic outcome in terms of surgical crown lengthening, gingival exposure, and lip repositioning. These three cases show how the planning of cases with excessive gingival display, VME, and APE can be treated with a planned surgical procedure that will at the same time solve the problem of gingival exposure and the position and support of the upper lip.

Background: A smile, a good harmonization of teeth, alveolar bones and gums inside the oral cavity can improve one’s appearance and self-confidence. Short clinical crowns have become a frequent chief complaint. One of reasons for this is the altered passive eruption. Objective: To describe the correction of altered passive eruption by performing crown lengthening with an osteotomy to achieve ideal clinical crowns and restore the functions and aesthetics. Case Report: A 31-year-old man was admitted to the Periodontics Clinic of Rumah Sakit Gigi dan Mulut, Universitas Gadjah Mada Prof. Soedomo, Yogyakarta, Indonesia, with a chief complaint of front teeth looking short. He was diagnosed with an altered passive eruption in connection with a gummy smile. Crown lengthening was performed by gingivectomy technique with osteotomy, and interdental papilla was preserved. Conclusion: Crown lengthening is an effective treatment in correcting dysfunctions and aesthetics due to altered passive eruption. Keywords: altered passive eruption, short clinical crowns, crown lengthening procedure, osteotomy, papilla preservation

Traumatic dental injuries are common in young patients and most often affect the maxillary anterior region, leading to complex aesthetic and functional challenges. This clinical report describes the comprehensive rehabilitation of a 17-year-old male who presented with severe trauma to the maxillary central incisors. Clinical and radiographic examinations revealed extensive tooth structure loss, short clinical crowns, diastemas and excessive gingival display. A prosthodontics-centered multidisciplinary approach was implemented, involving endodontic retreatment, orthodontic therapy, aesthetic crown lengthening, guided implant placement and definitive prosthetic restorations. Digital tools, including CBCT, intraoral scanning, and smile design software, aided diagnosis, planning and patient treatment. After orthodontic treatment and surgical crown lengthening to optimize teeth position and soft and hard tissue architecture, two dental implants were placed using a fully guided protocol. The definitive restorations included implant retained screw-retained zirconia crowns for the maxillary central incisors and lithium disilicate veneers for the maxillary adjacent teeth. The treatment sequence addressed patient's biological, functional and aesthetic concerns. This clinical report underscores the significance of diagnostics, multidisciplinary collaboration and correct treatment planning in achieving optimal long-term results for young patients with highly complex treatment needs, such as anterior dental trauma.


 Introduction: Gingival tissue plays an important role in smile aesthetics, especially in the anterior maxillary region. A gummy smile (GS) is a gingival condition that appears excessive when the patient smiles. The prevalence of gummy smile in individuals aged from 20 to 30 is 10% of population. It is more common in women and can cause aesthetic problems. Gummy smile aetiology is multifactorial. This case report discusses gummy smile case caused by altered passive eruption (APE) and associated with the presence of aberrant frenum. Case Report: A 19-year-old female patient with chief complaints of the excessive gingival display. The diagnosis of the case was confirmed by clinically healthy gingiva in an intact periodontium with gummy smile due to the presence of altered passive eruption type I-B accompanied by an aberrant frenum. The final surgical plan was aesthetic crown lengthening (CL) with flap surgery and osteotomy simultaneous with a frenotomy. Conclusion: The aesthetic crown lengthening surgery and frenotomy can be performed simultaneously to correct the gummy condition and improve the patient’s smile profile. Appropriate examination, diagnosis, and treatment planning help achieve optimal patient outcomes.

Managing excessive gingival display (EGD) is challenging and requires precise diagnosis and etiology-driven treatment for long-term stability. This report describes a digitally guided, staged approach combining esthetic crown lengthening (ECL) and lip repositioning (LR) for multifactorial EGD. A 28-year-old female presented with 7 mm of gingival display on dynamic smile, upper lip length of 19 mm, and lip mobility of 6 mm. The etiologic diagnosis was vertical maxillary excess (VME) Class II, hyperactive upper lip (HUL), and altered passive eruption (APE) (Coslet Type 1 B). Digital planning was performed using 3Shape intraoral scanning integrated with digital smile design (DSD) to establish target gingival zeniths and smile line. A dual-purpose three-dimensional (3D)-printed surgical guide (Form 3, Formlabs) was designed to (1) control the apical extent of crown lengthening and (2) visualize the anticipated dynamic lip line, targeting a residual gingival display of 2-3 mm. Phase 1 involved ECL with gingivectomy and osseous recontouring to reestablish biologic width and create ideal crown proportions. After 6 weeks of healing, LR was performed following Bhola's technique with a partial-thickness mucosal excision, selective myectomy, and deep horizontal mattress sutures for stabilization. Gingival display reduced from 7 mm at baseline to 0 mm at 3 months, and measured ~2-3 mm after 5 years of follow-up, maintaining a pleasing smile arc and high patient satisfaction. A digitally guided staged approach integrating ECL and LR effectively managed combined EGD etiology. The 3D-printed guide enhanced surgical precision and predictability, with sustained esthetic improvement at 5 years and minor recurrence (2-3 mm).

In many cases, the cause of a gummy smile is a combination of many simultaneously occurring factors. Therefore, a single method is certainly not effective in achieving the maximum aesthetic requirements. This study aims to evaluate the efficacy of combining clinical tooth crown lengthening surgery and subsequent BTX-A injection in gummy smile treatment using clinical and photographical assessment. 21 patients with an average length of excessive gingival display of at least 4 mm at maximum smiling point and with the height of keratinized gingiva ≥ 3 mm were recruited. Gingival exposure (GE) and clinical crown length (CCL) were measured at baseline (T0), two months after clinical crown lengthening surgery (T1), two weeks after BTX-A injection (T2), two months after BTX-A injection (T3). GE values at T1, T2 and T3 were significantly different (p <0.001). CCL was significantly changed after gingivectomy surgery (T1) compared to preoperative value (T0) (p <0.001). BTX-A could be considered a favorable adjunctive treatment for gummy smile patients after gingivectomy surgery.

Excessive gingival display (EGD) has a negative impact on a pleasant smile. Minimally invasive therapeutic modalities have become the standard treatment in many dentistry fields. Therefore, the aim of this study is to compare the clinical outcomes of open-flap (OF) and minimally invasive flapless (FL) esthetic crown lengthening (ECL) for the treatment of EGD. A split-mouth randomized controlled trial was conducted in 28 patients presenting with EGD. Contralateral quadrants received ECL using OF or FL techniques. Clinical parameters were evaluated at baseline and 3, 6, and 12 months post-surgery. The local levels of receptor activator of nuclear factor-κB ligand (RANKL) and osteoprotegerin (OPG) were assessed by enzyme-linked immunosorbent assay at baseline and 3 months. Patients' perceptions regarding morbidity and esthetic appearance were also evaluated. Periodontal tissue dimensions were obtained by computed tomography at baseline and correlated with the changes in the gingival margin (GM). Patients reported low morbidity and high satisfaction with esthetic appearance for both procedures (P >0.05). RANKL and OPG concentrations were increased in the OF group at 3 months (P <0.05). Probing depths were reduced for both groups at all time points, compared with baseline (P <0.05). There were no differences between groups for GM reduction at any time point (P >0.05). FL and OF surgeries produced stable and similar clinical results up to 12 months. FL ECL may be a predictable alternative approach for the treatment of EGD.

Excessive Gingival Display (EGD), commonly known as a gummy smile, is a significant aesthetic concern. The factors responsible for EGD include altered passive eruption, a short or hyperactive upper lip, vertical maxillary excess, or a combination of these. The classic treatment for severe cases of vertical maxillary excess and EGD is orthognathic surgery. However, Aesthetic Crown Lengthening (ACL) and Lip Repositioning (LR) can offer a conservative, minimally invasive and reliable alternative for treating EGD. This case report focuses on managing EGD using a conservative, minimally invasive mucosal strip surgical technique for a 23- year-old female patient who presented with a severe gummy smile. Management was planned with a combination of ACL and LR. A CAD-CAM milled surgical guide was designed and printed by superimposing Stereolithography (STL) files of digital impressions, photographs and Digital Imaging and Communications in Medicine (DICOM) files from a Cone-beam Computed Tomography (CBCT) scan to provide a suitable and predictable reference for ACL. The LR was performed by resecting a mucosal strip and coronally repositioning the upper lip, thereby reducing the depth of the upper vestibule to restrict lip elevation during smiling, which in turn reduces the gingival display. A substantial reduction of 4 mm of gingival display was seen post-operatively. ACL and LR aided with CBCT can be considered a safe and conservative treatment option for EGD.

Maxillary exostoses as contributing etiology to lip hypermobility and associated excessive gingival display: A clinical report

Lip repositioning surgery to address excessive gingival display induced by different etiologies has received major attention recently. Several techniques and variations have been reported, including myotomy or repositioning of the levator labii superioris muscle, Le Fort impaction, maxillary gingivectomies, botulinum toxin injections, and lip stabilization. This study reports a case of excessive gingival display treated by a modified combined approach. A 25-year-old woman with a 4- to 8-mm gingival display when smiling caused by a combination of short clinical crowns induced by an altered passive eruption and hypermobility of the upper lip underwent a staged esthetic crown-lengthening procedure followed by a modified lip repositioning technique. A description of the technique and a comparison with other modes of therapy is discussed. This modified approach for treating the hypermobile lip included a bilateral removal of a partial-thickness strip of mucosa from the maxillary buccal vestibule without severing the muscle, leaving the midline frenum intact and suturing the lip mucosa to the mucogingival line. The narrower vestibule and increased tooth length resulted in a symmetric and pleasing gingival display when smiling that remained stable over time. With proper diagnosis and sequence of therapy, modified lip repositioning surgery combined with esthetic crown lengthening can be used predictably to treat excessive gingival display and enhance smile esthetics.

Excessive gingival display (EGD) represents a high negative effect on the esthetic appearance. Esthetic crown lengthening (ECL) surgery is the cornerstone for the treatment of the gingival smile. However, whether to proceed with open-flap (OF) or minimally invasive flapless (FL) techniques remains unclear. We aimed in this systematic review and meta-analysis to compare the clinical outcomes between OF and FL in ECL surgeries. We searched PubMed, Cochrane CENTRAL, Scopus, and Web of Science (WOS) for randomized controlled trials including EGD patients undergoing ECL surgery with either OF or FL techniques. The primary outcome was the mean change of relative gingival margin (rGM), while the secondary outcomes were the mean changes in bleeding on probing (BOP), probing depth (PD), relative clinical attachment level (rCAL), and keratinized gingiva height (KGH). Continuous outcomes were assessed using standardized mean difference (SMD) with 95% confidence intervals (CIs) in a random-effects model. STATA 19MP (StataCorp LLC, College Station, TX) was used to pool all the statistical analyses. We included five RCTs with 180 patients in the analysis. Minimally invasive FL technique was associated with a significant reduction of rGM (SMD = -0.38; 95% CI -0.58 to -0.19, P < 0.001; I2 = 0%) compared to the conventional OF technique. Additionally, minimally invasive FL was associated with a significant reduction in BOP (SMD = -0.63, 95% CI -1.24 to -0.03, P = 0.04; I2= 73.31%) compared to the conventional OF technique. There were no significant differences regarding other studied outcomes. Minimally invasive FL and OF showed comparable results; however, the FL technique was associated with unfavorable clinical results of rGM for the treatment of EGD. Further large-volume RCTs are warranted to validate the findings.

Background: Altered passive eruption (APE) is one of the etiological factors associated with excessive gingival display and is commonly treated with esthetic crown lengthening (ECL). However, existing classification systems provide limited guidance for selecting appropriate treatment approaches. Objectives: The aim of this study was to evaluate (1) the expected outcome of ECL in eliminating unattractive excessive gingival display (4 mm) based on digital smile assessment and (2) the distribution of teeth and patients according to the modified APE classification. Methods: Forty-two Thai patients with APE underwent clinical examination, digital smile assessment, intraoral scanning, and CBCT. Predicted gingival display (PGD) was calculated to assess the expected outcomes of ECL. The modified APE classification, incorporating CEJ–BC distance and buccal bone thickness, was analyzed at both the tooth and patient levels. Results: A total of 252 maxillary anterior teeth were assessed. Most patients (78.57%) presented with APE and hyperactive upper lip. The mean gingival display (GD) was 6.04 ± 1.76 mm, with GD ≥ 4 mm observed in 92.86% of patients. The mean PGD was 3.56 ± 1.71 mm, and ECL was predicted to reduce GD to < 4 mm in 66.67% of patients. Teeth were classified as Class I (28.97%), II (15.48%), III (41.27%), and IV (14.28%); only Types II (11.9%) and III (88.1%) occurred at the patient level. Conclusions: ECL performed at the CEJ level is predicted to eliminate excessive gingival display in approximately two-thirds of APE patients. The modified APE classification offers guidance for selecting surgical approaches, highlighting the necessity of open-flap procedures and the limited applicability of flapless approaches.

An attractive smile enhances the appearance and acceptance of an individual in society. Gum exposure more than 3 mm is generally considered unattractive and known as a gummy smile, which is usually considered an aesthetic problem. At present, patients have a greater desire for more aesthetic results that may influence the planning of dental treatments. This case report aimed to describe the surgical sequence of aesthetic crown lengthening to improve smile profile and eliminate gummy smile. We reported a 21-year-old non-smoking woman with no pertinent medical history who presented with a chief complaint of an unattractive smile due to excessive gingival display. The gingival display in the smile was 5 mm, and the width to height ratio of the central incisor was 121%. Neither periodontal problems nor teeth mobility was detected. Assessment for the condition was excessive gingival display due to altered passive eruption. The overall prognosis for this case was good. The primary treatment plan proposed to the patient was an aesthetic crown lengthening. Altered passive eruption class I subtype A was a case conclusion, and aesthetic crown lengthening with gingivectomy without osseous reduction was the selected treatment. In conclusion, aesthetic crown lengthening should be considered as a surgical component of aesthetic therapy to improve smile profile and eliminate gummy smile.

Excessive gingival display that can be seen when a person smiles can cause non-esthetic problem. This gummy smile is mainly caused by an altered passive eruption, bony maxillary excess, and excessive maxillary lip mobility. Thus far, an altered passive eruption has been successfully treated using esthetic crown lengthening. Recently, an alternative to orthognathic surgery has been proposed for the treatment of a gummy smile. Studies using a lip repositioning procedure have actively been performed. In this report, we present three cases of treatment for excessive gingival display using the modified lip repositioning technique associated with esthetic crown lengthening.

Crown lengthening serves as a key procedure for addressing aesthetic concerns such as gummy smile, short clinical crowns, and uneven gingival contours. Advances in digital technology, particularly computer-aided design and computer-aided manufacturing (CAD/CAM), now allow precise translation of preoperative plans into surgical execution, enabling accurate control over gingival margin and alveolar ridge positioning. To standardize the clinical application of this technology, the Chinese Society of Digital Dental Industry (CSDDI) convened a panel of experts to develop this guideline document. It aims to define steps for digital data acquisition, integration, and design in guided crown lengthening within the aesthetic zone; standardize the digital workflow for designing surgical guides for aesthetic crown lengthening; assist clinicians in formulating appropriate digital surgical plans through thorough digital analysis and diagnosis; and offer practical guidance on performing crown lengthening surgery using digital guides in aesthetic areas. Ultimately, this guideline seeks to standardize the surgical protocol for digital guide assisted crown lengthening, thereby improving procedural accuracy and predictability of treatment outcomes.