Passive Eruption Research Articles

A Review of Current Techniques in Lip Reposition Surgery for Treating Excessive Gingival Display.

Excessive gingival display (EGD), commonly known as a gummy smile (GS), is a cosmetic concern that involves exposing a significant area of gum tissue during a smile, rendering it unaesthetic. Gingival exposure greater than 3 mm is deemed aesthetically displeasing and often necessitates treatment to mask the gummy smile. The causes of EGD are multifactorial, including altered passive eruption (APE), hypermobile upper lip (HUL), short lip length, increased vertical maxillary component, gingival hyperplasia, dentoalveolar extrusion, and more. As each aetiology requires different treatment modalities, patients with EGD should be thoroughly evaluated and individualized treatment plans should be developed. Lip repositioning surgery (LRS) is a minimally invasive conservative technique that decreases gummy smiles in patients with increased lip mobility and mild vertical maxillary excess. If the aetiology is multifactorial, LRS can be combined with other treatment modalities such as crown lengthening and gingivectomy for improved aesthetic outcomes. This review discusses the recent modifications and current techniques that have evolved from traditional LRS.

Clinical and radiographic assessment of gummy smile patients with altered passive eruption: a cross-sectional study in a Thai population.

The study aimed to evaluate the clinical crown length (CCL) among patients diagnosed with altered passive eruption (APE), the causes of a gummy smile, the prevalence of APE, and the correlation between parameters. A total of 86 gummy smile patients (516 teeth) underwent clinical examination and assessment using cone-beam computed tomography (CBCT), photography, and intraoral scanning. Significantly shorter CCL and distance between the cementoenamel junction and bone crest (CEJ-BC) were observed among APE-affected teeth (p < 0.05). Among the patients, 56.1% of patients were diagnosed with APE, and most of them were affected by a combination of APE and hypermobile upper lip (HUL). Based on 183 APE-affected teeth, the prevalence of APE types and subtypes was as follows: APE1A (96; 19.3%), APE1B (78; 15.9%), APE2A (8; 1.6%), and APE2B (1; 0.2%). Positive correlations were found between keratinized gingival width (KGW) and bone thickness (BT), while negative correlations were observed between gingival thickness (GT) and BT. Shorter CCL and CEJ-BC were the highlighted features of APE. APE affected approximately half of the gummy smile patients, with most of them presenting with a combination of HUL. Almost teeth affected by APE were classified as Type I, with a nearly equal distribution between subtypes A and B. The clinical and radiographic features of APE contribute to a better understanding of this condition and facilitate the management of patients affected by APE. Approximately half of gummy smile patients will require multidisciplinary treatment.

Management of Gummy Smile Using Esthetic Crown Lengthening Technique

Abstract Excessive gingival display is a major concern for a large number of patients visiting the dentist. It is a multifactorial condition that needs to be managed in a sequential manner in order to reach proper treatment technique that targets and resolves the underlying etiologies. There are different etiologies of a gummy smile, such as vertical maxillary excess, short and hyperactive upper lip, altered passive eruption, anterior dentoalveolar extrusion, or a combination of these causes. Many techniques have been used to restore the dentogingival relation for the management of gummy smile. The various treatment modalities for Excessive Gingival Display includes gingivectomy, modified lip repositioning, orthognathic surgery, orthodontic therapy, hyaluronic acid infiltration, botulin toxin injections. This case report deals with the correction of Excessive Gingival Display using conventional gingivectomy.

Etiologies of excessive gingival display in a Saudi population

IntroductionExcessive gingival display (EGD) is a mucogingival deformity characterized by overexposure of the maxillary gingiva while smiling. This cross-sectional study aimed to identify EGD etiologies and their prevalence in participants at King Saud University, Saudi Arabia. MethodsAdults with a gummy smile, who resided in Saudi Arabia, were nonsmokers, had good overall health, and had all their maxillary anterior teeth were eligible for inclusion. Participants were first screened by phone, and those who met the eligibility criteria were further screened at the Dental University Hospital (King Saud University, Riyadh, Saudi Arabia). The demographic characteristics of all eligible participants were recorded. Participants were further subjected to extraoral examination, which included gingival display (GD), vertical maxillary excess (VME), hypermobile upper lip (HUL), smile line, altered passive eruption (APE), gingival overgrowth, and short upper lip (SUL). Intraoral examination included periodontal pocket depth and bleeding upon probing. Student’s t-test was used to compare the mean GD values across the main etiologies (VME, HUL, APE, and SUL). ResultsAll 123 participants (mean age: 23.1 ± 0.2 years; 74 females) had EGD (i.e., GD ≥ 4 mm), of whom 55 (44.7 %) had a single etiology, and the remaining 68 (55.3 %) had > 1 etiology. APE was the predominant etiology (n = 90, 73.2 %) in the study population. Of these (n = 90), APE alone was prevalent in 29 (32.2 %) participants, whereas the remaining patients had APE in combination with other EGD etiologies (n = 61; 67.8 %). The presence of more than one EGD etiology in the same participant was associated with greater GD. The VME and HUL were significantly associated with smile line classes (p < 0.05). ConclusionsAPE (alone or in combination) was the predominant etiology of EGD in the study population. The presence of multiple EGD etiologies in the same patient emphasizes the need for an etiology-based, sequential, and multiple-treatment strategy to effectively manage EGD.

Digital resources for surgical and restorative treatment of excessive gingival display in one session.

This article aims to showcase the implementation of a digital workflow in addressing a case of multifactorial excessive gingival display in a patient with high esthetic demands, incorporating both surgical and restorative interventions in a single session. A 28-year-old female patient presented with excessive gingival display, attributed to a combination of short teeth due to altered passive eruption, lip hyperactivity, and a sub-nasal depression that lodged the upper lip during spontaneous smiling. The multidisciplinary treatment strategy encompassed surgical crown lengthening, the placement of a biovolume in the maxillary concavity, and the rehabilitation of the six anterior teeth with direct composite resin, all done in a single session. Smilecloud Biometrics was used to digitally plan the smile, and the final wax-up/mock-up was approved by the patient prior to any irreversible procedure. A digital planning center (GuiderLab) enabled the materialization of the virtual planning and the printing of the periodontal surgical guide, the biovolume, and the resin layering guides for the restorative technique. Adopting a digital workflow in multidisciplinary cases with excessive gingival display leads to predictable and more expedited outcomes, ensuring a favorable result between soft and hard tissues. Excessive gingival display is a condition with multifactorial etiologies, including dentoalveolar, periodontal, skeletal, or muscular origins, or a combination of these factors. The diagnoses of altered passive eruption and a hypermobile upper lip are common in daily clinical practice and can be successfully managed through surgical crown lengthening and filling of the maxillary concavity, respectively. To achieve the desired outcome, restorative procedures often complement these surgical interventions.

PERIO - PROSTHO: ENHANCING AESTHETICS FOR PATIENTS WITH ALTERED PASSIVE ERUPTION/GUMMY SMILE USING CAD/CAM TECHNOLOGY: A CASE REPORT

Periodontics and prosthodontics play crucial roles in enhancing the aesthetics of patients with altered passive eruption, commonly known as a gummy smile.Altered passive eruption refers to a condition where excessive gum tissue covers a significant portion of the teeth, resulting in a less aesthetic smile.The treatment approach for altered passive eruption typically involves a combination of periodontal procedures and prosthodontic interventions. One common technique is crown lengtheningoften followed by prosthodontic treatments to restore the function and aesthetics of the teeth.This work will mainly focus on the management of altered passive eruption in aesthetic anterior prosthodontic rehabilitations with the goal of improving the prosthetic and Aestheticoutcome through clinical case.

Evaluation of minimally invasive esthetic crown lengthening using an open flap versus flapless surgical approach: A randomized controlled clinical trial.

Esthetic crown lengthening (ECL) is commonly advocated to treat patients with altered passive eruption (APE). Since the introduction of the minimally invasive surgical concept, a limited number of studies have investigated this technique in a standardized manner, with further studies required to verify the validity and predictability of the minimally invasive FL-technique. The current randomized trial compares a minimally invasive (ECL), using piezosurgery with flapless-approach (FL), versus an open-flap (OF) approach in the management of patients with APE Type 1B. Twenty-four patients diagnosed with APE Type 1B were randomly assigned into test (FL) with tunneling approach or control (OF) group with minimally invasive flap reflection (n = 12/group). Postoperative pain was assessed during the first 48 h. Gingival margin (GM) level relative to a custom-made stent (rGM) and patient satisfaction were assessed preoperative, immediately after surgery, at 3 and 6 months postsurgically. Postoperative swelling was reported for the first week postsurgically. Plaque index (PI), bleeding on probing (BoP), clinical attachment level (CAL), pocket depth (PD) and pink esthetic score (PES), were evaluated at baseline and 6 months. Linear regression analysis was conducted for pain. OF-group reported significantly higher pain and swelling scores than FL-group during the first 48 h (p < 0.05). FL-group showed no significant differences regarding rGM between 3 and 6 months, in contrast to OF-group, where a significant decrease in rGM was notable (p < 0.05). No significant differences in PI, BoP, CAL, PD, PES, and patient satisfaction scores were evident between groups (p > 0.05). Regression analysis demonstrated that treatment and gender were significant predictors for pain (p < 0.05). Within the current study's limitations, piezo-surgical ECL with FL-approach presented significantly lower postoperative pain, swelling, and early GM stability compared to OF-approach. Piezosurgical ECL with a FL-approach can be considered a predictable technique with advantages over the OF-approach in the management of patients with APE Type1B.

Altered Passive Eruption among Patients Visiting Dental Outpatient Department in a Tertiary Care Center: A Descriptive Cross-sectional Study.

The eruption of teeth is considered to be a continuous phenomenon. Two types of eruption are possible namely, active and passive eruption. Failure in passive eruption (by the apical movement of gingiva from the enamel surface) generally results in a clinical condition known as altered passive eruption. It can result in the shortened crown height of a tooth and an esthetically unpleasant situation i.e., excessive gingival display or gummy smile. The main motto of this study was to find out the prevalence of altered passive eruption and associated gingival biotypes in adult patients visiting for dental treatment in tertiary centers along with strategically placed outreach centers. A descriptive cross-sectional study was done in the Department of Dentistry, Dhulikhel Hospital, and four outreach centers of the same hospital. The study was conducted from October 2022 to April 2023 after obtaining the ethical approval. Convenience sampling was done. Point estimate and 95% Confidence Interval were calculated. Among 165 patients, the prevalence of altered passive eruption was 21 (12.72%) (7.62-17.78 at 95% Confidence Interval). Furthermore, among 21 patients, the altered passive eruption was seen in the thick biotype patients in 16 (76.19%) and thin biotype patients in 5 (23.81%). The prevalence of altered passive eruption appeared to be equivalent when compared with the previous studies.

FUNCTIONAL CROWN LENGTHENING AS A PRE-RESTORATIVE PROCEDURE IN THE AESTHETIC ZONE

Introduction: Crown lengthening is a surgical procedure to increase the height of the clinical crown for aesthetic and restorative purposes, or combination. The indications include treatment of subgingival caries and altered passive eruption. Functional crown lengthening for restorative purposes in the esthetic zone should consider the concept of biologic width and the ideal proportion of the dentogingival complex. Case: A 39-year-old male patient was referred from the Department of Conservative Dentistry, RSGM UGM Prof. Soedomo to expose the maxillary anterior teeth crowns for full crown and veneer restorations. Clinical examination showed 11, 12, and 12 post root canal treatment with 3-4 mm remaining crowns. Teeth 13, 21, 22, and 23 appear short, excessive gingival display of 3 mm, with a diagnosis of altered passive eruption type 1B. Treatment: Functional crown lengthening was performed by gingivectomy followed by flap elevation, ostectomy, and osteoplasty. A fenestration was found at the apical of 22 and treated with regenerative procedure. Full crowns and veneers insertion was done 3 months after surgery. Crown lengthening as a pre-restorative procedure is a multidisciplinary treatment that considers the need for restoration by re-establishing the biologic width, to prevent inflammation and bone loss. In addition, adequate post- surgical tissue healing time prior to restoration is necessary to avoid gingival margin rebound and to assure long-term success of the restoration. Conclusionn : Functional crown lengthening as a pre-restorative procedure in the esthetic zone can gives satisfactory and stable results, with careful examination and correct surgical procedure.

Esthetic crown lengthening in the treatment of gummy smile associated with altered passive eruption: A case report.

Esthetic crown lengthening in the treatment of gummy smile associated with altered passive eruption: A case report.

Digitally planned surgical crown lengthening: a novel bone reduction strategy to correct a gummy smile.

This report describes the bone reduction guide which was digitally obtained to improve diagnosis, treatment outcome and follow-up. Treatment of gingival smiles due to altered passive eruption should include interdisciplinary planning and smile design to facilitate the prediction of treatment outcome. Crown lengthening surgery can be supported by digital tools to improve surgical planning and follow-up. A 30-year-old female patient was referred to a private dental clinic seeking solutions for her gingival smile. Based on the anatomical crown length, a smile design was created, and the patient was presented with a simulated smile before treatment. In the surgical phase, a full-thickness flap was raised in the upper jaw to achieve the desired outcome. Using cone-beam computed tomography to determine cementoenamel junction for smile design and treatment planning brings many benefits. Patients and clinicians can foresee treatment results. From there, appropriate changes can be made. The bone reduction guide is designed to rest on the bone to help the clinician cut the bone accurately and thoroughly follow the established plan.

Treatment for an Altered Passive Eruption (APE)

Altered Passive Eruption (APE) is a condition where the gingival margin is more incisal or occlusal than the cementoenamel junction. Apart from disrupting the aesthetics of a smile, this condition can also be a risk factor for periodontal disease. APE is characterized by a gummy smile and short-looking teeth. Periodontal crown lengthening surgery is a treatment option that can be given to treat this case. The choice of periodontal crown lengthening surgery procedure must be adjusted based on the APE classification of the patient's case. This case report aims to describe the management of APE type 1A with periodontal crown lengthening surgery through gingivectomy. A 25-year-old female patient came to RSGM UMY with complaint that the gums on the front teeth of the upper jaw seemed large. The patient's general health is good. The results of intraoral examination showed that there were an elevation of the gingiva towards the incisal direction, and the teeth appeared short on 12, 11, 21, and 22. The examination also showed the presence of cretinized gingival tissue that appeared larger vertically on 12, 11, 21, and 22. On radiographic examination, the distance between the cementoenamel junction and the crestal bone is greater than 1 mm. The patient's APE classification was type 1A, hence gingivectomy was performed in this case. In treating APE cases, determining the correct diagnosis and selecting appropriate therapeutic management must be considered according to the patient's case. All therapeutic decisions must be discussed with the patient in order to satisfy their desires

Treatment of excessive gingival display using conventional esthetic crown lengthening versus computer guided esthetic crown lengthening: (a randomized clinical trial)

BackgroundSurgical guides have been proposed in an attempt to reach more predictable outcomes for esthetic crown lengthening. The objective of the present study was to evaluate the effectiveness of esthetic crown lengthening using 3D-printed surgical guides in the management of excessive gingival display due to altered passive eruption type 1B.Materials and methodsSixteen patients diagnosed with altered passive eruption type 1B, were divided into two groups. In the control group, the procedure was carried out conventionally, and in the study group, a dual surgical guide was used. The parameters of wound healing (swelling, color, probing depth, bleeding index, and plaque index), pain scores, gingival margin stability, and operating time were assessed at 1 week, 2 weeks, 3 months, and 6 months postoperatively.ResultsThere was no statistically significant difference in terms of wound healing, pain scores, and gingival margin stability between both groups at different time intervals (P = 1), however, there was a statistical difference between both groups in terms of operating time with the study group being significantly lower (P < 0.001).ConclusionDigitally assisted esthetic crown lengthening helps shorten the operating time and reduces the possibility of human errors during the measurements. This will be useful in helping practitioners achieve better results.Practical implicationsThe conventional method remains to be the gold standard. However, shorter operating time and lower margins for errors will help reduce costs as the chair side time is reduced as well as the possibility for a second surgery is lower. This will improve patient satisfaction as well.

Esthetic Crown Lengthening: A Review

Esthetic Crown lengthening involves surgical procedures utilized to increase clinical tooth crown height, address uneven gingival margins and excess gingival display and correct gingival overgrowth. Excessive gingival display known as “Gummy Smiles” can occur for a number of reasons including altered passive eruption, high lip line, hypermobile upper lip an maxillary vertical excess. The goal of this article is to provide a review on Esthetic Crown lengthening.

Diagnosis and inter-disciplinary treatment of altered passive eruption, the digital evolution

Altered passive eruption (APE) is a condition better known as ‘gummy smile’, patients affected by APE display short and square clinical crowns and an excessive display of gingiva when smiling.APE was classified as type 1 or 2 depending on its features, in type 1 the gingival margin is coronal to the CEJ, the teeth look short and squared, in type 2 the gingival margin seems to be at the right position, it is the bone crest that is not. The position of the bone crest is defined by sub types A and B. In subtype A the bone crest is located 1.5 to 2 mm apical to the CEJ while in subtype B the alveolar bone crest is located near the CEJ and in some cases even above the CEJ.Nowadays a case of APE can be studied and 3D planned with a full support of digital dentistry. Once the process of planning is completed, the surgical stent is produced by a 3D printer, the patient is recalled for fitting the surgical stent and final check -up and the surgical procedure is performed.A case where Vertical Maxillary Excess (VME) and APE were present together is showed and the diagnosis and interdisciplinary treatment demonstrated.

Esthetic crown lengthening with concomitant localized gingival depigmentation – A case report

Dentofacial aesthetics can have psychological impact, which can manifest as a decreased sense of confidence and self-esteem in both social and work environments. This case report exhibits a method employed to address both the patient’s chief complaint likely post traumatic pigmentation, as well as the moderate case of delayed passive eruption, simultaneously. A healthy 29-year-old female presented with a chief complaint of melanin display on the facials of the maxillary central incisors since placement of a lingual bonded retainer. She also had a mild case of delayed passive eruption, resulting in short clinical crown length. Gingivectomy was performed to remove the melanotic area by making two incisions at the gingival collars of teeth #8 and #9, followed by the raising of a flap to perform osseous reduction on these teeth in order to achieve more ideal anterior display crown lengths. When the patient presented for a 30-month follow up, there was no return of the pigmentation. A minimal rebound of the gingival margins of the upper centrals had occurred. This treatment modality of utilizing an incision technique for removal of pigmented tissue while simultaneously achieving more ideal cuspid length is capable of rendering improved aesthetic results that are predictable and long lasting.

Creating smile aesthetics by using crown lengthening and upper lip repositioning surgical operations together in a gingival smile case: a case report

When the distance between the gingival margin and the lower border of the upper lip is more than 3 mm while smiling, it is called a gummy smile. The etiology of excessive gingival visibility is varied: delayed passive eruption, anterior dento-alveolar extrusion, vertical maxillary overhang, short upper lip, hypermobile upper lip, or a combination of multiple factors. The aim of our study is to diagnose gingival smile and explain the treatment of excessive gingival appearance due to vertical maxillary excess and hypermobile upper lip with crown lengthening and upper lip repositioning surgeries. A 27-year-old female patient presented to our clinic with the complaint of excessive gingival exposure while smiling. In the intraoral examination, it was determined that the patient had good oral hygiene, the upper lip was hypermobile, and the crown lengths of the upper central teeth were shorter than normal due to passive eruption. Gingivectomy, crown lengthening, and lip repositioning operations were planned for gummy smile treatment. For lip repositioning, the first incision was made from the mucogingival line of teeth numbered 14-24, the second incision was made 8-10 mm apically; and the tissue in between was excised. The wound edges were closed with 5.0 nylon mono sutures. Postoperative antibiotics, analgesics, and mouthwash were prescribed. The patient stated that he did not have any postoperative problems. The 6-month follow-up showed an uneventful recovery. In this case, the excessive gingival appearance was reduced by restricting the muscle traction of the elevator lip muscles, and the tooth length was increased with the crown length operation, providing aesthetic satisfaction for both the patient and the physician. As a result of our study, this procedure is safe for patients, less invasive, has minimal side effects, and may be an alternative to orthognathic surgery in appropriate cases for the correction of gingival smiles.

AESTHETIC IMPROVEMENT IN ONE VISIT PERIODONTAL PLASTIC SURGERY USING SCALPEL AND LASER SURGICAL TECHNIQUE (CASE REPORT)

Introduction: A charming smile is formed from good harmonization of teeth and gums. Short teeth clinical crown, dark gingival color, diastema between the maxillary central incisors can interfere the aesthetic of the smile. This case report aims to describe the treatment of periodontal plastic surgery in form of aesthetic crown lengthening, gingival depigmentation and frenectomy to improve function and aesthetic in one visit using scalpel and laser. Case: A 23 year old male patient complained that the maxillary front teeth spaced, short and small, and the gum of the upper jaw is dark, which caused aesthetic discomfort. Objective examination showed high frenal attachment reaching the interdental papilla to palatal, diastema of the maxillary central incisors, short clinical crown and brownish maxillary gingiva. aberrant frenum labialis superior, altered passive eruption and gingival hyperpigmentation diagnoses was made in this case. Case Treatment: Aesthetic crown lengthening treatment with scalpel, gingival depigmentation using scrapping technique and frenectomy using combination of laser and scalpel surgical technique was carried out in one visit. Discussions: The advantages performing three periodontal plastic surgeries in one visit is require just once preparation of surgical materials and instruments, once surgical trauma, once prescription and less number of control visits. Conclusions and Suggestions: Treatment of crown lengthening, gingival depigmentation and frenectomy in one visit are considered effective and efficient based on time, trauma, and costs required. The periodontal plastic surgery technique can be choosing based on clinical finding on patient, patient’s needed and clinical skills of operator.

Aesthetic rehabilitation on fractured and altered passive eruption anterior teeth: A case report

Objective: This case report aims to present the management of crown fractures with pulpal exposure caused by traumatic injury and a condition called gummy smile or altered passive eruption (APE), through a multidisciplinary approach.&#x0D; Case Report: A 24-year-old male patient came to the Dental Conservation Clinic RSGM Prof Soedomo FKG UGM, complained of broken teeth and pain in the upper front tooth due to an accident. #12 and #21 experienced horizontal discontinuity to the dentine surface and some lines on the labial surface and #11 underwent a fracture with exposure of the pulpal tissue. The patient wants to take care of broken teeth and improve his smiles.&#x0D; Results: A treatment plan was formulated, which consisted of a stepwise treatment including endodontic treatment, crown lengthening, prefabricated glass-fiber post followed by a core build-up, and finally, direct composite to achieve patient satisfaction.&#x0D; Conclusion: The careful planning of a multidisciplinary approach such as endodontics, periodontics, and direct restorations can treat patients with complex aesthetic complaints relating to problems with the tooth and its soft tissues, and immediate restoration for providing a fast, predictable, economical, yet satisfactory result to improves patient self-confidence.

Management of Concomitant Intrusion and Complicated Crown-Root Fracture Injury of Maxillary Central Incisors in a Child

Dental intrusions are a severe type of injury because they impact the neurovascular supply of the tooth as well as the supporting tissues which predispose the tooth to necrosis and root resorption. Management of these injuries requires repositioning of the teeth under close monitoring to avoid complications. The management becomes more comprehensive when an intrusion is combined with other injuries, such as a crown-root fracture. This case report represents a 4-year follow-up of a child who suffered from a concomitant injury of intrusion and complicated crown-root fracture to the maxillary immature permanent central incisors. The management involved a multidisciplinary approach including endodontics, pedodontics, orthodontics, periodontics, and prosthodontics. Given the guidelines of dental trauma and the circumstances of the case, the fractured teeth were root canal treated, filled with a bioceramic plug and gutta-percha, and then restored with posts/cores and temporary crowns. The intrusion was managed initially by passive eruption followed by an active orthodontic eruption, after which the teeth were restored with permanent ceramic crowns. Throughout the course of treatment, the teeth showed no complications of root resorption or ankylosis, although one tooth developed a periapical infection which was managed by apical surgery. At the 4-year follow-up, the teeth revealed healthy periodontium and good esthetics.