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Ocean View

The Examiner

Online Edition
May 2010
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Case Study
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Wade A. Diab, DDS, MS
3900 Frey Road, # 102
Kennesaw, GA 30144
770-426-1062
 
Greetings!
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I hope you had a good spring and are charged up for the summer.  I would like to present you with the fourth edition of the Examiner Online. Knowing what your periodontist can offer your practice could greatly help you in making treatment decisions that would give your patients the comfortable, functional and esthetic dentition they always deserve. I hope you find this publication helpful and please do not hesitate to contact me with any question.  Your input is greatly appreciated.
 
Thank you,
Wade A. Diab, DDS, MS

The Gummy Smile, FAQ's

Excessive Gingival Display
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The "Gummy Smile" is a common condition defined by the American Board of Periodontology as "Excessive Gingival Display".  This condition is often characterized by short clinical crowns and diagnosed as "Altered Passive Eruption".  Other conditions that can cause Excessive Gingival Display are a short upper lip (hyperactive lip) and maxillary vertical excess.
 
What is Altered Passive Eruption? The etiology of this condition is unknown, however; it appears that the sequence of the eruption of the dentition is altered during the passive phase. The passive eruption takes place by physiologic retreat of the alveolar bone and the gingival tissues exposing additional tooth structure and giving the teeth their normal length. The passive eruption occurs between the ages of 11 and 13 and is normally complete by the age of 14.
 
What is the treatment for Altered Passive Eruption? When this condition is diagnosed, the proper treatment is to perform cosmetic crown lengthening which includes recontouring of the gingival tissues in addition to reflecting a full thickness flap on the facial of the affected teeth and performing osseous recontouring.
 
What Happens if Osseous Recontourig was not Performed? If the alveolar bone on the facial of the affected teeth was not altered, the gingival tissues will rebound close to their original position before the surgery leading to less than favorable results.
 
Can Lasers be Used for The Cosmetic Crown Lengthening procedure?
Soft tissue lasers can be used in the soft tissue recontouring phase only.  Full reflection of a facial flap has to take place to allow access to the alveolar bone for proper osseous recontouring especially along the line angles of the affected teeth. 
Case Study
A fourteen year old female patient was referred to my office for the evaluation and treatment of her short teeth. She was in the process of having her orthodontic treatment completed and was concerned about her gummy smile.
 
Clinical Findings: The clinical examination revealed short clinical crowns with the length of the central incisors measuring 8 mm (normal range 10-12 mm). The patient displayed excessive amount of gingival tissues when smiling.  The cemento-enamel junction could not be detected using an explorer indicating that the crestal bone is at the CEJ.
 
Diagnosis:  Altered Passive Eruption.
 
Treatment Plan: Cosmetic crown lengthening with osseous recontouring.
 
Discussion: The goal of the treatment is to expose additional tooth structure thus reducing the excessive gingival display.  The periodontal surgery would also correct the width to length ratio of the maxillary anterior teeth. The crest of the alveolar bone has to be moved 3 mm apical to the CEJ to allow the attachment of the gingival fibers to the root surface and to reestablish the biologic width at the appropriate position.
 
 
Treatment Photographs
  

Excessive Gingival Display and Gummy Smile at initial presentation.
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Full thickness flap reflected after gingival recontouring.  Note the crestal bone is right at the CEJ.
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Osseous reshaping completed and 3 mm of root surface exposed to allow the attachement of the gingival fibers to the cementum.
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The flap is apically positioned and sutured with interrupted sutures.
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Post-operative photograph after six weeks of healing.
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Smile photograph after six weeks of healing.
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 2010. Wade A. Diab, DDS, MS
 
Wade A. Diab, DDS, MS
Diplomate, The American Board of Periodontology 
Implants & Periodontal Artistry
3900 Frey Road, Suite 102
Kennesaw, GA 30144
P 770-426-1062
F 770-426-6789