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| CASE REPORT |
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| Year : 2023 | Volume
: 13
| Issue : 1 | Page : 34-38 |
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Gummy smile to esthetic smile – Crown lengthening procedure
Shiny Inasu, Avaneendra Talwar, Biju Thomas
Department of Periodontics, A.B. Shetty Memorial Institute of Dental Sciences, Nitte (Deemed to be University), Mangalore, Karnataka, India
| Date of Submission | 22-Feb-2021 |
| Date of Acceptance | 11-Mar-2023 |
| Date of Web Publication | 28-Apr-2023 |
Correspondence Address:
Dr. Shiny Inasu
Manjaly Achandy House, Thrissur, Kerala
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jid.jid_7_21
 Abstract | | |
Gummy smile or excessive gingival exposure is an esthetically concern factor for women compared to men. Common causes for gummy smile are hypermobility of the upper lip, short upper lip, incompetent lip, altered passive eruption, bimaxillary protrusion, vertical maxillary excess, hyperfunction of labial elevator muscles, dental plaque, hereditary, and medications can cause abnormal gingival display. A 27-year-old male patient reported to the department of periodontology, with the chief complaint of overexposure of gums and dark color of upper and lower gums. The purpose of this case report is to present how to correct a gummy smile into an esthetic smile, using surgical scalpel method, considering two aspects of gingival health and appearance, which are: the gingival zenith and contour of gingival margins, avoiding violation of the biologic width.
Keywords: Crown lengthening, esthetics, gingivectomy, melanin, periodontal disease
How to cite this article:
Inasu S, Talwar A, Thomas B. Gummy smile to esthetic smile – Crown lengthening procedure. J Interdiscip Dentistry 2023;13:34-8 |
| Clinical Relevance to Interdisciplinary Dentistry | |  |
- An attractive smile means the level of exposure of the teeth, interdental papilla, and gingival margin
- Esthetic and functional are two essential aspects of crown-lengthening procedure
- Surgical modification of the gingival margins like gingivectomy is only required for Type I esthetic crown lengthening, without the need for osseous recontouring.
| Introduction | | |
In today's world, people are more concerned about their attractiveness, beauty, and personality.[1] Smile is one of the essential criteria in the world of esthetics, where one would desire it to be attractive and esthetically pleasing.[2] A smile is an expression of one's attitude, personality, joy, kindness, overall, a first impression about an individual, which helps them to communicate, socialize, and attract other people toward them.[2] People are more influenced through media as they represent a picture of the smile in a standardized way such that the awareness and need for cosmetic dentistry has increased dramatically in the society.[3]
Gummy smile or excessive gingival exposure is considered one of the unesthetically appearances seen among a few people. Other factors such as color of gingiva, position of the teeth, and gingival health are also considered during esthetic treatment procedures.[4],[5],[6] People tend to hide the smile or show a grimy face due to their gummy smile or black gums. Common causes for gummy smile are hypermobility of the upper lip, short upper lip, incompetent lip, altered passive eruption, bimaxillary protrusion, vertical maxillary excess, hyperfunction of labial elevator muscles, dental plaque, hereditary, and medications can cause abnormal gingival display.[7] A balance of an esthetic and attractive smile is the combination of gingiva health and appearance that is required for one's smile.[8] An attractive smile means the level of exposure of the teeth, interdental papilla, and gingival margin. The normal color of gingiva is “coral pink,” which is determined by the number of factors such as degree of keratinization, number of blood vessels, and thickness of the gingival epithelium.[9],[10],[11]
Biologic width is defined as the physiologic dimension of the junctional epithelium and connective tissue attachment; show a connective tissue attachment of 1.07 mm, above the alveolar bone crest, and a junctional epithelium, below the base of the gingival sulcus of 0.97 mm. Biologic width is the combination of these two measurements, i.e., 2.04 mm in average.[12]
Gummy smile can be corrected by various methods of gingivectomy or gingivoplasty using surgical scalpel, laser, or electrocautery. Care should be taken not to cause trauma to tissues such as creating gingival recession or exposing underlying bone that leads to violation of biologic width.[13],[14],[15]
Another important aspect in esthetic appearance is gingival contour influenced by the certain number of factors such as position and form of tooth, type of periodontium underlying bony architecture, and level of cementoenamel junction.[4],[5],[6] The six maxillary anterior teeth gingival margins and contour play an important role in dental esthetics and the appearance of patient's smile. Each anterior teeth gingival margin and contour are determined by the level of CEJs of the teeth.[16] The apical most position of the free gingival margin or marginal gingival scallop, located along the long axis of the tooth, is defined as gingival zenith (GZ).[17]
The GZ of each tooth can be established with the help of two reference points: apical contact area position of the tooth (ACAP) and proximal incisal contact area position.[18] ACAP of the tooth is obtained by recording the measurement made by a horizontal imaginary line extending from the tip of interdental papilla on mesial aspect of the tooth to the tip of interdental papilla on distal aspect of the tooth [Figure 1].[18] At the midpoint of both lines, a mark was made and later a vertical bisected midline (VBM) along the long axis of the tooth on free gingival margin is connected, the highest point of this line determines GZ positions [Figure 1].[18] This position differs among the anterior teeth, as GZ is located distally to the long axis of the central incisor and canine, whereas this position is located on the center of the tooth for lateral incisor.[17] A tangent line called gingival esthetic line was drawn connecting the GZ points of each tooth to locate GZ level on both sides [Figure 2].[18] A knife-edged gingival margins and cone-shaped interdental papilla tightly adapted to the teeth are two features that describe an ideal gingival architecture.[19] | Figure 1: ACAP: Apical contact area position, ICAP: Incisal contact area position, VBM: Vertical bisected line, GZP: Gingival zenith position[18]
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This case report presents how to correct a gummy smile into an esthetic smile, using surgical scalpel method considering two aspects of gingival health and appearance: GZ and contour of gingival margins, avoiding violation of biologic width.
| Case Report | | |
A 27-year-old male patient reported to the department of periodontology, with the chief complaint of overexposure of gums, dark color of upper and lower gums. The patient's medical history reported no relevant findings. An intraoral examination was carried out to examine oral health status of the patient and treatment plan was made based on final diagnosis.
After clear explanation of the surgical treatment to be performed, informed consent was obtained from the patient.
Initially, Phase I therapy that involves nonsurgical periodontal treatment such as full mouth oral prophylaxis using 0.12% chlorhexidine mouthwash was done before surgical treatment.
Phase II surgical procedure
After administering 2% lidocaine hydrochloride with adrenaline, the GZ position of central incisor, lateral incisor, and canine on both sides was located with the help of Willam's periodontal probe [Figure 3], [Figure 4], [Figure 5].
A surgical alteration of the gingival margin levels is sufficient for type I esthetic crown lengthening[20] without need for osseous recontouring. On the mid-buccal aspect of the teeth, a gingival demarcation was made with the help of a probe. With B. P (Bard-Parker) no 15, 0.5–1 mm from free gingiva, a 45° internal bevel incision was made following the CEJ of the tooth, preserving interdental papilla. The excised tissue was removed using a periodontal curette. Any remaining tissue tags and margins of gingiva were trimmed using Castroviejo micro periodontal scissors [Figure 6], [Figure 7], [Figure 8].
After gingivectomy procedure, the depigmentation procedure was done extending from 1st premolar on the right side crossing midline to 1st premolar on the left side. An epithelial layer was removed and after saline irrigation, the treated area was covered with surgical pack to prevent it from exposure and promote healing. Postoperative and oral hygiene instructions were advised to the patient. The patient was also advised to use 0.12% chlorhexidine digluconate mouthrinse. After 3 months, the patient was recalled for follow-up [Figure 9].
The healing was satisfactory. The patient had no postoperative pain or complaint, was very satisfied with the treatment procedures.
| Discussion | | |
In this case report, gummy smile was treated using scalpel method for Type I esthetic crown lengthening, without osseous reduction, which showed better results after 3 months of follow-up. Although there are other techniques for depigmentation and crown-lengthening procedure such as laser and electrocautery, for this case report scalpel method was used since the patient preferred the surgical method over laser as he was not comfortable with fumes and smell that comes while using laser. Patient's comfort and preference should also be considered before any treatment to be given, which would help the dental professionals to gain their trust, confidence and build on a patient–doctor relationship for future dental treatment.
Crown lengthening is a surgical procedure used for treating gummy smile or excessive gingival exposure. Dental esthetic is increasing in demand, due to the needs of patient and their interest in improving their appearance of the teeth and gums. GZ and contour are important factors to be considered during the surgical procedure.[1],[2],[14]
Esthetic and function are two essential aspects of the crown-lengthening procedure.[21] The rationale of this procedure was to achieve an esthetically acceptable result, without violating biological width, causing less discomfort, gingival inflammation, and gingival recession. Surgical modification of the gingival margins like gingivectomy is only required for Type I esthetic crown lengthening,[21] without the need for osseous recontouring. The depigmentation procedure involves the removal of epithelial layer, as the melanin pigments are found in basal and suprabasal layer of epithelium. However, repigmentation can occur due to the incomplete removal of pigments from gingival tissue mainly from interdental papilla. Patients should be explained the realistic results that can be obtained from this treatment option.
| Conclusion | | |
Crown lengthening is the proper therapeutic option for the treatment of gummy smiles. Overexposure or underexposure of teeth can cause an unesthetic appearance, excess removal of the gingival margin can cause recession, hence while carrying out surgical procedure, care should be taken to avoid violating biologic width and the contour of gingival margin should follow the level of CEJ of the tooth.
Author's contribution
All the authors have reviewed the concept, design, manuscript preparation, and editing of this article.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]
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