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| CASE REPORT |
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| Year : 2022 | Volume
: 7
| Issue : 2 | Page : 137-142 |
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Enhanced anterior esthetic using crown lengthening and depigmentation at single visit: Report of two cases and review of literature
Saad M AlQahtani
Department of Periodontics and Community Dental Sciences, College of Dentistry, King Khalid University, Abha, Saudi Arabia
| Date of Submission | 08-Oct-2022 |
| Date of Decision | 05-Nov-2022 |
| Date of Acceptance | 16-Nov-2022 |
| Date of Web Publication | 27-Dec-2022 |
Correspondence Address:
Dr. Saad M AlQahtani
Department of Periodontics and Community Dental Sciences, College of Dentistry, King Khalid University, Abha
Saudi Arabia
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/KKUJHS.KKUJHS_33_22
Gingival hyper-pigmentation becomes more obvious when it is associated with excessive gingival display. The treatment of excessive gingival display and depigmentation collectively are the key to patient satisfaction. The objective of the present article was to evaluate 6 months' result of surgical protocol that integrated surgical depigmentation, gingivectomy, and an apically positioned flap with osseous resective surgery to correct hyper-pigmentation and excessive gingival display in maxillary anterior teeth among different patients. The author has discussed in detail the selection of surgical techniques in different clinical conditions to achieve pleasant and long-term results. The selected techniques for depigmentation and crown lengthening resulted in excellent color and contour of the gingiva at the 6-month follow-up.
Keywords: Apically positioned flap, crown lengthening, depigmentation, gingivectomy, gummy smile
How to cite this article:
AlQahtani SM. Enhanced anterior esthetic using crown lengthening and depigmentation at single visit: Report of two cases and review of literature. King Khalid Univ J Health Sci 2022;7:137-42 |
How to cite this URL:
AlQahtani SM. Enhanced anterior esthetic using crown lengthening and depigmentation at single visit: Report of two cases and review of literature. King Khalid Univ J Health Sci [serial online] 2022 [cited 2023 Mar 21];7:137-42. Available from: https://www.kkujhs.org/text.asp?2022/7/2/137/365761 |
| Introduction | |  |
Esthetics plays a significant role in the current era of dentistry. Not only the clinician but also the patients have a greater desire about achieving esthetically pleasing results. A pleasant smile and healthy appearing gingiva are the important characteristics under the esthetic domain. A conservative display of 2–3 mm of gingival tissues adjoining the teeth plays a vital role in the esthetics of the anterior maxillary region.[1],[2] Ideally, when a patient smiles the inferior border of the upper lip should rest at the level of gingival height of contour for the six maxillary anterior teeth.[2] Abnormalities in symmetry contour and color of the gingiva concerning the teeth can considerably affect the harmonious emergence of the natural dentition.[3] Excessive gingival display and gingival hyperpigmentation are the main complaints registered by a large number of patients visiting dental clinics.
Gingiva hyper-pigmentation has always been a point of concern to a certain group of the population, especially females of the young age group. It is more appropriately termed as physiological pigmentation of the mucosa and gingiva. Melanoblasts are nonkeratinocytes present in the gingival epithelium, which are responsible for gingival pigmentation and can be attributed to genetic traits.[4] Melanin pigmentation can be observed among all races, at any stage of life and without any gender predilection.[5] Although gingival hyper-pigmentation is a completely benign condition without relating to a medical illness, its unesthetic manifestation is more prominent in patients having excessive gingival display during a smile.
The excessive gingival display is usually associated with the incomplete passive eruption, maxillary protrusion, hyperactive muscle of the upper lips, short lip length, and gingival enlargement. The differential diagnosis for excessive gingival display should be considered before opting for the treatment, in case of gingival enlargement or altered passive eruption, excessive gingival display can be efficiently improved and corrected by crown lengthening procedure.[6] By definition, crown lengthening is a surgical procedure intended to removal supporting periodontal tissue to increase the height of the clinical crown. The definitive objective of crown lengthening is to offer a tooth crown dimension sufficient for a stable dentogingival unit and the placement of a definitive margin of restoration. The biological width concept is an integral part of the crown lengthening procedure. This concept was put forth by Gargiulo et al. in their pioneering study, according to which the combination of these two measurements (connective tissue attachment: 1.07 mm, junctional epithelium: 0.97) constitutes the biological width (2.04 mm).[7]
Golden proportion was first introduced in dentistry by Lombardi. According to him, golden proportion was the vital measurement for use in defining tooth size, such as lateral to central incisor width and the canine to lateral incisor width are repeated in proportion. In addition, Levin suggested that when maxillary anterior teeth viewed form front, the width of the central incisor to that of the lateral incisor and the width of lateral incisor to that of the canine should be in golden proportion.
Esthetic crown lengthening can be accomplished with or without osseous reduction [Figure 1]. The decision whether or not to resect the supporting bone depends on the various factors as discussed below;
- Sulcus depth: Gingival sulcus depth is calculated to determine the nature of the pocket which can be a pseudo-pocket or true pocket. The surgical treatment will differ according to the nature of the pocket and the depth of the sulcus
- Biologic width: The dimension of the biological width should be maintained during any surgery aimed at crown lengthening. Any violation of the biological width will affect the health of the marginal periodontium
- Bone sounding: The level of the alveolar crest must be determined before any considerations regarding esthetic crown lengthening
- Crown-to-root ratio: Acceptable crown-to-root ratio is about 1:1. While crown lengthening excessive osseous reduction may lead to an altered crown to root ratio.
Gingival depigmentation can be defined as a periodontal plastic surgical procedure that is intended to correct or reduce gingival hyperpigmentation by using different techniques.[11] There are multiple techniques discussed in the current literature for the treatment of depigmentation which can be classified as enumerated in [Figure 2].
Similar results have been reported with different depigmentation techniques. The selection of a technique should be established on clinical expertise and personal preferences. Whichever technique is adopted should be simple, cost-effective, less time-consuming, and comfortable to the doctor as well as induce minimal morbidity to the patients and lead to minimal loss of the gingival structure.
In the current series of case reports, the author aimed at the correction of excessive gingival display and hyper-pigmented gingiva by utilizing the above concepts, to meet the esthetic demands of the patients with minimum morbidity.
| Case Reports | | |
Case 1
Clinical examination
A 24-year-old female visited the periodontics department with a complaint of excessive gingival display and gingival hyperpigmentation [Figure 3]a and [Figure 3]b. Past dental and medical history was noncontributory, and she denied a history of current or past smoking as well. The extra-oral finding revealed no significant findings. Her smile line extends to the second premolars, and while smiling approximately 4–5 mm of the gingival display was recorded [Figure 3]a. According to Liebart et al., the smile line was classified as class I concerning maxillary anterior region.[22] | Figure 3: (a) Profile view of excessive gingival display during smile (b) intraoral view of hyper melanin pigmentation of gingiva in both the arches
Click here to view |
Dental examination showed that the clinical apico-coronal dimension of maxillary anterior teeth was shorter compared to the anatomic crown. Although the anterior maxillary dentition appeared symmetric about their contra-lateral, they were not proportionate in vertical dimensions [Figure 3]b. In normal anatomical conditions, central incisors and canines are equal in the vertical dimension and are typically 20% longer than lateral incisors. In addition, the height-to-width ratio for the canine and lateral incisor should be 1.2:1 and 1.1:1 for the central incisor.[23]
On gingival examination, the patient revealed a sulcus depth of 3–4 mm in the maxillary anterior region along with a significant amount of melanin pigmentation discovered on the gingival anterior region of both the arches [Figure 3]b. Further clinical examination showed no tooth mobility and an adequate amount of attached gingiva. On complete periodontal examination, the patient was diagnosed with generalized severe Grade II plaque-induced gingivitis.
A review of the relevant radiographs showed no significant findings related to supporting periodontal structures. The marginal bone was within normal confines, and the crown-to-root ratio was favorable.
Treatment plan
Gingivectomy was planned in the 15–25 region followed by depigmentation in the 15–25 and 35–45 regions respectively. Surgical blade was used to execute the gingivectomy by external bevel incision and depigmentation by surgical scraping.
Procedure
A consent form was undersigned by the patients before the commencement of the surgical procedure. Local infiltration with 2% lignocaine (with 1:80,000 adrenaline) was used to anesthetize the surgical area. A periodontal probe was used to mark the bleeding point on the labial aspect of the maxillary anterior gingiva after calculating the ideal height for the anterior teeth. The marked bleeding points acted as a reference for the initial reverse bevel incision. The initial reverse bevel incision was performed by the no. 15 blade in a parabolic manner to achieve the ideal contour on 15–25 region [Figure 4]a. The incised gingival collar was separated by using crevicular and interdental incisions. Osseous resection was not required because the biological width was maintained. Depigmentation was achieved by epithelial scrapping using no. 11surgical blade in 15–25 and 35–45 regions, respectively. Utmost care was taken to ensure that all the remnants of the pigments were removed from the surface [Figure 4]a and [Figure 4]b. | Figure 4: (a) Intraoral view presenting gingiva immediately after gingivectomy and depigmentation procedure in anterior maxilla, and (b) depigmentation in anterior mandible
Click here to view |
Postoperative instructions and analgesics (ibuprofen 400 mg, three times a day for 3 days) were prescribed to the patient. Chlorhexidine mouthwash (0.2%, 10 ml, twice a day) was advised for 2 weeks postoperative to aid in plaque control. The patient was recalled at regular intervals to observe the healing and recurrence of the pigmentation in the surgical area. The patient was satisfied with the 6 months postoperative gingival appearance without any evidence of repigmentation [Figure 5]a and [Figure 5]b. | Figure 5: Six months post-operative view (a) profile view presenting improved smile line (b) intra-oral view presenting esthetically pleasant gingival appearance
Click here to view |
Case 2
Clinical examination
A 26-year-old female was referred to the periodontics department with a request to correct the unpleasant smile [Figure 6]a and [Figure 6]b. No relevant medical and personal habit history was recorded. On extra-oral examination, the patient revealed a class I smile line concerning maxillary anterior region with approximately 2–3 mm of gingival display [Figure 6]a.[22] | Figure 6: (a) Profile view of excessive gingival display during smile (b) intraoral view of hyper melanin pigmentation of gingiva in both the arches
Click here to view |
Dental examination showed that the maxillary anterior teeth had significantly shorter clinical crown height compared to the anatomic crown. On gingival examination, the patient revealed a probing sulcus depth of 2–3 mm in the maxillary anterior region along with excessive melanin pigmentation with anterior gingiva of both the arches [Figure 6]b. Further clinical and radiographic examination showed no significant findings related to supporting periodontal structures. On complete periodontal examination, the patient was diagnosed with generalized severe Grade II plaque-induced gingivitis.
Treatment plan
Apically repositioned flap was planned in the 15–25 region followed by depigmentation in the 15–25 and 35–45 regions, respectively. Surgical blade was used to perform internal bevel gingivectomy followed by osseous reduction using rotary instruments, whereas the surgical blade was used to perform depigmentation by surgical scraping.
Procedure
Informed consent got signed by the patients before the commencement of the surgical procedure. The surgical area was anesthetized by using local infiltration with 2% lignocaine (with 1:80,000 adrenaline). A periodontal probe was used to mark the bleeding point on the labial aspect of the maxillary anterior gingiva after calculating the ideal height for the anterior teeth. The marked bleeding points acted as a reference for the initial internal bevel incision. The initial internal bevel incision was performed by no. 15 blade in a parabolic manner to achieve the ideal contour on 15–25 region [Figure 7]a. The incised gingival collar was separated by using a crevicular and interdental incision. Depigmentation was achieved by epithelial scrapping using no. 11 surgical blade in 15–25 and 35–45 regions, respectively. Utmost care was taken to ensure that all the remnants of the pigments were removed from the surface [Figure 7]a and [Figure 7]b. | Figure 7: (a) Intraoral view presenting gingiva immediately after depigmentation and apically repositioned flap in anterior maxilla, and (b) depigmentation in anterior mandible
Click here to view |
Estimation of the biological width dimension revealed a violation of the biological width concept. Resective osseous surgery was planned to regain the biological width space. A full-thickness mucoperiosteal flap was reflected to accomplish the osseous resection by gaining access to the marginal alveolar bone. The palatal papillae were kept intact to prevent tissue recession. Osteotomy was only performed on the buccal side to protect the palatal attachment apparatus. For osteotomy, measurement of the distance between the marginal bone and gingival margin was recorded for the biologic width and sulcus depth maintenance, which should be about 3 mm. Osteotomy was performed by using low speed rotary handpiece with round carbide bur and manually by Schluger bone file under a copious amount of irrigation to avoid bone necrosis. The flap was sutured in an apical position with the use of 4-0 silk suture [Figure 7]a.
Postoperative instructions, analgesics, and mouthwash were prescribed to the patient. Patient was satisfied with the 6 months postoperative gingival appearance without any evidence of repigmentation [Figure 8]a and [Figure 8]b. | Figure 8: Six months postoperative view (a) profile view presenting improved smile line (b) intra-oral view presenting esthetically pleasant gingival appearance
Click here to view |
| Discussion | | |
A beautiful smile is culpable to the shape, color, and position of the gingiva in conjunction with the teeth.[24] Health and appearance of gingiva are the vital components for a pleasant smile. The color of the gingiva varied among different persons and it is associated with the degree of skin pigmentation. There are the various causes of gingival hyper-pigmentation mentioned in the literature.[25] However, melanin pigments are considered the most common cause of physiological gingival pigmentation. In the current case reports, we inquired about smoking habits because adverse habits (mainly smoking) stimulate melanin pigmentation production in females as compared to male patients.[20] Therefore, it is critical to recognize the reason for gingival hyperpigmentation before treatment planning.
Esthetic demand is the prime concern for the depigmentation procedure. Gingival depigmentation is classified under the periodontal plastic surgical procedure which utilizes the various techniques to eliminate gingival hyperpigmentation. Clinical experience, patient affordability, and individual preferences are the main decisive factors in the selection of depigmentation technique. Although among various depigmentation techniques, laser has been recognized as one of the most efficient, pleasing, and reliable techniques,[20] it also has its limitation like; delayed wound healing, thermal damage to adjacent structures, increase depth of penetration, and extensive armamentarium with the high costs of the procedure.[26]
In the current case reports, scalpel surgical technique was used to perform the depigmentation. In this technique, the gingival epithelium along with a thin layer of the underlying connective tissue is scraped by the use of a surgical blade. The scalpel technique is one of the most cost-effective techniques and also does not necessitate the use of complex instruments.[27] Furthermore, it is also proved that the healing of scalpel wounds is faster than any other technique.[28] However, the main shortcoming of scalpel surgery is bleeding during and after the procedure. This problem was resolved by the use of local hemostatic agents and through postoperative instruction to the patient. Gingival pigmentation is evident only when melanin pigments produced by melanoblasts are transferred to the superficial layers of the epithelium.[29] Therefore, recurrence of melanin pigmentation is expected and has been reported from 24 h to 8 years postoperatively.[30] However, in the current case reports, no evidence of repigmentation was reported at the 6-month postoperative period.
With the increasing demand for esthetic treatments in dentistry, esthetic crown lengthening surgeries have become an essential part of the treatment plan in the esthetic zone. Furthermore, these surgical procedures help in maintaining accurate bone dimensions and correct asymmetries related to gingival topography.[31] While treating the excessive gingival display (gummy smile), the clinician should explain to the patient the limitations and expected outcome of the procedure, besides, the patient should also have realistic expectations.
Maintenance of biological width and keratinized gingiva around the tooth are two vital principles followed in the crown lengthening procedure. Since the esthetic crown lengthening procedure employs gingivectomy to expose the desired tooth structure; hence, at least 2–5 mm of keratinized gingiva is essential to maintain gingival health.[32] In the present case reports, we calculated the attached and keratinized gingiva, and it was found to be adequate to perform the crown lengthening procedure. During osseous resection, the interproximal bone should be dealt with utmost precaution to maintain the anatomy of the interdental papilla in the posthealing phase. The optimum distance from the bone crest to the base of the contact point should be 5 mm or less to avoid papillary recession.[33] Studies have discovered, at least 3 mm of space should be present from the new gingival margin to the alveolar crest to maintain periodontal health.[34] This space will accommodate 2 mm of biological width and 1 mm of sulcus depth.
In the present case reports, the selection of the surgical procedure was based on the above-discussed principles. In the first case report, only gingivectomy was planned, because clinical examination revealed that probing sulcus depth was more than the required exposure of the tooth structure. Through an examination of the surgical site was performed to avoid any violation of the biological width. In the second case report, an apically displaced flap plus and resective osseous surgery was designed to correct excessive gingival display. The treatment plan was based on the finding that the probing sulcus depth was less than the required exposure of the tooth structure. Following gingivectomy resective osseous surgery was performed to maintain the biological space. A distance of 3 mm between the new gingival margin and labial crest bone was maintained throughout the flap. According to the studies, the periodontal structure continues to remodel after the crown lengthening procedure. In addition, the gingival recession has been reported between 6 weeks and 6 months in cases of crown lengthening performed by resective osseous surgery.[35] Hence, if prosthetic reconstructions are considered, recessions should be intimately monitored during the healing period.
| Conclusion | | |
Although gingival hyper-pigmentation and excessive gingival display are benign conditions, they are known to produce major esthetic concerns for many patients. Among various techniques available for depigmentation, a surgical blade is the most widely used. Surgical blade technique is simple, easy to execute, economical, causes less discomfort, and produces esthetically pleasant results. Similarly, for crown lengthening, the clinician should evaluate each case individually and accurately diagnose the case. The selection of the proper technique depends on the clinical parameters and individual patients' expectations. However, the clinician should be well worse with all diverse techniques and be capable to modify the technique when needed.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal 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]
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