14 May An indication for the Surgical treatment of Gummy Smile

Dr Daniele Bordonali

If the patient during smile exhibits a portion of the gum greater or equal to three millimetres, there is an indication for the surgical treatment of gummy smile

The gummy smile is classified into:

Type 1: the cej of the tooth is in the context of the keratinized tissue

Type 2: the cej of the tooth is located at the mucogingival junction

At these two types are added two subgroups:

a) the bone crest is located at a physiological distance from the cej of the tooth, that is, at a distance equal to or greater than a millimetre

b) the bony ridge covers the tooth’s enamel, and we do not have physiological minimum space for the formation of the connective tissue junction.

the clinical case presented is type1a.

The surgical technique for the treatment of the gummy smile is the apical repositioning flap associated with bone surgery: osteoplasty.
Ostectomy will be performed only where the bone crest is at a distance of less than one millimetre to the cej of the tooth.

The only gingivectomy without flap is never the treatment of gummy smile for the following reasons:

1) we can not know with certainty the relationship between the anatomical crown and the bone crest, we must in fact have always anatomical cement root area occupied by connective attachment, the minimum dimension is one millimetre. Patients with passive eruption often do not have the minimum millimetre connective tissue junction, so necessarily we must then perform a bone flap to change the profile in order to avoid the rebounding of the tissue during the maturation phase.

2) In case of gummy smile, we can have adjacent teeth with different bone contours: only with a flap, we have the possibility to carry out selective bone surgery.

3) last and most important thing only raising a flap we can change the bone thickness in buccal and interproximal areas, the thickness of the bone is the cause of gummy smile.
(Esthetic treatment of altered passive eruption periodontology 2000 Zucchelli G et All.)

Radiographic diagnosis of a gummy smile
(Zucchelli G. Technique)

It will be used a gutta-percha cone-like radiographic guide to determinate the actual length of the teeth to be treated.
The cone is applied to the clinical crown of the tooth by means of wax, an x-ray is performed to assess the anatomical cej of the tooth.
The distance in millimetres measured on Rx from the apex of the gutta-percha cone and anatomical cej of the tooth will allow us to make a radiographic diagnosis of a gummy smile. When this distance is greater than or equal to three millimetres, we are in the presence of an altered passive eruption.
This will also allow us to know in advance how much and how we have to anticipate the paramarginal incision:
for example, we know that in a physiological situation the gingival sulcus measuring one millimetre, if the distance is equal to three millimetres in the Rx the crown lengthening would be two millimetres, with five millimetres it would be four, and so on

Surgical Technique

the surgical technique consists in an inverse bevelled submarginal incisions, split thickness elevation of the surgical papillae, full thickness buccal flap reflection, removing secondary flaps.
Raised the flap and exposed the bone crest, we have to observe the distance from the cej to the bone crest of every single tooth. Osteoplasty with diamond bur is performed in the apical-coronal interdental areas to create areas with concavity between the two convex bone of the adjacent dental elements then osteoplasty to harmonize the bone profile.
After the step of osteoplasty, we have to evaluate the need to perform an osteotomy to give a correct morphology at the bone crest to the cej of the teeth or if the distance between the crest and the cej is less than one millimetre.
it is important that the cement root area we are going to expose with the possible osteotomy must not be smooth to not remove the cement to prevent excessive bone resorption.
In case there are areas that have the bone crest at a greater distance of the physiological millimetre is important not to change the profile of the bone crest with osteotomy, not levigate the root because these are areas of physiological dehiscence that depends from the position of the tooth.
Suturing positioning the gingival margin to the cej with interrupted sutures.

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