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C O N TINUING E D UC ATIO N 3

DIAGNOSIS AND TREATMENT PLANNING


FOR P REDICTABLE G INGIVAL C ORRECTION
OF P ASSIVE E RUPTION

KURTZMAN
Gregori M. Kurtzman, DDS*
Lee H. Silverstein, DDS, MS†

20
2

MARCH
While the need to maintain a dry operative field has traditionally caused complica-
tions during various soft tissue surgical procedures, the use of bipolar electrosurgi-
cal techniques can eliminate the need to maintain a dry field, thus increasing the
clinician’s ability to deliver predictable, long-term results. This case presentation
describes how to determine the presence of passive eruption, treatment plan its
correction, and surgically alter the gingiva to provide a more aesthetic smile.

Learning Objectives:
This article presents a step-by-step guide for smile correction in the presence of
passive eruption. Upon reading this article, the reader should:
• Recognize passive eruption.
• Determine proper position of the gingival margin as it relates to the
incisal edge.
• Be aware of how to surgically correct using bipolar electrosurgery.

Key Words: dry field, soft tissue, passive eruption, aesthetics

* Private practice, Silver Spring, Maryland.


†Private practice, Atlanta, Georgia.
Gregori Kurtzman, DDS, 3801 International Drive, Suite 102, Silver Spring, MD 20906
Tel: 301-598-3500 • E-mail: drimplants@aol.com

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P atients who clinically display excessive gingiva


and short teeth require a thorough diagnosis and
treatment plan to provide a predictable aesthetic out-
come.1-3 If a patient has Altered Passive Eruption (APE)
of the maxillary anterior teeth and has completed facial
growth,4,5 then the practitioner must first correct the
gingival levels with either a gingivectomy or aesthetic
crown lengthening procedures prior to initiating restor-
ative treatment, thus ensuring that the eventual gingival
margins of the maxillary anterior teeth will be at their
correct level.6 Figure 2. The preoperative photograph was reviewed, and the pro-
posed gingival margin excisions were marked.
Once the central incisor proportions are achieved,
practitioners should focus on the zenith or height of con-
tour of the gingival margin on the centrals.7 The proper
placement of the gingival zenith should be at the peak
of the parabolic curvature of the gingival margin, which
for the central incisors, canines, and premolars, should
specifically be located slightly distal to the middle of the
long axis on these teeth. This gives the central incisors,
canines, and premolars the subtle distal root inclination,
which is paramount for the scaffold of a beautiful smile.
The zenith for the lateral incisors is located at the midline
of the long axis of the tooth. Furthermore, the height of
Figure 3. A photo mock-up was made to demonstrate the approxi-
the gingival crest for the lateral incisors should be 1 mm mate location of the new gingival margin if a gingivectomy were to
be performed.

shorter than the gingival margins of the adjacent teeth.


Additionally, the gingival tissues should be manipulated
to have a resulting “knife-edge” gingival margin.8
Bipolar electrosurgery (eg, Bident Bipolar Surgical
Unit, Synergetics, Inc, King of Prussia, PA) allows the
clinician to use delicate incisions in a wet field, with-
out the need for lateral heat generation. This technique
allows intraoral soft tissue surgery to be performed in
a wet field, providing char-free, non-bleeding soft tis-
sue margins. This permits maintenance of the gingival
Figure 1. Preoperative appearance upon presentation demonstrates margin and elimination of postoperative shrinkage fol-
the presence of excessive gingival display with passive eruption,
bilateral peg laterals, and hyperplastic tissue. lowing healing.9-12

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presence of passive eruption. Also noted was the


presence of “peg-shaped” laterals bilaterally, which
were tipped both mesially and palatally.
A gingivoplasty was also scheduled to move
the gingival margin to be equal or apical to the
CEJ, and allow restorative correction of the lat-
eral incisors. To aid in the treatment planning, the
preoperative smile image was modified using
Adobe Photoshop (ie, Adobe, San Jose, CA) to indi-
cate the proposed location of the modified gingival
Figure 4. Pretreatment image demonstrates the presence of a wide margin (Figure 2). This was performed to deter-
band of attached gingiva, passive eruption of the anterior teeth, and
hyperplastic tissue. mine if sufficient attached gingiva would remain
following gingivoplasty.
Next, the cervical area of each of the teeth to
be treated in the maxillary anterior was altered on
the photograph to simulate the cosmetic change in
a photographic mockup (Figure 3). The patient indi-
cated that the suggested correction of the excessive
gingival display would meet her aesthetic concerns
and that she would consider placement of porcelain
veneers on the maxillary lateral incisors in the future.
As the mandibular passive eruption of gingiva was
not apparent when smiling, the patient declined
Figure 5. A panoramic radiograph was obtained preoperatively. The
patient’s bone levels were at the correct position 1 mm to 2 mm api- treatment of that gingival tissue (Figures 4 and 5).
cal to the CEJ, while the gingival margin was at the junction of the
apical and middle thirds of the coronal aspect.

Case Presentation
Treatment Planning
A 32-year-old female patient presented for treatment
of excessive gingival display in the anterior region
and requested a restorative option that would pro-
vide improved aesthetics (Figure 1). Initial clinical
examination revealed a wide band of attached
gingiva in the maxillary and mandibular anterior
with associated passive eruption. Periodontal prob-
ing indicated that the depth of the sulcus on the
facial of the maxillary anterior teeth was coronal to Figure 6. A surgical template was placed intraorally to review the
location of the proposed gingival margin in relation to the mucogin-
the cemento-enamel junction (CEJ), supporting the gival junction.

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Surgical Procedures
A line was drawn on the maxillary master model indi-
cating the intended position of the gingival margin
based on width-to-length criteria. A sheet of 0.30-inch
vacuform material (ie, Raintree Essix, Metairie, LA) was
thermoformed over the cast using a pressure former
(ie, Drufomat, Raintree Essix, Metairie, LA). Following
cooling, the thermoformed material was trimmed, scal-
loping the facial margin to follow the line that had been
placed on the master model. The edge was then colored
with a black permanent marker to increase intraoral vis- Figure 7. A Bipolar pen was used under copious irrigation to
follow the outline of the surgical template to position the revised
ibility during surgery (Figure 6). gingival margin.

Following administration of a local anesthetic


(ie, 4% Septocaine with 1:100,000 epinephrine,
Septodont, New Castle, DE), a periodontal probe
was used to feel the CEJ at the mesial, distal, and
midfacial aspect of each of the anterior teeth and
the premolars. The vacuform surgical template was
inserted, and the edge of the tray on the facial was
visualized in relation to the mucogingival line. A
3301 gingivectomy pen (ie, Bident, Synergistics USA,
King of Prussia, PA) was used with a Bident bipolar
surgical unit (ie, Synergistics USA, King of Prussia,
Figure 8. Initial markings based on the surgical stent made by the
PA) to follow the facial edge of the surgical stent surgical unit. Note absence of active bleeding.

from teeth #4(15) through #8(11). While applying


the bipolar pen, the assistant sprayed a continuous
stream of water over the field, followed by high-
volume evacuation to keep the tissue hydrated during
the procedure (Figure 7).
The surgical template was removed and the outline
of the proposed gingival margin was evaluated. The
gingivectomy pen was used to complete the contouring
gingival cut, creating a semilunar shape and sparing the
papilla (Figure 8). To avoid a resultant “black triangle,”
the papilla was not included in the gingivoplasty cut.
A periodontal scaler was used to detach the gingival
tissue from the tooth surface and remove any tissue tags
Figure 9. The gingivoplasty pen was utilized to plane back the bulky
remaining on each site. tissue at the papilla and provide a more natural contour.

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A 3302 gingivoplasty pen (ie, Bident, Synergistics


USA, King of Prussia, PA) was utilized to plane back
the thick tissue at the facial aspect of the papilla to
achieve normal contours and taper in the tissue (Figure
9). Again, water spray was used to maintain tissue
hydration and improve postoperative healing. Finally,
a 3102 coagulation ball pen (ie, Bident, Synergistics
USA, King of Prussia, PA) was used in the bipolar unit
on coagulation mode to seal any bleeding over the
gingivoplasty surface (Figure 10). The right quadrant
Figure 10. The ball pen was used in coagulation mode to cease tis- was compared to the left to ensure proper reduction,
sue oozing.
and the process was repeated on teeth #9(21) through
#13(25) (Figures 11 through 13). Because the patient’s
preoperative bone levels were acceptable, bone altera-
tion was not necessary.

Postoperative Instructions
The patient was dismissed and instructed to avoid spicy
foods and to use warm salt water rinses three to four
times daily until she presented for the follow-up appoint-
ment two weeks later. At the follow-up appointment,
the patient indicated that postoperative sensitivity and
gingival irritation were not experienced, and she was
Figure 11. Comparison of the treated right segment and the
satisfied with the improved smile (Figure 14). Clinical
untreated left segment showing the degree of tooth exposure
achieved to correct the passive eruption. examination noted a lack of gingival inflammation,
with the exception of a small spot on the papilla
between the right lateral incisor and central incisor.
All areas except the spot were covered with kerati-
nized gingiva that was less pigmented than what was
initially present.
At four weeks post surgery, the patient returned
and healing was noted as complete (Figure 15). The
patient indicated that she had received comments from
friends and family that she appeared to be smiling more.
Additionally, she commented that she was no longer self-
conscious about her smile and would, when finances
allowed, proceed with the recommended veneers on the
Figure 12. Immediately following gingival surgery, no tissue charring
was observed, and active hemorrhage was not evident. maxillary lateral incisors.

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Conclusion
Patients presenting with excessive display of gingival
tissue associated with passive eruption require correction
of the soft tissue prior to initiation of restorative proce-
dures for aesthetic smile enhancement. Use of the bipolar
surgical unit permits gentle soft tissue correction without
the associated postoperative inflammation reported with
monopolar surgery. Tissue margins remain in a stable
position following surgical correction, and restorative
procedures may be initiated immediately without con-
Figure 13. Appearance of the gingival tissues immediately following cern for apical migration of the gingival margin in the
gingival surgery to reshape and recontour the gingiva.
postoperative period.

Acknowledgement
The authors declare no financial interest in any of the
products cited herein.

References
1. Chiche G, Kokich V, Caudill R. Diagnosis and Treatment
Planning of Esthetic Problems. In: Pinault A, Chiche G, eds.
Esthetics in Fixed Prosthodontics. Carol Stream, IL: Quintessence
Publishing, 1994.
2. Studer S, Zellweger U, Schärer P. The aesthetic guidelines of the
mucogingival complex for fixed prosthodontics. Pract Periodont
Aesthet Dent 1996;8(4):333-341.
3. Kois JC. Altering gingival levels: The restorative connections.
Part I: Biological variables. J Esthet Dent 1994;6(1):3-9.
Figure 14. Two weeks post surgical treatment, slight inflammation
4. Kokich VG. Guidelines for managing orthodontic-
was noted on the papilla between teeth #7(12) and #8(11).
restorative treatment for the adolescent patient. Semin Orthod
1997;3(1):3-20.
5. Kokich V. Esthetics and anterior tooth position: An orthodontic
perspective. Part III: Mediolateral relationships. J Esthet Dent
1993;5(5):200-207.
6. Rüfenacht C. Structural Esthetic Rules. In: Fundamentals of Esthetics.
Carol Stream, IL: Quintessence Publishing;1992:134.
7. Ahmad I. Geometric considerations in anterior dental aes-
thetics: Restorative principles. Pract Periodont Aesthet Dent
1996;10(7):851-855.
8. Chalifoux PR. Checklist to aesthetic dentistry. Pract Periodont
Aesthet Dent 1990;2(1):9-12.
9. Malis LI. Electrosurgery and bipolar technology. Neurosurg
2006;58(suppl):ONS1-12.
10. Malis LI. Atraumatic bloodless removal of intramedul-
lary hemangioblastomas of the spinal cord. J Neurosurg
2002;97(suppl):1-6.
11. Livaditis GJ. Comparison of monopolar and bipolar electrosurgi-
cal modes for restorative dentistry: A review of the literature. J
Prosthet Dent 2001;86(4):390-399.
Figure 15. Postoperative appearance four weeks after surgical treat- 12. Tucker RD, Hollenhorst MJ. Bipolar electrosurgical devices.
ment. Note the absence of inflammation and improved aesthetics. Endosc Surg Allied Technol 1993;1(2):110-113.

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CONTINUING EDUCATION CE 3
CONTINUING EDUCATION

(CE) EXERCISE NO. 3


To submit your CE Exercise answers, please use the answer sheet found within the CE Editorial Section of this issue and complete as follows:
1) Identify the article; 2) Place an X in the appropriate box for each question of each exercise; 3) Clip answer sheet from the page and mail
it to the CE Department at Montage Media Corporation. For further instructions, please refer to the CE Editorial Section.

The 10 multiple choice questions for this Continuing Education (CE) exercise are based on the article “Diagnosis and treatment planning for
predictable gingival correction of passive eruption” by Gregori M. Kurtzman, DDS and Lee H. Silverstein, DDS, MS. This article is on Pages
000-000.

1. The margins of the surgical template are intended to: 6. The zenith of a maxillary central incisor should
a. Provide colorization that will improve visualization of the be positioned:
template’s margins intraorally during surgery. a. At the midline of the tooth.
b. Act as a guide for the new gingival margins position. b. Distal to the midline of the tooth.
c. Eliminate free-hand placement of the margins. c. Mesial to the midline of the tooth.
d. All of the above. d. Positioning varies patient to patient.

2. Passive eruption may be recognized by: 7. It is generally recommended that elimination of passive
a. Position of the sulcular attachment coronal to the CEJ. eruption be accomplished:
b. Length of the coronal aspect that is equal to the a. Prior to making final prosthetic impressions.
tooth’s width. b. Prior to the completion of definitive restorative therapy.
c. Presence of excessive gingival display. c. Following the completion of restorative rehabilitation.
d. Both a and b are correct. d. Both a and b are correct.

3. When correcting passive eruption, the papillae: 8. Why was treatment not performed on the mandibular
a. Should be included in the incision. teeth in the case presented?
b. Should not be included in the incision. a. Passive eruption was not evident on the mandibular teeth.
c. Should be excised with the flap. b. The patient declined treatment because the mandible
d. Both a and c are correct. was not visible when she smiled.
c. The presence of periodontal disease prevented treatment.
4. A gingivectomy may be used to correct passive d. All of the above.
eruption when:
a. An adequate band of attached gingiva will remain 9. The height of the gingival crest for the lateral incisors
following gingival excision. should be:
b. Bone does not require removal coronal to the new a. 1 mm shorter than the gingival margins of the
gingival margin position. adjacent teeth.
c. No “black triangles” are present. b. 1 mm longer than the gingival margins of the
d. All of the above. adjacent teeth.
c. Identical to the gingival margins of the adjacent teeth.
5. A surgical template is used to: d. None of the above.
a. Provide a guide as to the position of the new
gingival margin. 10. The proper placement of the gingival zenith is:
b. Provide a guide as to the position of the existing a. Distal to the long axis on all teeth.
gingival margin. b. The midline of the long axis for all teeth.
c. Provide a guide as to the position of the existing c. The peak of the parabolic curvature of the
osseous margin. gingival margin.
d. Provide a guide as to the position of the new d. Along the incline of the parabolic curvature of the
osseous margin. gingival margin.

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