CASE REPORT

Esthetic crown lengthening

in the treatment of gummy smile

Mauricio Andrés Tinajero Aroni, MSc

Diagnosis and Surgery, UNESP, São Paulo State University, Brazil

Suzane Cristina Pigossi, PhD

Clinics and Surgery, Federal University of Alfenas, Brazil

Elton Carlos Pichotano, PhD

Diagnosis and Surgery, UNESP, São Paulo State University, Brazil

Guilherme José Pimentel Lopes de Oliveira, PhD

Periodontia e Implantodontia, Universidade Federal de Uberlândia, Brazil

Rosemary Adriana Chierici Marcantonio, PhD

Diagnosis and Surgery, UNESP, São Paulo State University, Brazil

Correspondence to: Prof Suzane Pigossi

Clinics and Surgery, Federal University of Alfenas, Gabriel Monteiro da Silva St, 700 Alfenas Minas Gerais 37130-001, Brazil;
Tel: +55 35 3701-9000; Email: supigossi@ymail.com

370 | The International Journal of Esthetic Dentistry | Volume 14 | Number 4 | Winter 2019

Abstract
The aim of this article was to evaluate 1 year after sur-
gery a surgical protocol that included gingivectomy
and an apically positioned flap plus osseous resective
surgery to correct excessive gingival display (EGD) in
patients with altered passive eruption (APE) of the
maxillary anterior teeth. Six female patients aged 18 to
22  years were diagnosed with APE type 1B. Surgical
crown lengthening with flap surgery and bone recon-
touring was performed to achieve the biologic width.
Photographic images were analyzed to evaluate the
stable improvement of crown length before the pro-
cedure (baseline), immediately after surgery (immedi-
ate postoperative), and at 3 and 12 months postsur-
The International Journal of Esthetic Dentistry | Volume 14 | Number 4 | Winter 2019
ARONI ET AL
gery. Moreover, a lip repositioning procedure was also
performed in one case to complement the periodon-
tal therapy. Compared with baseline, an increase of
1.6 mm in the mean tooth crown height was ob-
served in the photographic analysis at 12 months. A
minimal difference was observed between the mean
tooth crown height immediate postoperative and at
12 months, which indicates stability of the gingival
margin. In conclusion, the surgical protocol outlined
in this article describing esthetic crown lengthening
for the treatment of APE/gummy smile resulted in pre-
dictable outcomes and stability of the gingival margin
1 year after surgery.
(Int J Esthet Dent 2019;14:370–382)
| 371
CASE REPORT
Case 1
a a
b b
c c
d d
Fig 1 Changes in tooth dimensions and gingival display of cases 1 to 6 from baseline (a), immediate postoperative (b), 3 months (c),
and 12 months (d) after the crown lengthening surgery.
Introduction
A harmonious smile is considered a symbol
of beauty in modern society.1 A multifacet-
ed scenario, including tooth form and posi-
tion, gingival tissue levels, and lip position
determine smile esthetics, which has been a
focus of dental treatment.1,2 There has been
particular interest in the treatment of exces-
sive gingival display (EGD), commonly
termed gummy smile, and periodontal plas-
tic surgery techniques have been used to
improve smile esthetics.1 EGD is character-
ized by an overexposure of the maxillary
gingiva during smiling or speaking.3 This
condition occurs in 10.57% of the popula-
372 | The International Journal of Esthetic Dentistry | Volume 14 | Number 4 | Winter 2019
Case 2 Case 3
a
b
c
d
tion,4 affecting people (predominantly
females) of 20 to 30 years of age.5
Possible etiologic factors for EGD in-
clude plaque or drug-induced gingival en-
largement or overgrowth, altered passive
eruption (APE), short clinical crowns, verti-
cal maxillary excess, hyperactive or short
upper lip presence or a combination of
these clinical conditions.6,7 From the clinical
perspective, APE is associated with in-
creased gingival band width and gingival ex-
posure during smiling.8 In a normal eruption
phase, the gum tissue migrates apically,
with gradual exposure of the tooth crown
stabilizing at the cervical level.9 Thus, mostly
due to developmental or genetic factors,

Case 4
a a
b b
c c
d d
the alteration in APE may lead to the per-
sistence of an excessive amount of soft tis-
sue over the enamel surface, resulting in an
excessive quantity of gingival tissue at the
maxillary anterior teeth during smiling.1
In addition, APE has been subclassified
into two types:10 type 1 is characterized by
an excessive amount of attached gingiva
with shorter crowns, while type 2 is a gum-
my smile associated with a normal gingival
dimension. In addition, two possible sub-
classes (A and B) have been suggested, de-
pending on the relationship of the bone
crest (BC) to the cementoenamel junction
(CEJ) of the tooth (BC–CEJ). In subcategory
A, the BC–CEJ is > 1.5 mm, allowing ade-
ARONI ET AL
Case 5 Case 6
a
b
c
d
quate space for the insertion of a connec-
tive tissue attachment to the root surface. In
subcategory B, this space is minimal and
does not allow for a correct biologic
width.1,11 Depending on the classification,
different possible treatments are indicated.
The treatment plan for APE type 1B should
include the management of the periodontal
tissue and incorporate gingivectomy and
apically positioned flap plus osseous resec-
tive surgery (esthetic crown lengthening
surgery).12 However, APE type 2 showing ex-
cessive growth of the maxillary process
generally requires a multidisciplinary treat-
ment plan, including orthognathic surgery
and orthodontic treatment.13 It is empha-
The International Journal of Esthetic Dentistry | Volume 14 | Number 4 | Winter 2019 | 373
CASE REPORT
sized that APE type 1 treatment is a chal-
lenge and is risky because excessive bone
resection on the maxillary anterior teeth
may lead to residual gingival recession.1,12
On the other hand, a limited resection may
result in coronal regrowth of the gingival
margin, reducing the length of the postsur-
gical clinical crowns.1 Therefore, an ade-
quately planned surgical procedure its es-
sential to guarantee proper treatment of
APE and satisfy patients’ expectations.
In some cases, where the EGD is caused
by the combined etiology of a hyperactive
upper lip and APE, other techniques are as-
sociated with crown lengthening surgery to
resolve the EGD. In these cases, procedures
such as botulinum toxin injection14 or lip re-
positioning15 have been proposed. The lip
repositioning technique is accomplished by
a single partial-thickness elliptical incision in
the depth of the anterior maxillary vestibule.
Then, the lip mucosa is sutured to the mu-
cogingival line.15 This technique was de-
signed to be shorter in duration and less ag-
gressive than orthognathic surgery, and also
causes fewer postoperative complications.16
The aim of this case series was to evalu-
ate the efficiency of a surgical protocol con-
sisting of gingivectomy and an apically re-
positioned flap combined with osseous
resective surgery to correct EGD in patients
with APE at the maxillary anterior teeth. The
gingival margin stability obtained with the
crown lengthening procedure was evaluat-
ed at 3- and 12-months postsurgery.
Case description
Inclusion criteria
Six periodontally and systemically healthy
female patients aged 18 to 22 years who
were non-smokers sought treatment. They
were dissatisfied with their smile esthetics
due to the overexposure of the maxillary
gingiva during smiling or speaking. During
374 | The International Journal of Esthetic Dentistry | Volume 14 | Number 4 | Winter 2019
the clinical intraoral examinations, the pa-
tients’ oral cavities were examined under
natural light using sterile instruments to re-
cord the plaque index (PI) and the gingival
index (GI) using the criteria proposed by Sil-
ness and Loe.17 Only patients with a PI and
GI of < 20% were included in the study.1
Moreover, all patients presented inadequate
tooth width and height proportions in the
superior anterior maxilla. These parameters
were detected using a specific probe (Chu’s
Aesthetic Gauges; Hu-Friedy). Transgingival
probing (TP) using a conventional periodon-
tal probe (Hu-Friedy) detected a BC–CEJ
distance of < 1.5 mm in the superior anter-
ior teeth. Based on this, the patients were
diagnosed with APE type 1B, and surgical
crown lengthening with flap surgery and
bone recontouring was the indicated treat-
ment (Figs 1a and 2a).
Esthetic crown lengthening and
frenectomy surgery
Local anesthesia was induced using a 4% ar-
ticaine solution with epinephrine 1:100,000
(Nova DFL). The surgical procedure was ini-
tiated with gingival demarcation on the mid-
buccal aspect of the teeth using a specific
probe (Chu’s Aesthetic Gauges) (Fig 2b and c).
After the gingival demarcation, the CEJ pos-
itions were checked with a conventional
periodontal probe (Hu-Friedy). An internal
bevel incision was made following the CEJ
anatomy using a No. 15  C blade at each
tooth (teeth 13 to 23), preserving the inter-
dental papillae (Fig 2d). The removal of the
marginal gingival strip was made with a
periodontal curette (Hu-Friedy) (Fig 2e). The
gingival contour was delineated using a
Goldman Fox microscale (Quinelato) to-
gether with delicate Goldman Fox pliers to
reduce the gingival volume (Fig 2f).
An intrasulcular incision was made, and a
conservative full-thickness flap to the level
of the mucogingival junction (MGJ) was
 ARONI ET AL

a b c

d e f

g h i

j k l

Fig 2 Representative case illustrating the esthetic crown lengthening surgical procedure (case 6). (a) Pretreatment view of the maxillary
anterior teeth. (b) Gingival margin measurement using a specific tip. (c) Gingival demarcation on midbuccal aspect. (d) External bevel incision
following the CEJ anatomy. (e) Gingival margin removal with a periodontal curette. (f) Gingival contour finalization using a Goldman Fox
microscale and pliers. (g) Full-thickness flap elevation. (h) Ostectomy and osteoplasty using carbide steel burs. (i) Ostectomy and osteoplasty,
final aspect. (j) Single interrupted sutures. (k) Labial frenectomy. (l) Immediate postoperative, final aspect.

raised on the buccal aspect, including teeth
13 to 23 (Fig 2g). Teeth 14 and 24 were also
affected by the APE and included in the flap.
The BC–CEJ distance was measured on the
midbuccal aspect, then carbide steel burs
and hand chisels were used for ostectomy
and osteoplasty, aiming to attain a 2-mm
BC–CEJ distance (Fig 2h and i). No inter-
proximal crestal bone was removed.
The flap was repositioned, and single in-
terrupted sutures (Cytoplast PTFE sutures,
PERIO USP, 4/0) were used to stabilize the
flap (Fig 2j). In all cases, the labial frenum was
closely attached to the gingival margin in the
superior incisive region. Then, a frenectomy
was made (Fig 2k) to complete the removal
of the frenum using the conventional tech-
nique described by Devishree et al.18 The fre-
num was engaged with a hemostat tweezer
inserted into the depth of the vestibule, and
incisions were placed on the upper and un-
derneath surfaces of the tweezer using a
No. 15 C blade. The triangular resected por-
tion of the frenum was removed, and a blunt
dissection was performed on the bone to
relieve the frenum attachment. The edges of
the wound were sutured with single inter-
rupted sutures (Cytoplast PTFE sutures,
PERIO USP, 4/0) (Fig 2l).
The patients were prescribed 0.12%
chlorhexidine gluconate (Periogard; Col-
gate) and instructed to rinse gently twice
daily for 15 days. Tooth brushing was to be
discontinued in the surgical area during this
time. An antibiotic (Azithromycin, 500 mg,
once daily) was prescribed for 3 days to pre-
vent possible postoperative infection. A
nonsteroidal anti-inflammatory (Nimesulide,
100 mg, 12/12 h) and an analgesic (Dipy-
rone, 500 mg, 6/6 h) were also prescribed.

The International Journal of Esthetic Dentistry | Volume 14 | Number 4 | Winter 2019 | 375
CASE REPORT

a b c

Fig 3 Scheme of image measurement standardization. (a) Digital ruler calibration using an initial photograph of the teeth with a millimeter
probe. (b) Dental crown width measurement in the initial photograph (baseline to preoperative) using a digital ruler. (c) Dental crown height
measurement in the initial photograph (baseline to preoperative) using a digital ruler.

Table 1 Dental crown height mean length (millimeters) obtained in each case at Postsurgical follow-up
baseline, immediate postoperative, 3 months, and 12 months

The 7-day postoperative healing was un-

Immediate
Baseline 3 months 12 months eventful and the sutures were removed. For
postoperative
Case 1 8.6 10.1 9.6 9.6 case 1, a restorative phase was carried out
3 months after the surgical crown length-
Case 2 5.8 7.0 6.9 8.2
ening procedure to close the diastema be-
Case 3 7.0 7.0 7.1 7.1
tween teeth 11 and 21 using composite res-
Case 4 7.3 9.2 9.3 8.9 in (Fig 1d). Patient photographs were taken
Case 5 6.0 6.8 6.3 6.2 before the surgery (baseline), immediately
Case 6 6.5 9.0 8.2 8.6 after the surgery (immediate postoperative),
after 3 months, and after 12 months (Fig 1a
Final
6.8 8.0 7.7 8.4 to d). The photographs were analyzed to
mean
evaluate the stability of the results of the
The distortion ratio was calculated by dividing the average width obtained in the final
photograph (immediately postoperative, 3 months or 12 months) by the width obtained in crown lengthening procedure. Distortions
the initial photograph (baseline). between the photographs were adjusted
using mathematic calculations following
the modified sequence proposed by Teren-
Table 2 Dental crown height mean length (millimeters) obtained in each case at zi et al19. The reference structures (dental
immediate postoperative and 12 months
crown width) were measured with the digi-
tal ruler of the digital smile design (DSD)
Immediate postoperative 12 months
program, using millimeters as the unit of
Case 1 9.3 8.7 measurement (Fig 3). First, the digital ruler
Case 2 9.0 9.2 was calibrated to a real measurement using
an initial photograph of the teeth with a
Case 3 7.2 7.2
millimeter probe in each case. The dental
Case 4 9.3 8.9 crown width of two teeth (superior central
Case 5 6.3 5.7 incisors) in the initial photograph (baseline
Case 6 10.0 9.6 – preoperative) was obtained. In the same
way, the widths of the same teeth were
Final
9.1 8.8 measured in the immediate postoperative
mean
The distortion ratio was calculated by dividing the average width obtained in the
and 3- and 12-month follow-up photo-
photograph at 12 months by the width obtained in the photograph at 3 months. graphs. An average of the two measure-

376 | The International Journal of Esthetic Dentistry | Volume 14 | Number 4 | Winter 2019

Case 1
a a
b b
Case 4
a a
b b
Fig 4 Changes in smile appearance in cases 1 to 6 from baseline (a) to 12 months (b) after the crown lengthening procedure.
ments was obtained for each photograph.
A distortion ratio was calculated by dividing
the mean width obtained in the final pho-
tograph (immediate postoperative, 3 or
12 months) by the width obtained in the ini-
tial photograph (baseline). This distortion
ratio was used to normalize the measure-
ments of crown length utilized to compare
the crown length after immediate postop-
erative, 3 and 12 months, with the crown
length obtained from the baseline photo-
graph (Table 1). Moreover, a distortion ratio
was also calculated by dividing the mean
width obtained in the 12-month photo-
graph by the width obtained in the immedi-
ARONI ET AL
Case 2 Case 3
a
b
Case 5 Case 6
a
b
ate postoperative photograph. This distor-
tion ratio was used to compare the crown
length obtained in the immediate postoper-
ative photograph with that obtained in the
12-month one (Table 2).
The smile photographs 1 year after the
crown lengthening procedure (Fig 4) show
a reduction in the gingival smile and a cor-
rection of the gingival zenith. Table 1 shows
a 1.2 mm increase in the average crown
length after the surgical procedure (differ-
ence between immediate postoperative
and baseline). After 12 months, the average
crown length remained 1.6 mm higher than
at baseline (difference between 12 months
The International Journal of Esthetic Dentistry | Volume 14 | Number 4 | Winter 2019 | 377
CASE REPORT

Fig 5 Lip reposition-

ing procedure
(case 6). (a to c)
Measurement of
keratinized gingiva.
(d and e) Elliptical
incision demarcation
using a marking
pencil. (f to i) Single
partial-thickness
a b c
elliptical incision.
(j) Simple interrupted
suture in the
medium, canine, and
molar regions.
(k) Immediate
postoperative, final
aspect.

d e

f g

h i

j k

378 | The International Journal of Esthetic Dentistry | Volume 14 | Number 4 | Winter 2019

a b
Fig 6 Changes in smile appearance in case 6 from baseline (a), to 12 months after the crown lengthening surgery (b), and 3 months after
the lip repositioning surgery (c).
postoperative and baseline). Moreover,
Table 2 shows a minimal difference (0.3 mm)
between the average crown length in the
immediate postoperative measurement and
12 months after the procedure; in other
words, the gingiva rebound 12 months after
the surgical procedure was only 0.3 mm,
indicating gingival margin stability after
12 months of follow-up.
Lip repositioning technique
One patient (case 6) was dissatisfied with the
degree of gingival exposure during smile
even after the crown lengthening proce-
dure. In this case, the EGD occurred due to
the combination of APE with a hyperactive
upper lip. Therefore, lip repositioning was
performed according to the technique pro-
posed by Rosenblatt and Simon20 to com-
plement the gummy smile treatment. The
preoperative protocol described above was
followed. The location of the mucogingival
junction and the keratinized gingiva size
were determined using a periodontal probe
(Fig 5a to c). A marking pencil was used to
outline the borders of the elliptical incision
(Fig 5d and e). The lower incision coincided
with the mucogingival line in order to avoid
any loss of attached gingiva, and was ex-
tended from the mesial aspect of the first
premolars bilaterally. The distance between
the superior and inferior borders was
1.5 mm, which was the length of the repos-
itioning desired in the patient’s smile as de-
termined by the preoperative measurement.
ARONI ET AL
c
A single partial-thickness elliptical incision
was created with a No. 15 C blade, removing
the epithelium but keeping the underlying
connective tissue intact (Fig 5f and i). Care
was taken to avoid damage to the minor sal-
ivary glands in the submucosa. The area of
frenectomy was approximated with a simple
interrupted suture (polyglycolic resorbable
5/0 suture, Vicryl; Ethicon/Johnson & John-
son) to ensure symmetry and proper midline
placement. Other key sutures were made
bilaterally in the canine and molar regions
(Fig 5j). Then, multiple interrupted sutures
were made between the initial key suture
placement areas to complete the wound
closure (Fig 5k). The same postoperative
protocol described above was followed,
and the patient was instructed to minimize
lip movements when smiling or talking for
2 weeks after the surgery. The sutures were
removed at the 2-week follow-up appoint-
ment. Postoperative healing was uneventful.
A minor scar formed on the suture lines but
remained invisible during smiling. The
3-month follow-up showed a reduction of
gingival display, and the patient was satisfied
with the final treatment result (Fig 6).
Discussion
A careful diagnosis and treatment plan are
essential to indicate the most predictable
APE treatment protocol.15 The most com-
mon diagnostic method is TP, which is used
to detect the CEJ subgingivally and to cal-
culate the real clinical crown dimension.21
The International Journal of Esthetic Dentistry | Volume 14 | Number 4 | Winter 2019 | 379
CASE REPORT
The soft tissue height is measured with a
periodontal probe down to the BC, and this
dimension can also be used to guide the
amount of osseous resection to be ful-
filled.22 Studies comparing TP with direct
bone-level measurements immediately af-
ter flap reflection suggest that TP is an accu-
rate method of determining BC levels.23,24
However, although transgingival bone prob-
ing measurements seem to be very close to
the histometric bone level,25 the use of cone
beam computed tomography (CBCT) has
also been proposed, which allows for the
three-dimensional (3D) visualization of the
alveolar bone/soft tissue as well as accurate
and precise measurements.26 A retrospec-
tive study by Batista et al27 showed that
CBCT enabled a precise diagnostic of the
reduced distance between the CEJ and the
BC as well as the precise determination of
the anatomical crown length, a key refer-
ence for APE surgical treatment.27 However,
TP alone was used to diagnose and select
all APE type 1B cases treated in this case se-
ries due to the unavailability of the patients
to undergo CBCT scanning during the sur-
gical planning period.
In this case series, Chu’s Aesthetic Gaug-
es were successfully used to guide the ex-
cess gingival tissue removal and correct the
tooth size proportion. These measurement
tips include Chu’s Proportion Gauge, which
represents an objective mathematic ap-
praisal of tooth size ranges.28 Additionally, a
full-thickness flap was performed to access
the BC and restore the biologic width, as-
suring the stability of the long-term clinical
results. Ribeiro et al29 suggested another
method to treat APE, ie, a minimally invasive
flapless esthetic crown lengthening proced-
ure using micro chisels, via incision without
flap elevation. However, in their randomized
controlled trial, the esthetic crown length-
ening, with or without flap elevation,
showed similar and stable clinical results for
up to 12 months.
380 | The International Journal of Esthetic Dentistry | Volume 14 | Number 4 | Winter 2019
Clinical studies evaluating the esthetic
crown lengthening procedure have shown
that less soft tissue rebound occurs when
the postoperative gingival margin is posi-
tioned 3 mm coronal to the surgically re-
duced BC, compared with flaps reposi-
tioned at or below it.6,18 In these case reports,
the BC was placed 2 mm apical to the CEJ,
and the flap 1 mm coronally, to allow for a
proper biologic width and to ensure the sta-
bility of crown height gained over time. In
these case reports, a clinically insignificant
gingival rebound of 0.01 mm was observed
between 3 and 12 months. On the other
hand, according to a review by Marzadori et
al,30 a buccal ostectomy should be per-
formed after choosing the guiding tooth,
following the esthetic proportion para-
meters. Thus, for these authors, the bone
reduction could be considered complete
when the flap was precisely adapted over
the underlying bone.30 The tissue biotype
might also significantly influence the gingi-
val tissue rebound, as previous studies have
shown that the mean tissue regrowth in pa-
tients with a thick biotype was significantly
greater than those with a thin one.31,32 There-
fore, the identification of tissue biotype is
necessary before crown lengthening sur-
gery, since the presence of a thick biotype
will require greater bone reduction to avoid
tissue rebound.31
The photographic analysis performed in
the present case series suggests that the
crown lengthening procedure described in
this article was successful in increasing the
clinical crown length and maintaining it for
12 months (average crown length 1.6 mm
higher than at baseline). The average crown
length values observed in these case reports
was 6.8 mm (baseline), 8.0 mm (immediate
postoperative), 7.7 mm (3-month follow-up),
and 8.4 mm (12-month follow-up) (Table 1).
Using the same surgical protocol, Silva et
al33 observed values of 8.5 mm (baseline),
10.3 mm (immediate postoperative) and

9.9 mm (6-month follow-up). Cairo et al1
also observed average crown length values
of 8.5 mm (baseline), 10.2 mm (immediate
postoperative), and 10.1 mm (6-month fol-
low-up). Moreover, certain clinical studies
have shown some gingival rebound ranging
from 0.1 to 0.2 mm over the time period.1,29
However, in these case reports, a clinically
insignificant gingival rebound of 0.3 mm
was observed between the immediate post-
operative measurement and the one taken
at 12 months (Table 2).
The case 6 patient was dissatisfied with
the degree of gingival exposure during smile
even after the crown lengthening proce-
dure. In this case, the EGD occurred due to
the combination of the APE with a hyperac-
tive upper lip. The less-invasive options for
hyperactive upper lip treatment are botuli-
num toxin injection14 or lip repositioning.16
Injecting overactive muscles with measured
quantities of botulinum toxin results in a re-
duction of muscle activity, a relaxing of the
lip muscles, and a decrease of the upward
pull on the lip.34,35 Although the botulinum
toxin injection is the least-invasive treat-
ment, the results are temporary and only
last for a period of 3 to 6 months before
slowly fading.35 Due to this, lip repositioning
was successfully indicated for the hyperac-
tive upper lip treatment in this case. A recent
systematic review published by Tawfik et al35
showed that lip repositioning successfully
reduced the EGD by 3.4 mm. Faus-Matoses
et al15 showed in three case reports that lip
repositioning can produce stable results
1 year after the procedure. Thus, lip repos-
itioning is indicated for patients with minor
discrepancies as well as for those who de-
sire a treatment that is less invasive than or-
thognathic surgery but which has a more
immediate (and long-term) result compared
with orthodontics or botulinum toxin injec-
tion treatment.35 However, this technique is
contraindicated in the presence of a mini-
mal zone of attached gingiva as well as in
ARONI ET AL
cases of several vertical maxillary excesses,
where an interdisciplinary approach is re-
commended.36
In a modified lip repositioning technique,
the maxillary labial frenulum is maintained,
and two mucosal strips (one at each side of
the frenulum) are removed.16 In this modifi-
cation, the frenulum helps to maintain the
position of the labial midline and prevents
changes in lip symmetry. However, the fren-
ulum maintenance can limit the correction
of the EGD in the region of the maxillary
central incisors during lip repositioning.15 A
recent clinical study showed that the modi-
fied lip repositioning technique shows less
relapse after surgery as well as excellent
cosmesis. Moreover, compared with the
conventional technique, it shows greater
sustainability after 6 months.37 In case 6 in
the present case series, the frenulum was
removed during the crown lengthening
procedure due to its insertion near to the
gingival margin. For this reason, in this case
the conventional lip repositioning technique
was utilized.
The methodological limitations of the
present case series include a relatively low
number of participants and the absence of
any clinical analysis of the periodontal
parameters to confirm the photographic
analysis described in this article. Therefore,
additional controlled clinical studies are
necessary to evaluate the long-term out-
comes of the procedure here described
with a larger sample size.
In conclusion, the surgical protocol in-
cluding gingivectomy and apically posi-
tioned flap plus osseous resective surgery
could be considered a predictable protocol
for the reduction of EGD associated with
APE.
Disclaimer
The authors declare that there are no con-
flicts of interest.
The International Journal of Esthetic Dentistry | Volume 14 | Number 4 | Winter 2019 | 381
CASE REPORT
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