Roberto Rossi, DDS, MScD

Private Practice
Genoa, Italy
Remo Benedetti, MD, DDS
Private Practice
Genoa, Italy
Regina Isabel Santos-Morales, DMD
Private Practice
Makati City, Philippines
CASE REPORT
THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 3 NUMBER 3 AUTUMN 2008
212
Treatment of Altered Passive
Eruption: Periodontal Plastic Surgery
of the Dentogingival Junction
Correspondence to: Dr Roberto Rossi
Torre San Vincenzo 2, 16121 Genova, Italy;
phone: 39 010 5958853; fax: 39 010 3460429; e-mail: drrossi@mac.com
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ROSSI ET AL
dentogingival unit. This article describes
how periodontal plastic surgery can re-
model the attachment apparatus, reestab-
lish the correct biologic width, eliminate
the excessive show of gingiva, and ex-
pose the correct dimensions of teeth. Api-
cally repositioned flaps with osseous re-
contouring can restore gingival health and
the esthetic parameters of the smile line.
(Eur J Esthet Dent 2008;3:212223.)
Abstract
Excessive gingival display, frequently seen
in adults and resulting in short clinical
crowns, has been described in the literature
by several authors as altered passive erup-
tion. It is defined as a dentogingival rela-
tionship wherein the gingival margin is po-
sitioned coronally on the anatomic crown
and does not approximate the cemento-
enamel junction due to the disruption in the
development and eruptive patterns of the
213
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214
the epithelial attachment.
8
Biologic width
has also been defined by Ingber et al as the
actual measurement between the bottom
of the gingival sulcus and the alveolar bone
crest.
9
They found that in healthy normal
gingiva, the distance from the CEJ to the
crest of the alveolar bone is on average
1.55 mm. They claim that this space is nec-
essary for a healthy and stable attachment
apparatus. This value should be under-
stood as a theoretical mean as there have
been no studies to show the variability of
this value in humans.
There have been several studies to de-
termine the accuracy of dentogingival
measurements. Using cadaver jaws,
Vacek et al support the concept that the
connective tissue attachment is less vari-
able than the epithelial attachment.
10
Their
mean measurements were 1.14 mm and
0.77 mm for epithelial and connective tis-
sue attachments, respectively, and these
were different from the previous paper.
Another paper, by Boyle et al, investigat-
ed the interproximal bone crest levels in
clinically healthy patients ranging in age
from 11 to 70 years using bitewing radi-
ographs.
11
Measurements taken from the
CEJ to the alveolar bone crest ranged be-
tween 0.2 mm and 2.15 mm, with a mean
distance of 1.24 mm. They found a graph-
ic expression of regression of CEJalveo-
lar bone crest distance with age. One of
the conclusions of this study was that the
normal CEJalveolar bone crest distance
of 1.5 mm described by Gargiulo et al
7
has
large variations, and may often be as little
as 0.2 mm. A more recent study, by
Alpiste-Illueca, using a reproducible radi-
ographic technique, found values of
2.05 mm for the CEJalveolar bone crest
distance and 2.0 mm for biologic width.
12
These results corroborate the notion that
The periodontal literature has described
delayed or altered passive eruption as the
condition in which the patient presents with
an excessive show of gingiva upon smiling
and when the gingival margin overlaps the
anatomical crown resulting in short clinical
crowns.
14
This display of excessive pink
soft tissue is also referred to as gummy
smile.
5
Anatomical consideration
In a normal situation, an adult dentate pa-
tient should display a dentogingival rela-
tionship where the gingival margin is locat-
ed on the enamel approximately 0.5 to
2 mm coronally to the cementoenamel
junction (CEJ).
2
The gingival margin is lo-
cated on the enamel whereas the junction-
al epithelium is located between the base
of the sulcus and the CEJ. The connective
tissue attachment apparatus has its fibers
embedded into the cementum and is locat-
ed between the alveolar bone and the CEJ.
The mucogingival junction is located api-
cal to the crest of bone. The histologic re-
lationships of the dentogingival junction
were studied by Sicher in 1959.
6
It is com-
posed of, first, the connective tissue fiber at-
tachment of the gingiva, and second, the
epithelial attachment.
6
In 1961, Gargiulo et
al studied these dimensions using human
cadaver teeth.
7
They found the distance
from the base of the epithelial attachment
to the crest of alveolar bone (connective tis-
sue attachment) to be constant. The mean
average length in all stages of eruption was
1.07 mm. The epithelial attachment was
variable and averaged 0.97 mm.
7
Biolog-
ic width was defined by Cohen in 1962 as
the space provided on the root surface for
the attachment of the connective tissue and
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Case reports
Clinical case 1 (Figs 1 to 5)
This is the case of a 30-year-old female
complaining of excessive gingival display
and short clinical crowns. The patient
showed poor oral hygiene and sponta-
neous bleeding in several sites (Fig 1).
After initial therapy consisting of oral hy-
giene instruction, scaling, and root planing,
the gingival condition improved. However,
the gingival margin remained on the
enamel coronal to the CEJ (Fig 2). Debride-
ment reduced inflammation, allowing ac-
curate evaluation of the extent of altered
passive eruption. This case was diagnosed
as delayed passive eruption of type II, sub-
types A and B, depending on the sites. Ra-
diographic examination revealed no bone
loss, and some areas showed bone close-
ly approximating the CEJs of the teeth.
Probing depth was 3 to 4 mm, revealing the
presence of pseudopockets. Bone sound-
ing was carried out to determine the level
the dimensions of the dentogingival unit
are highly variable.
The biologic width becomes significant
when maintaining gingival health of tissues
for restorative, orthodontic, periodontal, and
esthetic concerns.
Coslet et al have classified altered pas-
sive eruption in adult patients as follows.
1
I Gingival/anatomic crown relationship:
Type I gingival margin incisal to the
CEJ, where there is a noticeably wider
gingival dimension from the margin to
the mucogingival junction.
Type II dimension from the gingival
margin to the mucogingival junction
which appears to be within the normal
mean width, as described by Bowers
3
and Ainamo and Loe.
2
I Alveolar crestCEJ relationship:
Subtype A the alveolar crestCEJ dis-
tance is approximately 1.5 mm. This al-
lows for normal attachment of the gingi-
val fibers into cementum.
Subtype B the alveolar crest is at the
level of the CEJ.
Fig 1 (a and b) Initial presentation.
a b
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Fig 2 Reeval uat i on
stage after initial therapy.
Fig 3 (a, b and c) Intraoral views showing osseous contours upon flap reflection. Both central incisors (b) do
not have room for the connective tissue and the epithelial attachment (2.0 mm) as the osseous crest is <1 mm
from the CEJ.
Fig 4 (a, b and c) After osseous resective surgery, the interproximal bone has been shaped to accommo-
date the soft tissue contours and the alveolar crest has been scalloped to provide room for the biologic width.
a b c
a b c
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terproximal areas. During a recall visit of
the patient 5 years after the procedure, the
established dentogingival unit appeared
stable (Fig 5). In summary, by reducing soft
tissue inflammation, apical repositioning of
gingival flaps, and establishing a new bio-
logic width (2.0 mm) through osseous re-
sective surgery, the chief complaint of the
patient was met with an esthetic outcome.
Clinical case 2 (Figs 6 to 20)
This is the case of a 27-year-old female
complaining of gummy smile and short
clinical crowns (Figs 6 to 9). The patient was
tall and her short clinical crowns were dis-
proportionate to her face and her smile. The
patient exhibited adequate oral hygiene.
Radiographs showed very limited biologic
width on all the teeth of the upper arch
ROSSI ET AL
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217
of buccal bone and the position of the CEJ
in relation to the gingival margin.
After local anesthesia was administered,
marginal incisions were performed. Full-
thickness flaps were reflected buccally and
palatally to expose the underlying bone.
The height and thickness of the bone
showed biologic width was minimal
(0.5 mm) on the two maxillary central inci-
sors and 1.5 mm on the lateral incisors
(Fig 3). In some areas, such as the maxil-
lary left bicuspids, the alveolar bone was at
the CEJ, thus impinging the biologic width.
An osseous resective procedure provid-
ed biologic width of 2 mm in all teeth, thus
creating more space for the soft tissue to
be repositioned approximately at the CEJ
(Fig 4). Scalloping of the gingiva was then
performed using a no. 15c blade. The flaps
were sutured back with vertical mattress
sutures to reposition the papillae in the in-
Fig 5 Five-year follow-
up shows stability of the
established dentogingi-
val interface.
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Fig 6 The smile at rest position during the consulta-
tion visit.
Fig 7 The gummy smile at the consultation visit.
Fig 8 (a, b and c) Preoperative smile line.
Fig 9 (a, b and c) Preoperative clinical view.
a b c
a b c
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(Fig 10). The diagnosis was altered passive
eruption type I subtype B. The treatment
plan was to remove the excessive soft tis-
sue to expose the teeth fully to their natural
length and to remove osseous structure to
give room for a biologic width of at least
2 mm. In some areas, one-third of the clin-
ical crowns were covered with gingiva. The
clinical crown of the central incisor was
only 8 mm. However, the radiographic
length measured 12 mm (Figs 11 and 12).
The extent of soft tissue removal for each Fig 10 Radiograph showing the limited biologic
width; the osseous crest is close to cementoenamel
junction level.
Fig 11 Central incisor:
the anatomical crown
length was 12 mm.
Fig 12 Central incisor: the clinical crown length was
only 8 mm.
Fig 13 Initial scalloping of the soft tissues, through
submarginal incisions.
Fig 14 Removal of excessive soft tissue showing the
correct clinical crown exposure.
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After local anesthesia was administered,
scalloped incisions were made using a no.
15c blade to mark the extent of soft tissue
removal (Fig 13). Soft tissues were removed
and the true lengths of the clinical crowns
were exposed (Fig 14). Full mucoperiosteal
flaps were elevated buccally and palatally to
expose the thick, bulbous bony architecture
(Fig 15). Osseous crests were found ap-
proximating the level of the CEJ, thus not
allowing for the proper biologic width. Os-
seous recontouring provided at least 2 mm
space between the CEJ and the crest of the
alveolar bone from teeth 15 to 25, eliminat-
ing the thick bony ledges (Fig 16). The flap
was repositioned apically using single inter-
rupted resorbable sutures (Fig 17).
At the 6-month recall the patient showed
a marked improvement in soft tissue qual-
ity (Figs 18 to 20). The smile line showed
the full length of the teeth, with remarkable
esthetic enhancement of the smile.
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VOLUME 3 NUMBER 3 AUTUMN 2008
220
tooth was measured clinically and radi-
ographically prior to the procedure. The
surgical planning anticipated the removal
of at least 1 mm of alveolar bone at all the
sites to restore the correct minimum biolog-
ic width and to allow correct bone remod-
eling in order to provide adequate scallop-
ing and architecture (Fig 13).
Fig 15 Thick, bulbous osseous contours upon flap elevation, situated at almost the cementoenamel junction
level.
a b c
Fig 16 (a and b) Frontal view following osseous plastic surgery to provide space for the biologic width.
a
Fig 17 Single interrupted sutures in place.
b
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Discussion
Altered passive eruption is an uncommon
occurrence that is only diagnosed upon
clinical observation. It is defined as a dento-
gingival relationship wherein the margin of
the gingiva is positioned incisally/occlusal-
ly on the anatomic crown in adulthood and
does not approximate the cementoenamel
junction.
13
This means that the crowns of
the teeth appear very short and thus proj-
ect a gummy smile. The incidence of this
condition has not been fully studied in
adults, although Volchansky and Cleaton-
Jones, in a study in children aged between
6 and 16 years, found the incidence to be
12%.
14
In this study, they also observed that
clinical crown height increases with in-
creasing age. Thus, tooth eruption and for-
mation of the dentogingival junction should
be clearly understood prior to any treat-
ment.
Fig 18 (a, b and c) Healing at 6 months, showing healthy gingiva and proper exposure of enamel.
a b c
Fig 20 The new smile shows overall enhanced facial
esthetics.
Fig 19 The new smile line displays the appropriate amount of teeth and soft tissue, eliminating the gummy
smile.
a b
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Esthetic considerations
The dental practitioner can influence the
smile by correcting tooth length problems,
as in altered passive eruption cases. This
should be considered in relation to the lip
line of the patient. Tooth length has been
studied in the literature; Townsend report-
ed that canines and central incisors should
be at the same length, and the lateral inci-
sor should be 1 to 2 mm shorter.
19
There
should be an interdental papilla of 4.5 to
5 mm from the tip of the papilla to the
depth of the marginal scallop, and the
most apical part of the gingival scallop
should reflect the angle of the long axis of
the tooth. The author also mentioned that
the mean crown length for a maxillary cen-
tral incisor is 13.5 mm; for a maxillary later-
al incisor, 12 mm; and for a maxillary ca-
nine, 13 mm. Wheelers textbook
20
also
reported on tooth sizes, giving average
lengths for maxillary anterior clinical
crowns measured on extracted teeth. The
values given were 10.5 mm for maxillary
incisors, 9 mm for lateral incisors, and
10 mm for canines. These values should
serve as guides and should be regarded
as one important aspect of esthetic treat-
ment. Gingivectomy procedures can be
performed using these values, while also
keeping in mind Loe and Ainamos de-
scription of the ideal clinical crown size for
a particular patient (Fig 13).
2
In normal dentition, teeth and their alveoli
actively erupt from their crypts. They con-
tinue to erupt through the gingiva until they
make occlusal contact with the teeth in the
opposing arch.
15
Orban and Kohler in 1924
described the various stages of eruption of
teeth.
16
In stage 1, the epithelial attachment
is situated along the enamel surface im-
mediately above the CEJ. In stage 2, the
epithelial attachment is situated along both
the enamel above the CEJ and the cemen-
tum surface of the root of the tooth. In stage
3, the epithelial attachment is situated on-
ly on the cementum, immediately below
the CEJ. Stages 1 to 3 are physiologic in
nature. Finally, in stage 4 the epithelial at-
tachment migrates apically due to peri-
odontal disease or other pathologic condi-
tions.
Variations in the height of the gingival
margin on the anatomic crown have been
observed in adults at various ages.
Volchansky and Cleaton-Jones found that
in a study in children aged between 6 and
16 years, 12.1% of the 1,025 evaluated pa-
tients exhibited delayed passive eruption.
17
The same study found that eruption of
teeth was completed by the age of 12
years for the maxillary central incisors and
canines, and the maxillary lateral incisors
continued to demonstrate minor changes
in gingival margin position up to 16 years
of age. However, Morrow et al suggest that
passive eruption, resulting in increased
clinical crown length, seems to continue
throughout the teenage years, until the age
of 19.
18
It is, therefore, imperative that age is
also considered before treating altered
passive eruption cases.
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Conclusions
This paper provides clinical and biologic
presentations on the treatment of altered
passive eruption, using periodontal plastic
procedures such as esthetic crown length-
ening. Altered passive eruption occurs on
patients who exhibit unesthetic short clinical
crowns with gummy smiles. The dento-
gingival dimensions are taken into consid-
eration in careful diagnosis and treatment
planning of the cases. Clinical and radio-
graphic examinations dictate the necessary
removal of soft and hard tissues to achieve
the desired result. The reestablishment of a
new and correct biologic width and the ex-
posure of the correct length of the clinical
crown leads to excellent clinical, biologic,
and esthetic outcomes.
Resective procedure
Once the level of the gingiva has been es-
tablished, selective osseous recontouring
can be achieved by performing submar-
ginal incisions to the desired height of the
clinical crown.
20
A biologic width of at least
2 mm between the alveolar crest and the
CEJ should be attained to ensure the
health of the attachment apparatus
(Fig 16). The thickness of the gingiva
should also be taken into consideration
when the flaps are replaced, and mainte-
nance of a good zone of attached gingiva
should also be addressed.
14. Volchansky A, Cleaton-Jones
P. The position of the gingival
margin as expressed by clini-
cal crown height in children in
ages 616 years. J Dent Assoc
S Africa 1975;4:116122.
15. Evian CI, Cutler SA, Rosen-
berg ES, Shah RK. Altered
passive eruption: The undiag-
nosed entity. J Am Dent Assoc
1993;124:107110.
16. Orban B, Kohler, J. The physi-
ologic gingival sulcus. Z Stom-
atol 1924;22:353.
17. Volchansky A, Cleaton-Jones P.
Clinical crown height (length)
a review of published meas-
urements. J Clin Periodontol
2001;28:10851090.
18. Morrow LA, Robbins JW, Jones
DL, Wilson NHF. Clinical crown
length changes from age
1219: A longitudinal study. J
Dent 2000;28:469473.
19. Townsend CL. Resective sur-
gery: An esthetic application.
Quintessence Int
1993;24:535542.
20. Wheeler RC (ed). Wheelers
atlas of tooth form, ed 5.
Philadelphia: WB Saunders,
1984:136138.
8. Cohen DW. Pathogenesis of
Periodontal Disease and its
Treatment. Washington, DC:
Walter Reed Army Medical
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9. Ingber JS, Rose LF, Coslet JG.
The biologic width: A con-
cept in periodontics and
restorative dentistry. Alpha
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10. Vacek JS, Gher ME, Assad DA,
Richardson AC, Giambarresi
LI. The dimensions of the
human dentogingival junction.
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11. Boyle W, Via F, McFall W. Radi-
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crest height and age. J Peri-
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