Volume 85 • Number 4

Open-Flap Versus Flapless Esthetic

Crown Lengthening: 12-Month Clinical
Outcomes of a Randomized Controlled
Clinical Trial
Fernanda V. Ribeiro,*† Daniel Y. Hirata,* André F. Reis,* Vanessa R. Santos,* Tamires S. Miranda,*
Marcelo Faveri,* and Poliana M. Duarte*

Background: Excessive gingival display (EGD) has a neg-

ative impact on a pleasant smile. Minimally invasive thera-
peutic modalities have become the standard treatment in
many dentistry fields. Therefore, the aim of this study is to
compare the clinical outcomes of open-flap (OF) and mini-
mally invasive flapless (FL) esthetic crown lengthening
(ECL) for the treatment of EGD.

E
xcessive gingival display (EGD)
Methods: A split-mouth randomized controlled trial was or a ‘‘gummy smile’’ presents
conducted in 28 patients presenting with EGD. Contralateral a negative impact on esthetic
quadrants received ECL using OF or FL techniques. Clinical appearance.1,2 It is caused by the hy-
parameters were evaluated at baseline and 3, 6, and 12 peractivity of the elevator muscle of the
months post-surgery. The local levels of receptor activator upper lip, vertical overgrowth of the
of nuclear factor-kB ligand (RANKL) and osteoprotegerin maxilla, gingival enlargement, and/or
(OPG) were assessed by enzyme-linked immunosorbent as- altered passive eruption. Altered passive
say at baseline and 3 months. Patients’ perceptions regard- eruption is a clinical condition in which
ing morbidity and esthetic appearance were also evaluated. the gingival margin (GM) is positioned
Periodontal tissue dimensions were obtained by computed coronally on the anatomic crown due to
tomography at baseline and correlated with the changes in disorders in the eruptive patterns of the
the gingival margin (GM). dentogingival unit, resulting in short
Results: Patients reported low morbidity and high satis- clinical crowns.3,4
faction with esthetic appearance for both procedures The management of EGD may involve
(P >0.05). RANKL and OPG concentrations were increased a variety of treatment modalities, de-
in the OF group at 3 months (P <0.05). Probing depths pending on its specific etiology.2,4,5 If
were reduced for both groups at all time points, compared the EGD is related to altered passive
with baseline (P <0.05). There were no differences between eruption or gingival enlargement, it
groups for GM reduction at any time point (P >0.05). can be effectively corrected by peri-
Conclusions: FL and OF surgeries produced stable and odontal surgeries.4 Crown-lengthening
similar clinical results up to 12 months. FL ECL may be techniques, including the apically posi-
a predictable alternative approach for the treatment of tioned flap and gingivectomy with bone
EGD. J Periodontol 2014;85:536-544. recontouring as necessary, can improve
EGD and uneven gingival contour due to
KEY WORDS
delayed passive eruption.6,7 These sur-
Crown lengthening; esthetics, dental; gingivectomy; gical procedures must be able to reduce
gingivoplasty; surgery, plastic; surgical procedures, the excessive gingival tissue, expose the
minimally invasive. desirable clinical crowns, and reestablish
the appropriate biologic width.6,7 Sur-
* Department of Periodontology, Dental Research Division, Guarulhos University, prisingly, although the surgical manage-
Guarulhos, São Paulo, Brazil.
† Dental Research Division, School of Dentistry, Paulista University, São Paulo, Brazil. ment of EGD has been presented by
several case reports and case series,4,8-10
to date, no controlled clinical study has

doi: 10.1902/jop.2013.130145

536
J Periodontol • April 2014 Ribeiro, Hirata, Reis, et al.

compared surgical techniques for esthetic crown consent. This study protocol was previously ap-
lengthening (ECL). proved by the Guarulhos University Ethics Com-
Traditional ECL procedures generally involve el- mittee in Clinical Research. The ClinicalTrials.gov
evation of a full-thickness flap to access and re- identifier is NCT01821157.
contour the bone crest to preserve the biologic
Experimental Design and Treatment Protocols
width.7 These methods are often time-consuming,
In this prospective, split-mouth, randomized con-
require sutures, and may cause postoperative mor-
trolled clinical study, 28 patients requiring correction
bidity for the patient. Reducing the undesirable out-
of EGD received ECL using OF and FL techniques. A
comes of conventional surgeries and increasing
computer-generated table randomly distributed the
patient acceptance require less-invasive techniques
right quadrant to receive OF or FL techniques. Af-
that are able to achieve better or similar results with
terward, the contralateral left quadrant was allocated
less morbidity compared with traditional surgeries.
to the other group. The following treatments were
Because minimally invasive therapeutic modalities
performed.
have become the standard of care in many medical
OF ECL. For OF ECL (control group; n = 28 sides
and dentistry fields, this study evaluates a minimally
[105 teeth]), an internal beveled incision was per-
invasive surgical technique for ECL.11 This tech-
formed at the buccal aspect of the involved teeth.
nique is a modification of the conventional surgery
Afterward, a sulcular incision was completed to allow
in which the gingival and bone tissues are remod-
gingival tissue removal. A full-thickness mucoper-
eled without flap elevation. Therefore, this study aims
iosteal flap was reflected to remove and recontour
to compare the clinical outcomes of the conventional
bone tissue by means of surgical chisels, as neces-
open-flap (OF) and the minimally invasive flapless (FL)
sary, until a 3-mm distance was achieved between
ECL for the treatment of EGD up to 12 months. It is
the bone crest and the CEJ. The exposed root sur-
hypothesized that the FL surgery would yield similar
faces were carefully planed with curets. Interrupted
clinical results to the OF technique up to 12 months.
sutures were performed at the papilla to allow GM
MATERIALS AND METHODS stabilization in the CEJ position.
FL ECL. For FL ECL (test group; n = 28 sides [105
Inclusion and Exclusion Criteria
teeth]), internal beveled and sulcular incisions and
Twenty-eight systemically healthy patients (eight
gingival tissue removal were performed as described
males and 20 females, aged 21 to 40 years; mean
above for the control group, replacing the GM in the
age: 27.5 – 5.8 years) were selected among 59 pa-
CEJ position. However, the alveolar bone was re-
tients screened from the population referred to
moved and recontoured, as necessary, using mi-
Guarulhos University, São Paulo, Brazil, from January
crochisels, via incisions, without flap elevation. The
2011 until July 2011. All patients presented with
root surfaces were also carefully planed via incisions.
esthetic concerns regarding EGD due to altered
The required distance of 3 mm between the bone
passive eruption in at least three maxillary teeth
crest and the CEJ was checked by inserting a peri-
(central incisors, lateral incisors, canines, or pre-
odontal probe into the incision. Sutures were not
molars) per half contralateral quadrant. To perform
performed.
the diagnosis of altered passive eruption, the ce-
After both procedures, canines and central in-
mento-enamel junction (CEJ) was first located by
cisors should be at the same length, and the lateral
means of a manual periodontal probe. Afterward,
incisor should be 1 mm shorter. The same peri-
altered passive eruption was defined as a dentogin-
odontist (FVR) performed all surgeries. Chlorhex-
gival relationship in which the GM overlapped the
idine gluconate mouthwash (0.12%) was prescribed
enamel coronally to the CEJ, resulting in short clinical
twice a day for 2 weeks. Analgesics were prescribed
crowns. Inclusion criteria were: 1) >21 years old; 2) at
to control possible postoperative discomfort. The
least 20 teeth; 3) no sites with attachment loss and
sutures of control quadrants were removed after 7
probing depth (PD) >3 mm; and 4) full-mouth pla-
days. The surgical time for test and control, starting
que,12 bleeding on probing (BOP)12 and marginal
after anesthesia, was computed. Figures 1A to 1H
bleeding (MB) index scores of <15%. Exclusion criteria
illustrate both surgical techniques and their clinical
were: 1) pregnancy; 2) lactation; 3) history of
results.
smoking; 4) antimicrobial and anti-inflammatory
therapies during the previous 2 months; 5) previous Examiner Calibration
mucogingival surgery at the region to be treated; 6) Clinical examinations were performed by one trained
systemic conditions that could affect tissue healing (e. examiner (DYH), calibrated as previously de-
g., diabetes); and 7) use of orthodontic appliances. scribed.13 The intraexaminer variability was 0.16 mm
All eligible patients were informed of the nature, for PD and 0.18 mm for clinical attachment level
risks, and benefits of the study and signed informed (CAL). The parameters registered dichotomously (e.g.,

537
Flapless Esthetic Crown Lengthening Volume 85 • Number 4

most cervical point of the GM;

6) relative CAL (rCAL): dis-
tance from a fixed landmark in
the stent to the bottom of the
gingival sulcus; and 7) kerati-
nized gingiva height (KGH):
distance from the GM to the
mucogingival line. rGM was
also assessed immediately af-
ter surgery.
The relative bone level (rBL)
(i.e., the distance between a
fixed landmark in the stent and
the bone crest [BC]) was re-
corded before and after the
surgical procedures.
Enzyme-Linked
Immunosorbent Assay
To evaluate the effects of sur-
gery on alveolar bone remod-
eling, the gingival crevicular
fluid (GCF) levels of receptor
activator of nuclear factor-kB
ligand (RANKL) and osteopro-
tegerin (OPG) were assessed.
One site from each quadrant
was randomly chosen for GCF
Figure 1.
(A) Gingival display on full smile with an unsatisfactory gingival contour and crown size discrepancies. sampling at baseline and 3
(B) Internal bevel and sulcular incisions at the buccal aspect of the anterior teeth on the OF side. (C) months post-surgery. The GCF
Full-thickness mucoperiosteal flap elevation on the OF side. (D) Bone crest removal by means of surgical sampling protocol and volume
chisels to achieve a 3-mm distance between the bone crest and the CEJ. (E) Interrupted sutures on measurement were performed
the OF side. (F) Excessive gingival tissue removal on the FL side. (G) Removal and recontouring of the as previously described.14 The
alveolar bone crest using chisels, via incisions, without flap elevation on the FL side. (H) Inserting
a periodontal probe to check the distance of the bone crest to the CEJ/GM. (I) Immediate post-surgery view. strips were stored at -80C for
Note that sutures were not performed on the FL side. (J) Gingival aspect at 7 days post-surgery. Note subsequent assays. GCF sam-
the slight inflammation in the papillae of the OF side. (K) Gingival aspect at 3 months after surgery. Note ples were analyzed by enzyme-
remaining scars in the papilla areas of the OF side. (L) Gingival aspect at 12 months post-surgery. linked immunosorbent assay
(ELISA) for soluble RANKL
BOP) were calculated by the k-light test, and the in- (sRANKL) and OPG using commercially available
traexaminer agreement was >0.85. ELISA kits,§ according to the manufacturer’s rec-
ommendations.14 Results were reported as total
Clinical Monitoring
amount (picograms) and concentration (picograms
Periodontal measurements were performed using
per microliter GCF) of protein.
a manual probe.‡ An individual stent of ethylene-
vinyl acetate copolymer was used as a reference Cone Beam Computed Tomography
point for some clinical parameters. Grooves were To evaluate the hard and soft tissues of the buccal
drilled in the stent to standardize the localization and periodontal apparatus, soft-tissue cone beam com-
direction of the probe. The following parameters were puted tomography (ST-CBCT) was performed as
assessed on the mesio-buccal, mid-buccal, and previously described.15 At baseline, the CBCT scans
disto-buccal aspect of all included teeth at baseline were taken,i and the images (sections 1.0 mm apart)
and 3, 6, and 12 months post-surgery: 1) plaque were acquired using suitable software. Briefly, the
index (PI);12 2) MB: bleeding up to 15 seconds after individuals were submitted to a regular CBCT scan
probing along GM; 3) BOP: bleeding up to 15 sec- while wearing a plastic lip retractor in an inverted
onds after probing, at least 1 minute after MB re- position and retracting their tongue toward the floor
cording; 4) PD: distance between the GM and the
‡ UNC, Hu-Friedy, Chicago, IL.
bottom of the gingival sulcus; 5) relative GM (rGM): § Biomedica Medizinprodukte, Vienna, Austria.
distance from a fixed landmark in the stent to the i iCAT, Imaging Sciences International, Hatfield, PA.

538
J Periodontol • April 2014
of the mouth. These procedures prevented the in-
terference of the soft tissues of the lips, cheeks, and
tongue in the gingival tissue. The following mea-
surements were obtained in the buccal aspect of the
middle image section of each tooth with a digital
caliper rule: 1) bone thickness (BT, the width of the
buccal bone at a distance of 3 mm apical to the bone
crest); 2) CEJ-to-BC distance (CEJ-BC); 3) gingival
thickness (GT, the width of the buccal gingival tissue
at a distance of 3 mm apical to the bone crest); 4)
GM-to-BC distance (GM-BC); and 5) CEJ-to-GM
distance (CEJ-GM).
Patient Perceptions
Patient perceptions regarding morbidity and esthetic
satisfaction were evaluated with a questionnaire
administered by an assistant (TM). The questionnaire
was obtained upon completion of the procedure
(pain), at 7 days post-surgery (pain/discomfort,
swelling, hematoma, esthetic appearance), and at 6
months post-surgery (esthetic appearance). Re-
sponses were quantified with a visual analog scale
(VAS) of 100 mm in which 0 indicated ‘‘no’’ and 100
‘‘plenty.’’16 In addition, at 7 days and 6 months post-
surgery, a questionnaire recorded patient satisfaction
regarding the type of treatment, in terms of esthetic
appearance, by selecting one of the following
choices: totally satisfied, partially satisfied, or un-
satisfied.
Statistical Analyses
To validate the clinical comparisons of this paper,
a post hoc power calculation was performed based
on differences of 0.5 mm in GM between groups at 12
months post-surgery. Because no previous study
exists comparing OF and FL techniques, the authors
established that a difference of 0.5 mm in GM be-
tween the two approaches could be a relevant clinical
parameter to perform the power size calculation. In
addition, a standard deviation of 0.5 mm was de-
termined based on the observed standard deviation
of the difference in GM changes between groups at 12
months, considering all buccal sites (interproximal
plus mid-buccal sites). Based on these data, it was
determined that 16 patients per group would be
necessary to provide an 80% power with an a of 0.05.
Because 28 patients met the inclusion criteria, these
were all included in the study. The power calculation
took into account the split-mouth design.17
The primary outcome variable was mean change
in GM. Secondary outcomes included the additional
clinical parameters of patient perceptions and
RANKL and OPG levels. Data were examined for
normality by the Shapiro–Wilk test. The data that did
not achieve normality were analyzed using non-
parametric methods. The mean percentage of sites
with visible plaque accumulation, MB, BOP, and
Ribeiro, Hirata, Reis, et al.
mean PD, rGM, rCAL, KGH, and rBL were com-
puted, separately, for interproximal and mid-buccal
sites of control and test sides. Interproximal sites
included the mean of mesio- and disto-buccal
measurements. The changes in the rGM from
baseline to immediately after surgery and 3, 6, and
12 months and in rBL from baseline to immediately
after surgery were calculated for both groups.
Clinical differences between groups were compared
using the paired Student t test. Repeated-measures
analysis of variance and Tukey test were used to
detect differences within each group among time
points. The Mann-Whitney U test was used to
evaluate VAS scores of patient’s perceptions. The
satisfaction in terms of esthetic appearance was
compared by the x2 test. RANKL and OPG differ-
ences between groups and time points were com-
pared using the Wilcoxon test.
A model of multiple linear regression (MLR)
analysis was performed to estimate the association
between the dimensions of the soft and bone tissues
obtained by ST-CBCT, the treatment modalities, and
the changes in the GM. The outcome variable in this
model was the non-appearance of creeping attach-
ment of the GM in a coronal direction, at 12 months,
from the position defined immediately after surgery
(yes/no). The predictor variables included the sur-
gical modalities and the tomography measurements.
The level of significance was set at 0.05 for all
analyses.
RESULTS
The study population comprised 28 patients. One
patient did not return for the 3-month visit and was
excluded from the statistical analysis. Five patients
did not return for the 6-month and 12-month visits
(Fig. 2). Therefore, intention-to-treat clinical analy-
ses were performed in these five patients (their 3-
month data were carried forward). The patients did
not report adverse effects such as fever and in-
disposition after surgery. The mean surgical time was
lower for FL (mean: 31 – 12 minutes; range: 14 to 68
minutes) than for OF (mean 41 – 14 minutes; range:
20 to 66 minutes) (P <0.05).
Patient Perceptions
At 6 months, 11 patients perceived no differences
between surgical techniques regarding esthetic ap-
pearance; nine patients reported the FL side as more
esthetic than the OF side; and three patients pre-
ferred the appearance of the OF side. On the VAS,
there were no differences between groups for any
statement (P >0.05). There were no differences be-
tween groups regarding satisfaction with esthetic
appearance (P >0.05). In general, the patients re-
ported low levels of morbidity and high levels of
539
Flapless Esthetic Crown Lengthening
Figure 2.
Study design.
satisfaction with the esthetic appearance for both
surgical procedures (Table 1).
ELISA
There were no differences between groups regarding
the levels of RANKL and OPG at baseline (P >0.05)
(Table 2). The concentrations of OPG were higher in
the OF group than the FL group at 3 months post-
surgery (P <0.05) (Table 2). There was a significant
increase in the concentrations of RANKL and OPG in
the OF group at 3 months compared with baseline
(P <0.05) (Table 2).
Clinical
For the mid-buccal sites, there were no differences
between OF and FL for plaque accumulation, MB,
and BOP at any follow-up visit (P >0.05). The PD
and KGH means were reduced significantly at all
time points compared with baseline for both treat-
ments (P <0.05), without differences between groups
(P >0.05) (Table 3). Both therapies yielded an in-
crease in the mean rGM and rCAL at 3, 6, and 12
months (P <0.05) compared with baseline. The
mean rGM was higher in the OF group, compared
with the FL group at 3 months (P <0.05).
For the interproximal buccal sites, the PD means
decreased, while the rGM means increased signifi-
cantly at all time points for both treatments (P <0.05)
compared with baseline, without differences between
groups (P >0.05) (Table 3). The mean percentage of
plaque accumulation and the mean values of KGH
and rCAL did not change over time and did not differ
540
Volume 85 • Number 4
between groups at any time
point (P >0.05). The mean
percentage of BOP was higher
in the OF group than in the FL
group at 3 months (P <0.05). In
addition, the mean percentage
of BOP increased at 3 months
for the OF group compared
with baseline (P <0.05).
There were no differences
between groups for GM re-
duction (i.e., differences among
the rGM measurements at base-
line, immediately after surgery,
and at 3, 6, and 12 months)
at any time point (P >0.05).
In addition, the GM reduction
did not differ among time
points for any group (P >0.05)
(Table 4).
The mean levels of bone re-
moval were 1.4 – 0.8 and 1.2 –
0.7 mm (P >0.05) for the mid-
buccal sites of the OF and FL
groups, respectively. In addi-
tion, the mean levels of bone removal were 0.5 – 0.4
and 0.4 – 0.4 mm (P >0.05) for the interproximal
buccal sites of the OF and FL groups, respectively.
ST-CBCT
Mean BT values were 0.9 – 0.3 and 0.9 – 0.4 mm,
whereas mean GT values were 0.7 – 0.3 and 0.6 –
0.3 mm for the OF and FL sides, respectively. Mean
CEJ-BC distances were 1.2 – 0.5 and 1.1 – 0.5 mm,
mean CEJ-GM distances were 1.9 – 0.8 and 1.9 –
0.8 mm, and GM-BC distances were 3.0 – 0.8 and
3.1 – 0.7 mm for the OF and FL sides, respectively.
The MLR showed that the GT plus BT (i.e., both
measurements together) was the only variable that
significantly influenced the non-appearance of creep-
ing attachment of the GM in a coronal direction at
12 months, from the position defined immediately
after surgery. The non-appearance of creeping at-
tachment was associated with lower GT-plus-BT
measurements (GT plus BT, odds ratio = 2.73; 95%
confidence interval 1.02 to 7.34; P <0.001).
DISCUSSION
This study compares, for the first time, the clinical
effects of conventional OF and minimally invasive FL
crown-lengthening techniques for the treatment of
EGD. Both surgical modalities displayed successful
clinical outcomes up to 12 months, with slight
morbidity and suitable patient satisfaction. There-
fore, the hypothesis that the FL surgery for ECL
would yield similar clinical results to the OF
J Periodontol • April 2014 Ribeiro, Hirata, Reis, et al.

technique was accepted. The choice for a surgical requires scalloped incisions that could create mu-
technique for crown lengthening depends on a cogingival problems when the KG is inadequate,
number of factors, including the proportion of the whereas the OF technique allows preservation of the
attached gingiva area. All patients included pre- preexisting keratinized tissue and its replacement in
sented an adequate zone of KGH that would remain an apical position.
even after the removal of the required gingival tissue Both the OF and FL approaches produced sig-
(Table 3). Therefore, both surgical procedures were nificant reductions in the excessive gingival tissue, as
fully indicated for the selected patients. The FL observed by the increase in the rGM and rCAL levels
technique would be contraindicated in cases in which and decrease in the PD and KGH measurements over
the KGH is limited. In addition, the FL technique time, compared with baseline (Table 3). Further-
more, this study assesses the alterations in the GM as
an immediate outcome of surgical crown lengthening
Table 1. and over a 12-month healing period. The OF and FL
procedures resulted in a post-surgical immediate
Patient Perceptions Regarding Morbidity mean apical removal of the gingival tissue of 1.3 and
and Esthetic Appearance After Both 1.1 mm, respectively, considering all buccal sites. At
Surgical Procedures 6 and 12 months post-surgery, the GM reduction
achieved was 1.0 mm for both groups (Table 4). This
Evaluation Open-Flap Flapless finding shows that, once the level of the GM was
defined by both surgical procedures, its changes were
Day after surgery
VAS score (mm)
minimal up to 12 months. At 3 months post-surgery,
Pain during surgery 12.6 – 23.5 14.4 – 23.9 the mid-buccal GM of the OF group (6.8 mm) dis-
Pain immediately after surgery 14.2 – 24.2 13.0 – 23.3 played a higher distance from the reference point
compared with the FL group (6.5 mm). This negli-
7 days post-surgery gible difference is probably just a consequence of flap
VAS score (mm) elevation in the OF group, which may place the GM
Pain 18.6 – 24.5 9.6 – 16.8
more coronally during short-term healing. Likewise,
Swelling 13.9 – 19.1 11.3 – 19.4
Hematoma 11.3 – 19.8 8.3 – 18.1
a slightly higher level of BOP was observed in the
Improved appearance 86.4 – 16.2 83.1 – 20.3 interproximal buccal sites of the OF group at 3
Patient satisfaction (n) months compared with the FL group. This finding is
Partially satisfied 8 6 possibly a result of the tissue trauma/healing in the
Fully satisfied 20 22 interproximal areas due to papilla elevation and su-
ture.
6 months post-surgery
These clinical results are in agreement with
VAS score (mm)
Improved appearance 85.0 – 18.8 87.9 – 15.5
a previous investigation18 demonstrating that the
Patient satisfaction (n) changes in the GM from those defined after a con-
Partially satisfied 14 17 ventional OF crown lengthening were minimal at 6
Fully satisfied 9 6 months. Conversely, these findings are in contrast to
There were no differences between groups for any parameter by Mann–
those from an earlier report that observed a tendency
Whitney U or x tests (P <0.05). for the GM to grow coronally from the immediate
2

Table 2.
Mean (– SD) Levels of sRANKL and OPG at Baseline and 3 Months Post-Surgery

Open Flap Flapless

Bone-Related Factors Baseline 3 Months Baseline 3 Months

sRANKL pg/site 9.0 – 1.9 10.5 – 2.9 9.8 – 2.3 10.3 – 2.8
sRANKL pg/µL 0.5 – 0.2 0.9 – 0.8* 0.7 – 0.7 0.9 – 1.0
OPG pg/site 12.4 – 11.5 15.5 – 19.2 9.6 – 4.3 10.9 – 3.4

OPG pg/µL 0.5 – 0.4 1.2 – 1.4*† 0.5 – 0.6 0.7 – 0.5
* Significant differences between baseline and 3 months within a group by Wilcoxon test (P <0.05).
† Significant differences between OF and FL groups at 3 months post-surgery by Wilcoxon test (P <0.05).

541
Flapless Esthetic Crown Lengthening Volume 85 • Number 4

post-surgical level up to 12 months fol-

lowing crown-lengthening surgery.19

14.9 – 27.0
12.5 – 23.9

9.9 – 19.3
2.3 – 0.7b
2.4 – 0.7b
3.1 – 1.1b
3.0 – 1.0b
5.0 – 8.2a
12 Months

0.5 – 2.5
1.5 – 6.4

5.5 – 1.3
5.5 – 1.4
7.8 – 1.8
7.8 – 1.8
However, those authors performed an
apically positioned flap technique with
bone recontouring, where the GM was
positioned subcrestally at interproximal
sites and at the bone crest at the buccal/

7.2 – 13.3a
lingual sites. Deas et al.20 demonstrated
11.4 – 21.8
11.3 – 21.6
3.3 – 10.8

6.7 – 18.4
2.2 – 0.8b
2.2 – 0.6b
3.3 – 0.9b
3.0 – 0.8b
6 Months

0.0 – 0.0

5.6 – 0.9
5.5 – 0.8
8.7 – 1.3
8.5 – 1.4
Interproximal Buccal Sites

that a greater coronal rebound of the

gingival tissue occurred when the GM was
positioned closer to the bone crest during
the crown-lengthening surgery. However,

Different superscript letters indicate significant differences over time within a therapeutic group (repeated-measures analysis of variance and Tukey tests; P <0.05).
a minor rebound occurred at 6 months
9.8 – 18.4b*

when the GM was sutured at 3 mm from

Mean (– SD) of the Clinical Parameters at the Mid-Buccal and Interproximal Buccal Sites

3 Months

13.4 – 25.2
9.2 – 17.6

4.2 – 11.0
2.3 – 0.6b
2.3 – 0.6b
3.5 – 0.9b
3.3 – 1.0b
0.0 – 0.0
0.0 – 0.0

5.7 – 0.9
5.6 – 0.9
8.7 – 1.5
8.8 – 1.4
the bone. In the present study, the GM
was positioned at the level of the CEJ and
at 3 mm from the bone crest during the
OF and FL surgeries, providing a minimal
distance for the biologic width.17,21,22
Using micro-chisels, the FL approach
6.1 – 11.6a
6.8 – 20.7
2.9 – 0.6a
2.9 – 0.6a
2.7 – 1.0a
2.9 – 1.1a
Baseline

4.4 – 8.7
2.9 – 6.6
1.7 – 6.0
0.0 – 0.0

5.7 – 1.0
5.7 – 1.1
8.3 – 2.3
8.0 – 2.3
allowed bone recontouring in an apical
direction, via incisions, when the bone
crest was located at or close to the CEJ.
As the access to bone in the FL surgery is
‘‘blind,’’ the amount of bone removal was
* Significant differences between OF and FL groups within the 3-month time point (paired Student t test; P <0.05).
13.9 – 26.3
13.9 – 23.8

15.4 – 22.9
8.9 – 14.7
1.4 – 0.4b
1.5 – 0.5b
6.5 – 1.1b
6.2 – 1.4b
7.9 – 1.1b
7.7 – 1.1b
5.3 – 1.2b
5.4 – 1.3b
12 Months

1.9 – 6.7
0.9 – 0.5

guided by means of probing. This infers

that a tactile sensitivity is needed to
blindly locate the bone level in relation to
CEJ during the FL procedure, while the
OF approach benefits from the full visu-
alization of the bone level and removal.
14.8 – 27.1
11.1 – 21.7

5.6 – 24.4

9.0 – 17.5
9.2 – 16.7
1.3 – 0.3b
1.2 – 0.3b
6.7 – 1.1b
6.5 – 1.2b
7.9 – 1.1b
7.7 – 1.1b
5.6 – 1.2b
5.7 – 1.2b
6 Months

1.9 – 6.7

The minimally invasive FL technique

evaluated herein is not a mere gingivec-
Mid-Buccal Sites

tomy, as an alternative to the full-thick-

ness flap, because it includes bone crest
remodeling when necessary. The simple
6.8 – 1.1b*
12.0 – 26.3
10.8 – 23.6
3.7 – 11.4

8.3 – 21.9
6.8 – 20.7

excision of the gingival tissue without

1.2 – 0.3b
1.4 – 0.6b

6.5 – 1.2b
7.9 – 1.1b
7.8 – 1.1b
5.8 – 1.6b
6.0 – 1.7b
3 Months

1.9 – 6.7

bone remodeling would probably result in

coronal tissue regrowth during healing, if
the bone crest was <3 mm apical to the
post-surgical position of the GM.7,19
Thus, the similar stability of the GM of the
4.6 – 17.0
3.7 – 11.4

5.6 – 20.0
3.4 – 13.4
2.0 – 0.5a
2.1 – 0.6a
5.1 – 1.1a
5.1 – 1.1a
7.2 – 1.0a
7.2 – 1.0a
6.9 – 1.4a
6.5 – 1.5a
Baseline

2.0 – 7.3
0.0 – 0.0

FL group to that of the OF group is at-

tributed to the creation of a distance of 3
mm from the alveolar bone crest to the
GM.
The comparable stability of the GM,
Group

up to 12 months, after the OF and FL

OF

OF

OF

OF

OF

OF

OF
FL

FL

FL

FL

FL

FL

FL

surgeries was reinforced by the MLR

analysis. No surgical modality predicted
the non-appearance of the creeping at-
tachment of the GM in a coronal di-
rCAL (mm)

KGH (mm)
rGM (mm)
Plaque (%)

rection at 12 months from the position

Parameter

PD (mm)
BOP (%)
Table 3.

MB (%)

defined during surgery. Interestingly,

among the characteristics of the peri-
odontal tissues obtained by tomography,

542
J Periodontol • April 2014 Ribeiro, Hirata, Reis, et al.

Table 4. addition, the concentration of OPG was significantly

higher in the OF than the FL groups at 3 months.
Mean (– SD) Reduction in the GM From
Therefore, as expected, it seems that flap elevation
Baseline to Immediately After Surgery and may induce an intensified bone remodeling process.
3, 6, and 12 Months After Surgery However, these molecular events may not result in
any clinical consequences in relation to the success
Site and Time Point OF (n = 28) FL (n = 28) P of crown lengthening over time.
Compared with the traditional OF, the minimally
All buccal sites
Immediately after 1.3 – 0.5 1.1 – 0.5 0.25 invasive FL approach is expected to present advan-
3 months 1.2 – 0.5 1.0 – 0.5 0.19 tages with regard to duration of surgery, blood supply,
6 months 1.0 – 0.5 1.0 – 0.5 0.46 tissue manipulation and trauma, technical complexity,
12 months 1.0 – 0.6 1.0 – 0.5 0.66 wound stability, gingival architecture preservation,
and patient discomfort and morbidity. Regarding
Interproximal buccal sites
duration of surgery, the FL surgery resulted in a
Immediately after 1.0 – 0.7 0.8 – 0.6 0.11
25% reduction in surgical time compared with OF.
3 months 0.8 – 0.6 0.7 – 0.5 0.34
6 months 0.7 – 0.6 0.6 – 0.5 0.54 Considering patient morbidity, both techniques re-
12 months 0.7 – 0.6 0.6 – 0.6 0.72 sulted in minor discomfort (Table 1). However, it is
important to note that there was a tendency toward
Mid-buccal sites higher mean VAS score for pain on the OF side that
Immediately after 1.5 – 0.8 1.5 – 0.8 0.91 was probably related to the tissue reflection and
3 months 1.6 – 0.7 1.4 – 0.7 0.29
consequent higher surgical trauma. Regardless of
6 months 1.5 – 0.7 1.4 – 0.6 0.57
patients’ perceptions, the authors observed that the
12 months 1.3 – 0.8 1.3 – 0.7 0.76
FL approach permitted faster healing and lower tis-
There were no differences between treatment groups at any time point by
paired Student t test (P >0.05). There were no differences over time by
sue inflammation at 7 days, compared with the OF
repeated-measures analysis of variance and Tukey tests (P >0.05) within approach, especially in the papilla areas (Fig. 1J),
each therapeutic group.
where small remaining scars were noticed in the
papilla area of the OF sides up to 3 months (Fig. 1K).
a lower BT plus GT distance was the only significant A gummy smile can have an adverse effect on the
predictor for the non-appearance of creeping at- perception of a patient’s attractiveness, friendliness,
tachment. It has been suggested that the periodontal trustworthiness, intelligence, and self-confidence.16
biotype may influence the extent of tissue alteration Therefore, the correction of EGD is an important
after crown lengthening. A previous investigation element not only in the esthetics of the smile, but also
has demonstrated that the coronal regrowth of the in patient self-esteem. In this study, patients reported
soft tissue margin was more pronounced in patients high satisfaction with esthetic appearance at 7 days
with thick tissue biotype.18 It is important to note after both surgical approaches. These high levels of
that the patients included in this study presented esthetic appearance satisfaction were also main-
a mean BT of 0.9 – 0.3 and 0.9 – 0.4 mm for the OF tained at 3 months post-surgery for both the OF and
and FL sides, which probably contributed to the FL techniques, probably as result of the minimal
long-term success of the crown lengthening. The gingival regrowth over time.
FL is a technique sensitive to bone thickness, since
the reduction of bone in the buccal-palatal direction CONCLUSIONS
in cases of thick bone is not possible using this non- The OF and FL procedures produced stable and
invasive approach because the flap is not elevated similar clinical results up to 12 months for the
to completely access the bone tissue. Therefore, it is treatment of EGD. Therefore, FL crown lengthening
supposed that OF with osteoplasty/ostectomy would seems to be a feasible, predictable, and time-saving
be indicated in cases of thick periodontal biotype to method for the treatment of gummy smile due to
better predict the final position of the GM and reduce altered passive eruption.
the chances of tissue rebounding.
Studies have attributed a critical role to RANK, its ACKNOWLEDGMENT
ligand RANKL, and OPG in regulating osteoclasto- The authors report no conflicts of interest related to
genesis and bone remodeling.23,24 In the present this study.
study, the levels of OPG and RANKL are assessed in
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Correspondence: Prof. Poliana Mendes Duarte, Universi-
dade Guarulhos, Centro de Pós-Graduac xão e Pesquisa,
xa Tereza Cristina, 229 – Centro, Guarulhos, SP, Brazil,
Prac
07.023-070. Fax: +55 (11) 2464-1758; e-mail: pduar-
te@ung.br.
Submitted March 29, 2013; accepted for publication May
21, 2013.