J Clin Periodontol 2015; 42: 11261134 doi: 10.1111/jcpe.

12482

Aesthetic crown lengthening:
verson O. Silva1,2, Je

Cle
ssica M. S.
Soumaille2, Fabiano C. Marson1,
Patr
cia S. Progiante1 and Dimitris N.

periodontal and patient-centred Tatakis3

1
School of Dentistry, Inga

Maringa

University

, Parana
, Brazil; 2School
(UNINGA),

outcomes of Dentistry, State University of Maringa

(UEM), Maringa
, Parana



, Brazil; 3Division of
Periodontology, College of Dentistry, The
Ohio State University, Columbus, OH, USA

Silva CO, Soumaille JMS, Marson FC, Progiante PS, Tatakis DN. Aesthetic
crown lengthening: periodontal and patient-centred outcomes. J Clin Periodontol
2015; 42: 11261134. doi: 10.1111/jcpe.12482

Abstract
Aim: The objective of this prospective study was to assess clinical and patient-
centred outcomes of aesthetic crown lengthening surgery for the treatment of
altered passive eruption.
Materials and Methods: Twenty-two patients were treated and followed up for
6 months. The evaluated clinical parameters included, among others, probing
depth, clinical attachment level, clinical crown length (CLc), cemento-enamel junc-
tion to alveolar bone crest distance, gingival width (GW) and gingival display
(GD). Subjects completed surveys to evaluate satisfaction with smile, gingiva and
tooth features and experience with the procedure.
Results: Average CLc was 8.5  0.5 mm at baseline and significantly increased
(9.9  0.5 mm; p < 0.0001) at 6 months. Concomitantly, GW significantly
decreased from baseline (5.8  1.2 mm) to 6 months (4.9  1.1 mm; p < 0.008),
as did GD (from 2.6  2.0 mm to 1.1  1.9 mm; p < 0.0001). In contrast to their
pre-operative satisfaction level, the majority (73%) of patients were very satisfied
post-operatively with gingival and tooth display, when smiling or talking, and
with maxillary anterior tooth size and shape. All patients would undergo the pro- Key words: crown lengthening; gingiva;
cedure again and would recommend it to someone with a similar problem. periodontal; plastic surgery; surgery
Conclusion: Aesthetic crown lengthening surgery results in high levels of patient
satisfaction and predictable and stable outcomes in the short term. Accepted for publication 21 November 2015

Altered passive eruption (APE), a
condition characterized by gingival
margins located incisally to the tooth
cervical convexity, results in shorter
and more square clinical crowns
Conflict of interest and sources of
funding statement
The authors declare that there are no
conflicts of interest in this study.
No external funding, apart from the
support of the authors institution,
was available for this study.
1126
which can be perceived as unaes-
thetic (Robbins 1999, Sterrett et al.
1999, Rossi et al. 2008, Alpiste-
Illueca 2011). APE, which has also
been referred to as retarded passive
eruption (Sterrett et al. 1999),
incomplete passive eruption (Hemp-
ton & Esrason 1999) and delayed
passive eruption (Volchansky &
Cleaton-Jones 1974, Coslet et al.
1977), is fairly common; the reported
prevalence varies from 12%
(Volchansky & Cleaton-Jones 1974)
to 42% (Nart et al. 2014), depending
2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
on population examined and criteria
used. The exact mechanisms impli-
cated in APE remain to be estab-
lished; however, developmental and
genetic factors are thought to under-
lie this condition (Cairo et al. 2012,
Rossi et al. 2014).
Altered passive eruption is typi-
cally treated by aesthetic crown
lengthening surgery (ECLS) per-
formed by gingivectomy or apically
positioned flap with or without
ostectomy (Cairo et al. 2012). ECLS
has been described in case reports

(Alldritt 1966, Lai et al. 2001,
Roshna & Nandakumar 2005), case
series (Pontoriero & Carnevale 2001,
Shobha et al. 2010, Batista et al.
2012, Cairo et al. 2012, Deas et al.
2014) and a recent controlled clinical
trial (Ribeiro et al. 2014); however,
detailed patient-reported outcomes
for this common periodontal plastic
surgery procedure are lacking.
Therefore, the purpose of this
prospective study was to evaluate
the clinical characteristics of patients
with altered passive eruption, the
post-operative behaviour of soft tis-
sues following aesthetic crown
lengthening surgery, and to examine
patient-reported outcomes regarding
satisfaction with smile, gingiva and
tooth features and experience with
the procedure.
Materials and Methods
Study design and patient population
This study was a prospective inter-
ventional clinical trial aimed to eval-
uate clinical characteristics of
patients with APE and the post-
operative behaviour of soft tissues
during the first six post-operative
months after ECLS. Moreover, the
study examined patient-reported out-
comes regarding satisfaction with
smile, gingiva and tooth features and
experience with the procedure.
Informed consent was signed by
each of the subjects after explana-
tions on study objectives, design,
(a)
(d)
Fig. 1. Clinical image documentation of the aesthetic crown lengthening procedure utilized in this study: (a) Pre-operative view of
patient with altered passive eruption; (b) Internal bevel incision following CEJ anatomy; (c) Outlined strip of marginal gingiva
removed; (d) Mucoperiosteal flap elevated; (e) Ostectomy performed; (f) Flap repositioned and sutured.
2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
risks and potential benefits were pro-
vided. The State University of Mar-
ing
a (UEM) Ethics Committee
approved the experimental protocol
and consent form.
Participants were recruited
among patients presenting to the
Dental Clinic of UEM for aesthetic
evaluation of their smile. Inclusion
criteria were as follows: adult
(18 years old); non-smoker; peri-
odontally and systemically healthy;
no medication intake; 20 teeth (ex-
cluding third molars) and six maxil-
lary anterior teeth present; APE
diagnosis, defined as presence of
quadratic anterior teeth [crown
width/length ratio 0.85 (Sterret
et al., 1999)] and gingival margin
located incisal to the tooth cervical
convexity. Crown width (CW) and
crown length (CL) were measured
pre-operatively with a digital calliper
on a cast model, which was prepared
from polyvinylsiloxane impressions
of the maxillary anterior sextant; the
following parameters were measured
or calculated on each tooth: (i) CL,
measured as the distance between
incisal edge and gingival margin
(GM), along the tooth long axis, (ii)
CW, measured at the point between
incisal and middle third of CL; (iii)
CW/CL ratio, calculated.
Exclusion criteria were as follows:
orthodontic treatment; presence of
prosthetic crowns, extensive restora-
tions, extensive incisal edge attrition
or misalignment on maxillary ante-
rior teeth.
(b)
(e)
Aesthetic crown lengthening 1127
Study procedures
Aesthetic crown lengthening surgery
One-hour pre-operatively, patients
were given analgesic medication
(750 mg acetaminophen Cilag
Farmac^eutica Ltda., S~ ao Paulo, SP,
Brazil). Following extra- and intra-
oral antisepsis (2.0% chlorhexidine
solution and 0.12% chlorhexidine
rinse respectively; Farm
acia Ensino,
UEM, Maring
a, PR, Brazil), local
anaesthesia was achieved by infil-
tration (2% lidocaine with
1:100,000 epinephrine; DFL Ind. E
Com. Ltda, Rio de Janeiro, RJ,
Brazil).
The surgical procedure (Fig. 1a
f) was initiated with demarcation of
CEJ position on midbuccal aspect of
the teeth. An internal bevel incision,
following CEJ anatomy, was made
at each tooth, preserving inter-dental
papillae (Fig. 1b). This was followed
by an intra-sulcular incision,
removal of the strip of outlined mar-
ginal gingiva (Fig. 1c) and elevation
of a mucoperiosteal flap to the level
of the mucogingival junction (MGJ)
(Fig. 1d). The CEJ-alveolar bone
crest (ABC) distance was measured
on the midbuccal, and then hand
instruments (#2 Fedi, #36/37 Rhodes
chisels) were used for ostectomy and
osteoplasty (Fig. 1e), aiming to
attain a 2 mm CEJ-ABC distance.
Finally, the flap was repositioned
and mattress sutures (polyglactin
910) were used to stabilize the flap
(Fig. 1f). All surgeries were per-
(c)
(f)
1128 Silva et al.

formed by a sole experienced peri-
odontist.
Post-operative protocol
Patients were prescribed analgesic
(acetaminophen 750 mg, qid) and
anti-inflammatory (ibuprophen
600 mg, qid) medications for 3 days,
and instructed to use the chlorhexi-
dine rinse twice daily for 1 week.
They were also instructed to refrain
from mechanical plaque control in
the operated sextant for 1 week,
apply ice packs for the first day,
consume only soft foods during the
first week, and avoid any other
mechanical trauma to the area.
Participants were enrolled in a
professional plaque control pro-
gramme scheduled weekly for the
first 4 weeks, then at 3 and
6 months.
Clinical parameters
At baseline and throughout the
study, Visible Plaque Index (VPI)
and bleeding on probing (BOP) were
used to monitor oral hygiene and
gingival health conditions respec-
tively.
The following clinical parameters
were assessed on the midbuccal
aspect of the teeth using a periodon-
tal probe (UNC15 Hu-Friedy Mfg.
Co., LLC.): (i) probing depth (PD),
measured as the distance between
GM and bottom of the gingival sul-
cus; (ii) clinical attachment level
(CAL), measured as the distance
between CEJ and bottom of the sul-
cus; (iii) GM position, measured as
the CEJ-GM distance (Fig. 2); (iv)
clinical crown length (CLc) measured
as the distance between incisal edge
and GM (or CEJ when visible),
along the tooth long axis (Fig. 2);
(v) anatomic crown length measured
after flap elevation (CLf) as the dis-
tance between incisal edge and CEJ,
along the long axis of the tooth
(Fig. 2); (vi) CEJ to ABC distance
(CEJ-ABC), measured after flap ele-
vation along the tooth long axis
(Fig. 2); (vii) gingival width (GW),
measured as the distance between
MGJ and GM, using the visual
method (Guglielmoni et al. 2001)
(Fig. 2); (viii) gingival thickness
(GT), measured at the middle of
GW with a periodontal probe
inserted perpendicular to the surface
until firm resistance was met, and
recorded to the nearest millimetre;
(ix) percent of anatomic crown cov-
ered by gingival tissue, calculated as
the percent difference between CLf
and baseline CL (see above); and (x)
gingival display (GD), measured as
the distance between central incisor
GM during active smile and the infe-
rior border of the upper lip vermil-
ion (Silva et al. 2013). When the lip
covered part of the clinical crown,
GD was recorded as zero. The mea-
surements were recorded at baseline
(all parameters except CLf), during
surgery (CLf and CEJ-ABC), after
surgery completion (CLc and GW),
and at 30, 90 and 180 days (PD,
BOP, GM, CLc and GW) post-
operatively. GM, CLc and GW were
also recorded at 7 and 15 days post-
operatively. GD was recorded at
baseline and 180 days. A sole trained
and calibrated examiner, not
involved with treatment, assessed all
clinical parameters. To determine
examiner reliability, CLc and GW
were measured in triplicate over
3 weeks and the resulting coefficient
of variation was 3% for both
parameters.
Questionnaires
Satisfaction surveys were given to
the subjects at baseline and 7, 15, 30
and 180 days after the procedure.
The surveys included both Likert
scale and open-ended questions. The
questions addressed subject satisfac-
tion with smile, amount of gingiva
displayed, symptoms, pain, best and
worst aspect of the procedure, and
whether subject would undergo the
procedure again.

Data analysis

Tooth type (central incisor, lateral

incisor and canine) data for each
patient were calculated by averaging
the values of the two contra-lateral
same type teeth. Overall patient data
were calculated as mean value of all
three tooth types, by averaging the
three tooth type values. Descriptive
statistics were expressed as
mean  standard deviation (SD).
For all parametric variables,
Fig. 2. Clinical images illustrating the clinical measurements performed. CEJ-ABC: repeated measures ANOVA was used
distance between cemento-enamel junction (CEJ) and alveolar bone crest (ABC), mea- for examination of mean differences
sured after flap elevation; CLc: clinical crown length, measured as the distance between
between experimental periods, Tukey
incisal edge and gingival margin (GM), along the tooth long axis; CLf: anatomic
crown length, measured as the distance between incisal edge and CEJ, along the tooth test was used as a post hoc for means
long axis, measured after flap elevation; CW: crown width, measured at the point comparison and adjustments for
between incisal and middle third of CL; GW: gingival width, measured as the distance multiple comparisons were done with
between gingival margin (GM) and mucogingival junction; GM position: measured as Bonferroni test. Pearson correlation
the distance between CEJ and GM. test was performed to analyse the
2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
 Aesthetic crown lengthening 1129

correlation between crown length 6 months (p < 0.0001) (Table 1). 10.3 mm after flap suturing
and the other parameters. The signif- Average GM for all six anterior (p < 0.008). Among individual teeth,
icance level for rejection of the null teeth decreased from 1.9  0.4 mm only canines showed significant dif-
hypothesis was set at a = 0.05. at baseline to 0.1  0.1 mm at the ference in crown length between ele-
end of the procedure (after suturing; vated flap and sutured flap
p < 0.0001), and relapsed slightly to measurements (p < 0.045) (Table 2);
Results
0.5  0.3 mm at 6 months however, this difference was
(p < 0.0001 compared to baseline; <0.2 mm on average.
Study population
p < 0.0001 compared to end of sur- At baseline, the average CW/CL
Thirty-two patients (26 females, 6 gery) (Table 1). No teeth exhibited ratio was 0.96  0.09, 0.90  0.06
males), aged 23.5  2.7 years (range: gingival recession, either pre- or and 0.92  0.06 for central incisors,
1932 years), were recruited to the post-operatively. lateral incisors and canines respec-
study. Ten patients (6 females, 4 The tooth crown and gingival dis- tively. Central incisor, lateral incisor
males) did not complete the study play related parameters over time and canine teeth had 20.4%, 17.7%
due to failure to comply with proto- are detailed in Table 2. Average CLc and 15.5% of their anatomic crown
col/follow-up visits. Data from the for the six maxillary anterior teeth at covered by gingiva respectively
22 remaining patients, aged baseline was 8.5 mm (range: 7.0 (Table 2); the difference between
23.1  2.9 years (range: 19 11.0 mm) and increased significantly central incisor and canine teeth was
32 years), are reported here. The (p < 0.0001) at 3 (9.9 mm; range: significant (p < 0.01).
maxillary anterior sextant (canine to 8.012.0 mm) and 6 (9.9 mm; range: Central incisor teeth presented
canine) was operated upon in all 8.011.0 mm) months post-opera- the shortest CEJ-ABC distance
patients; therefore, reported data are tively; there was no significant differ- (1.0 mm; range: 0.02.0 mm), fol-
from six teeth per patient. ence between 3 and 6 months lowed by lateral incisor (1.3 mm;
(p = 0.72). At 6 months, central inci- range: 0.04.0 mm) and canine teeth
Clinical parameters
sor, lateral incisor and canine teeth (1.6 mm; range: 0.04.5 mm)
had 1.7  0.5 mm (range: 1.0 (Table 2); the difference between
Full-mouth VPI and BOP were 3.0 mm), 1.2  0.4 mm (range: 0.5 central incisor and canine teeth was
<20% throughout the study for all 2.0 mm) and 1.1  0.5 mm (range: significant (p < 0.05).
patients. Average PD for all six 02.0 mm) increase in CLc respec- Average GW decreased signifi-
anterior teeth decreased from tively; differences between baseline cantly at 6 months (p < 0.008), with
2.1  0.6 mm at baseline to and 6 months were statistically sig- lateral incisors having the greatest
1.1  0.2 mm at 6 months nificant for all tooth types GW, both at baseline and at
(p < 0.0001) (Table 1). Average (p < 0.0001). The changes in CLc 6 months (Table 2). Average GT on
CAL for all six anterior teeth were significantly different among central incisors was significantly
increased from 0.2  0.8 mm at tooth types (p < 0.006). Average CLf greater than on canine teeth
baseline to 0.6  0.4 mm at was 10.4 mm and decreased to (p < 0.05) (Table 2).
Average GD at baseline was
2.6 mm (range: 0.08.0 mm) and
Table 1. Periodontal clinical parameters over time was significantly reduced
(p < 0.0001) at 6 months to 1.1 mm
Central incisors Lateral incisors Canines All (range: 0.07.0 mm) (Table 2). A
PD (mm)
representative case is shown in
Baseline 2.1  0.4* 1.9  0.3* 1.8  0.3* 2.1  0.6* Fig. 3. Five patients at baseline
30 days 0.9  0.2 0.9  0.2 0.9  0.2 0.9  0.2 (23%) and three patients at
90 days 1.0  0.2 1.0  0.2 1.0  0.2 1.0  0.2 6 months (14%) presented gummy
180 days 1.1  0.4 1.1  0.3 1.1  0.3 1.1  0.2 smile (gingival display 4 mm).
CAL (mm)
Baseline 0.1  0.7* 0.2  0.6* 0.2  0.6* 0.2  0.8*
30 days 0.4  0.9 0.6  0.6 0.6  0.6 0.5  0.5 Patient-reported outcomes
90 days 0.5  0.6 0.4  0.6 0.4  0.6 0.4  0.4 Post-operative healing was unevent-
180 days 0.5  0.6 0.6  0.6 0.5  0.6 0.6  0.4 ful for study participants, all of
GM (mm)
whom denied smoking during fol-
Baseline 2.3  0.6* 1.7  0.6* 1.6  0.5* 1.9  0.4*
After suture 0.1  0.3 0.0  0.1 0.1  0.2 0.1  0.1 low-up. Only four patients (18%)
7 days 0.4  0.7 0.3  0.5 0.3  0.6 0.4  0.3 reported experiencing pain during
15 days 0.5  0.7 0.4  0.5 0.4  0.6 0.4  0.4 the first post-operative week
30 days 0.5  0.8 0.3  0.5 0.4  0.5 0.4  0.4 (VAS = 4 for all), with no pain
90 days 0.5  0.5 0.5  0.6 0.6  0.6 0.5  0.4 reported at the subsequent post-
180 days 0.5  0.5 0.5  0.5 0.5  0.5 0.5  0.3 operative visits. Most patients (82%)
GM, CLf Clc (at each time point); CAL, PD GM; PD, probing depth; CAL, clinical
reported taking analgesic and/or
attachment level; GM, gingival margin position; CLf, anatomic crown length; CLc, clinical anti-inflammatory medication up to
crown length. the third post-operative day; no
*
Significantly different from all other time points (p < 0.0001). patient reported taking any medica-

Significantly different from after suture (p < 0.0001). tion after this immediate post-opera-
2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
1130 Silva et al.

Table 2. Tooth crown and gingival display related parameters over time
Central incisors Lateral incisors Canines All

CLc (mm)
Baseline 8.9  0.6* 8.0  0.6* 8.8  0.8* 8.5  0.5*
After suture 11.0  0.6 9.7  0.5 10.3  0.6 10.3  0.5
7 days 10.7  0.6 9.4  0.6 10.1  0.6 10.1  0.5
15 days 10.7  0.6 9.3  0.6 10.1  0.7 10.0  0.5
30 days 10.7  0.7 9.4  0.7 10.1  0.7 10.0  0.6
90 days 10.7  0.5 9.2  0.6 9.8  0.8 9.9  0.5
180 days 10.6  0.5 9.2  0.5 9.9  0.7 9.9  0.5
CLf (mm) 11.2  0.6 9.7  0.6 10.4  0.7 10.4  0.5
Crown Coverage (%) 20.4  4.2 17.7  5.2 15.5  5.4 17.9  4.0
CEJ-ABC (mm) 1.0  0.5 1.3  0.8 1.6  0.9 1.3  0.6
GW (mm)
Baseline 6.1  1.4 6.5  1.4 4.9  1.4 5.8  1.2
After suture 4.7  1.2 5.1  1.4 3.8  1.2 4.5  1.1
7 days 5.2  1.3 6.0  1.5 4.2  1.5 5.1  1.2
15 days 5.1  1.2 5.7  1.4 4.3  1.5 5.0  1.2
30 days 4.9  1.4 5.5  1.5 4.1  1.3 4.8  1.3
90 days 4.8  1.3 5.6  1.5 4.2  1.6 4.9  1.4
180 days 4.8  1.1 5.7  1.4 4.3  1.2 4.9  1.1
GT (mm) 1.4  0.4 1.2  0.3 1.2  0.3 1.3  0.3
GD (mm)
Baseline 2.6  2.0*
180 days 1.1  1.9

Crown Coverage = [(Baseline CLc 9 100)/CLf] 100.

CLc, clinical crown length; CLf, anatomic crown length; CEJ-ABC, cement-enamel junction to alveolar bone crest distance; GW, gingival
width; GT, gingival thickness; GD, gingival display.
*
Significantly different from all other time points (p < 0.0001).

Significantly different from central incisor (p < 0.01).

Significantly different from baseline (p < 0.05).

Significantly different from baseline (p < 0.008).

Significantly different from central incisor (p < 0.05).

satisfied with gingival display when

(a)
Fig. 3. Representative case illustrating the changes in tooth dimensions and gingival
display from baseline (a) to 6 months post-operatively (b).
tive period. For the first post-opera-
tive week, reported complaints
included swelling (64%), light bleed-
ing (32%; up to day 3), discomfort
from sutures (23%), numbness in
operated area (9%) and sensitive
teeth (5%). At the 2-week post-
operative visit, 9% of patients
reported light bleeding, 9% sensitive
teeth and 5% light numbness. At the
1-month post-operative visit 5%
reported sensitive teeth and numb-
ness.
Pre-operatively, most patients
were not satisfied with their smile,
(b)
the amount of gingival or tooth dis-
play when smiling or talking, and
the size and shape of their upper
front teeth, whereas the opposite
was true post-operatively (Table 3).
Both pre-operatively and post-opera-
tively, patients were more satisfied
with their gingival and tooth display
when talking than when smiling
(Table 3); however, the crown
lengthening procedure improved
patient satisfaction with gingival and
tooth display both when smiling and
talking (Table 3). Post-operatively,
73% and 82% of patients were very
2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
smiling and when talking, and 73%
and 77% were very satisfied with
tooth display when smiling and
when talking respectively (Table 3).
The surgery resulted in 77% of
patients being very satisfied with the
size and the shape of their maxillary
anterior teeth, whereas pre-opera-
tively none were very satisfied with
tooth size and only 9% were very
satisfied with tooth shape (Table 3).
Although positive, the impact of the
procedure was less evident on
patient satisfaction with tooth colour
(Table 3).
When patients rated the amount
of gingival display when smiling, the
majority of them considered it to be
too much pre-operatively (64%)
and about right post-operatively
(82%) (Table 4). Post-operatively,
the majority of patients rated the
size (77%), length (77%) and width
(86%) of their maxillary anterior
teeth as about right, when pre-
operatively the overwhelming major-
ity considered the size (96%) too
small and the length (86%) too
 Aesthetic crown lengthening 1131

Table 3. Patient satisfaction survey responses

Parameter Time Satisfied

Not at all Slightly Somewhat Very Extremely

Smile Pre-op 2 (9%) 15 (68%) 4 (18%) 1 (5%)

Post-op 1 (5%) 7 (32%) 9 (41%) 5 (23%)
Gingiva shown when smiling Pre-op 11 (50%) 7 (32%) 4 (18%)
Post-op 2 (9%) 4 (18%) 10 (45%) 6 (27%)
Gingiva shown when talking Pre-op 4 (18%) 6 (27%) 9 (41%) 3 (14%)
Post-op 2 (9%) 2 (9%) 6 (27%) 12 (55%)
Teeth shown when smiling Pre-op 2 (9%) 17 (77%) 3 (14%)
Post-op 2 (9%) 2 (9%) 2 (9%) 9 (41%) 7 (32%)
Teeth shown when talking Pre-op 1 (5%) 12 (55%) 8 (36%) 1 (5%)
Post-op 2 (9%) 1 (5%) 2 (9%) 6 (27%) 11 (50%)
Size of upper front teeth Pre-op 7 (32%) 13 (59%) 2 (9%)
Post-op 3 (14%) 2 (9%) 6 (27%) 11 (50%)
Shape of upper front teeth Pre-op 1 (5%) 12 (55%) 7 (32%) 2 (9%)
Post-op 1 (5%) 4 (18%) 8 (36%) 9 (41%)
Colour of upper front teeth Pre-op 4 (18%) 12 (55%) 4 (18%) 2 (9%)
Post-op 3 (14%) 13 (59%) 4 (18%) 2 (9%)
Procedure experience 2 (9%) 2 (9%) 10 (45%) 8 (36%)
Procedure outcome 1 (5%) 3 (14%) 5 (23%) 13 (59%)

short (Table 4). Concomitantly, Discussion

most patients characterized the
shape of their maxillary anterior
teeth as square (73%) pre-opera-
tively and as rectangular (59%)
post-operatively (Table 4).
Most patients (81%) were very
satisfied with the procedure experi-
ence, i.e. the surgery and first post-
operative week, and with the out-
come of the procedure (Table 3).
Some patients considered the imme-
diate (first few days) post-operative
discomfort and/or appearance to be
the worst aspect of undergoing the
procedure (n = 6; 27%), whereas
about half of the patients (45%)
reported there was nothing about
the procedure they considered to be
the worst. For 91% of the
patients, the best part of undergoing
this procedure was the improvement
in the aesthetics of their smile.
While pre-operatively about half
of the patients (45%) reported being
apprehensive or very apprehensive
about undergoing the procedure,
82% reported post-operatively that
the experience was better or much
better than they anticipated
(Table 4). Considering the overall
experience (the procedure, the post-
operative course and the outcome),
100% of the patients would likely
choose to undergo the procedure
again. Equally, all of the patients
(100%) would recommend this pro-
cedure to someone with a similar
problem.
This prospective clinical trial aimed
to assess clinical and patient-centred
outcomes following aesthetic crown
lengthening surgery (ECLS) to treat
altered passive eruption (APE).
ECLS resulted in significant expo-
sure of the previously covered
crowns of the maxillary anterior sex-
tant and concomitant reduction in
the pre-operative gingival display
during smile. Patient satisfaction was
high, with 73% reporting that they
were very satisfied post-operatively
with gingival and tooth display,
whether during smiling or talking,
and with maxillary anterior tooth
size and shape. All patients reported
they would likely choose to undergo
the procedure again and would rec-
ommend this procedure to someone
with a similar problem. To the best
of our knowledge, this is the first
study to provide detailed patient-
centred outcomes regarding dental
and periodontal aspects following
ECLS.
This study participants had ana-
tomic crown lengths within normal
range (Sterrett et al. 1999, Alpiste-
Illueca 2011, Batista et al. 2012). In
APE, the difference between ana-
tomic and clinical crown length iden-
tifies the crown proportion covered
by gingiva. In this study, average
crown coverage was 20.4% for cen-
tral incisors. Alpiste-Illueca (2011)
concluded that a clinical APE diag-
nosis is most consistent with >19%
central incisor crown coverage (de-
termined radiographically; in this
study this measurement was deter-
mined clinically). In this study, the
mean CEJ-ABC distance on central
incisors was 1.0 mm, within the
range of mean values reported by
other APE studies (Alpiste-Illueca
2011, Batista et al. 2012).
Altered passive eruption treat-
ment should aim to achieve reduc-
tion in the excess gingival tissue, full
exposure of the anatomical crowns,
balance of the gingival contours, re-
establishment of the appropriate bio-
logical width (Camargo et al. 2007,
Hempton & Dominici 2010) and
improvement of the possibly associ-
ated excessive gingival display
(Ribeiro et al. 2014). The clinical
outcomes realized in this study indi-
cate that ECLS was successful in
increasing the clinical crown length
and maintaining it for 6 months.
The average clinical crown length
values recorded in this study at base-
line (8.5 mm), following flap sutur-
ing (10.3 mm) and at 6 months post-
operatively (9.9 mm) are indistin-
guishable from the respective values
(8.5, 10.2 and 10.1 mm respectively)
reported by Cairo et al. (2012). The
clinical crown length increases
attained in this study are similar to
the corresponding increases reported
by Batista et al. (2012). Consistently,
ECLS reduced GW on midbuccal
sites by 1.3 mm (this study) to

2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
1132 Silva et al.

Table 4. Patient rating survey responses

Pre-treatment (n = 22) Post-treatment (n = 22)

How would you rate the amount of gum showing when you smile?
Way too little
Too little 2 (9%) 4 (18%)
About right 1 (5%) 18 (82%)
Too much 14 (64%)
Way too much 5 (23%)
How would you rate the size of your upper front teeth?
Way too small 1 (5%)
Too small 20 (91%) 4 (18%)
About right 1 (5%) 17 (77%)
Too big 1 (5%)
Way too big
How would you rate the length of your upper front teeth?
Way too short
Too short 19 (86%) 3 (14%)
About right 3 (14%) 17 (77%)
Too long 2 (9%)
Way too long
How would you rate the width of your upper front teeth?
Way too narrow
Too narrow 7 (32%) 3 (14%)
About right 14 (64%) 19 (86%)
Too wide 1 (5%)
Way too wide
How would you rate the colour of your upper front teeth?
Way too bright
Too bright 9 (41%) 5 (23%)
About right 8 (36%) 13 (59%)
Too dark 5 (23%) 4 (18%)
Way too dark
How would you characterize the shape of your upper front teeth?
Square 16 (73%) 4 (18%)
Oval 2 (9%) 5 (23%)
Triangular 1 (5%)
Rectangular 3 (14%) 13 (59%)
How was the procedure experience compared to what you thought it would be?
Much worse
Worse 1 (5%)
Same as I thought 3 (14%)
Better 14 (64%)
Much better 4 (18%)

1.5 mm (Ribeiro et al. 2014) imme-
diately after surgery. However, over
time GW exhibits some rebound,
ranging from 0.1 to 0.2 mm (Cairo
et al. 2012, Ribeiro et al. 2014) to
0.5 mm (Batista et al. 2012, this
study). Longer follow-up periods are
needed to confirm long-term gingival
margin stability after ECLS in APE
patients.
A gummy smile (>3 mm of gingi-
val display during smiling) can result
in compromised aesthetics (Kokich
et al. 1999, van der Geld et al.
2007). The aetiology of gummy smile
varies and dictates the appropriate
treatment (Silberberg et al. 2009,
Silva et al. 2013). This study results
suggest that gingival display in APE
can be significantly reduced (by
1.5 mm on average) after routine
ECLS, with concomitant 40% reduc-
tion in gummy smile prevalence; rou-
tine ECLS outcomes regarding
gingival display have not been previ-
ously reported.
The fact that cases of gummy
smile were not eliminated by ECLS
implicates other causative factors, in
addition to APE. In a 3-case series,
Ribeiro et al. (2012) used a modified
ECLS, which included extended
osteoplasty of the entire buccal plate
of the teeth, with the reported gingi-
val display reduction ascribed to
both crown length increase and lip
dropping during smile; the latter
effect was attributed to diminished
lip tension during smiling as a result
of the reduced buccolingual bone
thickness. The results of Ribeiro
et al. (2012) suggest that modified
2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
ECLS in indicated cases could result
in greater gingival display reduction
compared to routine ECLS.
In this study post-operative heal-
ing was uneventful, with moderate
pain reported by few patients (18%)
during the first week and analgesic
medication consumed only during
the first three post-operative days.
Previous studies consistently indicate
that ECLS is a safe and low morbid-
ity procedure (Batista et al., 2012;
Cairo et al. 2012, Ribeiro et al.
2014).
Most patients (73%) were very
satisfied with the aesthetic outcome
of their smile. Batista et al. (2012)
reported that patients had high satis-
faction, but provided no specific
data. Cairo et al. (2012) and Ribeiro
et al. (2014) used VAS scale and

reported satisfied patients (mean
post-operative VAS values >85);
however, neither study reported
baseline satisfaction levels. The influ-
ence of gingival and tooth display
on smile aesthetics, and the opinions
of dental professionals, dental stu-
dents and laypersons have been
extensively investigated (Kokich
et al. 1999, Kaya & Uyar 2013,
Malkinson et al. 2013, Pithon et al.
2013). van der Geld et al. (2007)
evaluated patients self-perception on
smile attractiveness and reported
that tooth visibility and size and
upper lip position were critical fac-
tors in self-perception of smile
attractiveness. However, the patients
self-perception regarding dental and
periodontal aesthetics after treatment
for APE has been hitherto undocu-
mented. In this study, patients were
not satisfied with gingival and tooth
display when smiling or talking, or
the maxillary anterior tooth charac-
teristics prior to treatment. Post-
operatively, most patients became
very satisfied with these features.
Pre-operatively, patients thought
they showed too much gingiva when
smiling and that their maxillary
anterior teeth were too small, too
short and square; post-operatively,
the majority rated the amount of
gingival display as about right and
the teeth as being rectangular and
having the right size and length. The
lack of similar results from other
studies precludes any comparisons.
In conclusion, APE patients trea-
ted with routine ECLS experienced
high satisfaction, would choose to
undergo the procedure again and
would recommend this procedure to
someone with a similar problem.
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Address:
Cl
everson O. Silva
Rodovia PR 317, 6114
CEP: 87035-510
Maringa, PR, Brazil
E-mail: prof.cleversonsilva@gmail.com
1134 Silva et al.
Clinical Relevance
Scientific rationale for the study:
Altered passive eruption, often rep-
resenting an aesthetic concern for
patients, is routinely treated by aes-
thetic crown lengthening surgery.
Detailed patient-centred outcomes
regarding periodontal and dental
aspects following aesthetic crown
lengthening surgery have not been
previously investigated.
Principal findings: Treatment resulted
in significant exposure of previously
covered crowns and concomitant
reduction in pre-operative gingival
display during smile. Patient satisfac-
tion with gingival and tooth display,
when smiling or talking, and with
2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
maxillary anterior tooth size and
shape was high.
Practical implications: Aesthetic
crown lengthening surgery used to
treat altered passive eruption can
result in predictable and desirable
outcomes.