What is esthetic crown lengthening?
Esthetic crown lengthening is the periodontal plastic surgical procedure of which the facial gingival tissue is either removed or repositioned more apically so that we can eliminate or reduce the appearance of the gummy smile. With careful diagnosis and treatment planing, we can achieve a very esthetic, proportional smile in any individual. Treatment technique is varied from the method of which the tissue is removed, i.e., laser, regular blade, electro-surgical unit, or in many case we just reposition the tissue more apically.
How important is the diagnostic process of gummy smile?
In my opinion, diagnostic process is everything or the only thing that can ensure success of the treatment. Patient must not have any systemic health problem that is contraindicated to the surgical procedure. Noted that many medication contributes to uncontrolled gingival overgrowth (Nifedipine, Beta-blocker, Dilantine, Cyclosporine, etc…)
First of all, we must determine the gummy smile is due to the teeth hypoerupt or because of the excessive vertical growth of the maxilla. The first case can be correct with esthetic crown lengthening, the second must be correct with either orthodontics and/or oral maxillofacial surgery of which the entire maxillary process must be repositioned. Oral habits must be ruled out because they contribute to the developmental or growth problems (for example, narrow arch, mouth breather, thumb sucking, etc…) of the dentofacial structures, especially in children. Identify these pathological causes will allow us to early intervene and prevent the problem worsen or recur in the future.
The next step is determine the severity of the gummy smile appearance. The height to width ratio of central incisors is 11/8.5. We must look at how much the gingival tissue needed to be removed or repositioned apically. We also must look at the probing depth of the anterior teeth to locate the position of CEJ ( the border demarcated the root portion and the anatomical crown portion of the teeth) to determine whether alveolar bone removal is anticipated during the procedure. In many case, alveolar bone removal is the must to prevent relapse. The approximate preferred distance from alveolar bone crest to the CEJ is 2.5-3.0mm. When this distance is violated, we either will have regrowth of the gingival tissue in the future or inflammation (could be subclinical) of the pocket gingiva. In certain case, orthodontic therapy is used to intrude the teeth so that the entire attachment apparatus (the gingiva and CEJ) will reposition more apically and thus reduce the “gummy smile” appearance.
One area that is often overlooked is the methodology of which we reduce the gummy smile. The dentist/surgeon must look at the amount of attached gingiva on the buccal surfaces of the teeth. Literature have shown that the amount of attached gingiva contributes to the protection of bacterial invasion and prevent the inflammation to the gingiva. The dentist/surgeon must NOT remove the attached gingiva for the sake of reducing gummy smile. This happen many times when laser was used and flap was NOT raised or reflected due to the fact that laser was market as a tool to do quick surgical removal procedure without the need of anesthesia. However, due to the extensive involvement with the procedure, we always anesthetize patient and use our laser as to reduce hemostatis and provide the initial esthetic contouring of the gingiva. In many case, we combine the effects of limited tissue removal (to preserve the attach gingiva) with apically reposition flap (to reposition the gingival tissue more apically) to achieve our result.
Next, we must NOT forget the health of the periodontal apparatus, i.e., the periodontal ligament, the cemental attachment, and the alveolar bone. Healthy periodontal apparatus ALWAYS ensure beautiful appearance of the teeth. Inflamed gingiva never give the tooth the good appearance. There must be no bleeding upon probing, no vertical bone loss, or any sign or symptom of the PROGRESSION of gum disease. Neglecting the health of the periodontium may lead to excessive gingival recession, complication during healing, uneven gingival crest, and ultimately the ugly smile that is worse than the before picture!
Finally, we must paint the picture of the final smile to the patient. The success of this whole procedure base on how accurate we can reproduce this picture in real life. Before I start, my patient and I must know what the end looks like. I believe that there is NO such thing as “the smile look close enough to being good”.
How do we eliminate or remove the gum tissue?
Treatment technique is varied from the method of which the tissue is removed. They are:
- regular blade
- electro-surgery
- laser
- reposition flap more apically
As briefly mentioned above, we always anesthetized our patient. Regular blade provides speed and clean steril cut. Electrosurgery provides hemostasis while maintaining the speed efficiency. Laser provides excellent hemostasis, excellent post-operative healing, and excellent tissue control in term of thinning or contouring. However, laser cutting can be very slow and time consuming. Very often I use all three tools with judgement based on the amount of gingiva and the number of teeth involved. Finally, I always combine the removal of gingival tissue with flap reposition more apically as to deepen the vestibule (in many case it help to facilitate oral hygiene effort), to preserve attached gingiva (good protection from localized trauma and bacterial invasion), allow to visualize the alveolar bone crest and determine the need for bone contouring or removal. REMEMBER, tissue growth always followed bone support.
After the tissue is trim and removed to attain the smile we want, we always reflect the flap to recontour the bone crest. A small round bur should be used and make sure we have adequate water cooling during bone removal (to avoid dehiscence of bone, the cutting temperature should be under 47 degree Celsius). Next the flap is reposition and allow for free falling as patient practice his or her new smile. The gingival crest should not demonstrated any pulling movement as he or she smiles. If it does, releasing incision must be done.
Finally, we suture with either goretex suture or gut suture. I always avoid silk suture because even though it is inexpensive, it always attracted plaque and bacteria harboring to the surgical site. Goretex suture is nonresorbable, very expensive but they are very hygienic, ease of handling, and very strong. Gut suture is weaker but resorbable. Broken suture may lead to reattachment of gingiva at the less optimal location, healing with secondary intention, and subclinical infection due to food/bacteria penetrates the surgical site. We always want postop our patient thus Goretex suture is the material of choice. Patient will be post-op 1 days, 5 days (suture removal), 14 days (tissue heals clinically), and 28 days (tissue heals microscopically).
These are the protocol of which Dr. Bui follows in his periodontal therapy. It is not necessary the same or equivalent with other operator. Our method may be different, but the final result should be toward achieving that esthetic smile which everyone deserves.
Does the tissue grow back in time?
As mention above, more often we removed or recontour the bone crest as to ensure the biological width is NOT violated and thus the gingival crest will stay where it is placed as long as no other pathological process occurred. Patient will only have to maintain good oral hygiene with periodic cleaning every six months. The procedure is rather simple to execute but complex in diagnosis.
We offer payment plan with a low monthly payment and if paid in full in the time specified, you will not have to pay any interest. For any question, please do not hesitate to call our office at 281-579-6066.