https://doi.org/10.33805/2572-6978.

140
Volume 4 Issue 1 | PDF 140 | Pages 4

Dental Research and

Management
Case Report ISSN: 2572-6978
Digital Workflow for Periodontal Crown Lengthening in
Treatment of Altered Passive Eruption: Case Report
Vilma A Umanzor1, Hugo H. Romero2, Zamir Kafati3, Ana Rodriguez4, Juan
Guifarro5, Nadia Irias5
Affiliation
1
Private Practice, Periodontics and Implant Dentistry, Department of Social/Prevention, School of Dentistry, Universidad Nacional Autónoma de
Honduras (UNAH) Tegucigalpa, Honduras
2
Private Practice, Maxillofacial Surgeon, Professor at the Department of Maxillofacial Surgery, Hospital Escuela, Universidad Nacional
Autónoma de Honduras (UNAH) Tegucigalpa, Honduras
3
Private Practice, Universidad Nacional Autónoma de Honduras (UNAH) Tegucigalpa, Honduras
4
Private Practice, Universidad Católica de Honduras (UNICAH) Tegucigalpa, Honduras
5
Private Practice, Maxillofacial Surgeon, Hospital Escuela, Honduras
*
Corresponding author: Vilma A Umanzor, Private Practice, Periodontics and Implant Dentistry, Department of Social/Prevention,
School of Dentistry, Universidad Nacional Autónoma de Honduras (UNAH) Tegucigalpa, Honduras, E-mail: dravaumanzor@gmail.com
Citation: Umanzor VA, Romero HH, Kafati Z, Rodriguez A, Guifarro J, et al. Digital workflow for periodontal crown lengthening in
treatment of altered passive eruption: case report (2020) Dental Res Manag 4: 27-30.
Received: Mar 13, 2020
Accepted: Jul 10, 2020
Published: Jul 17, 2020
Copyright: © 2020 Umanzor VA, et al., This is an open-access article distributed under the terms of the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Abstract
This paper describes the treatment of a patient diagnosed clinically and based on cone beam computed tomography images with excessive
gingival display caused by altered passive eruption Type 1B. A digitally computer designed and 3-D printed surgical guide was fabricated for
crown lengthening to provide periodontal esthetics. The combination of intraoral scanners and cone-beam computerized tomography images,
and use of planning software, provides a very precise representation of the real conditions of the hard and soft tissues.
The design and fabrication of computer surgical guides can improve precision and predictability for surgical procedures and can be superior to
conventional free-handed surgery in terms of efficiency and treatment outcomes. Surgical experience and general understanding of computer
assisted systems and thorough knowledge of conventional protocols is mandatory to make routine use of these systems.
To select a treatment modality, the etiology must be clearly identified and the patient has to be informed of his options for treatment which for
this condition are a gingivectomy or an apically positioned flap with or without osseous reduction determined by the type of altered passive
eruption.
Keywords: Altered passive Eruption, Surgical stent, Digital workflow, Gingivectomy

Introduction
Cemento-Enamel Junction (CEJ) to the bone crest is within the norm of
Excessive Gingival Display (EGD) can be considered one of the main
1.5-2mm, while in subtype 1B the CEJ is almost coincident with the
concerns for patients regarding esthetics and its etiology has to be
alveolar crest [4]. In Type 2, the keratinized gingiva is narrower and the
identified in order to define the ideal treatment plan. The gummy smile
mucogingival junction closer to the CEJ, which could be attributed to a
has been defined as a smile showing more than 1.5-2 mm of the gingiva
failure of active or passive eruption. Type 1B is the most commonly
and affects 7% of men and 14% of women world-wide [1]. Etiology
encountered, and has been termed altered active eruption, which is a
varies, including gingival enlargement, Altered Passive Eruption (APE),
failure in the active eruption phase [4].
vertical maxillary excess, anterior dentoalveolar extrusion, short upper
lip, hyperactive upper lip, or a combination of the before mentioned
Crown lengthening is a periodontal procedure used to expose the tooth
factors [2].
structure for the purpose of reestablishing the appropriate supracrestal
tissue attachment space [5].
In altered passive eruption, the Free Gingival Margin (FGM) is located
more incisally or coronally over the enamel, resulting in short clinical
The most recent development in digital production of surgical guides is
crown length. The excessive gingival coverage of the anatomical crown
based on the superimposition of Cone Bean Computed Tomography
is caused by retardation of the passive eruption phase of tooth eruption
(CBCT) data and intra-oral scanning data. These guides are designed
[3].
and fabricated using computer-aided design/computer-aided
manufacturing technology with the use of printing or milling devices.
The distinguishing feature of Type 1 is a wide band of keratinized
These novel approaches improve positioning and accuracy of the
attached gingiva with an apical location of the mucogingival junction in
surgical procedures [6].
relation to the alveolar crest. In subtype 1A, the distance from the

Citation: Umanzor VA, Romero HH, Kafati Z, Rodriguez A, Guifarro J, et al. Digital workflow for
periodontal crown lengthening in treatment of altered passive eruption: case report (2020) Dental
Res Manag 4: 27-30.
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 Umanzor VA, et al. Dental Research and Management, 2020 PDF: 140, 4:1

Clinical Report
The patient presented to a private dental clinic for a crown lengthening
procedure to treat her excessive gingival display from tooth 1.3 to 2.3
(Figure 1). Her diagnoses of gingival excess was established after the
following examinations; periodontal probing, periapical radiographs,
phenotype evaluation, cone-beam computed tomography scan for
precise assessment of the osseous crest and its relation with the CEJ, for
this purpose, radiographic markers were placed on each clinical crown
and intraoral scans to obtain digital impressions of the maxilla, mandible
and their occlusal relation for guide processing (Figure 2).

Figure 2B: 3D scanned diagnostic model.

Figure 2
Figure 1A: Smile view.
The guide was fabricated using a 3-D printer through the polymerization
of an ultraviolet- sensitive liquid resin and was designed defining the
desired gingival margin and osseous crest position according to the
registration of the digitalized models onto the CBCT scans. Using
reference points CEJ to the crest leaving a 3mm distance between these
two reference points. (Figure 3). Surgical guide was fabricated using
BlueSkyBio and Meshmixer software.

An hour prior to surgery, the patient was prescribed a dose of 875mg of

amoxicillin and 125mg of clavulanate acid as a prophylactic antibiotic.
Figure 1B: Frontal view. Patient was also instructed to rinse for 1 minute using oral chlorhexidine
0.12% to minimize oral bacterial load.

Local anesthesia was administered with 4% articaine with adrenaline

1:100,000 to anesthetize the infraorbitary and nasopalatine nerves as
well as local infiltration.

The tooth supported 3D printed surgical stent was delivered to verify

adjustment and stability. And an internal bevel incision according to the
gingivectomy guide was designed and followed Intrasulcular incisions
at the papilla area and in the buccal aspect with the subsequent removal
of the collar tissue (Figure 4).
Figure 1C: Upper close-up view.
Figure 1: Preoperative photograph. A full-thickness mucoperiosteal flap was elevated on the buccal side to
access the alveolar bone crest without compromising the papilla from
1.3 to 2.3. The osteotomy was performed to reposition the buccal crest
3mm apically from the CEJ, using a low speed bur #701 with copious
irtigation using abundant saline solution. Evaluation of every tooth was
assessed to assure 3mm of supracrestal attachment space using a dental
probe. The flap was repositioned apically and suspensory continuous
suture was placed (Figure 5).

The patient was evaluated for suture removal 14 days after the surgery
(Figure 6) and follow-up examinations were performed at 2 weeks, 1,
3, 6 months and 1-year recall. Oral hygiene instructions and plaque
removal were performed at each visit accordingly. Post surgical
measures included ibuprofen 600mg every 8 hours for 7 days, 875mg of
amoxicillin and 125mg of clavulanate acid for 7 days, chlorhexidine
mouth rinse 0.12% 3 times a day for 21 days.

Patient was recommended to avoid brushing and rinsing during the first
24 hours, only consume soft foods for 1 week and avoid oral hygiene in
the treated areas for 7 days. 1 year after surgery we can observe the
stability, maturity and health of the periodontal tissues (Figure 7).
Figure 2A: CBCT initial exam.

Citation: Umanzor VA, Romero HH, Kafati Z, Rodriguez A, Guifarro J, et al. Digital workflow for periodontal
crown lengthening in treatment of altered passive eruption: case report (2020) Dental Res Manag 4: 27-
30.
28
 Umanzor VA, et al. Dental Research and Management, 2020 PDF: 140, 4:1

Figure 3: 3D printed model, surgical guide and CT measurements.

Figure 4A: Surgical guide positioned intraorally

B

A: Full-thickness flap elevated B: Osteotomy and osteoplasty

C: Flap repositioned.
Figure 4B: Gingivectomy and gingivoplasty. Figure 5
Figure 4

Citation: Umanzor VA, Romero HH, Kafati Z, Rodriguez A, Guifarro J, et al. Digital workflow for periodontal
crown lengthening in treatment of altered passive eruption: case report (2020) Dental Res Manag 4: 27-
30.
29
 Umanzor VA, et al. Dental Research and Management, 2020 PDF: 140, 4:1

Although, additional in vivo studies are necessary to justify the increase

in costs of computer guided techniques in comparison to conventional
protocols verified in final treatment outcomes, these virtually planned
and manufactured surgical guides seem promising for periodontal plastic
surgery.

To select a treatment modality, the etiology must be clearly identified

and the patient has to be informed of his options for treatment which for
this condition are a gingivectomy or an apically positioned flap with or
without osseous reduction determined by the type of APE [7].

Periodontal plastic surgery is used to achieve gingival symmetry and

harmony and therefore obtain esthetic outcome that meets the patient´s
demands. Esthetics-related crown lengthening surgery aims to provide
adequate clinical crown length, reduce gingival display, as well as meet
the patients esthetic demands [8].

The introduction of Computer-Aided Design and Computer-Aided

Manufacturing (CAD-CAM) techniques has helped surgeons perform
more precise and predictable surgeries that contribute to improved
esthetics, lover operative times and reduce morbidity [9].
Figure 6: Postoperative two weeks follow-up.
Summary
This article describes the treatment of a patient diagnosed with excessive
gingival display caused by altered passive eruption type 1B with the use
of a digitally designed and 3-D printed surgical guide for crown
lengthening periodontal plastic surgery.

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The combination of intraoral scanners and cone-beam computerized
tomography images, and use of planning software, provides a very
precise representation of the real conditions of the hard and soft tissues.
The design and fabrication of computer surgical guides can improve
precision and predictability for surgical procedures and can be superior
to conventional free-handed surgery in terms of efficiency and treatment
outcomes. Surgical experience and general understanding of computer
assisted systems and thorough knowledge of conventional protocols is
mandatory to make routine use of these systems.

Citation: Umanzor VA, Romero HH, Kafati Z, Rodriguez A, Guifarro J, et al. Digital workflow for periodontal
crown lengthening in treatment of altered passive eruption: case report (2020) Dental Res Manag 4: 27-
30.
30