Management of a recurrent gummy smile case after 7 years follow-up
Case Report
A 25-year-old African-American female first presented in December 2010 for assessment of her chief complaint that “I don’t like how much my gums show when I smile.” The patient was a non-smoker, systemically healthy and taking no medications. Clinically, there was excessive gingival display of maxillary teeth with approximately 6 to 8 mm of keratinized tissue on the facial aspect of #6 to 11 (Figure 1 and Figure 2). The probing depths were 1 to 3 mm and radiographic interdental bone levels were at the level of the adjacent cemento-enamel junctions (CEJ). After discussion with the patient about treatment options, the patient agreed to proceed with ECL surgery.
For the initial ECL procedure, a submarginal incision approximately 1-2mm away from the gingival margin was first made from teeth #6-11 as determined by a customized surgical template. After mucoperiosteal flap reflection, the bone level of teeth #6-11 was at the level of the CEJs (Coslet type IB case6) (Figure 3). Ostectomy and osteoplasty were done until the crestal bone level was approximately 2 mm apical to the CEJs (Figure 4).
The flap was sutured at the level of the CEJs (Figure 5). After the surgery, the patient was advised to use NSAIDs for post-surgical discomfort and to rinse with a chlorhexidine mouthrinse. Healing was good at one week with mild papillary inflammation and sutures were removed (Figure 6 and Figure 7). The patient failed to return for subsequent follow-up visits and was lost for additional follow-up.
Seven years later (August 2017), the patient came back for evaluation stating that “I want to have the gum surgery again.” The patient’s clinical presentation is depicted in Figure 8 showing relapse towards her initial presentation.
Treatment options were discussed including orthodontics and possible orthognathic treatment but the patient was only interested in a revision of the ECL procedure. After flap reflection, an additional 2 mm of radicular bone was removed as the diagnostic wax-up (Figure 9) and clinical mock-up revealed an additional 2 mm of tooth exposure was required for optimal tooth dimensions (Figure 10 and Figure 11). The flap was positioned at the level of the CEJs and sutured using simple interrupted 4-0 Vicryl sutures (Figure 12).
At one week, the patient only reported mild post-surgical discomfort. There was minimal inflammation with slight erythema of the interdental papillae of teeth #6-11. Three months after the surgery, the gingiva was healthy and the gingival margin was at the CEJs of teeth #6-11, which allowed clinical display of proper tooth length (Figure 13 and Figure 14). The patient was satisfied with the improved esthetic outcome during smiling.
Discussion
There are a few keys to successful management of this case:
- During the pre-surgical evaluation, bone sounding can help identifying bone crest position. The treatment options of gingivectomy, apically positioned flap alone or in combination with osseous surgery would be based on the bone margin to CEJ or the future crown margin. If it is less than 3 mm, osseous surgery will be necessary.
- The surgical stent fabricated based on the diagnostic wax-up can help determine the initial incision position to expose the ideal tooth contour.
- After gingivectomy and flap reflection, the amount of bone reduction (ostectomy) should equal to the amount of additional tooth length exposure desired to accommodate the dimension of the SCTA to minimize risk of relapse.
Conclusion
The dimensions of the supracrestal tissue attachment (SCTA) are likely to be predetermined and given no planned alteration of the position of the incisal edges, the amount of bone reduction (ostectomy) should equal the amount of additional tooth exposure that is desired to accommodate dimensions for SCTA to minimize relapse.