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Currently, the gingival
complex is a vital
aspect of any restorative
treatment plan.
Clinicians now are
beginning to recognize
the importance of the
gingival complex in
the treatment of short
clinical crowns.
tooth eruption to a level apical to the cervical convexity of the clinical crown.
By contrast, passive eruption is a biologic process whereby tooth eruption occurs
normally. During this normal tooth eruption the dentogingival junction
shifts apically. 6 This process occurs when active eruption is complete and may
continue until the early or mid-20s of adulthood. 7 At this time, the free gingival
margin approximates the CEJ. Gottlieb and Orban classified passive eruption
into four stages, believing this was a continuous physiologic process of tooth
eruption (Figure 1). Although some debate currently exists when passive eruption
becomes pathologic, it is generally accepted that cementum exposure or
gingival recession (Stage 4) is a pathologic process.
APE is one of the most commonly overlooked causes of short clinical crowns.
Although literature provides limited information regarding the incidence of
APE, Volchansky and Cleaton-Jones 7 found that 12 percent of patients studied
had signs of APE. 8 Excessive gingival display has been estimated at 7 percent
of men and 14 percent of women. 2 Thus any clinician must be cognizant of the
dentogingival complex and be comfortable with the differential diagnoses of
a gummy smile when striving for long-term optimal restorative esthetics and
gingival health.
Gargioulo and Ainomo 9,10 described the typical dentogingival relationship with
the free gingival margin being located in close proximity to the CEJ. However,
if APE exists, the gingival complex is situated in a more coronal position, making
the CEJ difficult to detect clinically and thus displaying the pathognomonic
signs of short clinical crowns and excessive gingival display.
Figure 3A: Initial presentation: Teeth
6-11 appear short and boxy.
Coslet and others 11 classified APE into two case types, based on the gingival
and osseous relationships. Type 1 presents with a noticeably wider band of
keratinized tissue and Type 2 exhibits a smaller band of keratinized tissue falling
within normal limits (Figure 2). Types 1 and 2 each have subcategories, A
and B. In the A subgroup, the osseous crest is located 1.5 mm to 2 mm below
the CEJ 9 (normal), while in the B subgroup, the osseous crest is found directly
adjacent the CEJ.
This article presents treatment for two common types of APE found clinically.
To date, no scientific literature has investigated the incidence of Coslet’s four
classifications of APE. However, it is believed that Type 1B is more prevalent. 1
This article presents and discusses the more common case types and the treatments
employed to achieve long-term esthetic results.
CASE REPoRTS
– Coslet Type 1A –
A 26-year-old woman presented with a chief complaint of “short teeth” (Figure
3A). After a comprehensive clinical facial and dentogingival examination, both
centrals were found to have little or no incisal wear and were approximately
8.5 mm in length (Figure 3B). The CEJ was undetectable clinically and the patient
was diagnosed with APE.
Figure 3B: Initial presentation: Short
clinical crowns, teeth 8 & 9 measure
8.5 mm in length.
Local anesthesia (AstraZenca Pharmaceuticals LP) was used before further examination.
Periodontal probing revealed a gingival sulcus of 3 mm, while bone
sounding revealed a probing depth of 5 mm from the free gingival margin to
the osseous crest, indicating a diagnosis of APE Type 1A. To achieve an ideal
central incisor length of 10.5 mm, 12 an esthetic crown lengthening procedure
was indicated.
During surgery, an inverse bevel incision following the CEJ was used. An effort
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