Gummy Smiles: The Challenge of Gingival

Excess: Prevalence and Guidelines for

Clinical Management
Thomas C. Waldrop

Orthodontic treatment planning should be a multidisciplinary approach to

achieve periodontal health and maximal esthetics. The presence of altered
passive eruption may complicate treatment in the presence of inflammation
and compromise esthetic outcomes. The prevalence, diagnosis, and treat-
ment of active and arrested passive eruption in the orthodontic patient will
be the focus of this article. In a recent landmark study, the prevalence of
altered passive eruption in postorthodontic patients, and the same patients
5 years after treatment, were studied for their need for periodontal plastic
surgery, esthetic crown lengthening. Less than ideal smile characteristics,
namely length-to-width ratios and asymmetry, were found in 65% and 60%
of patients, respectively. Enhancing orthodontic results and providing the
patient with maximal esthetic results can be achieved through the control of
inflammation and esthetic crown lengthening. (Semin Orthod 2008;14:
260-271.) © 2008 Published by Elsevier Inc.

dolescents and adults, in general, want to a difference between the orthodontist and the
A look better and feel better about their facial
appearance. Often this can be achieved by subtle
patient and parent as to perceived needs and the
normative needs of treatment.1 For these rea-
changes in tooth alignment and gingival con- sons, contemporary orthodontic care should be
tours. These changes can dramatically alter their a team approach to achieve periodontal health
appearance and self-esteem. Hence, patients and maximal esthetic results. The patient’s peri-
seek orthodontic care to have their “teeth straight- odontal health and cosmetic requirements may
ened” in their hope of attaining a perfect smile. require one or several dental disciplines. De-
Obtaining that perfect smile is more complex pending on the patient’s periodontal status and
than just aligning the teeth. In today’s esthetic cosmetic demands the interdisciplinary ap-
environment the orthodontic specialty focuses proach may include the disciplines of periodon-
on interdisciplinary treatment planning. No tics, maxillofacial surgery, restorative dentistry,
longer can one discipline manage the patient and dental implants.
seeking maximal esthetic results. The orthodon-
tist has a great influence on the decisions pa-
tients make during treatment planning. There is Smile Dynamics
This article will focus primarily on adolescent
patients with periodontal conditions requiring
Professor, Director Graduate Periodontics Program, School of
Dentistry, Virginia Commonwealth University, Richmond, VA. interdisciplinary treatment planning between
Address correspondence to Thomas C. Waldrop, DDS, MS, Pro- orthodontists and periodontists, specifically, en-
fessor, Director Graduate Periodontics Program, Virginia Common- hancing orthodontic results and creating the
wealth University, School of Dentistry, P.O. Box 980566, Rich- most pleasing smile for the patient through the
mond, VA 23298-0566. Phone: (804) 828-4867(vcu-gums); Fax: control of inflammation and the incorporation
(804) 828-0657; E-mail: tcwaldro@vcu.edu
© 2008 Published by Elsevier Inc. of periodontal plastic surgery, and esthetic
1073-8746/08/1404-0$30.00/0 crown lengthening in the overall orthodontic
doi:10.1053/j.sodo.2008.07.004 treatment plan.

260 Seminars in Orthodontics, Vol 14, No 4 (December), 2008: pp 260-271

 Gummy Smiles 261

Smile Dynamics—Extraoral contact area length, and location. The third is

the “façade,” which includes the attached gin-
The goal of treatment is to maximize the es-
giva, interdental papilla, and free gingival mar-
thetic and physiologic clinical outcome of orth-
gins.
odontic treatment. Patients favor a smile that is
symmetrical and displays maximal anatomical
crown.2 This can be done by creating gingival
Foundation: Biologic Width, Gingival and
symmetry and maximizing anatomical crown ex-
Alveolar Thickness
posure. To predict treatment needs during treat-
ment planning, two aspects of the smile should Garguilo and coworkers3 described a coronal-
be considered. The first is the “frame” of the apical zone of connective tissue and epithelial
smile, which includes the surrounding facial fea- attachment (junctional epithelium) to the root
tures. The frame of the smile includes looking at of the tooth measuring an average of 2.04 mm.
total facial symmetry and asymmetry, the plane The mean depth of the facial gingival sulcus in
of the eyes, position of the nose to the chin, the health, probed with approximately 25 g of force,
patient’s smile during “lip rise,” and the distance was 0.69 mm. The sum of these measurements in
and symmetry between the commissures. health is constant and predictable. The com-
bined value, 2.73 mm, has been described as the
Smile Dynamics—Intraoral biologic width.4 In cases of altered passive erup-
The second aspect of the smile is the infrastruc- tion, the crest of the alveolar bone may closely
ture of the smile, which is made up of three approximate the cemento-enamel junction
areas that should be evaluated independently (CEJ) and in some pathological circumstances
and as a composite picture during treatment appear coronal to the CEJ. Hence a normal
planning. The first is the foundation, consisting biologic width is not present and the epithelial
of the “biologic width” and the patient’s “bio- attachment lies on enamel, resulting in coronal
type,” tissue, and bone thickness. The second displacement of the gingival crevice and margin
focus should be on the “pillars” of the smile, with gingival masking of the anatomical crown
which include observing tooth length, width, (Fig 1).

Figure 1. (A) Arrested altered passive eruption postfixed appliance therapy with gingival disease “masking.” (B)
Gingival flap reflected with osseous crest located at the CEJ for the central incisors and cuspids. (C) Bone
removed to created biologic width, 3.0 mm. (D) After healing with ideal 1:1 clinical-to-anatomic crown ratio.
(Color version of figure is available online.)
262 T.C. Waldrop

The facial-lingual thickness of the attached general reference. In the orthodontic patient
gingiva and bone is important because it pro- the desired clinical crown length will be deter-
vides stability to the gingival margin and resis- mined before and after treatment by location of
tance to gingival recession. Different periodon- the CEJ and the subjective preferences of the
tal biotypes, thick-flat versus thin-scalloped, patient and doctor.
respond differently to inflammation, orthodon- The coronal width is the mesio-distal di-
tic movements, and surgical insult.5 Thickness of mension from one contact area to the other.
the alveolar bone and gingiva may determine Based on ancient concepts, Ward11 developed
whether or not the orthodontist can advance or a set of proportionate values that today are
tip teeth without producing a bony dehiscence generally accepted as ideal. The preferred an-
and gingival recession. In addition, the ability to atomical crown width-to-height ratio is 78%,
change gingival margin location through tooth with an acceptable range of 66% to 80%.
movement maybe affected by whether the bio- These values hold true regardless of race or
type is thick or thin. gender.12 The width of the central incisors
should be 60% wider than the lateral incisors
and the latter should be 60% wider than the
Pillars: Tooth Length, Width, and Contact
canine.13 If the lateral incisor is assigned a
Past research has indicated that esthetics is not value of 1.0, the central incisor and cuspid are
entirely a subjective field. The teeth, lips, and 1.6 and 0.6 times the width of the lateral inci-
the gingival architecture determine the esthetic sor (Fig 2).
appearance of the smile.6 There are rules and The incisal-apical dimension of the contact
values that stay within some observed ranges and point should not extend below the gingival mar-
may be considered ideal. This allows for the gin. This may result in shortened papilla affect-
comparison of research data and enables the ing esthetics. In addition, gingival embrasure
clinician to determine if their patient differs distortion makes the use of dental floss and the
from the norm or is physiologically optimal. removal of interproximal dental plaque (bacte-
Early research to define ideal values used the rial biofilm) colonies difficult. The distortion of
mathematic proportions described by the an- gingival embrasures by arch length deficiency
cient Greeks to define the concept of ideal den- (“crowding”) thus justifies orthodontic align-
tal esthetics.7,8 The pillars of the human smile ment. Furthermore, the vulnerability of the gin-
conform to a predictable incisal-apical dimen- gival embrasure is also why therapeutic distor-
sion. The anatomic crown should be fully ex- tion of dental contact areas by interproximal
posed for maximum esthetic values making the enamel reduction (so-called stripping or tooth
clinical-to-anatomic crown ratio 1:1. Wheeler9 slenderizing) should be done most judiciously.
described normal value lengths for the maxillary
anterior clinical crowns; however, these were av-
erage lengths measured on extracted teeth, and
they did not allow for any soft tissue coverage or
attachment to the crown. He reported normal
values of 10.5 mm, 9.0 mm, and 10.0 mm for
central incisors, lateral incisors and canines, re-
spectively. The description of Loe and Ainamo10
of normal gingival attachment when combined
with these values provides a more ideal and
workable clinical crown size. The authors found
an average of 0.5 to 2 mm of gingiva covering
the anatomic crown. Therefore, minimum nor-
mal length for the anterior teeth would be 8.5
mm, 7 mm, and 8 mm, for maxillary central Figure 2. Acceptable anatomical crown width-to-
height ratio and dimensions, gingival asymmetry, pa-
incisors, lateral incisors, and canines, respec- pillae fill the interdental spaces, and the gingival scal-
tively. It should be noted that these measure- lop follows the long axis of the tooth. (Color version
ments are mean crown lengths used only as a of figure is available online.)
 Gummy Smiles 263

Deviation from ideal may result in poor esthetics trol of inflammation tooth alignment, tipping
and gingival inflammation. versus bodily movement, expansion versus retru-
sion, and contact management during orth-
odontic treatment may influence esthetic out-
Façade: Attached Gingiva, Free Gingival
comes.
Margin, and Interdental Papillae
The attached gingiva should be pink and nat-
urally pigmented, stippled, and uniform in
Definitions and Standards
contour. The facial gingival margin should be
knife edge and free of gingival inflammation The amount of tooth surface and gingiva the
and located 0.5 to 2 mm coronal to the CEJ. In patient shows is influenced by the dynamics of
addition the focus should be on margin loca- tooth eruption.18 Gingival excess is defined as
tion, type of scallop, and location of the apex abnormal location of gingival margin due to
of the scallop. The gingival scallop should fol- pseudopocketing, inconsistent gingival margins,
low the contour of the CEJ in health with the excessive gingival display, or inflammatory en-
apex located at the junction of the middle and largement (hypertrophy).
gingival third of the crown for the central Active eruption is the movement of the tooth
incisors. toward the occlusal plane. Passive eruption is the
The gingival esthetic line (GAL) is a line con- apical migration of the gingival margin. Altered
necting the apices of the gingival scallop.14 passive eruption is the delay in the apical migra-
There should be symmetry in the gingival com- tion of the epithelial attachment toward the root
position as it relates to this line. Within the smile surface at the CEJ. Altered passive eruption can
the anterior maxillary teeth play a specific es- be either delayed or arrested. In delayed altered
thetic role.15 From an artistic perspective, cen- passive eruption a normal biologic width is es-
tral incisors symbolically can be interpreted as tablished while in arrested altered passive erup-
providing stability and balance, while lateral in- tion there is minimal connective tissue attach-
cisors provide charm and canines bring strength ment and the JE is located on enamel. Altered,
to the esthetic zone. Canines and central inci- active and arrested, passive eruption can be the
sors should be the same length and lateral inci- cause of excessive gingiva display in the peri-
sors 1 to 2 mm shorter. The most apical part of odontally healthy orthodontic patient. In one
the gingival scallop should reflect the angle of study of 1025 patients some form of “delayed
the long axis of the tooth, and there should be passive eruption” was found in 12% of the pa-
an interdental papilla of 4.5 to 5.0 mm from the tients.19 In the active orthodontic patient altered
tip of the papilla to the depth of the marginal passive eruption may be superimposed with gin-
scallop (Fig 2). gival enlargement and be exaggerated by poor
The gingival papilla should fill the gingival oral hygiene.
embrasure. The interradicular distance between Closely related to altered passive eruption is
teeth and the distance between the alveolar crest the amount of keratinized gingiva that is shown
and contact will influence the papillae. The pa- when smiling. The amount of gingiva shown is
pillae will fill the embrasure when the distance composed of attached gingiva, gingiva attached
between alveolar crest and the contact are less to bone and root surface, and unattached or
than 5 mm.16 This decreases to 56% of the time “free gingiva,” gingiva coronal to the epithelial
when the distance is 6 mm and 27% at 7 mm. attachment, which includes the gingival crevice
When the interradicular distance between cen- and gingival excess. The unattached free gingiva
tral incisors is greater than 2.4 mm the distance is often referred to as the “gingival unit” in
from contact to alveolar crest loses its influ- contrast to its complement element of the peri-
ence.17 odontium, the periodontal “attachment appara-
In the orthodontic patient, maximal esthetics tus.” When considering optimal gingival show in
or the ideal smile cannot be achieved unless all an ideal smile, Chiche and Pinault20 stated that
components of the smile are examined before up to 3 mm of gingival tissue may be shown in
and after tooth movement and realistic treat- those with high smile lines before esthetics is
ment goals are anticipated. In addition to con- compromised.
264 T.C. Waldrop

The age of the patient, completion of erup- Prevalence of Excessive Postorthodontic

tion of the teeth in the adolescent or young Gingival Display
adult, and gingival margin location was found
to be complete by age 12 for the maxillary Until recently prevalence information on exces-
central incisors and canines. The maxillary sive gingival display and the need for esthetic
lateral incisors continued to demonstrate mi- crown lengthening has not been available. Prev-
nor changes in gingival margin position up to alence data are important to clinicians in that
16 years of age.21 A more recent study sug- the data provide information on how often they
gested that active passive eruption, resulting in should be looking for a given condition. If prac-
increased clinical crown length, appears to titioners observe a prevalence more or less than
continue throughout the teenage years, until the accepted prevalence data indicates, they
at least age 19.22 After this point, active altered should reevaluate their diagnostic methods. In
passive eruption would be considered inactive general, the subjective field of dental esthetics is
altered passive eruption (Fig 3). difficult to study objectively.

Figure 3. (A) Active altered passive eruption preorthodontic treatment. (B) Inactive altered passive eruption
postorthodontic therapy. (C) Postsurgical ideal esthetic crown length. (Color version of figure is available
online.)
 Gummy Smiles 265

For the first time a recent study evaluated the need for esthetic crown lengthening on a pa-
need for periodontal plastic surgery, esthetic tient and tooth level.
crown lengthening, in a pre- and postorthodon- Measurements with a digital caliper were
tic population.23 The purpose was to apply ac- taken for tooth numbers 6, 7, 8, 9, 10, and 11
cepted standards for esthetics and determine (the maxillary anterior sextant measured from
the prevalence of the need for esthetic crown the patient’s right to left) both from preorth-
lengthening in a population of patients recently odontic models and postorthodontic models.
completing orthodontic therapy. Second, the Measurements were made from the gingival
study proposed to reevaluate those patients at margin to the incisal edge, and both apical and
least 5 years later for changes in marginal gingi- coronal to a line drawn between the tips of the
val position and determine the need for esthetic papillae on either side of the teeth. Measure-
crown lengthening. Based on these findings, es- ments were also taken for the distance between
thetic crown lengthening to maximize esthetic the interproximal contacts as seen from the
results should be part of the orthodontic treat- frontal view. Calculations made from the data
ment planning. The study consisted of two parts were a ratio of the gingival versus the incisal
with data compiled at least 5 years apart. The measurements, the ratio of width to length, and
following is a review of that study. comparison of all measurements to accepted
normal values. Central incisors with a greater
than 80% width-to-length ratio were placed in
Part 1
the group requiring esthetic crown lengthening.
The first part of the study was designed to eval- Patients requiring removal of excessive gin-
uate plaster models for clinical crown size, both giva, esthetic crown lengthening, were placed
length and width, for subjects who had under- into this group if they exhibited one of the
gone orthodontic treatment. Inclusion criteria following: (1) clinical crowns with at least 1 mm
were those subjects who had completed orth- of difference in length between symmetrical
odontic movement of the maxillary central inci- teeth, (2) canine to central length discrepancies
sors (#8 and 9), lateral incisors (#7 and 10), and greater than 1 mm, or (3) clinical crowns with
canines (#6 and 11). All teeth in the study were less than 4 mm of depth of scallop. Age and
measured on the plaster models using digital gender of the subjects from which the models
calipers. Data obtained from measurements were developed were also tested as potentially
were compared with each other and to accepted significant cofactors in excessive gingival display.
“ideal” values. Ideal crown length was defined as Statistical analysis was performed using a re-
11 to 13 mm for centrals, 10 mm for lateral peated measures analysis of variance for all three
incisors, and 11 to 13 mm for canines. These time points. Statistical analysis was also used to
dimensions were a wide enough range to ac- determine the proportion, which was then con-
count for normal variation. Normal crown verted to a percentage of subjects whose values
length was also used for comparison, including lie outside of the accepted normal values for
an allowance of 2.0 mm for soft tissue coverage tooth sizes and ratios. Tooth-to-tooth values
of the anatomic crown. were tested for significance by paired t test, as
In addition, clinical crown width-to-length ra- were pre- and postorthodontic measurements.
tio was analyzed. For the study, a maximum of Age and gender were tested by analysis of vari-
80% width-to-length ratio qualified as within ance (ANOVA) for significance.
normal limits. Ideal papillary height was defined
as 4.5 to 5.0 mm. This was also the measure for
Part 2
depth of the gingival scallop from the base of the
scallop to papilla tip. It was determined (1) how The second part of the study included patients
many teeth had a scallop of this depth and those who had completed orthodontic treatment for
values, (2) which teeth differed by a statistically more than 5 years. Measurements included the
significant amount, and (3) classified that tooth, distance from the zenith of the scallop to the
smile, and subject into the patient group requir- incisal edge for the central incisors, lateral inci-
ing esthetic crown lengthening. The data were sors, and canines. The measurement widths of
then compiled to give a prevalence value for the the maxillary anterior clinical crowns were not
266 T.C. Waldrop

repeated and the widths from part 1 were used were at a distance of greater than 1 mm from
in part 2 of the study. this line.
The study confirmed the need to evaluate the In part 2 of the study 31 subjects were avail-
orthodontic patient during treatment planning able for clinical examination. There were 21
for esthetic crown lengthening to enhance orth- female subjects and 10 male subjects. The age
odontic and esthetic outcomes. In part 1, 200 distribution for patients was 11 to 15 years, 2
plaster models were measured. At the time of patients, 16 to 20 years, 16 patients, 21 to 30
model fabrication, 101 of 166 subjects for whom years, 10 patients, and 31⫹ years, 3 patients.
age data could be located were younger than 18 Clinically, crown lengths had mean values of
years old, and 69 were younger than 16 years 7.6 mm for #5, 9.6 mm for #6, 8.3 mm for #7, 9.8
old. There were 119 female subjects and 81 mm for #8, 10.1 mm for #9, 8.7 mm for #10, 9.5
males. mm for #11, and 7.6 mm for #12. Width of teeth
did not change and no teeth had exposed ce-
mento-enamel junctions.
Gender Differences Were Not Significant
The dimensions of all canines, centrals, and
Preorthodontic clinical crown lengths had mean lateral incisors increased from preorthodontic
postorthodontic values of 8.7 mm for tooth #6, to postorthodontic examinations, but not signif-
7.8 mm for #7, 9.3 mm for #8, 9.4 mm for #9, 7.9 icantly. However, by the clinical examination,
mm for #10, and 8.7 mm #11. Mean width for after 5 years all maxillary anterior clinical crowns
each clinical crown measured from a frontal increased in length, and all but tooth # 8 had
view was 4.3 mm for #6, 5.6 mm for #7, 8.7 mm statistically significant increases (P ⬍ 0.006).
for #8, 8.8 mm for #9, 5.8 mm for #10, and 4.1 From the clinical examination data, calculated
mm for #11. width-to-length ratios for incisors were a mean of
Lateral incisors and canines were significantly 65% for #7, 88% for #8, 87% for #9, and 67% for
longer following orthodontic therapy compared #10. Ten percent of the #7 teeth had a width-to-
with pretreatment values (P ⬍ 0.001). However, length ratio greater than 80%. Sixty-one percent
central incisors did not have a significant in- of subjects had a ratio greater than 80% for #8,
crease in crown length following orthodontic 71% for #9, and 10% for #10. The following
therapy (P ⬎ 0.05). Calculated width-to-length teeth had at least 100% width-to-length ratio: 0%
ratios for incisors were a mean of 73% for #7, for #7, 10% for #8, 13% for #9, and 0% for #10.
94% for #8, 95% for #9, and 73% for #10. For By subject, 32% of subjects had at least one
tooth #7, 24% had a width-to-length ratio central incisor with a width-to-length ratio of at
greater than 80%. Eighty-five percent of subjects least 100%.
had a ratio greater than 80% for #8, 90% for #9, Interestingly, 36% of patients had an asymme-
and 33% for #10. By tooth, 2% of #7, 29.5% of try of at least 1 mm between a tooth and its
#8, 30% of #9, and 4% of #10 had at least 100% antimer, or between a maxillary canine and its
width-to-length ratio; 36.5% of subjects had at ipsilateral central incisor. Analysis of the gingival
least one central incisor with a width-to-length esthetic line showed 62 lateral incisors were at
ratio of at least 100%. the canine and central position and the gingival
Sixty-eight percent of subjects had an asym- margin of 28 laterals were 0 to 1 mm from the
metry of at least 1 mm between the tooth and its line. Twenty-four incisors were found actually
antimer, or between a maxillary canine and its apical to this line, and 10 of them were at a
ipsilateral central incisor. For gingival scallop distance of greater than 1 mm from this line.
depth measurements 818 (68.6%) of teeth had a The results of this study showed that a large
scallop measuring 2 to 4 mm in depth, 177 percentage of patients in orthodontic practice
(14.8%) a scallop depth of 0 to 2 mm, and 197 may benefit from esthetic crown lengthening
(16.5%) had a scallop depth greater than 4 mm. procedures to create proportion, symmetry, and
For GAL analysis 391 lateral incisors were com- illusion of a perfect smile.
pared with canine and central position. The gin- When values for maxillary anterior clinical
gival margin of 333 laterals was found to be 0 to crowns in this study were compared with ac-
1 mm from the GAL. Twenty-four incisors were cepted ideal clinical crown lengths they were
found actually apical to this line, and 34 of them from 1.7 to 2.3 mm shorter at the end of orth-
 Gummy Smiles 267

odontic treatment. Canines and lateral incisors ratio of 87% to 88%, and still 61% to 71% of
averaged more than 2 mm shorter than the ideal them exceeded the allowed 80% tooth width-to-
length. These crown lengths were determined length ratio. Therefore, more than half of the
after removal of the fixed appliance and were central incisors examined exceeded the upper
the result of one or a combination of the follow- values of the ideal width-to-length ratios. The
ing: inflammation, gingival enlargement (hyper- central incisors are the focal point of the smile,
plasia), and altered passive eruption. During the and only slight changes in ideal width-to-length
clinical examination at least 5 years later, the ratio give the illusion of excessive gingiva or
mean observed lengths of all clinical crowns had short teeth (Fig 4A).
increased, yet lengths were still from 0.9 to 1.5 Ideal scallop depth should be 4.5 to 5 mm.
mm shorter than ideal. Despite these dramatic As scallop depth is synonymous to papilla
differences from the ideal, it was determined height, a common guide is for papilla length
that a proportionate comparison, width-to- to be one-half the height of the crown. The
length ratio, would be the most reliable indica- study revealed that 83% of the teeth examined
tor of ideal clinical crown size. had scallop depths less than ideal, or less than
Width-to-length comparisons were even more one-half the height of the crown. Only 16.5%
evident in their discrepancy from ideal values of clinical crowns had a scallop depth of at
than were those for clinical crown length alone least 4 mm, and the average crown length for
at the completion of orthodontics. Mean ratios central incisors was 9.3 to 9.4 mm. Even 4 mm
of 94% to 95% of central incisors, and 85% to would be too short.
90% of central incisors, exceeded the allowed In addition, it was found that only 45% of
80% tooth width-to-length ratio. Lateral incisors lateral incisors were in a proper relationship to
had an acceptable mean ratio of 73%. Five years the GAL, and the remaining 55% were ⬎1 mm
later, the width-to-length ratio of the lateral in- from the GAL. Correction of this aspect of the
cisors had remained well within the accepted smile contributes to creating proportion and il-
values. Central incisors demonstrated a mean lusion of the smile in the finished case.

Figure 4. (A) Tooth width-to-length ratio of 100%. (B) Tooth width-to-length ratio of 80%. (C) Tooth
width-to-length ratio of 66%. (D) Gingival asymmetry. (Color version of figure is available online.)
268 T.C. Waldrop

Symmetry and harmony in the smile also con- ment of the gingiva over the anatomical crown,
tribute to the final case. After orthodontic ther- should be distinguished from simple, reversible
apy, 68% of patients had an asymmetry of at least edema as a result of repeated exposure to bac-
1 or greater in the clinical crown length of ca- terial plaque. This may result in reversible or
nines compared with their antimer, central inci- irreversible gingival enlargement depending on
sors compared with their antimer, and central the relative edematous or hyperplastic compo-
incisors compared with ipsilateral canine. Five nents respectively.
years after completion of orthodontics this asym- Pocket formation without attachment loss
metry still existed in 61% of the patients. This (pseudopocketing) or with attachment loss
asymmetry becomes very evident when compar- (periodontal bone loss) can occur in either
ing central incisors and even canine to canine event, and about 10% of adolescent may have
and can only be corrected by esthetic crown undiagnosed permanent attachment loss.26 With
lengthening (Fig 4D). any kind of pocket formation an environment is
established for Gram-negative bacterial prolifer-
ation and deeper pocket formation. Active or
Management of Inflammation and
arrested altered passive eruption only compli-
Gingival Excess
cates this pathologically qualitative shift by add-
Control of inflammation (and its consequent ing to pocket depth and excessive gingival dis-
permanent hyperplasia) and the incorporation play. That is, when passive eruption is slowed or
of esthetic surgery into the treatment plan to stopped completely the effects of plaque-in-
maximize health and postorthodontic anatomi- duced gingival enlargement and altered passive
cal crown length should be identified before eruption are additive and pathologic.
fixed appliance therapy to warn the patient of It is essential that periodontal probing cou-
this common side effect and incorporate into pled with periodic radiographs be accomplished
the initial case presentation. For treatment plan- before, during, and after treatment but not nec-
ning purposes patients who present for orth- essarily by the orthodontist alone. Probing with
odontic treatment can be categorized into 4 appropriate diagnostic force will determine
types based on gingival condition, gingival mar- pocket depth and attachment level relative to
gin location, and clinical-to-anatomic crown ra- the CEJ. Probing depths apical to the CEJ are
tio (CAR): type I, good oral hygiene, gingival pathognomonic of periodontal attachment loss
health, and normal ratio (CAR); type II, poor (“bone loss”) with or without gingival inflamma-
oral hygiene and gingivitis, but normal CAR; tion. In altered passive eruption the base of the
type III, good oral hygiene, gingival health, and gingival sulcus or crevice is located coronal to
abnormal CAR; and type IV, poor oral hygiene, the CEJ. Regardless of the cause of gingival en-
gingival inflammation, and abnormal CAR. largement, probing should be done even if the
The development of gingivitis and gingival tissue appears healthy. This is because “gingival
enlargement in association with altered passive masking” may be occurring.27 Disease masking
eruption are a common problem in the orth- refers to symptomatic (palliative) care that elim-
odontic patient. Dental plaque-induced gingivi- inates or ameliorates important superficial signs
tis may be modified by local contributing factors and symptoms, plaque, calculus, and marginal
including fixed appliances and by systemic fac- inflammation, but obscures or completely
tors, puberty, menstrual cycle, and diabetes, all “masks” a deeper or more profound disease pro-
common factors in the orthodontic practice. cess. Disease masking is an iatrogenic etiologic
Bacterial plaque is the primary etiology causing factor that can evoke significant dento-legal im-
gingivitis; specifically, the following putative pe- plications. Deep probing depths and delayed
riodontopathogenic species: Treponema denticola, bleeding on probing when marginal tissues ap-
Porphyromonas gingivalis, Tannerella forsythia, Pre- pear healthy may indicate an established and
votella nigrescens, Prevotella intermedia, Fusobacte- progressive infection more apically. Therefore,
rium, and Actinobacillus actinomycetemcomitans radiographs should be taken to evaluate crestal
have been found in the subgingival bacterial bone height and density; in areas of question
biofilms (plaque) of orthodontic patients.24-26 probing should be done below the contact point
Gingival hyperplasia, the permanent encroach- with the probe angled 15 degrees from the ver-
 Gummy Smiles 269

tical coordinate or less. There is no diagnostic with maximal force into the gingival sulcus
substitute for skilled clinical probing with a cor- through the epithelial and connective tissue at-
rect angle and diagnostic force, and radiographs tachment to locate the osseous crest. In most
alone should not be used to diagnose periodon- cases of delayed passive eruption the bone mar-
tal attachment loss. gin is located at the CEJ or less than 2 mm from
In the types II and IV patient, control of the CEJ, and the case requires gingival contour-
inflammation is the first step in management of ing, crown lengthening, with osseous resection.
excessive gingival tissues. Recent research has If only gingival resection (gingivectomy) is done
shown that brushing and flossing plus the addi- in these cases the surgery may fail because the
tion of an essential oil-containing mouth rinse gingival margin will rebound.30,31 When bone is
significantly reduces plaque and gingivitis in pa- removed to establish room for biologic width,
tients undergoing orthodontic treatment.28 The the surgery is successful because the gingival
bristles of even the most well-designed tooth- margin will stabilize (Fig 5).32,33
brush can rarely achieve a depth greater than 0.5 Removal of excessive gingival tissue should be
to 1.5 mm.29 Oral hygiene instruction, prophy- accomplished with a surgical flap technique.34,35
laxis, periodontal instrumentation, and referral Removal of excessive gingival tissue may be done
to a professional colleague when indicated are during treatment to improve hygiene and access
paramount to control of inflammation and gin- to orthodontic hardware. It may also be done
gival stability. Once periodontal health has been following treatment to remove hyperplastic tis-
established a more accurate diagnosis of exces- sue and for improving the esthetics of the pa-
sive gingival tissue can be given because infec- tient’s smile. When excessive gingival tissue is
tion-mediated edema can be distinguished from removed midcourse of orthodontic therapy with-
permanent gingival hyperplasia and altered pas- out a resective approach, a second surgery may
sive eruption. need to be performed to definitively stabilize the
In the types III and IV patient, the appear- gingival margin from “rebound” or recurrent hy-
ance of an abnormal clinical crown ratio may be perplasia. Consequently, flap surgery appears to be
the result of poor oral hygiene, altered passive most efficient technique because it allows for ac-
eruption, or a combination of the two. Coronal cess and removal of excessive bone. A simple
and apical excessive gingiva should be distin- gingivectomy does neither and leads to gingival
guished. Excessive coronal gingiva may be de- rebound and a need for more surgery. Visualiza-
fined as gingiva occurring coronal to the CEJ tion of the alveolar crest is just as important as
resulting in less than ideal coronal-apical tooth the removal of excessive gingiva. The flap ap-
length. In fully erupted teeth the facial gingival proach is the best approach because it maxi-
margin is located on the enamel 0.5 to 2 mm mizes therapeutic benefit while minimizing bio-
coronal to the CEJ. However, soft tissue excess logical cost (tissue morbidity) and risk (relapse).
does not capture the entire domain of excessive
gingival display; excessive apical gingival display
Conclusion
may be explained by excessive vertical bony di-
mension of the maxilla or alveolus. This may be Clearly, the need for esthetic crown lengthening
the result of a thick alveolus, exostosis, vertical to meet ideal esthetic values exists in the orth-
maxillary excess, or a combination of these fac- odontic population. In the prevalence study re-
tors. viewed, the clinical crown length of the maxil-
The gingival margin can be moved via tooth lary central incisors did not change from
movement by extrusion, intrusion, retrusion, preorthodontic to postorthodontic values. After
flaring, or rotation with or without decortication 5 years the mean clinical length of all the max-
surgical facilitation. In the adolescent the final illary anterior teeth increased in clinical crown
location of the bone margin to the CEJ and length, although not to the level of the ideal.
subsequently to the connective and epithelial The majority of patients who were examined at 5
attachment (biologic width) will determine gin- years were between the ages of 16 and 30 with
gival margin location, namely if the bone margin more than half of the subjects aged 16 to 20.
is at least 2 mm from the CEJ as determined by Since active altered passive eruption resulting in
bone sounding. Bone “sounding” is probing increased clinical crown length occurs up to at
270 T.C. Waldrop

Figure 5. (A) After debonding. Altered passive eruption with superimposed gingival enlargement due to poor
oral hygiene. (B) Gingival excess post hygiene phase (periodontal phase I therapy). (C) Esthetic crown
lengthening shows bone crest at CEJ. (D) Postsurgical treatment with ideal crown dimensions, gingival health,
and architecture. (Color version of figure is available online.)

least age 19,22 passive eruption had occurred in 5. Is there gingival asymmetry?
these patients but at 5 years would be catego- 6. Does the patient have a thin or thick biotype?
rized as inactive altered passive eruption. 7. Will tooth movement affect final gingival
In 61% to 71% of the patients the central margin location?
incisors had a width-to-length ratio that ex- 8. Does probing apical to the contact point ex-
ceeded the accepted ideal value. In addition, ceed a physiological optimal?
61% of patients displayed gingival asymmetry 9. Does probing cause bleeding?
from cuspid to cuspid. More than 50% of the
Ultimately, orthodontic treatment planning
patients had a gingival esthetic line discrepancy
should include evaluation of gingival health and
that contributed to less than ideal esthetics.
the parameters of esthetics and anticipate the
Clearly the maxillary anterior teeth, specifically
need for periodontal plastic surgery to provide
the central incisors, are the key to the perfect
patients the option of a more esthetic smile.
smile. How the gingival inflammation, gingival
Realistically, all bacteria cannot be totally elimi-
architecture, and the location of the gingival
nated from the mouth. However, gingival health
margin are managed will enhance orthodontic
can be maintained by minimizing the threat of
outcomes. With this in mind the following ques-
periodontal pathogens. The objective of any ev-
tions should be asked:
idence-based periodontal therapy is to minimize
1. Does the gingiva have normal color (coral the threat of damage to the dental foundation
pink) and firm consistency? and empower the patient, through increased
2. How much gingiva does the patient show skill and an enlightened awareness of therapeu-
(gingival display) when they smile? tic options, for an informed consent to care. In
3. Where is the CEJ located? the present day computerized practice, facial
4. Does the patient have a clinical-to-anatomic and smile analysis can be done on before and
crown ratio of less than 1:1? after images to evaluate these parameters.
 Gummy Smiles 271

Therefore, all clinicians must work together with 16. Tarnow DP, Magner AW, Fletcher P: The effect of the
each other and with patients to determine their distance from the contact point to the crest of bone on
the presence or absence of the interproximal dental
goals and expectations, and perform compre- papilla. J Periodontol 63:995-996, 1992
hensive treatment to best achieve those desired 17. Martegani P, Silvestri M, Mascarelo F, et al: Morphometric
results. study of the interproximal unit in the esthetic region to
correlate anatomic variables affecting the aspect of soft
tissue embrasure space. J Periodontol 78:2260-2265, 2007
Acknowledgments 18. Gottlieb B, Orban: Active and passive eruption of teeth.
The author acknowledges the Master of Science work and J Dent Res 1933;13:214
invaluable research efforts of Dr. David Johnson and Dr. 19. Volchansky A, Cleaton-Jones P: Delayed passive erup-
Brian Konikoff. These brilliant professionals took a vision tion—a predisposing factor to Vincent’s infection. J
that I had and, with collaboration, ran with the idea to make Dent Assoc S Afr 29:291-294, 1974
a significant contribution to the practice of orthodontics, 20. Chiche GJ, Pinault A: Esthetics of Anterior Fixed Prosth-
periodontics, and biological science. Also thanks to the odontics. Quintessence Publishing, 1994
Guest Editor, Dr. Neal C. Murphy, for his invaluable encour- 21. Volchansky A: The position of the gingival margin as
agement and insight, and Mr. Greg Werner, UCLA School of expressed by clinical crown height in children aged 6-16
Dentistry student and future orthodontist, for his clerical years. J Dent 4:116-122, 1976
contributions. 22. Morrow LA, Robbins JW, Jones DL, et al: Clinical crown
length changes from age 12-19 years: a longitudinal
study. J Dent 28:469-473, 2000
References 23. Konikoff BR, Johnson DC, Schenkein HA, et al: Clinical
crown length of the maxillary anterior teeth preorth-
1. Hamdan A: The relationship between patient, parent,
odontics and postorthodontics. J Periodontol 78:645-
and clinicians perceived need and normative orthodon-
653, 2007
tic treatment need. Eur J Orthod 26:265-267, 2004
24. Lee SM, Yoo SY, Kim HS, et al: Prevalence of putative
2. Dunn W, Murchison D, Broom J: Esthetics: patients’
periodontopathogens in subgingival dental plaques
perception of dental attractiveness. J Prosthodont 5:166-
from gingivitis lesions in Korean orthodontic patients. J
171, 1996
3. Garguilo AW, Wentz FM, Orban B: Dimensions and Microbiol 3:260-265, 2005
relations of the dentogingival junction in humans. J 25. Naranjo AA, Triviño ML, Jaramillo A, et al: Changes in
Periodontol 32:261-267, 1961 the subgingival microbiota and periodontal parameters
4. Ingber JS, Rose LF, Coslet JG: The biologic width—a before and 3 months after bracket placement. Am J
concept in periodontics and restorative dentistry. Alpha Orthod Dentofacial Orthop 3:17-22, 2006
Omega 70:62-65, 1977 26. Capelli DP, Ebersole JL, Kornman KS: Early onset peri-
5. Olson M, Lindhe J: Periodontal characteristics in indi- odontitis in Hispanic adolescents associated with A. ac-
viduals with varying forms of the upper central incisors. tinomycetemcomitans. Community Dent Oral Epide-
J Clin Periodontol 18:78-82, 1991 miol 22:116-121, 1994
6. Garber D, Salama M: The aesthetic smile: diagnosis and 27. Greenwell H, Bissada NF, Dodge JR: Disease masking: a
treatment. Periodontology 2000 11:18-28, 1996 hazard of nonsurgical periodontal therapy. Periodontal
7. Levin EI: Dental esthetics and the golden proportion. J Insights 14-19, 1998
Prosthet Dent 40:244-251, 1978 28. Tufekci E, Casagrande ZA, Lindauer ST, et al: Effective-
8. Lombardi RE: The principles of visual perception and ness of an essential oil mouthrinse in improving oral
their clinical application to denture esthetics. J Prosthet health in orthodontic patients. Am J Orthod, in press
Dent 1973;29:358 29. Waerhaug J: Effect of toothbrushing on subgingival
9. Wheeler RC: Wheeler’s Atlas of Tooth Form. Philadel- plaque formation. J Periodontol 52:30-34, 1981
phia, Saunders, 1984 30. Bragger U, Lauchenauer D, Lang NP: Surgical lengthen-
10. Loe H, Ainamo J: Anatomical characteristics of gingivae—a ing of the clinical crown. J Clin Periodontol 19:58-63, 1992
clinical and microscopic study of free and attached gingi- 31. Pontoriero R, Carnevale G: Surgical crown lengthening:
vae. J Periodontol 37:5-13, 1966 a 12-month clinical wound healing study. J Periodontol
11. Ward DH: Proportional smile design using the recurring 72:841-848, 2001
esthetic dental (RED) proportion. Dent Clin North Am 32. Oakley E, Rhyu IC, Karatzas S, et al: Formation of the
45:143, 2001 biologic width following crown lengthening in nonhu-
12. Gillen RJ: An analysis of selected normative tooth pro- man primates. Int J Periodontics Restorative Dent 19:
portions. Int J Prosthodont 7:415, 1994 529-541, 1999
13. Levin EL: Dental esthetics and the golden proportion. J 33. Lanning SK, Waldrop TC, Gunsolley JC, et al: Surgical
Prosthet Dent 40:244, 1978 crown lengthening: evaluation of the biologic width. J
14. Ahmad I: Geometric considerations in anterior dental Periodontol 74:468-474, 2003
esthetics: restorative principles. Pract Periodont Aesthet 34. Townsend CL: Resective surgery: an esthetic application.
Dent 10:813-822, 1998 Quintessence Int 24:535-542, 1993
15. Touati BT: Defining form and position. Pract Periodont 35. McGuire MK: Periodontal plastic surgery. Dent Clin
Aesthet Dent 10:802-803, 1998 North Am 42:411-465, 1998