Case Report

Treatment of altered passive eruption by surgical gingivectomy: A case report

Pooja Darakh1,*, Yogesh Khadtare2, Pramod Waghmare3, Amita Mali4
1PG Student, 2Assistant Professor, 3Professor, 4Professor & HOD, Dept. of Periodontology,

*Corresponding Author:
Email: [email protected]

Abstract
In recent times, dentists, as well as patients, have developed greater awareness about the impact of teeth and gingiva in the
attractiveness of smile. Short clinical crowns are considered unaesthetic and bring patients’ to the dentist to rectify their gummy
smile. The gingival complex plays a vital role in the overall beauty of an individual’s smile. Altered passive eruption is a clinical
situation that occurs due to excessive gum overlapping the enamel, thus contributing to a gummy smile. Many techniques are
available to correct the problem of gummy smile due to altered passive eruption. However, there has to be a sound knowledge
about the classification and treatment options of altered passive eruption so as to treat patients’ accurately. Careful consideration
of biologic width and the dentogingival junction is needed to adequately diagnose the true etiology and plan an effective
treatment. In the current case report, altered passive eruption was treated with surgical gingivectomy.

Keyword: Altered passive eruption, Esthetic smile, Gingivectomy

Introduction
An esthetic smile is considered as an important
aspect of person’s beauty. The periodontal tissues are
considered as an important factor to achieve this
esthetic smile. To achieve excellent periodontal
esthetics it requires treatment planning with evolution
of all factors that interfere with the symmetry of smile
elements.
A smile may be considered as pleasant when the
upper teeth are completely exposed, and approximately
1mm of buccal gingival tissue is visible. However, a Fig. 1: Active and passive phases of dental eruption
gum exposure not exceeding 2-3mm is also considered
pleasant, whereas an excessive exposure (> 3 mm) is Passive eruption can be divided into 4 stages
generally considered not attractive by many patients according to the relationship between the epithelial
[Allen, 1988].(1) Excessive gingival display is a attachment and the CEJ[Fig. 2].(6)
condition characterized by excessive exposure of the In stage 1, the epithelial attachment —the junctional
maxillary gingiva during smiling, commonly called a epithelium — rests on the enamel surface.
“gummy smile”.(2) Gummy smile or excessive gingival In stage 2, the epithelial attachment rests on the enamel
display may be because of several factors such as surface and the cemental surface apical to the CEJ.
gingival enlargement, altered passive eruption, In stage 3, the epithelial attachment rests on the
insufficient clinical crown, vertical maxillary excess cemental surface, and
and short lip.(3) Evaluation of crown length is important In stage 4, inflammation causes the epithelial
because it may be principal cause of excessive gingival attachment to migrate apically
display.(4)
Altered passive eruption (APE) is characterized by
excessive gingiva in relation to the crown of the tooth.
This condition can be localized or generalized and
should be considered while planning orthodontic,
restorative and esthetic treatment.
Tooth eruption can be active or passive[Fig. 1].
Active eruption is the movement of teeth in occlusal
direction while passive eruption is exposure of teeth by
apical migration of gingiva.(5)

Fig. 2: Stages of passive eruption ( Gottlieb and

Orban)

International Journal of Periodontology and Implantology, April-June 2017;2(2):64-68 64

Pooja Darakh et al. Treatment of altered passive eruption by surgical gingivectomy: A case report

bone crest and cementoenamel junction is 1.5- 2 mm

When passive eruption does not progress stage 1 or (which allows a normal dimension of connective fiber
stage 2, it is referred to as altered passive eruption attachment in the root cement), while in subtype B the
(APE). bone crest lies very close to, or even at the same level
APE is classified into two types [Coslet et al]:(7) as the cementoenamel line [Fig 3].
APE TYPE 1- It is determined by exclusive failure of
passive eruption, giving rise to excessive gingival
overlap on the anatomical crown of the tooth,while in
contrast the distance from the bone crest to the
cementoenamel junction would be normal.
APE TYPE 2-It is determined by primary failure of
active eruption phase, as a result of which the tooth will
not emerge sufficiently from the alveolar bone, thereby
leaving cementoenamel junction very close to bone
crest. This would prevent apical migration of gums
during passive eruption phase. Fig. 3: Morphological classification of altered
Both types are in turn classified into subtypes A passive eruption (APE) according to Coslet
and B[Table 1]. In subtype A, the distance between the

Table 1: Classification of altered passive eruption

Type Description Treatment
1A Osseous crest apical to the cemento enamel junction (CEJ) Gingivectomy
Adequate amount to attached gomgova
Gingival margin incisal to the CEJ
1B Osseous crest at the CEJ Gingivectomy and osseous
Inadequate amount of attached gingiva surgery
Gingival margin incisal to the CEJ
2A Osseous crest at the CEJ Apically positioned flap
Inadequate amount of attached gingiva
Gingival margin incisal to the CEJ
2B Osseous crest at the CEJ Apically positioned flap and
Inadequate amount of attached gingiva osseous surgery
Gingival margin incisal to the CEJ

The occurrence of altered passive eruption is unpredictable, but the frequency in the general population is about
12%.(8) To diagnose altered passive eruption, clinical examination is required. The common clinical signs are
a. The square appearance of the crowns. The gums positioned coronally over the tooth produce a square clinical
crown silhouette, when the actual anatomical shape may be ovoid or elliptic, and thus esthetically much more
attractive.
b. On smiling, the gums are exposed by the upper lip. When such gum exposure exceeds 2-3 mm, it can produce a
poor esthetic effect known as gummy smile.(9)
c. Flattened gingival festooning.
Normally the CEJ lies just apical to gingival margin of the crown. Sulcus depth is usually 2 to 3mm. In APE,
the CEJ might be from 5 to 10mm apical to gingival margin. (10)
This problem can be corrected by various periodontal surgeries like gingivectomy, gingivoplasty, apically
displaced flap with or without osseous resection and undisplaced flap.(11)
The present case report describes the patient with APE treated with gingivectomy.

Case Report
A 23 year old female patient reported to the Department of Periodontology with the complain of bleeding gums
since last 6months. She also complained of display of gingiva when she smiles.
There was no history of any systemic illness. Furthermore, there was no history of any adverse habits.
Clinically, intraoral examination showed that gingiva was pink with slight melanin pigmentation with soft and
edematous consistency and bleeding on probing was present. The probing depths were in the range of 3-5mm.
Routine blood investigations were carried out and it showed normal values. The bone sounding was carried out in
order to determine the level of bone and position of CEJ in relation to gingival margin and gingival biotype. The
gingiva was of thick flat biotype.

International Journal of Periodontology and Implantology, April-June 2017;2(2):64-68 65

Pooja Darakh et al. Treatment of altered passive eruption by surgical gingivectomy: A case report

The case was diagnosed as delayed passive

eruption of Type I Subtype A in relation to tooth upper
right second premolar to upper left second premolar.
Since the tissue from bone to gingival crest was more
than 3mm and there was adequate zone of attached
gingiva, gingivectomy was planned.
The patient was explained about the surgical
procedure and informed consent was obtained.
Thorough scaling and polishing was done and oral
hygiene instructions were given. The diagnostic cast Fig 7: Excision of the tissue
were made and used to prepare stents. The stent was
used as a guideline for creating a new gingival margin
and the markings were made on the gingiva. After
administration of LA, external bevel incision was given
in the region of upper right second premolar to upper
left second premolar.
The curettes were used to remove marginal collar
of the tissue and debridement was done. The
periodontal dressing was then placed in that area. The
patient was given antibiotics and analgesics and was Fig 8 : Excised tissue
recalled after 7days, 1 month and 3 month for follow
up.

Fig 9: Immediately after treatment

Fig 4: Pre –operative

Fig 10:1 week post-operative view

Fig 5: Pocket marking done

Fig 11: 1month post-operative view

Fig 6: The stent used as a guideline

International Journal of Periodontology and Implantology, April-June 2017;2(2):64-68 66

Pooja Darakh et al. Treatment of altered passive eruption by surgical gingivectomy: A case report

as orthognathic surgery and plastic surgery. These

invasive techniques are considered in cases with excess
vertical maxillary excess and hypermobile/short upper
lip.
The choice of the surgical procedure is based on
the gingival architecture, the level of crestal bone and
the amount of keratinized gingiva. If it is anticipated
that 2-3mm of keratnised gingiva will be present after
surgery than external bevel gingivectomy is preferred.
Fig 12: 3months post-operative view In the present study the patient showed APE type 1
because she had an increase in gingiva when free
Discussion gingiva from mucogingival junction was measured.
Altered passive eruption is an uncommon Hence the gingivectomy procedure was planned. The
occurrence that is diagnosed by clinical observation. It procedure gave successful and desired results with
is defined as dentogingival relationship wherein the uneventful healing.
margin of the gingiva is positioned incisally/ occlusally
on the anatomic crown in adulthood and does not Conclusion
approximate the CEJ[Volchansky 1974].(12) The first The gummy smile due to altered passive eruption
step in diagnosing altered passive eruption is observing posseses challenge to the dentist but with correct
the patient while smiling naturally.(13) Several diagnosis and appropriate therapy for excessive
authors(14,15) have suggested evaluating the smile for the gingival display, dental esthetics can be improved. The
amount of incisor and gingival display and the harmony in the smile was obtained through correct
transverse dimension of the smile, whereas Sarver diagnosis and treatment planning. External bevel
[2001](16) suggested evaluating the patient with a posed gingivectomy is an important choice of treatment
(voluntary) and unposed (involuntary) smile. If there is because it is less invasive technique and it is possible to
an excessive display of gingiva during the smile, further establish esthetic smile through it.
diagnostic data are required. First, the length and
activity of the upper lip must be evaluated. If the References
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