One of the most common esthetic situations that I see in my practice day-to-day are people who have excessive gingival tissue over their maxillary anterior teeth. They present with maxillary anteriors that seem out of proportion, small and square. Sometimes this is a part of what they would like to alter and it comes up in my pre-clinical interview, and other times it is something I make note of as I am doing my exam. The patient I am talking about, is most often female, I have not gone to the literature to see if this has been proven scientifically, but it is the trend in my world. When I do the dentition exam they have very little to no wear on their maxillary anteriors, so they haven’t worn the teeth down into a short, square shape.
Once I have my photos and I begin the analysis, this group of patients also has good tooth display at rest, so their incisal edges are in the correct position in their face for their age and gender. The last piece of the treatment planning puzzle is to now look at where gingival crest should be relative to normal tooth proportion, and here is where my drawings and their mouths differ.
Where the tissue should be to give them a beautiful smile is apical to its actual position.
The next Questions to answer are:
- Where is the CEJ, relative to the base of the sulcus and the crestal bone?
- How deep is the sulcus, and can we remove only tissue?
I answer these questions through perio charting, looking for the CEJ with an explorer in the sulcus and radiography. Many of these patients simply need a gingivectomy to return the pink esthetics to normal, and the results in their smiles is phenomenal. Others, will need facial crown lengthening with osseous re-contouring to keep the tissue int he corrected position, but they begin in my office with the gingivectomy.
The process begins for me with a conversation and I will show the patient on a keynote presentation where I have drawn in the changes over their photos, and often include photos of other patients who have had this procedure. The next piece is to create a trial smile using composite on a model of their teeth. This is an overlay I create, trim and polish like a provisional, and use for patient communication and as my surgical template. If the patient is ready to go, I now have them back, utilize the trial smile as a template and complete the gingivectomy.
In my hands this has become a very simple and predictable procedure using a DEKA CO2 Laser. The tissue management with the laser is clean, no bleeding, healing is rapid and my patients report very little post op discomfort.In cases where I am altering the pink esthetics, but also have restorative to do like direct composite or provisionalizing, the CO2 laser allows me to maintain a clean enough field that they can be same day procedures.
For patients that are still processing having the procedure, I will bring them in to try in the trial smile ( whether you charge for this is a personal decision), and often send them home with it in a retainer case, so they can snap it on and show family and friends. It is one of the most powerful case acceptance tools I have learned in my practice for both esthetic perio changes and anterior restorative changes.
Patients who will need osseous re-contouring, I follow the same process of completing the gingivectomy and then at three to six weeks they see the periodontist who now has the new gingival crest as a reference and simply lays a flap and removes the bone. If you prefer the patient can take the trial smile with them to the surgeon’s, where it becomes his/her surgical guide and they can do both pieces of the procedure.