Altered Passive Eruption and Active Secondary Eruption

CLINICAL RESEARCH
Altered passive eruption (APE)

and active secondary eruption
(ASE): differential diagnosis and
management
Irfan Ahmad, #%4
Consultant Prosthodontist, Department of Substitutive Dental Sciences,
College of Dentistry, University of Dammam, Kingdom of Saudi Arabia
Correspondence to:*SGBO"INBE #%4

%FQBSUNFOUPG4VCTUJUVUJWF%FOUBM4DJFODFT $PMMFHFPG%FOUJTUSZ 6OJWFSTJUZPG%BNNBN 10#PY %BNNBN
,JOHEPNPG4BVEJ"SBCJB5FM&NBJMJBINBECET!BPMDPN JBINBE!VPEFEVTB
352
THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY
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Abstract more, the differential diagnosis between

the two, and that between other mirror-
The process of tooth eruption consists of ing conditions, is essential for arriving
two phases, active and passive. While at a definite diagnosis and correct treat-
the distinction is unequivocal, the mech- ment strategies, which may be similar
anism is ambiguous. This article com- but have different consequences. This
pares and contrasts altered passive article concludes with two case studies
eruption (APE) and active secondary that show the management of APE and
eruption (ASE). Although these phases ASE, highlighting the treatment similari-
present with similar clinical manifesta- ties and differences that are dependent
tions, each has its own etiology, physio- on the specific etiology.
genesis, and pathogenesis. Further- (Int J Esthet Dent 2017;12:352–376)
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CLINICAL RESEARCH
Introduction medication, or a coronal location of the

gingival margin due to erratic eruption
&YDFTTJWF NBYJMMBSZ HJOHJWBM EJTQMBZ patterns. In addition, numerous mirror-
colloquially referred to as a “gummy ing conditions, unrelated to dental and/
smile,” detracts from pleasing anterior or gingival factors, also manifest as a
pink esthetics.1 People who have this XJEFCBOEPGNBYJMMBSZHJOHJWB"TXFMM
esthetic aberration often suffer from so- as detracting from anterior pink esthet-
cial stigma, ridicule, and sarcasm, and JDT FYDFTTJWFNBYJMMBSZHJOHJWBMEJTQMBZ
are erroneously judged by others in can impact on oral health and the lon-
terms of their intellect, trustworthiness, gevity of the dentition. The correction
friendliness, and self-confidence.2 The of these anomalies is often not straight-
EFHSFF PG NBYJMMBSZ HJOHJWBM FYQPTVSF forward, and its success frequently de-
in patients with a gummy smile has at- pends on correct diagnosis and subse-
tracted much attention in the dental quent appropriate treatment. Treatment
literature. The accepted norm among may involve surgical, restorative, pros-
clinicians for anterior pink esthetics is thetic or orthodontic treatment, muscu-
NNBNFBTVSFNFOUUIBUJTFOEPSTFE lature taming, or a combination of these
CZ JOOVNFSBCMF UFYUT BOE TVSWFZT PO modalities.
the subject.However, it should be re-
membered that opinions are subjective.
Surveys of populations in different coun- Definitions
tries with disparate esthetic values and
differing education levels, social mores, #FGPSFFNCBSLJOHPOUIJTEJTDVTTJPO JU
and religious taboos will have different is important to avoid ambiguity by defin-
outcomes. So while surveys can serve ing some basic dentogingival anatomi-
as a general guide, there are instances, cal terminology (Fig 1).
GPSFYBNQMF XIFSFEJTDFSOJOHQBUJFOUT The cervicoincisal height of the
NBZSFHBSEBOZBNPVOUPGHJOHJWBMFY- crowns of natural teeth is classified into
posure or any minor gingival zenith dis- three categories: clinical length, ana-
parity as detrimental to their smile and tomical length, and biological length.
general appearance. Therefore, in order Clinical crown length is the visible height
to avoid treatment failure, it is essential measured from the incisal edge to the
to take heed of patients’ wishes, irre- most coronal aspect of the free gingival
spective of the clinical and laboratory margin (FGM). The anatomical crown
prowess.7 length, which may or may not be clini-
5IF DMJOJDBM BQQFBSBODF PG FYDFT- cally visible, is the distance from the in-
sive gingival display is usually concur- cisal edge to the cementoenamel junc-
rent with short clinical crowns relating to tion (CEJ). Lastly, the biological crown
dental or gingival factors. Dental causes length, which is invisible and determined
include acute trauma, rampant decay, or either through radiography, tactile bone
attrition due to tooth surface loss (TSL), sounding, or by raising a mucogingi-
while gingival causes include gingival val flap, is the distance from the incisal
hypertrophy due to systemic illness or edge to the midfacial alveolar bone crest
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Keratinized gingiva (FGM Mucogingival junction – red

to mucogingival junction)
Biologic width (epithelial

attachment to alveolar
bone crest)
Sulcus depth (FGM to Alveolar bone crest – yellow

epithelial attachment)
CEJ (cementoenamel junction) – blue

Clinical crown length
(incisal edge to FGM)
FGM (free gingival margin ) – pink
Anatomical crown length

(incisal edge to CEJ)
Biologic crown length

(incisal edge to bone
crest)
Fig 1 Dentogingival terminology.
(clinical crown length + sulcus depth + primary eruption, from when the tooth
biologic width). emerges into the oral cavity until it reach-
Other terminologies include the vis- es its antagonist counterpart. This is fol-
ible width of keratinized gingiva, which lowed by passive eruption, which results
is measured from the coronal aspect in apical migration of the gingiva to fully
of the FGM to the mucogingival junc- FYQPTFUIFDMJOJDBMDSPXO"MUIPVHIUIF
tion; and the invisible biologic width, active phase (active primary eruption)
which is the linear measurement from predominates during the juvenile and
the epithelial attachment to the alveolar puberty phases of development,10 it
CPOFDSFTU DPOTJTUJOHPGBQQSPYJNBUFMZ can nevertheless be triggered through-
1 mm of connective tissue and 1 mm out life11 as active secondary eruption
of epithelial attachment, and which is (ASE) when a tooth is unopposed by its
a prerequisite for periodontal integrity antagonist. Situations causing interoc-
and health. DMVTBMDMFBSBODFJODMVEFNJTTJOHPSFY-
tracted teeth, loss of tooth substrate fol-
lowing trauma, caries, TSL (tooth wear),
Physiogenesis of tooth periodontal disease or intentional space
creation to stimulate this process, eg,
eruption
the Dahl concept.12
The physiogenesis of tooth eruption Passive eruption is histologically di-
consists of two distinct phases: active vided into four stages:
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CLINICAL RESEARCH
1. The epithelium attachment of the den- ever, in APE (also known as delayed
UPHJOHJWBM DPNQMFY %($
JT FOUJSFMZ passive eruption or retarded passive
located on enamel, coronal to the CEJ. eruption), the FGM is located more incis-
2. The epithelium attachment is partly ally or coronally over the enamel, result-
on enamel and partly on cementum. ing in short clinical crown lengths and a
5IFFQJUIFMJVNBUUBDINFOUJTFOUJSFMZ so-called gummy smile.
PODFNFOUVN XJUIJUTDPSPOBMBQFYBU 5IF FYDFTTJWF HJOHJWBM DPWFSBHF
the CEJ. of the anatomical crown seen in APE
5IFFQJUIFMJVNBUUBDINFOUBOE'(. is caused by retardation of the pas-
are apical to the CEJ (gingival reces- sive eruption phase of tooth eruption.
sion). There are two morphological types of
APE (Type 1 and 2), each with two fur-
The prevalence of altered passive erup- UIFS TVCEJWJTJPOT 4VCUZQF " BOE #

tion (APE) is around 12% in the popu- (Fig 2). In both types, the FGM is in a
lation.4UBHFTUPBSFSFHBSEFEBT more coronal position.
normal physiological processes, while The distinguishing feature of Type 1
UIF MBTU TUBHF DIBSBDUFSJ[FE CZ FYQP- is a wide band of keratinized attached
sure of cementum, is considered path- gingiva with a grossly apical location
ological and is caused by sequelae to of the mucogingival junction in relation
QFSJPEPOUBMEJTFBTFPS5ZQF"4& FY- to the alveolar crest. In subtype 1A, the
plained below). distance from the CEJ to the bone crest
JTXJUIJOUIFOPSNPGøUPNN XIJMF
JOTVCUZQF# UIF$&+JTBMNPTUDPJODJ-
Etiology dent with the alveolar crest.
In Type 2, the keratinized gingiva is
Altered passive eruption (APE) narrower and the mucogingival junction
closer to the CEJ, which could be at-
In normal circumstances, the DGC is lo- tributed to a failure of active or passive
cated near the CEJ, with the FGM slightly eruption. In subtype 2A, the distance
concealing the anatomical crown. How- between the CEJ and the alveolar bone
is normal (accommodating the normal
CJPMPHJDXJEUI
XIJMFJOTVCUZQF# UIF
$&+ BMNPTU BQQSPYJNBUFT UIF BMWFPMBS
crest, allowing little space for the epithe-
lium and connective tissue attachments.
5ZQFT#BOE#BSFDPNNPOJOBEP-
lescence but rare in adulthood, ie, they
are a transitionary phase to the second-
BSZEFOUJUJPO*OBEEJUJPO 5ZQF#JTUIF
Type 1A Type 1B Type 2A Type 2B most commonly encountered, and has
been termed altered active eruption,
Fig 2 Coslet’s altered passive eruption (APE)
which is a failure in the active eruption
classification. phase. This interruption, or diapause, in
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Occlusal
plane
Initial position: Final location: Initial position: Final location: Initial position: Final location:
eg, tooth wear, level to oc- eg, unop- beyond oc- eg, unop- root exposure
presence of clusal plane posed tooth clusal plane – posed tooth – long clinical
opposing – short clinical or antagonist normal clinical or antagonist crown length
antagonist crown length tooth wear crown length tooth wear
Type 1 Type 2 Type 3
Alveolar compensation Overeruption with PG Extrusion

(overeruption with PG coronal to occlusal plane (overeruption without PG
level with occlusal plane) coronal to occlusal plane)
PG = periodontal growth
Fig 3 Active secondary eruption (ASE) classification.
the tooth eruption process is attributed teeth during mastication. However, with-
to a variety of causes, including genetic out this periodic stimulation, the erup-
predisposition, unfavorable environ- tion process is once again activated.
mental and systemic factors such as ASE occurs when interocclusal space
occlusal interferences, root ankylosis, is created, either by a variety of unwant-
incomplete root formation, space limita- ed causes such as missing antagonist
tions, thick periodontal biotypes, cardio- teeth, TSL, dental caries, acute traumas,
facial spacial relationship of the jaws, chronic periodontitis, mesial tilting of op-
and metabolic disruption (hormones posing teeth, or intentional orthodontic
and growth factors).17 Whether a single space creation.
factor or multiple factors are responsible Three types of ASE are described
remains an enigma, since physiogene- 'JH
*O5ZQF UIFUPPUITVGGFST54-
sis of tooth eruption is still unresolved, and over-erupts to meet its antagonist
and further research is required for elu- counterpart in order to maintain oc-
DJEBUJOHUIJTDPNQMFYQIFOPNFOPO clusal vertical dimension (OVD) or face
height, also known as dentoalveolar
Active secondary eruption (ASE) compensation. This is achieved by
periodontal growth and the concomitant
The occlusion of the dentition is main- migration of the alveolar housing and
tained in a state of equilibrium due to periodontal ligament toward the occlusal
intermittent stimulation by antagonist plane, resulting in a short clinical crown
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CLINICAL RESEARCH
recession), where the tooth maintains its

occlusal position while the FGM recedes
apically. In addition, depending on tooth
configuration in the arch, ASE can also
be accompanied by mesial drifting and
tilting caused by missing teeth, tooth
wear, or loss/fracture of dental restor-
ations/prostheses.
As mentioned earlier, ASE can also
be intentionally activated for correcting
certain hard and soft tissue anomalies
Fig 4 &YDFTTJWF NBYJMMBSZ HJOHJWBM EJTQMBZ OPU CZNFBOTPGPSUIPEPOUJDFYUSVTJPO NPW-
caused by APE or ASE.
ing the DGC in a coronal direction to
line up erratic gingival zeniths, leveling
arches, creating a favorable crown/root
length and disparate gingival zeniths.20 ratio, increasing bone volume prior to
It is important to realize that dentoal- implant placement, and raising the OVD
veolar compensation is a reaction to an for compensating TSL using the Dahl
event (interocclusal space and lack of principle.
intermittent stimulation), while the action
of compensation is accomplished by
triggering ASE with periodontal growth. Differential diagnosis and
Type 2 is also characterized by peri-
mirroring conditions
odontal growth, but is initiated by a miss-
ing antagonist tooth or antagonist tooth Differential diagnosis between APE,
wear. In this scenario, the tooth over- ASE, and other mirroring conditions in-
erupts coronal to the occlusal plane, volves four diagnostic stages.
maintaining its original crown length but The first diagnostic stage is visual
with disparity of the gingival zeniths, as assessment, determining the degree
the tooth is more coronal compared with PG NBYJMMBSZ HJOHJWBM FYQPTVSF BOE UIF
adjacent teeth. MFOHUIPGUIFUFFUIJOUIFNBYJMMBSZBOUFS-
-BTUMZ 5ZQF BMTP LOPXO BT FYUSV- JPS TFYUBOU EVSJOH TNJMF EZOBNJDT SF-
sion) involves unilateral overeruption of QPTFBOEMBVHIUFS
*GFYDFTTJWFHJOHJWBM
the tooth in a coronal direction, beyond FYQPTVSFJTFWJEFOU CVUUIFUFFUIIBWF
the occlusal plane, leaving the FGM in an average width/length (w/l) ratio in the
JUT PSJHJOBM MPDBUJPO BOE UIFSFGPSF FY- SFHJPO PG 22 with the length of the
posing the dentin and cementum of the DFOUSBMJODJTPSTBQQSPYJNBUFMZNN
root surface, resulting in a long clinical and there are no signs of tooth wear, then
crown length. If the tooth is unopposed, the patient does not have APE or ASE
it will continue erupting until reaching 'JH
*OUIFTFDJSDVNTUBODFT UIFXJEF
the antagonist alveolar ridge.21 This CBOEPGNBYJMMBSZHJOHJWBMEJTQMBZDPVME
type of movement is distinguished from be attributed to other mirroring condi-
UIBUPDDVSSJOHJOTUBHFPG"1& HJOHJWBM tions such as Angle Class II, division II;
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Angle Class III; a short upper lip (aver- USBOTQBSFODZ FYQPTFE EFOUJO
age female lip is 21 mm, and male lip 5IJTJTBTJNQMJTUJDJOEFY TJODFUPEBUF
JT NN
hypertonicity of the orofa- there is no single internationally recog-
DJBM NVTDMFT EFOUPBMWFPMBS FYUSVTJPO OJ[FE JOEFY PG 54- GPS DMJOJDBM BOE SF-
QSPUSVTJPOPGUIFQSFNBYJMMBJODSFBTFE search applications that encompasses
WFSUJDBM EJNFOTJPO PG UIF NBYJMMB DBOU- etiology, morphology, prevalence, ter-
JOH PG UIF JODJTBM QMBOF BOEPS NBYJMMB minology, pathogenesis, monitoring, or
or a combination of these anomalies. management of this insidious condi-
If any of these are suspected, crown tion.
lengthening is futile, as creating long The second diagnostic stage is the
clinical crown lengths will deteriorate location of the CEJ by periodontal prob-
white esthetics and further compound ing. If TSL is evident, with the CEJ situat-
the already compromised pink esthet- ed within the sulcus near the FGM, and
ics. Therefore, other treatment options the measurement from the CEJ to the
should be considered, depending on incisal edge (anatomical crown length)
the etiology, including orthodontics, JTNN UIFEJGGFSFOUJBMEJBHOPTJT
orthognathic surgery, local muscle re- is ASE. In the absence of tooth wear,
MBYBOUT MJQ FMPOHBUJPOT XJUI SIJOPQMBT- reduced clinical crown length, and the
ties, lip muscle detachments, myoto- CEJ not situated within the sulcus or
mies, surgical lip repositioning,27 or a near the FGM, the diagnosis is APE (see
combination of these modalities. Hence, 'JH

differential diagnosis is quintessential The third diagnostic stage is bone
for informing patients of available thera- sounding for ascertaining the type of
pies, and most importantly, for ensuring APE. If the periodontal probe measure-
SFBMJTUJDPVUDPNFTBOEFYQFDUBUJPOT ment from the FGM to the alveolar crest
*O UIF QSFTFODF PG FYDFTTJWF NBYJM- JTNN XJUIBOBQJDBMMPDBUJPOPGUIF
lary gingival display and reduced clinic- mucogingival junction, then the diagno-
al crown length, the differential diagnosis is APE Type 1A, and with a normal lo-
sis is either APE or ASE. APE is clinically cation of the mucogingival junction, the
diagnosed as short clinical crowns with diagnosis is Type 2A. However, when
PSNPSFDPWFSBHFPGUIFBOBUPNJDBM the measurement from the FGM to the al-
crown by the overlying gingiva, which WFPMBSDSFTUBQQSPYJNBUFTNNPSMFTT
is flattened and festooned, with the in- and the mucogingival junction is apical
UFSQSPYJNBM QBQJMMB CBTF XJEFS UIBO JUT PSOPSNBM UIFEJBHOPTJTJT5ZQF#BOE
DPSPOBMBQFYIFJHIU0OUIFPUIFSIBOE 5ZQF# SFTQFDUJWFMZ 'JH

short clinical crowns with apparent tooth The fourth diagnostic stage is radio-
wear are diagnosed as ASE, usually by graphic evaluation, either by parallel pro-
attrition at the incisal edges. The wear at mMFSBEJPHSBQIZ 113Y
or cone beam
the incisal edges is classified according DPNQVUFE UPNPHSBQIZ $#$5
con-
UPUIF4NJUIBOE,OJHIU5PPUI8FBS*OEFY firming the thickening of both the crestal
(TWI) for attrition as follows: 0 = intact in- alveolar bone and the connective tissue
cisal edge; 1 = non-visualization of the attachment, as well as the location of the
enamel lobes; 2 = the dentin is seen by CEJ.5ZQJDBMMZ "1&5ZQFT#BOE#
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CLINICAL RESEARCH
Table 1 Differential diagnosis of APE and ASE
APE ASE
Short clinical Yes Yes (Type 1)

crown length
Long clinical No :FT 5ZQF
crown length
Tooth wear No Yes
Missing antago- No :FT 5ZQFTPS
nist tooth/teeth
CEJ location to Apical to FGM Normal parameters to FGM (Types 1

FGM and 2) or
$PSPOBMUP'(. 5ZQF
Alveolar crest /FBSFS$&+ 5ZQFT#BOE#

PS Nearer occlusal plane (Types 1 and 2) or
location to CEJ/ Normal parameters to CEJ (Types 1A Normal parameters to occlusal plane
occlusal plane and 2A) 5ZQF
Keratinized gingi- 8JEF 5ZQFT"BOE#

PS Wide (Types 1 and 2) or
val width /PSNBMQBSBNFUFST 5ZQFT"BOE#
/PSNBMQBSBNFUFST 5ZQF
Mucogingival "QJDBM 5ZQFT"BOE#

PS Normal parameters
location /PSNBMQBSBNFUFST 5ZQFT"BOE#
APE - altered passive eruption

ASE - active secondary eruption
are diagnosed when there are smaller Management of APE

biologic widths (ie, a smaller distance and ASE
from the CEJ to the crestal bone, leaving
little space for the connective tissue and The implications of APE to oral heath are
epithelial attachments), while in Types possible risk to periodontal pathosis, in-
1A and 2A, the relationship of the CEJ cluding chronic inflammation, acute ne-
and alveolar crest is normal, around crotizing ulcerative gingivitis or gingival
øUPNN hyperplasia. However, the salient is-
Finally, the sulcus depth can be within sues are either compromised pink es-
normal parameters (1 mm), and hence thetics, which prompts patients to seek
its depth is an unreliable diagnostic in- professional help, or when restorative
dication of APE, and in the presence of treatment is contemplated on the affect-
short clinical crowns, bone sounding ed tooth/teeth. If uncorrected, and the
is a better diagnostic assessment tool restorative margins are placed supra-
(Table 1). or equigingivally, the esthetic anomalies
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include short wide crowns with a large gingivectomy alone suffices, leaving
XM SBUJP FYQPTVSF BOEPS TUBJOJOH PG NNGSPNUIF'(.UPUIFBMWFPMBSDSFTU
the restoration finish line, persistence for maintaining the biologic width and
PGFYDFTTJWFHJOHJWBMEJTQMBZPSHVNNZ HJOHJWBMTVMDVT$POWFSTFMZ JO5ZQFT#
smile, and festooned flattened gingiva. BOE# HJOHJWFDUPNZQMVTPTTFPVTSF-
All of these compromise the dentofacial cession by ostectomy and osteoplasty
esthetic composition or attractiveness of are indicated for removing crestal bone
the smile. Conversely, subgingival mar- BOEDSFBUJOHUIFOFDFTTBSZNNTQBDF
gins can violate the biologic width, caus- from the FGM (2 mm for biologic width,
ing periodontal insult, again resulting in and 1 mm for sulcus). However, depend-
unsightly and unhealthy pink esthetics. ing on the location of the mucogingival
The clinical implications of ASE can be junction, the flap design and reposition-
short or long capriciously shaped clin- ing may require modification for ensur-
ical crowns, depending on the type of ing an adequate band of keratinized gin-
active eruption; unsightly uneven incisal giva for periodontal health. The incisions
edges; erratic gingival zenith margins; and tissue resection (soft and hard) are
BOEEFOUJOFYQPTVSFBUUIFJODJTBMFEHFT limited to the facial aspect, and involve
and/or root surfaces, causing sensitivity reestablishing the correct gingival scal-
and discoloration, combined with accel- lops for mimicking underlying osseous
erated tooth substrate loss with possible architecture. In addition, gingivectomy
fracture and/or endodontic involvement. incisions are confined within the facial
Following precise diagnosis, a man- line angles for creating the correct gin-
agement strategy is planned. This gival scallop, without resecting the in-
strategy may simply involve restorative UFSQSPYJNBM QBQJMMBF UP BWPJE DSFBUJOH
corrections, or it may necessitate perio- unwanted gingival embrasures causing
plastic surgery, orthodontics, orthog- so-called “black triangles.” The soft tis-
nathic surgery, systemic or local muscle sue healing process is erratic, at times
SFMBYBOUT PSBDPNCJOBUJPOPGUIFTFEJT- with postsurgical recession or a coronal
ciplines. rebound of the FGM. Furthermore, the
If the diagnosis is limited to APE, there healing period is variable, from a few
is only one option: periodontal plastic weeks to several years, depending on
surgery for crown lengthening, either surgical protocols, as well as patient
gingivectomy alone or gingivectomy with constitutional and systemic factors.
osseous resection, depending on the For patients with high lip lines, minor
relationship of the alveolar crest to the gingival zenith aberrations after healing
CEJ, and the width of keratinized gingi- can be corrected with judicial incisions
va. The outcomes of these procedures with scalpel blades or diode lasers.
are predictable, with a high degree of Correcting asymmetrical gingival
patient satisfaction. The significance margins for ASE is also accomplished
of bone sounding is in determining with perioplastic surgery, or alternatively
which crown-lengthening procedure is by orthodontic intrusion, usually in com-
required. With Types 1A and 2A, and bination with restorative or prosthetic
assuming adequate keratinized tissue, modalities for replacing the lost enam-
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CLINICAL RESEARCH
el and dentin, depending on wheth- left central incisor, necessitating a full-

er the etiology is TSL or unopposed coverage crown. The right central inci-
BOUBHPOJTU T
8IJMFGPS"1& FYDFTTUJT- sor escaped major trauma but incurred
sue removal establishes correct gingival minor incisal edge damage, which was
[FOJUITBOEFYQPTFTUIFDMJOJDBMDSPXO repaired with a resin-based composite
to its proper w/l ratio, a similar protocol restoration. Although unable to fully ar-
GPS "4& SFTVMUT JO FMFDUJWF FYQPTVSF PG ticulate her esthetic anomalies, she was
the tooth root surface, which may re- generally unhappy with the appearance
quire desensitizing agents or restorative of her smile, and described her anterior
coverage for protecting the vulnerable teeth as “short and fat.” Esthetic analys-
FYQPTFEEFOUJO5IFTFDPOEPQUJPOGPS is revealed a lack of tooth display dur-
correcting ASE is orthodontic intrusion JOHUIFIBCJUVBMMJQQPTJUJPO 'JH
BSF-
for reestablishing correct gingival zenith versed smile line during repose smiling
heights, plus either resin-based compos- and laughter; a small median diastema;
ite or porcelain restorations for replacing eschewed dental midline; and incisal
TSL. Furthermore, the etiological causes plane canting to the left, an anomaly
should be addressed, missing teeth re- generally regarded as one of the most
placed, counseling given for mitigating displeasing features of a smile 'JH

TSL, and nightguards provided to curb Further scrutiny established short clin-
and minimize occlusal parafunctional ical crown lengths of the canines and
activities. Finally, it is prudent to foresee central incisors, lack of dominance of
UIFDPOTFRVFODFTPGFYUSBDUJPOTGPSQSF- the central incisors, and a defective
venting ASE, and patient counseling is bulbous crown on the left central incisor
essential to limit future unnecessary and causing bruising of the gingival margin.
costly treatment. In addition, the left lateral incisor sagged
The following two case studies il- coronal to the incisal plane, while the left
lustrate the correction of APE and ASE canine displayed a distofacial rotation,
using a combination of perioplastic both of which disrupted the pleasing
surgery and restorative/prosthetic ap- distal incisal embrasure progression
proaches for the restitution of pink and 'JH
5IFHJOHJWBM[FOJUITPGUIFNBY-
white anterior esthetics. They highlight JMMBSZTFYUBOUXFSFFSSBUJD DBVTFECZUIF
the similarities and differences in treat- short clinical crown lengths of the ca-
ment modalities for short clinical crowns nines and central incisors. This resulted
with different etiologies. JO FYDFTTJWF HJOHJWBM FYQPTVSF FTQF-
cially on the left. In addition, a wide band
of keratinized attached gingiva was evi-
Case study 1: APE dent apical to the anterior teeth, and the
canine gingival zeniths were coronal to
"ZFBSPMEGFNBMFXBTSFGFSSFEUPUIF that of the central incisors, creating a
dental hospital with a request for improv- gingival esthetic line (GAL) Class IV on
ing her anterior dental esthetics. Coun- both sides.
TFMJOHSFWFBMFEUIBUBOBDDJEFOUZFBST The provisional diagnosis was APE
before had caused the fracture of her Type 1A on the central incisors and left
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Fig 5 Dentofacial preoperative view of the ha- Fig 6 Dentofacial preoperative view during smil-
CJUVBMMJQQPTJUJPOTIPXJOHMBDLPGBOUFSJPSNBYJMMBSZ ing showing a reversed smile line, median diastema,
tooth display. slanted dental midline, and incisal plane canting to
the left.
Fig 7 Dental preoperative view showing lack of Fig 8 %JBHOPTUJD XBYVQ PG UIF DFOUSBM JODJTPST
dominance of the central incisors, short clinical for increasing the length of the porcelain laminate
crowns of the central incisors and canines, and dis- veneer (PLV) on tooth 11, and the all-ceramic crown
ruptive distoincisal embrasure progression on the POUPPUI XJUIBDPSSFTQPOEJOHTJMJDPOFJOEFYGPS
MFGUTJEFPGUIFNBYJMMBSZTFYUBOU an intraoral mock-up and temporization.
MBUFSBM JODJTPS BOE 5ZQF # PO UIF DB- NNNN

JODSFBTJOH
OJOFT #POF TPVOEJOH FTUBCMJTIFE UIBU UIFJS MFOHUI GSPN UP NN UP BM-
surgical crown lengthening would be MPX HSFBUFS UPPUI FYQPTVSF EVSJOH UIF
necessary, involving gingivectomy alone habitual lip position, which is regarded
for teeth 11, 21, and 22, and gingivec- as a prerequisite for a youthful appear-
tomy with osseous recession for teeth ance.
BOE UP DSFBUF TQBDF GPS UIF CJP- 'PMMPXJOH QSPQIZMBYJT UIF PGGFOEJOH
MPHJDXJEUI"EJBHOPTUJDXBYVQ 'JH
crown on the left central incisor was re-
was utilized for simulating the correct moved, revealing circumferential inflam-
XM SBUJP PG UIF DFOUSBM JODJTPST UP NBUJPO PG UIF HJOHJWBM NBSHJOT 'JHT
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CLINICAL RESEARCH
Fig 9 Facial view after removing the defective Fig 10 Occlusal view after removing the defec-
horizontally overcontoured crown on the left central tive horizontally overcontoured crown on left central
incisor, showing circumferential inflammation of the incisor, showing circumferential inflammation of the
gingival margins. gingival margins.
Fig 11 Periodontal probe showing the proposed Fig 12 Periodontal probe showing the proposed
GAL Class I on the right side. GAL Class I on the left side.
and 10). A chairside, correctly fitting

acrylic temporary restoration was fabri-
cated for promoting gingival health.
The subsequent stage was esthetic
crown lengthening of the canines and
left lateral incisor for creating a GAL
Class I on both the right and left sides of
UIF NBYJMMBSZ TFYUBOU 'JHT BOE

After bone sounding under local anes-
thesia, bleeding points were placed for
guiding the ensuing surgical proced-
Fig 13 #MFFEJOHQPJOUUPHVJEFUIFHJOHJWFDUPNZ VSFT 'JH
5IF JOJUJBM TUFQ XBT DBS-
incision.
rying out a gingivectomy by incising
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AHMAD
Fig 14 (JOHJWFDUPNZPOUFFUIBOEQSJPSUP Fig 15 (JOHJWFDUPNZPOUPPUIUPJODSFBTFUIF

EJTDBSEJOHUIFFYDFTTHJOHJWBMUJTTVF clinical crown length for establishing the correct w/l
SBUJPPG
Fig 16 Papillae preservation incisions followed Fig 17 *OUFSSVQUFE TVUVSFT OPOSFTPSCBCMF

CZnBQFMFWBUJPOUPFYQPTFPTTFPVTCPOFDSFTUBQ- securing the flap around the left canine following
QSPYJNBUJOHUIF$&+ DPOTJTUFOUXJUI"1&5ZQF# ostectomy and osteoplasty.
Fig 18 Ten-day healing prior to suture removal. Fig 19 Five-week healing showing establishment
of GAL Class I on the right and left sides (compare
with Fig 7).
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CLINICAL RESEARCH
Fig 20 Facial view showing gingival health around Fig 21 Occlusal view showing gingival health
MFGUDFOUSBMJODJTPSQSFQBSBUJPO DPNQBSFXJUI'JH
around left central incisor preparation (compare
with Fig 10).
Fig 22 Minimally invasive tooth preparation for Fig 23 Isolation with gingival retraction cord, a
a PLV on the right central incisor, confined to the wooden wedge, and polytetrafluoroethylene (PTFE)
enamel layer to enhance adhesive bonding with a tape during the adhesive cementation protocol.
resin-based cement.
FYDFTT UJTTVF UP UIF DPSSFDU HJOHJWBM sulcus from the gingivectomy margin to
[FOJUI IFJHIUT VTJOH B /PD TDBMQFM the midfacial osseous crest. A similar
blade, guided by the bleeding points procedure was performed on the right
QMBDFECFGPSFIBOE 'JHTBOE
" canine, but using a flapless approach.
full-thickness mucoperiosteal flap was Since the left lateral incisor was an APE
SBJTFEBSPVOEUIFMFGUDBOJOFUPFYQPTF Type 1A, surgery was limited to a gin-
the osseous crest, which was adjacent givectomy without osseous contouring.
to the CEJ, confirming the provisional The crown lengthening was completed
EJBHOPTJT PG "1& 5ZQF # 'JH
"O by suturing the flap around the left ca-
ostectomy and osteoplasty were per- OJOFXJUIOPOSFTPSCBCMFJOUFSSVQUFE
formed around the left canine, creating sutures (Fig 17). Uneventful healing
BNNTQBDFGPSUIFCJPMPHJDXJEUIBOE JT TIPXO JO 'JHVSFT BOE BGUFS
366
70-6.&t/6.#&3tAUTUMN 2017
AHMAD
EBZT BOE XFFLT SFTQFDUJWFMZ "U sive protocol. The teeth were isolated
a later date, crown lengthening, limited with gingival retraction cord, a wood-
to gingivectomy, was carried out for the en wedge, and polytetrafluoroethylene
central incisors for establishing a more (PTFE) tape during the cementation pro-
apical position of the gingival zeniths. DFEVSF 'JH
"SFTJOCBTFEDFNFOU
A further 2 months was allowed for (Variolink Veneer, Ivoclar Vivadent) with
the tissues to mature and gingival ze- BEFOUJOCPOEJOHBHFOU 0QUJ#POE953
niths to stabilize before proceeding Kerr) adhered the ceramic restorations
with tooth preparations for the central with a hermetic seal at the margins. Fi-
incisors. During this healing phase, the nally, judicial esthetic contouring was
patient bleached her teeth to improve carried out on the left lateral incisor and
the shade prior to delivery of the de- canine to harmonize the distal incisal
finitive restorations. The preparation for embrasure progression. The postopera-
the full-coverage all-ceramic crown on tive results show integration of the indi-
the left central incisor was refined, and rect ceramic restorations with the soft
the acrylic temporary crown relined un- tissue, dominance of the central inci-
til gingival health was evident (Figs 20 sors, increased crown lengths of the ca-
and 21). On the right central incisor, the nines and central incisors with the cor-
porcelain laminate veneer (PLV) prep- rect w/l ratios, elimination of the incisal
aration was minimal, confined to the cant on the left, and GAL Class I on both
enamel layer, and defining the cervical, TJEFT 'JHTø UPø
5IF EFOUPGBDJBM
JOUFSQSPYJNBM BOE QBMBUBM mOJTI MJOFT WJFXTIPXTBDDFQUBCMFNBYJMMBSZHJOHJ-
(Fig 22). Following the fabrication of WBM FYQPTVSF EVSJOH B SFMBYFE TNJMF B
the feldspathic PLV and all-ceramic IPS smile line coincident with the curvature
FNBY *WPDMBS 7JWBEFOU
DSPXO JO UIF PGUIFMPXFSMJQ BOEJODSFBTFEUPPUIFY-
dental laboratory, the latter was bonded posure during the habitual lip position
to the tooth substrate using an adhe- 'JHTøBOEø

Fig 24 Postoperative view in centric occlusion Fig 25 Postoperative anterior view showing GAL
showing increased clinical crown lengths of the $MBTT*POUIFSJHIUBOEMFGUNBYJMMBSZTFYUBOU/PUJDF
NBYJMMBSZDBOJOFTBOEDFOUSBMJODJTPST UPHFUIFSXJUI the esthetic contouring by enameloplasty on the left
increased anterior overbite of the latter, and impec- lateral incisor and canine to establish correct distal
cable gingival health (compare with Fig 7). progression of the incisal embrasures.
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CLINICAL RESEARCH
Fig 26 Postoperative right lateral view showing Fig 27 Postoperative left lateral view showing GAL
GAL Class I and correct w/l ratios of the right canine Class I and correct w/l ratios of the left canine and cen-
and central incisor following esthetic crown length- tral incisor. Notice the esthetic contouring by enamelo-
ening. plasty on the left lateral incisor and canine to establish
correct distal progression of the incisal embrasures.
Fig 28 Dentofacial postoperative view during a Fig 29 Dentofacial postoperative view showing
SFMBYFE TNJMF TIPXJOH DPJODJEFODF PG UIF JODJTBM NBYJMMBSZJODJTPSEJTQMBZEVSJOHUIFIBCJUVBMMJQQPT-
plane with the curvature of the lower lip, acceptable JUJPO DPNQBSFXJUI'JH

NBYJMMBSZ HJOHJWBM FYQPTVSF QFSQFOEJDVMBS EFOUBM
midline, and elimination of the cant on the left (com-
QBSFXJUI'JH

Case study 2: ASE line, lack of dominance of the central in-

DJTPST BOE FYDFTTJWF HJOHJWBM EJTQMBZ
"ZFBSPMEXPNBOBUUFOEFEUIFTQF- BQJDBM UP UIF DBOJOFT 'JH
*OUSBPSBM
cialty clinic of the dental hospital com- FYBNJOBUJPOmOEJOHTJODMVEFETIPSUDMJO-
plaining of a “crooked smile” and gaps ical crown length of the canines, consid-
between her teeth. The dentofacial com- erable TSL on the facial surfaces of the
position revealed a substantial median NBYJMMBSZBOUFSJPSUFFUIEVFUPBCSBTJPO
NBYJMMBSZEJBTUFNB 54- BSFWFSTFETNJMF and serrated incisal edges caused by
368
70-6.&t/6.#&3tAUTUMN 2017
AHMAD
attrition. In addition, cervical decay was

evident on the right canine, as well as a
defective composite veneer on the right
MBUFSBMJODJTPS 'JH
5IFHJOHJWBM[F-
niths of the canines on both sides were
coronal to that of the central incisors,
consistent with a GAL Class IV gingival
TDBMMPQJOHPGUIFNBYJMMBSZTFYUBOU5IF
occlusal view confirmed tooth wear with
EFOUJO FYQPTVSF TDBMF BDDPSEJOH UP
the Smith and Knight TWI classification
'JH
0UIFSEFOUBMJTTVFTTVDIBTBO Fig 30 Dentofacial preoperative view during a
SFMBYFETNJMFTIPXJOHBSFWFSTFETNJMFMJOF NBYJM-
anterior mandibular diastema, defective
lary median diastema, TSL, serrated and abraded
mYFEQBSUJBMEFOUVSFT BOENJTTJOHNBO- JODJTBMFEHFT BOEFYDFTTJWFHJOHJWBMEJTQMBZBQJDBM
dibular teeth also required addressing to the canines.
at a later date.
The diagnosis for the short clinical
crowns of the canines was ASE Type
I, caused by attrition and subsequent
dentoalveolar compensation moving
the gingival zeniths (and dentogingival
DPNQMFY
DMPTFS UP UIF PDDMVTBM QMBOF
5IFUSFBUNFOUQMBOGPSUIFNBYJMMBSZTFY-
tant was, firstly, esthetic crown lengthen-
ing to increase the clinical crown lengths
of the canines and thereby reduce gin-
HJWBMFYQPTVSFEVSJOHTNJMJOH4FDPOEMZ
Fig 31 Frontal preoperative view showing cervi-
prepless direct composite restorations
cal decay on the right canine, defective composite
to establish correct w/l ratios of the cen- veneer on the right lateral incisor, and TSL caused
tral incisors, eliminate the median dias- by abrasion and attrition.
tema, replace the defective filling on the
right lateral incisor, remove the cervical
decay on the right canine, and replace
the facial surface enamel loss caused
by abrasion.
"GUFS QSPQIZMBYJT B EJBHOPTUJD XBY
VQXJUIBTJMJDPOFJOEFYXBTGBCSJDBUFE
and used as a framework for guiding the
esthetic crown lengthening and resin-
CBTFE DPNQPTJUF SFTUPSBUJPOT 'JH

To achieve correct proportion for the left
DBOJOF UIFFYJTUJOHDMJOJDBMDSPXOMFOHUI Fig 32 Occlusal preoperative view showing tooth
PGNN 'JH
SFRVJSFEJODSFBTJOHUP XFBSXJUIEFOUJOFYQPTVSF 4NJUIBOE,OJHIU58*

369
70-6.&t/6.#&3tAUTUMN 2017
CLINICAL RESEARCH
Fig 33 %JBHOPTUJDXBYVQBOETJMJDPOFJOEFYGPS Fig 34 &YJTUJOHDMJOJDBMDSPXOMFOHUIPGMFGUDBOJOF

guiding crown lengthening and composite fillings. PGNN
Fig 35 Proposed clinical crown length of left ca- Fig 36 #POFTPVOEJOHPGNNGSPNUIF'(.UP

OJOFPGNN the midfacial osseous crest.
Fig 37 (JOHJWFDUPNZ VTJOH B /PD TDBMQFM Fig 38 5IFNNPGJODJTFEHJOHJWBJTSFNPWFE

blade. with a periodontal curette.
370
70-6.&t/6.#&3tAUTUMN 2017
AHMAD
Fig 39 Periodontal probe showing coincidence Fig 40 Creating a new biologic crown length of
of the central incisor and canine gingival zeniths, NNPOUIFMFGUDBOJOF
with a 1-mm coronal lateral incisor gingival zenith,
which is consistent with a GAL Class I.
NN 'JH
5IFCPOFTPVOEJOHPG for stabilization of the gingival zeniths; in
NN 'JH
NFBOUUIBUUPMFOHUIFO the interim period, the patient opted for
UIF DMJOJDBM DSPXO MFOHUI UP NN home bleaching prior to the restorative
would require ostectomy for creating a QIBTF 'JH

CJPMPHJDBMDSPXOMFOHUIPGBQQSPYJNBUF- The restorative stage commenced by
MZ ø UP NN XJUI B UP NN using a transparent composite shade
space for the new biologic width. The in- (Empress Direct, Ivoclar Vivadent) for
itial step was a gingivectomy to remove building up the incisal edges of the cen-
NNPGHJOHJWBUPDSFBUFB("-$MBTT tral incisors, aided by the previously
* 'JHTø UPø
4VCTFRVFOUMZ B GVMM GBCSJDBUFETJMJDPOFJOEFYGSPNUIFEJBH-
thickness flap was elevated following OPTUJD XBYVQ 'JH
"MM DPNQPTJUF
JOUFSQSPYJNBMBOETVMDVMBSJODJTJPOT BOE restorations were performed according
vertical and horizontal ostectomy and
osteoplasty were carried out using end-
cutting and cylindrical burs, respective-
ly, under copious irrigation with sterile
TBMJOF'JHVSFTIPXTUIFOFXCJPMPHJD
DSPXO MFOHUI PG UIF DBOJOF PG BQQSPYJ-
NBUFMZ NN " TJNJMBS QSPDFEVSF
was performed on the right canine, and
the flaps were sutured. Uneventful heal-
ing after 10 days shows a more cervical
location of the gingival zeniths around
CPUIDBOJOFT 'JH
/PUFIPXUIFJO-
creased clinical crown lengths of the ca-
OJOFT BSF BU UIF FYQFOTF PG SPPU FYQP- Fig 41 Ten-day healing showing longer clinical
TVSF"GVSUIFSNPOUITXBTBMMPXFE DSPXOTPGCPUINBYJMMBSZDBOJOFT
371
70-6.&t/6.#&3tAUTUMN 2017
CLINICAL RESEARCH
Fig 42 "GUFS NPOUIT PG IFBMJOH BOE QPTU Fig 43 Incisal edge build-up of the central inci-
CMFBDIJOH DPNQBSFXJUI'JH
sors with a transparent shade resin-based compos-
JUFVTJOHUIFTJMJDPOFJOEFYPGUIFEJBHOPTUJDXBYVQ
TIPXOJO'JHVSF
Fig 44 Postoperative result showing the restitu- Fig 45 Postoperative result showing GAL Class
tion of pink and white anterior dental esthetics by *POUIFSJHIUBOEMFGUTJEFTPGUIFNBYJMMBSZTFYUBOU
esthetic crown lengthening and prepless composite DPNQBSFXJUI'JH

SFTUPSBUJPOT SFTQFDUJWFMZ DPNQBSFXJUI'JH

Fig 46 Postoperative dentofacial view showing

BDDFQUBCMFNBYJMMBSZHJOHJWBMFYQPTVSFBOEBTNJMF
line coincident with curvature of the lower lip (com-
QBSFXJUI'JH

372
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AHMAD
Differential diagnoses of short clinical crown length –

location of the CEJ to FGM
Fig 47 Differential
diagnosis of APE and
ASE by location of the
CEJ relative to the FGM.
In APE, the CEJ is locat-
ed apical to the FGM, ASE Type 1 APE Type 1A & 1B
while in ASE, the CEJ (active secondary eruption) (altered passive eruption)
BQQSPYJNBUFTUIF'(.
to strict prepless and adhesive proto- crowns with compromised pink esthet-
cols, relying on micromechanical and ics, and while the treatments in both cas-
chemical adhesion of a dentin bonding es were similar and involved perioplastic
BHFOU 0QUJ#POE 953
5IF QPTUPQFSB- surgery, the etiology – and hence future
tive result shows the correct w/l ratio of management – was different. In the first
the central incisors, median diastema case (APE), the crown lengthening itself
closure, and replacement of the lost was a fait accompli, while in the second
enamel and dentin due to the previously case (ASE), the patient required dietary
NFOUJPOFE 54- 'JHT BOE
5IF advice, nightguards, and future period-
dentofacial view during repose smil- ic reviews for monitoring parafunctional
JOH TIPXT SFEVDFE HJOHJWBM FYQPTVSF activity for the cessation and mitigation
BSPVOEUIFNBYJMMBSZDBOJOFT ("-$MBTT of TSL.
*POUIFSJHIUBOEMFGUTJEFTPGUIFNBYJM- One of the defining features for the
MBSZ TFYUBOU 'JH
EPNJOBODF PG UIF differential diagnosis of both APE and
central incisors, and a smile line parallel ASE is the location of the CEJ. In the
UPUIFDVSWBUVSFPGUIFMPXFSMJQ 'JH
first case (APE), the location of the CEJ
Finally, the patient was counseled about was apical to the FGM, while in the sec-
diet and oral hygiene procedures, and POEDBTF "4&
UIF$&+BQQSPYJNBUFE
provided with nightguards to mitigate UIF $&+ 'JH
5IFSFGPSF BDIJFWJOH
tooth wear and protect the composite the correct clinical crown lengths for the
restorations. "4& QBUJFOU OFDFTTJUBUFE FYQPTJOH UIF
root surface, which in itself could cause
future problems that would require de-
Discussion sensitizing agents and/or protecting the
FYQPTFE EFOUJO XJUI SFTUPSBUJWF NBUFS-
In the two case studies discussed here, ials. In addition, the ASE case showed
the esthetic anomaly was short clinical TSL at the incisal edges of the canine,
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CLINICAL RESEARCH
while in the APE case, the canines were tions, the dental and gingival causes of
pristine and unworn. Furthermore, the short clinical crowns are APE or ASE,
keratinized band of tissue in the APE and differential diagnosis of the two is
patient was wide, which is consistent essential for arriving at correct man-
with APE Type 1, while in the ASE case agement strategies of these conditions,
study, this width was within the norm due which compromise anterior dental es-
to dentoalveolar compensation. Finally, thetics. The two case studies presented
since soft tissue healing is erratic, pe- in this article show striking clinical simi-
riodic monitoring is essential for both larities, but with different etiologies and
cases to ensure long-term periodontal diagnoses. Although the initial treatment
health and the maintenance of both pink may be similar, the long-term manage-
and white esthetics. ment differs, and careful counseling and
monitoring is essential for ongoing oral
health, function, and esthetics.
Conclusion
This discussion has focused on short Acknowledgment
DMJOJDBM DSPXOT DPODVSSFOU XJUI FYDFT-
TJWF NBYJMMBSZ HJOHJWBM EJTQMBZ EVF UP The author would like to thank Professor
various soft and hard tissue anomalies. Khalid Almas for his participation in the
Apart from numerous mirroring condi- APE clinical case study.
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Altered Passive Eruption and Active Secondary Eruption

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Altered Passive Eruption and Active Secondary Eruption

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CLINICAL RESEARCH

Altered passive eruption (APE)

Correspondence to:*SGBO"INBE #%4

Abstract more, the differential diagnosis between

Introduction medication, or a coronal location of the

Keratinized gingiva (FGM Mucogingival junction – red

Biologic width (epithelial

Sulcus depth (FGM to Alveolar bone crest – yellow

CEJ (cementoenamel junction) – blue

Anatomical crown length

Biologic crown length

Fig 1 Dentogingival terminology.

Type 1 Type 2 Type 3

Alveolar compensation Overeruption with PG Extrusion

Fig 3 Active secondary eruption (ASE) classiﬁcation.

recession), where the tooth maintains its

Table 1 Differential diagnosis of APE and ASE

Short clinical Yes Yes (Type 1)

Long clinical No :FT 5ZQF

Tooth wear No Yes

Missing antago- No :FT 5ZQFTPS

CEJ location to Apical to FGM Normal parameters to FGM (Types 1

Alveolar crest /FBSFS$&+ 5ZQFT#BOE#

Keratinized gingi- 8JEF 5ZQFT"BOE#

Mucogingival "QJDBM 5ZQFT"BOE#

APE - altered passive eruption

are diagnosed when there are smaller Management of APE

el and dentin, depending on wheth- left central incisor, necessitating a full-

MBUFSBM JODJTPS BOE 5ZQF # PO UIF DB- NNNN

and 10). A chairside, correctly ﬁtting

Fig 14 (JOHJWFDUPNZPOUFFUIBOEQSJPSUP Fig 15 (JOHJWFDUPNZPOUPPUIUPJODSFBTFUIF

Case study 2: ASE line, lack of dominance of the central in-

attrition. In addition, cervical decay was

Fig 33 %JBHOPTUJDXBYVQBOETJMJDPOFJOEFYGPS Fig 34 &YJTUJOHDMJOJDBMDSPXOMFOHUIPGMFGUDBOJOF

Fig 35 Proposed clinical crown length of left ca- Fig 36 #POFTPVOEJOHPGNNGSPNUIF'(.UP

Fig 37 (JOHJWFDUPNZ VTJOH B /PD TDBMQFM Fig 38 5IFNNPGJODJTFEHJOHJWBJTSFNPWFE

Fig 46 Postoperative dentofacial view showing

Differential diagnoses of short clinical crown length –

"MMFO&14VSHJDBMDSPXO 1BTTJB/ #MJU[. 4USVC+3 .BDIBEP"8 .BVSP"16TF

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Long clinical No :FT 5ZQF

Missing antago- No :FT 5ZQFTPS

Alveolar crest /FBSFS$&+ 5ZQFT#BOE#

Keratinized gingi- 8JEF 5ZQFT"BOE#

Mucogingival "QJDBM 5ZQFT"BOE#

MBUFSBM JODJTPS BOE 5ZQF # PO UIF DB- NNNN

Fig 14 (JOHJWFDUPNZPOUFFUIBOEQSJPSUP Fig 15 (JOHJWFDUPNZPOUPPUIUPJODSFBTFUIF

Fig 33 %JBHOPTUJDXBYVQBOETJMJDPOFJOEFYGPS Fig 34 &YJTUJOHDMJOJDBMDSPXOMFOHUIPGMFGUDBOJOF

Fig 35 Proposed clinical crown length of left ca- Fig 36 #POFTPVOEJOHPGNNGSPNUIF'(.UP

Fig 37 (JOHJWFDUPNZ VTJOH B /PD TDBMQFM Fig 38 5IFNNPGJODJTFEHJOHJWBJTSFNPWFE

"MMFO&14VSHJDBMDSPXO 1BTTJB/ #MJU[. 4USVC+3 .BDIBEP"8 .BVSP"16TF