Esthetic Crown Lengthening with Reverse Vestibuloplasty
Use of laser therapy aids in reducing excessive gingival display to help create an esthetic smile.
By Edward Kusek, DDS
Optimizing the esthetic outcome for patients requires a multidisciplinary approach. Sophisticated patients want their dental concerns treated without the appearance of any restoration. This case presentation describes the planning and treatment steps for the creation of an esthetic smile with the use of laser technology. Smile design should involve the evaluation of certain elements in a specific sequence:
1. Facial analysis.
2. Dento–facial analysis (maxillofacial–mandibular relationships to the face and the dental midline relationship to the face).
3. Dento–labial analysis (the relationship of the teeth to the lips).
4. Dento–gingival analysis (the relationship of the teeth to the gingiva).
5. Dental analysis (the intertooth and intratooth relationships, ie, form and position with color).1
The smile analysis evaluation should begin with the observation of the facial elements. Guidelines should be followed for facial form and balance that can be affected by dental treatment. Regardless of how attractive the teeth appear, if they do not relate spatially to the facial structures, the result will be unesthetic.2
This article describes the use of esthetic crown lengthening, alterations of tooth position, and the use of reverse vestibuloplasty to reduce excessive gingival display aided by the use of laser therapy. The patient was a 20-year-old woman who was dissatisfied with her excessive gingival display. She had completed orthodontics 3 years prior, and she and her family were not interested in orthognathic surgery. Upon observation, the patient’s teeth were found to be abnormally short, thus causing her gingiva to appear to be a more dominant feature. Her midline was correct and occlusion was in Class I. After initial consultation, the following dental records were taken: Panorex, periodontal probing, maxillary and mandibular impressions, 12-shot photographs per the American Academy of Cosmetic Dentistry (AACD), and facebow. The patient and her family were asked to return in a few weeks to have the case presented to them, as the author perceived it could be resolved.
The first step in treatment planning was to send the study models outlining where the author wanted to place the dental–gingival margins that would correctly fit the facial dimensions. Several studies have confirmed that an ideal tooth proportion is approximately 80% (width/length) within maxillary anterior dentition.1 This 80% tooth proportion value allows one to mathematically determine objective measurements when re-establishing the tooth width and length relative to the gingival architecture of the supporting periodontal tissues.3
Once the esthetic wax-up was received from daVinci Dental Studios (www.davincismile.com), photographs were taken of the wax-up so the author could Photoshop the teeth into the patient’s dental arch. These photographs would be presented in the consultation as a possible stopping point if the patient so desired. Finally, the patient’s photographs were Photoshopped again to show what could happen if a reverse vestibuloplasty (lip tuck) was completed.
After presenting all of the options to the patient and both of her parents, it was concluded that they were interested in the entire treatment. They were informed of the costs, as well as time involvement, postoperative care, and the progressive steps necessary to accomplish the treatment.
Excessive gingival display (gummy smile) can be a major cause of patient embarrassment. In a gummy smile, the gingiva is the dominant feature when compared to the lips and teeth. Normal gingival display is limited to the region between the inferior border of the upper lip and gingival margin of the anterior central incisors during a smile. In contrast, a gingiva-to-lip distance of 4 mm or more, known as a “gummy smile,” is classified as unattractive.4
Excessive gingival display has four possible etiologies.5 First, it may be a result of delayed eruption in which the gingiva fails to complete the apical migration over the maxillary teeth to a position that is 1 mm coronal to the cemento–enamel junctions (CEJs). In these patients, restoring the normal dento–gingival relationships can be achieved with esthetic crown lengthening. The procedure involves moving the gingival margins apically through soft and hard tissue manipulation.
The second possible cause is compensatory eruption of the maxillary teeth with coronal migration of the attachment apparatus, which includes the gingival margins. Orthodontic leveling of the gingival margins of the maxillary teeth may be considered in this possibility. Resective surgery is also possible but may expose the narrow root surface and necessitate a restoration.
The third possibility is vertical maxillary excess, in which there is an enlarged vertical dimension of the midface and incompetent lips. Treatment involves orthognathic surgery to restore normal inter-jaw relationship and to reduce the gingival display. This involves hospitalization and significant side effects for patients.
Finally, when the patient smiles, if the upper lip moves in an apical direction and exposes the dentition and excessive gingival tissue, then surgical lip repositioning may be utilized to reduce the labial retraction of the elevator smile muscle and minimize the gingival display. This case followed this category.5
Surgical crown lengthening in periodontally healthy patients has traditionally been performed to re-establish the biologic width of the dentogingival complex.6 Several authors have suggested that a minimum of 3 mm of supracrestal tooth structures be obtained during surgical crown lengthening7-9
The first stage of treatment consisted of esthetic crown lengthening with the use of an Ir;Cr:YSSG laser (Biolase Technology, www.biolase.com) to aid in completion. During the preliminary examination, the patient was found to have a thick biotype (Figure 1). The zone of attached keratinized gingival tissue was broad. Based on the patient’s dental–facial analysis, it was determined that approximately 3.5 mm of tissue should be reduced. It was estimated the patient had 8 mm of attached tissue in the area from teeth Nos. 6 to 11. Removing 3.5 mm of attached tissue in this area would leave 0.5 mm of tissue recession after surgery, thus leaving around 4 mm of attached tissue in this area for esthetics and enough tissue to suture to for the lip tuck procedure. Surgical crown lengthening in periodontally healthy patients has traditionally been performed to re-establish the biologic width of the dento–gingival complex (DGC) as an adjunct to esthetic restorative procedures. This would expose dentition past the CEJ and require the placement of eight porcelain veneers to gain proper clinical length.
The use of the YSGG laser aids in the healing of the hard and soft tissues and decreases the postoperative swelling and pain associated with this surgery.10 The ability to complete surgery and, during the same appointment, prepare the teeth for porcelain veneers, saves time for the patient and the clinician. Traditional methods would delay this process by 3 months or more.
Surgical Treatment Phase
The first surgical appointment was done with the use of IV sedation. Venipuncture was accomplished in the right antecubital fossa. Intravenous sedation was performed to produce a mildly sleepy state. The drugs used were Versed, Nubain, and Benadryl. On completion of the sedation, dexamethasone, Depo-Medrol (IM), and cefazolan were given, along with a local anesthetic consisting of 20 mg of lidocaine with 10 mcg of epinephrine and 5 mg of Marcaine with 5 mcg of epinephrine. A surgical stent was used from pre-determined measurements of the extent of tissue to be removed. Tissue was removed with the use of a Waterlase MD gold handpiece (Biolase Technology) with tip length and width of 6 mm and 500 µm in diameter. The setting used to remove the tissue was 1.25 W 30 Hz 5/14 (water/air pressure). The area was outlined first by de-epithializing the tissue (laser used in a defocused mode without use of water), which forms a white patch where the laser energy has been placed without actually vaporizing any tissue (Figure 2); thus, if the outline is not exact, all that is needed to do is to rehydrate the tissue and change the outline with new laser energy. The heat produced while de-epithializing the tissue is approximately 60ºC. After the removal of the desired amount of tissue (Figure 3), the symmetry of adjacent teeth to the height of their tissue contours was checked (Figure 4). The sulcus depth was then sounded with a periodontal probe (Figure 5).
As discussed previously, the goal is to achieve 3 mm of sulcular depth. Laser energy was then increased to 2.0 W 30 Hz 21/51 to remove bone from the alveolar crest to allow correct sulcular depth (Figure 6). The tip length was 9 mm and the diameter was 600 µm in diameter. It is important to point the laser energy parallel to the root surface to prevent any notching or cutting of the root surface. To remove any sharp spicules from the trimmed ridge, a curette was used to polish the bone and feather-edge it to prevent any troughing of the bone (Figure 7). After finishing the case, the tissue was de-epithialized with the laser at the setting of 1.0 W 20 Hz 0/14. This causes slight potholes in the tissue to increase vascularization, which, in turn, increases the healing process.11-13 Biostimulation (Laser Smile, Biolase Technology) was done under pulsating mode with 1.5 W 30/30 for 30 seconds. Using biostimulation allows the cells to repair themselves quickly and reduces histamine release.14-17
The patient did not like the appearance of her teeth. Teeth Nos. 6 and 11 were rotated. Teeth Nos. 7 through 10 had lingual inclinations, thus providing an unesthetic smile. These considerations were discussed at the initial consultation, as was the need to correct these problems with porcelain veneers.
Teeth were prepared to receive feldspathic veneers (daVinci Dental Studios); an Expasyl™ (Kerr Corporation, www.kerrdental.com) retraction system was placed gently into the newly formed sulcus (Figure 8) and rinsed, and an impression was taken with Aquasil™ (DENTSPLY Caulk, www.dentsply.com) material. Temporaries were achieved by etching a small area of each tooth with laser energy 1.25 W 20 Hz 7/14 and then application of S&E bonding agent (Kuraray Dental, www.kuraraydental.com) to each of the lased areas. Luxatemp™ (DMG America, www.dmg-america.com) material was used with the construction of a putty stent that was fabricated by the wax-up (Figure 9) completed by daVinci Dental Studios. This would give the patient a chance to view the shape and estimated color of the veneers (which can be altered prior to completion of the final veneers). The bite was adjusted, the surface of the temporary veneers was polished (Figure 10), and a composite sealer (OptiGuard™, Kerr Corporation) was applied to maintain color and give appropriate glaze. Postoperative instructions were given to the patient and her driver for care of the temporary restorations. Analgesics provided were Darvocet N-100 12 tabs Q 4 to 6h prn dental pain and the use of peroxide and water in a 50/50 mixture.
The healing process was uneventful; slight adjustments were made to lateral incisors per the patient’s request (Figure 10). The veneers were seated 3 weeks later with local anesthetic only, 4 cc of 20 mg lidocaine with 10 mcg of epinephrine, and 4 cc of 5 mg Marcaine with 5 mcg of epinephrine. After removal of the temporaries with a scaler, the surface was cleaned with peroxide and water and re-etched with the laser as described above, but this time the etching was applied to the entire surface of the tooth that was to receive the veneer. New silane agent was applied to the etched surface of the veneer. Cementation was achieved using Ensure clear (DeltaMed, www.deltamed.de) with S&E bonding agent. The bite was adjusted where needed and the surfaces were polished with a porcelain polishing kit (Brassler USA, www.brasselerusa.com) and a diamond polishing paste (Diamond Twist, Premier Dental, www.premusa.com). At this appointment, impressions were taken for the fabrication of a Proform Niteguard (Dental Resources, www.dental-resources.com) to prevent any parafunctional dysfunctions for nighttime use. The patient was scheduled for an occlusal check in 2 weeks, along with final photographs of the veneer seating and to re-determine the extent of reverse vestibuloplasty that would need to be accomplished.
The second surgery was scheduled 2 months after seating the veneers to allow the attached tissue to heal. This surgery was done under IV sedation, as discussed previously, with the same drugs used during the first surgery. An indelible pencil was used to outline the area of tissue to be removed (Figure 11). The area consisted of 4.5 mm in width to be removed with laser settings of 1.75 W 20 Hz 7/14 ( Figure 12 and Figure 13). The extension of the resection was from first bicuspid to first bicuspid (Figure 14). The tissue was scored and a band of tissue with higher wattage (2.0 W 30 Hz 7/14) was necrotized to create a zone of scar tissue that would prevent the tissue from pulling back to its original position (Figure 15). The area was then sutured with the use of 4.0 vicryl, while making sure the midline was correct and that facial symmetry was maintained. The area was de-epithialized with an YSGG laser to aid in the healing process and followed with the use of biostimulation, both as described previously. Medications prescribed were Maxodone for the analgesic and dexamethasone for prevention of swelling. Postoperative instructions were given to the driver along with written instructions for the patient, who was seen in 1 week for a postoperative check (Figure 16). At this appointment the patient’s smile showed symmetry, and correct height of tissue was exposed upon a full smile. Sutures were removed at the second week with excellent healing. Figure 17 shows a full facial view of the completed results after 1 month of healing.
Dentistry can be a life-changing process, as evidenced with this young patient. At the outset she was afraid to open her mouth to expose her unusual display of gingival tissue, which, in turn, affected her self-confidence. In the end, the patient altered her facial presentation to improve her self-confidence, a metamorphosis that occurred in only 3 months. The pre-planning of the case allowed for easy completion, and the patient understood how the treatment sequence would sequentially change her appearance. Laser technology made the entire process faster to accomplish, with minimal postoperative discomfort.
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About the Author
Edward Kusek, DDS, Private Practice, Sioux Falls, South Dakota, Adjunct Professor, University of South Dakota, Sioux Falls, South Dakota