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Photos: Dr. Richard Amato
Creating a balanced and aesthetically pleasing smile is an intricate process that involves precise attention to the ratios of teeth, gingival architecture, and buccal corridors. A harmonious smile not only enhances facial aesthetics but also contributes to overall confidence and well-being of our patients. In the realm of cosmetic dentistry, tools like lasers have made procedures like gingivectomy more accessible and efficient for dental providers. Laser Gingivectomy, also known as Laser Gingival Recontouring is a remarkable and minimally invasive procedure to treat areas that have inadequate tooth height due to pseudo-pockets or gingival overgrowth. However, while this procedure can yield remarkable results in some cases, it can also lead to complications if not performed with proper prior evaluation and diagnosis. The key to differentiating between success and failure lies in understanding the concept of biologic width. This critical aspect dictates whether a simple Laser Gingival Recontouring or a more complex Aesthetic Crown Lengthening, a surgical procedure that removes both boney hard tissue and soft tissue, is necessary for achieving optimal results.
Diagnosis and Evaluation
The cornerstone of any successful dental procedure, particularly full mouth, full-arch, esthetic procedures, is accurate diagnosis and comprehensive evaluation. Smile design goes beyond surface structure aesthetics; it requires understanding of the underlying bone and how the interplay of tooth structure, gum, and bone contributes to the final treatment plan and outcome. Periodontal charting, radiographic analysis, tissue biotype analysis, smile shape and harmony analysis are all essential steps in this process. A thorough assessment allows the clinician to determine the most appropriate treatment path. Central to this evaluation is the concept of biologic width, which is the distance established by the junctional epithelium and connective tissue attachment to the root surface of a tooth, the height between the deepest point of the gingival sulcus and the crest of the alveolar bone. The average biologic width is 2.04 mm, but it can range from 0.75 to 4.3 mm depending on the patient. So what does this mean? In laymen’s terms it is how much gum the body needs to have on top the of the bone. If the body needs 3 mm of gum above the bone and the gum is trimmed leaving only 1mm the body will rebound and regrow that gum. This is why bone needs to be removed in some cases to have the gum line remain in both a stable and desirable position. Evaluation of the biologic width as well as gingival phenotype will determine viable treatment options. Respecting this space is crucial to prevent adverse outcomes, such as gingival rebound, where the body attempts to re-establish its natural anatomy. Simply put if the gum is trimmed causing the edge of the gingival margin to be too close to the crest of bone it will grow back to reestablish this biologic width distance. If biologic width is violated during a laser gingivectomy, and restorative materials like veneers are placed within this zone, the initial results may appear stunning. However, over time, the body’s attempt to restore biologic width can result in compromised aesthetics and function, with results ranging from bone loss around teeth to inflamed red gingival margins or in some cases even the development of granulation type tissue around the veneer margins. Correct diagnosis and holistic understanding are key to successful outcomes.
Beyond Gingivectomy and Crown Lengthening
In some cases, patients present with challenges that extend beyond what gingivectomy or crown lengthening alone can address. For instance, gummy smiles in patients with already properly portioned teeth will not benefit from removing gum. In these scenarios a full-face proportion analysis will often point to maxillary excess. Cases of maxillary excess, where the upper jaw is disproportionately long, collaboration with an Oral Maxillofacial Surgeon and Orthodontist are necessary. The oral surgical team can surgically reduce the vertical dimension with orthognathic surgery and the orthodontic team can ensure proper tooth position throughout the process (Fig. 2). Every case demands a thorough analysis of the patient's facial structure, including the upper, midface, and lower face, as well as the gingival and tooth support structures. A comprehensive evaluation allows dental teams to work together across specialties, combining their expertise to develop a treatment plan that meets patients’ needs and expectations. A team approach ensures all aspects of patients’ smiles are considered, leading to an optimal and sustainable results.
Crown lengthening and gingivectomy are powerful tools in the pursuit of an ideal smile, but their success depends heavily on proper evaluation, diagnosis, and interdisciplinary collaboration. Understanding the critical role of biologic width is essential in determining the appropriate treatment for each patient. While lasers have simplified procedures like gingivectomy, they must be used with caution to avoid compromising long-term results. In cases where gingivectomy or crown lengthening alone is insufficient, additional treatments such as orthodontics and orthognathic surgical intervention may be necessary to achieve the desired outcome. By adopting a comprehensive, team-based approach to smile design, dental professionals can provide patients with results that are not only aesthetically pleasing but also functionally sound and sustainable.
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