·       CEJ: This is visualized directly when there is gingival recession, however, it can be located subgingivally using the periodontal probe or an explorer.

·       Alveolar Crest: Direct bone level (DBL) measurement obtained after reflection of the surgical flap is considered the most accurate method and the gold standard for detecting the location of the alveolar crest. However, it is an invasive procedure that causes discomfort to patients and may not always be applicable in the pre-surgical planning and diagnosis phases.

Photographs

The series of extraoral and intraoral pre-surgical photographs is taken of the patient:

·       Extraoral: Frontal at rest (Figure 2), Frontal with a wide smile (Figure 3), Lateral right and Lateral left (Figure 4).

·       Intraoral: Frontal (Figure 5), Upper Occlusal and Lower Occlusal (Figure 6), Right Lateral and Left Lateral (Figure 7).

Classification

For this clinical case, it was decided to opt for the modified classification of Ragghianti, in 2016 (7). Where the altered passive eruption is accompanied by the altered active eruption, complementing the Colset classification.

Where the thickness of the gingiva is maintained in Type I and Type II, it is classified as altered passive eruption alone or is supplemented by altered active eruption. Highlighting as follows:

·       Keratinized gingiva >2mm with a distance of 1.5mm from the cemento-enamel junction (CEJ) to the alveolar crest. (Type I, altered passive eruption alone).

·       Keratinized gingiva ?2mm with a distance of 1.5mm from the cemento-enamel junction (CEJ) to the alveolar crest. (Type II, altered passive eruption alone).

·       Keratinized gingiva >2mm with insufficient distance from the cemento-enamel junction (CEJ) to the alveolar crest. (Type I, altered passive eruption accompanied by altered active eruption).

·       Keratinized gingiva ?2mm with insufficient distance from the cemento-enamel junction (CEJ) to the alveolar crest. (Type II, altered passive eruption accompanied by altered active eruption).

Decision making

Classifying the patient as: Keratinized gingiva >2mm (Figure 8) with insufficient distance from the cemento-enamel junction (CEJ) to the alveolar crest. (Type I, altered passive eruption accompanied by altered active eruption). It was decided to make internal bevel incisions modifying the future gingival contour plus bone resective surgery to restore the measurements of the supracrestal insertions.

Surgical Procedure

Bleeding Points (Bone Probing): The esthetic crown lengthening procedure has traditionally been guided on the basis of clinical evaluation of parameters by direct visual assessment and bone probing [8]. We perforated the gingival tissues, at the zenith according to the dental piece, with a periodontal probe (Hu-Friedy /CP15), thus creating bleeding points (Figure 9). It was performed with a periodontal probe (Hu-Friedy /CP15) and the points were connected in a scalloped form (15c scalpel).

These points are then connected in a scalloped form (15c scalpel) to represent the future gingival contour of all the teeth to be treated (pz # 15 to 25) (Figure 10). The internal bevel technique at 45° of the scalpel blade was used, subsequently, the soft tissue was removed with a universal curette (Hu-Friedy), all this preserving the interdental papillae.

Intrasulcular incisions were made to raise a full-thickness flap, without exceeding the mucogingival line, using a 2-9 molt curette (Supremo) (Figure 11).

To preshape bone recontouring (ostectomy and osteoplasty), leaving the bone crest 2 to 3 mm from the newly outlined gingival margins and thus limiting the amount of gingival rebound. The amount of bone resection should be gradually reduced with a high powered turbine and burs intended for gingival lengthening, towards the line angles to avoid loss of interdental bonding and black triangles (Figure 12).

We finished the surgery by repositioning the flap and making sutures. A vertical mattress was placed on the interdental papilla of the incisors, while suspensory stitches were made in the other areas (Nylon 5.0 suture thread) (Figure 13).

Post-surgical measures: The patient was prescribed 0.12% chlorhexidine (Encident) as a rinse for 15 days until the stitches were removed. Suspension of tooth brushing in the area. A non-steroidal anti-inflammatory drug (sodium naproxen, 550mg, every 12h x 3 days) and an analgesic (paracetamol, 1g, every 12h x 3 days) were also prescribed.

Results

Stitches were removed 15 days after surgery without incident (Figure 14). The last photograph of the post-surgical patient was taken, evidencing the change and improving the proportion of the dental pieces (Figure 15).