Treatment of the gingival smile: aesthetic coronary elongation by apical replacement flap.

gingival smile


Patient is 18 years old, systemically healthy, with no pathological history of interest and no known allergies. Go to the consultation for aesthetic reasons, to treat your gingival smile and solve the asymmetry between pieces 11 and 21. She is in good condition of oral and dental health. She’s recently finished his orthodontic treatment.

gingival smile


The etiological diagnosis revealed altered passive rash and mild lip hypermobility as causes of his gingival smile. The presence of vertical excess of the maxilla, dentoalveolar extrusion and short lip is ruled out as possible causes of his gingival smile. The LAC is located hidden under the gingival margin on all upper teeth. As for the aesthetic analysis, in addition to excessive exposure of gum in smile, the sizes and proportions of the upper front teeth were considered inadequate, and an asymmetry is observed between the sizes of the central incisors, with the most coronal gingival margin in tooth 11. The rest of the margins have good symmetry and harmony between them. Other aesthetic parameters, such as resting tooth exposure, the position of the incisal edges, and the color of the teeth, are considered appropriate.


In order to improve the aesthetics of the smile, the patient is asked to treat the altered passive rash by means of an apical repositioning flap, correcting the 11-21 asymmetry by gingivectomy. Likewise, the treatment of lip hypermobility is considered through the administration of botulinum toxin by a specialist in aesthetic medicine, or through a lip replacement technique. The patient decides to perform only the apical repositioning flap, understanding that this will solve the asymmetry and improve tooth sizes and proportions, but it will not completely solve the excessive gum exposure in maximum smile.

Description of the procedure
The apical replacement flap was made only on the vestibular aspect, so a palatine flap was not raised. Under infiltrative local anesthesia, the paramarginal incision was designed in tooth 11 with a periostotome. Once verified, the 45-degree internal bezel paramarginal incision was made with a micro-photurí blade and the gum impeller was removed. Then, full thickness intrasulcular incisions were made and a mucoperiosteal flap was raised above the mucogingival line to give mobility to the flap and allow its apical repositioning. The ostectomy was performed with a multiplier counter-angle and a cylindrical cutter with cutting capacity only at the tip, flat in shape. The ostectomy was then reviewed with a chisel, beveling the marginal bone to avoid excessive thickness that could promote a coronal migration of the gingival margin during healing. A distance of 3 mm between the LAC and the marginal bone was left for the re-establishment of biological width at the cervical level. In the interproximal locations a distance of 3 mm was also left, performing interproximal ostectomy – when necessary – with a 15C scalpel blade used as a microsel. The osteroplasty was performed with a multiplier counter-angle and a round diamond and long stem cutter. The vestibular bone contour was redefined, especially in the posterior sectors, eliminating bone prominences typical of cases of altered passive eruption, establishing a harmonic vestibular contour and giving visibility to root prominences. Finally, the flap was apically repositioned, making the gingival margins coincide with the LACs, and it was sutured with vertical dentate mattress stitches.


During the first 10 months of follow-up, good stability in the position of the gingive margins is observed. The result of the treatment was satisfactory for the patient even though the resolution of her gingival smile is not complete.

gingival smile


The gingival smile usually presents a multifactorial etiology, with dental causes, such as altered passive eruption, skeletal causes, such as maxillary vertical excess and dentoalveolar extrusion, and muscular causes, such as hypermobility of the upper lip or short lip. Therefore, the management of the gingival smile requires an etiological diagnosis and an adequate aesthetic analysis to orient the treatment and expectations of the patient towards realistic goals.

When the gingival margins have adequate and harmonic scalloping, we can take advantage of this circumstance to simplify the coronary elongation surgical procedure. One of the points that requires greater surgical prowess in this type of interventions is the realization of paramarginal incisions. The apical replenishment flap can function as a simpler alternative, avoiding paramarginal incisions or making them only in asymmetrical locations. Proper bone surgery is crucial to allow the restoration of biological width at the cervical level and its long-term stability.

In this case the different aesthetic defects of the smile identified in the diagnosis were resolved in a single surgical procedure: excessive gingival exposure in smile, asymmetry, sizes and inadequate tooth proportions. The postoperative period developed without incident and the results were satisfactory to the patient, observing good stability over time, without variations in the position of the gingival margin.



Please accept the Terms and Conditions to proceed.