CASE REPORT
Section: Dentistry
www.ijcmr.com
Altered Passive Eruption: Periodontal Surgical Management of Two
Cases
Radia Hamdoun1, Oum Keltoum Ennibi2, Zouhir Ismaili3
Type 2: Normal height of keratinized tissue, but all the gum
ABSTRACT is on the dental crown and the mucogingival line is on the
Introduction : Altered passive eruption is a condition in same level as the cementoenamel junction.
prominence rather than at the cementoenamel junction. It’s a In 1996, Garber and Salama2,5 established a nuance in this
developmental anomaly clinically associated with a gingival classification, based on the distance between the top of the
smile with short, square teeth. Difficult to detect, most of these crestal bone and the cementoenamel junction, by subdividing
cases are often overlooked or misdiagnosed it into two types:
Case report: This work highlights the clinical presentation
of altered passive eruption of two cases along with sequential Subcategory A: Distance between crestal bone and
approach for management of each condition. The follow-up cementoenamel junction is greater than 1 mm.
was 12 months.
Subcategory B: Distance between crestal bone and
Conclusion: Altered passive eruption presents a great
challenge for the practitioner with regards to both diagnosis cementoenamel junction is less than 1 mm.
and therapeutic management. The practitioner must make the This classification is essential when selecting a therapeutic
right diagnosis, establish an appropriate treatment plan, and procedure (Table 1). The practitioner must make the right
discuss the various therapeutic possibilities with the patient in diagnosis, establish an appropriate treatment plan, and
order to satisfy their esthetic request. discuss the various therapeutic possibilities with the patient
in order to satisfy their esthetic request. Periodontic plastic
Keywords: Altered Passive Eruption, Esthetic, Gingival, procedures offers the best solution by eliminating the excess
Periodontal Surgery
of gingiva and enhancing the gingival esthetics.6 The aim
of this article is to expose, through two clinical cases, the
periodontal management of altered passive eruption using
INTRODUCTION two different techniques.
Esthetic requests have become an increasingly common reason CASES REPORT
for consultation at the dentist. A smile must have a certain
number of parameters to be considered esthetic. Altering one Case 1:
of these parameters can be a source of disharmony, making A 28-year-old patient in good general health was attended the
the smile unsightly; such is the case in certain situations Department of Periodontology complaining of an unsightly
with the gingival smile. A smile is considered gingival if smile. Examination of the smile revealed a high smile line
a wide gum line (> 3 mm) is exposed during a restrained (Fig. 1). Intraoral physical examination showed the presence
smile.¹ Gingival smile has many etiologies, including short of a high height of keratinized tissue (> 3 mm) as well as short,
lip, significant vertical maxillary growth, and/or significant square teeth (Fig. 2). Radiographic examination showed a
gingival growth.¹ One cause that is often overlooked is normal distance between the cementoenamel junction and
incomplete or altered passive eruption. Altered passive the top of the crestal bone (Fig. 3). A type 1A altered passive
eruption (APE) is attributable to a developmental anomaly 1
Specialist in Periodontology Department of Periodontology,
during the passive phase of eruption and alters several smile
Institution: Faculty of Dental Medicine, Mohammed V University
parameters, making the smile unsightly.²,³ Goldman and in Rabat, Morocco, 2Specialist in Periodontology, Professor,
Cohen (1968) defined altered passive eruption as a situation Department of Periodontology Institution: Faculty of Dental
in which “the gingival margin in the adult is located incisal Medicine, Mohammed V University in Rabat, Morocco, 3Specialist
to the cervical convexity of the crown and removed from in Periodontology, Professor, Department of Periodontology.
the cementoenamel junction of the tooth” instead of being Institution: Faculty of Dental Medicine, Mohammed V University
located 1 or 2 mm from the cementoenamel junction, as it in Rabat, Morocco.
would be normally. The result is a short clinical crown with
Corresponding author: Dr. Radia Hamdoun, Department of
a square appearance.2,3
Periodontology, Faculty of Dental Medicine, Mohammed V
In 1977, Coslet et al. classified APE into two types based
University, Institute Rabat, Rabat, Morocco
on the location of the mucogingival line with respect to
the crestal bone in other words, related to the height of the How to cite this article: Radia Hamdoun, Oum Keltoum Ennibi,
keratinized tissue.2,4 Zouhir Ismaili. Altered passive eruption: periodontal surgical
management of two cases. International Journal of Contemporary
Type 1: High height of keratinized tissue; in this case, the Medical Research 2019;6(12):L1-L4.
mucogingival line is positioned very apically with respect to
the crestal bone. DOI: http://dx.doi.org/10.21276/ijcmr.2019.6.12.5
International Journal of Contemporary Medical Research L1
ISSN (Online): 2393-915X; (Print): 2454-7379 | ICV: 98.46 | Volume 6 | Issue 12 | December 2019
Hamdoun, et al. Altered Passive Eruption: Periodontal Surgical Management
Section: Dentistry
eruption was diagnosed. Treatment involved an internal Radiographic examination showed a proximity between the
bevel gingivectomy to remove the surplus keratinized tissue. top of the crestal bone and the cementoenamel junction (Fig.
After local anesthesia, an internal bevel incision was made 8). Clinical and radiological signs confirmed the etiology
following the line of gingival festoons, and intrasulcular of APE type 1B. Treatment first involved removing excess
and horizontal incisions were made to detach the coronary keratinized tissue by external bevel gingivectomy (Fig. 9).
gingival band and increase coronal height. At one week after After healing and removal of the multi-bracket appliance, an
the procedure, the patient had a harmonious and esthetic apically displaced flap procedure was performed, followed
smile (Fig. 4 and 5).The patient is seen regularly for control by a bone resection, due to the persistent short and square
sessions. appearance of the teeth in addition to a slight gingival smile
Case 2: (Fig. 10, Fig. 11, Fig. 12). The patient was satisfied with the
A 24-year-old patient in good general health was referred end result. Periodontal maintenance sessions were set up
by the Department of Dentofacial Orthopedics for a gummy with the patient (Fig. 13).
smile (Fig. 6). Clinical examination showed the presence of DISCUSSION
increased gingival height, short and square teeth (Fig. 7).
Passive eruption is a normal phase of dental eruption in
which the gingival margin migrates apically to its normal
Diagnosis Treatment position; otherwise, the tooth remains partially covered by
Altered Passive Eruption 1A Gingivectomy the gum. It is in this scenario that we speak ofAPE, but from
Altered Passive Eruption 1B Gingivectomy + Bone Resection what age can we start talking about it? Morrow et al. (2000)
Altered Passive Eruption 2A apically displaced flap conducted a study on 1,018 individuals aged 11-12 years at
Altered Passive Eruption 2B apically displaced flap + Bone baseline, who were monitored up until 18-19 years of age.
Resection
They noted that the height of the clinical crown continued to
Table-1: The Treatment of APE according to its classification
1 2
3 4
5
Figure-1: Initial smile of the patient; Figure-2: Preoperative view; Figure-3: Retro-alveolar X-ray showing a normal distance between
the cemento-enamel junction and the vertex of the bony; Figure-4: Gingivectomy and repositioning of the flap; Figure-5: Final result
(1 year)
L2
International Journal of Contemporary Medical Research
Volume 6 | Issue 12 | December 2019 | ICV: 98.46 | ISSN (Online): 2393-915X; (Print): 2454-7379
Hamdoun, et al. Altered Passive Eruption: Periodontal Surgical Management
Section: Dentistry
6 7
8 9
10 11
12 13
Figure-6: Initial smile of the patient: sourire gingival; Figure-7: Preoperative view; Figure-8: Preoperative retro-alveolar X-ray; Figure-9:
External bevel gingivectomy; Figure-10: Persistence of the short and square appearance of the teeth after; Figure-11: Flap elevation and
bone resection; Figure-12: Repositioning of the flap and sutures; Figure-13: Final result (1 year)
increase until patients reached 18-19 years of age, at which smiling.
time it stabilized.7 Therefore, it is only from 18-19 years of The next step is to measure the clinical crowns in order to
age that an APE diagnosis can be made. Before this age, the assess their dimensions while looking for short and square
passive phase of the dental eruption is considered not yet teeth. Several articles have studied the dimensions of clinical
crowns in permanent dentition.8,9 In their studies of facial
complete and the gingival margin situation is not stable.
esthetics, Ward concluded that the width-to-length ratio is
In order to diagnose an APE, we start with an extra-oral
the most reliable measure for indicating the ideal size of
examination, which includes an assessment of the symmetry a clinical crown. The ideal length-to-width ratio is 0.75 to
and height of the face, smile line, and lip height and mobility. 0.8.8,9
The average height of the maxillary lip at rest is 20 to 22 Subsequently, a more in-depth examination of the
mm in women and 22 to 24 mm in men.² The shorter the periodontium is performed (height of the keratinized
upper lip, the more the maxillary teeth will be exposed when gingiva, probing depth, irregular gingival festoons, etc.).15
International Journal of Contemporary Medical Research L3
ISSN (Online): 2393-915X; (Print): 2454-7379 | ICV: 98.46 | Volume 6 | Issue 12 | December 2019
Hamdoun, et al. Altered Passive Eruption: Periodontal Surgical Management
Section: Dentistry
The cementoenamel junction (CEJ) is normally apical to Periodontol. 2014; 18:488-92.
the gingival margin of the crown. Sulcus depth is usually 2. Mele M, Felice P, Sharma P, Mazzotti C, Bellone P,
2 to 3mm. If this junction is located in a normal position in Zucchelli G. Esthetic treatment of altered passive
the gingival sulcus, the patient does not have an APE. If the eruption. Periodontol 2000. 2018; 77:65-83.
3. Alpiste-Illueca F. Altered passive eruption (APE): a
CEJ is not detectable in the sulcus, an APE diagnosis can
little known clinical situation. Med Oral Patol Oral Cir
be made and the top of the crestal bone is then identified.2,10
Buccal. 201; 16:e100–e104.
The top of the crestal bone is identified by a probe through 4. Coslet GJ, Vanarsdall R, Weisgold A. Diagnosis
the attachment system once the site is anesthetized, or by and classification of delayed passive eruption of the
performing a retro-alveolar X-ray using the parallel planes dentogingival junction in the adult. Alpha Omegan.
technique.2,10 A height of 2 mm must be found between the 1977; 10:24–28.
top of the crestal bone and the CEJ junction; this is the case 5. Garber DA and Salama MA. The esthetic smile:diagnosis
in subcategory A. When the summit of the crestal bone is and treatment. Periodontol 2000. 1996; 11:18–28.
at the same level as the cementoenamel junction, this is 6. Cairo F, Graziani F, Franchi L, Defraia E, Pini Prato
subcategory B. GP. Periodontal plastic surgery to improve aesthetics in
In the case 1, patient showed APE type 1 because she had patients with altered passive eruption/gummy smile: A
an increase in gingiva when free gingiva from mucogingival case series study. Int J Dent. 2012; 2012:837658.
7. Morrow LA, Robbins JW, Jones DL, Wilson NHF.
junction was measured. The subcategory was A because
Clinical longitudinal changes fromage 12–19 years: a
the presence of a normal distance between the CEJ and
longitudinal study. J Dent. 2000; 28:469–73.
the top of the crestal bone. In the clinical case 2, patient 8. Ward, D. H. A study of dentists’ preferred maxillary
showed APE classified as type I, because she had an increase anterior tooth width proportions: comparing the recurring
of gingival height, short and square teeth. Her condition was esthetic dental proportion to other mathematical and
subclassified as subgroup B because a proximity between the naturally occurring proportions. J Esthet Restor Dent.
top of the crestal bone and the cementoenamel junction was 2007; 19, 324–37.
shown. 9. Melo M, Ata-Ali F, Huertas J, Cobo T, Shibli J A et al.
The fact that there are many clinically similar etiologies of Revisiting the Maxillary Teeth in 384 Subjects Reveals
the gingival smile can lead to confusion for practitioners. A Deviation From the Classical Aesthetic Dimensions.
Hence, the advantage of knowing all the etiologies of the Sci Rep. 2019; 9-730.
10. Nart J, Carrió N, Valles C, Solís-moreno C, Nart m,
gingival smile, their clinical manifestations, and the elements
Reñé R and et al. Prevalence of altered passive eruption
that allow us to differentiate them from one another.2,11
in orthodontically treated and untreated patients. J
Treatment options for APEs depending upon the diagnosis Periodontol. 2014; 85:e348-353.
can be selected.2,11 Periodontal treatment of an APE is 11. Ahmad I. Altered passive eruption (APE) and active
surgical, and relies on a crown lengthening performed via secondary eruption (ASE): differential diagnosis and
gingivectomy or apically displaced flap procedure (if the managment. Int J Esthet Dent. 2017; 12:352-76.
initial keratinized gingiva is not enough) to remove excess 12. Marzadori M, Stefanini M, Sangiorgi M, Mounssif
tissue and reconstruct the anatomical shape of the dental I, Monaco C, Zucchelli G. Crown lengthening and
crowns.2,11,12 When the bone crest is less than 3 mm distant restorative procedures in the esthetic zone. Periodontol
from the CEJ, it is necessary to perform bone resection by 2000. 2018; 77:84-92.
osteotomy to recreate a biological space compatible with
periodontal health.11,12 In some cases, treatment of APE Source of Support: Nil; Conflict of Interest: None
involves a prosthesis or an orthodontic forced eruption.2,11,12 Submitted: 30-10-2019; Accepted: 25-11-2019; Published: 15-12-2019
In the first case, the appropriate treatment was crown
lengthening with mucoperiosteal flap through internal-
beveled, due to the large amount of keratinized gingiva to
remove excess keratinized tissue and restore an adequate
shape to the gingival margin. In the second case, the
gingivectomy was associated with a bone resection by
osteotomy to recreate the necessary biological width.
The management of gingival smile related to an APE
presents a real challenge for the practitioner which must
know the various signs of APE in order to make the correct
diagnosis and establish an appropriate treatment plan to meet
the esthetic request of the patient.
REFERENCES
1. Sepolia S, Sepolia G, Kaur R, Gautam DK, Jindal V,
Gupta SC and et al. Visibility of gingiva – An important
determinant for an esthetic smile. J Indian Soc
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International Journal of Contemporary Medical Research
Volume 6 | Issue 12 | December 2019 | ICV: 98.46 | ISSN (Online): 2393-915X; (Print): 2454-7379
