3D-printed PMMA implant for gingival smile treatment through the VISTA technique: A report of a new approach.

BACKGROUND: A gingival display higher than 3 mm is considered a characteristic of a gingival smile (GS). Several etiological factors have been associated to GS and for this reason various treatments have been proposed according to its etiology. The aim of this study is to present a case with an alternative technique to treat GS with minimally invasive vestibular incision subperiosteal tunnel access (VISTA) and polymethyl methacrylate (PMMA) implants for lip repositioning. METHODS AND RESULTS: The patient, a 25-year-old woman diagnosed with excessive gingival exposure, had previously done botulinum toxin (BoNT) injections and did not like the result. She had a major subnasal depression and the upper lip would lodge in there during spontaneous smile. She was informed about all options of treatment and agreed to a lip repositioning installing a customized PMMA implant. CONCLUSION: This is the first study to our knowledge to present a case with use of a PMMA implant associated with the VISTA approach for lip repositioning and gingival smile correction. The results are encouraging, and the patient was satisfied with results accomplished by this technique. KEY POINTS: Why is this case new information? This is a new and innovative surgical approach for gingival smile with PMMA implants through a minimally invasive technique (VISTA). What are the keys to successful management of this case? Well-defined presurgical planning and the presence of the upper lip lodging in the subnasal depression during spontaneous smile. What are the primary limitations to success in this case? Cases with vertical maxillary excess and those in which osteotomy/osteoplasty is indicated. It is a technique-sensitive treatment dependent on the clinician's experience.

Gingival fenestration defect treated with gingivectomy and gingivoplasty: A case report with an 8-year follow-up.

INTRODUCTION: Gingival fenestration (GF) is scarcely reported in the literature. We present a unique case of GF defect combined with gingivitis and altered passive eruption (APE). CASE PRESENTATION: An 18-year-old female patient with gingivitis, APE, and GF in the mandibular left central incisor presented for periodontal treatment. The gingival lesion was successfully treated with basic periodontal therapy gingivectomy, and gingivoplasty and resulted in an excellent aesthetic long-term outcome. This case report shows its 8-year clinical follow-up. CONCLUSION: There are no earlier reports dealing with the use of gingivoplasty for the treatment of GF, as it is not the usual therapeutic intervention for these defects. Gingivoplasty proved to be effective in treating GF. Why is this case new information? Available literature on gingival fenestration defects does not describe gingivectomy and gingivoplasty as a treatment of choice. Gingivectomy and gingivoplasty proved to be effective in treating gingival fenestration defects. What are the keys to successful management of this case? Proper diagnosis. What are the primary limitations to success in this case? Gingival fenestration has been defined when the overlying gingiva is denuded, exposing the root to the oral cavity. However, in this case report, only the crown was exposed because the patient had altered passive eruption.

Treatment of gummy smile combining crown lengthening, lip repositioning, and the use of polyester threads.

INTRODUCTION: The case report presents a new possibility of treatment for a gummy smile in a patient with multiple etiologies, such as altered passive eruption and hypermobility upper lip. At first, crown lengthening was not sufficient to achieve the desired aesthetic result, being necessary its combination with lip repositioning. CASE PRESENTATION: Crown lengthening surgery (CLS) was performed in a 20-year-old woman, with a gingival display of 7.5 mm, having her gingival exposure reduced to 5.5 mm. Because the patient continued unsatisfied after 6 months, a new procedure was adopted. To reduce even more her gingival exposure, lip repositioning technique was performed associated with myotomy and the insertion of polyester threads as a physical barrier to prevent relapse. CONCLUSION: The result of the gingival display was reduced to 2.5 mm, removing the condition of a gummy smile after the combination of both techniques: crown lengthening, and lip repositioning. KEY POINTS: Why is this case new information? Association of the technique of lip repositioning and myotomy, the insertion of polyester threads that act as a physical barrier against recurrence. What are the keys to successful management of this case? Correct etiological diagnosis. Prior application of botulinum toxin. Respect the period of 1 month for the insertion of the polyester thread, helping to preserve the suture (limitation of movement). What are the primary limitations to success in this case? Make the patient aware not to move the lips with the hands in order to observe the incision.

Modified gingivoplasty for hereditary gingival fibromatosis: two case reports.

BACKGROUND: Hereditary gingival fibromatosis (HGF) is characterized by sub-epithelial fibromatosis of keratinized gingiva resulting in a fibrotic enlargement of keratinized gingiva. The treatment choice is gingivectomy, which can be performed with an internal or external bevel incision conventionally. However, both techniques can hardly resume the natural status of gingiva, and have a certain recurrence rate, especially in the cases which have limited width of attached gingiva. CASE DESCRIPTION: Two cases of HGF with the chief complaint of difficulty in mastication, pronunciation, and poor esthetics were presented. After the initial periodontal therapy, a novel gingivoplasty modified with a crevicular incision was applied. A full thickness flap above the mucogingival junction and a split flap below the junction were raised. Then, fibrotic connective tissue was completely eliminated and keratinized gingival epithelium was preserved. The fibrotic alveolar bone was shaped by handpiece and bur. Finally, the flap was apically repositioned and sutured. Twelve months after surgery, the gingiva recovered with normal color, contour and consistency. CONCLUSIONS: Compared to traditional gingivectomy, modified gingivoplasty which focuses on eliminating pathological fibrotic connective tissue can completely resume the natural appearance of gingiva and demonstrate no tendency of recurrence.

Diagnostic Mock-Up as a Surgical Reduction Guide for Crown Lengthening: Technique Description and Case Report.

Background and Objectives: The report describes a technique using a diagnostic mock-up as a crown-lengthening surgical guide to improve the gingival architecture. Materials and Methods: The patient's primary concern was improving her smile due to her "gummy smile" and short clinical crowns. After clinical evaluation, surgical crown lengthening accompanied by maxillary central full-coverage single-unit prostheses and lateral incisor veneers was recommended. The diagnostic mock-up was placed in the patient's maxillary anterior region and used as a soft tissue reduction guide for the gingivectomy. Once the planned gingival architecture was achieved, a flap was reflected to proceed with ostectomy in order to obtain an appropriate alveolar bone crest level using the overlay. After six months, all-ceramic crowns and porcelain veneers were provided as permanent restorations. Results: A diagnostic mock-up fabricated with a putty guide directly from the diagnostic wax-up can be an adequate surgical guide for crown-lengthening procedures. The diagnostic wax-up was used to fabricate the diagnostic mock-up. These results suggested that it can be used as a crown-lengthening surgical guide to modify the gingival architecture. Several advantages of the overlay used in the aesthetic complex case include: (1) providing a preview of potential restorative outcomes, (2) allowing for the appropriate positioning of gingival margins and the desired alveolar bone crest level for the crown-lengthening procedure, and (3) serving as a provisional restoration after surgery. Conclusions: The use of a diagnostic mock-up, which was based on a diagnostic wax-up, as the surgical guide resulted in successful crown lengthening and provisional restorations. Thus, a diagnostic overlay can be a viable option as a surgical guide for crown lengthening.

Use of Botulinum Toxin Before Surgical Lip Repositioning: A Randomized Clinical Trial.

This study aimed to determine whether administering botulinum toxin type A (BT) prior to surgery would stabilize surgical lip repositioning. A randomized controlled parallel-group clinical trial was performed. A total of 18 participants with excessive gingival display (EGD) were divided into two groups. For the test group (TG), BT was injected into the smile muscle locations 15 days before the surgical procedure. For the control group (CG), only lip repositioning surgery was performed. Gingival display (GD) and upper lip displacement (LD) were measured 3 and 6 months postoperatively. Data were submitted to ANOVA, Tukey, and t tests. For GD and LD, the changes were statistically significant between the measurements taken at the baseline, 3-month, and 6-month marks. The GD presented a reduction of 5.2 ± 1.1 mm in TG and 3.2 ± 1.4 mm in CG after 6 months. The LD measurements reduced 45% for TG and 26% for CG in 6 months. The injection of BT 15 days before lip repositioning surgery provided more stable results and effectively reduced the GD at 6 months.

Double guide concept: A new digital paradigm for the treatment of altered passive eruption in patients with high esthetic expectations.

Digital guides (also known as stents) have become commonly used in daily dental practice. CBCT, digital impressions, and stereolithographic models are considered extremely helpful to create guides for the planning and resolution of surgical cases. In recent years, in periodontal surgery and in particular for the treatment of altered passive eruption (APE), there has been an increasing use of digitally designed guides to improve esthetic outcomes and achieve more predictable results. Digital custom-made guides can be used to improve safety and precision in crown lengthening procedures in patients with APE who have high esthetic expectations. Although most approaches described in the literature show guides used for primary flap or gingivectomy design, the precision of bone recontouring and ostectomy plays a key role in soft tissue rebound and in the final esthetic outcome. The present article describes a new approach using two different guides for soft tissue design in patients with APE.

Clinical advantages of improving the excessive gingival display (EGD) by surgical repositioning of the upper lip.

OBJECTIVES: The objective of this study is to minimize gingival display by surgical repositioning of the upper lip and to suggest this technique as an alternative treatment modality to orthognatic surgery for treatment of excessive gingival display. MATERIALS AND METHODS: Forty-eight patients were selected with gingival display of more than 2 mm during maximal smiling. All patients underwent surgical repositioning of the upper lip, aimed at limiting elevator muscle activity to treat excessive gum exposure. Patients were regathered in 1 week for the follow-up postoperative symptoms according to VAS scale to evaluate pain and swelling. Reference values were given to patients. RESULTS: The study has indicated good results and stability especially to patients with skeletal class I classification along with medium and thick biotype of attached gingiva without hypermobile upper lip. CONCLUSION: Surgical repositioning of the upper lip is an effective way to improve a patient's gingival smile caused by degree I and II VME in combination with HUL as an alternative treatment modality to orthognathic surgery. This method is less invasive and cost-effective, causes minimal postoperative complications, and provides faster recovery. CLINICAL RELEVANCE: Excessive gingival display (EGD) with various etiologies requires several proper treatment modalities. The proposed modified method of lip repositioning to reduce the degree of gingival display is less aggressive, reliable, and causes fewer postoperative complications compared to orthognathic surgery.

A 15-year Follow-Up of a Gingivectomy Procedure for Idiopathic Gingival Fibromatosis: A Case Report and Literature Review.

Few long-term reports exist concerning the treatment of idiopathic gingival fibromatosis, which is a rare autosomal dominant genetic disorder associated with non-inflammatory, benign, and chronic fibrous gingival proliferation and which causes serious esthetic problems. The aim of this study was to report a case of idiopathic gingival fibromatosis treated with a gingivectomy using an inverse bevel flap method and comprehensively followed up for 15 years. A female patient visited a pediatric dentist at 7 years of age; however, a gingivectomy was not performed until the age of 20 years because of an uncertain prognosis. Now, more than 15 years after the gingivectomy, there has been no significant recurrence and the disease is well managed. Treatment by gingivectomy with an inverse bevel flap approach may provide long-term prevention of recurrence of gingival fibromatosis into adulthood. The aim of this study was to obtain new findings on the pathogenesis and prognosis of this rare disease and to review the case reports previously published.

Clinical efficacy of lip repositioning technique and its modifications for the treatment of gummy smile: systematic review and meta-analysis.

OBJECTIVE: To systematically review the literature regarding the clinical efficacy of reducing excessive gingival display (EGD) using the surgical lip repositioning technique (LRT) and its modifications. The question to address was: "What is the clinical efficacy of the surgical LRT and its modifications in patients with EGD?" MATERIAL AND METHODS: Four databases (MEDLINE-PubMed, Scopus, EMBASE, and CENTRAL) were searched up to December 2021 (PROSPERO-CRD42020205987). Randomized, non-randomized controlled and prospective case series with a minimum of 6-month follow-up were eligible for inclusion. Two meta-analyses were performed using the mean difference (MD) between baseline and different follow-up periods (6 and 12 months). Subgroup analyses were performed using the different modifications of LRT. RESULTS: The electronic research retrieved 783 studies. Only 13 met the inclusion criteria and were included in the statistical analysis. Six modifications of the original LRT were identified. An overall EGD reduction of -3.06 mm (95%CI: -3.71-2.40), -2.91 mm; (95%CI: -3.66-2.15) and -2.76 mm; (95%CI: -3.83--1.70) was achieved after 6, 12, and 36 months, respectively, compared to baseline (P < 0.01). Meta-analysis revealed that the use of LRT with periosteal suturing showed the greatest decrease in EGD with 5.22 mm (95% CI: 4.23-6.21; P < 0.01) at 6 months and 4.94 mm (95% CI: 3.86-6.02; P < 0.01) at 12 months. CONCLUSIONS: Both the original LRT and its different modifications reduce EGD and provide good results and overall patient satisfaction at 6, 12, and 36 months of follow-up. CLINICAL RELEVANCE: Evaluating the different modifications of the LRT can be a guiding aspect for the clinical and surgical approach to be used in patients with EGD.

Management of excessive gingival display with mucosal coronally positioned flap.

OBJECTIVE: Current methods of managing excessive gingival display, an aesthetic concern, with gingivectomy, orthodontic intrusion, restorative dentistry and even botulinum toxin, have often been unsatisfactory. This study evaluates the efficacy of mucosal coronally positioned flap (MCPF) for reduction of gingival display. MATERIAL AND METHODS: Eight healthy patients, above 18 years, with either short or hyperactive upper lip, gingival display ≥4 mm during smiling or vertical maxillary excess, were recruited into the study. The smile line, upper lip length, upper lip vermillion length, distance between the lips and amount of gingival display along with clinical indices were assessed. The patients then underwent MCPF procedure and were re-evaluated for healing of the surgical site after 15 days and at 3 months. Patients also provided their perceptions of outcome of treatment, through a questionnaire. Paired t test and Repeated measures ANOVA were used for data analysis. RESULTS: Significant improvement in the gingival display was noted 3 months after the procedure, while no concomitant changes were observed in other parameters like upper lip length, vermillion length and distance between the lips post operatively. CONCLUSION: The results of the study suggest that the MCPF procedure provides satisfactory results in terms of reduction of gingival display. Simplicity of the surgical procedure makes it an attractive option for patients without any gross skeletal abnormalities.

Utilisation of an 810 nm diode laser for surgical management of oral soft tissues related to orthodontic treatment: A case series.

The present case series demonstrates the efficacy of an 810 nm diode laser for the surgical management of oral soft tissues related to orthodontic treatment. Three orthodontic patients aged 16-23 years underwent operculectomy, ablation of soft-tissue overgrowth over orthodontic appliance and gingivectomy along with gingival recontouring procedures, respectively, using the 810 nm diode laser. In each case, an initiated laser fibre tip was utilised to ablate the tissue at the treatment site by making a light contact with the tissue (average power output = 1-1.6 W, continuous wave emission mode, fibre diameter = 400 µm, spot size = 0.0013 cm2, energy density = 124.9-199.9 J/cm2, irradiance = 796-1273 W/cm2, total energy dose = 300-480 J). The maximum total length of treatment was 300 s (5 min). None of the patients reported any instantaneous or delayed postoperative complications over six months. Utilisation of the 810 nm diode laser for surgical management of oral soft tissues related to orthodontic treatments can be considered safe, effective and justifiable over the conventional scalpel technique; however, it must be performed by trained and experienced clinicians only.

Tratamiento del agrandamiento gingival inducido por placa bacteriana asociado a factores locales: Reporte de un caso clínico / Treatment of Gingival Enlargement Induced by Dental Plaque Associated with Local Factors: Case Report

Resumen Los agrandamientos gingivales inducidos por placa bacteriana asociados a factores locales como el uso de aparatología ortodóntica, son frecuentemente observados en pacientes jóvenes, con un inadecuado control del biofilm dental. Dentro de la terapéutica recomendada para tratar dicha condición se encuentra la fase higiénica periodontal y el abordaje quirúrgico. Se presenta un caso clínico de un paciente de 16 años con agrandamiento gingival y su respectivo tratamiento.

Absytract Dental plaque-induced gingival enlargements associated with local factors such as the use of orthodontic appliances are frequently observed in young patients, with inadequate dental biofilm control. Among the recommended therapeutics to treat this condition is the Nonsurgical phase and the surgical approach. A clinical case of a 16-year-old patient with a gingival enlargement and its respective treatment is presented.

Planejamento digital para cirurgia de aumento de coroa clínico estético: relato de caso / Digital planning for aesthetic clinical crown increase surgery: case report

A exposição excessiva de gengiva durante o sorriso é denominada como sorriso gengival. O fator etiológico dessa alteração é variado e sua identificação é fundamental para confecção de um plano de tratamento eficaz. O planejamento clínico pode ser realizado utilizando uma abordagem dinâmica e digital do sorriso. Sendo assim, software, exames imaginológicos, modelo virtual 3D e guia cirúrgico aumentam a qualidade e a precisão do tratamento, trazendo inúmeros benefícios para o paciente. Objetivo: demonstrar a importância do fluxo digital no planejamento e na correção do sorriso gengival. Relato de caso: paciente apresentou queixas em relação ao tamanho dos dentes e ao excesso de exposição de gengiva durante o sorriso. Após exames clínico e radiográfico, foi possível realizar o diagnóstico do fator etiológico como erupção passiva alterada (EPA). O tratamento de escolha foi o recontorno gengival associado à realização de osteotomia e osteoplastia. Para uma maior precisão do tratamento, foi confeccionado um guia cirúrgico duplo. Após o procedimento, a paciente foi orientada e medicada. Considerações finais: a abordagem digital do sorriso favoreceu um tratamento cirúrgico preciso, eficaz e satisfatório para a paciente, reestabelecendo assim a harmonia dento-gengivo-facial.(AU)

Excessive gum exposure during a smile is called a gum smile. The etiologic factor of this alteration is varied, the identification is essential to create an effective treatment plan. Clinical planning can be performed using a dynamic and digital smile approach. Therefore, software, imaging tests, 3D virtual model and the surgical guide increase the quality and precision of the treatment thus bringing numerous benefits to the patient. Objective: this case report aims to demonstrate the importance of digital flow in smile planning and correction of a gum smile. Case report: the patient presented complaints regarding tooth size and excessive gum exposure during the smile. After the clinical and radiographic examination, the etiological factor was diagnosed as an altered passive eruption (APE). The treatment of choice was the gingival contour associated with osteotomy and osteoplasty. For the precision of the treatment, a double surgical guide was made. After the procedure the patient was guided and medicated. Conclusion: the digital smile approach favored an accurate, effective and satisfactory surgical treatment for the patient thus restoring the tooth-gingival-facial harmony.(AU)

Agrandamiento gingival inducido por fenitoínas / Phenytoin induced gingival enlargement

Se entiende por agrandamiento gingival el incremento en masa y volumen del tejido gingival. Se considera una condición benigna de la cavidad oral, por lo general de manejo rutinario, que logra regularse con medidas simples de control del biofilm microbiano. El agrandamiento gingival puede ser producido por diversas condiciones clínicas, hereditarias, deficiente higiene oral o fármacos. La epilepsia afecta a 1% de la población mundial y requiere el uso de fármacos antiepilépticos o anticonvulsivantes para lograr su control, dentro de éstos la fenitoína actúa como un bloqueador selectivo de los canales de sodio sensibles al voltaje y constituye uno de los fármacos más empleados por su capacidad en el control de crisis focales y generalizadas. La fenitoína se ha relacionado con los agrandamientos gingivales como uno de sus efectos adversos, los cuales se incluyen dentro de las enfermedades por fármaco inducidas en la cavidad oral. El objetivo de este artículo es brindar la información necesaria sobre el manejo correcto de pacientes con agrandamiento gingival producido por fenitoínas y a la vez poder conocer las consecuencias de estos fármacos en la cavidad oral (AU)

Gingival enlargement means the increase in mass and volumen of the gingival tissue. It is considered a benign condition of the oral cavity, usually of routine management, wich can be regulated with simple measures of biofilm control. The gingival enlargement can be produced by diverse clinical conditions, hereditary deficient oral higiene or drugs. Epilepsy affects 1% of the world population and requires the use of antiepileptic or anticonvulsant drugs to achieve its control, within these phenytoin acts as selective blocker or voltage ­ sensitive sodium channels and is one of the most used grugs for its ability to control focal and generalized crises. Phenytoin has been linked to gingival enlargement as one of its adverse effects which is included within the drug diseases induced in the oral cavity. The objective of this article is to provide the necessary information on the correct managment of patients with gingival enlargemen produced by phenytoins and at the same time to know the consequences of these drugs in the oral cavity (AU)

Rare case report of idiopathic gingival fibromatosis in childhood and its management.

Idiopathic gingival fibromatosis (GF), also known as gingivomatosis, is a rare condition in childhood, with an unknown aetiology. The oral manifestations of the condition are varied and depend on the severity and age of involvement. This paper describe the case of a 5-year-old male child with extensive gingival enlargement covering almost all the maxillary and mandibular teeth resulted in difficulty with speech, mastication and poor aesthetics. Clinical and radiographic examination along with haematological investigations ruled out any systemic association. The case was managed with conventional scalpel blade surgery along with electrocautery under general anaesthesia yielding good results without any recurrence after a 12-month follow-up. The results revealed that the oral manifestations of GF depend on its severity and the age of onset. Timely intervention can help to prevent associated complications in a growing child.

Use of Tuberosity Connective Tissue for Root Coverage and Ridge Augmentation: Background and Technique.

Excess tissue often exists distal to the upper second molar, creating a pocket in the maxillary tuberosity. When removed from this location, this tissue can serve as an optimal piece of connective tissue (CT), helping to both prevent periodontal disease and treat periodontal recession while also aiding in restorative dentistry. This tissue is an ideal CT for root coverage and soft-tissue ridge-augmentation grafting. This article provides an overview of CT grafting, including a discussion of tuberosity CT and its advantages versus palatal CT. The authors describe two techniques for harvesting tuberosity tissue for CT grafts, the distal gingivectomy technique and the distal wedge technique, and show examples of various uses of tuberosity tissue for CT grafts.

Treatment of Physiologic Gingival Pigmentation with Surgical Blade: A 25-Year Follow-up.

Gingival hyperpigmentation in the anterior region in people with a high smile line is an esthetic concern. Gingival depigmentation can be achieved through various procedures. Most techniques have shown successful short-term results; however, recurrence is observed in 50% of patients after 2 to 4 years. A 46-year-old woman presenting with a large black zone of gingival hyperpigmentation in the anterior maxilla was treated with scalpel blade excision. At 25 years after the depigmentation procedure, the patient displayed no recurrence.

Comparison of Gingival Troughing by Laser and Retraction Cord.

This study was aimed at comparing the most common two methods for gingival troughing: presaturated cord and lasers (including diode, Nd:YAG, and Er:YAG). A total of 108 anterior teeth (58 maxillary and 50 mandibular) in 50 patients were included in this study. Gingival treatment was carried out in the following four groups: presaturated cord, diode laser, Nd:YAG laser, and Er:YAG laser. The gingival width and gingival recession (GR) were measured at different times (at the time of treatment, after 1 week, and after 4 weeks). The presaturated cord resulted in significantly higher (P < .05) GR than lasers and narrower gingival sulci. Er:YAG laser resulted in the quickest and most uneventful wound healing when compared to diode and Nd:YAG lasers.

[Perfecting smile esthetics: keep it pink!] / Comment parfaire l'esthétique du sourire : toujours en rose !

INTRODUCTION: Smile aesthetics is based on numerical, physical, physiological and psychological data regarding beauty, while taking into account the desires of the patient. It is determined by the shape, colour and position of the lips, teeth and gingival tissues. Periodontal examination in both the facial and labial settings supports analysis of the gingival display during natural and forced smiling, the health of the periodontium, the gingival contours, the aesthetic gingival line, and the presence of the papillae. MATERIALS AND METHODS: All these data will help establish a gingival aesthetic score to determine the causes of disharmony and possible treatment. DISCUSSION: During implementation of the global orthodontic treatment plan, periodontal plastic surgery can change the gingival appearance and morphology in order to restore the harmony of the smile. Subtractive periodontal plastic surgery treats biological space defects and excess tissue during incomplete passive eruption by gingivectomy or apically positioned flap, combined, or not, with osteoplasty or osteoectomy. Finally, injections of hyaluronic acid in the papillae can plump them up and minimize the size of any black holes.