Review

Crown Lengthening Surgery in the Esthetic Area for Optimized

Results: A Review with Surgical Recommendations
Sérgio Kahn 1 , Walmir Júnio de Pinho Reis Rodrigues 2 , Alexandra Tavares Dias 3 , Rodrigo Resende 4 ,
Juliana Campos Hasse Fernandes 5 and Gustavo Vicentis Oliveira Fernandes 6, *

1 Independent Researcher, Rio de Janeiro 22410-001, RJ, Brazil

2 Department of Periodontology, UNIFESO University Center Organ Mountains,
Teresópolis 25964-004, RJ, Brazil
3 Periodontics Department, Rio de Janeiro State University, Maracanã, Rio de Janeiro 20550-013, RJ, Brazil
4 Department of Oral Surgery, Federal Fluminense University, Niterói 24220-900, RJ, Brazil
5 Independent Researcher, St. Louis, MO 63104, USA
6 Periodontics, Missouri School of Dentistry and Oral Health, A. T. Still University, St. Louis, MO 63104, USA
* Correspondence: [email protected] or [email protected]

Abstract: Background: Crown lengthening (CL) in esthetic areas has become a versatile procedure
with applications in many clinical situations. Knowledge concerning different periodontal pheno-
types, and the supracrestal tissue attachment (STA)—former biological width—has allowed for a
better understanding of surgical management, allowing for the individualization of surgical ther-
apy. This review presented an individualized surgical approach to CL in esthetic areas based on
evaluating the phenotype and current considerations about the STA, correlating them to suggestive
surgical techniques. Methods: For an individualized surgical approach, it is primarily necessary
to understand STA, including the relationship and distance between the cementoenamel junction
(CEJ) and the bone crest (BC) and the position of the free gingival margin (FGM); secondarily, it is
necessary to verify the periodontal phenotype to prepare surgical planning (gingivectomy or osseous
resection/contouring). Three periodontal phenotypes are recognized, presenting different biological
Citation: Kahn, S.; Rodrigues, behaviors due to specific characteristics implicitly correlated to soft tissue management. Results:
W.J.d.P.R.; Dias, A.T.; Resende, R.; Then, after assessing the distance from the CEJ to the BC, the position of the FGM, and the periodontal
Fernandes, J.C.H.; Fernandes, G.V.O. phenotype, it is possible to individualize the treatment according to the phenotype. In cases of a thin
Crown Lengthening Surgery in the and scalloped periodontium with delicate gingiva, there might be the presence of bone dehiscence,
Esthetic Area for Optimized Results: fenestration, and instability in the healing of the gingival margin, bringing extra attention to tissue
A Review with Surgical
manipulation and suggesting a minimally invasive technique (no flap). A partial-thickness flap is
Recommendations. Surgeries 2024, 5,
recommended for a thick and scalloped periodontium, keeping the periosteum adhered to the bone.
1043–1055. https://doi.org/
For periodontium B (fibrous and dense gingiva and tissue resistant to injuries), the surgical approach
10.3390/surgeries5040084
recommended is an open full-thickness flap with osteotomy for horizontal and vertical bone volume
Academic Editors: Bruno Chrcanovic removal. Then, observing first the specific parameters, such as the STA, CEJ, BC, FGM, and KTW,
and Kenzo Hiroshima and then the characteristics of periodontal phenotypes, it is possible to determine the individualized
Received: 27 August 2024 surgical strategy and a reasonable surgical approach to tissue manipulation in clinical CL surgeries.
Revised: 2 October 2024 Conclusions: The surgical approach must be defined according to individualized planning since
Accepted: 26 November 2024 several variables can influence the dynamics of the periodontal tissues.
Published: 28 November 2024
Keywords: crown lengthening; periodontal biotype; biological width; phenotype; surgery

Copyright: © 2024 by the authors.

Licensee MDPI, Basel, Switzerland.
1. Introduction
This article is an open access article
distributed under the terms and
1.1. Esthetic in Dentistry
conditions of the Creative Commons Esthetics is a branch of philosophy that aims to study nature, beauty, and sensations
Attribution (CC BY) license (https:// transmitted by human beings. An attractive and pleasant smile promotes well-being and
creativecommons.org/licenses/by/ increases self-esteem [1]. Current approaches to anterior esthetic rehabilitation include
4.0/). therapies such as contact lenses, ceramic veneers, fillers, digital smile planning, and surgical

Surgeries 2024, 5, 1043–1055. https://doi.org/10.3390/surgeries5040084 https://www.mdpi.com/journal/surgeries

Surgeries 2024, 5 1044

techniques for soft and hard tissues [2–4]. In this context, crown lengthening (CL) surgery
in esthetic areas is often requested to achieve harmony between white and pink esthetics [3].

1.2. Gingival Exposition During a Natural Smile

In a natural scenario, the ideal smile exposes a 1 or 2 mm gingival margin, which
should present harmony with the upper lip; healthy gingival tissues filling the interproxi-
mal spaces; teeth with adequate anatomy, proportions, and color; and a lower lip parallel
to the incisal edges of the upper anterior teeth [4,5]. According to the smile’s classification
based on the quantity of tooth and gingival tissue exposed in a natural smile, the smile
can be classified into three types: low smile (<75% of the upper incisors exposed); medium
(75–100% of the anterior teeth exposed together with the interproximal gingiva); and high
(100% of the upper incisors and part of the gingival tissue exposed) [6].
In scenarios with excessive gingival tissue covering the teeth (shorter than usual), the
smile is recognized as a “gummy smile”. Typically, at least 3 mm or more of the gingiva
is exposed, negatively influencing the esthetic. This occurs when an excessive gingiva
is presented during the upper lip movement in a spontaneous smile. A gummy smile is
defined as a high smile; conversely, not every type of smile is considered a gummy smile [7].
Furthermore, it constitutes a very complex entity, which may involve one or several different
etiologies (vertical maxillary growth, altered passive eruption, dentoalveolar extrusion,
short upper lip, and hyperactive upper lip, in addition to a combination of several factors)
and which often requires multidisciplinary approaches [8,9].

1.3. Periodontal Treatment for Excessive Gingival Exposition

Periodontal surgery is intended to correct the gummy smile, changing the final position
of the free gingival margin (FGM); typically, the cementoenamel junction (CEJ) is used
as a reference. Classically, it is mandatory primarily to understand STA—including the
relationship between CEJ and the bone crest (BC), the distance between them, the position
of the free gingival margin (FGM), and the mucogingival junction (MGJ) or keratinized
tissue width (KTW)—in order to achieve the surgical approach.
Since 2019, numerous studies have been published, exploring various aspects such
as surgical techniques, patient outcomes, digital planning, and considerations for achiev-
ing optimal esthetic results using CL. Some studies have focused on refining surgical
techniques to minimize patient discomfort and maximize esthetic outcomes. In 2024,
Rieska et al. [10] examined the use of laser-assisted CL compared to traditional methods;
their results showed that applying laser techniques reduced bleeding and healing time. In
addition, new surgical tools and equipment, such as ultrasonic devices, have been evalu-
ated for their efficacy in esthetic CL. Alhumaidan et al. [11] compared these innovations
to traditional techniques, demonstrating reduced tissue trauma and improved precision;
Carrera et al. [12] highlighted that using 3D imaging and digital planning software to
customize surgical approaches for patients can lead to more predictable and satisfactory
outcomes, obtaining more precise planning and execution for procedures as CL.
Thus, proper soft tissue management is crucial to achieving a natural-looking result.
Narayan et al.’s study [13] demonstrated the importance of maintaining soft tissue integrity
and symmetry. After applying different techniques to prevent recession and ensure a
harmonious gingival contour, the authors discussed soft tissue regrowth. Understanding
the biological processes involved in the healing after CL is essential for predicting long-term
outcomes. Other authors [14,15] have evaluated histological changes in gingival tissue
post-surgery, providing insights into factors influencing healing and tissue stability.

1.4. Patient-Correlated Factors

It is always necessary to consider individual patient factors, such as age, smoking
status, and overall periodontal health, which can significantly impact the procedure’s
success. Silva et al. [16] showed that the CL procedure significantly improved smile
attractiveness for laypersons and dental professionals. Altayeb et al. [17] reported the
Surgeries 2024, 5 1045

periodontal phenotype affected the gingival margins and the healing time, while the
surgical technique affected the short-term results and procedure-related morbidity; hence,
personalized treatment planning is essential.
Furthermore, the success of esthetic CL is measured by clinical parameters and patient
satisfaction. Newaskar et al. [18] evaluated patient-reported outcomes post-surgery. The
results from the surgical day and after seven days showed that visual analog scores (VAS)
were the lowest for CL compared to soft tissue graft procedures. This result follows the
time necessary for the surgical procedure; CL had lower complications due to its prevalence
related to the surgical time.

1.5. Complications Associated with CL

While esthetic CL is generally considered a safe procedure [19,20], complications can
occur. Common complications, such as infection and over-contouring, and strategies for
prevention and management, should be heeded as another common complaint factor is
the long-term results. Moreover, a lack of concept understanding or incorrect obtention
of periodontal parameters can cause imprecision and failures; it is essential to achieve the
correct values of the STA, the correct distance between the CEJ and the BC, the correct
position of the FGM, the KTW, and the periodontal phenotype to prepare surgical planning
(gingivectomy or an osseous resection/contouring surgery).
Ensuring the long-term stability of esthetic outcomes is a primary concern. In a
study, Guarnieri et al. [21] assessed the stability of CL results over 15 years, finding
that proper technique and follow-up care are critical for maintaining results. However,
when exploring the relationship between CL and subsequent restorative procedures [22],
interdisciplinary collaboration is necessary to optimize esthetic and functional outcomes
and avoid adverse results.
Thus, the objective of the present review was to show an individualized surgical
approach by, after assessment of the CEJ–BC and FGM position, evaluating the periodontal
phenotype and via individualization of the STA for CL surgeries in the esthetic area.

2. Literature Review
2.1. Periodontal Phenotype
The periodontal phenotype is a fundamental characteristic of dental treatment plan-
ning and predictability [23]. Recently, the American Academy of Periodontology (AAP),
with the European Federation of Periodontology (EFP), suggested periodontal phenotype
terminology instead of periodontal biotype, which is more related to genetic characteristics.
In addition, phenotype considers genetic characteristics and environmental factors. Peri-
odontists and dentists must evaluate it as an essential characteristic that can influence the
final treatment of a surgical, restorative, or orthodontic procedure.
After the essential measurement of the STA, including the distance between the CEJ
and the BC, the verification of the FGM position, and also of the available KTW, which is
usually satisfactory in the esthetic region, the phenotype should be precisely evaluated
in order to recommend the CL procedures. The periodontal phenotype includes the
gingival phenotype (gingival thickness and KTW) and the bone morphotype (thickness
of the vestibular bone wall) [24]. Understanding the patient’s periodontal measurements
and phenotype may be crucial for predicting the inflammatory burden, type of surgical
interventions, and restorative procedures.
Some authors have indicated different parameters that define the periodontal
phenotype [25]; therefore, gingival and bone thickness, as well as KTW, were considered
the main factors in its definition. A systematic study explored the influence of different
periodontal phenotypes on CL procedures, suggesting tailored protocols based on phe-
notype to optimize surgical results [24]. In populational research, including 510 healthy
patients from Pakistan, three quarters (76%) exhibited a thick gingival phenotype and 24%
a thin phenotype [26]. In addition, a higher prevalence of the thin phenotype was found
at sites with gingival recession [27]. Thus, understanding the importance of a periodontal
Surgeries 2024, 5 1046

phenotype can be considered key to many activities in dentistry [28,29]. In addition, the
length-width ratio of the dental crown, papilla height, and age are already understood as
parameters for diagnosing the periodontal phenotype [30–33].
The criteria for identifying the periodontal phenotype have evolved substantially over
time, including invasive (drilling the gingiva with a periodontal probe or endodontic spacer,
a rubber cursor [34], and a customized caliper [35]) and non-invasive methods (through
visual examinations [31,36–38], the use of ultrasound [32,33,39] and transparency [40,41],
and cone beam computed tomography (CBCT) associated with gingival retractors or CBCT
for soft tissues [41–44]). However, to date, there is no single standard classification based
on these, perhaps due to the methods’ shortcomings. The visual method requires the
experience of a professional [45,46]; ultrasound devices are not easily affordable, while the
transparency of the probe seems to only assess the thickness of the gingival tissue without
incorporating the thickness of the bone tissue.
Two types of periodontal phenotype were recommended: flat–thick and thin–
scalloped [37,38]. However, current studies demonstrate that these two categories do
not cover the entire population. A third type of periodontium, classified as thick–scalloped,
seems to fit a portion of the population not yet included in previous classifications [40]
(Table 1).

Table 1. Classification of the periodontal phenotype proposed by De Rouck [40].

Code Phenotype Description

Elongated teeth; narrowly inserted gingival band; thin gingival thickness; scalloped
A1 Thin–Scalloped
gingival margin
Elongated teeth; narrow band of attached gingiva; thick gingival thickness; scalloped
A2 Thick Festonated
gingival margin
B Thick–Flat Short, wide teeth; wide band of attached gingiva; thick gingiva; flat gingival margin

Bone probing, a procedure widely used in CL to locate BC, can be used, but it may
require more precision. After anesthesia, the periodontal probe is inserted into the gingival
sulcus towards the BC. CBCT of soft tissues permits the diagnosing and classifying of
periodontal phenotypes for reproducibility and accuracy, in addition to measuring bone
and gingival thickness. Other structures and measurements that are challenging to observe
clinically, such as the CEJ and the BC, could also be identified.

2.2. Supracrestal Tissue Attachment (STA) (Former Biological Width)

STA is considered an inviolable parameter that should be respected during restorative
procedures. Its assessment is essential in diagnosing and treating a “gummy smile” [46].
Gargiulo et al. [47] measured the dimensions of the tissues involved in the tooth–gingival
junction in cadavers. The average found for the junctional epithelium and connective tissue
was 2.04 mm, separated from the gingival sulcus, which measured 0.69 mm. A proportional
relationship between these components was observed.
Thus, it is initially suggested that 3 mm would be needed between the margin of the
restoration and the BC for correct periodontal tissue healing [48]. However, the literature
demonstrates that factors such as the type of tooth, the position of the tooth in the arch,
the presence of restoration, the healing time after clinical CL surgery, and periodontal
disease can affect STA measurements [49]. Vacek et al. [50] observed that molars and teeth
with subgingival restorations had significantly greater STA measurements, confirmed by
other authors [51]. Therefore, despite being helpful, the STA measurements obtained were
average, and generalization is not recommended [49,52]. It is ideal for surgical planning to
correlate these variations and consider the STA individually [53], especially in the presence
of different periodontal phenotypes.
Surgeries 2024, 5 1047

2.3. Surgical Strategy

By determining the periodontal phenotype, a surgical treatment plan can be decided
to correct the gummy smile and increase the clinical crown length of the teeth. In a thin–
scalloped periodontium, as previously stated, where the tissue is more fragile, and where
there might be the presence of dehiscence and fenestration, there is a greater tendency to
achieve a gingival recession and less stability of the gingival margin. Then, maintenance of
STA around 2 mm (from the CEJ to the CB) may be sufficient.
In a thick–scalloped periodontium, where the periodontal phenotype presents
thick–flat and thin–scalloped tissue characteristics, 3 mm may be adequate; whereas for a
flat–thick periodontium, with fibrous and dense gingiva, the tissues are resistant to injuries,
and there is a greater tendency for periodontal pockets formation, with a favorable stability
of the gingival margin healing, and often the need to perform vertical and horizontal os-
teotomy; a greater biological distance is recommended, i.e., 4 mm (it is worth highlighting
that this value can vary, and sometimes, 3 mm can be enough). Some factors that also can
interfere in the treatment planning are cultural differences between countries (depending
on where the patient comes from, esthetic value (there are differences between South
America and Europe, e.g.,), and the professional’s scientific background. It is necessary and
recommended to consider those aspects as well.

2.4. Surgical Approach and Clinical Recommendations

Since tissues have different behaviors due to various characteristics, it is implicit that
soft tissue management must be individualized according to the STA (CEJ–BC and FGM)
and periodontal phenotype. Table 2 presents suggestions for surgical approach and strategy
based on the phenotype; this suggestion can better guide the clinicians for CL development.
It is worth remembering that the CL procedure, mainly when developed in the esthetic
area, is a high-level complexity treatment, and this review presents a simplified strategy to
permit an increase in knowledge. All periodontal measurements must be obtained prior to
any surgery.

Table 2. Simplified surgical approaches and strategies suggested/recommended according to peri-

odontal phenotype [54].

Periodontal Phenotype (Gingival Surgical Approach (Sorted by the

Surgical Strategies
Phenotype and Bone Morphotype) 1st Option Recommended)
No flap (flapless) or
A1—Thin and scalloped CEJ–BC distance: 1–2 mm
careful partial flap *
A2—Thick and scalloped Partial thickness flap or flapless CEJ–BC distance: 2–3 mm
B—Thick and flat Full thickness flap CEJ–BC distance: 3–4 mm
CEJ: cement–enamel junction; BC: bone crest. * The careful flap depends on professional experience and use of
adequate instruments and materials.

Periodontium A1, thin and scalloped: in this type of periodontium, where there is a
delicate gingiva, there is the presence of anatomical flaws such as bone dehiscence and
fenestration and instability in the healing of the FGM. Extra attention must be paid to
tissue manipulation, and a minimally invasive technique is recommended, which means
not opening a periodontal surgical flap (i.e., the flapless technique) or, depending on the
professional experience and instruments and materials used, a careful partial flap.
Periodontium A2, thick and scalloped: This type of periodontium presents charac-
teristics of both a thick and a thin periodontium. Therefore, an individualized surgical
approach is necessary for this type of periodontium. To protect against anatomical flaws
and provide access to periodontal structures, a partial-thickness flap, where the periosteum
is adhered to the bone, is recommended.
 where the periosteum is adhered to the bone, is recommended.
the healing process of the FGM appears to be stable, with less contraction of the surgical
Periodontium B: The surgical approach to this type of periodontium
wound. There is often a need for osteotomy and the removal of horizontal bone volume,
from the other two periodontal phenotypes. Anatomical characteristics, su
not just a vertical osteotomy, to preserve the supracrestal tissues. For this situation, we
Surgeries 2024, 5 and dense gingiva and tissue resistant to injuries, can be used as1048 justificat
recommend opening a full-thickness flap.
the healing process of the FGM appears to be stable, with less contraction o
Three clinical scenarios are described below, presenting different strategies and
wound. There is often a need for osteotomy and the removal of horizontal
surgical approaches after observing
Periodontium the surgical
B: The phenotype.approach to this type of periodontium should differ
not
from
just
the
a vertical
other two
osteotomy,
periodontal
to preserve
phenotypes. Anatomical
thecharacteristics,
supracrestal tissues. For this
Clinical case 1—phenotype A1, thin and scalloped: For patients such with as fibrous
a thin
recommend
and dense gingiva opening
and tissuea full-thickness flap.
resistant to injuries, can be used as justification. Likewise,
periodontal phenotype, a flap
the healing is not
process of indicated;
the FGM only
appears to thestable,
be removal of contraction
with less the marginal of thegingival
surgical
Three clinical scenarios are described below, presenting different s
tissue through gingivectomy
wound. There and gingivoplasty
is often is shown
a need for osteotomy and the to avoid
removal the risk bone
of horizontal of exposing
volume,
surgical approaches after
notfenestration
just a vertical osteotomy,
observing
to preserve
the phenotype.
theflaps.
supracrestal tissues. For chisels
this situation, we
bone dehiscence and and damage to thin Working with to better
Clinical case 1—phenotype
recommend opening a full-thickness flap. A1, thin and scalloped: For patients
contour the bone margin or piezoelectric
Three clinical ultrasound
scenarios are adescribed with thin and calibrated tips is
periodontal phenotype, flap is below, presenting different
not indicated; only the strategies
removal and surgi-
of the mar
possible (Figure 1).cal approaches after observing the phenotype.
tissue through gingivectomy and gingivoplasty is shown to avoid the ris
Clinical case 1—phenotype A1, thin and scalloped: For patients with a thin periodontal
bone dehiscence
phenotype, a flap is notand fenestration
indicated; and damage
only the removal to thin
of the marginal flaps.tissue
gingival Working
through with ch
gingivectomy and gingivoplasty is shown to avoid the risk
contour the bone margin or piezoelectric ultrasound with thin and caliof exposing bone dehiscence
and fenestration and damage to thin flaps. Working with chisels to better contour the bone
possible (Figure 1).
margin or piezoelectric ultrasound with thin and calibrated tips is possible (Figure 1).

Figure 1. A patient presenting phenotype A1. Use of tunneled osteotomy with a piezoelectric
device.

Clinical case 2—phenotypeA patient

Figure 1. 1.
A2, thick
presenting
and scalloped:
phenotypephenotype
The osteotomy
A1. Use of tunneled
technique used for patients
with a piezoelectric device.
Figure A patient presenting A1. Use of tunneled osteotomy with a pie
with an intermediate periodontal phenotype is a split flap (partial thickness flap). This
device.
way, we can assess theClinical
height case 2—phenotype A2, thick and scalloped: The technique used for patients
of the bone crest without the risk of exposing anatomical
with an intermediate periodontal phenotype is a split flap (partial thickness flap). This way,
accidents such as dehiscence
we canClinical and
assess the bone
height fenestrations.
of the If the
bone crest without necessary,
risk osteotomy
of exposing anatomical should be
case 2—phenotype A2, thick and scalloped: The accidents
technique use
performed to establish biological
such as dehiscence space
and bone (Figure 2). If necessary, osteotomy should be performed to
fenestrations.
with anbiological
establish intermediate periodontal
space (Figure 2). phenotype is a split flap (partial thickn
way, we can assess the height of the bone crest without the risk of exposin
accidents such as dehiscence and bone fenestrations. If necessary, osteoto
performed to establish biological space (Figure 2).

Figure 2. A patient presenting phenotype

Figure 2. A patient A2,phenotype
presenting followingA2,the surgical
following strategy
the surgical respecting
strategy respectingthe
the distance
distance
of 3 mm from the CEJofto thefrom
3 mm BC.the CEJ to the BC.
Clinical case 3—phenotype B, thick–flat: for patients with a thick and flat periodontal
phenotype, the technique used is the reflection of a full-thickness flap to observe the height
Figure 2. Acrest
of the bone patient presenting
and reposition it atphenotype A2, following
the appropriate the surgical
height to re-establish the strategy
biologicalrespect
of 3 mm
space from thetissue
(supracrestal CEJ attachment)
to the BC. using osteotomy and osteoplasty (Figures 3 and 4).
Surgeries 2024, 5, FOR PEER REVIEW 7
Clinical case 3—phenotype B, thick–flat: for patients with a thick and flat periodontal
phenotype, the technique used is the reflection of a full-thickness flap to observe the height
Surgeries 2024, 5 of the bone crest and reposition B,
it thick–flat:
at the appropriate
Clinical case 3—phenotype for patientsheight
with a to re-establish
thick the biological
1049
and flat periodontal
space (supracrestal
phenotype, tissue attachment)
the technique using osteotomy
used is the reflection and osteoplasty
of a full-thickness (Figures
flap to observe 3 and 4).
the height
of the bone crest and reposition it at the appropriate height to re-establish the biological
space (supracrestal tissue attachment) using osteotomy and osteoplasty (Figures 3 and 4).

Figure 3. 3.
Figure AA patient
patientpresenting
presenting phenotype
phenotype BBthat
thatcan
canbebe removed
removed by 4by
mm 4 mm (CEJ–BC)
(CEJ–BC) following
following the the
Figurestrategy.
surgical 3. A patient presenting phenotype B the
thattrans-surgical
can be removed by 4 mmwhere
(CEJ–BC) following the
surgical strategy. Surgical picture showing the trans-surgical moment, where the alveolar bone was was
Surgical picture showing moment, the alveolar bone
surgical
being strategy.
removed; Surgical picture showing the trans-surgical moment, where the alveolar bone was
being removed;1 1mmmmmore
more needs tobe
needs to becut
cuttotoachieve
achievethethe desired
desired result.
result.
being removed; 1 mm more needs to be cut to achieve the desired result.

Figure 4. Another case of phenotype B is being demonstrated (initial picture, trans-operative picture,
Figure 4. Another caseofofphenotype
phenotype B
Figure 4. Another case B isisbeing
beingdemonstrated
demonstrated (initial picture,
(initial trans-operative
picture, picture,
trans-operative picture,
and final picture)
picture) to
to exemplify
exemplify and
and illustrate
illustrate the
the surgical
surgical strategy
strategy proposed.
proposed.
and final picture) to exemplify and illustrate the surgical strategy proposed.
3. Discussion
3. Discussion
3. Discussion
3.1. Periodontal Phenotypes
3.1. Periodontal Phenotypes
3.1. Periodontal Phenotypes
The concept of periodontal phenotype has gained significant attention in dentistry,
The concept of periodontal phenotype has gained significant attention in dentistry,
particularly with respect to understanding its implications for periodontal health and
The concept
particularly withofrespect
periodontal phenotypeits
to understanding hasimplications
gained significant attention
for periodontal in dentistry,
health and
treatments. It encompasses gingiva (gingival thickness, width, and morphology) and un-
particularly
treatments. withIt respect to gingiva
encompasses understanding (gingival its implications
thickness, width, for
andperiodontal
morphology) health
and and
derlying alveolar bone characteristics, which are influenced by genetic and environmental
treatments.
underlying
factors. It alveolar
encompasses
Therefore, it is worth gingiva
bone highlighting (gingival
characteristics, which
that primary thickness, width,
are influenced
measures must beandby morphology)
genetic
correctly and and
obtained
environmental
underlying factors.
alveolar Therefore,
bone it is worth
characteristics, highlighting
which that
are
(i.e., the distance between the CEJ and the CB, the position of the FGM) to support the sur- primary
influenced measures
by must
geneticbe and
correctly
environmental obtained (i.e., the
factors. Therefore,
gical strategy adopted. distance
Recent studies between
it ishave
worth the CEJ and
highlighting
emphasized the CB, the position
that primary
the importance of the
measures the
of recognizing FGM)must be
to support
correctly
periodontal the
obtained surgical
phenotype strategy
(i.e., the
at a distanceadopted.
site-specific between Recent
level asthe studies
CEJ and
variations have emphasized
the
exist the importance
CB, thedifferent
between position of the
teeth andFGM)
of recognizing
regions within the
the periodontal
mouth, which phenotype
can leadat toamore
site-specific level as variations
individualized and effective existtreatment
between
to support the surgical strategy adopted. Recent studies have emphasized the importance
different teeth
approaches [55,56]. and regions within
For instance, the mouth,
a study demonstrated which can lead
that 25% to more individualized and
of recognizing the periodontal phenotype at a site-specific levelofaspatients exhibited
variations existtwo
between
effective treatment approaches [55,56]. For instance, a study
distinct periodontal phenotypes across different teeth, suggesting a need for individualized demonstrated that 25% of
different
patients teeth and regions
exhibited two within
distinct the mouth,
periodontal which can
phenotypes leaddifferent
across to moreteeth,
individualized
suggesting and
clinical assessment [55]. The periodontal phenotype’s role in surgical decision-making and
effective
a need treatment
foron approaches [55,56].
individualized For instance, a study demonstrated that in25% of
its impact the prognosis clinical assessment
of periodontal [55]. The
procedures has periodontal
fundamentalphenotype’s
importance. role In this
patients exhibited
surgicalitdecision-making
regard, two distinct
also plays a crucial androle periodontal
its in
impact
overall phenotypes
onperiodontal
the prognosis across different teeth,
of periodontal procedures has
health. suggesting
a need for individualized
fundamental
Some importance.
authors clinical
In
have demonstrated assessment
this regard, it also
the [55]. aThe
plays
importance periodontal
crucial phenotype’s
role in overall
of accurately assessing periodontal
the peri-role in
surgical
health.decision-making
odontal phenotype beforeand its impact
surgical procedures. on the prognosis
A thicker of periodontal
gingival phenotype isprocedures
generally has
Some with
fundamental
associated authors
importance.
betterhave Indemonstrated
this regard,
periodontal itthe
also
health outcomes, importance
plays of accurately
a crucial
providing role in
greater assessing
overall
resistance the
periodontal
to peri-
periodontal phenotype before surgical procedures. A
odontal breakdown [28,57,58]. Conversely, a thin gingival phenotype is usually associated
health. thicker gingival phenotype is
generally
withSome associated
increased
authors with better
susceptibility
have toperiodontal
periodontalthe
demonstrated health
disease,outcomes, providing
with a heightened
importance greater
of accuratelyrisk ofresistance
gingival the
assessing
to periodontal
recession and breakdown
bone dehiscence [28,57,58].
[58,59]. Conversely,
This a thinunderscores
relationship gingival phenotype
clinicians’ is need
usually
to
periodontal phenotype before surgical procedures. A thicker gingival phenotype is
associated
evaluate thewith increasedphenotype
periodontal susceptibility beforeto periodontal disease, with
initiating treatment a heightened
planning [60]. Thus, riskthe
of
generally associated with better periodontal health outcomes, providing greater resistance
gingival recession
periodontal phenotype and is bone dehiscence
an essential [58,59].to
parameter This relationship
be identified underscores
in the clinicians’
surgical planning to
to determine
periodontal
need the breakdown
to evaluate the periodontal
surgical–therapeutic[28,57,58]. Conversely,
phenotype
approach before
for ainitiating
the “gummythin gingival
treatment
smile.” phenotype
planning is[60].usually
associated with increased susceptibility to periodontal disease, with a heightened risk of
gingival recession and bone dehiscence [58,59]. This relationship underscores clinicians’
need to evaluate the periodontal phenotype before initiating treatment planning [60].
Surgeries 2024, 5 1050

3.2. Classification and Correlations

Among the various existing classifications, the one proposed by De Rouck et al. [40] is
currently recommended. This classification defined three distinct groups: thin–scalloped;
thick–scalloped; and thick-flat. This classification seems to better categorize the definition
of phenotypes in the population with permanent teeth [24]. Moreover, alveolar bone
morphology, which is considered another critical component of the periodontal phenotype,
has been shown to correlate with the gingival phenotype. The thickness of the buccal
bone plate varied significantly among individuals and was influenced by the position of
the teeth in the arch [57,58]. This variation can affect the treatment approach, especially
in cases involving periodontal surgery, where the integrity of the surrounding bone is
paramount [56,57].
The interplay between gingival and alveolar bone phenotypes requires a comprehen-
sive evaluation to ensure optimal treatment outcomes. Studies have also explored the
role of immune responses in periodontal health, mainly focusing on the polarization of
macrophages within the periodontal tissues. The balance between M1 (pro-inflammatory)
and M2 (anti-inflammatory) macrophages is crucial in the context of periodontal disease [61];
its imbalance may lead to exacerbated tissue destruction [62–64]. For instance, studies have
indicated that hyperglycemia can skew the macrophage polarization toward the M1 pheno-
type, worsening periodontal inflammation in diabetic patients [62,65]. This highlights the
importance of considering systemic health factors when assessing periodontal phenotypes
and their implications for treatment.

3.3. Periodontal Phenotype and STA

Understanding the relationship between the CEJ, BC, and FGM, which will result in
the STA, is necessary for an individualized surgical approach. The distance from the CEJ to
the CB and the position of the FGM are required. Secondarily, the periodontal phenotype
needs to be verified to permit the preparation of the surgical planning, i.e., whether it will
follow only gingivectomy or involve osseous resection/contouring. Hence, it is possible to
individualize the treatment according to the phenotype.
Some studies have evaluated the relationship between the STA and the periodontal
phenotype. Arora et al. [51,53] classified the phenotype as thick–flat and thin–scalloped,
observing the transparency of the periodontal probe. STA measurements were significantly
more significant in the thick–flat phenotype, and there was a positive correlation between
the size of the STA and gingival thickness. Ghahroudi et al. [66] also observed that patients
with a thick periodontal phenotype had larger STA dimensions.
The strategies and surgical approaches proposed/suggested/recommended by the
present review apply those findings to the surgical techniques in order to correct and
treat the “gummy smile”. Consequently, they will increase the clinical crown in esthetic
areas, considering an individualized treatment plan to optimize the outcomes, avoiding or
reducing failures and complications, and increasing the predictability of the results.
Some studies evaluated the behavior of the tissue related to the STA after a surgical
procedure to increase the clinical crown length. They demonstrated that the STA showed
reduced measurements in the initial healing period. It was re-established throughout
3 to 6 months, with a slight clinical attachment gain and resorption of the bone crest in the
apical direction [67–69]. This resorption was correlated with the need to create space to
achieve the readaptation of the STA [70].
This review’s recommendation/suggestion regarding the final distance necessary
between the CB and the CEJ after ostectomy to re-establish the STA vary according to the
phenotype: (A1) CEJ−CB = 2 mm; (A2) CEJ−CB = 3 mm; and (B) CEJ−CB = 4 mm. As
Mele et al. [71] reported, other authors have made general considerations for this distance
without personalization. Levine and McGuire [72], Claman et al. [73], and Abou-Aray
and Souccar [74] suggested a distance of ≥3 mm between the BC and the gingival margin;
Batista et al. [75] and Ribeiro et al. [76] suggested a distance of 3 mm from the BC to the
CEJ. Other authors reduced this measure: Cairo et al. [77] and Zucchelli [78] considered
Surgeries 2024, 5 1051

keeping 1 mm; whereas Camargo et al. [79] and Rossi et al. [80] suggested 2 mm; and
finally, Dolt and Robbins [81] and Robbins [82] suggested a distance between the BC and
the CEJ of 2.0–2.5 mm.

3.4. Flapless Technique, Piezoeletric, and Laser

The most complex technique option, the flapless technique, performs an intra-gingival
sulcus osteotomy using micro-chisels, a piezoelectric device, or a small diamond-round bur
to treat the patient [83]. The results are favorable and more predictable, permitting better
soft tissue healing, reduced surgical time, no sutures, and less postoperative discomfort,
mainly for A1 phenotype (thin) cases and KTW of at least 3 mm. This technique should be
avoided in patients with thick and flat phenotypes; these patients require a more precise
and well-designed osteotomy in order to achieve a better adaptation of the soft tissues,
mainly in the cervical area and region of the papillae [84].
Specifically for piezoelectric bone surgery, a bloodless site and decreased undesir-
able inflammatory responses (edema and pain) are achieved, and the osteotomy can be
considered more predictable [85,86]; the microvibrations allow for a precise cut of only
mineralized tissue without damaging soft tissues, even in accidental contact, mainly when
using a specific periodontal tip with a 3 mm level that guides the clinician to a more accurate
and safer osteotomy.
Regarding the laser (Er,Cr: YSGG [erbium, chromium: yttrium–scandium–gallium–
garnet; 2780 nm]) used for periodontal surgeries [87], it involves the concept of minimally
invasive surgical procedures [88,89]. It is more precise than rotary instruments, causing less
collateral and thermal damage to the root surface [90]. It ablates hard and soft tissues with
excellent surgical precision and minimal collateral effects. Therefore, precautions should be
taken to ensure a safe and efficient osteotomy, such as the use of a specific tip (prism chisel
tip) and enhancing the laser parameters that could help in cooling (a short pulse duration
[60 µs], fewer pulses [20 Hz], and more water irrigation). The Er,Cr: YSGG laser-assisted
surgical procedure can be considered predictable, providing similar outcomes when using
a flap or flapless approach.

3.5. Tissue Healing After Surgery and Final Considerations

Regarding tissue growth during healing after clinical CL surgery, Arora et al. [53]
demonstrated that after 6 months, there was greater post-surgical average tissue growth
related to the thick–flat phenotype (0.70 ± 0.51 mm) compared to the thin–scalloped
phenotype (0.37 ± 0.46 mm). Likewise, Pontoneiro and Carnevale [85] also observed that
patients with a thick phenotype showed greater tissue growth coronally after a 12-month
follow-up. In this way, that our approach considers the STA in a varied way and is
associated with a specific type of phenotype is justified in that the surgical approach results
are more predictable and stable.
In this context, the surgical–therapeutic approach to the “gummy smile” must consider
the relationship between the periodontal phenotype and the STA; then, the analysis of
these parameters guides the execution of surgical techniques. Moreover, this review
presents safe/secure suggestions for professionals on how to acquire more predictability
in the results of esthetic CL. Sometimes, different approaches can be performed, mainly
depending on the professional’s surgical experience, which will use a full-thickness flap
in a thin phenotype, for example, and obtain a satisfactory result. However, it is worth
highlighting that this article suggests means of better approaching the patient with a greater
chance of success.

4. Conclusions
It is possible to conclude that individualized assessments of specific measurements
(distance between the CEJ and the CB; the position of the FGM) and periodontal phenotypes
are essential for tailoring effective treatment strategies. Surgical approaches must be defined
according to individualized planning since several variables can influence the dynamics
Surgeries 2024, 5 1052

of the STA. Moreover, specific characteristics regarding culture, aesthetic values, and the
school the professional graduated from might interfere with the desired outcome and
should be assessed.

Author Contributions: Conceptualization, S.K., W.J.d.P.R.R. and A.T.D.; methodology, S.K., W.J.d.P.R.R.,
A.T.D. and G.V.O.F.; software, ø; validation, S.K., W.J.d.P.R.R., A.T.D., R.R., J.C.H.F. and G.V.O.F.;
formal analysis, S.K., W.J.d.P.R.R., A.T.D., R.R., J.C.H.F. and G.V.O.F.; investigation, S.K., W.J.d.P.R.R.,
A.T.D., R.R., J.C.H.F. and G.V.O.F.; resources, S.K., A.T.D., J.C.H.F. and G.V.O.F.; data curation, S.K.,
W.J.d.P.R.R., A.T.D., R.R., J.C.H.F. and G.V.O.F.; writing—original draft preparation, S.K., W.J.d.P.R.R.,
A.T.D., R.R., J.C.H.F. and G.V.O.F.; writing—review and editing, S.K., W.J.d.P.R.R., A.T.D., R.R.,
J.C.H.F. and G.V.O.F.; visualization, S.K., W.J.d.P.R.R., A.T.D., R.R., J.C.H.F. and G.V.O.F.; supervision,
S.K. and G.V.O.F.; project administration, S.K., A.T.D. and G.V.O.F.; funding acquisition, ø. All authors
have read and agreed to the published version of the manuscript.
Funding: There was no funding associated with this study.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Data Availability Statement: The original contributions presented in the study are included in the
article, further inquiries can be directed to the corresponding author.
Conflicts of Interest: The authors declare no conflicts of interest.

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