One area that often becomes an interdisciplinary dilemma is the management of dentogingival discrepancies, such as uneven gingival levels. Interestingly, these issues may be successfully addressed through adjunctive orthodontic therapy or surgical procedures like gingivectomy or clinical crown lengthening. Both disciplines may successfully reposition the tissues, attaining more aesthetically pleasing results. However, there are important nuances that should be highlighted to reach a desired solution and convey these to the patients so they can ultimately agree on the best route of treatment.

A Dentogingival Discrepancy Case Study via the Buyer’s Journey

An image shows uneven gingival levels
Figure 1: A visual representation depicting uneven gingival levels.

This patient presented to our dental office with a chief concern associated with her desire to have a more pleasing smile. She was told elsewhere that she needed ceramic veneers in her front six teeth to enhance her smile but wanted to explore more treatment options.

To guide our patient, we normally rely on the buyer’s journey protocol, which walks the patient through a linear three-stage process:

  1. The awareness stage (understand the nature of the problem),

  2. The consideration stage (entertain the different routes of treatment), and

  3. The decision stage.

It is important to mention that when patients express desire to have an esthetic treatment, the treating team needs to understand what their motivation behind this is, and what area(s) do they specifically want to correct.

Therefore, the way we enter the esthetic awareness stage is by walking them through the four generically different potential areas. Utilizing our systematic approach, we go to our esthetic checklist consisting of evaluating the following:

  • Color or tooth shade

  • Contour or tooth shape, where we look for short, worn teeth or if they are square, oval, or triangular

  • Arrangement, which involves alignment, is how one tooth relates to the others

  • Position, which is how teeth fit in the smile

If the esthetic concern falls into the position area, we then continue to describe the more specific potential tooth position discrepancies. These discrepancies are often the cause of esthetic dilemmas.

We break down the position into five essential elements.

  1. Midline

  2. Incisal edge

  3. Occlusal plane

  4. Buccal corridor, and

  5. Gingival levels

An important aspect to remember when walking patients through the esthetic awareness stage is that in most cases, the relevance of these parameters is commensurate with the dynamics of their upper lip, which may influence each parameter differently.

An image depicting a contour discrepancy associated with the two central incisors
Figure 2: Photo of contour discrepancy associated with the two central incisors.

When closely looking at all these parameters, we notice there is a contour discrepancy associated to the two central incisors. The incisal edges appear worn, and the tooth proportion is off. Normally, we’d like to see a width to length ratio within 75 to 80%. In her case, it seems more like 60% so there is a short clinical crown.

An image showing a comparison between the ideal width-to-length tooth ratio and that of the patient's
Figure 3: Image comparing ideal width-to-length tooth ratio to that of the patient's.

When it comes to arrangement, the alignment does not appear to be all that harmonious, with the lateral incisors being a bit flared facially.

And as far as position goes, all parameters appear to be in good shape (midline, incisal plane, occlusal plane, buccal corridor) except for the gingival levels of the central incisors. These appear to be a few millimeters more coronal than what we would expect them to be. As we see the patient smiling, this does create some visual tension and an esthetic discrepancy.

What seems to have happened here is a compensatory eruption of the centrals as the incisal edges were worn.

There is also gingival recession associated with the maxillary left canine.

So now we need to convey these findings as part of the awareness stage.

Once the patient is clear regarding such discrepancy, we can then do a mockup addressing only the two central incisors, by augmenting facial contour and bringing the gingival margin a few millimeters more apical. This now gives the patient an idea of where we want to go. Now, we move forward to the consideration stage.

Surgical v. Orthodontic Options for Uneven Gingival Levels

A series of images showing the progression from the patient's pre-treatment central incisors to the crown lengthening veneer, and finally to the post-treatment central incisors
Figure 4: (A) Patient's pre-treatment central incisors, (B) Crown lengthening veneer, (C) Post-treatment central incisors.

Altering the gingival levels of the two central incisors may be accomplished either by a surgical approach, such as gingivectomy or clinical crown lengthening, or via an orthodontic approach involving the intrusion of the central incisors and alignment of the teeth, followed by the placement of two ceramic veneers.

So as part of our consideration stage we go through the pro-con list of doing each one of these solutions which looks something like this:

 

Crown Lengthening

Orthodontic Intrusion Protocol

Pro: The main advantage here would be not having to utilize orthodontic appliances and probably the overall treatment time would be within 4 months.

Con: Crown lengthening may get the tissue where we want it, but based on the position of the CEJ we would likely expose cementum which may decrease the predictability of our bonded ceramics.

Pro: Doing the orthodontic intrusion protocol, would;

  1. reposition the gingival margin where it belongs esthetically, and

  2. give us the possibility of bonding our veneer in enamel which increases the overall long-term predictability of the restoration.

Con: The main disadvantage for the patient is that the orthodontic therapy would require a longer period of time, more towards 9 months of therapy.

 

A connective tissue graft was also proposed to correct the gingival recession associated to the left canine.

From a communication standpoint, the key is spending enough time with patients to make sure they understand the implications that both solutions entail. This helps outweigh the need for immediate gratification for the more long-term predictable outcome by giving the patient more context in order to reach the decision stage.

Photos of the orthodontic approach to dentogingival discrepancies
Figure 5: Photos of the orthodontic approach to dentogingival discrepancies.

Fortunately, the patient was able to comprehend that orthodontics was the best approach as it would reposition the gingival margins to their original position and we moved forward with the orthodontic intrusion of the centrals, as you can see in the above images.

In these situations, it is important to do some interim composite bonded restorations at the incisal edges of the centrals. This provides an esthetic provisional solution that compensates for the incisal offset produced by the intrusion. Particularly, since there is a stabilization period of three months, we proceeded with a minimally invasive preparation. We mainly fabricated additive restorations.

We had proposed to the patient addressing the gingival recession of the left canine by means of a connective tissue graft. The patient opted to do a composite restoration to mask the shade discrepancy in the meantime and delay the possibility of a surgical approach.

In this picture you will notice the preparations and the provisional restorations, and finally impressions were made, and two feldspathic ceramic veneers were fabricated and bonded in place.

An image demonstrating minimally invasive preparations
Figure 6: Minimally invasive preparations.

 

An image showing the placement of a retraction cord before making the impression
Figure 7: Retraction cord is placed prior to making the impression.

 

An image depicting the provisional restorations in place
Figure 8: Provisional restorations in place.

 

An image illustrating the fabrication process of felspathic ceramic restorations
Figure 9: Fabrication of felspathic ceramic restorations.

 

A series of four images displaying the post-treatment results
Figure 10: Post-treatment results (a-d).

Choosing the Right Approach to Gingival Level Esthetic Discrepancies

Correcting uneven gingival level esthetic discrepancies can be approached either by implementing a surgical or an orthodontic protocol.

Choosing which is the more favorable approach depends upon:

  1. The need to restore (if there is incisal wear) the teeth.

  2. The actual location of the CEJ.

Exposing cementum decreases the predictability of bonded restorations; therefore, the orthodontic approach would be preferred in these cases. In an era when patients often prioritize the least time-consuming approach, it becomes imperative to (paradoxically) spend enough time educating patients to understand the rationale for choosing orthodontic adjunctive therapy.

Using the buyer's journey as a way to guide the patient through the value of longer-term treatment for resolving dentogingival discrepancies helps the patient understand all the options. By educating patients about the benefits of comprehensive treatment, including orthodontic and surgical approaches, practitioners can empower them to make informed decisions that prioritize long-term oral health and esthetic outcomes.

Ricardo Mitrani, D.D.S., M.S.D., is a Spear Resident Faculty member.


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