The Effect of Using Two Different Suturing Techniques on Free Gingival Marginal Stability After Esthetic Crown Lengthening for Treatment of Gummy Smile (Randomized Clinical Trial)
Phase: NA
Conditions: Altered Passive Eruption of Teeth
Sponsor: Ain Shams University

The Effect of Using  Two Different Suturing 
Techniques on Free Gingival  Marginal Stability  
after Esthetic Crown Lengthening for Treatment 
of Gummy Smile  
(Randomized Clinical Trial) 
 
Methodology 
 
 
Document date: 3 /1/2020 

                                                 Material and Method
 
 
26 
 
 
Sample selection and assignment: 
   Thirty patients (26 females, 4 males), who were 
candidates for esthetic crown lengthening, participated in 
this prospective clinical trial. 
    The subject was recruited consecutively from the 
outpatient clinic of Oral Medicine, Periodontology, oral 
Diagnosis and Radiology Department, Faculty of Dentistry, 
Ain Shams University and faculty of dental medicine, Misr 
international University. The purpose of the study was 
explained to all patients and an informed consent was 
signed before the conduction of the study.  The proposal 
was presented to the faculty of Dentistry Ain Shams 
University Research Ethics committee and was approved 
before starting the research ()  
Patient selection: 
Inclusion Criteria: 
1. Patients complaining from gummy smile (altered passive 
eruption)  
2. Age range (21-40) years.  

                                                 Material and Method
 
 
27 
 
3. Bone level is 2 mm or less from the cemento enamel 
junction  
4. Teeth included were free from any periodontal 
destruction  
5. Good compliance with the plaque control instructions 
following initial therapy.  
6. Availability for follow up and maintenance program.  
 
Exclusion criteria: 
1. Presence of systemic diseases which could influence 
the outcome of the therapy (American society of 
anesthesiologists I, ASA I). 
2. Patient suffering from periodontitis stage 4 grade C. 
3. Presence of smoking habit. 
4. Presence of occlusal interferences. 
5. Pregnant females and lactating females. . 
6. Vulnerable groups of patients (handicapped, mentally 
retarded and prisoners). 
7.  Restored teeth.  
 
 
 
  

                                                 Material and Method
 
 
28 
 
Grouping Criteria:  
 The study consisted of two groups the number of patient 
was determined by sample size calculation through G 
power analysis (15 patients). Patients were randomly 
selected 
using 
computer 
generated 
randomization 
(www.randomizer.org). 
 
Group 1 (15 patients) (Periosteal suture)  :  
Esthetic crown lengthening procedure: internal bevel, 
sulcular and interdental incisions, flap elevation, bone 
removal then   External vertical mattress suture was done 
(periosteal suture). 
  
Group 2 (15 patients) (Figure of eight suture)  :  
Esthetic crown lengthening procedure: internal bevel, 
sulcular and interdental incisions, flap elevation, bone 
removal then modified interrupted suture was done (Figure 
of eight suture). 
 
 
 
 
 

                                                 Material and Method
 
 
29 
 
III- Assessments: 
1-Clinical parameters: 
For the selected sites, the following clinical parameters 
were assessed preoperative (baseline) 3 and 6 months after 
surgical procedure. 
1. Plaque index Silness and Löe 1964 
2. Gingival Index Löe and Silness 1963. 
3.  Probing depth (PD) Glavind and Loe, 
1967 
4. Length  of Attached gingiva 
2-Esthetic outcome evaluation: 
The following parameters were assessed 1, 3 and 6 months 
after surgical procedure: 
 Level of the gingival margin (GM) through 
measurement of the crown length from the reference 
point in the surgical stent to the gingival margin 
(Deas et al., 2004). 
 Marginal tissue contour (MTC) using root coverage 
esthetic score (RES) system (Cairo et al. 2009): Zero 
points = irregular gingival margin (does not follow 
the CEJ); 1 point =proper marginal contour/ 
scalloped gingival margin (follows the CEJ).  

                                                 Material and Method
 
 
30 
 
 Papillary fill using classification of papillary fill 
(Jemt 1997) which it’s score is as follows: 
PIS1: entire papilla missing, lack of convexity  
PIS 2: fills less than the interdental space, slight 
convexity. 
PIS 3: fills more than half the interdental space but 
no complete fill 
PIS 4: papilla fills the entire space, harmonic 
gingival contour 
PIS 5: hyperplastic papilla covering too much tooth 
structure, irregular tissue contour 
 Patient satisfaction prior surgery and 6 months post-
surgery (Silva et al., 2015). 
Patient satisfaction criteria  
Prior to surgery  
 How would the patient rate the gun shown when 
smiling, size of the upper teeth, the length of 
upper teeth and the width of it (way too little, 
too little, about enough and too much way too 
much) 
After surgery 
 Is the patient satisfied with the gingival display 
during talking and smiling, teeth display during 

                                                 Material and Method
 
 
31 
 
talking 
and 
smiling 
(not 
at 
all, slightly, 
somewhat, very and extremely). 
 How was the procedure experience (much 
worse, worse, same as I thought, better and 
much better). 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

                                                 Material and Method
 
 
32 
 
Presurgical therapy: 
 Full 
Conventional 
periodontal 
treatment 
including supra, subgingival scaling and root 
planning were performed using hand scalers and 
curettes. 
 Oral hygiene instructions( regular brushing 3 
times/day, flossing and using mouthwash ) were 
repeated until patients had achieved a proper 
level of oral hygiene where plaque index (PI) ≤ 
1. 
 Teeth were examined for caries, periapical 
infection and restorative procedures in order to 
be treated. 
 Assessment parameters were recorded prior to 
surgery using UNC-15* manual probe (Hu 
Friedy)  
 Alginate impressions were made 4 weeks 
following initial therapy of each maxillary arch 
to fabricate customized probing stents. Full-arch 
probing stents were made on stone casts Stents 
were trimmed to the height of contour, and 
                                                                
 
* PCPUNC15 Single-ended, color-coded probe. ergonomic handle. University of 
North Carolina, Hu Friedy, USA. 
 

                                                 Material and Method
 
 
33 
 
grooves were placed at sites to be measured with 
a narrow fissure bur to act as reference points for 
clinical parameters assessment. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

                                                 Material and Method
 
 
34 
 
(IV) Surgical procedures 
Group (1)  
1) Anesthesia 
(Articaine 
HCL 
4% 
containing 
epinephrine at a concentration of 1:100,000)† was 
administrated at the selected teeth. 
2) The tooth width to length ratio was determined 
according to the golden proportions (RED: The 
successive width proportion, when viewed from the 
facial aspect, should remain constant as we move 
posteriorly from the midline) (Ward 2001) 
3) Bone sounding was done( patient was given 
anesthesia probing until  the bone level was done 
using UNC-15‡ manual probe )   to determine the 
bone position in relevance to the CEJ position then  
bleeding points were done to determine the amount 
of the gingival tissue that was removed  
                                                                
 
† Artinibsa 4%cartouches de 1.8ml ,inibisa dental. 
‡ PCPUNC15 Single-ended, color-coded probe. ergonomic handle. University of 
North Carolina, Hu Friedy, USA. 
 

                                                 Material and Method
 
 
35 
 
4) Primary 
submarginal 
incision, 
secondary 
intrasulcular then tertiary incision at the papillary 
area were done using the surgical blade (15c)§  
5) Full thickness flap reflection at the crestal bone area 
using mucoperiosteal **elevator was done, while at 
the papillary area partial thickness flap using the 
surgical blade (15c)†† was done. 
6) After flap reflection the supracrestal soft tissue 
were removed using surgical curette‡‡ (universal 
curette 2R/2L,4R/4L) 
7) Ostectomy 3mm from the cemento enamel junction 
were performed using end cutting burs§§. Root 
surfaces were scaled to remove remnants of 
supracrestal connective tissue fibers.  
8) Flap was repositioned by external vertical mattress 
(periosteal 
suture) 
suturing 
technique 
using 
resorbable 5-0 vicryl sutures*** 
 
                                                                
 
§ Trinon sterile scalpel Blades ,lot0483,Germany 
** Buser Periosteal handle #6, Hu- Friedy, USA. 
†† Trinon sterile scalpel Blades ,lot0483,Germany 
‡‡ Universal  Curettes(2R/2L),(4R/4L), Hu-Friedy ,USA 
§§  Midwest operative Carbide burs,FG,End cutting, #957,1.0mmdiamter,3.7mm 
length,10/Pkg,Dentsply Midwest,Patterson item#493-0079,Mfg item#:389278.  
*** Assut Sutures, Absorbabale (PGA) 5-0 USP, braided violet coated 3/8 
rev.cutt.17mm, AM trading. 

                                                 Material and Method
 
 
36 
 
 
Fig (3): Showing diagram for the periosteal suture 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

                                                 Material and Method
 
 
37 
 
Group (2)  
1) Anesthesia 
(Articaine 
HCL 
4% 
containing 
epinephrine at a concentration of 1:100,000)††† was 
administrated at the selected teeth. 
2) The tooth width to length ratio was determined 
according to the golden proportions (RED). 
3) Bone sounding was done to determine the bone 
position to in relevance to the CEJ position then  
bleeding points were done to determine the amount 
of the gingival tissue that was removed  
4) Primary 
submarginal 
incision, 
secondary 
intrasulcular then tertiary incision at the papillary 
area were done. 
5) Full thickness flap reflection at the crestal bone area 
using mucoperiosteal‡‡‡ elevator was done, while at 
the papillary area partial thickness flap using the 
surgical blade (15c)§§§ was done. 
                                                                
 
††† Artinibsa 4%cartouches de 1.8ml ,inibisa dental. 
‡‡‡ Buser Periosteal handle #6, Hu- Friedy, USA. 
§§§ Trinon sterile scalpel Blades ,lot0483,Germany 

                                                 Material and Method
 
 
38 
 
6) After flap reflection the supracrestal soft tissue 
were removed using surgical curette**** (universal 
curette 2R/2L,4R/4L) 
7) Ostectomy 3mm from the cemento enamel junction 
were performed using end cutting burs††††. Root 
surfaces were scaled to remove remnants of 
supracrestal connective tissue fibers.  
8) Flap was repositioned by modified interrupted 
(figure of 8 suture) suturing technique using 
resorbable 5-0 vicryl sutures‡‡‡‡. 
 
 
Fig (4): Showing a diagram for the interrupted modified 
sutur 
                                                                
 
**** Universal  Curettes(2R/2L),(4R/4L), Hu-Friedy ,USA 
†††† Midwest operative Carbide burs,FG,End cutting, #957,1.0mmdiamter,3.7mm 
length,10/Pkg,Dentsply Midwest,Patterson item#493-0079,Mfg item#:389278. 
‡‡‡‡ Assut Sutures, Absorbabale (PGA) 5-0 USP, braided violet coated 3/8 
rev.cutt.17mm, AM trading. 

                                                 Material and Method
 
 
39 
 
V-Postoperative care: 
- All patients had received antibiotic for 1 week 
 ( Augmentin 1 gm every 12 hours§§§§, metronidazole***** 
500gm every 12 hours) and analgesics( Brufen †††††400 
every 8 hours)  were  prescribed for the patient and 
instructed to avoid brushing at the surgical site  
-  Patients were instructed to rinse twice daily with Tantum 
verde◘ mouth rinse or hot saline mouthwash and to avoid 
mechanical plaque removal at the site of surgery 
-  Sutures were removed after 2 week. 
-  Patients were instructed not to brush for 2 weeks and not 
to floss the surgical area for 4 weeks. 
- After 15 days patient were instructed to use modified bass 
technique for tooth brushing (Carranzaa 12th edition) 
 
 
 
 
                                                                
 
§§§§ Augmentin 1gm,Medical union pharmaceuticals( MUP) Egypt under license 
from ,Glaxosmithkline 
*****  Flagyl 500 mg, sanafi Aventis Egypt under license of sanafi Aventis French. 
††††† Brufen 400mg, Al kahira  pharm. and chem..Ind.Co. under license from abbott 
laboratories 
◘ Tantum Verde Mouthwash and Gargle(Benzydamine hydrochloride 0.15g): Bottle 
of 125 ml, Eipico Egypt under license of A.C.R Angelini Francesco.SpA.Italy 

                                                 Material and Method
 
 
40 
 
VI-Postoperative evaluation and assessment: 
 
Monthly recall appointments were scheduled  
-  The follow up period included oral examination, plaque 
and calculus removal when necessary 
- 
Clinical and esthetic parameters were evaluated and 
scored by a separate operator at 1, 3 and 6 months 
postoperative the patient satisfaction was evaluated 6 
months post-operative only 
 All data were statistically analyzed           
VII-Statistical analysis: 
    Statistical analysis was then performed using a 
commercially available software program (SPSS 18; SPSS, 
Chicago, IL, USA). 
   Values were presented as mean, standard deviation (SD), 
median, range and confidence intervals. Data were 
explored for normality using Kolmogorov-Smirnov test of 
normality. For parametric data, Independent t test was used 
for 2 group’s comparisons, while ANOVA test was used to 
compare different observations.  
 

                                                 Material and Method
 
 
41 
 
   Plaque and gingival indices and most values of difference 
and percent change were non-parametric and were 
compared using Mann Whitney U test for intergroup 
comparisons, while Friedman test and Wilcoxon signed 
Rank test were used for intragroup comparisons 
Qualitative data were expressed as frequencies and 
percentages and were compared using Chi square test 
The level of significance was set at P ≤ 0.05.