Insight 106 — Gingival Lift: Why Removing Gingiva Alone Is Sometimes Not Enough
A patient comes in unhappy that their anterior teeth look short. We decide to lengthen the crowns with a gingival lift and then move on to laminates or composite. But before deciding how much gingiva to remove, there is a more important question: where is the bone beneath this gingiva?
Not all the tissue we see over the crown is excess gingiva. Part of it is needed to maintain the natural attachment of the gingiva to the tooth; what for years we knew as Biologic Width, and what the new classification of periodontal diseases calls Supracrestal Tissue Attachment.
If we shorten the gingiva without regard for this attachment, the result on the day of surgery may be completely different from the result a few months later.
When can we remove only gingiva?
When the bone position is favorable and soft tissue sits excessively over the crown, a gingivectomy can expose more of the crown, provided enough room remains for the natural attachment of the tissues.
But sometimes the bone crest is so close to the CEJ that there is not enough room to move the gingival margin apically. If we remove only gingiva in this situation, it may migrate back toward its previous position during healing, a phenomenon we call rebound.
The problem becomes more serious when the margin of the laminate or crown is also placed at the new position. If the margin enters the zone of the supracrestal attachment, we may face chronic inflammation, bleeding, tissue loss or recession. In other words, to make the crown longer, we have put periodontal health and the esthetic result at risk.
How do we know whether bone must be removed too?
One practical method is bone sounding under anesthesia. With a probe we locate the bone crest and measure how much distance to the bone would remain if the gingival margin were moved to the desired position.
A figure of about 3 mm is usually put forward as a clinical guide, but it is not a fixed rule for every patient. Sulcus depth, tissue thickness and the position of the CEJ also matter in our decision.
If there is not enough room, we may need crown lengthening with bone recontouring (osseous crown lengthening), not merely gingival removal. This is especially true in patients with thick gingiva, in whom the gingiva is more likely to rebound during healing.
The point is that a gingival lift is not just about moving the gingival margin; we have to be sure the tissues can stay healthy and stable in their new position.
So before deciding how many millimeters of gingiva to remove, we need to know how many millimeters we are from the bone.
This page is intended for educational use by dentists and dental students.