The young woman arrived with a long-standing concern: crowded upper front teeth, protruding canine teeth, and excessive gum display when smiling. She was only 19 years old, but the lack of confidence caused by her smile had accompanied her for years. At the Universitas Gadjah Mada Dental Hospital, her treatment journey became more than just a matter of wearing braces.
This case was published in the Journal of International Dental and Medical Research (Volume 18, Issue 1, 2025) by a research team from the Faculty of Dentistry, Universitas Gadjah Mada (FKG UGM), including Dr. drg. Dyah Karunia, Sp.Ort., and Dr. drg. Ananto Ali Alhasyimi, MDSc., Sp.Ort., Subsp.DDTK(K), who served as the corresponding author. Their findings emphasize an aspect that is often underestimated in clinical practice: orthodontic treatment alone is not always sufficient.
When Teeth Are Aligned, the Gums May Still Tell Another Story
The patient was diagnosed with Class I malocclusion accompanied by bimaxillary prognathism, a condition in which the anterior teeth of both the upper and lower jaws are positioned further forward than their ideal location. Her facial profile was convex, with a Class II skeletal relationship. Initial examination revealed an overjet of +2.39 mm, an overbite of +1.87 mm, a persistent tooth 63, and an anterior gingival display exceeding 2 mm.
Bimaxillary protrusion is not an uncommon condition, particularly among Asian populations. Genetic factors, mouth-breathing habits, and patterns of lip and tongue movement contribute to its development. The problem is often not limited to tooth position but also involves how the surrounding soft tissues respond.
The treatment team installed fixed orthodontic appliances using the MBT technique with 0.022-inch slot brackets. Before bracket placement, the persistent tooth 63 was extracted. Over an 18-month period, the archwire sequence progressed from 0.012-inch NiTi wires to 0.017 × 0.025-inch stainless steel wires, supported by open coil springs and power chains to close the diastema and improve dental interdigitation.
The dental results were promising. However, one problem remained: the patient’s smile still revealed more than 2 mm of gingiva. Her teeth appeared short and square. The braces had completed their mechanical task, but the aesthetic harmony of the smile was not yet achieved.
Biological Width and a Challenging Clinical Decision
Further examination using a UNC-15 periodontal probe revealed that the biological width in the region of teeth 15 to 25 was less than 2.0 mm. The diagnosis was altered passive eruption (APE) type 1B, a condition in which gingival tissue fails to migrate to its proper position, causing the clinical crowns to appear shorter than their ideal proportions.
This was where periodontal treatment became essential. The team decided to perform crown lengthening combined with osteoreduction, a procedure involving the removal of alveolar bone to achieve an appropriate biological width.
The procedure began with an aseptic technique using povidone iodine, followed by local anesthesia administration in the mucobuccal fold. Incisions were made from tooth 15 to tooth 25 using a #15-C scalpel blade. A flap was elevated, and osteoreduction was performed using a bone bur and low-speed handpiece. Bone reduction was calculated based on bone sounding, allowing connective tissue attachment to reach 1.07 mm and creating an ideal biological width of 2.04 mm. The flap was then repositioned and sutured, followed by the placement of periodontal dressing.
The patient underwent follow-up examinations one week, two weeks, one month, and two months after surgery. No complications were reported.
A Balanced Smile with Long-Lasting Results
The changes documented after completion of the entire treatment sequence were significant. The overjet decreased from +2.39 mm to +2 mm, while the overbite improved from +1.87 mm to +2 mm. The left canine relationship shifted from Class II to Class I. Post-treatment cephalometric analysis showed: An increase in the SNA angle from 78.7° to 81.4°, an increase in the SNB angle from 72.8° to 77.4°, a reduction in facial convexity angle from 14.7° to 13.7°, a significant increase in the interincisal angle from 110.7° to 126.6°
“The gingival tissue showed good health, normal shape, and the patient expressed high satisfaction with the achieved results.” — Alissa Shella Destyarrum et al., Journal of International Dental and Medical Research, 2025
This case provides a concrete example of why an interdisciplinary approach is not merely an additional option but a clinical necessity. APE is a condition that can easily be overlooked because its appearance is not always obvious, particularly when patients primarily complain about crowded or protruding teeth. Without careful periodontal assessment, treatment may result in teeth that are technically well aligned but a smile that remains aesthetically disproportionate.
For Dr. drg. Dyah Karunia, Sp.Ort. and the FKG UGM research team, this case was not only about surgical techniques or orthodontic mechanics. It was about understanding that the human face functions as an integrated system, and that an ideal smile is created through effective collaboration between multiple dental disciplines.
Authors: Nanda Ayu; drg. Achmad Zam Zam Aghasy, M.Kes.
Photo: Pexels