Now that we have discussed the various causes of teeth that appear short, let us examine how our diagnosis will influence the methods we use to correct the problem.
If our radiographs and sounding show us that the cause of the short teeth is altered active eruption, then we know that only a full thickness flap will resolve the problem. This is because the crest of bone is too close to the CEJ. The connective tissue attachment, which is part of the biologic width, cannot take place on enamel. It can only take place on the root. Therefore, we must remove enough bone so that one to two millimeters of root is exposed apical to the CEJ. By definition, if we need to remove bone we must elevate a flap. If we try to just remove gingiva without removing any bone ( a gingivectomy, whether done with a scalpel or a laser), then the gingiva will just grow back to protect the underlying bone.
If the cause of the short teeth is wear of the incisal enamel due to occlusal problems like bruxing then the biologic width may be in the correct place, i.e., the crest of bone is 2 mm from the CEJ so that there is room for both the junctional epithelium and the connective tissue attachment between the CEJ and the crest of bone. In this case, it may be possible to create room for crowns of adequate length by changes in the occlusal scheme like opening the bite and no surgery of any kind will be required.
Similarly, if the cause of the short teeth is a habit, then it may be possible to correct the problem by eliminating the habit and allowing the teeth to erupt normally. Generally speaking, this will take a long time and is unpredictable so, most likely, orthodontic intervention would be required.
The only time that a gingivectomy alone will correct the problem is in the case of altered passive eruption. A blade or a laser could be used to remove excess gingiva so that only a millimeter or so remains above the epithelial adherence.
As you can see, making the correct diagnosis will lead to the correct treatment. Since this series is about aesthetic crown lengthening, I will discuss the surgery in greater detail in future articles.