When we think that part of a treatment plan will include altering the gingival esthetics, one of the things we are tasked with is determining where we want the tissue to be. The first step as always is making a determination about incisal edge position
in the face. Using a lips at rest photograph
and full face image for my patient with altered passive eruption, we determined that her incisal edges are correctly positioned.
Once we know the position of the incisal edges (either existing or a planned position) we can then use this information to plan the position of the gingival margins. Tooth proportion becomes the next building block in the planning puzzle. When we look at esthetic evaluation we know that beautiful anterior teeth are usually between 70-80% width to length ratio. This variability allows us to accommodate other clinical considerations, as well as patient preference. As a starting point I begin with 75%, and then look at the other parameters. If the patient has excessive gingival display, and one of the hoped for outcomes is to minimize the amount of gingiva, you may want to alter your drawing increasing the length and then evaluate the esthetic result. On the other hand if you have excessive sulcus depth and you want to see what the esthetic outcome would be if you stay within the confines of the sulcus, place the proposed gingival margin accordingly and assess the result.
The final placement is based on creating an acceptable esthetic result for the patient, and although I can work with photographs the best way to help the patient is to show them the proposed result in their mouth. To do this I create a composite mock-up on a model of the patient’s teeth. It incorporates the new incisal edge position and the new gingival position and will snap over the patient’s teeth so they can see the proposed changes in their smile. This composite mock-up can also be used as a surgical guide for the crown lengthening, and as a guide for the lab to create a wax-up.