Tooth eruption consists of anactive and a passive phase.Active eruption is themovement of the teeth in the direc-tion of the occlusal plane, whereaspassive eruption is related to theexposure of the teeth by apicalmigration of the gingiva.

Originally thought to be a nor-mal physiologic process, passiveeruption can at times be consid-ered a pathologic process.

Gottlieb et al divided passiveeruption into four stages based uponthe relationship between the

Altered Passive Eruption -- The Undiagnosed Condition

From Our Officeto Yours...

Altered passive eruption ischaracterized by excessive gingivain relation to the crown of thetooth. This condition may be local-ized or generalized, may exist inconjunction with or without peri-odontal disease and should beconsidered in planning for restora-tive, orthodontic and esthetic den-tistry.

While altered passive eruptionis usually diagnosed by clinicalobservation, this condition is oftenoverlooked or unrecognized.Failure to recognize this conditioncan result in compromised clinicaloutcomes.

Correct diagnosis of alteredpassive eruption and proper thera-py will result in improved dentalcare and esthetic results for ourpatients. This issue of ThePerioDontaLetter will addressthese considerations.

As always, we welcome yourquestions and suggestions.

epithelial attachment and thecementoenamel junction (CEJ).

In Stage 1, the teeth reach theline of occlusion and the junction-al epithelium lies totally on thetooth enamel.

In Stage 2, the epithelial attach-ment rests partially on the enameland partially on the cementum apicalto the CEJ. The base of the sulcus isstill on the enamel.

In Stage 3, the entire junctionalepithelium lies totally on thecementum with the base of the sul-cus at the CEJ.

Figure 1. This16-year-oldfemale exhibitedvery shortclinical crownsas a result ofaltered passiveeruption. (Seephotos page 2)

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I. Stephen Brown, D.D.S. 220 South 16th Street, Suite 300, Philadelphia, PA 19102 (215) 735-3660

The Brown

I. Stephen Brown, D.D.S., Periodontics & Implant Dentistry

Eruption does not cease whenteeth make occlusal contact withteeth in the opposing arch but con-tinues throughout life. If the junc-tional epithelial tissues do notrecede to the CEJ by adulthood,corrective measures may berequired to maintain health orenhance esthetics.

The Biologic Width

Gargiulo et al established a def-inite dimensional relationshipbetween the crest of the alveolarbone, connective tissue attachment,epithelial attachment and sulcusdepth. They called this relationshipthe biologic width.

Gargiulo found that the widthof the connective tissue attachment,however, remains fairly constantwith a mean average of 1.07mm.The junctional epithelium normallyaverages 0.97mm. The combineddimension of the connective tissueattachment and the epithelialattachment averages 2.04mm.

When contemplating any surgi-cal, restorative or orthodontic pro-

Finally, in Stage 4, the epithelialattachment lies totally on thecementum, the base of the sulcus ison the cementum, and a portion ofthe root may be clinically exposed.Proliferation of the junctionalepithelium onto the root is accompa-nied by degeneration of gingival andperiodontal ligament fibers and theirdetachment from the tooth. It is cur-rently believed this degeneration isthe result of chronic inflammationand therefore represents a patholog-ic rather than a physiologic process.

When passive eruption does notprogress past stage one or two, it isreferred to as altered or delayed. Thiscreates a clinical crown that appearsshort due to the presence of excessgingiva which covers the enamel.

Occurrence of altered passiveeruption is unpredictable, but theincidence in the general populationis about 12 percent.

Diagnosing AlteredPassive Eruption

Clinically, the most obvioussign of altered passive eruption is a

short-looking tooth. Altered pas-sive eruption is a physiologic vari-ation with excess gingiva coveringthe crown of the tooth.

Normally, the CEJ lies just api-cal to the gingival margin of theanatomic crown. Sulcus depth usu-ally measures 1 to 3mm. In casesof altered passive eruption, the CEJmight be up to 10mm apical to thegingival margin.

There may be no other clinicalsigns of disease such as bleedingupon probing, suppuration, inflam-mation or radiographic bone loss.

In some cases, excess gingivaltissue interferes with oral hygieneand contributes to plaque accumula-tion. Probing depth often reveals adeep sulcus associated with marginalinflammation of the gingival tissues.

Restorations and orthodonticappliances placed in or near the sul-cus may contribute to an exaggerat-ed inflammatory response. In-creased probing depth may be theresult of excessive soft tissue ratherthan attachment loss. However, inthe periodontally susceptiblepatient, attachment loss and boneresorption may occur as well.

Figure 2. Upon flap reflection,the anatomic crowns have justbarely erupted through thealveolar process. The bone isat the cemetoenamel junctionwhich prevents gingivalattachment to the root surface.

Figure 3. 3mm of bone wasremoved to create room for anormal biologic width attachedto the cementum and the gingi-val margins were repositionedapically with papilla retention.

Figure 4. Two-weeks postoperatively, the teeth have apleasing cosmetic appearanceand the dimensions of theclinical crowns are normal.

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cedure, maintenance of the biolog-ic width is essential.

Periodontal Treatment,Esthetic Considerations

and RestorativeRequirements

Altered passive eruption shouldbe treated if periodontal disease is evi-dent or if there are restorative, ortho-dontic or esthetic considerations.

Additionally, if excessive tissuefollowing orthodontic therapy isnot resolved, gingival surgery isindicated.

It is incumbent upon theorthodontist to recognize thataltered passive eruption will notresolve itself and will require acorrective periodontal procedure.

The management of alteredpassive eruption may include peri-odontal surgery, crown lengthen-ing, and in selected cases, forcederuption.

As with all periodontal treatment,the initial phase involves a properdiagnosis and control of etiology.

When periodontal surgical pro-cedures are indicated, the objectiveis to apically position the soft tissueto the appropriate esthetic heightwhile producing sufficient soundtooth structure so the biologicwidth will not be violated whenrestorative procedures are imple-mented.

Altered passive eruption cancause anterior teeth to appear tooshort and contribute to excessivegingival display.

When full exposure of theanatomic crown is achieved surgi-cally to eliminate excessive gingi-val display, there is a dramaticimprovement in esthetics.

Crown lengthening is an inte-gral component of the esthetic

armamentarium for treating thesesituations because it provides ade-quate tooth structure while simulta-neously assuring the integrity ofthe biologic width.

When periodontal surgical pro-cedures are indicated to enhancerestorative dentistry, it is impera-tive the surgeon and the restorativedentist have excellent communica-tion, to ensure the most favorableclinical outcomes for theirpatients.

In summary, altered passiveeruption may present as a non-pathologic entity or as a pathologiccondition requiring various formsof more aggressive treatment.

The indications for surgicalintervention may include peri-odontal, restorative, orthodonticor cosmetic issues and all ofthese must be respectful of thebiologic width.

We hope this discussion ofaltered passive eruption will helpin the diagnosis and treatment ofthis often overlooked and unrec-ognized condition.

As always, we look forwardto collaborating with you in thediagnosis and treatment planningof these interesting cases andthank you for the opportunity toparticipate in the care of yourpatients.

Figure 5. Orthodontic therapyin altered passive eruptioncreates a large gingivalappearance with short teeth.

Figure 6. Two weeks postoperatively, the teeth have amuch more pleasing, naturalappearance and orthodonticmovement is facilitated.

Figure 7. A gummy smile isthe result of altered passiveeruption.

Figure 8. Two weeks followingosseous resection and apicalflap positioning, the smileis cosmetically pleasing.

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