New Gummy Smile Study Reveals a Choice: The Same Beautiful Result, Two Radically Different Journeys
Laser-Assisted Esthetic Crown Lengthening: Open-Flap Versus Flaplesss (Part 1) https://doi.org/10.11607/prd.5335
Walid Altayeb, PhD
Josep Arnabat, PhD
Sam B. Low, MS
Ahmed Abdullah, PhD
Georgios Romanos, PhD
Open-Flap and Flapless Er,Cr:YSGG Laser-assisted Esthetic Crown Lengthening: A Comparative Study of Patient Perceptions (Part 2) https://doi.org/10.1155/ijod/1776661
Laser-Assisted Esthetic Crown Lengthening: A Comparative Analysis
Many of us dream of a bright, confident smile, but the thought of dental surgery—especially a cosmetic procedure—can be daunting. One common aesthetic concern that leads people to consider surgery is a "gummy smile," where an excessive amount of gum tissue is visible when smiling.
Fortunately, modern dentistry offers solutions. A recent study by Prof. Altayeb's team provides powerful new insights by comparing two advanced laser techniques for correcting this issue, both part of a modern push towards minimally invasive dentistry designed for greater precision and patient comfort. The first is a traditional "open-flap" (OF) method, which involves creating and repositioning a flap of gum tissue. The second is a minimally invasive "flapless" (FL) method. While both techniques create beautiful results, the study revealed surprising and impactful differences, not in the final look, but in the patient's journey to get there.
Ultimately, this research challenges the traditional definition of a successful procedure. It proves that the patient's journey is not secondary to the outcome, but an integral part of it. When considering any treatment, isn't it worth asking not just about the final outcome, but about the comfort and quality of the entire experience?
Executive Summary: Key Research Findings
Equivalent Clinical Efficacy
Both open-flap and flapless methods achieve successful, predictable esthetic outcomes for treating "gummy smile." After 9 months, no significant difference existed in gingival tissue rebound between groups.
Superior Patient Experience
Flapless patients reported significantly lower post-operative morbidity, including reduced anxiety, pain, swelling, bleeding, and tooth sensitivity, requiring less pain medication.
Enhanced Efficiency
The flapless technique reduced average surgical time by 15 minutes, benefiting both clinicians and patients through reduced chair time and associated anxiety.
Positive Patient Perception
56% of flapless patients found surgery less challenging than anticipated, compared to only 5% of open-flap patients. All flapless patients would undergo the procedure again if needed.
Study Design and Methodology
Randomized Controlled Trial
The study employed a rigorous randomized controlled trial design with 36 healthy patients aged 22-45 with altered passive eruption requiring crown lengthening on six maxillary anterior teeth. Participants were randomly allocated into two equal groups of 18 patients each.
All surgical procedures were performed by a single operator using an Er,Cr:YSGG laser for precision ablation of both soft and hard tissues, ensuring consistency and eliminating operator variability in the results.
- 14 males, 22 females enrolled
- Single operator for all procedures
- Er,Cr:YSGG 2780-nm laser used
- 9-month follow-up period
Assessment Metrics
Clinical Efficacy: Periodontal health indices and Gingival Margin Level measured at baseline, post-surgery, and at 1, 3, and 9-month follow-ups.
Patient Outcomes: Self-administered questionnaires using 5-point Likert scale evaluated post-surgical morbidity at 1 week and esthetic satisfaction at 9 months.
Procedural Efficiency: Precise recording of surgical procedure duration for both techniques.
Surgical Technique Comparison
Open-Flap (OF) Technique
Traditional approach involving apically positioned flap creation, followed by osseous recontouring. The flap is then repositioned and sutured, requiring more extensive tissue manipulation and healing time.
- Flap elevation required
- Direct visualization of bone
- Suturing necessary
- Longer procedure time
Flapless (FL) Technique
Minimally invasive approach with initial gingivectomy followed by osseous recontouring performed through the gingival sulcus without raising a flap, resulting in less tissue trauma and faster healing.
- No flap elevation
- Sulcular approach
- No sutures required
- Reduced procedure time
Clinical Efficacy Results
The research established that both laser-assisted techniques are predictable and effective, producing comparable and stable clinical results after 9 months of follow-up. The gingival margin level showed initial coronal growth in the first 3 months but demonstrated significant stability between 3-month and 9-month follow-ups for both groups.
OF Group Tissue Rebound
Mean tissue rebound at 9 months (± 0.32 mm)
FL Group Tissue Rebound
Mean tissue rebound at 9 months (± 0.29 mm)
Follow-up Period
Months of clinical monitoring and assessment
A critical finding revealed that tissue rebound was significantly higher in patients with thick periodontal phenotype compared to thin phenotype, regardless of surgical method. This highlights the importance of phenotype assessment in treatment planning. The OF group showed slightly higher Gingival Index and Bleeding on Probing scores at 1-month follow-up due to greater tissue trauma, but these differences resolved by 3 months.
Patient-Perceptions: A Clear Winner
While clinically equivalent, the two techniques produced vastly different patient experiences. The flapless procedure was associated with significantly lower post-operative morbidity and more positive overall perception across all measured parameters.
The difference in patient perception of surgical difficulty was particularly striking. In the flapless group, 56% found the surgery less challenging than anticipated, while only 5% of open-flap patients reported the same experience.
Procedural Efficiency and Time Savings
Open-Flap Average Time
77.8 ± 7.46 minutes average surgical duration
Flapless Average Time
62.7 ± 4.87 minutes average surgical duration
Time Reduction
Approximately 15 minutes saved with flapless technique
The flapless technique demonstrated significant advantages in surgical efficiency, reducing average procedure time by approximately 15 minutes compared to the open-flap surgery. This time savings is attributed to the elimination of steps required for raising, positioning, and suturing a flap.
This streamlined approach provides multiple benefits: reduced patient chair time, decreased anxiety exposure, enhanced clinical workflow, and improved practice efficiency. The time savings, combined with reduced post-operative complications, creates a more positive experience for both patients and practitioners.
Patient Satisfaction and Recommendations
Flapless Group Results
- 100% would undergo procedure again if needed
- 100% would recommend to others
- 56% found surgery less challenging than expected
- High satisfaction with final esthetic outcome
The unanimous positive response from flapless patients underscores the superior patient experience achieved through this minimally invasive approach.
Open-Flap Group Results
- 75% would undergo procedure again if needed
- 89% would recommend to others
- 5% found surgery less challenging than expected
- High satisfaction with final esthetic outcome
While still positive, the open-flap results show notably lower patient willingness to repeat the experience, reflecting the increased morbidity associated with this technique.
"At 9 months, both groups reported high satisfaction with the final esthetic outcome, but the journey to achieve these results differed significantly in terms of patient comfort and recovery experience."
Clinical Implications and Practice Integration
This research provides compelling evidence that laser-assisted flapless esthetic crown lengthening represents a paradigm shift in periodontal surgery. The findings demonstrate that clinicians can achieve identical long-term clinical outcomes while significantly improving the patient experience through technique selection.
Assessment and Planning
Evaluate periodontal phenotype as a critical factor in treatment planning, as thick phenotype patients show higher tissue rebound regardless of technique used.
Technique Selection
Consider flapless approach as first-line treatment for appropriate cases, reserving open-flap technique for complex anatomical situations requiring direct bone visualization.
Patient Communication
Inform patients about the benefits of flapless technique, including reduced morbidity, faster recovery, and improved comfort during and after surgery.
Practice Implementation
Integrate laser technology and flapless protocols to enhance practice efficiency, patient satisfaction, and clinical outcomes while maintaining predictable results.
The research strongly suggests that the laser-assisted flapless ECL technique should be considered the preferred approach for managing altered passive eruption cases, offering a more patient-friendly and efficient procedure without compromising clinical quality or long-term stability.
Conclusions and Future Directions
Professor Altayeb's comprehensive research provides definitive, evidence-based guidance for clinical decision-making in esthetic crown lengthening procedures. The study's dual focus on clinical outcomes and patient-centric measures offers a complete picture that prioritizes both treatment efficacy and patient experience.
Evidence-Based Practice
Flapless technique delivers equivalent clinical results with superior patient outcomes, supporting its adoption as the preferred approach for appropriate cases.
Practice Efficiency
15-minute time savings per procedure enhances clinical workflow while reducing patient anxiety and improving overall treatment experience.
Patient-Centered Care
Prioritizing patient comfort and satisfaction through technique selection represents the future of modern periodontal practice.
For dental professionals seeking to offer patients a less invasive and more comfortable treatment option without sacrificing clinical quality, the flapless technique presents a compelling alternative. By incorporating these evidence-based findings into practice, clinicians can improve the overall quality of care and achieve superior patient satisfaction while maintaining predictable, stable clinical results.
This research establishes a new standard for esthetic crown lengthening procedures, demonstrating that advanced laser technology combined with minimally invasive techniques can transform the patient experience while preserving clinical excellence. The future of periodontal surgery lies in this patient-centered approach that prioritizes both clinical outcomes and treatment experience.
Laser-Assisted Esthetic Crown Lengthening: Open-Flap Versus Flaplesss (Part 1)
Open-Flap and Flapless Er,Cr:YSGG Laser-assisted Esthetic Crown Lengthening: A Comparative Study of Patient Perceptions (Part 2)
Walid Altayeb DDS, MSC, PhD
President of Academy of Laser Dentistry 2024-2025
• Master of Science in Periodontics in 2004 ,Doctorate of Philosophy PH.D in Periodontics in 2007, Master of Academy of Laser Dentistry in 2014
• Guest Professor Faculty of Dental Medicine, Istanbul Ayden University, Istanbul, Turkey
• Prof. a c at Master Laser Dentistry Università Cattolica del Sacro Cuore di Roma, Italy
• Over the last seven years, he has provided more than 1574 CPD hours in the field of Esthetic Periodontics, Implantology, and Laser Dentistry.
• Dr. Altayeb is working in private as Periodontist and Implantologist in Tamim Dental Polyclinic, Doha, Qatar & Dr. Imran Aestheticare Center, Dubai, UAE.
Walid Altayeb (@walidaltayeb) • Instagram photos and videos
