Pink-White Esthetic Optimization in Excessive Gingival Display Using Crown Lengthening and Direct Composite Veneering

An esthetic smile plays a pivotal role in enhancing patient confidence and social well-being. Smile esthetics are influenced by multiple factors, including maxillary anterior tooth morphology, lip length and mobility, periodontal health, and the degree of gingival display. Short clinical crowns associated with excessive gingival display are generally perceived as unesthetic and frequently require esthetic crown lengthening. Altered active eruption (AAE) and altered passive eruption (APE) represent common etiologic factors in such presentations. Management typically involves gingivectomy with or without osseous resection while ensuring adequate space for the supracrestal tissue attachment. Violation of the supracrestal tissue attachment may lead to gingival inflammation, recession, and alveolar bone loss; therefore, a postoperative healing period of 3-6 months is recommended to allow soft tissue maturation and assessment of marginal gingival stability. Conventionally, restorative rehabilitation following esthetic crown lengthening has relied on invasive approaches, including porcelain-fused-to-metal crowns, all-ceramic crowns, and porcelain veneers. However, evidence supporting minimally invasive or noninvasive restorative modalities-particularly direct composite restorations-remains limited. This case series is aimed at describing a minimally invasive restorative protocol utilizing direct nanocomposite veneering following esthetic crown lengthening and soft tissue maturation to achieve favorable pink esthetic score (PES) and white esthetic score (WES) outcomes. Two patients presenting with a gummy smile, microdontia, and spacing in the maxillary anterior region were diagnosed with APE Type I associated with AAE and exhibited low baseline PES and WES values. Diagnosis was established through clinical transgingival probing, cone-beam computed tomography (CBCT), diagnostic casts, and digital smile design. Treatment involved esthetic crown lengthening via gingivectomy and ostectomy, followed by a 3-month healing period for soft tissue maturation. Subsequently, minimally invasive direct veneering was performed using a bioactive nano-hybrid composite. This approach resulted in improved pink and white esthetic outcomes while preserving tooth structure and maintaining periodontal health. At approximately 24 months of follow-up, minor restoration chipping was observed, along with mild gingival inflammation associated with plaque accumulation, whereas gingival levels remained relatively stable, ranging from -1.5 to +0.5. The primary limitation of this case series is the absence of long-term data regarding color stability, periodontal response and restorative complications.