Public esthetic awareness is centered on an attractive smile, and excess gingival display is a frequent complaint from patients seeking to improve their appearance. Excessive gingival display is widespread condition that adversely affects the aesthetic of the smile.¹ The aetiology may be due to skeletal, muscular or dentogingival abnormalities including elongated maxilla, short and/or hypertonic maxillary lips, dentoalveolar compensation Angle’s Class II or Class III occlusion and Altered Passive Eruption (APE). ²

         The most common aetiology is altered passive eruption.³ Goldman & Cohen (1968), defined altered or retarded passive eruption as a situation in which the gingival margin in the adult is located incisal to the cervical convexity of the crown and removed from the cemento–enamel junction of the tooth.⁴

         Although the increasing demand for improving aesthetics is becoming an important part of the current practice of periodontal surgery, the medical literature related to the treatment of the gingival smile is still insufficient, incoherent, and not supported by the necessary statistical analysis. There are various treatment modalities for excessive gingival display which include lip repositioning, crown lengthening, botulinum toxin-A injections and orthognathic surgeries. The treatment of choice for altered passive eruption is crown lengthening.

         According to Glossary of Periodontal terms (2001), crown lengthening is a surgical procedure devised to increase the extent of supragingival tooth structure for restorative or esthetic purpose, or combination of both by apically positioning the gingival margin, removing supporting bone, or both.⁵ This procedure reduce the excessive gingival tissue, expose the desirable clinical crown, and re-establish the appropriate biologic width. Several surgical techniques were proposed most of them include apically repositioning flap with osseous surgery or gingivectomy for the treatment of excessive gingival display. Conventional open flap generally include elevation of full thickness flap to access and recontour the bone crest to preserve the biologic width. The disadvantages of this technique are, often time-consuming, may cause pain, bleeding, post operative morbidity, gingival tissue rebound and require suture.⁶ The surgical techniques that include flap elevation

cause more coronal displacement of the gingival margin.⁷ Therefore, more effective and less invasive treatment modalities are needed.

        The advantages of minimally invasive techniques are to alleviate post treatment side effects, accelerate healing, and avoid bone resorption caused by the elevation of full thickness flap.⁸ The flapless technique is considered to be a promising alternative approach and is a suture-less, atraumatic, and  less invasive technique that has been shown to increase patient satisfaction and comfort.¹

        Piezosurgery is proposed as a minimally invasive surgical procedure include high precision, a design that increases ease of curvilinear osteotomy, less trauma to soft tissue, preservation of neurological and vascular structures, promote neo-osteogenesis, reduced hemorrhage that improves viability in working area, minimal thermal damage to the bone, as well as overall improvement of healing.⁹