Piezoelectric-assisted Flapless Technique associated with esthetic rehabilitation: a case report

Técnica Flapless assistida por piezoelétrico associada a reabilitação estética: relato de caso

ABSTRACT

The esthetics of the smile depends on the harmony between teeth and periodontal tissues, with clinical crown lengthening being an essential strategy in cases of dental disproportions and excessive gingival display. This case report describes the application of the flapless technique, assisted by piezoelectric ultrasound and diamond tips produced by chemical vapor deposition, in a female patient dissatisfied with dental wear, tooth color, and tooth shape. The study was approved by the research ethics committee under protocol number 94187425.1.0000.0095. After clinical and tomographic evaluation, digital planning was performed, followed by the fabrication of a mock-up and a surgical guide for minimally invasive gingivoplasty and osteotomy. The flapless approach allowed precise reduction of the alveolar crest without flap elevation, preserving soft tissues, reducing surgical time, and promoting lower postoperative morbidity. After 30 days, adequate healing, gingival margin stability, and absence of inflammation were observed. Subsequently, dental preparations and the fabrication of lithium disilicate ceramic laminates restored tooth shape, color, and proportion. The outcome demonstrated harmonious integration between periodontal tissues and restorations, reestablished masticatory function, and high patient satisfaction. This case reinforces that the flapless technique associated with piezosurgery constitutes a minimally invasive, safe, and predictable approach for periodontal management in esthetic rehabilitations, providing long-lasting esthetic outcomes and increased patient comfort, in accordance with current evidence on conservative and predictable strategies in esthetic dentistry.

Indexing terms
Gingivoplasty; Mouth rehabilitation; Piezosurgery

RESUMO

A estética do sorriso depende da harmonia entre dentes e tecidos periodontais, sendo o aumento de coroa clínica uma estratégia essencial em casos de desproporção dentária e exposição gengival excessiva. Este relato de caso descreve a aplicação da técnica flapless, assistida por ultrassom piezoelétrico e pontas diamantadas produzidas por deposição química de vapor, em uma paciente do gênero feminino insatisfeita com o desgaste dentário, a cor e o formato dos dentes. O estudo foi aprovado pelo Comitê de Ética e Pesquisa sob o número de protocolo CAAE: 94187425.1.0000.0095. Após avaliação clínica e tomográfica, realizou-se planejamento digital, confecção de mock-up e guia cirúrgica para gengivoplastia e osteotomia minimamente invasiva. A abordagem flapless permitiu o rebaixamento preciso da crista óssea sem elevação de retalho, preservando tecidos moles, reduzindo tempo cirúrgico e promovendo menor morbidade pós-operatória. Após 30 dias, observou-se cicatrização adequada, estabilidade da margem gengival e ausência de inflamação. Posteriormente, os preparos dentários e a confecção de laminados cerâmicos em dissilicato de lítio restabeleceram forma, cor e proporção dentária. O resultado final evidenciou integração harmoniosa entre tecidos periodontais e restaurações, função mastigatória restabelecida e elevada satisfação da paciente. Este caso reforça que a técnica flapless associada à piezocirurgia constitui uma abordagem minimamente invasiva, segura e previsível para o manejo periodontal em reabilitações estéticas, proporcionando resultados estéticos duradouros e maior conforto ao paciente, alinhando-se às evidências atuais da literatura sobre estratégias conservadoras e previsíveis na odontologia estética.

Termos de indexação
Gengivoplastia; Reabilitação bucal; Piezocirurgia

INTRODUCTION

The pursuit of a harmonious smile encompasses, in addition to the correct proportion of dental elements, their harmony with the periodontium [¹]. Factors such as tooth position, color, and anatomy, combined with the anatomical balance of the lips, the amount of gingival exposure, and its cervical contour, contribute to a smile considered aesthetically pleasing [²].

In this context, patients who present gingival smiles characterized by soft tissue exposure greater than 3 mm or alterations in the cervical contour that affect the balance of gingival tripoidism require some type of intervention prior to dental rehabilitation procedures [³].

One treatment option is gingivoplasty associated or not with osteotomy [⁴]. Gingivoplasty is defined as the surgical procedure involving excision of soft gingival tissue with the objective of altering the gingival contour [⁵]. For aesthetic smile correction, the indication for bone tissue remodeling is determined by the relationship between the alveolar bone crest and the cementoenamel junction [⁶]. This distance corresponds to the biologic width, which ideally should range from 1.5 mm to 2.0 mm [⁷]. When this minimum distance is not respected, gingivoplasty must necessarily be combined with osteotomy; otherwise, it may result in chronic inflammation, discomfort, loss of attachment, and a high probability of gingival relapse to its original position, compromising the long-term aesthetic outcome [⁸].

In this scenario, aiming at minimally invasive dentistry, conservative surgical techniques have undergone increasing technological advancement, one of which is the “flapless” technique used to perform crown lengthening. This approach is characterized by the absence of flap elevation during surgery and enables osteotomy to be performed through the gingival sulcus using appropriate instruments [⁹].

The technique consists of lowering the alveolar bone crest in order to increase the clinical crown length and promote aesthetic smile harmonization [¹⁰]. Unlike conventional approaches, the flapless technique eliminates the need for gingival flap elevation to access the bone crest, allowing greater control and predictability of bone removal. In addition, it is associated with reduced surgical time and a faster and more comfortable postoperative period, since sutures are not required, thereby favoring tissue healing [¹¹].

For the precise execution of the flapless technique, the use of ultrasonic technology is essential, with piezoelectric ultrasound being a determining factor for the predictability of osteotomy, providing greater safety and precision compared to conventional rotary instruments [¹²]. Its selective bone cutting allows controlled and millimetric removal of mineralized tissue through the gingival sulcus, while preserving adjacent soft tissue structures [¹³]. Furthermore, reduced heat and noise generation contributes to greater intraoperative comfort and a lower risk of thermal damage, consolidating the piezoelectric device as a fundamental resource for a minimally invasive and safe approach in aesthetic rehabilitation [¹⁴].

The predictability of the flapless technique is further enhanced by the use of piezoelectric devices with CVD diamond inserts (CVDentus®). Chemical Vapor Deposition (CVD) technology provides ultrasonic tips with greater durability and resistance to wear [¹⁵]. This technology results in superior cutting uniformity during osteoplasty, ensuring stable performance and precise control of bone removal by the clinician, which is essential for the long-term success of aesthetic gingival contouring [¹⁶].

Considering the above, this case report aims to elucidate the predictability and advantages of the minimally invasive flapless approach assisted by piezoelectric ultrasound for the proper reestablishment of gingival architecture and biological width, which are fundamental for the success of subsequent prosthetic aesthetic rehabilitation.

CASE REPORT

The study was approved by the Research Ethics Committee under protocol number CAAE: 94187425.1.0000.0095. For the preparation of this case report, the informed consent form was presented to and signed by the patient.

A 65-year-old female patient sought dental care at a postgraduate dental school in Curitiba, Paraná, Brazil, with a chief complaint related to dental aesthetics, reporting that her teeth were severely worn and that she was dissatisfied with their color and shape. A thorough anamnesis was performed, and clinical examination revealed dental wear associated with bruxism, with the habit confirmed by the patient, absence of dental caries, darkened tooth coloration, and the presence of healthy gingival tissue, with a large amount of attached gingiva and a thick gingival phenotype (figure 1).

Figure 1
Initial frontal intraoral view of the smile, showing dentogingival disharmony, dental wear, and chromatic alteration.

Complementary tomographic examinations were performed to define the treatment plan, which consisted of oral hygiene instructions, supragingival scaling and corono-radicular prophylaxis, at-home tooth whitening with individualized trays using carbamide peroxide bleaching gel, gingivoplasty and clinical crown lengthening of teeth 15 to 25 using the flapless technique, followed by the fabrication of ceramic laminate veneers on the same teeth. At the end of the prosthetic rehabilitation, a occlusal splint will be fabricated for the patient.

After patient approval, the proposed treatment was initiated. Periodontal scaling and tooth whitening were performed using a carbamide peroxide bleaching gel for three hours (Whiteness Perfect 16%, FGM, Joinville, Brazil). After color stabilization, intraoral scanning of the maxillary and mandibular arches was performed using an intraoral scanner (i500, MEDIT, Smart Dent, São Paulo, Brazil) for virtual planning, and initial photographs were obtained. Digital planning using the software (EXOCAD) allowed aesthetic smile analysis, and virtual diagnostic waxing was performed following dentofacial harmony principles to restore the dental structures lost due to bruxism.

Immediately after approval of the virtual diagnostic waxing, the model was printed using a 3D printer, a silicone guide was fabricated for mock-up execution, and a surgical guide was produced for gingivoplasty (figure 2).

Figure 2
3D model obtained from the virtual diagnostic wax-up, mock-up, and surgical guide.

With the surgical guide in position, the incision for gingival correction was performed using a 15C scalpel blade, followed by osteotomy. For the osteotomy, piezoelectric ultrasound was used (CVDentus – DentSurg, Clorovale Diamantes, São Paulo, Brazil) with crown lengthening inserts #TR1PK, #VR1RPK, and #VR1LPK (figure 3). Due to the use of piezoelectric technology, gingival flap elevation to access the bone crest was unnecessary, as this technique allows controlled and predictable bone removal. At the end of the surgical stage, biologic width measurements were verified by periodontal probing, and the immediate postoperative clinical aspect was assessed (figure 4).

Figure 3
CVDentus® diamond-coated piezoelectric tips (#TR1PK, #VR1RPK, and #VR1LPK) and their clinical application in flapless osteotomy using piezoelectric ultrasound for aesthetic crown lengthen.

Figure 4
Final operative aspect following gingivoplasty associated with flapless osteotomy.

After the healing period, the patient returned for the prosthetic rehabilitation phase. Satisfactory periodontal tissue healing was observed after 30 days, with adequate gingival margin stability, absence of inflammatory signs, and maintenance of the surgically obtained gingival architecture (figure 5). The patient reported no pain or discomfort during the postoperative period, corroborating the low morbidity associated with the flapless approach assisted by piezosurgery.

Figure 5
Clinical aspect after healing, showing adequate periodontal tissue repair, gingival margin stability, and absence of inflammatory signs.

Piezoelectric ultrasound with diamond inserts was also used for tooth preparation. The selected tips were #CR4XR and #CR4 for finishing, and #CR4U for refinement. The ceramic laminate veneers were fabricated in shade BL3 – Bleach (Ivoclar Vivadent, Schaan, Liechtenstein) using lithium disilicate material (E.max CAD, Ivoclar Vivadent, Schaan, Liechtenstein), predictably restoring tooth form, color, and proportions.

The final outcome demonstrated harmonious integration between periodontal tissues and ceramic restorations, with satisfactory smile aesthetics, restored masticatory function, and a high degree of patient satisfaction (figure 6). These findings confirm that the association between a minimally invasive periodontal approach and adhesive prosthetic rehabilitation constitutes a safe, predictable, and effective clinical alternative for multidisciplinary aesthetic treatment.

Figure 6
Final clinical aspect after ceramic laminate rehabilitation, showing dentogingival harmony and smile aesthetics.

DISCUSSION

Minimally invasive approaches represent the current paradigm in contemporary dentistry, in which the constant introduction of new techniques seeks to promote clinical excellence, aiming at the restoration of function, health, and primarily, smile aesthetics [¹⁷]. Smile harmonization is established through comprehensive planning and integrated procedures, encompassing gingival recontouring and correction, which constitute a crucial step for the predictability of the prosthetic rehabilitation phase [¹⁸].

In this context, the indication for gingivoplasty techniques with or without osteotomy has become increasingly common due to the growing popularity of multidisciplinary dental rehabilitation [¹⁹]. For the indication of cosmetic gingival recontouring, periodontal evaluation is mandatory and must necessarily take into account the patient’s periodontal biotype and the need to reestablish the biologic width. These clinical criteria are essential to ensure proper adaptation of periodontal structures and long-term gingival margin stability, serving as the foundation for the success of any aesthetic rehabilitative treatment [²⁰].

As evidenced in the present report, the correction of dental disproportion and the treatment of gingival smile frequently require periodontal procedures with osteotomy for the proper reestablishment of the biologic width [²¹]. Conventionally, clinical crown lengthening surgeries are performed through the elevation of mucoperiosteal flaps to expose the bone structure and allow remodeling [²²]. However, flapless surgery, characterized by the absence of flap elevation, represents an evolution in the concept of minimally invasive approaches [⁹]. This technique allows osteotomy to be performed directly through the gingival sulcus, with the aid of specific ultrasonic instruments, such as the piezoelectric device [¹²]. The superiority of the flapless approach lies in the reduction of postoperative morbidity and optimization of soft tissue healing [¹⁰], which were crucial aspects that justified its selection for the present clinical case.

The benefits associated with the flapless technique, such as procedural safety and considerable clinical advantages, are widely confirmed by recent studies with high methodological rigor. A recent systematic review concluded that patients treated with the flapless approach presented significantly lower pain and swelling and demonstrated earlier gingival margin stability when compared to the open-flap technique, confirming that minimally invasive approaches reduce postoperative morbidity [²³]. Similarly, a randomized clinical trial [²⁴] observed lower mean values of pain, bleeding, and surgical time in the flapless group, corroborating the findings of Ribeiro et al. [¹⁰] and validating the reduced surgical time observed in the present case. These results reinforce the superiority of the flapless approach by eliminating the need for sutures or surgical dressings, presenting less inflammation and bleeding, and promoting rapid tissue recovery.

The use of piezoelectric ultrasound in this protocol is fundamental. In addition to producing less noise and being better tolerated by patients, its instruments are less traumatic to dental structures and provide more precise and smoother delineation of bone margins [¹²]. The use of piezoelectric devices with diamond-coated inserts (CVDentus®), combined with ultrasonic technology, enables bone removal with greater cutting precision and definition, ensuring increased patient comfort [¹⁵].

Recent evidence from scientific literature supports the adoption of minimally invasive approaches. A randomized controlled clinical trial directly compared the conventional open-flap technique with esthetic crown lengthening performed using piezosurgery associated with the flapless approach [²⁵]. The results demonstrated that the flapless protocol presents high clinical predictability, in addition to significant advantages over the conventional technique, particularly regarding greater stability of aesthetic outcomes and reduced postoperative morbidity [²].

Long-term predictability is a crucial requirement, especially in clinical cases involving subsequent oral rehabilitation, which demand lasting gingival stability [²⁶]. The literature corroborates the longevity of this approach, as a study that evaluated clinical crown lengthening using piezoelectric surgery over a four-year period demonstrated that the flapless approach is clinically effective and highly predictable in achieving stable gingival margins [²⁷]. These findings support the aesthetic and functional longevity achieved in the present work, confirming the need for a stable periodontal foundation for rehabilitative success.

Despite the undeniable clinical advantages of the flapless protocol in terms of predictability and postoperative comfort, it is imperative to recognize its limitations. The primary restriction lies in the lack of direct visualization of the bone crest, an inherent characteristic of not elevating the flap. This visual limitation requires a high degree of tactile sensitivity and operator proficiency, relying entirely on precise ultrasonic instrumentation and meticulous monitoring of bone removal [¹²]. Therefore, the flapless technique is contraindicated in cases of complex bone deformities or when extensive bone removal is required, situations in which the full-flap approach remains safer and more predictable [¹⁰].

The present case report demonstrates that clinical crown lengthening performed using a flapless approach, assisted by piezoelectric ultrasound and enhanced using diamond-coated CVD inserts (CVDentus®), constitutes an effective, predictable, and biologically favorable clinical alternative for periodontal management in aesthetic rehabilitations. This technique enabled proper reestablishment of biologic width, achievement of harmonious and stable gingival architecture, and reduction of postoperative morbidity, reflected by reduced discomfort and rapid tissue recovery. When indicated based on a rigorous periodontal diagnosis and executed with appropriate instrumentation, this minimally invasive approach establishes a consistent periodontal foundation for subsequent prosthetic rehabilitation, corroborating current evidence in the literature and reinforcing its clinical applicability in selected cases.

CONCLUSION

Clinical crown lengthening using the flapless approach, assisted by piezoelectric ultrasound and combined with diamond-coated CVD inserts, proved to be a safe, predictable, and minimally invasive alternative for periodontal management in aesthetic rehabilitations, promoting adequate reestablishment of the biologic width, gingival stability, and reduced postoperative morbidity, in addition to greater patient comfort, provided it is correctly indicated and performed.

Thus, this minimally invasive approach constitutes a consistent therapeutic alternative for periodontal management in aesthetic rehabilitations that require clinical predictability and enhanced patient comfort.

• Article aligned with the Good Health and Well-Being goal of the Sustainable Development Goals (SDGs).
• How to cite this article
  Hermeling JMPD, Cheniski DA, Reis GES, Sponchiado AP. Piezoelectric-assisted Flapless Technique associated with esthetic rehabilitation: a case report. RGO, Rev Gaúch Odontol. 2026;74:e20260033. http://dx.doi.org/10.1590/1981-86372026003320250124

Data Availability

No new data were created or analyzed in this study.

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Edited by

• Assistant editor
  Luciana Butini Oliveira

Publication Dates

• Publication in this collection
  24 Aug 2026
• Date of issue
  2026

History

• Received
  13 Dec 2025
• Accepted
  07 July 2026