etiology and management of gummy smile

1. Gummy smile and its
Management
N L N VAIDEHI
III MDS

2. CONTENTS
INTRODUCTION
PREVALANCE
FACIAL ESTHETICS
ETIOLOGY OF GUMMY SMILE
DIAGNOSIS
TREATMENT
CONCLUSION
REFERENCES
2

3. INTRODUCTION
 A wonderful smile is an essential feature of beauty to
which society gives an increasing importance currently.
 The evaluation of smile has become an important part of
our clinical assessment with a greater emphasis on
dynamic evaluation.
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4. 4
GUMMY SMILE or HIGH SMILE LINE or GINGIVAL SMILE LINE is a condition characterized
by excessive exposure of maxillary gingiva during smiling

5. “
 10% of 20- to 30-year-old subjects.
 women (14%) than in men (7%).
 Peck et al (1992) -26%of a sample of orthodontic patients displayed 2mm
or more of the maxillary gingiva when smiling.
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PREVALENCE

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▫ cultural and ethnic preferences.
▫ In some European countries gingival display of up to 4 mm or
more is acceptable,
▫ Exposure greater than 2-3 mm is considered unsightly in the
USA.
▫ 6%- caucsasian Asia (Jensen et al 1999) 6

7. FACIAL ESTHETICS
7
FACTORS
AFFECTING SMILE

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A ‘normal’ smile line is
one in which the upper
anterior teeth are
completely visible and
the lower border of the
upper lip reveals 1–2
mm of gingiva.
A ‘low’ smile line is
described as one in
which the lower border
of the upper lip covers
25% of the upper
anterior teeth.
A ‘high’ smile line, also
known as a ‘gummy
smile’, is described as
one having more than
2mm of maxillary
gingival display.
SMILE LINE
Peck et al(1992)

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10. 1. Glabellla
2. Nasion
3. Menton
Facial symmetry and proportions in both
frontal and lateral views:
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11. Clinical crown height
 widest mesiodistal
length (perpendicular
to the long axis)
 longest apico-coronal
length (parallel to the
long axis) of the test
teeth on each cast
 The mean mesiodistal
tooth widths for male
and female patients
were, respectively, 8.59
and 8.06 mm for the CI,
6.59 and 6.13 mm for
the LI and 7.64 and 7.15
mm for the canine
The mean apico-coronal
tooth lengths for male and
female
patients, respectively, were
10.19 and 9.39 mm for the
central incisor, 8.70 and 7.79
mm for the lateral incisor
and 10.06 and 8.89 mm for
the canine
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12. ETIOLOGY
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Altered passive eruption
Vertical maxillary excess
Hypertonicity of upper
lip/short upper lip
Skeletal abnormality and
Dentoalveolar protruberance
Uneven gingival margins -
maxillary anterior Teeth
supra eruption

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Altered passive eruption

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Coslet et al(1977)

16. 16
Mariana et al
(2016)

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Vertical maxillary excess
Garber DA, Salama MA. The aesthetic smile: diagnosis and
treatment. Periodontology 2000. 1996 Jun;11(1):18-28.

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Short upper lip
Sub-nasale to
lower border of
the upper lip.

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Short clinical crowns
Uneven gingival margins

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LIP LENGTH for
short upper lip
Male: 22-24mm
Female: 20-22 mm

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If the cemento–enamel junction is located in a normal
position in the gingival sulcus, the patient does not
have altered passive eruption. When the cemento–
enamel junction is not detectable in the sulcus, a
diagnosis of altered passive eruption may be made
and crestal ‘bone sounding’ is then performed.
DETECTION FOR ALTERED
PASSIVE ERUPTION
Mele M, Felice P, Sharma P, Mazzotti C, Bellone P, Zucchelli G. Esthetic
treatment of altered passive eruption. Periodontology 2000. 2018
Jun;77(1):65-83.

23. Transgingival probing
The probe is then pushed
through the base of the
sulcus until the alveolar crest
is engaged and this
measurement is recorded
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24. Radiographic
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VERTICAL MAXILLARY
EXCESS
-Palatal and incisal plane measurement.
-open bite
-excessive interlabial gap
Silberberg N, Goldstein M, Smidt A. Excessive gingival display--etiology, diagnosis,
and treatment modalities. Quintessence International. 2009 Nov 1;40(10).

27. 27
Seixas MR, Costa-Pinto RA, de Araújo TM. Checklist of esthetic features to consider in diagnosing
and treating excessive gingival display (gummy smile). Dental Press Journal of Orthodontics. 2011
Mar 1;16(2).

28. 28
Silberberg N, Goldstein M, Smidt A. Excessive gingival display--etiology, diagnosis,
and treatment modalities. Quintessence International. 2009 Nov 1;40(10).

29. Treatment
29
Gummy smile
Non surgical surgical
Lip repositioning,
Orthodontic,
Orthognathic surgeries
Gingivectomy, Apically
repositioned flap
Botox

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BOTOX
Botox is indicated when the gummy smile is due to hyper functional upper lip elevator muscles
(muscular capacity to raise the upper lip is higher than average).
Botox is the trade name for the neurotoxin protein botulinum toxin type A produced by fermentation
of anaerobic bacterium clostridium botulinum.
It is a stable, sterile, vacuum-dried powder that is diluted with saline solution without preservatives
for it to be injected.
Each vial of BOTOX contains
1. 100 Units (U) of Clostridium botulinum type Aneurotoxin complex,
2. 0.5 milligrams of Albumin Human,
3. And 0.9 milligrams of sodium chloride in a sterile, vacuum-dried form without a preservative.

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Mechanism of Action
BOTOX decreases muscle activity by blocking overactive nerve
impulses that trigger excessive muscle contractions or glandular
activity.

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How often do patients need to return for additional injections?
Effect of Botox is seen within 5-10 days and lasts about 6 months, with a range
of 4 to 8 months, at which time the patient can return to repeat the process. It is
important not to give injections prematurely (before the effects of the treatment
have worn off), as this can result in a buildup of antibodies to Botox that would
dilute the effect of further treatments.

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35. Surgical
treatment
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Type IA Gingivectomy
Type IB Flap procedure with internal bevel
incision and osseous resection.
Type IIA Apically repositoned Flap procedure
Apical reposition of the flap to preserve
the keratinized gingiva.
Type IIB Apically repositoned Flap procedure
with osseous resection.
Apical repositioning of the flaps to
preserve the keratinized gingiva.
Altered passive eruption

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TYPE 1-A

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TYPE 1-B

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Short clinical crowns
Crownlengthening
Aesthetic
Restorative
Scalpel
Lasers
Electrocautery
Burs

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Vertical maxillary excess

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Lip repositioning
technique
Lip repositioning procedure - 1973 by Rubinstein and Kostianovsky as part of
medical plastic surgery. Later on, it was introduced in dentistry, after being
modified in 2006 by Rosenblatt and Simon.
The surgery aims to limit smile muscle pull (zygomaticus minor, levator anguli,
orbicularis oris, and levator labii superioris) by reducing the depth of the upper
vestibule.
Indications:
Hypertonicity of lip.
short upper lip.
Vertical maxillary excess(Degree I)
Contraindications:
Inadequate width of attached gingiva
Vertical maxillary excess(Degree II & III)

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-Lip elongation associated with rhinoplasty (Ezquerra et al. 1999)
- Detachment of lip muscles(short upper lip) (Litton and Fournier 1979)
-
- Myotomy and partial removal (Miskinyar1983, Ishida et al. 2010)
- (Due to the occurrence of relapse, modified
the original technique into myectomy and partial resection
of the Levator labii superioris instead of complete separation
from the bone)

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RIBERO et al
2013

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CASE REPORT WITH COLLAGEN membrane

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57. CONCLUSION
▫ A correct diagnosis dictates the best treatment approach.
▫ A good understanding of the periodontal anatomy as well as the biologic
response to each of the surgical techniques is crucial in achieving stable
results.
▫ As such, dentists must define the basic tenets of an aesthetic smile -
extending that vision beyond simply "pretty teeth“ to a concept whereby total
dentofacial harmony is developed.
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58. REFERENCES
▫ Jensen JÖ, Joss AN, Lang NP. The smile line of different ethnic groups in
relation to age and gender. Acta Med Dent Helv. 1999;4(2):38-46.
▫ Garber DA, Salama MA. The aesthetic smile: diagnosis and treatment.
Periodontology 2000. 1996 Jun;11(1):18-28.
▫ Cohen ES. Atlas of cosmetic and reconstructive periodontal surgery. PMPH-
USA; 2007.
58

59. ▫ Vital Ribeiro-Júnior N, de Souza Campos TV, Guilherme Rodrigues J, Martins
A, Modolo T, Silva CO. Treatment of excessive gingival display using a
modified lip repositioning technique. International Journal of Periodontics &
Restorative Dentistry. 2013 May 1;33(3).
▫ Sahoo KC, Raghunath N, Shivalinga BM. Botox In Gummy Smile-A Review.
Indian Journal of Dental Sciences. 2012 Mar 1;4(1).
▫ Polo M. Botulinum toxin type A (Botox) for the neuromuscular correction of
excessive gingival display on smiling (gummy smile). American journal of
orthodontics and dentofacial orthopedics. 2008 Feb 1;133(2):195-203.
▫ Seixas MR, Costa-Pinto RA, de Araújo TM. Checklist of esthetic features to
consider in diagnosing and treating excessive gingival display (gummy smile).
Dental Press Journal of Orthodontics. 2011 Mar 1;16(2).
59

60. ▫ Silberberg N, Goldstein M, Smidt A. Excessive gingival display--etiology,
diagnosis, and treatment modalities. Quintessence International. 2009 Nov
1;40(10).
▫ Mele M, Felice P, Sharma P, Mazzotti C, Bellone P, Zucchelli G. Esthetic
treatment of altered passive eruption. Periodontology 2000. 2018
Jun;77(1):65-83.
▫ Tawfik OK, El‐Nahass HE, Shipman P, Looney SW, Cutler CW, Brunner M. Lip
repositioning for the treatment of excess gingival display: A systematic review.
Journal of Esthetic and Restorative Dentistry. 2018 Mar;30(2):101-12.
▫ Moura D, Lima E, Lins R, Souza R, Martins A, Gurgel B. The treatment of
gummy smile: integrative review of literature. Revista clínica de periodoncia,
implantología y rehabilitación oral. 2017 Apr;10(1):26-8.
60

61. ▫ Abou-Arraj RV, Souccar NM. Periodontal treatment of excessive gingival
display. InSeminars in Orthodontics 2013 Dec 1 (Vol. 19, No. 4, pp. 267-278).
WB Saunders.
▫ Thaker DD, Shah S, Shah RS, Kikani A. An integrated modified lip
repositioning using bioresorbable collagen membrane: A long-lasting
auxiliary treatment approach for gummy smile. J Int Clin Dent Res Organ
2019;11:43-8.
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