Gummy Smile Correction with Diode Laser: Two Case Reports

Abstract

Beautification of smiles is becoming an everyday requirement in dental practice. Apart from teeth, gingiva also plays an important role in smile esthetics. Excessive visualization of gingiva is a common complaint among patients seeking esthetic treatment. A wide variety of procedures are available for correction of excessive gum display based on the cause of the condition. Soft tissue diode laser contouring of gingiva is a common procedure that can be undertaken in a routine dental setting with excellent patient satisfaction and minimal post-operative sequale. Two cases of esthetic crown lengthening with diode laser 810 nm are presented here.

Full text

89
Journal of International Oral Health 2015; 7(Suppl 2):89-91
Gummy smile correction with laser… Narayanan M et al
Case Report
Received: 25th April 2015 Accepted: 27thJuly2015 ConictsofInterest:None
SourceofSupport:Nil
Gummy Smile Correction with Diode Laser: Two Case Reports
MaheshNarayanan1, S Laju2,SusilMErali3,SunilMErali4, Al Zainab Fathima5, P V Gopinath6
Contributors:
1Professor and Head, Department of Periodontics, Malabar
Dental College, Edapal, Kerala, India; 2Reader, Department
of Prosthodontics, Malabar Dental College, Edapal, Kerala,
India; 3Reader, Department of Orthodontics, Malabar Dental
College, Edapal, Kerala, India; 4Professor and Head, Department
of Conservative Dentistry, Malabar Dental College, Edapal,
Kerala, India; 5Reader, Department of Oral Pathology, Malabar
Dental College, Edapal, Kerala, India; 6Reader, Department of
Periodontics, Malabar Dental College, Edappal, Kerala, India.
Correspondence:
Dr. Narayanan M. Opposite Municipal Bus Stand, Kodungallur,
Trichur - 680 664, Kerala, India. Phone: +91-09745625211.
Email: drmaheshn@gmail.com
How to cite the article:
Narayanan M, Laju S, Erali SM, Erali SM, Fathima AZ, Gopinath PV.
Gummy smile correction with diode laser: Two case reports. J Int
Oral Health 2015;7(Suppl 2):89-91.
Abstract:
Beautication of smiles is becoming an everyday requirement in
dental practice. Apart from teeth, gingiva also plays an important
role in smile esthetics. Excessive visualization of gingiva is a
common complaint among patients seeking esthetic treatment.
A wide variety of procedures are available for correction of excessive
gum display based on the cause of the condition. Soft tissue diode
laser contouring of gingiva is a common procedure that can be
undertaken in a routine dental setting with excellent patient
satisfaction and minimal post-operative sequale. Two cases of
esthetic crown lengthening with diode laser 810 nm are presented
here.
Key Words: Crown lengthening, diode laser gum contouring,
gingival esthetics, gummy smile
Introduction
A gummy smile is a condition that aects the condence of
many young people. It is caused by a variety of factors. The
main causes include excess gum covering the teeth, an excess
of the maxilla, a short upper lip, or hyperactivity of the upper lip
that retracts too much during full smile. When 3 mm of gum is
displayed on smiling it is perceived as unesthetic or unnatural.
Many individuals with the gummy smile are embarrassed to
smile naturally and often end up in life not expressing their
full potential. The method for correction of the gummy smile
depends on nding the basic cause. In pronounced cases where
there is an excess amount of maxillary jaw bone, orthognathic
surgery in conjunction with orthodontic treatment is required
for obtaining the best possible result. Cases where the gummy
smile is due to gum overgrowth over the teeth can be more
easily corrected via a gingivectomy or “gum contouring”
procedure where excess gum is removed to expose the natural
length of the teeth.
Beautiful smiles are produced by three main parameters that
are the teeth, the gums, and the lips, respectively. There are few
instances where gum recontouring is necessary. First in cases of
altered passive eruption, while other is clinical crown height of
the tooth is less than anatomic crown height producing short
teeth which are square and wide.1 This may result in high smile
line, with resulting appearance of “gummy smile.” Dentists can
easily modify the shape of the tooth, the interdental papilla,
and contour of the gums while it may be dicult to correct
discrepancies of the lip and position of lip in speech. In all
corrections of gingival particular attention has to be given in
preserving the biologic width.2
A classification system for esthetic crown lengthening
procedures has been proposed by Lee.3
Type I: Sucient soft tissue present allowing gingival exposure
of the alveolar crest or violation of the biologic width.
Corrective procedure may be performed by the restorative
dentist. Provisional restorations of the desired length may be
placed immediately.
Type II: Sucient soft tissue allows gingival excision without
exposure of the alveolar crest, but in violation of the biologic
width. These conditions will tolerate a temporary violation
of the biologic width, allows staging of the gingivectomy and
osseous contouring procedures. The provisional restorations of
the desired length may be placed immediately, requires osseous
contouring, and may require a surgical referral.
Type III: The gingival excision to the desired clinical crown
length will expose the alveolar crest. Staging of the procedures
and alternative treatment sequence may minimize display of
exposed subgingival structures. The provisional restorations of
the desired length may be placed at second-stage gingivectomy,
requires osseous contouring, and may require a surgical referral,
limited exibility.
Type IV: The gingival excision will result in an inadequate band
of attached gingiva, limited surgical options, no exibility, a staged
approach is not advantageous, may require a surgical referral.
Pretreatment planning
As in any case of esthetic dental treatments, certain
parameters have to be cr itically assessed prior to performing

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Journal of International Oral Health 2015; 7(Suppl 2):89-91
Gummy smile correction with laser… Narayanan M et al
gummy smi le correction.4 This w ill help in proper treatment
planning for the patient.
1. Patients expectations, systemic health, and habits;
2. Height, symmetry of face and smile line;
3. Lip thickness, size, and prole
4. Size and shape of the teeth
5. Gingival biotype and width of keratinized gingiva;
6. Thickness and contour of the alveolar bone.
A study cast and radiographs obtained will help in preparation
of a surgical template5 which can help in precisely planning the
amount of gingival tissue removal and also plan to provide ideal
gingival shape and contour.
The gingival shape refers to the curvature of the gingival
margin. The gingival zenith for maxillary lateral incisors and
the mandibular incisors must coincide with their longitudinal
axis while that for central incisors and canines may alter with
slight distal to the longitudinal axis (Figure 1). The gingival
contour, when compared with gingival shape, it refers to the
three-dimensional description of gingival topography. Ideal
gingival contour has sharp interdental papillae and equally
tapered gingival margins at the cervical third region of the
tooth.
The gingival countouring can be performed by many means
including scalpel surgery, electrocautery, and lasers. In most of
the cosmetic dentistry cases, cosmetic gingival contouring can
be successfully performed by the soft tissue diode laser.7 The
soft tissue diode laser helps to establish a state of hemostasis
and facilitate gingival recontouring. In some cases of minor
corrections laser gum contouring can be done even without
local anesthetics.
Case Report
A female patient aged 18 years reported to the periodontist
with a complaint of an excessive show of gums while smiling.
On clinical examination of the patient, it was assessed that she
had a combination of the skeletal problem along with altered
passive eruption where 3-4 mm of her teeth was hidden under
the gums (Figure 2a). Although a combination of orthognathic
surgery and gingival recountouring was advised to her, she
opted for only laser gingival contouring alone.
A stent was prepared preoperatively assessing the amount
of gingiva that can be excised after ensuring that sucient
biologic width remains (Figure 2b). The diode laser excision
was performed at 1.5 watts continuous mode with an activated
tip (Figure 2c). Post-operative healing was uneventful with an
acceptable smile for the patient (Figure 2d).
A 25-year-old female presented with a complaint of an excessive
show of gums and whitish prominence of gums while smiling.
Clinical examination of the patient revealed excessive gingiva
covering the teeth with uneven gingival margins as well as
exostosis in the maxilla close to the premolar – Molar buccal
gingival region which displayed as whitish prominences when
the patient smiled (Figure 3a). Laser gum recountouring was
advised for the anterior region with ostectomy for buccal bone
removal in the posterior region. She opted for both treatments
and her smile drastically improved. The diode laser contouring
was done at 0.8-1.2 watts continuos mode with an activated tip
(Figure 3b). The power used was lesser for this patient due to
the presence of more melanin in the gums. The post-operative
event was uneventful (Figure 3c). After osseous recountouring
the patient was satised with the results obtained (Figure 3d).
Discussion
Aesthetic gum contouring with diode laser is predictable and
minimally invasive procedure that can produce immediate
results and is easily acceptable to the patient.8 The use of diode
laser enables complete control over the procedure for even
the general dentist as it allows for repeated contouring, better
vision in a bloodless eld to bring out excellent results in terms
of height, contour and symmetry of the gingiva.
The major factor to be taken into consideration, while doing
excision is to preserve the biologic width. Biological width
is a summation of junctional epithelium and supra crestal
connective tissue attachment. Alteration of biological width
Figure 1: Recommended zenith placement relative to long
axis of maxillary anterior teeth. Note that lateral incisor zenith
coincides with long axis of tooth, whereas zeniths of central
incisors and canines are slightly distal to long axis.6
Figure 2: a) Preoperative smile, b) with acrylic stent, c) diode
laser excision, d) one month post opeartive smile.
d
c
b
a

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Journal of International Oral Health 2015; 7(Suppl 2):89-91
Gummy smile correction with laser… Narayanan M et al
may lead to gingivitis, discomfort, recession, adjacent bone
loss, and pocket formation. This value becomes more critical
when crowns or veneers are planned after gingival contouring.
The soft tissue diode laser 810 nm has a high anity for melanin
and hemoglobin and is better equipped to perform soft tissue
procedures in the oral cavity.9 This laser does not interact
with dental hard tissues at lower power settings and hence
post-operative sequale are more predictable. This property of
the laser allows for a comfortable single sitting gingivectomy.
While doing the procedure with the laser it is important to
realize that the laser does not cut like a blade; instead, the tissue
is ablated by the laser energy at the ber tip.9 The activated laser
tip is simply guided along the precise route desired to let the
highly directed laser energy do the work. The tip of the ber
is then directed at the rolled margin in a sweeping motion to
ablate the margins and bevel them to the desired sharpness.
3 weeks after gingival shaping and contouring, the tooth has a
much more esthetic appearance.
Although used with right parameters laser are excellent,
sometimes excess carbonization can occur with increased
power settings leading to unwanted sequale such as tooth
sensitivity, gingival recession, and post-operative pain. The
clinician has to be wary of these events while performing the
procedure.
Conclusion
The excessive gingival display is a common concern among
many patients. Most of these patients are not willing to undergo
a major surgical procedure to correct this problem. The diode
lasers provide the clinician with a tool to provide minimally
invasive surgical alternative for the patient. Both the patients
who opted for the procedure did not have any postoperative
pain or discomfort. They were followed up for 1 year with
excellent results which have sustained.
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Figure 3: (a) Preoperative smile, (b) Diode laser contouring,
(c) 2 week postoperative gingival contour, (d) One month
post operative smile.
d
c
a
b