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Gummy Smile: A Review of Etiology, Manifestations, and Treatment

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  • BankokThonburi University

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Excessive gingival display, as known as Gummy Smile, is a clinical condition which is attracting a great attention and focus recently. Having knowledge and background about the cause and the treatment of each case of excessive gingival display is essential for making the accurate diagnosis and performing the correct procedure. This article reviews the most common causes of excessive gingival display, manifestations of this condition, and some of the important treatment options for Gummy Smile. In addition, the article also puts the light on some points regarding the accepted measurement in several studies, and considers the prediction planning for Gummy Smile associated with a skeletal etiology.
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Volume 71, No.1: 2019 Siriraj Medical Journal www.smj.si.mahidol.ac.th
168
Basel Mahardawi, B.D.S.*, Teeranut Chaisamut, D.D.S.*, Natthamet Wongsirichat, B.Sc., D.D.S.*,**
*Department of Oral Maxillofacial Surgery, Faculty of Dentistry, Mahidol University, Bangkok 10400, **Walailak University International College of
Dentistry, Bangkok 10400, ailand.
Gummy Smile: A Review of Etiology,
Manifestations, and Treatment
Corresponding author: Natthamet Wongsirichat
E-mail: natthamet.won@mahidol.ac.th
Received 25 August 2018 Revised 6 December 2018 Accepted 24 December 2018
ORCID ID: http://orcid.org/0000-0003-3005-2680
http://dx.doi.org/10.33192/Smj.2019.26
ABSTRACT
Excessive gingival display, or what is known as Gummy Smile, is a clinical condition which is attracting a great
attention and focus recently. Having knowledge and background about the cause and the treatment of each case of
excessive gingival display is essential for making the accurate diagnosis and performing the correct procedure. is
article reviews the most common causes of excessive gingival display, manifestations of this condition, and some
of the important treatment options for Gummy Smile. In addition, the article also puts the light on some points
regarding the accepted measurement in several studies, and considers the prediction planning for Gummy Smile
associated with a skeletal etiology.
Keywords: Excessive gingival display; gummy smile; vertical maxillary excess (Siriraj Med J 2019;71: 168-174)
INTRODUCTION
A wonderful smile is an essential feature of beauty to
which society gives an increasing importance currently.
e concept of a nice smile basically depends on the
entity of three anatomic components: gum, teeth, and
lips.1 In the meantime, an increasing awareness regarding
beauty and physical appearance has become a motivation
for every clinician to evaluate the important aspects of
patient’s smile and link the dynamic relationship between
the teeth, gingiva, and lips together when smiling.2
e gingiva is a crucial aspect to be considered in
the esthetics of smiling1, in which the upper lip should
be elevated around 80% of its normal length, exposing
teeth and gingiva.3 Sharma et al.,2 dened the normal
gingival display as the gum exposure between the inferior
border of upper lip and gingival margin of anterior central
incisors when smiling. An exposure of gingiva around 0-2
mm when smiling, and 2-4 mm of the maxillary incisor
edges when the lips are at the rest state are considered as
acceptable. While more than 2 mm of gingival exposure
when a person smiles is stated by experts as an excessive
gingival display, or what is known as “Gummy Smile”,4
which is more of a descriptive term than a diagnosed
condition, and aects a notable proportion of the population,
especially women who are aected more than men.5
Maxillary excess both vertically and anterioposteriorly
(Bimaxillary protrusion), hyper mobility of the upper
lip due to hyper function of labial elevator muscles, and
excessive gingival display associated with altered passive
eruption are the three major causes of this condition.6
In addition to the stated reasons, medications, dental
plaque, hereditary and incompetent lip can also result
in abnormal gingival display.5
For adults, improved aesthetic outcomes are becoming
increasingly essential in these procedures to the point
where some patients are pursuing only the esthetic side,
Mahardawi et al.
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not a functional benet.7 erefore, nding an eective
treatment for each cause of the gummy smile is a must.
Etiologies of gummy smile:
Many studies have stated the main causes of excessive
gingival display, presenting the most important factors
which may lead to having a Gummy Smile. e study
of Roe et al.,8 described that lip length and the upper
lip mobility rate are the main contributing factors. e
previous research of Peck et al.,9 stated that the exposure
of teeth and gingiva depends on the integrated eects
of a number of variables (increased muscle capacity,
vertical maxillary excess, greater interlabial gap at resting
position, and the amount of overjet and overbite). Pausch
et al.,4 mentioned that abnormal gingival and maxillary
anterior teeth display may take place due to numerous
anatomic or functional factors, either hereditary or
inborn. A narrow upper lip, an irregular eruption of teeth,
excessive protuberance or vertical maxillary growth, and
hypermobility of the maxillary lip and elevator muscle
are common reasons for a Gummy Smile.
In fact, several contributing factors are aecting
individuals to have a Gummy Smile. Sometimes one of
them is presented, although in some cases more than only
one cause can be seen. Correct diagnosis of the reason
leads to a proper treatment plan. e most common and
discussed factors associated with Gummy Smile are:
Altered passive eruption:
Also known as impaired passive eruption,1 is dened
as a condition in which the relationship between teeth,
alveolar bone in the maxilla, and the so tissues displays
an excessive gingiva. is, in turn, reveals the clinical
characteristic of Gummy Smile.10 In other words, altered
passive eruption (APE) is characterized by excessive
gingival exposure in relation to the crowns of the maxillary
teeth.11 In this case, the gingiva fails to migrate in the
apical direction during the eruption of teeth, thus,
it remains in a coronal position in relation with the
cementoenamel junction (CEJ), which results in having
an unacceptable gingival exposure and unfavorable small
size of the teeth when smiling.5 Miskinyar et al.,12 found
that the prevalence of this condition is about 12% of the
population. Altered passive eruption was rst identied
by the study of Coslet et al.,
13
and according to Rossi et al.,
10
it was classied into two types and two subtypes (Fig 1):
1. Type I : the vertical length of keratinized gingiva
is greater than normal, the mucogingival junction
(MGJ) is located in an apical position to the level of the
cementoenamel junction (CEJ), and clinical crowns
appear shorter.
2. Type II : the vertical dimension of the keratinized
gingiva is normal, although the mucogingival junction
is positioned at the level of the CEJ.
2.1 Subtype A : the measurement between the
maxillary alveolar crest and the CEJ is around 1.5 mm,
and in this case a regular attachment can be found.
2.2 Subtype B : the level of maxillary alveolar
crest is at the level of the CEJ, or occlusal to the CEJ in
some cases.
Bony maxillary excess:
This includes vertical maxillary excess and
bimaxillary protrusion.
Vertical maxillary excess:
Wolford et al.,15 defined Maxillary vertical
hyperplasia or vertical maxillary excess as an excessive
vertical growth of the maxilla which may or may not lead
to an anterior open bite. In his study Robbins16 explained
that to make the correct diagnosis, the face must be
divided into three equal thirds or parts for the critical
evaluation of the height of the face. Vertical maxillary
excess is noticed when the length of the lower third of
the face is more than the other two thirds, causing an
excessive gingival display.5
In the analysis of the face, vertical maxillary excess
has the following features: longer lower third of the face,
in relation with the upper and middle thirds, a greater
display of maxillary incisors at rest, an incompetent
lip, inclination towards class II malocclusion with or
without open bite, and a noticeable Gummy Smile. e
nose is longer as well, the alar bases are small and the
zygoma appears to be generally at. e lower third of
the face is long, leading to a retrognathic shape of the
jaw.17 Furthermore, the incisal edge of the upper anterior
teeth might be covered by the lower lip because of the
extravagant downward growth of the maxilla.16 Peck et
al.,9 and Mackley18 found that a Gummy Smile is highly
related to anterior vertical maxillary excess (about 2-3
mm). Moreover, Ezquerra and Berrazueta19 discuss
that excessive maxilla associated with the protrusion of
anterior alveolar bone consequently produce a Gummy
Fig 1. Classication of altered passive eruption (APE)14
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Smile. Whilst Wu et al.,6 in their study also stated that
anterior maxillary height (upper incisor to the palatal
plane) was considerably more in both male (+1.03 mm)
and female (+2.13 mm) groups who have Gummy Smile.
Bimaxillary protrusion:
Bimaxillary protrusion is a frequently diagnosed
deformity in African Americans20 and Asian populations as
well. is deformity is described regarding the protrusive
and buccally positioned maxillary and mandibular incisors,
as well as the enlarged prostration of the lips. It can be
found with an incompetent lip, excessive gingival display,
mentalis strain with an anterior open bite. Bimaxillary
protrusion refers to an abnormally protruded maxillary
and mandibular dentoalveolus. Generally, this presents
with malocclusion and dentoalveolar aring of both the
maxillary and mandibular anterior teeth, which cause
the lips to be protruded, thus, producing an additional
convexity of the facial prole. Bimaxillary protrusion is
mainly accompanied by several degrees of lip deciency
(dened as more than 4 mm of lip detachment at the rest
state). e tendency of the anteroposterior correlation is
to be a class II malocclusion with a decient mandible,
although it may also range from severe class II to class
III.21
The etiology behind bimaxillary protrusion is
associated with various reasons between genetics and
environment, such as mouth breathing, lip biting habit
and large size of the tongue.22
Keating et al.,23 discovered that in Caucasians with
bimaxillary protrusion, it is likely to notice a posterior
cranial base which is shorter than normal, a prognathic
maxilla with vertical excess, mild class II skeletal
occlusion, and a prostrate prole.
Conditions causing gingival enlargement
Gingival enlargement might be the outcome of
bacterial plaque-enhanced chronic inammation and
medications.5 Narwal et al.,24 showed in their case report
an abnormal unilateral palatalso tissue enlargementin a
61-year-old hypertensive female using amlodipine, which
is a safe antihypertensive drug. Ritchhart et al.,25 stated a
process behind uncontrolled cell proliferation in drug-
induced gingival overgrowth which is the suppression
of apoptotic pathways, with the following eect on the
normal gingival formation by cell turnover. Hormonal
dierences which take place in pregnancy and puberty,
in addition to the use of oral contraceptives have been
associated with gingival overgrowth.5 Other eects such
as age, demographic and pharmacokinetic changes,
genetic predisposition, oral hygiene condition, as well as
molecular and cellular variables may impact the mechanism
of gingival enlargement.25, 26 Orthodontic treatment
using orthodontic appliances can also participate in
the presence of gingival enlargement.27 In the case of
leukemia, leukemic cells might inltrate to the gingiva,28
and this will cause some manifestations to be present
such as gingival enlargement and bleeding.29
Short upper lip
e upper lip length is dened as the length from
the base of the nose (subnasale point) to the inferior
part of the upper lip (upper lip stomion point),8 which
is normally around 23 mm in males and 20 mm in
females.3 If an individual with excessive gingival display
has a short upper lip as well, the esthetic compromise
will be aected.16 e diagnosis of an excessive gingival
display can be done regarding the clinical measurement
of the upper lip length with an excessive amount of
tooth display at rest.5 Conversely, Roe et al.,8 found in
their study that in maximum smile, there is no notable
dierence in the gingival display between an individual
with a short or normal upper lip, and they concluded that
the association of some factors such as higher muscle
capacity, vertical maxillary excess, excessive interlabial
gap at rest, and the amount of overjet and overbite have
a greater eect on the gingival display than the upper
lip length itself. Moreover, Sarver et al.,30 explained that
what is crucial is the correspondence between the upper
lip length, the maxilliary incisors, and the commissure
of the mouth. In other words, the lip length should be
almost equal to the commissure of the mouth.
Hypermobility of the upper lip:
In the case of normal face height, gingival levels,
lip length and length of central incisors in a patient who
has an excessive gingival display, the possible etiology
is hypermobility of the maxillary upper lip.16 Upper lip
mobility was explained as the volume of lip movement that
exists when an individual smiles. is was measured by
deducting the incisal shown at rest from the dentogingival
display during a full smile. Hypermobility of the upper
lip is associated with a hyper function of the lip elevator
muscles and basically leads to excessive gingival display.19
Peck and Peck31 reported an average lip movement
of 5.2 mm (23% decrease) from a measured lip length
of 22.3 mm during a full smile. Furthermore, in a study
evaluating spontaneous smiles, Tarantili et al.,32 identied
a 28% decrease in the initial upper lip length, while
Roe et al.,8 concluded the overall means of lip mobility
for females with normal lip length, females with short
lip length, males with normal lip length and males with
Mahardawi et al.
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short lip length were 5.8 ± 1.7 mm, 5.0 ± 1.3 mm, 6.7 ±
1.5 mm, and 5.7 ± 1.1 mm, respectively. Moreover, Sabri
et al.,3 stated that in smiling, the upper lip is elevated by
about 80% of its original length. Bhola et al.5, as well as
Robbins16 stated that the upper lip is generally elevated
around 6-8 mm from the rest position to the position
reached when a full smile takes place.
Treatment of gummy smile:
Excessive gingival display can be managed by a
variety of procedures. ese procedures include non-
surgical and surgical methods. e underlying cause of
excessive gingival display or Gummy Smile has the main
eect on the type of procedure that will be performed.33
Non-surgical procedures may include Botulinum toxin
type A injection as well as orthodontics, While surgical
procedures might include lip repositioning or orthognathic
surgery following orthodontics.
Robbins16 dened the healthy gingiva as having
a minimal length of approximately 3 mm from the
gingival crest to the alveolar crest. In the case of altered
passive eruption, a higher amount will exist, and the
treatment of choice is normally gingivectomy following
by aesthetic crown lengthening to attain the desired
dimension and morphology of teeth. However, when the
diagnosis shows bone levels close to the CEJ, a gingival
ap with ostectomy is performed, or what is also known
as an apically positioned ap.34 Orthodontic eruption
or intrusion can also be done when having gingival
asymmetry on one or multiple anterior teeth34
In the case of vertical maxillary excess, the only
treatment option to consider is orthognathic surgery.11 is
is applied to impact the maxilla considering the amount of
gingival exposure diagnosed. Maxillary impaction allows
correction of the Gummy Smile, long face syndrome,
specic types of open bite from a skeletal origin and labial
sealing.35 e Le Fort I osteotomy of the maxilla allows
reduction of bone between the nasal oor and apices of
maxillary teeth which permits superior repositioning
(impaction) of the maxilla.17
When having bimaxillary protrusion, the treatment
option may be composed of rst premolar extractions
followed by the osteotomy through the extraction sites
to mobilize the anterior segment of the maxilla. e aim
is to setback the segment in addition to lesseningthe
labial aring of the incisors. Maxillary setback alone
can sometimes provide a substitute for the treatment of
anterioposterior maxillary excess without any need for
tooth extraction or segmental osteotomy in these cases:
(1) it is contraindicated to perform extractions in
an orthodontic diagnosis (no dental crowning, adequate
curve of Spee, etc.),
(2)the proclination of maxillary incisors can be
adjusted to an acceptable position with a Le Fort I osteotomy
in addition to clockwise rotation.21
In the presence of external factors causing gingival
overgrowth, the treatment plan should be focused on the
exact cause of the enlarged gingiva. Meticulous history
taking, in addition to an excisional/incisional biopsy and/
or hematologic/histologic inspection might be performed
generally to make the correct diagnosis of the uncommon
conditions of gingival enlargement. Plaque control is an
important aspect of treatment in all the patients. Some
of these cases may resolve when the external element
that is inducing the gingival enlargement is adjusted or
suspended, For example, gingival overgrowth during
pregnancy and puberty might need the elimination of
all local irritants followed by surgical treatment for the
removal of any brotic residuals.36
For the excessive gingival display resulted from
short upper lip and/or hypermobility of the upper
lip, a surgical procedure known as lip repositioning
surgery is preferred for a minimally invasive surgery.
It is composed of an oval mucosal excision followed
by coronally advanced ap. is procedure is done to
reduce the hyperactivity of the elevator muscles and
reform the depth of the vestibule.37 It was rst described
by Rubinstein and Kostianovsky38 and the aim was the
treatment of excessive gingival display associated with
hypermobility of the lip, and was then modied by Litton
and Fournier39 to include also the treatment of Gummy
Smile caused by short upper lip, by separating the muscles
from the underlying bony structures to place the upper
lip in a coronal position. is surgical procedure was
accompanied with no complications, although there were
some incidences of relapse,40 consequently, some attempts
were done to improve it by Miskinyar.12 Recently, Bhola
et al.,5 described a technique similar to the one which was
described by the article of Rubinstein and Kostianovsky
under the name of Lip Stabilization Technique (LipStaT).
e only obvious dierence between the two techniques
is that in LipStaT, a vertical incision is done posteriorly
to connect the inferior incision (at the mucogingival
junction) and the superior incision (into the vestibule).
e ratio of this incision is the height being double of
gingival exposure during a full smile. While in Rubinstein
and Kostianovsky technique, the two incisions were
approximated till they meet posteriorly.
Currently, another nonsurgical treatment option is
the injection of Botulinum toxin type A which has been
suggested for treatment of hypermobility of the upper
lip, but this may only provide temporary advantages.41
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172
Polo41 reported a relapse of around 2 mm aer 24
weeks of following up. is was similar for Indra et al.,42 by
reporting a relapse of treatment in the third month. Yet it is
still a viable option for those who do not prefer undergoing
surgeries, and need only a minimal treatment procedure.
DISCUSSION
It was stated recently that the dimension and visibility
of teeth, and upper lip position were crucial eects when
judging smile attractiveness.43 Many studies described the
acceptable gingival exposure and the concept of Gummy
Smile (table below). Having an acceptable smile in the
eyes of other people is, in fact, a subjective view, because
the perception of a nice smile has diered from country
to country, from study to study, and even when males
or females are evaluating the smile. In other words, a
study showed that the male raters diered in respect of
gender specicity when judging the attractiveness of
the smile, while female raters rated males less gender
specic.4 erefore, no reliable or unied measurements
were stated in the literature regarding a clear description
of having an attractive smile or when it is diagnosed as
a Gummy Smile. Although the dierent visions of an
accepted gingival exposure were evaluated in dierent
countries, they should be identical for the same ethnic
origins. Sabri et al3 concluded that an ideal smile has
the features of an upper lip that will reach the gingival
edges when smiling, in addition to an upward or straight
curvature through the philtrum and commissures; with
maxillary incisal margins parallel to the lower lip line;
with no lateral negative space or minimal if it presents;
and a commissural line, as well as an occlusal frontal
plane parallel to the line drawn through the pupils of the
eyes; and attractive integration of gingiva and teeth. e
acceptable amount of gingival exposure when smiling
was mentioned in several studies. For instance, Kokich
et al.,44 reported noticeably unattractive lip to gingiva
distance when the exposure is 4 mm by laypersons and
when it is 2 mm by orthodontists, while Geron and Atalia45
accepted only 1 mm of gingival display when smiling.
Pausch et al.,4 concluded in their study that a 0- to 2-mm
exposure of the maxillary gingiva was acceptable when
an individual smiles. In addition to that, they found that
although the Gummy Smile is unattractive, it is much
better than invisible or minimally visible maxillary teeth
when smiling. Bhola et al.,5 explained that aected by
the increased aesthetic concerns, a gingival exposure of
more than 1 mm during smiling might be diagnosed as
excessive gingival display (EGD). Van der Geld et al.43
concluded in their study that a lip line height that exposed
more than 4 mm of gingival display was considered as
a Gummy Smile line. Jannani et al.46 stated that a smile
is introduced as attractive when the maxillary teeth are
entirely shown in addition to approximately 1 mm of
gingival display. However, a gingival display not more
than 2-3 mm is also contemplated as acceptable, while
a disproportionate exposure (>3 mm) is basically stated
as not pleasant. Pinto et al.,11 mentioned three kinds of
a smile: high, medium and low, and the high smile is
considered acceptable when accompanied with exposed
gingiva of 1 to 3 mm.
Moreover, treatment of Gummy Smile was being
practiced many years ago. Several techniques and procedures
were developed to reduce the excessive gingival display
and change it into an aesthetic, acceptable appearance.
Taking the bony maxillary excess into consideration,
a review of the literature may conclude that although
the treatment of Gummy Smile caused by vertical
maxillary excess and/or bimaxillary protrusion is not a
new procedure, no studies have made a clear treatment
plan, and no one has described a step by step way to
predict the treatment according to a certain prediction
plan before performing orthognathic surgery, based
on clear measurements of moving the maxilla. us, a
thorough prediction and movement plan of the maxilla
for Gummy Smile treatment might be of a great value to
help surgeons establish an accurate treatment plan based
on scientic data, not only experience. e acceptable
gingival exposure and the diagnosis of Gummy Smile
in some previous studies is shown in Table 1.4,5,11,43-46
CONCLUSION
Gummy Smile is a condition in which an increasing
awareness has been noticed recently. erefore, it is
attracting more attention from all the clinicians to nd
the best solutions with the least complications and
relapse, as well as the most satisfying results for every
patient. Additional unied standards of accepting and
not accepting the amount of gingival exposure might
be better to help with diagnosing and deciding whether
to perform surgery or consider the gingival exposure as
acceptable. is should be decided considering the ethnic
origin and trying to collect a wider range of opinions, not
only taking experts’ view because they will judge more
critically. is could be done by performing a greater
statistical analysis regarding this topic, including more
people to evaluate and judge.
In addition, clear prediction planning of moving
the maxilla to improve the condition of Gummy Smile,
taking into account if it is resulted from vertical maxillary
excess alone or with bimaxillary protrusion, would be of
a great benet to perform a well-planned surgery. is
Mahardawi et al.
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TABLE 1. Acceptable gingival exposure and the diagnosing of Gummy Smile in some studies in the literature.
Authors Year Acceptable gingival exposure Having a Gummy Smile
Kokich et al44 1999 Less than 4 mm by laypersons 4 mm or more by laypersons 2 mm or
Less than 2 mm by orthodontists more by orthodontists
Geron and Atalia45 2005 Untill 1 mm More than 1 mm
Van der Geld et al.43 2011 Untill 4 mm More than 4 mm
Jannani et al.46 2014 2-3 mm More than 3 mm
Pinto et al.11 2015 1-3 mm More than 3 mm
Bhola et al.5 2015 Untill 1 mm More than 1 mm
Pausch et al.4 2017 0-2 mm More than 2 mm
surgery should be done according to certain principles and
criteria, not depending upon each surgeon’s experience
or preference. To reach this stratied surgical plan, this
literature review suggests further studies to design a
prediction formula of moving the maxilla, following
certain calculations regarding the amount of vertical
maxillary excess, bimaxillary protrusion, x-rays, and
considering opinions of experienced surgeons to get
the best aesthetic results.
ACKNOWLEDGMENTS
e authors would like to acknowledge the sta,
dental assistants, and our colleagues in the Department
of Oral and Maxillofacial Surgery, Faculty of Dentistry,
Mahidol University.
Funding: e authors received no funding
Conict of interest: e authors declared that they have
no conicts of interest.
Ethics approval: Not required
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Mahardawi et al.
... El concepto de una sonrisa depende básicamente de la entidad de tres componentes anatómicos: encía, dientes y labios. (Gonzales-Medina et al., 2021;Mahardawi et al., 2019). La visualización gingival excesiva (EGV), también llamada sonrisa gingival, se define como una condición no patológica en donde podemos observar una exposición gingival de más de 4 mm que se toman desde el extremo inferior del labio superior y el margen gingival de los dientes (Jasser, 2019). ...
... Entre las etiologías que se han descrito para la sonrisa gingival encontramos la longitud y la tasa de movilidad del labio superior, la erupción pasiva alterada, el exceso vertical del hueso maxilar, el mayor espacio interlabial en posición de reposo y la cantidad de overjet y sobremordida (Mahardawi et al., 2019). ...
... Este artículo revisa las causas más comunes de visualización gingival excesiva, las manifestaciones de esta afección y algunas de las opciones de tratamiento importantes para la sonrisa gingival. (Mahardawi et al., 2019) En el caso de la erupción pasiva alterada el tratamiento puede ser gingivectomía y alargue de corona clínico, en el exceso vertical se sugiere únicamente la cirugía ortognática, en el caso de la protrusión maxilar se recomienda la extracción de los primeros premolares. En el caso de las condiciones que causan el agrandamiento se recomienda tratar la causa para así reducir el exceso gingival. ...
Article
Full-text available
La sonrisa gingival es una condición no patológica en donde existe una exposición excesiva de la encía de más de 4 mm que afecta la estética de los pacientes. Es una condición multifactorial por lo que realizar un correcto diagnóstico es primordial para poder determinar un correcto plan de tratamiento. La cirugía de reposicionamiento de labios es una técnica que se ha implementado para tratar la sonrisa gingival la cual consiste en eliminar una banda de mucosa del vestíbulo, logrando así un colgajo entre la unión de la línea mucogingival y apical a la musculatura del labio superior acortando de esta manera el vestíbulo y reduciendo la excesiva exposición gingival. El objetivo de este artículo es conocer los avances y las consideraciones a tomar en cuenta para la realización de la técnica de reposicionamiento labial como tratamiento para la sonrisa gingival. Metodología: se realizó una revisión de la literatura de los últimos 5 años mediante una búsqueda electrónica en las bases de datos de Science Direct, Scielo, Pubmed y Google Académico. Resultados: Se incluyeron 22 artículos científicos en los cuales observamos la etiología, ventajas y cómo ha evolucionado la técnica a largo del tiempo. Conclusión: es una técnica muy utilizada al ser poco invasiva, presenta menos complicaciones postoperatorias, una recuperación más rápida que puede usarse en combinación con otras técnicas quirúrgicas o no quirúrgicas, sin embargo; se necesitan más estudios a largo plazo ya que sigue existiendo un alto riesgo de recidiva.
... Нос также длиннее, основания скул маленькие, а скуловая кость, как правило, плоская. Нижняя треть лица длинная, что приводит к ретрогнатической форме челюсти [6]. ...
... Narwal и соавт., показали в своем клиническом случае аномальное одностороннее увеличение мягких тканей неба у 61-летней женщины с артериальной гипертензией, принимавшей амлодипин, который является безопасным антигипертензивным препаратом [5,8] Гормональные изменения, которые имеют место во время беременности и полового созревания, в дополнение к использованию оральных контрацептивов, могут также быть связаны с чрезмерным ростом десен [6]. ...
... Гипермобильность верхней губы. В случае нормальной высоты лица, уровня десен, длины губ и длины центральных резцов у пациента с чрезмерным выступанием десен возможной этиологией является гипермобильность верхней губы верхней челюсти [6]. ...
Article
У человека могут быть идеально ровные и белые зубы, но «десневая» улыбка способна перечеркивать это достоинство. По статистике, такое явление довольно частое, и многие сильно переживают по этому поводу. К счастью, данную природную особенность с современными технологиями можно успешно исправить. Все клиницисты уделяют больше внимания поиску наилучших решений с наименьшими осложнениями и рецидивами, а также наиболее удовлетворительным результатам для каждого пациента, имеющего «десневую» улыбку.
... Possui caráter multifatorial devido às diversas etiologias, sendo possível dividi-las em: dentário, gengival, ósseo e muscular. E possui como principais: o crescimento vertical da maxila, a hiperplasia gengival, a erupção passiva alterada e o lábio superior curto ou hiperativo (Kuhn-Dall'Magro et al., 2015;Aly, Hammouda, 2016;Mahardawi, et al., 2019). ...
... momento em que o lábio superior se desloca em uma direção apical maior que 8 mm e exibe os dentes e o excesso de gengiva, a média de contração também é 1,5 a 2 vezes mais elevada. (Bhola et al., 2015;Jananni, et al., 2014;Mahardawi, et al., 2019). ...
... As principais etiologias do SG são decorrentes da erupção passiva alterada, coroas clínicas curtas, dentes com formas normais que apresentam crescimento ósseo aumentado, excesso vertical da maxila, lábio superior curto ou com hipermobilidade, hiperplasia gengival medicamentosa, periodontite ou gengivite crônica (Sousa et al., 2010;Mahardawi, et al., 2019). Dentre estas etiologias, a paciente apresenta erupção passiva alterada, hipermobilidade do lábio e um leve crescimento vertical de maxila. ...
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Introdução: Exposição gengival excessiva ou “sorriso gengival” apresenta um desafio estético que pode ser tratado por diferentes modalidades, dependendo das etiologias subjacentes. Objetivo: O objetivo deste estudo foi relatar o tratamento periodontal de um caso de sorriso gengival, discutindo os fatores etiológicos associados. Relato do caso: Paciente O.S.M.A., sexo feminino, 23 anos, procurou o Projeto de Extensão em Periodontia Clínica e Cirúrgica (PROEPECC) demonstrando insatisfação com o seu sorriso, no qual apresentava coroas clínicas curtas e exposição gengival excessiva. Após os exames clínicos, identificou-se que se tratava de um quadro de erupção passiva alterada do tipo I B e hipermobilidade do lábio superior. O tratamento proposto foi a realização de gengivectomia em campo aberto com osteotomia. Resultados: Desde o pós-operatório imediato a paciente já exibia uma melhora significativa no sorriso. A paciente foi reavaliada com 6 meses após o ato cirúrgico e observou-se um sorriso mais harmônico, conforme havia sido inicialmente planejado, apresentando os tecidos gengivais com contornos regulares e zênites gengivais de incisivos centrais, laterais e caninos posicionados adequadamente. Conclusão: A exposição gengival excessiva causada por erupção passiva alterada apresenta um excelente prognóstico quando o caso é bem diagnóstico e planejado, observando a etiologia multifatorial do sorriso gengival.
... 8 Smile arc merupakan hubungan antara tepi insisal gigi anterior pada rahang atas dengan kurvatura bibir bagian bawah pada saat pasien tersenyum. 4,7,9,10 Gingival display didefinisikan sebagai gusi yang terlihat antara batas inferior bibir atas dan margin gingiva gigi insisif sentral rahang atas ketika pasien tersenyum. 9,11 Komponen lain yang berpengaruh terhadap estetika senyum selain smile arc dan gingival display adalah buccal corridor. ...
... 4,7,9,10 Gingival display didefinisikan sebagai gusi yang terlihat antara batas inferior bibir atas dan margin gingiva gigi insisif sentral rahang atas ketika pasien tersenyum. 9,11 Komponen lain yang berpengaruh terhadap estetika senyum selain smile arc dan gingival display adalah buccal corridor. Buccal corridor didefinisikan sebagai ruang gelap yang berada diantara permukaan bukal gigi posterior dan sudut bibir bagian dalam ketika seseorang tersenyum. ...
Article
Full-text available
ABSTRAK Pendahuluan: Perawatan ortodonti dilakukan untuk mengoreksi maloklusi sehingga dicapai oklusi yang baik dalam melakukan fungsi maupun estetika. Salah satu penilaian estetika bisa dilihat dari buccal corridor yang terlihat ketika tersenyum. Perawatan ortodonti pada maloklusi kelas I dapat dilakukan dengan pencabutan atau tanpa pencabutan. Perawatan tersebut dapat memengaruhi tampilan pasien saat tersenyum. Penelitian ini dilakukan untuk mengetahui perbandingan buccal corridor pada maloklusi kelas I sebelum dan sesudah perawatan dengan dan tanpa pencabutan gigi premolar yang dirawat dengan alat ortodonti cekat menggunakan software Image-J . Metode: Jenis penelitian analitik komparatif dengan sampel penelitian berupa fotografi frontal pasien maloklusi kelas I dentoskeletal yang telah selesai dirawat alat ortodonti cekat di Klinik PPDGS Ortodonti RSGM Unpad pada tahun 2015 – 2019 sebanyak 30 sampel tanpa pencabutan dan 14 sampel pencabutan empat gigi premolar pertama. Sampel diambil dengan menggunakan teknik purposive sampling. Pengukuran buccal corridor dilakukan menggunakan software Image-J. Analisa data menggunakan uji paired t-test, sedangkan untuk membandingkan perubahan antara kelompok pencabutan dan tanpa pencabutan dilakukan uji independent t-test. Hasil: Terdapat penurunan yang signifikan buccal corridor pada kelompok tanpa pencabutan yaitu sebesar 2,45% 3,41% ( p < 0,05), tidak terdapat penurunan yang signifikan buccal corridor pada kelompok pencabutan yaitu sebesar 0,51% 3,47% ( p >0,05) dan perbandingan perubahan nilai buccal corridor pada perawatan dengan pencabutan dan tanpa pencabutan menunjukkan hasil yang tidak signifikan ( p >0,05). Simpulan: Terdapat penurunan buccal corridor sesudah perawatan pada kelompok tanpa pencabutan, tidak terdapat penurunan pada buccal corridor sesudah perawatan pada kelompok pencabutan dan tidak terdapat perbedaan buccal corridor antara kelompok pencabutan dan tanpa pencabutan gigi premolar. Kata kunci: buccal corridor ; ekstraksi; non-ekstraksi. ABSTRACT Introduction: Orthodontic treatment was performed to correct malocclusion to obtained good occlusion in performing both function and aesthetics. One of the aesthetics assessments can be seen from the buccal corridor which is visible when it smiles. Orthodontic treatment in class I malocclusion can be treated with extraction or without extraction. The treatment can affect the patient’s appearance when smiling. This study was conducted to analized the comparison of the buccal corridor in class I malocclusion before and after treatment with and without premolar extraction which is treated with fixed orthodontic appliances. Methods: This study was conducted of comparative analysis and the sample of this study consisted of frontal photography of dentoskeletal class I malocclusion patients who had finished being treated with fixed orthodontics appliances at the Orthodontic Clinic of RSGM Unpad in 2015 – 2019, as many as 30 samples without extraction and 14 samples fours first premolars extraction. The sample were taken using purposive sampling technique. Buccal corridor measured using Image-J software. Analisa data menggunakan uji paired t-test , sedangkan untuk membandingkan perubahan antara kelompok pencabutan dan tanpa pencabutan dilakukan uji independent t-test. Results: There was a significant decrease in the buccal corridor in the non-extraction group, which was 2.45% ± 3.41% (p<0.05), there was a non-significant decrease in the buccal corridor in the extraction group, which was 0.51% ± 3.47% (p>0.05) and the comparison of changes in the value of the buccal corridor in the treatment with extraction and without extraction showed no significant result (p > 0.05). Conclusion: There was a decrease in the buccal corridor after treatment in the non-extraction group, there was a decrease in the buccal corridor after treatment in the extraction group and there was no difference in the buccal corridor between extraction and non-extraction premolar groups. Keywords: buccal corridor; extraction; non-extraction.
... Having a good smile has been linked to having a good shape of the dental and jaw outline, with associations with the function of the lip muscles [6,7]. According to Camara, a fine-drawn smile in an individual is achieved when there is an arc curve of gums at the edge of the incisal edge of the central, lateral, canines, and premolars with less than 3 mm of gum exposure [8]. ...
Article
Full-text available
Background: Gummy smile (GS) has a direct effect on individuals, especially among young adults, because of its association with smile avoidance. The younger populations are sensitive about their smiles and prefer aesthetic, beautiful smiles, a lack of which can negatively impact their quality of life. Objectives: This study aims to measure the GS prevalence among young adults aged 16 to 18 attending high schools in Ha’il City, Saudi Arabia, evaluating oral health related to quality of life (OHQoL) in those suffering GS by using the OHQoL questionnaire (OHIP-14). Methods: A cross-sectional study was conducted on 385 female high school students located in Ha’il. Students with GS took a survey on oral health using OHIP-14. For this, SPSS was used to analyze the data. Results: The study included 200 people with GS (52%). The mean age was 18±0.01. The prevalence of GS was analyzed, with a mean value of 4.68±1.2 mm, indicating most students had GS ranging between 4 and 5 mm. The most frequent value for all items in the OHIP-14 questionnaire was 1, indicating that students often had their quality of life affected. The non-parametric Kruskal-Wallis test indicated the results had a significant value (p < 0.05), showing a positive and significant association. Conclusion: Based on the OHIP-14 questionnaire and respecting the methodology, it was concluded that the quality of life has been affected for all female students with GS. The high prevalence for ages 16-18 showed most students agreed their lives were being affected by GS and their condition needed to be treated. It was also confirmed by the significant association of GS with items of oral health and quality of life.
... A slight showing of the gums while smiling will offer a younger aspect and can be considered attractive for some people. Several authors state that a showing of 1 mm up to 2 mm of the gums is normal [19]. According to some studies, an ideal smile needs to expose the whole length of the maxillary teeth with up to 1 mm showing of the gingival tissue [20]. ...
Article
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Introduction: One of the main elements of facial esthetics is represented by the smile. A harmonious proportion between the elements of facial esthetics is an important subject of interest in dentistry. Aim of the study: This research aims to evaluate the impact of the gummy smile on future dental practitioners. Materials and Methods: A survey containing 16 questions was designed to find out the students’ perceptions about the ideal smile and if the gingival smile is considered youthful or unpleasing. The impact on their self-esteem, their willingness to change the gummy smile or not, the nonsurgical and surgical methods of treatment were also evaluated. Results: 212 answers were recorded and analyzed. Nearly three quarters (70.3%) of the respondents believe that having a gummy smile is unesthetic, while only 29.3% considered it to be a sign of youth. Self-esteem can be affected by having a gingival smile, but, according to the results, most of the students (45.8%) said that their daily lives have not been affected by it, 40.6% said that in a small amount, 10.4% said that their self-assurance has been very affected and only 3.3% admitted that the gummy smile distressed their confidence. When asked if they were willing to correct their gingival smile, 51.4% were open to improving it while 48.6% would not change it. Conclusions: Among dentistry students, excessive showing of the gums is believed to be unesthetic rather than a sign of youthfulness. The respondents are generally not affected in their daily life by having a gummy smile. Education regarding the methods of correcting it still needs to be addressed amongst future dental practitioners.
... Common causes for gummy smile are hypermobility of the upper lip, short upper lip, incompetent lip, altered passive eruption, bimaxillary protrusion, vertical maxillary excess, hyperfunction of labial elevator muscles, dental plaque, hereditary, and medications can cause abnormal gingival display. [7] A balance of an esthetic and attractive smile is the combination of gingiva health and appearance that is required for one's smile. [8] An ...
Article
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Gummy smile or excessive gingival exposure is an esthetically concern factor for women compared to men. Common causes for gummy smile are hypermobility of the upper lip, short upper lip, incompetent lip, altered passive eruption, bimaxillary protrusion, vertical maxillary excess, hyperfunction of labial elevator muscles, dental plaque , hereditary, and medications can cause abnormal gingival display. A 27-year-old male patient reported to the department of periodontology, with the chief complaint of overexposure of gums and dark color of upper and lower gums. The purpose of this case report is to present how to correct a gummy smile into an esthetic smile, using surgical scalpel method, considering two aspects of gingival health and appearance, which are: the gingival zenith and contour of gingival margins, avoiding violation of the biologic width.
... Gummy Smile (GS) can be due to excessive vertical bone growth, dento-alveolar extrusion, short upper lip, upper lip hyperactivity or altered passive eruption (APE) [1][2][3]. ...
Article
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Background: Excessive gingival display or "gummy smile" is a clinical condition where a maxillary gum shows between the inferior line of the superior lip and the gingival line of the incisive superior during a spontaneous smile. The aim of this research was to understand the various skeletal and dentoalveolar components contributing to a gummy smile in a sample of 120 patients. Material and methods: This retrospective case-control study had the primary objectives of analyzing the existence of a correlation between the presence of gingival exposure and the alteration of the inclination of the upper incisors with respect to the Frankfurt plane, the Palatine plane (bi-spinal) and to the NA line in a sample of orthodontic patients, and also evaluating the association with skeletal, dental, and aesthetic cephalometric parameters. Result and conclusions: In our study, it's emerged a correlation between the gingival exposure and the presence of alterations to incisal torque in the vestibular direction and the quantity of maxillary gingiva evident during the smile, which is correlated in particular to the Is-Sts distance, overjet and overbite. The major indicative data, therefore, are related to the vertical position of the upper incisors, in particular with respect to the upper lip and to the sagittal position.
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Este artigo explora o papel crucial da cirurgia de aumento de coroa clínica na reabilitação estética e funcional em Odontologia, com foco nas indicações, planejamento e procedimentos específicos em Periodontia. Baseado em uma revisão bibliográfica abrangente, são discutidas técnicas cirúrgicas e considerações essenciais para assegurar o sucesso desses procedimentos. Destaca-se a importância do diagnóstico preciso, planejamento detalhado e avaliação individualizada para alcançar resultados estéticos e funcionais satisfatórios. Conclui-se que a cirurgia de aumento de coroa clínica é uma ferramenta valiosa na restauração dentária, contribuindo para melhorias duradouras na saúde bucal e na qualidade de vida dos pacientes.
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c Aim: To evaluate the prevalence and factors associated with gummy smiles in adolescents aged between 15 and 18 years attending high school. Methods: The cross-sectional and quantitative study was carried out during the Covid-19 pandemic, with 160 adolescents, from two public (A1) and two private (A2) schools chosen by lottery, divided into two groups: G1 (with gummy smile) and G2 (no gummy smile). A clinical examination was carried out on the adolescents, investigating the presence or absence of a gummy smile (GS), by analyzing the variables (interlabial distance at rest, upper incisor exposure at rest, smile arc, measurement from the subnasal to the upper lip philtrum, upper lip length, upper lip thickness, hypermobility and lower/middle third ratio). Means and dispersion were obtained, and the Chi-square association test was applied, to compare the results between A1 and A2 and between G1 and G2. Results: The prevalence of GS was 33.8% (=54). It was found that no statistically significant associations were found (p > 0.05), regarding the type of school and gender with the presence of GS in adolescents. There was no statistically significant difference (χ² = 1.82; p = 0.07) between the groups and the age of adolescents. There was a significant association between the studied variables and GS (p < 0.05). Conclusion: The prevalence was high with a predominance of females. There were no statistically significant associations regarding the type of school and gender, but there was a significant association between gummy smile and lip dimensions.
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The oral cavity manifests signs of various systemic diseases. This entails thorough examination of the oral mucosa, gingiva, teeth, tongue and other oral tissues. Occasionally, oral signs can be an expression of systemic conditions such as endocrine imbalance, nutritional deficiencies and blood disorders. Leukemia is a malignancy of white blood cells, which may result in significant morbidity and mortality. Oral changes maybe the first and only presenting features in leukemia patients, making it imperative for the dentist to diagnose the disease accurately. © 2018 Journal of Oral and Maxillofacial Pathology | Published by Wolters Kluwer - Medknow.
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This clinical report describes the successful use of lip repositioning technique for the reduction of excessive gingival display. The lip repositioning technique was performed with the main objective of reducing gummy smile by limiting the retraction of elevator muscles (e.g., zygomaticus minor, levator anguli, orbicularis oris, and levator labii superioris). This technique includes removing a strip of mucosa from the maxillary buccal vestibule, creating a partial-thickness flap between mucogingival junction and upper lip musculature, and suturing the lip mucosa with mucogingival junction, resulting in a narrow vestibule and restricted muscle pull, thereby reducing gingival display.
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Introduction: The Class I skeletal deformity associated with vertical maxillary excess is a rare condition reported in the literature. Surgical impaction allows the correction of the long face and gummy smile. Objective: This case report aimed to evaluate the positioning of the condyle after Le Fort I osteotomy associated with mandibular selfrotation. Case report: The patient underwent orthognathic surgery for the correction of maxillary vertical excess. Tomography studies were performed to evaluate the initial and final position of the condyle. The patient improved mastication, breathing and phonetics, with esthetic benefit. Conclusion: After the Le Fort I osteotomy and mandibular self-rotation, the condyle remained stable occupying a new anterior-superior position in the glenoid fossa and patient’s TMJremained asymptomatic after 9 months of postoperative follow-up.
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