ArticlePDF Available

Abstract and Figures

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.
Content may be subject to copyright.
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.
Volume 71, No.1: 2019 Siriraj Medical Journal
www.smj.si.mahidol.ac.th 169
Review Article SMJ
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
Volume 71, No.1: 2019 Siriraj Medical Journal www.smj.si.mahidol.ac.th
170
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.
Volume 71, No.1: 2019 Siriraj Medical Journal
www.smj.si.mahidol.ac.th 171
Review Article SMJ
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
Volume 71, No.1: 2019 Siriraj Medical Journal www.smj.si.mahidol.ac.th
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.
Volume 71, No.1: 2019 Siriraj Medical Journal
www.smj.si.mahidol.ac.th 173
Review Article SMJ
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
REFERENCES
1. Izraelewicz-Djebali E, Chabre C. Gummy smile: orthodontic or
surgical treatment? Dentofacial Anom Orthod 2015;18:102.
Published online: 04 September 2015.
2. Sharma A, Sharma S, Garg H, Singhal V, Mishra P. Lip
repositioning: A boon in smile enhancement. J Cutan Aesthet
Surg 2017;10:219-22.
3. Sabri R. e eight components of a balanced smile. J Clin
Orthod 2005;39:155-67.
4. Pausch NC, Katsoulis D. Gender-specific evaluation of
variation of maxillary exposure when smiling. J Craniomaxillofac
Surg 2017;45:913-20.
5. Bhola M, Fairbairn PJ, Kolhatkar S, Chu SJ, Morris T, de
Campos M. LipStaT: e Lip Stabilization Technique- Indications
and Guidelines for Case Selection and Classication of Excessive
Gingival Display. Int J Periodontics Restorative Dent 2015;35:
549-59.
6. Wu H, Lin J, Zhou L, Bai D. Classication and craniofacial
features of gummy smile in adolescents. J Craniofac Surg
2010;21:1474-9.
7. Charrier JB. Orthognathic surgery of adults and facial aesthetics.
J Dentofacial Anom Orthod 2012;15:302.
8. Roe P, Rungcharassaeng K, Kan JYK, Patel RD, Campagni WV,
Brudvik JS. e Inuence of Upper Lip Length and Lip Mobility
on Maxillary Incisal Exposure. Am J Esthet Dent 2012;2:116-
125.
9. Peck S, Peck L, Kataja M. e gingival smile line. Angle Orthod
1992;62:91-100.
10. Rossi R, Brunelli G, Piras V, Pilloni A. Altered passive eruption and
familial trait: a preliminary investigation. Int J Dent 2014;
2014:874092.
11. Pinto SCS, Higashi C, Bonafé E, Pilatti GL, Santos FA, Tonetto
MR, et al. Crown Lengthening as Treatment for Altered Passive
Eruption: Review and Case Report. World J Dent 2015;6:178-
83.
12. Miskinyar SA. A new method for correcting a gummy smile.
Plast Reconstr Surg 1983;72:397-400.
13. Coslet JG, Vanarsdall R, Weisgold A. Diagnosis and classication
of delayed passive eruption of the dentogingival junction in
the adult. Alpha Omegan 1977;7:24-8.
14. Alpiste-Illueca F. Altered passive eruption (APE): a little-known
clinical situation. Med Oral Patol Oral Cir Bucal 2011;16:
e100-4.
15. Wolford LM, Karras SC, Mehra P.Considerations for orthognathic
surgery during growth, part 2: maxillary deformities. Am J
Orthod Dentofacial Orthop 2001;119:102-5.
16. Robbins JW.Dierential diagnosis and treatment of excess
gingival display. Pract Periodontics Aesthet Dent 1999;11:265-
72.
17. Nascimento Meger M, Tiboni F, dos Santos FS, Verbicaro
T, Deliberador TM, Scariot R, et al. Surgical correction of
Volume 71, No.1: 2019 Siriraj Medical Journal www.smj.si.mahidol.ac.th
174
vertical maxillary excess associated with mandibular self-
rotation. RSBO 201714:56-61.
18. Mackley RJ. An evaluation of smiles before and aer orthodontic
treatment. Angle Orthod 1993;63:183-90.
19. Ezquerra F, Berrazueta MJ, Ruiz-Capillas A, Arregui JS. New
approach to the gummy smile. Plast Reconstr Surg 1999;104:1143-
50.
20. Scott SH, Johnston LE. e perceived impact of extraction. and
nonextraction treatments on matched samples of. African
American patients. Am J Orthod Dentofacial Orthop 1999;116:
352-8.
21. Chu YM, Bergeron L, Chen YR. Bimaxillary protrusion: an
overview of the surgical-orthodontic treatment. Semin Plast
Surg 2009;23:32-9.
22. Lamberton CM, Reichart PA, Triratananimit P. Bimaxillary
protrusion as a pathologic problem in the ai. Am J Orthod
1980;77:320-9.
23. Keating PJ. Bimaxillary protrusion in the Caucasian: a cephalometric
study of the morphological features. Br J Orthod 1985;12:193-
201.
24. Narwal A, Singh V, Bala S. Drug-induced atypical hyperplasia
enveloping salivary gland malignancy. J Indian Soc Periodontol
2017;21:409-11.
25. Ritchhart C, Joy A. Reversal of drug-induced gingival overgrowth
by UV-mediated apoptosis of gingival broblasts - an in vitro
study. Ann Anat 2018;217:7-11.
26. Nakib N, Ashra SS. Drug-induced gingival overgrowth. Dis
Mon 2011;57:225-30.
27. Trossello VK, Gianelly AA. Orthodontic treatment and periodontal
status. J Periodontol 1979;50:665-71.
28. Savona M, Talpaz M. Chronic myeloid leukemia: changing the
treatment paradigms. Oncology (Williston Park) 2006;20:
707-11.
29. Chowdhri K, Tandon S, Lamba AK, Faraz F. Leukemic gingival
enlargement: A case report and review of literature. J Oral
Maxillofac Pathol 2018;22(Suppl 1):S77-S81.
30. Sarver DM, Ackerman MB.Dynamic smile visualization and
quantication: Part 2. Smile analysis and treatment strategies.
Am J Orthod Dentofacial Orthop 2003;124:116-27.
31. McNamara JA. Jr, Brust EW, Riolo ML. So tissue evaluation
of individuals with an ideal occlusion and a well-balanced
face. In: McNamara JA Jr. (Ed.) Esthetics and the Treatment
of Facial Form. Monograph 28. Craniofacial Growth Series.
Center for Human Growth and Development, Ann Arbor;
1993.
32. Tarantili VV, Halazonetis DJ, Spyropoulos MN.e spontaneous
smile in dynamic motion. Am J Orthod Dentofacial Orthop
2005;128:8-15.
33. Abdullah WA, Khalil HS, Alhindi MM, Marzook H. Modifying
gummy smile: a minimally invasive approach. J Contemp Dent
Pract 2014;15:821-6.
34. Dolt AH 3rd, Robbins JW. Altered passive eruption: an etiology
of short clinical crowns. Quintessence Int 1997;28:363-72.
35. Steinhäuser S, Richter U, Richter F, Bill J, Rudzki-Janson I.
Prole changes following maxillary impaction and autorotation
of the mandible. J Orofac Orthop 2008;69:31-41.
36. Agrawal AA. Gingival enlargements: Dierential diagnosis
and review of literature. World J Clin Cases 2015;3:779-88.
37. Humayun N, Kolhatkar S, Souiyas J, Bhola M. Mucosal coronally
positioned ap for the management of excessive gingival
display in the presence of hypermobility of the upper lip and
vertical maxillary excess: a case report. J Periodontol 2010;81:
1858-63.
38. Rubinstein AM, Kostianovsky AS. Cosmetic surgery for the
malformation of the laugh: Original technique in Spanish.
Prensa Med Argent 1973;60:952.
39. Litton C, Fournier P. Simple surgical correction of the gummy
smile. Plast Reconstr Surg 1979;63:372-3.
40. Grover HS, Gupta A, Luthra S. Lip repositioning surgery:
A pioneering technique for perio-esthetics. Contemp Clin
Dent 2014;5:142-45.
41. Polo M. Botulinum toxin type A (Botox) for the neuromuscular
correction of excessive gingival display on smiling (gummy
smile). Am J Orthod Dentofacial Orthop 2008;133:195-203.
42. Aly LA, Hammouda NI. Botox as an adjunct to lip repositioning
for the management of excessive gingival display in the presence
of hypermobility of upper lip and vertical maxillary excess.
Dent Res J (Isfahan) 2016;13:478-83.
43. Van der Geld P, Oosterveld P, Schols J, Kuijpers-Jagtman AM.
Smile line assessment comparing quantitative measurement and
visual estimation. Am J Orthod Dentofacial Orthop 2011;139:
174-80.
44. Kokich Jr VO, Kiyak HA, Shapiro PA. Comparing the Perception
of Dentists and Lay People to Altered Dental Esthetics. J Esthetic
Dentistry 1999;11:311-24.
45. Geron S, Atalia W. Inuence of sex on the perception of oral
and smile esthetics with dierent gingival display and incisal
plane inclination. Angle Orthod 2005;75:778-84.
46. Jananni M, Sivaramakrishnan M, Libby TJ. Surgical correction
of excessive gingival display in class I vertical maxillary excess:
Mucosal strip technique. J Nat Sci Biol Med 2014;5:494-8.
Mahardawi et al.
... 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. ...
Article
Full-text available
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. ...
... Excessive gingival display, or what is known as Gummy Smile, is a condition which affords a great attention. The gingiva is a crucial aspect to be considered in the esthetics of smiling, in which the upper lip should be elevated around 80% of its normal length, exposing teeth and gingiva [1]. Sharma., et al. defined the normal gingival display as the gum appearance between the lower border of upper lip and gingival margin of central incisors at smiling. ...
Article
Excessive gingival show is mainly caused by hypermobility of the upper lip, altered passive eruption, gingival hyperplasia, and bony maxillary vertical excess. Orthognathic surgery is the optimal treatment option for patients with moderate and severe vertical maxillary excess. Surrounding anatomic structures and soft tissue changes such as alternation in the nasal morphology confine the amount of impaction. Therefore, Le Fort 1 may be performed in conjunction with horseshoe osteotomy or partial turbinectomy. The possible necessity of further mandibular orthognathic surgeries and chin repositioning has to be considered. No common major complication and long-term relapse have been reported for maxillary impaction.
Article
Full-text available
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.
Article
Full-text available
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.
Article
Full-text available
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.
Article
Full-text available
This case report relates a patient with altered passive eruption (APE) treated with surgical crown lengthening. There is a strong association between smile esthetics and periodontal tissues. ‘Gummy smile’ constitutes a relatively frequent esthetic disadvantage characterized by excessive display of the gums during upper lip smiling. One situation that can lead to gummy smile is APE. There are many important diagnostic factors connected with APE. These include making a correct diagnosis; considering facial and oral features before considering the most appropriate periodontal treatment. A 21-year-old female patient presented to the dental clinic expressing to be discontent with her smile, due to the display of gingiva when she smiles. Before choosing the adequate treatment, esthetics and periodontal factors were analyzed. In the present case report, surgical crown lengthening was the treatment chosen. Through a correct diagnosis and technique, it was possible to obtain harmony in the smile. Crown-lengthening surgery is an important choice of treatment, because it is a less invasive technique and it permits the establishment of an esthetical smile. How to cite this article Pinto SCS, Higashi C, Bonafé E, Pilatti GL, Santos FA, Tonetto MR, Lima SNL, Bandéca MC. Crown Lengthening as Treatment for Altered Passive Eruption: Review and Case Report. World J Dent 2015;6(3):178-183.
Article
Gingival enlargement is a very common side effect associated with the administration of several drugs, mainly anticonvulsants, calcium channel blockers (CCBs), and immunosuppressants. Amlodipine (a CCB) is a safe antihypertensive drug with a longer duration of action. Gingival enlargement induced by amlodipine is less prevalent among CCBs. Since the pathogenesis is not well understood, it is still a challenge for clinicians to diagnose and manage cases effectively. This case presents an atypical unilateral palatal gingival enlargement in a 61-year-old hypertensive female taking amlodipine. Difficulty for a pathologist in diagnosing in spite of repeated sample submission from the lesion and repeated failure for the operator to reach the underlying pathology due to amlodipine-induced hyperplasia have also been discussed in this case report. ©2018 Indian Society of Periodontology | Published by Wolters Kluwer - Medknow.
Article
Gingival Overgrowth (GO) is an undesirable result of certain drugs like Cyclosporine A (CsA). Histopathology of GO shows hyperplasia of gingival epithelium, expansion of connective tissue with increased collagen, or a combination. Factors such as age, gender, oral hygiene, duration, and dosage also influence onset and severity of GO. One of the mechanisms behind uncontrolled cell proliferation in drug-induced GO is inhibition of apoptotic pathways, with a consequent effect on normal cell turnover. Our objective was to determine if UV photo-treatment would activate apoptosis in the gingival fibroblast component. Human gingival fibroblast cells (HGF-1) were exposed to 200ng/ml or 400ng/ml CsA and maintained for 3, 6, and 9 days, followed by UV radiation for 2, 5, or 10minutes (N=6). Naïve (no CsA or UV), negative (UV, no CsA), and positive controls (CsA, no UV) were designated. Prior to UV treatment, growth media was replaced with 1M PBS to prevent absorption of UV radiation by serum proteins, and cells were incubated in growth media for 24hours post-UV before processing for TUNEL assay, cell proliferation assays, or immunofluorescence. Data showed a temporal increase in proliferation of HGF-1 cells under the influence of CsA. The 200ng/ml dose was more effective in causing over-proliferation. UV treatment for 10minutes resulted in significant reduction in cell numbers, as evidenced by counts and proliferation assays. Our study is a first step to further evaluate UV-mediated apoptosis as a mechanism to control certain forms of GO.
Article
Introduction: Excessive exposure of maxillary teeth when smiling can have a negative effect on the aesthetics and attractiveness of the face. The presented study was aimed to evaluate the effect of different amounts of gingival exposure on the perception of such human characteristics and qualities as age, attractiveness, gender specificity, and felt sympathy in the context of the whole face. Materials and methods: Forty-two participants (21 female and 21 male students of Dental Medicine) were recruited as evaluators for the study. Two average-looking subjects (one female, one male) were photographed. The images were processed to create a series of eight clones with different gingival exposure (shift A-H; A = full over-exposure, H = invisibility of the crown surfaces of the teeth). The panellists evaluated characteristics as attractiveness, gender specificity, age, and felt sympathy. Results: 42 participants joined the study (21 female, 21 male). Shift H was assessed as worst for sympathy and attractiveness, and resulted in the highest estimated age. Best attractiveness was observed for shifts C and D. Gender dimorphism was noticed, with own gender being rated as less attractive and opposite gender as more attractive. Conclusions: Female and male evaluators assess excessive gingival and maxillary incisor display differently for female and male probands. Excessive over- or underexposure of the maxillary gingiva and teeth when smiling is perceived as unattractive and results in less observer sympathy.
Article
Background Excessive gingival display (GD) is a frequent finding that can occur because of various intraoral or extraoral etiologies. This work describes the use of a mucosal repositioned flap for the management of a gummy smile associated with vertical maxillary excess (VME) and hypermobility of the upper lip followed by injection of Botox. Materials and Methods Seven female patients in the age range of 17–25 years presented with a gummy smile. At full smile, the average GD ranged from 6 to 8 mm. A clinical examination revealed hypermobility of the upper lip. A cephalometric analysis pointed to the presence of VME. The mucosal repositioned flap surgery was conducted followed by injection with botulinum toxin type A (Botox) 2 weeks postsurgically. Results After 4 weeks, results were definitely observed with a decrease from 8 mm gingival exposure to 3 mm, which was considered as normal GD for an adult during smiling. Conclusion For patients desiring a less invasive alternative to orthognathic surgery, the mucosal repositioned flap is a viable alternative. Moreover, Botox is a useful adjunct to enhance the esthetics and improve patient satisfaction where surgery alone may prove inadequately in moderate VME.
Article
This study was designed to determine the esthetic perception of men and women to variations in upper and lower gingival display at smile and speech and to incisal plane tilting. Composed photographs of smile and speech with varying amounts of gingival exposure of the upper and lower teeth and gingiva at smile and at speech and with varying degrees of incisal plane tilting were rated for attractiveness by two groups of lay people. The images were presented as male or female images. A total of 300 questionnaires, including 7500 images, were evaluated by 100 subjects. The results showed that images were scored as less attractive as the amount of upper and lower gingival display was increased during smile and speech. The amount of gingival exposure graded in the esthetic range was up to one mm for the upper incisors and zero mm for the lower incisors. Incisal plane tilting was graded as unesthetic when above two degrees of deviation from the horizontal. Male and female evaluators scored images differently with upper gingival exposure. Female evaluators gave statistically significant higher scores than male evaluators to upper gingival exposure images at smile and speech of both males and females, suggesting that females are more tolerant of upper gingival exposure. Images were scored differently when presented as male or female images. Female images were scored lower by both male and female evaluators, suggesting that additional efforts should be taken in female patients to achieve an esthetic result.