Introduction
Gummy smile is excessive gingival appearance during smiling. It is a major esthetic concern in young people. Gingival display of more than 4 mm is generally considered unesthetic. Prevalence of gummy smile is 7% in males and 14% in females, as reported according to a face aesthetic survey.
Ideal smile
For an ideal smile appearance, a normal gingival display between inferior border of upper lip and gingival margins of maxillary anterior teeth, during a posed smile, should be 1 to 2 mm only.
Etiology of gummy smile
Etiology of gummy smile is multifactorial including soft tissue excess and hard tissue excess. Unesthetic smile appearance also includes dental malalignments and gingival overgrowth.
(Chart 1: Etiology of gummy smile)
Treatment options
Surgical esthetic procedure is always art work. Treatment of gummy smile depends on etiology, perceptions and expectations of patients along with surgical esthetic limitations.
- Gingivectomy
- Crown lengthening
- Lip repositioning
- Orthodontics
- Prosthetic tooth positioning
- Botox
- Orthognathic surgery
Surgical strategic treatment planning
(Flow chart 1 : Etiology and treatment options relationship)
Surgical procedures for gummy smile correction
1) Gingivectomy
Gingival hyperplasia is a common etiology for gummy smile. Gingival hyperplasia can be effectively treated with gingival reshaping and gingivectomy surgery. When marginal gingiva is more than 2 mm, then gingivoplasty should be considered.
Steps:
- Surgery can be done under maxillary local anesthesia.
- Then bleeding points can be marked with a marker/probe and the points can be joined to prepare a line of excision.
- After that, an external bevel gingivectomy incision should be placed, in the anterior region on the facial surface only, using surgical blade no 15, placed 45° angle to the tooth’s long axis, apically to the bleeding points.
- Then, forceps with the help of Orban knife can be used to remove the excised gingival segment.
- Afterwards, the gingiva should be contoured and scraped to remove residual tissue tags.
- Finally, a periodontal dressing should be applied to gingiva.
(Image 1: Gingivectomy for gummy smile management )
2) Crown lengthening with osteoplasty
For maxillary anterior short crown cases, this procedure is useful.
Steps:
- After local anesthesia for maxilla, a full thickness mucoperiosteal flap should be raised.
- Then the desired vertical osteoplasty required interdentally can be done.
- Gingival flap repositioning with sutures can be done.
- Osteoplasty underneath the gingival flap is key to prevent gingival relapse.
(Image 2: Crown lengthening for gummy smile correction)
3) Lip repositioning
Lip repositioning is a simple surgical procedure to treat gummy smile. The procedure restricts the muscle pull of the elevator lip muscles, thereby reducing the gingival display while smiling.With the help of this procedure, 4 to 5 mm gummy smile can be corrected. Surgery can be done for upper lip reposition only.
Steps:
- Lip repositioning surgery can be planned under local anesthesia.
- After local anesthesia, the surgical site should be marked with an indelible pencil, from maxillary right first molar to maxillary left first molar vestibular mucosa.
- A partial thickness flap should be raised from mesial line angle of left maxillary first molar to the mesial line angle of right maxillary first molar at the mucogingival junction.
- A second incision, 10–12 mm above the first incision, should be made in the labial mucosa.
- The two incisions should be joined on either side and a strip of partial thickness flap should be removed, exposing the underlying connective tissue .
- The two incisions should then be approximated using continuous interlocking sutures.
(Image 3: Lip repositioning surgery)
4) Orthognathic surgery (Maxillary Superior positioning)
Most often, gummy smile is of alveolo-skeletal origin: basal, alveolar or a combination of the two. This is due to excessive vertical growth of the maxilla or superior alveolar bone, causing discrepancy between the upper lip and gum line in spontaneous smiling. For vertical maxillary bone excess and gummy smile more than 5 to 10 mm, ideal treatment will be orthognathic surgery. Maxillary Le Forte 1 procedure is performed.
Steps:
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