A clinical case by our Community member Dr Mohammed Shaga
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Displaying an optimal amount of gingiva while smiling is one of the critical elements in the ideal conceptual smile.
In orthodontics and aesthetic dentistry, it is not rare to encounter a patient complaining of a ‘gummy smile’ or an excess gingiva on smiling. Therefore, it is essential to understand the etiology, biology, and management strategies associated with this clinical condition. These fundamental principles will increase the probability of achieving an aesthetic and healthy outcome for the patients.
Gingival display of more than 4 mm of gingiva is considered by many to be unattractive. The cause of the gummy smile can be multifactorial and must be accurately diagnosed to render an appropriate treatment.
Common etiological factors include:
1. Increased vertical growth of the maxilla
2. Hypermobility of muscles of facial expression
3. Altered active or passive eruption of teeth
4. Short clinical crown
5. Short lip length
The treatment modalities vary according to the etiology of the gummy smile – the key is accurately recognizing the cause of the pathology. In some cases, the gummy smile results from more than one factor, e.g., vertical maxillary excess and hypermobile lip, and a combination of techniques can be implemented from less to excusive approach:
1. Hyaluronic acid
2. Botulin toxin
3. Modified lip repositioning
4. Gingivectomy
5. Crown lengthening
6. Orthodontic treatment
7. Orthognathic surgery
This article will review the etiology, diagnosis, and surgical approaches in treating the gummy smile and restoring the smile with direct composite veneers.
Fig.1
28-year old female patient came to the clinic suffering from a gummy smile and sought treatment and diagnosis. The patient has a short clinical crown, diastema, and vertical maxillary growth.
The treatment plan involves aesthetic approach and surgical approach with a three dimensional (3D) surgical guide, including the following steps:
1. Orthodontic
2. Gingivectomy
3. Crown lengthening
4. Finally, restoring with direct composite veneers
Fig.2
The orthodontic treatment plan consisted of upper fixed edgewise appliances to distribute the space between anterior tooth according to the golden proportion during 5 months.
Fig.3
Digital Smile Design (DSD) planning for ideal shape and size of crowns and correct distribution of spaces between anterior teeth by orthodontic treatment.
Fig.4
Surgical guide was designed via Computer aided design-Computer aided manufacturing (CAD-CAM) software (Exocad) utilizing a DSD combined with the direct clinical and radiographic information. This guide was designed to transfer two critical information to the periodontist namely location of gingival margins and to indicate the supra-crestal attachment apparatus (Biological width 3 mm). This precision guide was prepared sing a 3D printer (Anycubic 3D). The fit and the design of the guide were confirmed intra-orally before surgery.
Fig.5
Initial incision marking and gingivectomy using the guide.
Fig.6
Evaluating the alveolar crest level before ostectomy using the guide then, completion of ostectomy and exposing the cemento-enamel junction with decent amount of area for establishing supra-crestal attachment apparatus (biological width). There were no bone reduction interproximally.
Sutures in place with 5.0 polypropylene sutures were used.
Fig.7
6 weeks after crown lengthening and complete healing.
Fig.8
Ideal gingival architectures were established including the locations of zenith point in relation with the midline of the teeth.
Fig.9
Before and after the crown lengthening procedures.
Fig.10
Final step in the treatment plan included the placement of a direct composite veneer.
Fig.11
Rubber dam placement (split dam technique after minimal preparation).
Fig.12
Etching with 37% phosphoric acid for 30 seconds and washing with water for 60 seconds to ensure a complete removal of the etching gel residues and multiple coats of bonding agent are applied.
Fig.13
A 0.3-0.5 palatal shell was built with the enamel shade (free hand using the celluloid strips).
Fig.14
Lateral view of the palatal shell.
Fig.15
Layering of a dentin shade is easily accomplished with a LM Solo instrument (LM arte), and shaping the mamelons with a fissura instrument (LM arte) while preserving a small space for the incisal effects using transparent masses.
Fig.16
The small space between the mamelons and the incisal halo were covered with a translucent shade, slightly covering the mamelon tips and finally covering the labial surface with the enamel shade.
Fig.17
Extra-oral postoperative situation after one month of composite veneer.
Fig.18
Intra-oral postoperative situation after one month of composite veneer.
Fig.19
Lateral view of the final situation.
Fig.20
Surface texture and gingival healing.
Fig.21
Before and after the aesthetic crown lengthening procedures and the direct composite veneer.
Conclusions
Understanding the fundamental features of the ‘ideal’ smile and the contributing craniofacial hard and soft tissues is critical in recognizing and establishing a correct diagnosis. However, smile can be subjective and patient input is mandatory to define the treatment goals. Identifying etiological factor(s) of the excess gingival display is also crucial in treatment planning and management. Incorporating digital technology in the different phases of treatment can clarify the communication between the patient and multiple clinicians involved.
Bibliography
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- Jae W. Chang, James Andrews, Larjava Hannu Larjava. Contemporary Aesthetic Crown Lengthening: An Interesting Orthodontic/Periodontics Case Utilizing Digital Design, Digital Planning and 3D Printing Technology to Aid in Patient Management. 2022.
- Levine RA, McGuire M. The diagnosis and treatment of the gummy smile. 1997 Aug;18(8):757-62, 764.
- Spear FM, Kokich VC, Mathews DP. Interdisciplinary management of anterior dental esthetics. J Am Dent Assoc. 2006;137(2):160-169.
- Hassanpour, Stephen J. Spano. Treating the “Gummy Smile” with Aesthetic Crown Lengthening. 2017.
- Abdulkareem Alhumaidan, Ayed Alqahtani, Faisal al-Qarni. 3D-Printed Surgical Guide for Crown Lengthening Based on Cone Beam Computed Tomography Measurements: A Clinical Report with 6 Months Follow Up. 2020.
