Gummy smile: orthodontic or surgical treatment? · PDF fileGummy smile: orthodontic or...

DOI: 10.1051/odfen/2014036 J Dentofacial Anom Orthod 2015;18:102� The authors

1

Article received: 15-07-2014.Accepted for publication: 02-08-2014.

This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0),which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Gummy smile: orthodontic or surgicaltreatment?

E. Izraelewicz-Djebali1,2, C. Chabre1,3

1 Docteur en chirurgie dentaire

2 Interne des hopitaux de Paris

3 Maıtre de conferences des universites – Praticien hospitalier

ABSTRACT

Orthodontists today have to meet their patients’ increasing demand foresthetic satisfaction. This quest for youth and beauty is a new developmentin orthodontics, leading practitioners to try to discern the elements thatdetermine facial esthetics and to set out rules and principles. The essentialfactor in this demand doubtless concerns a youthful and harmonious smile.

Excessive gingival display in smiling may make the smile displeasing oreven repulsive. Correcting ‘‘gummy smile’’ thus becomes a prime treatmentobjective in response to patient demand.

Assessment should therefore seek the etiology of gummy smile, as thiswill determine optimal treatment, which is usually orthodontic or orthodonticand surgical.

Which cases call for one approach or the other? This is the question thepresent articles seeks to answer.

KEY WORDS

Smile, esthetics, orthodontic correction

INTRODUCTION

Patients today no longer consult only forfunctional reasons but increasingly for es-thetic reasons, and notably to increase thebeauty of their smile. Smiling involves cri-teria of beauty to which society todaygives increasing importance and, while thesmile may be a ‘‘killer app’’ for somepeople, it can constitute a real complex, or

indeed a handicap, for others, especially insome forms of ‘‘gummy smile’’.

After detailed analysis of the smile, thepresent study seeks to identify the causesof gummy smile so as to determine opti-mal treatment.

SMILING AND ESTHETICS

The esthetics of smiling basically de-pends on the relations between three ana-tomic components: gum, teeth and lips.

• The gum is an important element in theesthetics of smiling; harmony is boundup with several criteria, including

Address for correspondence:

Elsa Izraelewicz-DjebaliService d’orthodontieGroupe hospitalier Pitie-Salpetriere47-83, boulevard de l’Hopital75651 Paris Cedex [email protected]

Article available at http://www.jdao-journal.org or http://dx.doi.org/10.1051/odfen/2014036

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gingival health, the alignment andshape of the tooth necks, anesthetically pleasing gingival line,and a harmonious smile line.

• The teeth also make an importantcontribution to the sense ofharmony of the face and smile,depending on their size, shapeand color, but also on arcadesymmetry, which is an aspect ofoverall intra- and inter-arcaderelations.

• The lips are the third essentialcomponent having a major im-pact on the beauty of the smile,as they delimit the esthetic area2.Their inter-relation and lengthgreatly determine the amount ofteeth and gums exposed duringsmiling.

The smile line is primordial. Thereare three main types23,9:

• a low smile line, exposing lessthan 75% of anterior maxillarycoronary height; this patternspredominates in males;

• a medium line, exposing 75–100% of anterior maxil larycoronary height and the inter-proximal gum;

• and a high line, exposing theentire coronary height and acontinuous band of gum. This isthe pattern that will particularly

interest us here, as this is the so-called ‘‘gummy smile’’ (Fig. 1).

It may be wondered which elementsgo to making a smile ‘‘beautiful’’.According to Miller, the following char-acteristics are required12:

• the marginal gum along the max-illary teeth should follow theshape of the upper lip, while theincisor edge of the anterior teethshould tend to follow the shapeof the lower lip;

• the marginal gum should besymmetrical between left andright;

• the central incisors and caninesshould be of the same length(about 13 mm) and the lateralincisors should be 1 or 2 mmshorter;

• the line of the upper lip shouldtouch the marginal gum of thecentral incisors and canines andthe lower lip should touch theincisor edge of the 6 anteriormaxillary teeth;

• tooth dimensions should reflectthe ‘‘golden number’’ of es-thetics8.

When is a smile ‘‘gummy’’?

According to Allen, a smile issaid to be gummy if more than 2 or

Figure 1The different types of smile line4.

E. IZRAELEWICZ-DJEBALI, C. CHABRE

2 Izraelewicz-Djebali E., Chabre C. Gummy smile: orthodontic or surgical treatment?

3 mm of gum is visible during sus-tained smiling; this is confirmed onforced smiling2.

Gummy smiles are not necessarilyesthetically displeasing if certain rulesof harmony are respected: it is notthe excess soft tissue in itself that isdispleasing, but rather its relationwith the teeth and lips (Fig. 2).

It is thus up to the patient to de-cide whether his or her gummy smilelooks displeasing.

How to diagnose gummy smile?

Gummy smile is fairly easy to diag-nose; determining its causes, on theother hand, is more complicated. Forthis reason, complete diagnosis is re-quired, to determine not only facialand oral but also cephalometric char-acteristics.

Many authors have tried to definenormality in the esthetics of thesmile and face. The smile cannot beconsidered apart from the surround-ing face, nor the face without thesmile. Esthetic assessment is impor-tant to selecting treatment objec-tives7.

After examining all the compo-nents of the face, the practitioner fo-cuses on intraoral examination,analyzing the various smile compo-nents, and especially the teeth andperiodontium.

Although clinical analysis is primor-dial in gummy smile, radiographyenables:

• skeletal etiology to be confirmed;• the occlusion plane and the

orientation of the palatine planeto be analyzed;

• and dental-labial relations to beassessed.

ETIOLOGY OF GUMMY SMILE

It is essential to determine theetiology of a gummy smile in orderto optimize treatment. There arethree main etiologies, which may insome cases be combined.

Cutaneo-mucosal origin

To analyze this form, the patientneeds to be examined at rest,to assess upper lip length.

Figure 2Harmonious gummy smiles9.

GUMMY SMILE: ORTHODONTIC OR SURGICAL TREATMENT?

Rev Orthop Dento Faciale 2015;18:102. 3

Cutaneo-mucosal etiology is revealedby various factors:

• upper lip length, considered thinif <20 mm25, increasing thevisibility of the teeth at rest(Fig. 3);

• another cause may be upper liplevator muscle hypertonicity dur-ing smiling, leading to excessivegum exposure (Fig. 4).

According to Peck and Peck, sub-jects with gummy smile have moreeffective upper lip muscles13.

Dento-periodontal origin

Secondly, there are three forms ofdento-periodontal etiology:

• abnormal maxillary incisor size,with clinically short crowns dueto relative microdontia or bruxism;

the gum exposed during smilinglooks all the greater in com-parison with the shortness of theincisors;

• gingival hypertrophy and hyper-plasia, defined as abnormal hy-pertrophic development of thegum, especially at the interdentalpapillae, covering part or even allof the crown, with estheticallydispleasing results2;

• finally, impaired passive eruptionis an abnormality of dental devel-opmental, which is arrested ordelayed2.

Gum tissue is then in a coronaryposition with respect to the enamel-cement junction, inducing pro-nounced gummy smile and short,square teeth.

In all the above situations, theamount of gum exposed in smilingappears greater if the incisors are

Figure 3Girl with thin (15 mm) upper lip22.

Figure 4Gummy smiles of muscular origin.



short, creating an unfavorable gum/crown ratio with excessive gumexposure.

Alveolo-skeletal origin

Most often, however, gummysmile is of alveolo-skeletal origin: ba-sal, alveolar or a combination of thetwo. This is due to excessive verticalgrowth of the maxilla or superioralveolar bone, causing discrepancybetween the upper lip and gum linein spontaneous smiling. This is themost common etiology1.

It may be related to superior labio-version, an anteroposterior abnormal-ity localized at the incisors, withexcessive vestibular inclination of theteeth. This leads to dento-mucosalsliding of the upper lip, revealing awide band of gum7.

It may also be due to anterior max-illary dento-alveolar protrusion, due toover-eruption of the maxillary incisorsand their dento-gingival complex.This is usually caused by anteriorsupra-occlusion, with discordance be-tween the occlusion planes of theanterior and posterior sectors.

This etiology should be differen-tiated from occlusion plane tilt, as-sessed on lateral teleradiograph.

The other possible etiology isexcessive vertical maxillary growth,usually associated with so-called‘‘long face’’ syndrome. Occlusion

analysis usually finds Angle class IImalocclusion, sometimes associatedwith a gap or supra-occlusion due todento-alveolar compensation.

According to Peck et al.13, the dis-tance between the palatine plane andthe free edge of the maxillary inci-sors has been shown to be about2 mm greater in gummy smile thanin controls (Fig. 5).

TREATMENT OF GUMMY SMILE

Treatment options for excessivegum exposure in smiling depend onthe specific diagnosis.

As seen above, etiology is varied,and treatment has to take account ofthis (Fig. 6).

Figure 5Cephalometric analysis: anterior maxillary height is mea-sured between the palatine plane and the free edge ofthe superior maxillary incisor.



As mentioned in the Introduction,gummy smile is not necessarily dis-pleasing and in some cases absten-tion may be the attitude of choice;likewise if the patient is not moti-vated or cooperative.

In all other situations, adaptedtreatment should be planned.

Surgical treatment for gummysmile of cutaneo-mucosal origin

In cutaneo-mucosal etiologies, re-construction surgery of the soft tis-sue, and notably of the upper lip,may correct gummy smile. Whateverthe abnormality of the lip, the objec-tive is to weaken the lip levator

muscles to achieve a more coronaryposition and reduce gum expose1.

More recently, type A botulinumtoxin injection, essentially describedby Polo in 2005, has provided a non-operative solution. Reduced exposureis obtained by weakening upper-liplevator muscle contractility. This isreversible, and injection has to berenewed16,17.

Treatment for gummy smile ofdento-periodontal origin

In dento-periodontal etiologies, per-iodontal treatment can harmonize thecontour of the gum, with or withoutassociated implantation.

Gummy smile

BONE etiology PERIODONTALetiology

DENTO-ALVEOLARetiology

CUTANEO-MUCOSALetiology

Incomplete passiveeruption / gingival

hyperplasia

Abnormal size and growth

Orthodontics and/ororthognathic surgery

Gingivoplastyplus possible

implant

Orthodonticsor implant

Surgery or botulinumtoxin injection

Figure 6Treatment flowchart according to etiology.



• Periodontal treatment

Periodontal treatment alone cannotmeet patient expectations unlessgum exposure is mild: for example,in case of impaired passive eruptionor gingival hyperplasia, where period-ontal treatment is very appropriate.

Coronary lengthening (of the clini-cal crown) may be achieved either bygingivectomy by internal beveling orby an apical flap, with or withoutbone resection.

More recently, developments in la-ser surgery have simplified whatcould be heavy procedures, therebyextending indications19–21.

• Implantation

In gummy smile caused by abnormaltooth size, with well-positioned gum,implantation is required to achieve clini-cal coronary lengthening1, and shouldbe considered in case of:

s clinically short crown;s defective repair or esthetic

complaint;s or root exposure following

periodontal treatment, inducinghypersensitivity in the teeth.

Orthodontic treatment in gummysmile of alveolar origin

Correcting gummy smile may be anespecially complex objective for theorthodontist. Only moderate gummysmile of alveolar origin responds to iso-lated orthodontic treatment. Gummysmile of alveolar origin is generally as-sociated with supra-occlusion limitedto the incisor group. In verticallynormal gummy smile, intrusion of the

maxillary incisors is the treatment ofchoice15.

Moreover, except in particularly se-vere cases, gummy smile is rarelythe prime target of orthodontic treat-ment. Rather, it is usually associatedto correction of malocclusion, deter-mining the treatment plan8.

Treatment can be undertaken at avery early age to prevent onset of su-pra-occlusion14. Once gummy smilehas emerged, there are orthodonticmechanisms to improve the relationbetween upper lip and teeth, redu-cing gum exposure.

Conventional techniques can beused: e.g., Ricketts’ basal arch toachieve superior incisor intrusion7.

This intrusion, however, is difficultto obtain and is often accompaniedby molar extrusion, which may notbe desired, especially in hyperdiver-gent subjects with gummy smile.

More recently, the development ofmini-screw bone anchors has ex-tended the possibilities of orthodontictreatment: anterior vertical excessfound in adults can now be correctedby intrusion, limiting unwanted side-effects in the posterior sectorsby appropriate mini-screw position-ing15,11,24 (Fig. 7).

This technique is increasingly usedto correct gummy smile in adults, asmini-screws combine several advan-tages:

• easy of fitting and ablation;• immediate implementation;• patient comfort;• relatively low cost15,24.It is an interesting alternative to the

risks and demands of orthognathic



surgery, the previous attitude ofchoice.

Orthodontic-surgical treatmentof gummy smile of skeletal origin

In some cases, isolated orthodon-tic treatment will not be enough tocorrect large excess anterior gum ex-posure, especially when of skeletal

origin and extending beyond the pre-molars1.

Surgery, comprising total or seg-mental maxillary osteotomy, can im-prove the relation between themaxillary arcade and the upper lip18,5.

Lefort I osteotomy is usually per-formed, consisting in mobilizing theentire maxillary plate by resecting aband of bone tissue so as to achievemaxillary intrusion3,6,10.

DATA ANALYSIS FROM CASE REPORTS

To illustrate the above, we reporttwo cases managed using differenttreatments, according to the etiologyof the gummy smile:

• orthodontic treatment for alveolaretiology;

• orthodontic plus surgical treat-ment for skeletal etiology.

Method of analysis

To analyze the effects of differenttreatments, measurements were madeon pre- and post-treatment lateral telera-diographs in the two patients:

• Esthetically, distance betweenthe free edge of the superior

incisor and the stomion, to as-sess treatment impact on incisorposition with respect to the lipsat rest, the normal value being2 mm (Fig. 8).

• At dento-alveolar level, superiorincisor movement after treatment,assessed on 3 measurements:

s difference between initial andfinal apex;

s difference in free edge on theFrankfurt plane, these 2 mea-surements assessing verticalmovement;

s inferoposterior angle betweensuperior incisor axis and Frankfurtplane, to assess sagittal version(Fig. 9).

Figure 7(a) Diagram of incisor intrusion using mini-screws11, and (b) treatment of supra-occlusion by mini-screwanchorages15.



• Skeletally, movement in the pa-latine plane, measuring:

s Angles between palatine planeand nasion-basion and sellaturcica-basion reference planes,to assess any palatine plane tilt;

s Distance between ENA andENP points and Frankfurtplane, pre- and post-treatment(Fig.10).

Gummy smile of alveolar origintreated orthodontically (Chabre)

Morgane C., aged 13 years, pre-sented with a harmonious face exter-nally, but fairly severe lingual versionof the maxillary incisors (Fig. 11).Intraorally, she showed Angle class Imolar and canine class II relation-ships, with severe anterior crowding,supra-occlusion and Spee’s curvature(Fig. 12).

After analysis of panoramic and lat-eral radiographs and 3D models, andgiven the reasons for consultation,maxillary incisor intrusion was cho-sen to correct the gummy smile, as-sociated to premolar extraction inboth arcades (14/24-34/44) to correctcrowding and the curve of Spee.

Figure 8Measurement of distance between free edge of the

superior incisor and stomion.

Figure 9Dento-alveolar effects of treatment.



A fixed multi-attachment devicewas fitted, with a segmented Rickettsmechanism, using a basal intrusionarch and T-loops to draw back thecanines (Fig. 13).

Effects were analyzed on pre- andpost-treatment lateral teleradiographs

and general superimpositions on theFrankfurt plane (Fig. 14).

Multi-ring treatment using a seg-mented technique was able to cor-rect the patient’s gummy smile,limited to the incisors, by pure ortho-dontic incisor intrusion (Fig. 15).

The cephalometric measurementsconfirmed that:

• esthetically, intrusion improvedthe position of the maxillaryincisor with respect to the sto-mion, as seen on external photo-graphs of the smile at end oftreatment;

• in dento-alveolar terms, not onlyintrusion but significant vestibularversion of the superior incisorwas obtained by radiculo-palatinetorque, helping improve the in-cisor axis;

• skeletally, following treatmentthere was no tilt but only low-ering of the palatine plane, re-lated to growth, partly maskingthe dento-alveolar effects.

Figure 10Skeletal effects of treatment.

Figure 11Pre-treatment external photographs.



Figure 12Pre-treatment intra-oral photographs and 3D models.

Figure 13Intra-oral photographs during treatment.



Figure 14Lateral teleradiographs (a) before and (b) after orthodontic treatment; drawings at (c) start and (d) end of

treatment; and (e) general superimpositions in the Frankfurt plane.



Pre-treatment Post-treatment

Esthetic d (free edge sup. incisor to stomion) 8 mm 3 mm

Dento-alveolar

d (initial to final apex) �4 mm

d (BL to Frankfurt plane) 5.4 cm 5 cm

Angle (sup. incisor to Frankfurt plane) 80� 104�

Skeletal

Angle (ENA-ENP/BaNa) 30� 30�

Angle (SN/ENA-ENP) 14� 14�

d (ENA to Frankfurt plane) 23.5 mm 25 mm

d (ENP to Frankfurt plane) 22 mm 23 mm

Figure 15(a, b, c) External photographs and (d) smile at end of treatment.



Gummy smile of skeletal origin,managed by orthodontics andorthognathic surgery (Bedarand Charrier)

The second case is that of Ms M.,aged 26 years, who consulted forpurely esthetic reasons, as sheloathed her own smile.

She presented with a lengthenedface and labial intra-occlusion at rest,revealing the maxillary incisor groupand showing a generally convex pro-file. Examination of her smile, whichwas the focus of interest, found itdisharmonious, revealing a band ofgum of about 11 mm all along the ar-cade: i.e., ‘‘gummy’’ smile (Fig. 16).

Intraorally, there was no major oc-clusion abnormality, and notably nosupra-occlusion, with Angle class Ibut very significant anterior verticalexcess (Fig. 17).

After complete analysis of theorthodontic file, orthodontic plus sur-gical treatment was planned in agree-ment with the maxillofacial surgeon:multi-attachment treatment to alignthe maxillary and mandibular arcades

ahead of bimaxillary osteotomy asso-ciated to genioplasty.

As in the previous case, treatmenteffects were assessed in esthetic,dento-alveolar and skeletal terms, onpre- and post-treatment lateral telera-diographs (Fig. 18).

In this patient:• Esthetically, significant ‘‘intru-

sion’’ of the maxillary incisorscan be seen on external photo-graphs of the smile at end oftreatment. The 11-mm gum bandhas been reduced to 3 mm afterorthodontic-surgical treatment.The surgeon deliberately left this3-mm band, to allow for soft-tissue weakening with age.Moreover, as maxillary impactionsurgery affects the nose, enlar-ging the wings, this had to becontrolled according to the pa-tient’s baseline morphology.

• In dento-alveolar terms, not onlyintrusion but significant vestibularversion of the superior incisorswas obtained with respect to thedisplacement of the maxilla as awhole.

Figure 16External photographs.



Pre-treatment Post-treatment

Esthetic d (free edge sup. incisor to stomion) 7 mm 1 mm

Dento-alveolar

d (initial to final apex) �6.5 mm

d (BL to Frankfurt plane) 5.175 cm 4.44 cm

Angle (sup. incisor to Frankfurt plane) 115.5� 125�

Skeletal

Angle (ENA-ENP/BaNa) 23� 20�

Angle (SN/ENA-ENP) 5.5� 3.5�

d (ENA to Frankfurt plane) 17 mm 11 mm

d (ENP to Frankfurt plane) 27 mm 25.5 mm

Figure 17(a) Intraoral photographs; (b) pre-treatment panoramic radiograph.



Figure 18 a, bLateral teleradiograph (a) beforeand (b) after orthodontic-surgical

treatment.

Figure 18 c, d, e(c) Drawings at start and (d) end of treatment, and (e) superimpositions in Frankfurt plane.



• Skeletally, the palatine planetilted up and forward followingtreatment. Impaction was greateranteriorly than posteriorly.

Gummy smile was corrected byimpaction of the entire maxilla(Fig. 19).

CONCLUSION

Although moderate gummy smile(<4 mm) can be quite acceptable andesthetically pleasing if the gum ishealthy, more pronounced cases areless well tolerated and require treat-ment.

When gummy smile is basicallydue to strong vertical alveolar growthat the incisors, isolated orthodontictreatment can provide satisfactory re-sults, especially with the develop-ment of bone anchorages, extendingthe potential of classic orthodontics.Maxillofacial surgery, however, is in-dispensable when etiology is basal,

related to excessive vertical growthof the maxilla as a whole.

Case studies have shown that, ac-cording to the type of treatment, es-thetic, dento-alveolar and skeletalconsequences differ. It is thereforeessential to set treatment objectivesin agreement with patient expecta-tions as of the first examination, soas to select the most appropriateform of treatment.

Figure 19( a, b, c, d) External photographs and (e) smile at end of treatment.

Conflicts of interest: The author declares noconflict of interest.



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