This presentation gives a brief description of the clinical features and causes of gummy smile conditions , their clinical and differential dignosis , as well as the different treatment methods that may be used to correct these problems .

1. Diagnosis &Treatment of
Gummy Smile Conditions
Dr. Marwan Mouakeh . DDS, D.Od.Sc
Academic Consultant of Al-Hokail Polyclinic Academy
AL-Khobar – KSA

2.  Definition of the Gummy Smile
 Excessive Gingival Display During Smiling

3.  Prevalence :
 7% of young adult males
 14% of young adult females
Diamond O . Facial esthetics and orthodontics , J Esthet Dent,1996
 Peck et al , 1992
26% of a sample of orthodontic
patients displayed 2 mm or
more of maxillary gingiva when
smiling .

4. Classification of the Smile
• Posed or Social Smile
•UnPosed or Emotional Smile:
 Voluntary
 Static
 Not elicited by emotion
 Fairly Reproducible
 Involuntary & Spontaneous
 Dynamic
 Elicited by joy or mirth
 Hardly Reproducible
 Characterized by more lip
elevation than posed smile

5. Elements of an Esthetic Smile

6. 
Elements of an Esthetic Smile
 A normal gingival display between
the inferior border of the upper lip and
the gingival margin of the maxillary
anterior teeth during a ” posed smile “
is 1 -2 mm
Vig & Brundo, J Prosthet Dent, 1978
The maxillary anterior teeth should
be completely displayed during a full
smile .

7. •Tjan AH et al, Some esthetic factors in a smile. J Prosthet Dent. 1984
 Smile Type ( According to Smile Line )
Low S.L : Less than 75% of the clinical crown height of the
maxillary incisors is displayed .
Average S.L : 75% - 100% of the clinical crown height of the
maxillary incisors is displayed .
High S.L: About 2 mm of the contiguous maxillary gingiva is
revealed .
Low
Average
High

8.  Smile Line
High = 11%
•Tjan AH et al, Some esthetic factors
in a smile. J Prosthet Dent. 1984
Average = 69%
Low = 20%

9.  Sarver , AJO-DO 2001
 Most orthodontists and
dentists prefer that the
elevation of the lip for the
posed smile stop at the
gingival margins of the
maxillary incisors.”

10.  An excessive gingival-to-lip distance of 4mm or more is classified
as “ unattractive “ by lay people and general dentist .
Kokich et al , J Esthet Dent, 1999

11. 
Elements of an Esthetic Smile
 The Gingival Crest of of the
maxillary central incisors and
cuspids should be at the same
level , while the lateral incisors
are slightly coronal ( 1 mm) .

12. •
•Elements of an Esthetic Smile
 Symmetrical Exposure of
the anterior teeth with the
maxillary midline aligned
with the face midline

13. •Elements of an Esthetic Smile
 The Teeth should fit the rule of
“ Golden Proportion “
 The Perceived Width of the
maxillary anterior teeth as
viewed from the direct anterior
should have a ratio of 1 : 0.618
with the tooth adjacent to it .

14. •Elements of an Esthetic Smile
 Smile Arc :
• The
Incisive Edges of the
maxillary teeth are parallel
to the lower lip

15.  The
Resting Incisor -to-Lip Relationships
 Lips Slightly Contact
 Lips Relaxed

16.  The
Resting Incisor -to-Lip Relationships
• In Adolescents
3 to 4 mm of
the maxillary central incisors
should be displayed at rest .
• One Dental characteristic of
aging is decreased upper
incisor show and increased
lower incisor display .

17.  The
Resting Incisor -to-Lip Relationships
• Excessive exposure
of the
maxillary incisors at rest
• Decreased
exposure of the
maxillary incisors at rest

18. 2 Factors Influencing the Gingival Display :
1 - Age
 Gingival Smile Line Diminishes With Age
2 - Sex
 Low Smile Line is a Male Characteristic , While
High Smile Line Is a Female Characteristic

19.  In most children ,lip incompetency , is considered as a” transient
condition” that will be self-corrected after puberty due to the
maturation of the oro-facial musculature .

20.  The effects of maturation and aging on the soft
tissues of the face can be summarized as:
(1) lengthening of the resting philtrum and commissure heights,
(2) decrease in turgor (or tissue “fleshiness”),
(3) decrease in incisor display at rest,
(4) decrease in incisor display during smile, and
(5) decrease in gingival display during smile .
Dynamic smile visualization and quantification : Part 2. Smile analysis and treatment
strategies . David M. Sarver, DMD, MS, and Marc B. Ackerman, DMD
(Am J Orthod Dentofacial Orthop 2003;124:116-27)

21. Causes of the Gummy Smile

22. Gummy Smile
- Etiological Factors :
 Vertical Maxillary Excess / Protrusion
 Overeruption of Maxillary Incisors
 Short Upper Lip
 Hypermobile Upper Lip
 Altered ( Delayed ) Passive Eruption
 Compensatory Eruption of the Maxillary Teeth with
Concomitant Coronal Migration of the Gingival
Margins .

23.  Vertical Maxillary Excess :
- Long lower third of the face
- Lip Incompetence

24.  Vertical Maxillary Excess
 Rest position of a patient with
vertical maxillary excess
demonstrating “ incompetent lips “
 Smile view of a patient with
vertical maxillary excess

25.  Maxillary protrusion
• 6 mm Gingival Display When Smiling
• 4 mm Incisor Exposure in relaxed lip position
• Class II-1, OJ=8mm

26.  Maxillary protrusion
• SNA = 85°
•SNB = 76 °
• ANB=+9 °
•NS/ GoMe = 39 °
• pp / GoMe = 31 °
• Skeletal Cl.2 : maxillary protrusion .
• Increased AFH & ALFH

27. Example
6
mm gingival exposure
on smiling
6
mm incisor display at rest

28. Example
• Short
Philtrum
• Maxillary protrusion
• Increased AFH & ALFH
• Excessive protrusion of UI
Vertical Maxillary Excess
Maxillary Protrusion

29.  Over - eruption of the Maxillary Incisors
- Excessive vertical growth of maxillary anterior
dento-alveolar complex

30.  Over - eruption of the Maxillary Incisors
- Excessive vertical growth of maxillary anterior
dento-alveolar complex

31.  Short Upper Lip :
- Short philtrum relative to the commissures
 The average length of the upper lip is :
• 22-24 mm in males
• 20-22 mm in females

32. • Short upper lip type
• Between 6 and 40 years :
• Philtrum lengthening > Commissures lengthening

33.  Hypermobile Upper Lip :
- Extreme elevation of the upper lip on smile due
to hyperfunction of the elevator muscles
 Apical movement of the upper lip,
from rest to maximum smile, is more
than 9-10 mm .
 The average elevation of the
upper lip on smile is : 7-8 mm

34.  Hyperomobility of the Upper Lip
 Normal Vertical Proportions
 Normal Clinical Crown Lengths
 Excessive Contraction of the Elevators of the upper lip

35.  Altered ( Delayed ) Passive Eruption
• Delayed
migration of the gingival
margin in an apical direction

36. Tooth Eruption
Active Eruption
 Movement of the teeth in
the occlusal direction
Passive Eruption
 Exposure of the teeth by
apical migration of the
gingiva

37.  Delayed Passive Eruption
• During adolescence, the gingival
margin migrates apically until it
reaches its adult position of 1mm
coronal to the cemento-enamel
junction( CEJ) .
al

38.  Altered Passive Eruption
• Failure of the gingival tissue to adequately recede to the
proper level relative to the cemento-enamel junction( CEJ) .
al
 Prevalence : 12.1% ( 7% in men , 14% in women )

39. Active Altered Passive Eruption
 The Active Eruption of the teeth is complete by age 12 for the
maxillary central incisors and canines. The maxillary lateral
incisors continue to demonstrate minor changes in gingival margin
position up to 16 years of age.
Volchansky A: The position of the gingival margin as expressed by clinical crown
height in children aged 6-16 years. J Dent 4:116-122, 1976

40.  Inactive Altered Passive Eruption
 A Condition in which the
Gingival Margin is positioned
coronally on the anatomic
crown in adulthood and does
not approximate the CEJ .

41.  Clinical Crown Length
Vertical height of the maxillary
central incisor in adult is normally
between 9-12 mm , with an average
of :
10.6 mm in males , and
9.5 mm in females

42.  Clinical Crown Length
Ideal maxillary central incisor proportion is
approximately 80% width compared with height, with
ranges between 66% and 80%

43.  Diagnosis of Altered Passive Eruption
• Clinical crowns << the anatomic crowns
 Evaluation of the position of the cementoenamel
junction( CEJ) of the maxillary incisors relative to both
the gingival margins and incisal edges of these teeth.

44.  Short clinical crown height associated with a Gummy
Smile condition could be due to :
- Lack of eruption
- Gingival enlargement
- Severe attrition

45.  Detorqued or Lingually tipped maxillary incisors :
- Lower crown position and subsequent increase in
tooth and gingival display .
“Iatrogenic “ Gummy Smile

46.  Summary : Etiological Classification of
Gummy Smile Conditions
 Skeletal Type
 Dento –Alveolar Type
 Muscular Type
 Short Upper Lip Type
 Dento-gingival Type

47. Differential Diagnosis
• When planning treatment for a gummy smile the
key is to diagnose the reason for excessive
gingival margin-to -lip distance when the patient
smiles .

48. Gummy Smile
- Differential Diagnosis
1st Step
 Assessment of the upper lip relative to the incisal
edges of the maxillary incisors At Rest :
- Normal incisor display = 3- 4 mm

49. Gummy Smile
- Differential Diagnosis
 Normal ( 3- 4 mm) incisor display At Rest , But there
is a Gummy Smile ???
- The G.S Is due to either :
- Hyperomobility of the Upper Lip or
- Altered Passive Eruption

50. Gummy Smile
- Differential Diagnosis
 Hyperomobility of the Upper Lip
•M.Polo . AJO-DO,2008
The incidence of gummy smile
secondary to hyperfunctional upper lip
elevator musculature is about 0.1%.
A marked tendency for greater incidence
of excessive gingival display appears to
be present in females .

51. Gummy Smile
- Differential Diagnosis
 Assessment of the upper lip relative to the incisal
edges of the maxillary incisors At Rest :
- If incisor display > 3- 4 mm then the
Possible Causes :
• Short Upper Lip
• Overeruption of Maxillary Incisors
• Vertical Maxillary Excess

52. Gummy Smile
- Differential Diagnosis
• Short Upper Lip ,vs,
• Overeruption of Maxillary Incisors
• Vertical Maxillary Excess
 Evaluation of the Lower Anterior Face Height
Cephalometrically :
- If Normal : the problem is related to short
upper lip

53. Normal Vertical Proportions

54. • Short upper lip type
8 mm Incisor display at rest
4 mm Gingival display on smiling

55. Gummy Smile
- Differential Diagnosis
• Short Upper Lip ,vs,
• Overeruption of Maxillary Incisors
• Vertical Maxillary Excess
 Evaluation of the Lower Anterior
Face Height Cephalometrically :
- If Increased : the problem is due to
Vertical Maxillary Excess

56. Gummy Smile
- Differential Diagnosis
• Overeruption of Maxillary Incisors ,vs,
• Vertical Maxillary Excess
- Coronal Positioning of Maxillary Incisors ( Relative to
Post. Occlusal Plane ) IF they were Over-erupted .

57. Gummy Smile
- Differential Diagnosis
 In the case of Vertical Maxillary Excess :
Both anterior and posterior teeth are overerupted
relative to the patient’s facial soft tissues

58. Differential Diagnosis of the Gummy Smile

59. Treatment Methods
Treatment of the Gummy Smile Varies
According to the Etiological Factors ,
Perception and Expectations of the
Patient .

60.  Treatment Options
 Control or modification of certain aspects of facial
growth ( growing patients )
 Maxillary incisor intrusion by Orthodontic means .
 Surgical maxillary impaction
 Gingivectomy and Apically Repositioned Flap
 Restriction of the upper lip elevation when smiling
( surgical , Botox injection … )
• The Definitive Diagnosis of the Problem Determines
the Appropriate Treatment .

61.  Treatment Alternatives
 Orthodontics
 Orthognathic Surgery
 Periodontal Surgery
 Cosmetic Surgery

62.  Growth Modification Therapy in
Children & Adolescents
• Vertical Maxillary Excess
• Lip Incompetency & Gummy Smile

63. • High – pull headgear
• Bite blocks

64. • High-Pull Headgear + TPA
• 4x4 Extraction

65. Intrusion of Maxillary
Anterior Teeth

66.  Excessive Vertical Growth of Maxillary
Anterior Dento-alveolar Complex
•Burstone’s One-piece Intrusion Arch

67.  Burstone’s One-piece Intrusion Arch
Should be used in association with TPA and High-pull Headgear

68.  Intrusion of the super-erupted maxillary anterior teeth

69.  Intrusion of the Over-erupted maxillary anterior teeth

70.  Anterior High-Pull Headgear

71. Correction of Severe Overbite and Gummy Smile in
Patients with Bimaxillary Protrusion
MICKELSON RIO LIMA DE OLIVEIRA COSTA, DDS, MD, PHD
MYRELA GALVÃO CARDOSO COSTA, DDS, MD
CRISTINA BACELLAR DE PINHO, DDS
CÁTIA CARDOSO ABDO QUINTÃO, DDS, MD, PHD
JCO 2010
Case Report

72.  Correction of Severe Overbite and Gummy Smile in
Patients with Bimaxillary Protrusion .
 A 14-year-old female, Chief Complaints : Gummy Smile
& Crowding .
 Convex Profile & Lip Incompetence

73.  Class
II malocclusion, deep overbite, excessive facial height,
moderate arch length discrepancy, and “gummy smile” due to
vertical maxillary excess .

74.  Moderate
arch length discrepancy

75.  Class
II skeletal relationship,
retrognathic mandible,
slightly excessive mandibular
plane angle, and
 protrusive upper incisors

76. Treatment Plan :
Extraction of the upper and lower
first premolars to obtain space for
leveling and alignment of the
dentition and to reduce the labial
protrusion .

High-pull J-hook headgear

77. Lower Arch : Segmented mechanics to retract canines & intrude
lower incisors ( modified utility arch )

78.  Intrusion of the over-erupted anterior teeth with modified
utility arch .

79.  After 36 months of treatment

80.  After 36 months of treatment

81.  After 36 months of treatment

82.  After 36 months of treatment

83.  After 36 months of treatment

85.  Excessive growth of the anterior maxillary
dentoalveolar complex
• Use of Mini-implants Mechanics

86. Mini-screw Application For Gummy
Smile Correction
*Tülin (Uğur) TANER DDS, PHD, *Soner KAMACI DDS,
**Bahadır GİRAY DDS, PhD
Hacettepe University Faculty of Dentistry Department of Orthodontics
** Hacettepe University Faculty of Dentistry Department of Oral Surger y
*

87. •A 20 y . o. Female
•Gummy Smile
•Straight profile
•Slight upper lip
prominence

88. •Deep Overbite = 8 mm,
Maxillary incisors extrusion
• Overjet = 4 mm
• Class II Subdivision- left
side

89. •Discrepancy = - 2 mm

90. •Mild Skeletal Class 2 , mandibular
retrusion
•Slightly decreased FMA
• Retroclined upper& lower
incisors

91. •Initial maxillary alignment & leveling : 16x 16 NiTi
• 2 Mini-screws implants bilaterally inserted between
maxillary central & lateral incisor roots.
• An 18 mm Sentalloy Coil spring attached to segmental
arch S.S 16 X 22 ( 80 g intrusive force for 5 months ) .

92. •Removal of mini-screws after intrusion of the maxillary incisors.
• Completing leveling & alignment of the maxillary posterior and
lower teeth .
Tülin (Uğur) TANER DDS, PHD, *Soner KAMACI DDS, **Bahadır GİRAY DDS, PhD

93. •Eureka spring to correct Class II relation on the
left side ( 4 months )
Tülin (Uğur) TANER DDS, PHD, *Soner KAMACI DDS, **Bahadır GİRAY DDS, PhD

94. •Total Tretment time = 28 months
Tülin (Uğur) TANER DDS, PHD, *Soner
KAMACI DDS, **Bahadır GİRAY DDS, PhD

95. •Final occlusal relations
Tülin (Uğur) TANER DDS, PHD, *Soner KAMACI DDS, **Bahadır GİRAY DDS, PhD

97. Tülin (Uğur) TANER DDS, PHD, *Soner KAMACI DDS, **Bahadır GİRAY DDS, PhD

98. Tülin (Uğur) TANER DDS, PHD, *Soner KAMACI DDS, **Bahadır GİRAY DDS, PhD

99. Tülin (Uğur) TANER DDS, PHD, *Soner KAMACI DDS, **Bahadır GİRAY DDS, PhD

101. Surgical - Orthodontic Correction
of the Gummy Smile

102. • Gummy Smile Due to:
 Vertical Maxillary Excess

103. • Treatment of Gummy Smile Due to:
Vertical Maxillary Excess
• Superior Repositioning of the Maxilla through
Le Fort I Osteotomy .
 Indications:
- Long lower face height
- Lip incompetence
- Excessive exposure of maxillary anterior teeth
• Limitation : the upper lip may be considerably shortened

104.  Surgical Maxillary Impaction

105.  Vertical Maxillary Excess
 Combined Orthodontic – Surgical Treatment
Courtesy , Dr . Nabil Abo Chebel, Beirut-Lebanon

106.  Surgical Correction of Vertical Maxillary Excess
 Le Fort I differential impaction
 Bilateral sagittal split ramal osteotomy & advancement
 Osseous Genioplasty : Chin advancement & height reduction

107.  Surgical Correction of Vertical Maxillary Excess
 Maxillary Impaction : Le Fort I Osteotomy .
 Mandibular Advancement : Modified Obwegeser
 Genioplasty : Chin advancement & height reduction

108.  Surgical Correction of Vertical Maxillary Excess
Courtesy , Dr . Nabil Abo Chebel, Beirut-Lebanon

109. Management of Altered ( Delayed )
Passive Eruption

110.  Altered passive eruption
 Treatment Options :
• Ginigivectomy
• Apically Repositioned Flap

111.  Biological width
Distance of gingival margin to bone on labial is 3mm. 2 mm of
this is crevice depth, and 1mm. is for connective tissue between
probable depth and crest of bone.

112. Treatment of Altered Passive Eruption : Gingivectomy
 5 millimeters of crevice depth with adequate band of
Keratinized tissue .
Gingivectomy can be used to increase crown length by
up to 3 mm

113.  Gingivectomy
 This patient requires 3 mm of
crown lengthening
 Sufficient crevice depth and
Keratinized tissue

114.  Treatment of Altered Passive Eruption : Gingivectomy
 Crowns placed twelve weeks after Gingivectomy

115. Treatment of Altered Passive Eruption :
- Apically Repositioned Flap
 Short clinical crowns with
large gingival display on
smiling
Insufficient gingival crevice
depth for Gingivectomy

116. Treatment of Altered Passive Eruption :
- Apically Repositioned Flap
• Flap elevated and bone recontoured

117. Treatment of Altered Passive Eruption :
- Apically Repositioned Flap

118. Treatment of Altered Passive Eruption :
- Apically Repositioned Flap

119.  Gingival hyperplasia
Surgical removal after debanding if needed to enhance
posttreatment stability
If interfere tooth movement - surgical removal

120. • Hypertrophic gingival margins
Laser Gingivectomy

121.  Treatment of Hypermobile Upper Lip :
- Surgical Lip Repositioning
- Botox Injection
 Objective :
- To Decrease the amount of lip elevation on smiling .
- Lowering the height of the gingivolabial sulcus .

122.  Simon,Rosenblatt and Dorfman. J Cosmetic Dentistry ,Spring 2007
Lip Repositioning Technique

123.  Simon,Rosenblatt and Dorfman. J Cosmetic Dentistry ,Spring 2007
Lip Repositioning Technique
•The procedure restricts the muscle pull of the elevator lip
muscles by shortening the vestibule , thus reducing the gingival
display when smiling .

124. Surgical Lip Repositioning Technique
 Simon,Rosenblatt and Dorfman. J Cosmetic Dentistry ,Spring 2007

125. Surgical Lip Repositioning
 Simon,Rosenblatt and Dorfman. J Cosmetic Dentistry ,Spring 2007

126.  Hypermobility of the Upper Lip
Surgical Lip Repositioning
Preoperative
3 months post-operaion
1 year post-operaion
 Simon,Rosenblatt and Dorfman. J Cosmetic Dentistry ,Spring 2007

127.  Treatment of Hypermobile Smile
Surgical Lip Repositioning

128. •
Efficiency of Gummy Smile Correction Using the Myotomy of the Elevator of
the Upper Lip Muscle . Luis H. Ishida

129.  Hypermobility of the Upper Lip
 Injection of Botox to reduce excessive
gingival display on smiling
Botulinum toxin type A in the treatment of excessive gingival display . Mario Polo ,
(Am J Orthod Dentofacial Orthop 2005;127:214-8)

130. Botulinum toxin type A (Botox) for the neuromuscular correction of excessive
gingival display on smiling (gummy smile) .
Mario Polo , Am J Orthod Dentofacial Orthop 203-133:195;2008
 Musculature of the face: pinpointing sites for injection.

131. • When injected intramuscularly at therapeutic doses, BTX-A produces
partial chemical denervation of the muscle, resulting in localized reduction
in muscle activity.
Botulinum toxin type A in the treatment of excessive gingival
display . Mario Polo , (Am J Orthod Dentofacial Orthop 2005;127:214-8)

132. Botulinum toxin type A (Botox) for the neuromuscular correction of excessive
gingival display on smiling (gummy smile) .
Mario Polo , Am J Orthod Dentofacial Orthop 203-133:195;2008
BTX-A injections for the neuromuscular correction of gummy smile
caused by hyperfunctional upper lip elevator muscles was effective and
statistically superior to baseline smiles , although the effect was transitory .

133. Dr. Marwan Mouakeh