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QUINTESSENCE INTERNATIONAL

Excessive gingival display— Etiology, diagnosis, and treatment modalities Nir Silberberg, DMD1 /Moshe Goldstein, DMD2 / Ami Smidt, DMD, MSc, BMedSc2

Extensive exposure of the gingiva during a smile, called excessive gingival display, may be a point of concern for both patients and clinicians. Patients often present to the dental clinic seeking a solution to their “gummy” appearance. A clinician must fully understand the various factors involved in this situation, to provide patients with an appropriate answer. Thorough examination followed by the right diagnosis is imperative for achieving an esthetic and predictable result in the treatment of such situations. The aim of this article is to discuss the various aspects of excessive gingival display and its etiology and to present the current solutions that exist in the literature. (Quintessence Int 2009;40:809–818)

Key words: altered passive eruption, diagnosis, etiology, excessive gingival display, gummy smile, vertical maxillary excess (VME)

Facial expressions and the smile are key

filling the entire interproximal spaces, (4) har-

components for nonverbal communication.

mony between the anterior and posterior

The smile has an important role in the deter-

segments (gradation principle5), (5) teeth in

1

correct anatomy and proportion (form and

An esthetic or pleasing smile is com-

position), (6) proper color and shade of the

mination of the first impression of a person. 2

posed of 3 primary components : the teeth,

teeth, and (7) lower lip parallel to the incisal

lip framework, and the gingival scaffold. An

edges of the maxillary anterior teeth and to

ideal esthetic and pleasing smile presents

the imaginary line going through the contact

the following characteristics (Fig 1)

3,4

: (1) min-

points of these teeth.

imal gingival exposure, (2) symmetric display

The description excessive gingival display,

and harmony between the maxillary gingival

commonly called gummy smile, is used

line and upper lip, (3) healthy gingival tissue

when there is an overexposure of the maxillary gingiva during a smile6 (Fig 2). In severe cases, the overexposure is also seen in repose of the mouth and lips (Fig 3). In most

1

Graduate Student, The Center for Graduate Studies in Prosthodontics, Department of Prosthodontics, Faculty of Dental Medicine, The Hebrew University–Hadassah, Jerusalem, Israel.

cases, the more the gingival tissues are displayed during the smile, the more unesthetic the smile appears.7 The prevalence of exces-

2

Director, Graduate Studies in Periodontics, Department of Periodontics, Faculty

of Dental Medicine, The Hebrew

University–Hadassah, Jerusalem, Israel. 3

Head, The Center for Graduate Studies in Prosthodontics,

sive gingival display is 10% of the population between the age of 20 and 30 years, and it is seen more in women than in men. 1,8 The inci-

Department of Prosthodontics, Faculty of Dental Medicine,The

dence of this condition gradually decreases

Hebrew University–Hadassah, Jerusalem, Israel.

with age as a consequence of dropping of

Correspondence: Dr Nir Silbeberg, The Center for Graduate

the upper and lower lips, which in turn leads

Studies in Prosthodontics, Department of Prosthodontics,

to a decrease in exposure of the maxillary

Faculty of Dental Medicine, The Hebrew University–Hadassah, PO Box 12272, Jerusalem 91120, Israel. Fax: 972-2-6429683.

mandibular incisors.9,10

Email: [email protected]

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incisors and an increase in exposure of the

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QUINTESSENCE INTERNATIONAL Silberberg et al

Fig 1

A young woman presenting an ideal pleasing smile.

Fig 2

Excessive gingival display of a young female patient during a normal smile.

Fig 3

A severe case of excessive gingival display presenting an overexposure of anterior gingiva in repose.

Hair 1/2

1/3

1/3 Brows Width equal to brow-to-chin

1/3

Fig 4 (above) A woman presenting pleasing gingival exposure during smiling. Fig 5 (right) nation.

1/2 Stomion Lips

1/3

1/3 2/3

Reference lines for facial exami-

Glabella Eyes 1/3 Nose

Subnasale

1/3

Soft tissue menton

When analyzing a smile, one must bear in

Accessory horizontal lines are the ophriac

mind that a certain amount of gingival expo-

line (a line going through the eyebrows) and

sure during a smile is considered esthetically

the commissural line. These lines should be

pleasing, which gives the expression of a

parallel to the interpupillary line, thus creating

youthful look4,11 (Fig 4).

an overall harmony of the face. These lines can be used as a reference for orienting the incisal plane, the occlusal plane, and the gingival contour. A line perpendicular to the

DIAGNOSIS

interpupillary line should divide the face into 2 symmetrical parts.

For a correct diagnosis, a thorough examina tion must be performed.

Face height is usually analyzed by dividing the face into thirds. The middle and lower thirds are more involved in the esthetic con-

Facial examination

sideration of the patient. When measured in

Facial symmetry and proportions in both

repose, these two thirds should be equal.

frontal and lateral views. Assessment of

The lower third can br further divided by the

facial symmetry is made with respect to the interpupillary line. This horizontal line divides

stomion into upper one-third and lower two thirds12–15 (Fig 5).

the face into equal halves.

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Subnasale

Lower border of the upper lip

Fig 6 Upper lip length is measured between the 2 lines.

Upper lip length at rest (Fig 6). Upper

Fig 7

A low smile line in a man.

incisal edges and the curvature of the lower

lip length is measured from the subnasale to

lip. The gingival margins of the maxillary cen-

the lower border of the upper lip. The aver-

tral incisors and the canines should be sym-

age lip length is 20 to 24 mm 13 in young

metric and in a more apical position than

adults and tends to increase with age.

those of the lateral incisors. Chiche and

Display of maxillary central incisors at

Pinault12 considered symmetry of the gingival

rest. Maxillary central incisor display at rest,

margins at the midline (central incisors) to be

on average, is 3 to 4 mm in young women

essential, while more laterally a certain

and 2 mm in young men and tends to

amount of asymmetry is permissible.

decrease with age.

9

Amount of gingival exposure during

Intraoral examination

rest, speech, smile, and laughter. During

Occlusal plane. The occlusal plane should

an extensive smile, the upper lip should rest

be evaluated by comparing it to the anatom-

at the level of the midfacial gingival margins

ic landmarks in the same way determined

of the maxillary anterior teeth. 13

during fabrication of complete dentures. The

Smile line. This term expresses the posi-

occlusal plane should closely coincide with

tion of the upper lip relative to the maxillary

the imaginary line connecting the commis-

incisors and gingiva during a natural full

sures of the lips and two-thirds the height of

1,8

A high smile line reveals the entire

the retromolar pad.10 In this way, during a

crown of the tooth and an abundant amount

smile, there is mild exposure of the tips of the

of gingiva (excessive gingival display). In the

mandibular canines and premolars.

smile.

average smile line, 75% to 100% of the

Harmony of the dental arches. The

crowns is revealed with the interproximal gin-

anterior (incisal part) and posterior segments

giva. A low smile line is when less than 75%

should be in harmony with one another and

of the crowns is revealed (Fig 7). A low smile

have no major discrepancies.

line is predominantly a male characteristic,

Anatomy, proportions, and color of the

whereas a high smile line is predominantly a

teeth. Lombardi 5 pointed out the impor-

11

female trait.

tance of the proportions between width and

Gingival margin outline. In patients with

length in the dimensions of individual teeth.

excessive gingival display, any irregularities

A comparison between the anatomic crown

and disharmony in the alignment of the gin-

height (incisal edge to cementoenamel junc-

gival margin may have a significant effect on

tion [CEJ]) and the clinical crown height

smile

exist

(incisal edge to free gingival margin) will help

between the gingival line in the anterior and

esthetics.

Harmony

determine whether short clinical crowns are

12,15

posterior segments.

should

The outline of the gin-

gival margins should be parallel to both the

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a result of incisal wear or of a coronal posi tion of the gingival margin over the teeth.


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Fig 8 A boy with pronounced gingival enlargement due to cyclosporine treatment.

Periodontal examination. The width and

thickness of the keratinized attached gingiva

Fig 9 A girl with altered passive eruption of multiple teeth. Teeth appear short and square.

Altered/delayed passive eruption Passive eruption is a normal condition in

must be measured, as well as probing depth,

which the gingival margins recede apically to

clinical attachment level, and crestal bone

the level of the CEJ after the tooth has erupt-

level with respect to the CEJ. The position of

ed completely. In cases in which the gingival

the free gingival margins relative to the CEJ is

margins fail to recede to the level of the CEJ,

another important issue. The periodontal bio-

the condition is named altered passive erup-

type may influence the reaction of the gingival

tion. Because the gingival tissues are posi-

tissues to periodontal therapy and surgery.

tioned coronal to the CEJ, the teeth appear

There are 3 periodontal biotypes: thin and scalloped, normal, and thick and flat.

15,16

short and square (Fig 9).

This

This condition may involve multiple teeth

information has a crucial influence on the

or an isolated tooth. The incidence of altered

treatment strategies and decisions.

passive eruption in the general population is

A correct diagnosis of excessive gingival

about 12%. The physiologic condition of pas-

display performed according to all the above-

sive eruption may continue even in the third

mentioned issues allows the clinician to

decade of life; therefore, the diagnosis of

select the proper treatment modality and

altered passive eruption must be made with

achieve a clinical result that satisfies both

respect to age.

patient and operator.

The alveolar crest may be at the level of the CEJ or 1 to 2 mm apical to it, as exists in a healthy condition. Parallel radiography will help determine the level of the alveolar crest

ETIOLOGY OF EXCESSIVE GINGIVAL DISPLAY AND TREATMENT MODALITIES

interproximally, and probing to bone (sounding) will determine its level facially and orally.13,18,19 A classification for altered passive erup-

Plaque-/drug-induced gingival enlargement

tion was suggested by Coslet et al20:

This is a condition in which the enlarged gin-

• Type 1A—excessive amount of keratinized

gival tissues are covering the clinical crowns,

gingiva with normal alveolar crest–to–CEJ

creating an unesthetic appearance (Fig 8). It

relationship

is most often related to dental plaque and

• Type 1B—excessive amount of keratinized

inflammation but can be associated with

gingiva with osseous crest at the CEJ level

medication such as phenytoin, cyclosporine,

• Type 2A—normal amount of keratinized

and calcium channel blockers. Treatment of

gingiva with normal alveolar crest–to–CEJ

this condition should focus on meticulous

relationship

oral hygiene. Sometimes, periodontal sur-

• Type 2B—normal amount of keratinized

gery will be needed to eliminate the exces-

gingiva with osseous crest at the CEJ level

13,17

sive amount of soft tissues.

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Fig 10 Excessive gingival display due to overeruption of the maxillary incisors. Note the discrepancy in the occlusal plane between the anterior and posterior segments.

Fig 11 A typical case of vertical maxillary excess. Note the amount of gingival tissues exposed and the lower lip covering the maxillary canines and premolars.

Fig 12 Cephalometric analysis. The anterior maxillary height is measured between the palatal plane and the incisal edge of the maxillary incisors.

1

Palatal plane 3 Incisal edge

Altered passive eruption may be resolved

Vertical maxillary excess (VME)

with periodontal surgery. The selected surgi-

This condition involves an overgrowth of the

cal procedure depends solely on the type of

maxilla in the vertical dimension. Many times,

altered passive eruption.

it appears with a long-face syndrome. 12,21 An increase in facial height appears mainly in the

Anterior dentoalveolar extrusion

lower half of the face, and in contrast to over-

Overeruption of the maxillary incisors with

eruption of the maxillary incisors, harmony of

their dentogingival complex leads to a more

the occlusal plane between the anterior and

coronal position of the gingival margins and

the posterior segments is found. Because the

excessive gingival display. This condition

occlusal plane is relatively lower than normal,

may be associated with tooth wear at the

individuals with VME will have excessive gingi-

anterior region (compensatory incisor over-

val display with the lower lip covering the

eruption) or with anterior deep bite. In cases

incisal edges of the maxillary canines and pre-

with deep bite, there is usually a discrepancy

molars (Fig 11). These clinical findings may

in the occlusal plane between the anterior

lead the clinician toward diagnosing VME,

and posterior segments (Fig 10).

which must be confirmed with a cephalomet-

Treatment of this condition may include

ric radiograph reading. It was found in a gummy

moving the gingival margin apically, surgical

between the palatal plane and the incisal edge

periodontal

without

of the maxillary incisors (anterior maxillary

adjunctive restorative therapy, or an interdis-

height) was approximately 2 mm higher than

correction

with

or

ciplinary comprehensive treatment plan.

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2,12,15

smile

group8 that

orthodontic intrusion of the involved teeth

the

distance

in individuals without gummy smiles (Fig 12).


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Tabl e 1

Classification of vertical maxillary excess* Gingival and mucosal

Degree

display (mm)

I

2–4

II

4–8

III

≥8

Treatment modalities

Orthodontic intrusion Orthodontics and periodontics Periodontal and restorative therapy Periodontal and restorative therapy Orthognathic surgery (Le Fort I osteotomy) Orthognathic surgery with or without adjunctive periodontal and restorative therapy

*Taken from Garber and Salama2

Fig 13

A girl with short upper lip.

In cases of VME, most often, the length of

a high lip line raise the upper lip an average

the upper lip is normal, although clinically, it

of 1 extra millimeter, or nearly 20% more,

appears relatively short.

than the reference group during a smile.

A classification of VME was introduced by Garber and Salama in 1996

2

The treatment modalities recommended

offering 3

for short upper lip and hyperactive upper lip

degrees of gingival exposure and correspon-

are similar. Plastic reconstructive surgery

ding treatment modalities (Table 1).

was the solution offered in several reports published in the 1970s and 1980s for treat-

Short upper lip

ment of such conditions. The first technique

In this instance, the upper lip is shorter than

reported was the lip adhesion technique

15 mm, measured from the subnasale to the

described by Rubinstein and Kostianovsky. 23

lower border of the upper lip 22 (Fig 13).

In this technique, the internal connection of

Interestingly, a number of studies showed

the upper lip is severed, and an elliptical

that in most cases of excessive gingival dis-

piece of tissue is removed from the dissected

play, the upper lip length is normal even

area. Then, a lower connection is established

though the lip appears clinically short. 8 The

between the upper lip and gingival soft tis-

treatment modality recommended for this

sues, about 4 mm above the free gingival

condition will be discussed ahead.

margin. This procedure of reconnection restricts upper lip elevation during the smile,

Hyperactive upper lip

limiting the amount of gingival tissue expo-

This condition represents increased activity

sure. Litton and Fournier in 1979 24 discussed

of the elevator muscles of the upper lip dur-

and supported this treatment modality in

ing smile. According to the study of Peck et

their work and recommended that it be used

8

al, individuals with excessive gingival display

more widely. Their modification was to

present significantly more efficient lip-eleva-

detach the lip muscles from the bony struc-

tion musculature compared to those with

tures in cases of short upper lip to increase

average smile lines. In this study, people with

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the lip length.

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Excessive gingival and teeth display Increased incisor exposure during rest Normal lip length

Normal incisor exposure during rest

Short upper lip

Difference between anterior and posterior occlusal planes

Harmonious occlusal plane

Incisor overeruption

VME

Short clinical crown Incisal attrition

Hyperactive mobile upper lip

Differential diagnosis

Incisor overeruption (compensatory)

Fig 14

No attrition

Normal clinical crown length

Altered passive eruption (1 or more teeth)

Gingival hyperplasia

A flow chart to determine the correct etiology of excessive gingival display.

In 1983, Miskinyar, 25 being disappointed

Polo in 200528 offered the use of botu-

with the previous technique, described the

linum toxin injections as a new nonsurgical

levator myectomy and partial removal tech-

method for treating excessive gingival dis-

nique. Ellenbogen and Swara

26

described

play. The toxin is injected into the area of the

the implant spacer technique in 1984. These

upper lip to decrease the elevating muscle

2 techniques were based on the same con-

activity, aimed in particular at the levator labii

cept of transecting the levator labii superioris

superioris muscle. The major disadvantage

muscle (or part of it), one of the essential muscles participating in smile formation.

of this technique is the short effect of the toxin, which lasts only 3 to 6 months.

According to the authors, this procedure

In contrast to the above-mentioned treat-

results in a decreased elevation of the upper

ment options, some cases of excessive gingi-

lip during smile. Ellenbogen and Swara

val display due to short or hyperactive upper

offered insertion of a space maintainer (sili-

lip may be treated by periodontal surgery

cone, cartilage, polyamide, or turbinate

with or without an adjunct restorative therapy.

bone) to prevent the muscle from reconnecting. Another important factor in the presence

Asymmetric upper lip

of such an implant spacer is its ability to limit

In 2001, Benson and Laskin 29 evaluated the

the activity25,26 of the elevator muscles. The

smile in a group of 195 subjects and found

latter reports presented good results with a

9% with asymmetric smile, due to canting of

limited number of complications but had no

the upper lip. This asymmetry can lead to

follow-ups. A literature search conducted by

excessive and asymmetric gingival exposure.

the authors of this review in search of

When this asymmetry appears only during a

updates in this field revealed a small and

smile, (in most cases) it is uncorrectable. It is

nonsignificant number of current reports on

imperative to draw the patient’s attention to

these methods with no actual innovations. In

such an asymmetry before the onset of any

a recent publication, the original lip adhesion technique23 was used with a follow-up of 8 months reporting good results.

27

comprehensive dental treatment. A flow chart that can help determine the correct etiology of a specific excessive gingival display case is shown in Fig 14.

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In general, cases of excessive gingival dis-

and bony support. Af ter periodontal surgery,

play may have more than one etiology and

it becomes more difficult to achieve an

should therefore be diagnosed carefully, and

esthetic result with the restorative treatment.

an interdisciplinary treatment should be con-

Because the remaining roots have a smaller

sidered. It is of high importance to involve the

diameter, it becomes complicated to deal with

patient throughout the process of diagnosing

the emergence profile and the big interproxi-

and treatment planning. An informed patient

mal distances that lead to the “black holes”

is a key factor to treatment success and per-

appearance.

sonal satisfaction.

Restorative therapy should be planned in cases of excessive gingival display in the following situations: (1) short clinical crowns due to loss of tooth structure (ie, tooth wear);

TREATMENT CONSIDERATIONS

(2) existing faulty restoration or following an esthetic complaint by the patient; and (3) exposed roots as a consequence of peri-

As stressed before, proper examination and correct diagnosis must be performed before deciding whether to include periodontal sur-

odontal therapy causing teeth hypersensitivi ty and impaired esthetics. When planning restorative treatment after

gery in the treatment. A decision has to be

periodontal surgery, one of the important

made on the type of surgery, with or without

issues to be considered is soft tissue matu-

bone resection

6,29–31

:

ration. During this period, changes may occur in the coronoapical position of the free

• Gingivectomy is indicated when there is

gingival margins, and thus careful observa-

excess keratinized soft tissue and the

tion and evaluation of tissue healing is need-

bone level is appropriate. Careful evalua-

ed before the case can be finalized. The

tion must take place before surgery so that

preparation finishing line must be placed

adequate keratinized gingival tissues will

supragingivally during the healing period,

remain after surgery. This procedure

avoiding any disturbance to the maturation

applies to cases of gingival overgrowth

process. 33 In esthetic regions, a healing peri-

and altered passive eruption type 1A.

od of at least 6 months should be allowed fol-

• Apically positioned flap without osseous

lowing the periodontal surgical procedure for

resection is recommended for cases in

the final maturation and location of the free

which the bone level is appropriate but

gingival margins.13,34,35 After proper healing

gingivectomy will leave less than 3 mm of

and maturation of the tissues, final prepara-

keratinized gingival tissues. This is per-

tion of the teeth will be performed, where the

formed in cases of altered passive erup-

finishing line is set no deeper than 0.5 mm subgingivally. 13

tion type 2A. • Apically positioned flap with osseous

The extent of the periodontal corrective

resection is recommended for all other

procedure for excessive gingival display

cases where osseous resection is required.

depends on the patient’s display during smile

The osseous resection should bring the

and repose. Because most people (about

bone crest 2.5 to 3.0 mm away apically

80%) expose the maxillary teeth from second

from the CEJ or from the definite location

premolar to second premolar while smiling,1

of the finishing line of the fi nal restoration to

the surgical procedure should be performed

achieve a physiologic biologic width.

between the first molars to achieve a harmonious smile and correct gingival contours. 18

It is imperative to evaluate the root length of

Prediction of the final outcome of peri-

the teeth before surgery. Any procedure that

odontal and restorative therapy is important

needs a considerable amount of bone resec-

in treating cases of excessive gingival dis-

tion will result in a relative reduction in the

play. Therefore, it is recommended to use a

bony support and has a negative influence

surgical stent during surgery. 33 The first step

on the crown-to-root ratio, 32 teeth mobility,

is to prepare a total waxup of the teeth and

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Fig 15a and 15b

Use of a surgical stent during periodontal surgery in a case with excessive gingival display.

Fig 16 Use of a surgical stent to determine the flap position at the end of surgery.

Figs 18a and 18b gingival display.

Fig 17 Three-week follow-up. Use of surgical stent in monitoring the tissue position and maturation.

Before and after comprehensive periodontic and restorative treatment of excessive

create a correct gingival contour on a study

CONCLUSION

model. A surgical acrylic stent is made according to the waxup, which provides sev-

Excessive gingival display is an esthetic con-

eral advantages (Figs 15a and 15b): preoper-

cern both to the patient and the clinician,

ative imaging of the final result in the mouth,

especially when restoration of the anterior

allowing in cases of excess keratinized gingi-

teeth is indicated. Understanding the etiolo-

val tissues a definite incision line of the gin-

gy and treatment options is crucial in the

givectomy, guiding the osteotomy for correct

process of treatment of a patient with a

osseous architecture and proper soft tissue

gummy smile. The principles and concepts

healing, determining the flap position at the

discussed in this review will lead the clinician

end of surgery (Fig 16), and monitoring the

toward achieving an esthetic result and

tissue position and maturation during follow-

patient satisfaction with the performed treat-

ups (Fig 17).

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818

VOLUME

40

•

NUMBER

10


Excessive Gingival Display - Final

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