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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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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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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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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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