Diagnosis &Treatment of
Gummy Smile Conditions

Dr. Marwan Mouakeh . DDS, D.Od.Sc
Academic Consultant of Al-Hokail Polycli...
 Definition of the Gummy Smile

 Excessive Gingival Display During Smiling
 Prevalence :
 7% of young adult males
 14% of young adult females
Diamond O . Facial esthetics and orthodontics , J Es...
Classification of the Smile

• Posed or Social Smile

•UnPosed or Emotional Smile:

 Voluntary
 Static
 Not elicited by...
Elements of an Esthetic Smile

Elements of an Esthetic Smile
 A normal gingival display between
the inferior border of the upper lip and
the gingival...
•Tjan AH et al, Some esthetic factors in a smile. J Prosthet Dent. 1984

 Smile Type ( According to Smile Line )
Low S.L ...
 Smile Line
High = 11%

•Tjan AH et al, Some esthetic factors
in a smile. J Prosthet Dent. 1984

Average = 69%

Low = 20%
 Sarver , AJO-DO 2001
 Most orthodontists and

dentists prefer that the
elevation of the lip for the
posed smile stop at...
 An excessive gingival-to-lip distance of 4mm or more is classified
as “ unattractive “ by lay people and general dentist...

Elements of an Esthetic Smile
 The Gingival Crest of of the
maxillary central incisors and
cuspids should be at the sa...
•
•Elements of an Esthetic Smile
 Symmetrical Exposure of
the anterior teeth with the
maxillary midline aligned
with the ...
•Elements of an Esthetic Smile

 The Teeth should fit the rule of
“ Golden Proportion “
 The Perceived Width of the
maxi...
•Elements of an Esthetic Smile
 Smile Arc :
• The

Incisive Edges of the
maxillary teeth are parallel
to the lower lip
 The

Resting Incisor -to-Lip Relationships

 Lips Slightly Contact

 Lips Relaxed
 The

Resting Incisor -to-Lip Relationships

• In Adolescents

3 to 4 mm of
the maxillary central incisors
should be disp...
 The

Resting Incisor -to-Lip Relationships

• Excessive exposure

of the
maxillary incisors at rest

• Decreased

exposu...
2 Factors Influencing the Gingival Display :
1 - Age
 Gingival Smile Line Diminishes With Age

2 - Sex
 Low Smile Line i...
 In most children ,lip incompetency , is considered as a” transient
condition” that will be self-corrected after puberty ...
 The effects of maturation and aging on the soft
tissues of the face can be summarized as:
(1) lengthening of the resting...
Causes of the Gummy Smile
Gummy Smile
- Etiological Factors :
 Vertical Maxillary Excess / Protrusion
 Overeruption of Maxillary Incisors
 Short...
 Vertical Maxillary Excess :
- Long lower third of the face
- Lip Incompetence
 Vertical Maxillary Excess

 Rest position of a patient with
vertical maxillary excess
demonstrating “ incompetent lips ...
 Maxillary protrusion

• 6 mm Gingival Display When Smiling
• 4 mm Incisor Exposure in relaxed lip position

• Class II-1...
 Maxillary protrusion

• SNA = 85°
•SNB = 76 °
• ANB=+9 °
•NS/ GoMe = 39 °
• pp / GoMe = 31 °

• Skeletal Cl.2 : maxillar...
Example

6

mm gingival exposure
on smiling
6

mm incisor display at rest
Example

• Short

Philtrum

• Maxillary protrusion
• Increased AFH & ALFH
• Excessive protrusion of UI

Vertical Maxillar...
 Over - eruption of the Maxillary Incisors

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

- Excessive vertical growth of maxillary anterior
dento-alveolar complex
 Short Upper Lip :
- Short philtrum relative to the commissures

 The average length of the upper lip is :
• 22-24 mm in...
• Short upper lip type

• Between 6 and 40 years :
• Philtrum lengthening > Commissures lengthening
 Hypermobile Upper Lip :
- Extreme elevation of the upper lip on smile due
to hyperfunction of the elevator muscles
 Api...
 Hyperomobility of the Upper Lip

 Normal Vertical Proportions
 Normal Clinical Crown Lengths
 Excessive Contraction o...
 Altered ( Delayed ) Passive Eruption
• Delayed

migration of the gingival
margin in an apical direction
Tooth Eruption
Active Eruption
 Movement of the teeth in
the occlusal direction

Passive Eruption
 Exposure of the teeth...
 Delayed Passive Eruption

• During adolescence, the gingival
margin migrates apically until it
reaches its adult positio...
 Altered Passive Eruption
• Failure of the gingival tissue to adequately recede to the
proper level relative to the cemen...
Active Altered Passive Eruption

 The Active Eruption of the teeth is complete by age 12 for the
maxillary central incis...
 Inactive Altered Passive Eruption

 A Condition in which the
Gingival Margin is positioned
coronally on the anatomic
cr...
 Clinical Crown Length
Vertical height of the maxillary
central incisor in adult is normally
between 9-12 mm , with an a...
 Clinical Crown Length

Ideal maxillary central incisor proportion is
approximately 80% width compared with height, with...
 Diagnosis of Altered Passive Eruption

• Clinical crowns << the anatomic crowns

 Evaluation of the position of the cem...
 Short clinical crown height associated with a Gummy

Smile condition could be due to :
- Lack of eruption
- Gingival enl...
 Detorqued or Lingually tipped maxillary incisors :
- Lower crown position and subsequent increase in
tooth and gingival ...
 Summary : Etiological Classification of
Gummy Smile Conditions
 Skeletal Type
 Dento –Alveolar Type
 Muscular Type
 ...
Differential Diagnosis
• When planning treatment for a gummy smile the
key is to diagnose the reason for excessive
gingiva...
Gummy Smile
- Differential Diagnosis

1st Step

 Assessment of the upper lip relative to the incisal
edges of the maxill...
Gummy Smile
- Differential Diagnosis
 Normal ( 3- 4 mm) incisor display At Rest , But there
is a Gummy Smile ???
- The G...
Gummy Smile
- Differential Diagnosis
 Hyperomobility of the Upper Lip
•M.Polo . AJO-DO,2008

The incidence of gummy smi...
Gummy Smile
- Differential Diagnosis
 Assessment of the upper lip relative to the incisal
edges of the maxillary incisor...
Gummy Smile
- Differential Diagnosis
• Short Upper Lip ,vs,
• Overeruption of Maxillary Incisors
• Vertical Maxillary Exc...
Normal Vertical Proportions
• Short upper lip type

8 mm Incisor display at rest

4 mm Gingival display on smiling
Gummy Smile
- Differential Diagnosis
• Short Upper Lip ,vs,
• Overeruption of Maxillary Incisors
• Vertical Maxillary Exc...
Gummy Smile
- Differential Diagnosis
• Overeruption of Maxillary Incisors ,vs,
• Vertical Maxillary Excess
- Coronal Posi...
Gummy Smile
- Differential Diagnosis
 In the case of Vertical Maxillary Excess :
Both anterior and posterior teeth are o...
Differential Diagnosis of the Gummy Smile
Treatment Methods
Treatment of the Gummy Smile Varies
According to the Etiological Factors ,
Perception and Expectations ...
 Treatment Options
 Control or modification of certain aspects of facial
growth ( growing patients )
 Maxillary incisor...
 Treatment Alternatives
 Orthodontics

 Orthognathic Surgery
 Periodontal Surgery
 Cosmetic Surgery
 Growth Modification Therapy in
Children & Adolescents

• Vertical Maxillary Excess
• Lip Incompetency & Gummy Smile
• High – pull headgear

• Bite blocks
• High-Pull Headgear + TPA

• 4x4 Extraction
Intrusion of Maxillary
Anterior Teeth
 Excessive Vertical Growth of Maxillary
Anterior Dento-alveolar Complex

•Burstone’s One-piece Intrusion Arch
 Burstone’s One-piece Intrusion Arch
Should be used in association with TPA and High-pull Headgear
 Intrusion of the super-erupted maxillary anterior teeth
 Intrusion of the Over-erupted maxillary anterior teeth
 Anterior High-Pull Headgear
Correction of Severe Overbite and Gummy Smile in
Patients with Bimaxillary Protrusion
MICKELSON RIO LIMA DE OLIVEIRA COST...
 Correction of Severe Overbite and Gummy Smile in
Patients with Bimaxillary Protrusion .

 A 14-year-old female, Chief C...
 Class

II malocclusion, deep overbite, excessive facial height,
moderate arch length discrepancy, and “gummy smile” due ...
 Moderate

arch length discrepancy
 Class

II skeletal relationship,
retrognathic mandible,
slightly excessive mandibular
plane angle, and
 protrusive upp...
Treatment Plan :
Extraction of the upper and lower
first premolars to obtain space for
leveling and alignment of the
denti...
Lower Arch : Segmented mechanics to retract canines & intrude
lower incisors ( modified utility arch )
 Intrusion of the over-erupted anterior teeth with modified
utility arch .
 After 36 months of treatment
 After 36 months of treatment
 After 36 months of treatment
 After 36 months of treatment
 After 36 months of treatment
 Excessive growth of the anterior maxillary
dentoalveolar complex
• Use of Mini-implants Mechanics
Mini-screw Application For Gummy
Smile Correction
*Tülin (Uğur) TANER DDS, PHD, *Soner KAMACI DDS,
**Bahadır GİRAY DDS, Ph...
•A 20 y . o. Female
•Gummy Smile

•Straight profile
•Slight upper lip
prominence
•Deep Overbite = 8 mm,
Maxillary incisors extrusion
• Overjet = 4 mm
• Class II Subdivision- left
side
•Discrepancy = - 2 mm
•Mild Skeletal Class 2 , mandibular
retrusion
•Slightly decreased FMA
• Retroclined upper& lower
incisors
•Initial maxillary alignment & leveling : 16x 16 NiTi
• 2 Mini-screws implants bilaterally inserted between
maxillary cent...
•Removal of mini-screws after intrusion of the maxillary incisors.
• Completing leveling & alignment of the maxillary post...
•Eureka spring to correct Class II relation on the
left side ( 4 months )
Tülin (Uğur) TANER DDS, PHD, *Soner KAMACI DDS, ...
•Total Tretment time = 28 months

Tülin (Uğur) TANER DDS, PHD, *Soner
KAMACI DDS, **Bahadır GİRAY DDS, PhD
•Final occlusal relations
Tülin (Uğur) TANER DDS, PHD, *Soner KAMACI DDS, **Bahadır GİRAY DDS, PhD
Tülin (Uğur) TANER DDS, PHD, *Soner KAMACI DDS, **Bahadır GİRAY DDS, PhD
Tülin (Uğur) TANER DDS, PHD, *Soner KAMACI DDS, **Bahadır GİRAY DDS, PhD
Tülin (Uğur) TANER DDS, PHD, *Soner KAMACI DDS, **Bahadır GİRAY DDS, PhD
Surgical - Orthodontic Correction
of the Gummy Smile
• Gummy Smile Due to:
 Vertical Maxillary Excess
• Treatment of Gummy Smile Due to:
Vertical Maxillary Excess

• Superior Repositioning of the Maxilla through
Le Fort I Os...
 Surgical Maxillary Impaction
 Vertical Maxillary Excess

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

 Le Fort I differential impaction
 Bilateral sagittal split ramal os...
 Surgical Correction of Vertical Maxillary Excess

 Maxillary Impaction : Le Fort I Osteotomy .
 Mandibular Advancement...
 Surgical Correction of Vertical Maxillary Excess

Courtesy , Dr . Nabil Abo Chebel, Beirut-Lebanon
Management of Altered ( Delayed )
Passive Eruption
 Altered passive eruption

 Treatment Options :
• Ginigivectomy
• Apically Repositioned Flap
 Biological width

Distance of gingival margin to bone on labial is 3mm. 2 mm of
this is crevice depth, and 1mm. is for ...
Treatment of Altered Passive Eruption : Gingivectomy

 5 millimeters of crevice depth with adequate band of
Keratinized ...
 Gingivectomy
 This patient requires 3 mm of
crown lengthening
 Sufficient crevice depth and
Keratinized tissue
 Treatment of Altered Passive Eruption : Gingivectomy

 Crowns placed twelve weeks after Gingivectomy
Treatment of Altered Passive Eruption :
- Apically Repositioned Flap

 Short clinical crowns with
large gingival display...
Treatment of Altered Passive Eruption :
- Apically Repositioned Flap

• Flap elevated and bone recontoured
Treatment of Altered Passive Eruption :
- Apically Repositioned Flap
Treatment of Altered Passive Eruption :
- Apically Repositioned Flap
 Gingival hyperplasia
Surgical removal after debanding if needed to enhance
posttreatment stability
If interfere tooth mo...
• Hypertrophic gingival margins

Laser Gingivectomy
 Treatment of Hypermobile Upper Lip :
- Surgical Lip Repositioning
- Botox Injection
 Objective :
- To Decrease the amou...
 Simon,Rosenblatt and Dorfman. J Cosmetic Dentistry ,Spring 2007

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

Lip Repositioning Technique

•The procedure restricts t...
Surgical Lip Repositioning Technique

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

 Simon,Rosenblatt and Dorfman. J Cosmetic Dentistry ,Spring 2007
 Hypermobility of the Upper Lip
Surgical Lip Repositioning

Preoperative

3 months post-operaion

1 year post-operaion

...
 Treatment of Hypermobile Smile
Surgical Lip Repositioning
•

Efficiency of Gummy Smile Correction Using the Myotomy of the Elevator of
the Upper Lip Muscle . Luis H. Ishida
 Hypermobility of the Upper Lip
 Injection of Botox to reduce excessive
gingival display on smiling

Botulinum toxin typ...
Botulinum toxin type A (Botox) for the neuromuscular correction of excessive
gingival display on smiling (gummy smile) .
M...
• When injected intramuscularly at therapeutic doses, BTX-A produces
partial chemical denervation of the muscle, resulting...
Botulinum toxin type A (Botox) for the neuromuscular correction of excessive
gingival display on smiling (gummy smile) .
M...
Dr. Marwan Mouakeh
Diagnosis and treatment of gummy smile
Diagnosis and treatment of gummy smile
Diagnosis and treatment of gummy smile
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Diagnosis and treatment of gummy smile

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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 .

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Diagnosis and treatment of gummy smile

  1. 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. 2.  Definition of the Gummy Smile  Excessive Gingival Display During Smiling
  3. 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. 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. 5. Elements of an Esthetic Smile
  6. 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. 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. 8.  Smile Line High = 11% •Tjan AH et al, Some esthetic factors in a smile. J Prosthet Dent. 1984 Average = 69% Low = 20%
  9. 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. 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. 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. 12. • •Elements of an Esthetic Smile  Symmetrical Exposure of the anterior teeth with the maxillary midline aligned with the face midline
  13. 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. 14. •Elements of an Esthetic Smile  Smile Arc : • The Incisive Edges of the maxillary teeth are parallel to the lower lip
  15. 15.  The Resting Incisor -to-Lip Relationships  Lips Slightly Contact  Lips Relaxed
  16. 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. 17.  The Resting Incisor -to-Lip Relationships • Excessive exposure of the maxillary incisors at rest • Decreased exposure of the maxillary incisors at rest
  18. 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. 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. 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. 21. Causes of the Gummy Smile
  22. 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. 23.  Vertical Maxillary Excess : - Long lower third of the face - Lip Incompetence
  24. 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. 25.  Maxillary protrusion • 6 mm Gingival Display When Smiling • 4 mm Incisor Exposure in relaxed lip position • Class II-1, OJ=8mm
  26. 26.  Maxillary protrusion • SNA = 85° •SNB = 76 ° • ANB=+9 ° •NS/ GoMe = 39 ° • pp / GoMe = 31 ° • Skeletal Cl.2 : maxillary protrusion . • Increased AFH & ALFH
  27. 27. Example 6 mm gingival exposure on smiling 6 mm incisor display at rest
  28. 28. Example • Short Philtrum • Maxillary protrusion • Increased AFH & ALFH • Excessive protrusion of UI Vertical Maxillary Excess Maxillary Protrusion
  29. 29.  Over - eruption of the Maxillary Incisors - Excessive vertical growth of maxillary anterior dento-alveolar complex
  30. 30.  Over - eruption of the Maxillary Incisors - Excessive vertical growth of maxillary anterior dento-alveolar complex
  31. 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. 32. • Short upper lip type • Between 6 and 40 years : • Philtrum lengthening > Commissures lengthening
  33. 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. 34.  Hyperomobility of the Upper Lip  Normal Vertical Proportions  Normal Clinical Crown Lengths  Excessive Contraction of the Elevators of the upper lip
  35. 35.  Altered ( Delayed ) Passive Eruption • Delayed migration of the gingival margin in an apical direction
  36. 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. 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. 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. 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. 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. 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. 42.  Clinical Crown Length Ideal maxillary central incisor proportion is approximately 80% width compared with height, with ranges between 66% and 80%
  43. 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. 44.  Short clinical crown height associated with a Gummy Smile condition could be due to : - Lack of eruption - Gingival enlargement - Severe attrition
  45. 45.  Detorqued or Lingually tipped maxillary incisors : - Lower crown position and subsequent increase in tooth and gingival display . “Iatrogenic “ Gummy Smile
  46. 46.  Summary : Etiological Classification of Gummy Smile Conditions  Skeletal Type  Dento –Alveolar Type  Muscular Type  Short Upper Lip Type  Dento-gingival Type
  47. 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. 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. 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. 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. 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. 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. 53. Normal Vertical Proportions
  54. 54. • Short upper lip type 8 mm Incisor display at rest 4 mm Gingival display on smiling
  55. 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. 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. 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. 58. Differential Diagnosis of the Gummy Smile
  59. 59. Treatment Methods Treatment of the Gummy Smile Varies According to the Etiological Factors , Perception and Expectations of the Patient .
  60. 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. 61.  Treatment Alternatives  Orthodontics  Orthognathic Surgery  Periodontal Surgery  Cosmetic Surgery
  62. 62.  Growth Modification Therapy in Children & Adolescents • Vertical Maxillary Excess • Lip Incompetency & Gummy Smile
  63. 63. • High – pull headgear • Bite blocks
  64. 64. • High-Pull Headgear + TPA • 4x4 Extraction
  65. 65. Intrusion of Maxillary Anterior Teeth
  66. 66.  Excessive Vertical Growth of Maxillary Anterior Dento-alveolar Complex •Burstone’s One-piece Intrusion Arch
  67. 67.  Burstone’s One-piece Intrusion Arch Should be used in association with TPA and High-pull Headgear
  68. 68.  Intrusion of the super-erupted maxillary anterior teeth
  69. 69.  Intrusion of the Over-erupted maxillary anterior teeth
  70. 70.  Anterior High-Pull Headgear
  71. 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. 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. 73.  Class II malocclusion, deep overbite, excessive facial height, moderate arch length discrepancy, and “gummy smile” due to vertical maxillary excess .
  74. 74.  Moderate arch length discrepancy
  75. 75.  Class II skeletal relationship, retrognathic mandible, slightly excessive mandibular plane angle, and  protrusive upper incisors
  76. 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. 77. Lower Arch : Segmented mechanics to retract canines & intrude lower incisors ( modified utility arch )
  78. 78.  Intrusion of the over-erupted anterior teeth with modified utility arch .
  79. 79.  After 36 months of treatment
  80. 80.  After 36 months of treatment
  81. 81.  After 36 months of treatment
  82. 82.  After 36 months of treatment
  83. 83.  After 36 months of treatment
  84. 84.  Excessive growth of the anterior maxillary dentoalveolar complex • Use of Mini-implants Mechanics
  85. 85. 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 *
  86. 86. •A 20 y . o. Female •Gummy Smile •Straight profile •Slight upper lip prominence
  87. 87. •Deep Overbite = 8 mm, Maxillary incisors extrusion • Overjet = 4 mm • Class II Subdivision- left side
  88. 88. •Discrepancy = - 2 mm
  89. 89. •Mild Skeletal Class 2 , mandibular retrusion •Slightly decreased FMA • Retroclined upper& lower incisors
  90. 90. •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 ) .
  91. 91. •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
  92. 92. •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
  93. 93. •Total Tretment time = 28 months Tülin (Uğur) TANER DDS, PHD, *Soner KAMACI DDS, **Bahadır GİRAY DDS, PhD
  94. 94. •Final occlusal relations Tülin (Uğur) TANER DDS, PHD, *Soner KAMACI DDS, **Bahadır GİRAY DDS, PhD
  95. 95. Tülin (Uğur) TANER DDS, PHD, *Soner KAMACI DDS, **Bahadır GİRAY DDS, PhD
  96. 96. Tülin (Uğur) TANER DDS, PHD, *Soner KAMACI DDS, **Bahadır GİRAY DDS, PhD
  97. 97. Tülin (Uğur) TANER DDS, PHD, *Soner KAMACI DDS, **Bahadır GİRAY DDS, PhD
  98. 98. Surgical - Orthodontic Correction of the Gummy Smile
  99. 99. • Gummy Smile Due to:  Vertical Maxillary Excess
  100. 100. • 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
  101. 101.  Surgical Maxillary Impaction
  102. 102.  Vertical Maxillary Excess  Combined Orthodontic – Surgical Treatment Courtesy , Dr . Nabil Abo Chebel, Beirut-Lebanon
  103. 103.  Surgical Correction of Vertical Maxillary Excess  Le Fort I differential impaction  Bilateral sagittal split ramal osteotomy & advancement  Osseous Genioplasty : Chin advancement & height reduction
  104. 104.  Surgical Correction of Vertical Maxillary Excess  Maxillary Impaction : Le Fort I Osteotomy .  Mandibular Advancement : Modified Obwegeser  Genioplasty : Chin advancement & height reduction
  105. 105.  Surgical Correction of Vertical Maxillary Excess Courtesy , Dr . Nabil Abo Chebel, Beirut-Lebanon
  106. 106. Management of Altered ( Delayed ) Passive Eruption
  107. 107.  Altered passive eruption  Treatment Options : • Ginigivectomy • Apically Repositioned Flap
  108. 108.  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.
  109. 109. 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
  110. 110.  Gingivectomy  This patient requires 3 mm of crown lengthening  Sufficient crevice depth and Keratinized tissue
  111. 111.  Treatment of Altered Passive Eruption : Gingivectomy  Crowns placed twelve weeks after Gingivectomy
  112. 112. Treatment of Altered Passive Eruption : - Apically Repositioned Flap  Short clinical crowns with large gingival display on smiling Insufficient gingival crevice depth for Gingivectomy
  113. 113. Treatment of Altered Passive Eruption : - Apically Repositioned Flap • Flap elevated and bone recontoured
  114. 114. Treatment of Altered Passive Eruption : - Apically Repositioned Flap
  115. 115. Treatment of Altered Passive Eruption : - Apically Repositioned Flap
  116. 116.  Gingival hyperplasia Surgical removal after debanding if needed to enhance posttreatment stability If interfere tooth movement - surgical removal
  117. 117. • Hypertrophic gingival margins Laser Gingivectomy
  118. 118.  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 .
  119. 119.  Simon,Rosenblatt and Dorfman. J Cosmetic Dentistry ,Spring 2007 Lip Repositioning Technique
  120. 120.  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 .
  121. 121. Surgical Lip Repositioning Technique  Simon,Rosenblatt and Dorfman. J Cosmetic Dentistry ,Spring 2007
  122. 122. Surgical Lip Repositioning  Simon,Rosenblatt and Dorfman. J Cosmetic Dentistry ,Spring 2007
  123. 123.  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
  124. 124.  Treatment of Hypermobile Smile Surgical Lip Repositioning
  125. 125. • Efficiency of Gummy Smile Correction Using the Myotomy of the Elevator of the Upper Lip Muscle . Luis H. Ishida
  126. 126.  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)
  127. 127. 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.
  128. 128. • 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)
  129. 129. 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 .
  130. 130. Dr. Marwan Mouakeh

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