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Effective Gummy Smile Treatments
- 1. Gummy Smile Dr. Diana Mostafa
- 2. • Introduction • Etiology • Evaluation of gummy smile • Diagnosis of Gummy smile • Treatment modulates (surgical and non surgical )
- 3. What is the beautiful smile ?? It is a matter of Pink & White
- 4. Gummy smile • Is excessive exposure of maxillary gingiva during smiling. • Prevalence: Females > Males
- 6. Periodontal deformities - Gingival hyperplasia. - Delayed passive eruption of teeth. The Etiology Soft tissue deformities - High lip line - Short upper lip - Lip hypermobility Dental deformities - Short clinical crown. - Extrusion of maxillary teeth. Skeletal deformities - Vertical maxillary excess - Maxillary protrusion
- 8. 1.Extraoral facial examination Facial symmetry and proportions. 2. Evaluate the morphology of upper lip • The average lip length is measured from the subnasale to most inferior portion of the upper lip in midline. • Normal length: Males=23mm, Females=20 mm (if less=short lip) • Lip length roughly should be equal to commissure height .
- 9. 3. Assessment of upper lip to incisal edge of maxillary incisor at rest. • display of maxillary central incisors at rest position of the lips (normal =3-4mm) 4.Amount of gingival display during smile Normal display of gingiva is 1-2mm.
- 10. 5. Evaluation of the smile line Maxillary Lip line Amount of cervico-incisal of ant. Maxillary teeth High lip line >100% Standard lip line 75-100% Low lip line <75%
- 11. 6. Occlusal plane and crown dimensions • It is done by drawing imaginary line connecting the commissures of the lips and two third the height of the retromolar pad. • Evaluate the length and width of the anatomical crowns.
- 12. 7. Periodontal examination • The width and thickness of keratinized tissues must be measured (adequate or not ). • PD & CAL • Crestal bone level with respect to CEJ. • Gingival biotype ( thin & scalloped , normal , thick & flat)
- 13. 8. Radiographic examination Cephalometric radiograph :to detect any increase in lower anterior height, occlusal plan angle & skeletal classes. Periapical radiographs: to detect CEJ location, root length and bony support. GP
- 15. Gummy smile Increase incisor exposure during rest Normal incisor exposure during rest Normal lip length Short lip length Short clinical crown Normal clinical crown Difference between anterior and posterior occ. plan Incisor overeruption Harmonious occ. plan VEM Incisal attrition No attrition Altered passive eruption or gingival hyperplasia Hyperactive upper lip
- 17. Surgical options •1- Crown lengthening •2- Lip reposition •3- Myectomy •4-Orthognathic surgery Non- Surgical options • 1- Orthodontic treatment • 2- Restorative treatment • 2- Botox injections • 3- Filler
- 18. Gingivectomy Or Periodontal surgery Indicated in case of G. hyperplasia - gummy smile. PD >2mm Needs adequate K. gingiva. Scalloped marginal incision + raising flap w/without crestal bone reduction 2.5 mm away from CEJ w/without apically repositioned flap. Disadv: risk of ID recession (black triangle) It is only indicated when there are gingival hyperplasia or abnormal dentogingival relationship.
- 19. Gingivectomy Blade gingivectomy (external bevel ) Laser gingivectomy Electrosurgery PD=2mm
- 22. Treatment choice according to type of altered passive eruption!!!
- 23. Type IA Type IB Type IIA Type IIB Type I >2mm Type II <2mm Bone crest apical to the CEJ (passive) adequate attached gingiva . Bone crest at CEJ (active) adequate attached gingiva . Bone crest apical to CEJ (passive) inadequate keratinized tissues. Bone crest at CEJ (active) inadequate keratinized tissues. Gingivectomy Periodontal flap with bone reduction Apically displaced flap Apically displaced flap with bone reduction
- 24. Lip reposition It is indicated for patients with GS caused by muscular cause. It is done to limit the pulling of the elevator lip muscles during smiling. Done by removing a strip of mucosa from the maxillary vestibule by a partial-thickness flap between the MGJ and the upper lip musculature. The lip mucosa is then sutured to the MGJ ……….causing narrower vestibule + restricted muscles. Contraindications 1-Inadequate width of attached gingiva. 2-Patients with severe vertical maxillary excess
- 26. Myectomy It is a surgical procedure to detach smile muscle attachment to prevent relapse. Done by placement of spacer between elevator muscles of lip and anterior nasal spine.
- 28. Orthognathic surgery • Indicated for vertical maxillary excess and to balance the relative positions of the upper and lower jaws.
- 30. Orthodontic treatment When the cause is dentoalveolar extrusion.
- 31. Restorative solution • Indicated in short crowns cases especially incisal attrition. • Commonly done with crown lengthening .
- 32. Botox injections botulinum toxin produces partial chemical denervation of the muscle, resulting in localized reduction in hyperactive upper labial muscles activity. It is very effective but temporary .
- 34. Filler injection(hyaluronic acid) It changes the shape of the lip, and also restrict the movement of muscle fibers in the lip acc. To injection site. Fanning retrograde administration technique (from piriformis fossa) Lip filler
- 35. • A retrograde fanning technique was used from the piriformis fossa to the midline in a supramuscular plane. • This creates a structural support and the lip was enhanced.
- 36. Gummy smile • Orthodontic intrusion only • Orthodontic & periodontic Rx • Periodontic & restorative Rx • Periodontics & restorative Rx • Orthognathic surgery • orthognathic surgery with /without other dental Rx.
- 37. SMILE IS A FREE THERAPY DON’T HIDE IT Thank you Instagram @dr.diana.mostafa
- 38. Dr. Diana Mostafa • Periodontist in Private Reval Clinics, Riyadh, KSA. • Demonstrator and academic periodontist in faculty of dentistry, Alexandria University, Egypt. • Previous lecturer & course director of periodontology courses, Vision Colleges, Riyadh, KSA. • Main and corresponding author in many international journals • Editor in Pan African journal. • Peer reviewer in SCOUPS and PUBMED journals. Instagram @dr.diana.mostafa
- 40. Gingivectomy + Botox injections
- 41. Myectomy using spacer + crown lengthening with bone reduction + veneers
- 42. Crown lengthening + restorative Rx
- 43. Orthodontic Rx + gingivectomy + Restorative RX
- 44. Gingivectomy + Botox + lip filler
- 46. Gingivectomy + Restorative treatment
- 47. Gingivectomy+ orthodontic Rx + veneers + lip filler
Editor's Notes
- At the beginning, the face height should be measured; the length of the middle third of the face should equal the lower third of the face. The mid-face is measured from the glabella, the most prominent point of the forehead between the eyebrows, to subnasale, the point below the nose. The lower third of the face is measured from the subnasale to the lower boarder of the chin.( ) these measurements help in recognizing the etiology if it is skeletal or not. Next , the length and activity of the upper lip must be evaluated; the average maxillary lip length at rest (from subnasale to the most inferior portion of the upper lip at the midline ) is about 23mm in males and 20mm in females and the average maxillary incisor display of 1.91 mm in men and 3.40mm in women.(10, 23) If the maxillary lip measurement is shorter than the norms, a diagnosis of short lip can be diagnosed. While , the amount of translation of the maxillary lip from the rest position to that seen during a dynamic smile is the key to identifying whether the patient has hyperactivity lip muscles or not. (14)
- Chu gauge
- Slow ortho. Extrusion ………eruption of tooth slowely bringing the alv. Bone anf g. tissue with it Rapid ortho. Extrustion …..prevent bone and G> to follow the tooth.
- Advantages Adequate contouring and controls hemorrhage. Disadvantages Contraindicated for incompatible or poorly shielded cardiac pacemakers. Unpleasant odor. If it touches the bone, irreparable damage can be occur.
- In Type I, there is an excessive amount of keratinized gingiva and the MGJ apical to the alveolar crest. A and B depending on the relationship of the osseous crest to the CEJ of the tooth. In type IA, the dimension between the osseous crest and the CEJ is more than 1 mm. Therefore, adequate connective tissue attachment component in the biologic width, which make a simple Gingivectomy the best treatment to remove the excess gingiva. While in Type II B, the osseous crest is in close proximity to the CEJ, so adequate space for the connective tissue attachment component of the biologic width. Therefore, a crown lengthening procedure with bone reduction to move the crestal bone apically will be necessary to provide stable results. In contrast to Type II, there is no excessive amount of keratinized gingiva but MGJ is near to CEJ. Treatment requires apical positioned flap with or without osseous reduction to provide more ideal esthetics.(20,21)
- This spacer is placed with nasal approach between the elevator muscles of the lip and the anterior nasal spine, thus preventing the superior displacement of the repositioned lip. Lip repositioning has also been performed in conjunction with rhinoplasty.[26]
- Treatment strategy of gummy smile Type 1. There is an important lack of structural support that, besides a gummy smile, causes a drop of the tip of the nose Upper image: The recommended strategy is 0.6 mL/per side of high-density hyaluronic acid (HA) filler (RHA4®, Teoxane, Geneve, Switzerland) administered by means fanning retrograde technique with a blunt microcannula. In this case it would be necessary to inject an additional bolus (blue ellipse) of 1 mL–2 mL of HA 23 mg/mL. Lower image: The recommended strategy is 0.6 ml/per side of high-density hyaluronic acid (HA) filler (RHA4®, Teoxane, Geneve, Switzerland) administered by means fanning retrograde technique with a blunt microcannula. Additionally, small boluses (blue ellipses) 0.4 mL–0.6 mL de HA 23 mg/mL at the end of each fanning retrograde administration upon reaching the central region of the white lip and circumscribed to the edges of the insertion of the nasal wings. a Frontal view. b lateral view