Differential diagnosis and management of gummy smile
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Differential diagnosis and management of gummy smile
- 1. GUMMY SMILE:GUMMY SMILE: Differential diagnosisDifferential diagnosis and Management .and Management . Dr. ABHILASHA GOYAL PG STUDENT
- 3. Introduction • The smile has an important role in the determination of the first impression of a person. • The evaluation of smile has become an important part of our clinical assessment with a greater emphasis on dynamic evaluation. • Frontal examination is gaining its due importance.
- 4. 3 primary factors affecting a smile
- 5. COMPONENTS OF BALANCED SMILE
- 6. DEFINITION Matthews TG. The anatomy of a smile. J Prosthet Dent 39: 128- 134, 1978Matthews TG. The anatomy of a smile. J Prosthet Dent 39: 128- 134, 1978
- 7. At smiling Over exposure seen in repose of lips
- 8. PREVALANCE • 7% of young adult males • 14% of young adult females • Peck et al , 1992 : 26% of a sample of orthodontic patients displayed 2 mm or more of maxillary gingiva when smiling . Diamond O . Facial esthetics and orthodontics , J Esthet Dent,1996
- 9. DIAGNOSIS Excessive gingival display / Gummy smile is a descriptive term rather than a diagnosis, which would mandate the initiation of a specific therapy. Numerous factors Interplay of several etiologies
- 10. FACIAL EXAMINATION 1.Facial symmetry and proportions in both frontal and lateral views:
- 11. 2. Upper lip length at rest
- 12. 3. Display of maxillary central incisors at rest
- 13. 4. Amount of gingival exposure • During a full smile , the upper lip should move to the tooth- gingiva interface on the maxillary central incisors and canines. • Normal – 1-2mm • Most orthodontists and dentists prefer that the elevation of the lip for the posed smile stop at the gingival margins of the maxillary incisors.”
- 14. Smile line • It is the position of the upper lip relative to the maxillary incisors and gingiva during a natural full smile. Tjan AH et al
- 15. 5. Gingival margin outline The gingival margins of the maxillary central incisors and the canines should be symmetric and in a more apical position than those of the lateral incisors. Chiche and Pinault considered symmetry of the gingival margins at the midline (central incisors) to be essential, while more laterally a certain amount of asymmetry is permissible.
- 16. The effect of maturation and aging on the soft tissue of face : • Lengthening of the resting philtrum and commissural height. • Decrease in the turgor (tissue fleshiness) • Decrease in incisor display at rest • Decrease in incisor display during smiling • Decrease in gingival display during smiling Dynamic smile visualization and quantification : Smile analysis and treatment strategies . David M. Sarver, DMD, MS, and Marc B. Ackerman, AJODO 2003; Dynamic smile visualization and quantification : Smile analysis and treatment strategies . David M. Sarver, DMD, MS, and Marc B. Ackerman, AJODO 2003;
- 18. 1. Occlusal plane • The occlusal plane should closely coincide with the imaginary line connecting the commissures of the lips and two-thirds the height of the retromolar pad. • In this way, during a smile, there is mild exposure of the tips of the mandibular canines and premolars.
- 19. 2. Anatomy, proportions, and color of the teeth. • ANATOMY Peg laterals A comparison between the anatomic crown height will help determine whether short clinical crowns are a result of incisal wear or of a coronal position of the gingival margin over the teeth
- 20. Proportions • 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 .
- 21. 3. Periodontal examination. • The width and thickness of the keratinized attached gingiva must be measured, as well as probing depth, clinical attachment level, and crestal bone level with respect to the CEJ. • There are 3 periodontal biotypes: Thin and scalloped Normal Thick and flat • This information has a crucial influence on thetreatment strategies and decisions.
- 23. Periodontal Delayed passive eruption Gingival hyperplasia Soft tissue Morphologically short upper lip Hypermobile upper lip Dental Short clinical crown Anterior dentoalveolar extrusion Loss of torque on the anteriors Skeletal Vertical maxillary excess Rotations of maxilla Diagnosis and treatment planning of excessive gingival display - Review JIOS 2006Diagnosis and treatment planning of excessive gingival display - Review JIOS 2006
- 24. ALTERED / DELAYED PASSIVE ERUPTION
- 25. Normal anatomy
- 26. Classification ( coslet et al) Coslet JG, Vanarsdall R, Weisgold A. Diagnosis and classification of delayed passive eruption of the dentogingival junction in the adult. Alpha Omegan 1977;70:24–28.
- 27. Clinical diagnosis of altered passive eruption
- 29. MANAGEMENT
- 30. GINGIVECTOMY
- 31. APICALLY POSITIONED FLAP WITH OSTEOTOMY
- 32. MORPHOLOGICALLY SHORT UPPER LIP • Common cause . • The average lip length is measured from subnasale to most inferior portion of the upper lip in midline. • Normal upper lip length is about 23mm in males and 20mm in females. • Lip length should be roughly equal to commissure height. Diagnosis and treatment planning of excessive gingival display - Review JIOS 2006Diagnosis and treatment planning of excessive gingival display - Review JIOS 2006
- 34. Management Diagnosis and treatment planning of excessive gingival display - Review JIOS 2006Diagnosis and treatment planning of excessive gingival display - Review JIOS 2006
- 35. HYPERACTIVE UPPER LIP • At repose : 3-4mm of maxillary central incisors are displayed • At full smile : entire clinical crown (10-11mm) is exposed • Upper lip translates 6-8mm from repose to full smile • In a patient with hyperactive upper lip ,the lip may translate 1.5 to 2 times more than the normal distance
- 36. MANAGEMENT
- 37. Commonly used : • Objective : To decrease the amount of lip elevation on smiling Lowering the height of gingivolabial sulcus
- 39. • The procedure restricts the muscle pull of the elevator lip muscles by shortening the vestibule, thus reducing the gingival display while smiling Eliminating a Gummy Smile with Surgical Lip Repositioning. Simon, Rosenblatt, Dorfman, The Journal of Cosmetic Dentistry • Spring 2007 Eliminating a Gummy Smile with Surgical Lip Repositioning. Simon, Rosenblatt, Dorfman, The Journal of Cosmetic Dentistry • Spring 2007
- 41. Injection of Botox to reduce excessive gingival display on smiling
- 42. • When injected intramuscularly at therapeutic doses BTX-A produces partial chemical denervation of muscles, resulting in localized reduction in muscle activity. Botulinum toxin type A in the treatment of excessive gingival display. Mario Polo, AJODO 2005)Botulinum toxin type A in the treatment of excessive gingival display. Mario Polo, AJODO 2005)
- 43. • BTX-A injections (2.5 units in both right and left LLSAN and LLS, and Zm muscles) are given for the neuromuscular correction of excessive gingival display (gummy smile) caused by hyperfunctional upper lip elevator muscles . • It is effective and statistically superior to baseline smiles , although the effect is transitory.
- 44. PLAQUE-/DRUG-INDUCED GINGIVAL ENLARGEMENT • A condition in which the enlarged gingival tissues are covering the clinical crowns, creating an unesthetic appearance . • It is most often related to dental plaque and inflammation but can be associated with medication such as phenytoin, cyclosporine, and calcium channel blockers. Excessive gingival display— Etiology, diagnosis, and treatment modalities Nir Silberberg, Moshe Goldstein,Smidt, QUINTESSENCE INTERNATIONAL 4; 10; 2009
- 45. MANAGEMENT Excessive gingival display— Etiology, diagnosis, and treatment modalities Nir Silberberg, Moshe Goldstein,Smidt, QUINTESSENCE INTERNATIONAL 4; 10; 2009
- 48. MANAGEMENT
- 49. ANTERIOR DENTOALVEOLAR EXTRUSION • Overeruption of the maxillary incisors with their dentogingival complex leads to a more coronal position of the gingival margins and excessive gingival display. • This condition may be associated with tooth wear at the anterior region (compensatory incisor over eruption) or with anterior deep bite. • In cases with deep bite, there is usually a discrepancy in the occlusal plane between the anterior and posterior segments
- 50. MANAGEMENT
- 51. Orthodontic intrusion • Burstones one piece intrusion arch Anterior dentoalveolar extrusion Should be used in association with High Pull Headgear or TPA
- 52. Use of mini implants Orthodontic treatment of gummy smile by using mini-implants : Treatment of vertical growth of upper anterior dentoalveolar complex. Tae-Woo Kim, Benedito Viana Freitas.Dental Press J. Orthod. 2010. Orthodontic treatment of gummy smile by using mini-implants : Treatment of vertical growth of upper anterior dentoalveolar complex. Tae-Woo Kim, Benedito Viana Freitas.Dental Press J. Orthod. 2010.
- 53. LOSS OF TORQUE OR PALATALLY TIPPED MAXILLARY INCISORS MANAGEMENT : If iatrogenic – incorporation of torque in the wire
- 58. Intraoral examination • Constricted maxillary arch– may result in crossbite • Frequently anterior openbite • Flat or accentuated curve of spee • Crowding
- 59. CEPHALOMETRIC CHARACTERISTICS • Increased lower anterior face height. • Steep mandibular plane angle • Decreases palatal to occlusal plane angle • Increased anterior dentoalveolar height • Increase in ANS-Pr value • Maxillary incisor display >3mm at rest • Mostly skeletal Class II ; occasionally Class I
- 60. MANAGEMENT
- 61. MANAGEMENT
- 62. Superior and distal displacement of maxilla Clockwise rotation of palatal plane Reduction in SNA angle Relative intrusion of maxillary molars. High pull headgear with or without maxillary splint
- 63. Mandibular bite blocks with vertical pull chin cup • Vertical pull chin cup in association with cervical headgear , produces significant favorable skeletal and dental alterations by inhibiting maxillary molar eruption and descent of maxilla and redirecting mandibular growth in a more horizontal direction. It provides: 1. Decreased gonial angle 2. Redirection of condylar growth 3. Increased posterior height.
- 64. Case of gummy smile due to VME treated with orthognathic surgery
- 65. •
- 69. DIFFERENTIAL DIAGNOSIS IN A NUTSHELL • When planning a treatment for gummy smile the key is to diagnose the reason for excessive gingival margin to lip distance when the patient smiles.
- 70. Step 1: • Assessment of the upper lip to the incisal edgeof the maxillary incisors At Rest: • Normal display : 3-4mm
- 71. Normal incisal display at rest, but there is a Gummy smile?? • Gummy smile is either due to :
- 72. If incisor display at rest is more than 3-4mm ?? • Possible causes are :
- 73. Short upper lip vs Vertical maxillary excess & Over eruption of anterior maxillary dentoalveolar segment • Evaluation of lip length • Evaluation of lower anterior facial height cephalometrically: If normal : the problem is related to short upper lip If increased : the problem is due to VME
- 75. SUMMARY Excessive gingival display— Etiology, diagnosis, and treatment modalities Nir Silberberg, Moshe Goldstein,Smidt, QUINTESSENCE INTERNATIONAL 4; 10; 2009 Excessive gingival display— Etiology, diagnosis, and treatment modalities Nir Silberberg, Moshe Goldstein,Smidt, QUINTESSENCE INTERNATIONAL 4; 10; 2009
- 76. TAKE HOME MESSAGE ….. With increasing awareness, esthetics has become the major concern of people. Orthodontist play a major role in diagnosing gummy smile. An interdisciplinary approach is needed for management of gummy smiles to achieve stable results.
- 77. REFERENCES • Peck S, Peck L, Kataja M. The gingival smile line. Angle Orthod 1992;62:91–100 • 'Diagnosis and treatment planning of EXCESSIVE GINGIVAL display- A REVIEW‘.JIOS 2006 • J Williams Robbins. Differential diagnosis and treatment of excessive gingival display;Pract Periodont Aesthet Dent 1999;11(2). • Dynamic smile visualization and quantification : Smile analysis and treatment strategies . David M. Sarver, DMD, MS, and Marc B. Ackerman, AJODO 2003. • Excessive gingival display— Etiology, diagnosis, and treatment modalities Nir Silberberg, Moshe Goldstein,Smidt, QUINTESSENCE INTERNATIONAL 4; 10; 2009 • Arthur Dolt, J William Robbins.Altered Passive eruption:an etiology of short clinical crowns. QUINTESSENCE INTERNATIONAL 1997
- 78. See what you know – know what you see THANK YOU
Editor's Notes
- At the end the seminar learner should understand:
- FACIAL expressions and the smile are key components for non verbal communication Smile is more than a form of communication; it is kind of socialization and attraction. 3 just as the focus is shifting from static occlusion to dynamic occlusion , Frontal examination is gaining its due importance. Among the frontal features competence of lips increased incisal show and gummy smile have become the major concern off pateints
- 1. The lip line is the amount of tooth exposure during a smile or the height of the upper lip relative to the maxillary central incisors. 2 The smile arc is a hypothetical curved line drawn along the edges of the four maxillary incisors that has to coincide or run parallel with the curvature of the inner border of the lower lip. Ideally, the clinical crowns of the maxillary incisors are displayed between the upper and lower lips. Consonant and non consonant 3 The upper lip curvature is the curve direction from the central position to the corner of the mouth upon smiling. It is a muscle-driven position and can be upward, straight or downward. 4 The lateral negative space is the area between the buccal outline of the maxillary posterior teeth and the corners of the mouth in wide smiling. If present – expansion.considered uesthetic by orthodontist 5 Smile symmetry refers to the relative symmetric placement of the corners of the mouth in the vertical plane. It is the coincidenceof commissural and pupillary lines for example. 6 The occlusal line is the line running from the tip of one canine to the other. From a distance, the occlusal line is parallel to the commissural line. 7 The dental components of the smile relate to the size, shape, texture and colour of teeth, as well as their alignment, axial inclination, dental midline symmetry and arch form. 8 The gingival components relate to the colour, contour, texture and height of the gingiva.
- When analyzing a smile, one must bear in mind that a certain amount of gingival exposure during a smile is considered esthetically pleasing, which gives the expression of a youthful look
- Incidence of this condition gradually decreases with age as a consequence of dropping of the upper and lower lips which in turn leadds to a decrease in the exposure of the maxillary incisors and an increase in exposure of the mand. Incisors.
- While numerous factors may cause EGD, it is common for the condition to occur as a result of interplay of several etiologies. For these reasons it is essential thar a DD should be formulated.
- For correct diagnosis a thorough examn shud be performed. Accessory horizontal lines are the ophriac line (a line going through the eyebrows) and the commissural line. These lines should be parallel to the interpupillary line, thus creating an overall harmony of the face. A line perpendicular to the interpupillary line should divide the face into 2 symmetrical parts. Face height is usually analyzed by dividing the face into thirds. The middle and lower thirds are more involved in the esthetic consideration of the patient. When measured in repose, these two thirds should be equal. The lower third can br further divided by the stomion into upper one-third and lower twothirds
- Tends to decrease with age as a consequence of dropping of the upper and lower lips which in turn leadds to a decrease in the exposure of the maxillary incisors and an increase in exposure of the mand. Incisors.
- 1-2mm is also considered normal.. When analyzing a smile, one must bear in mind that a certain amount of gingival exposure during a smile is considered esthetically pleasing, which gives the expression of a youthful look If the upper lip exposes more than 2mm of gingiva then the EGD poses and esthetic compromise
- In patients with excessive gingival display, any irregularities and disharmony in the alignment of the gingival margin may have a significant effect on smile esthetics.
- Passive eruption and thinning of lip..flaccidity So we sould plan our tt keeping in mind the aging process ..if we bring normal incisal exposure in adlo then maybe after 10-15 yrs he/she will have a low smile line- givn a older appearance.
- Lombardi pointed out the importance of the proportions between width and length in the dimensions of individual teeth. Anatomic (incisal edge to cementoenamel junction [CEJ]) and the clinical crown height (incisal edge to free gingival margin)
- 1. Active eruption is the occlusal movement of the tooth as it emerges from its crypt in the gingiva. This phase ends when the tooth makes contact with the opposing toooth in the oral cavity .
- The distance from alveolar crest to gingival crest is 3mm which includes 1mm for sulcus depth 1mm for epithelial attachment and 1mm for connective tissue
- This condition may involve multiple teeth or an isolated tooth. The incidence of altered passive eruption in the general population is about 12%.
- Bone sounding- give LA –locate cej ..push the probe apically till it contacts the alveolar crest - measure
- IT IS the goal of the crown lengthening procedure to expose virtually all of the anatomic crown.
- Crown lengthening
- In V-Y cheiloplasty, an incision is made in the anterior maxilla in the vestibule, with a vertical incision behind the philtrum.Mattress sutures are then used to close these incisions, resulting in a vertical scar closure, and reorientation of the muscles to reduce the mobility of the upper lip on smile
- IF THE FACE HEIGHT gingival levels lip length length of the central incisors are all within the acceptable limits in a patient with EGD the likely DD is hyperactive upper lip. In full smile the maxillary lip moves to the tooth gingiva interface on the central incisors and canines. The incisal edges of the max. anterior teeth should parallel the mandibular lip – consonant smile. The gingival level of lateral shouls be a lil lower than centrals and canines. According to the study of Peck et al, individuals with excessive gingival display present significantly more efficient lip-elevation musculature compared to those with average smile lines.
- The mean gingival exposure reduction was 5.2 mm. Gingival display gradually increased from 2 weeks postinjection through 24 weeks, but, at 24 weeks, average gingival display still had not returned to baseline values.
- Phenytoin – anticonvulsants- epilepsy Cc blockers- Cyclosporine- immunosuppressant- Of all cases of DIGO, about 50% are attributed to phenytoin, 30% to cyclosporins and the remaining 10-20% to calcium channel blockers.
- A short clinical crown can lead to an increased gingival display. Average vertical height of maxillary incisor is 1 O.6mm in males and 9.8mm in females. A short clinical crOwn can be due to the attritio n, partial eruption o r excessive gingival encroachment
- Phtos shown ant. Dentoalveolar extrusion.. Burstones one piece utility arch is used to intrudes the centrals laterals…but this shoud be used in associatn with a hugh pull head gear or tpa to prevent the reciprocal forces on upper molars
- 1.6 x 6.0 mm mini-implant (Jeil Med. Co., Seoul, Korea) and NiTi closed coil spring to intrude and procline the retroclined extruded incisors. B) Intraoral photos of Case 1. C) Upper central incisors intruded and proclined as one-piece intrusion arch made with 0.019 x 0.025-in stainless steel box wire was used to prevent impingement of gingival tissue.
- Iatrogenic gummy smile Careful monitoring of the vertical parameters and sound knowledge o f biomechanics is essential to avoid the clinical situation
- Many times, it appears with a long-face syndrome.
- It provides If maxillary transverse discrepancy exists – best way is to use rapid palatal expansion along with full posterior occlusal coverage for better vertical control This also prevents undesirable buccal tipping of the posteriors and overhanging of palatal cusps that further accentuates mandibular clockwise rotation. For retention posterior bite blocks are use
- Performing a maxillary impaction in cases wi th normal upper incisor to lip resting relationship leaves the resting incisor show at 0 to 1 mm, clearly makes the patient look o lder. Thinning of the vermillion border and worseningof the c urvature of the resting lip line also compromises facial esthet lcs.
- Inferior rotation as in altered head posture in airway impairment due to adenoids, patient has altered head posture to facilitate breathing tongue drops down mandible rotates downward… Function affects form