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Differential diagnosis and management of gummy smile

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gummy smile

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  • Hi doc. Can you send this ppt to me to be used for academic purpose only. I am Vamsi Lavu, Associate professor in Periodontics, Sri Ramachandra dental College, Chennai. My mail id is vamsilavu@rediffmail.com
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Differential diagnosis and management of gummy smile

  1. 1. GUMMY SMILE:GUMMY SMILE: Differential diagnosisDifferential diagnosis and Management .and Management . Dr. ABHILASHA GOYAL PG STUDENT
  2. 2. LEARNING OBJECTIVES
  3. 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. 4. 3 primary factors affecting a smile
  5. 5. COMPONENTS OF BALANCED SMILE
  6. 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. 7. At smiling Over exposure seen in repose of lips
  8. 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. 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. 10. FACIAL EXAMINATION 1.Facial symmetry and proportions in both frontal and lateral views:
  11. 11. 2. Upper lip length at rest
  12. 12. 3. Display of maxillary central incisors at rest
  13. 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. 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. 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. 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;
  17. 17. INTRAORAL EXAMINATION
  18. 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. 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. 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. 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.
  22. 22. DIFFERENTIAL DIAGNOSIS AND MANAGEMENT
  23. 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. 24. ALTERED / DELAYED PASSIVE ERUPTION
  25. 25. Normal anatomy
  26. 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. 27. Clinical diagnosis of altered passive eruption
  28. 28. MANAGEMENT
  29. 29. GINGIVECTOMY
  30. 30. APICALLY POSITIONED FLAP WITH OSTEOTOMY
  31. 31. 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
  32. 32. Management Diagnosis and treatment planning of excessive gingival display - Review JIOS 2006Diagnosis and treatment planning of excessive gingival display - Review JIOS 2006
  33. 33. 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
  34. 34. MANAGEMENT
  35. 35. Commonly used : • Objective :  To decrease the amount of lip elevation on smiling Lowering the height of gingivolabial sulcus
  36. 36. Lip repositioning technique
  37. 37. • 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
  38. 38. Injection of Botox to reduce excessive gingival display on smiling
  39. 39. • 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)
  40. 40. • 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.
  41. 41. 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
  42. 42. MANAGEMENT Excessive gingival display— Etiology, diagnosis, and treatment modalities Nir Silberberg, Moshe Goldstein,Smidt, QUINTESSENCE INTERNATIONAL 4; 10; 2009
  43. 43. SHORT CLINICAL CROWN
  44. 44. MANAGEMENT
  45. 45. 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
  46. 46. MANAGEMENT
  47. 47. Orthodontic intrusion • Burstones one piece intrusion arch Anterior dentoalveolar extrusion Should be used in association with High Pull Headgear or TPA
  48. 48. 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.
  49. 49. LOSS OF TORQUE OR PALATALLY TIPPED MAXILLARY INCISORS MANAGEMENT : If iatrogenic – incorporation of torque in the wire
  50. 50. VERTICAL MAXILLARY EXCESS
  51. 51. Facial evaluation
  52. 52. Intraoral examination • Constricted maxillary arch– may result in crossbite • Frequently anterior openbite • Flat or accentuated curve of spee • Crowding
  53. 53. 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
  54. 54. MANAGEMENT
  55. 55. MANAGEMENT
  56. 56. 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
  57. 57. 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.
  58. 58. Case of gummy smile due to VME treated with orthognathic surgery
  59. 59.
  60. 60. ROTATION OF MAXILLA
  61. 61. 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.
  62. 62. Step 1: • Assessment of the upper lip to the incisal edgeof the maxillary incisors At Rest: • Normal display : 3-4mm
  63. 63. Normal incisal display at rest, but there is a Gummy smile?? • Gummy smile is either due to :
  64. 64. If incisor display at rest is more than 3-4mm ?? • Possible causes are :
  65. 65. 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
  66. 66. 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
  67. 67. 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.
  68. 68. 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
  69. 69. See what you know – know what you see THANK YOU

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