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Year : 2019  |  Volume : 7  |  Issue : 2  |  Page : 38-43

Interdisciplinary management of a patient with a gummy smile

Department of Prosthodontics, Faculty of Dentistry, Alexandria University, Alexandria, Egypt

Date of Web Publication1-Oct-2019

Correspondence Address:
Aly Ahmed Abdelrehim
Faculty of Dentistry, Champolion Street, Azarita, Alexandria University, Alexandria
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jomr.jomr_13_19

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This article describes the novel use of cone-beam computed tomography (CBCT) to predictably plan a crown-lengthening procedure without osseous contouring. The method aimed to achieve maximum incisal tooth reduction while avoiding endodontic treatment as a method for conservative management of a patient with excessive gingival display. Managing the case involved performing gingivoplasty without osseous recontouring. Prosthetic reconstruction was also performed to replace the missing canines and adjust the incorrect position of the maxillary incisors. A CBCT was used to precisely locate the alveolar bone level and pulp chamber level to avoid the risk of pulp exposure during tooth preparation. Laser was used to perform gingivoplasty. Computer-aided design/Computer-aided manufacturing technology was used to construct all-ceramic restorations making the use of smile design and virtual articulator features in the software. The patient's excessive gingival display was conservatively treated without osseous surgery or root canal treatment. Six monthly checks were performed for 5 years to check pulp vitality, and all teeth responded normally to vitality tests. The patient expressed great satisfaction with the result with minimal postoperative pain. With careful preoperative planning and novel use of CBCT, esthetic, and conservative treatment of excessive gingival display was made possible, while avoiding osseous resective surgery and root canal treatment. This made the treatment prompt with little need for a recovery period, more appealing to the patient, and longevity of treatment was ensured.

Keywords: Computer-aided design/computer-aided manufacturing, cone-beam computed tomography, gingival display, gummy smile, laser

How to cite this article:
Khamis MM, Abdelrehim AA. Interdisciplinary management of a patient with a gummy smile. J Oral Maxillofac Radiol 2019;7:38-43

How to cite this URL:
Khamis MM, Abdelrehim AA. Interdisciplinary management of a patient with a gummy smile. J Oral Maxillofac Radiol [serial online] 2019 [cited 2023 Mar 22];7:38-43. Available from: https://www.joomr.org/text.asp?2019/7/2/38/268235

  Introduction Top

Although various studies differ in the esthetically acceptable amount of gingival display showing during smiling, the term “gummy smile” is usually used when more than 3 mm of gingivae is visible over the maxillary teeth during smiling.[1],[2] Many causes have been reported for gummy smiles include:[3] increased vertical dimension of the midface, excessive apical movement of the upper lip, and maxillary teeth over eruption or delayed eruption of teeth.[3],[4],[5],[6] When soft-tissue modification is planned, the balance between three fundamental smile components must be achieved: (a) the lip framework, (b) gingival scaffold, and (c) the teeth[7] [Figure 1]. During smiling, normal maxillary incisors display is 38.9% of the total distance shared between the lips and the incisors, while smiling the upper lip contributes to 60.9% of the smile.[8] Kois[9] stated that to properly perform an esthetic and stable gingival recontouring, two biological factors are essential: the location of the base of the sulcus to properly predict termination of the tooth preparation and the location of the osseous crest to preserve the biological width.
Figure 1: Frontal view displaying ratio of (a) lip to (b) gingiva to (c) teeth before treatment

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Common treatments include surgery to the upper lip, injection of botulinum toxin,[10] orthodontic intrusion of the teeth,[11] esthetic-crown lengthening using standard gingivoplasty, or apically repositioned flap with or without osseous contouring.[12] There has been a controversy around the effects of osseous resective surgery and its effect on the periodontium,[13] and other treatments options are invasive or extensive in duration.

When the incisal level is in the correct position, only crown lengthening will suffice to correct the gingival display to treat gummy smile. However, if its position is incorrect, tooth restorations must be fabricated. Therefore, to properly establish a correct and stable line of treatment, the level of the pulpal tissue, osseous crest, and level of the incisal edge must be precisely evaluated.[14] This case report introduces additional preparatory steps that ensure no requirement for osseous resection or root canal treatment to deliver an efficient and noninvasive gummy smile treatment.

  Case Report Top

A healthy, 25-year-old female patient presented with bilaterally missing upper canine teeth, significant protrusion together with downward displacement of the maxillary incisor teeth that were spaced and malformed, as well as an unesthetic gummy smile [Figure 1] and [Figure 2]. A previous attempt was made to correct the condition orthodontically that proved unsatisfactory for the patient. Orthognathic surgery was also rejected by the patient due to concerns of general anesthesia and an extensive healing; the patient requested a conservative and rapid approach.
Figure 2: Profile view of the patient before treatment

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The treatment of choice was to start with gingivoplasty to the upper anterior segment removing as much of the gingiva as possible. The treatment aimed to avoid removing any of the alveolar bone so not to compromise the crown-to-root ratio of the maxillary anterior teeth. To correct the downward and outward displacement of maxillary anterior teeth, crown restoration of the teeth was to be carried out postgingivoplasty. The challenges associated with this line of treatment were as follows: first, to properly locate the level of the alveolar bone clinically; second, to estimate the maximum amount of tooth reduction that would not end up with an anterior open bite and at the same time without needing to perform endodontic treatment to the prepared teeth. The main goal was to be as conservative as possible.

Treatment started by constructing study casts as well as a cone-beam computed tomography (CBCT). The patient's CBCT was used to estimate the level of the alveolar bone corresponding to each tooth. On a sagittal cut made at the midline of each tooth, the distance between the tip of the incisal edge of the tooth and the crest of the alveolar bone was measured [Figure 3]. Using the same measurement, a caliper was used in the patient's mouth to determine the bone position on the labial surface of the gingiva corresponding to every tooth [Figure 4]. To avoid violating the biological width, gingivoplasty was executed 2 mm less than the measurements made on the CBCT. A bleeding point was placed on the gingiva and demarking the proper level for gingivoplasty for the four anterior teeth and first premolars bilaterally. Gingivoplasty was performed using an erbium chromium yttrium scandium gallium garnet type of laser (Waterlase, Biolase, Irvine, CA, USA) [Figure 5] and [Figure 6]. A sapphire tip (MGG6-9 mm in length) was used at settings of 2.5W, 25 Hz, H-mode, together with 30% water and 20% air. The tip was moved slowly in a horizontal direction and in a noncontact mode to produce a definite smooth cut creating a scalloped gingival contour keeping the gingival zeniths in a proper level. It was also directed at a 45° angle to the surface of the gingiva from an apical to coronal direction to create a finely beveled gingival margin. The gingiva was left to heal for 10 days.
Figure 3: The use of cone-beam computed tomography to locate the bone level

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Figure 4: The use of a caliper accurately to transfer the measurements intraorally

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Figure 5: The use of Er Cr: YSGG Laser to delineate the level of gingivoplasty

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Figure 6: The use of Er Cr: YSGG Laser to perform gingivoplasty

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To evaluate the amount of tooth reduction for the four anterior teeth, two factors were considered: the amount of overbite and the level of the pulp chamber of each tooth. To measure the amount of overbite, the study casts were used. While the upper and lower models were in occlusion, a line was drawn on the labial surface of the lower anterior teeth, tracing the incisal edge of the upper anterior teeth [Figure 7] and [Figure 8]. The distance between the incisal edge of the lower anterior teeth and the drawn line was measured; 1 mm was subtracted from this measurement for each tooth. This represented the proper position of the future incisal edge of the upper anterior teeth. The 1-mm deduction was to keep a slight vertical overlap for esthetic and phonetic purposes.
Figure 7: Study casts in occlusion to assess and measure the amount of overbite

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Figure 8: Pencil line drawn on lower incisors corresponding to maximum overbite

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To avoid pulp exposure during tooth reduction, the distance between the incisal edge of the maxillary anterior teeth and the pulp chamber was measured reusing the CBCT. On the same sagittal cut made in the middle of the mesiodistal dimension, a line was drawn from the tip of the incisal edge to the roof of the pulp chamber for each maxillary anterior tooth. A perpendicular line was then drawn from the roof of the pulp chamber to the labial surface forming a right-angled triangle. Using the Pythagoras' theorem, the hypotenuse (lying on the labial surface) was calculated [Figure 9]. This measurement was transferred to the patient's mouth, accurately indicating the position of the pulp chamber; 1 mm was then subtracted to follow common practice to preserve the dentine incisal to the pulp ensuring longevity of vitality.
Figure 9: The use of Pythagoras' theorem on the cone-beam computed tomography to accurately locate the pulp chamber in relation to the labial surface

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The amount of incisal tooth reduction in the maxillary anterior teeth was defined by the measurements of the amount of vertical overlap together with the level of the pulp chamber. In the patient's mouth, a caliper was used to mark the amount of incisal tooth reduction; a line was drawn on the labial surface of the maxillary anterior teeth with an indelible pencil to provide a guide during tooth preparation. The prepared teeth included the four maxillary incisors and first premolars bilaterally, and an optical impression was made immediately after tooth preparation. The CEREC system (Sirona Dental Systems GmbH, Bensheim, Germany) with 4.2 software was used for that purpose. Two bilaterally fixed partial dentures were constructed chair side to restore the missing canines. The two central incisors were constructed separately and un-splinted to the fixed partial dentures. Lithium disilicate (IPS e.max computer-aided design [CAD], Ivoclar Vivadent AG, Schaan, Liechtenstein) was used to construct the restorations. The occlusal plane orientation, midline position and teeth design, and contour were produced guided by the smile design feature in the software [Figure 10]. The patients' picture while smiling was superimposed over the virtual casts of the prepared teeth so that the smile design was more predictably formulated. The patient was allowed to visualize the smile design and approve it before the restorations were milled. The virtual articulator feature was also used to check and modify occlusal contacts in the different excursive movements to avoid excessive forces on the all-ceramic restorations. The restorations were milled, tried in the patient mouth, then crystallized, and glazed. They were then cemented.
Figure 10: Smile design feature on CEREC software

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The patient was recalled back every 6 months for 5 years to check gingival contour and pulp vitality. Gingival contour height was measured using a caliper from the middle of the incisal edge to the gingival margin on the centrals, laterals, and first premolars on each side. A thermal test was performed for the four anterior incisors, and first premolars. No significant gingival margin changes were noted, and all the teeth responded normally to pulp vitality. [Figure 11], [Figure 12], [Figure 13] show the final restorations after they were delivered to the patient.
Figure 11: Intraoral view after treatment

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Figure 12: Occlusal view after treatment

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Figure 13: Frontal view after treatment

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  Discussion Top

The challenge presented with this patient was the demand for a rapid solution to the problem without resorting to any elective tissue cutting such as bone removal (osseous crown lengthening) or root canal treatment. The current technology was therefore utilized to properly plan a conservative approach. The models in occlusion provided a measure of the overbite and the amount of possible occlusal reduction. Using the CBCT, an exact measurement was made to determine the position of bone to avoid osseous recontouring. The 2-mm supracrestal and a proper healing period allowed for recovery of the periodontium and creation of a new supracrestal gingival complex.[15] The idea behind using the Pythagoras' theorem to determine the amount of incisal reduction was that the direct distance from the incisal edge to the pulpal roof was in fact different from the distance on the labial surface. For this reason, the position of the pulp was needed to be determined in relation to the labial surface to give the operator a reference while reducing the anterior teeth. This allowed for maximum reduction of the anterior teeth without pulpal exposure. According to many studies,[16],[17],[18] the pulp vitality of teeth prepared for receiving a full coverage crown is greatly affected. Cutting dentine makes it more permeable and disturbs the microcirculation. Therefore, the level of pulp needed to be accurately determined. Using this line of treatment, the patient received a fast and conservative solution; the excessive gingival display was reduced with accurate measurements. The amount of gingival display was reduced by 5 mm [Figure 14], and the missing canines and occlusal displacement of the anterior teeth have been corrected with fixed partial dentures constructed using CAD/computer-aided manufacturing technology. The outcome of this treatment left the patient with a proper gingival display, and a good looking smile was restored.
Figure 14: The decreased ratio of gingival display (b) in relation to lips (a) and teeth (c)

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Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

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Bhola M, Fairbairn PJ, Kolhatkar S, Chu SJ, Morris T, de Campos M. LipStaT: The lip stabilization technique – Indications and guidelines for case selection and classification of excessive gingival display. Int J Periodontics Restorative Dent 2015;35:549-59.  Back to cited text no. 3
Silva CO, Ribeiro-Júnior NV, Campos TV, Rodrigues JG, Tatakis DN. Excessive gingival display: Treatment by a modified lip repositioning technique. J Clin Periodontol 2013;40:260-5.  Back to cited text no. 4
Chandrasekharan D, Balaji SM. Intrusion of anterior teeth to improve smile esthetics. J Maxillofac Oral Surg 2010;9:27-9.  Back to cited text no. 5
Maynard JG Jr., Wilson RD. Physiologic dimensions of the periodontium significant to the restorative dentist. J Periodontol 1979;50:170-4.  Back to cited text no. 6
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Kois JC. Altering gingival levels: The restorative connection part I: Biologic variables. J Esthet Restor Dent 1994;6:3-7.  Back to cited text no. 9
Silva CO, Ribeiro-Júnior NV, Campos TV, Rodrigues JG, Tatakis DN. Excessive gingival display: Treatment by a modified lip repositioning technique. J Clin Periodontol 2013;40:260-5.  Back to cited text no. 10
Chandrasekharan D, Balaji SM. Intrusion of anterior teeth to improve smile esthetics. J Maxillofac Oral Surg 2010;9:27-9.  Back to cited text no. 11
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Selipsky H. Osseous surgery – How much need we compromise? Dent Clin North Am 1976;20:79-106.  Back to cited text no. 13
Arias DM, Trushkowsky RD, Brea LM, David SB. Treatment of the patient with gummy smile in conjunction with digital smile approach. Dent Clin North Am 2015;59:703-16.  Back to cited text no. 14
Lanning SK, Waldrop TC, Gunsolley JC, Maynard JG. Surgical crown lengthening: Evaluation of the biological width. J Periodontol 2003;74:468-74.  Back to cited text no. 15
Zach L. Pulp lability and repair; effect of restorative procedures. Oral Surg Oral Med Oral Pathol 1972;33:111-21.  Back to cited text no. 16
Pashley DH. Clinical considerations of microleakage. J Endod 1990;16:70-7.  Back to cited text no. 17
Whitworth JM, Walls AW, Wassell RW. Crowns and extra-coronal restorations: Endodontic considerations: The pulp, the root-treated tooth and the crown. Br Dent J 2002;192:315-20, 323-7.  Back to cited text no. 18


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14]

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