International Journal of Dental and Health Sciences

Review Article Volume 04,Issue 05

GUMMY SMILE AND ITS MANAGEMENT

Amit Ahirwal1, Shruti Mehta2, Varun Kumar3, Praveen Kumar Singh4,Swapnil Sachan5, Saurabh
Gupta6
1.M.D.S, Oral And Maxillofacial Surgeon, M.J Hospital Bhopal, M.P.
2.M.D.S, Oral And Maxillofacial Surgeon, New Delhi
3.M.D.S, Oral And Maxillofacial Surgeon, CEO S.P Dental and Maxillofacial Trauma centre, Jammu, J & K.
4.M.D.S, Oral And Maxillofacial Surgeon, Gorakhpur,U.P.
[Link] Student, DJ College of Dental Sciences, Modinagar,U.P.
[Link] Student, Government Dental College Indore, M.P.

ABSTRACT:
Gummy Smile is a condition in which there is overexposure of the maxillary gingiva during smiling. It
can be a source of embarrassment for some patients. It occurs because of various intraoral and
extra-oral etiologies. The proper diagnosis and determination of its etiology are essential for the
selection of the right treatment modality. This article gives a detailed information about the
condition of gummy smile, various etiological factors which are responsible for the condition and the
various treatment modalities available such as Gingevectomy, Lip repositioning, Botox etc. which can
be used for the effective management and cure of this condition.
Key-words: Gummy smile, vertical maxillary excess, Crown Lengthening, Gingevectomy, Lip
Repositioning, Botox

INTRODUCTION

Smile can be described as a status of the orthodontic treatment is to improve

orofacial complex where muscles of the dental esthetics. The best
facial expression are harmonized. orthodontically treated subjects may not
Various muscles such as the frontalis, be satisfied by the treatment, if soft
orbicularis oculi, orbicularis oris, tissue problem is not corrected. Patient
zygomaticus major, risorius, platysma desire to look good not only in a static
and depressor anguli oris work in pose but also during dynamic facial
harmony to provide various facial expression.
expression.[1]
Excessive gingival display is a condition
The components of a smile can be in which there is an overexposure of the
evaluated according to different factors : maxillary gingiva during smiling.[7] The
gingival smile is also known as ―gummy
a. Anatomical components.[2,3] smile, high lip line, short upper lip, and
b. Smile lip line full denture smile. Gummy smile is
c. Dental smile lines.[4] defined as the exposure of excessive
d. Facial character.[5,6] gingival tissue in maxilla. Patients with
The smile along with speech, visibly excessive gingival display experience
displays the results of orthodontic dissatisfaction with their clinical
treatment.. The main reason people seek appearance. It can affect about 10.5% of

*Corresponding Author Address: Dr. Amit Ahirwal. E-mail: [Link]@[Link]

 Ahirwal A..et al, Int J Dent Health Sci 2017; 4(5):1239-1246
the population.[8] with a female 7. Hereditary pattern also play a role in
predominance (2:1).[9] A normal gingival etiology of gummy smile.
display between the inferior border of
the upper lip and the gingival margin of 8. Uneven balance between facial bones,
the anterior central incisors during a especially the Maxilla and Mandible.
normal smile is 1-3 mm.[10] An excessive
9. Particular childhood habits like thumb
gingivae-to-lip distance of 4 mm or more
sucking, tongue thrusting, pencil biting
is classified as unattractive.[11]
can heavily lead to unwanted,
ETIOLOGY OF GUMMY SMILE uncontrolled growth of the upper jaw
along with flaring of the upper front
Etiology of gummy smile can be Skeletal, teeth and resultant the fan shaped jaw
Gingival or Muscular .Various etiologies growth.
are :
Treatment options for correction of
[Link] upper lip which is measured from gummy smile range from Le fort I
sub nasal to inferior border of upper lip. osteotomy, crown lengthening,
The average length of maxillary lip is 20- gingivectomy, intrusion, myectomy ,
22 mm in young adult females and 22-24 muscle resection , Botox injection . The
mm in young adult males [11] . exact cause of gummy smile decides the
procedure which will be used to correct
2. Vertical maxillary excess. it. If the gummy smile is due to small
amount of excess gum tissue, a
[Link] upper lip which lead to
gingivectomy may be a better option. A
exposure of the dentition and undesired
Botox injection is best for when the
gingiva in a smile.
upper lip raises to an extreme degree
[Link] eruption of the during smile. Botox weakens the
maxillary teeth with concomitant coronal response of muscles to nerve signals, so
migration of the attachment apparatus, when you smile, your muscle response
which includes the gingival margins. will be less severe. Botox is indicated
when the gummy smile is due to hyper
5. Delayed eruption in which the gingiva functional upper lip elevator muscles.
fail to complete the apical migration over Muscles responsible for upper lip
the maxillary teeth to a position that is movement during smile are:[13]
1mm coronal to the cement-enamel
junctions.[12] 1. Levatorlabiisuperioris (LLS)
[Link]
6. Other causes include, Plaque-or drug- (LLSAN)
induced gingival enlargement, short [Link] major
clinical crown length or a combination of 4. Zygomaticus minor
multiple causes. 5. Depressor septii
MANAGEMENT OF GUMMY SMILE
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There are many methods for the plaque or drug induced, altered or
treatment of Gummy Smile. For the delayed passive eruption and short
correct management of gummy smile clinical crown length .The procedure
the etiology of the condition has to be involves moving the gingival margins
identified correctly. The following apically through soft resection.
treatment methods can be used for the
correction of gummy smile : Crown lengthening procedure is used to
increase the height of the clinical crowns
1. Orthognathic Surgery : In patients by removing part of the gingival tissue.
which present with excessive gingival Crestal bone can also be removed along
display due to anterior dentoalveolar with gingival tissue. The procedure
extrusion and vertical maxillary excess, designed according to the demand of the
Orthognathic surgery is the treatment of clinical crown height or the planned
choice. The orthognathic surgical prosthetic crown or veneer.[16] The
procedure which is performed to treat removal of gingival tissue is performed
such a condition is Lefort 1 maxillary using blades, lasers, or electrocautery.[17]
osteotomy surgery. In LeFort 1 maxillary This procedure may also require
osteotomy the maxillary bone is adjunctive procedures which may
osteotomized in the semi-horizontal include Odontoplasty, placing veneers,
plane to disengage it from the cephalic crowns, or even extraction, alveolar
end and the disengaged part can be bone reconstruction, orthodontic
moved into a more favorable position. treatment, and implant-based
The movement can be accomplished in rehabilitation.[18]

three dimensions as needed. The

procedure is mainly directed toward Aadvantages:[17,18]
reducing the maxillary excess by moving
1. It is done under local anesthesia
the maxilla in the superior direction.[14]
2. Less intraoperative bleeding occurs if
Aadvantages: It improves the shape of laser is used
the face and smile. 3. Better postoperative recovery.

Disadvantages:It requires hospitalization,

general anesthesia, requires prolonged Ddisadvantages: No major disadvantage
recovery time, postoperative but may sometimes require
complications such as swelling, pain, recountouring of gingival tissue.
midface paresthesia, difficulty eating,
3. Surgical Lip repositioning : Surgical
minor changes in nasal shape, and
procedures to correct Excessive gingival
general discomfort can occur [15].
Display include detachment of lip
2. Gingevectomy : This surgery can be muscles , myotomy and lip repositioning
performed in cases of gingival (LR) . The procedure includes removing a
enlargement which is caused due to strip of mucosa from the maxillary buccal
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vestibule and creating a partial thickness the inhibition of the exocytosis of
flap between the mucogingival junction acetylcholine which causes a
and the upper lip musculature. The lip neuromuscular blocking effect.
mucosa is then sutured to the muco- [21]Therapeutic doses of botox causes

gingival line, resulting in a narrower partial paralysis of the muscles.[20] The

vestibule and restricted muscle pull. This disadvantage of this technique is that it‘s
reduces the gummy smile.[19] not permanent and it needs frequent
application every several months . The
4. Botox : For the correction of gummy duration of treatment results with Botox
smile nonsurgical procedures which can is three to four months. Repeated
be performed include the use of treatments with Botox for lip
botulinum toxin A (botox). Botox is the stabilisation shows sustained results and
trade name for the neurotoxin protein a lowered required dose of Botox in
botulinum toxin type A. This protein is subsequent treatment episodes.
produced by fermentation of anaerobic
bacterium clostridium botulinum. Type A Procedure for injection: Botox is
toxin is one of the seven distinct injected into the hyperactive elevator
botulinum toxins produced by different muscles of lip and blocks excessive
strains of the bacterium.[21,22] It is a contractions and hence prevent the lip
sterile, vacuum-dried powder which is from being pulled too far up during
diluted with saline solution without smiling. Prior to injection, reconstitute
preservatives for it to be injected. The vacuum-dried BOTOX, with 0.9% Sodium
total "dose" of Botox in each vial is Chloride Injection.[13] Proper amount of
always 100 units but different amounts diluents are drawn in the appropriate
of saline solution can be used with each size syringe, and slowly injected into the
vial depending on the intended use.[13] vial. Administer this solution within four
hours after reconstitution. During this
Each vial of BOTOX contains : time period, reconstituted BOTOX should
be stored in a refrigerator (2° to 8°C).
a)100 Units (U) of Clostridium botulinum
Mario Polo has advocated injection of
type A neurotoxin complex,
botox at levatorlabiisuperioris,
b) 0.5 milligrams of Albumin Human levatorlabiisuperiorisalaequenasi ,
levatorlabiisuperioris / zygomaticus
c) 0.9 milligrams of sodium chloride in a minor overlap and in severe cases at
sterile, vacuum dried form without a depressor nasii & Orbicularis Oris also.
preservative.
The ideal dosage is 2.5 U per side at the
Mechanism of Action of Botox : It causes levatorlabiisuperioris &
muscle paralysis by inhibiting levatorlabiisuperiorisalaequenasi, 2.5 U per
acetylcholine release at the side at the levatorlabiisuperioris /
neuromuscular junction. This results in

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zygomaticus minor sites, and 1.25 U per 5. Infection
side at the Orbicularis Oris sites.[13] 6. Redness
7. Swelling
Effect of Botox is seen within 5-10 days Advantages:
and it lasts about 6 months. It is
important not to give injections 1. This treatment takes less than a
prematurely (before the effects of the minute to perform, is a relatively
treatment have worn off), as this can painless and predictable procedure.
result in a buildup of antibodies to Botox
that would dilute the effect of further 2. Psychological benefit to the patient
treatments.
3. Minimally invasive
Contraindications :
Disadvantages:[23]
1. Presence of inflammation or
1. Short term effect
infection at the site of proposed
injection [Link] or unnatural appearance
2. During pregnancy or breast feeding. of smile sometimes due to improper
3. Known hypersensitivity or allergies to injection technique
human albumin, Botox toxin, or
saline solution. 3. Cost factor
4. Anyone taking Aminoglycoside
CONCLUSION:
antibiotics because aminoglycosides
may interfere with neuromuscular Smile of a person is an important
transmission and potentiate the aesthetic feature and in current modern
effect of Botox therapy society a pleasing smile directly have an
5. Anyone with known motor impact on the personality of a person.
neuropathy, neuromuscular Gummy Smile is very unpleasing
disorders such as amyotrophic lateral aesthetic condition and have a
sclerosis, myasthenia gravis, psychological effect on the patient and
Lambert-Eaton Syndrome, muscular can lower their self confidence.
dystrophy, multiple sclerosis. Correction of this condition is very
6. Anyone taking Calcium Channel important for the overall pleasing
Blockers. appearance of any person. Correct
etiology for gummy smile should be
identified and should be managed
Side effects :
accordingly from the available options of
1. Nausea treatment which is best suitable for the
2. Inflammation patient.
3. Tenderness
4. Localized pain.
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FIGURES :

Fig.1 Normal gingival display during Fig.2 Exessive gingival display

during smile
smile

Fig. 4 Marking of incision for

Fig. 3 Gingevectomy procedure surgical lip repositioning

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Fig. 5 Exposed submucosa after

removal of epithelial discard

Fig. 6 Botulinum Toxin vial

Fig.7 Sites for botox injection

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