Gummy smiles are becoming an increasingly apparent problem for patients. Here Manrina Rhode discusses treatment options available.
Almost once a week someone contacts me to discuss reduction of a gummy smile. There is a large demand for it, once patients are aware this is something you can help with.
When analysing a gummy smile there are several factors to consider.
Is it a gummy smile?
In my experience normal gingival display is between 0-3mm. When the patient covers their teeth when they smile, I constitute it as a low smile line. If they have more than 3mm gingival display then this is a high smile line.
I note smile lines for all my patients at the new patient consultation in records.
Ask the patient to smile and measure gingival display on one particular tooth and note this down, stating which tooth. It is standard practice to measure from the zenith (the highest point of the gum) on one of the central incisors, to the lip smile line.
Also note that when you ask a patient to smile they may give you their ‘photo smile’. It’s good to try and make them laugh in conversation and note while they laugh where their lip lifts to.
You will need to recreate this maximum smile when measuring.
Is it gummy because of teeth size, hypermobile lip, long maxilla or a combination?
The average length of a central incisor is 11mm. I also routinely measure the length of central incisors and note these down at the new patient consultation in my records.
If the tooth length is, for example, 8mm and there is 4mm of gingival display, then you are aware that by lifting the gum by 3mm you will gain a more attractive sized tooth and solve the associated excessive gingival display.
Be aware that sometimes in these cases you need to lift gum on 8-10 upper teeth.
If tooth size is fine but just the lip is hypermobile, then this requires treatment of lip movement.
If there is an elongated maxilla, then consider surgical options.
Toxin injections and/or lip fillers
For most of these patients, the first treatment is toxin injections using your preferred toxin. For example Botox or Azzalure.
This prevents excessive lifting of the upper lip on smiling and would need repeating initially every four months. With recurrence the frequency required will decrease.
Patients also find some reduction of their gummy smile with lip filler, as the larger lip covers more of their gum.
Gingivectomy or surgical gum lift
If the patient has excessive gingival display and a shortened central incisor, then you may want to consider lengthening the tooth with a surgical gum lift.
It’s rare that a gingivectomy alone is enough. You need to use smile design principles to work out how much gum would need removing. Then check for biological width between bone and gum.
If there is more than 3mm space between bone and gum, then gum alone can be removed, gingivectomy. However, if this would invade biological width, then it’s important to complete a surgical gum lift removing gingiva and bone.
If completing a gum lift consider restorative options after. Will it expose root surface? How will this be covered? With bonding or veneers?
This will also need discussing with the patient and including in the treatment plan.
Also if gum has overgrown, then consider why this has happened. In my experience it’s usually because of an anterior grinding habit. That would also need controlling to increase longevity and predictability of your gum lift.
Surgical lip stabilisation
There is an option to complete a surgical lip stabilisation procedure. However, it’s tricky to find clinicians offering these as they are not predictable and can relapse.
If the reason for the problem is a long mandible, then the patient may want to consider orthognathic surgery.
Also, whitening the patients teeth won’t help reduce the gummy smile, but can make the teeth more visible and the gummy smile less apparent.
Is it important to do a correct analysis to establish the reason for the patients gummy smile. Then explain appropriate treatment options thoroughly.
I like to start with least invasive and build up to more involved treatments. Often patients will start with toxin injections and then decide if they want more from there.
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