A gummy smile is a highly subjective diagnosis that shows tremendous variability over dental and non-dental populations. When patients identify gingival display as an area of concern, a restorative dentist has to be able to determine the etiology prior to investigating treatment options.
The gingival level is the gingiva to lip relationship. A study conducted by Dr. Vincent Kokich Jr., asked a group of lay people, orthodontists and general practitioners what they thought about acceptable gingiva levels for smiles. The results are somewhat surprising.
Lay people: Those who were not professionals viewed the threshold at 3mm; when the gums hit the 3 mm mark they rated the smile as less attractive.
Orthodontists: Orthodontists rated their threshold at 2 mm, the strictest requirement in the study group.
General practitioners: Surprisingly, the threshold for GPs was 4 mm, the most lenient of the study group. The important question is: When do we treat a gummy smile? When it bothers the patient. The ideal target is to get somewhere under 3 mm for patients who desire to change their smiles. Before treatment, it’s necessary to understand exactly what causes a gummy smile. There are at least seven different causes, and if you don’t diagnose the cause correctly, you’re going to pick the wrong treatment for your patients.
The Seven Causes
- Short upper lip (if a patient has an extremely short upper lip it’s not going to cover gingiva and their upper teeth)
- Hypermobile lip (lip moves too much)
- Vertical maxillary excess VME (short ramus and overgrowth of maxilla)
- Anterior over-eruption (excess overbite)
- Wear and compensatory eruption
- Altered active eruption (the teeth don’t make it out of bone)
- Altered passive eruption (gingiva doesn’t recede as the person matures)
Three Traditional Methods for Treating a Gummy Smile
Orthodontics: Intrudes over erupted teeth and levels them to correct position so that it eliminates gingival display.
Periodontal surgery: Crown lengthening to move gingival levels apically, typically performed on short teeth.
Orthognathic surgery: Moves the maxilla in an apical direction impacting the maxilla.
For instances when these traditional methods of treatment won’t work, such as a patient has a hypermobile lip, there are a couple of non-traditional methods:
Botox: Studies suggest Botox, when injected into the muscles of the upper lip can to be an effective method; however, the improvement is temporary and must be repeated every three to six months.
Lip repositioning surgery: Severs the muscles that elevate the lip so it can no longer rise as far in a smile. An irreversible solution diagnosis is the key to a successful outcome.
Steve Ratcliff, D.D.S., M.S., Spear Faculty and Contributing Author