The beauty in facial esthetics: Gummy smile and options of treatment The Saudi Journal for Dental Research (2014) 5, 71–72 King Saud University The Saudi Journal for Dental Research www.ksu.edu.sa www.sciencedirect.com The beauty in facial esthetics: Gummy smile and options of treatment Peer review under responsibility of King Saud University. Production and hosting by Elsevier 2352-0035 � 2014 Production and hosting by Elsevier B.V. on behalf of King Saud University. http://dx.doi.org/10.1016/j.sjdr.2014.06.001 Gummy smile is defined as exposure of a large amount of gin- gival tissues it is also known as a high lip-line. Numerous fac- tors attribute to the gummy smile condition, such as; hyperactivity of the Orbicularis Oris muscle, altered passive eruption and reason connected to the dentogingival com- plex. 1–3 Additional factors determine the smile-line like the form and volume of the lips, the facial muscles, the teeth, and the gingival tissue. The ideal situation for an esthetic smile is the exposure of minimal gingival tissues with normal teeth height and a good balance with the upper lip. 3 As the facial esthetics can be severely affected by the gummy smile, consideration of the available options of treat- ment is a must to adjust the condition but only upon the patient request. One of the earliest ways to correct this prob- lem was to undergo Orthognathic surgery to reposition the front segment of the upper jaw when the patient has a basal bone deformity. 1 However, because of the surgical difficulty, the pain, the hospitalization, and the intrinsic complications, patients are not enthusiastic to go through this treatment. 4,5 Accordingly other treatment alternatives were established, which are less painful and less expensive. Lip repositioning procedure is one of these procedures 6 ; it is a possible and inex- pensive option of treatment. It is a relatively simple approach where by repositioning of the upper lip to a lower position with some minor periodontal cosmetic surgery minimizes the appearance of a high lip line. 7,8 The procedure is performed under local anesthetic and involves the surgical re-attachment of the gingival tissue under the lip to restrict the extent that the lip can go excessively upward when smiling. The result of this procedure is very satisfying to the patient. 6–9 Gingivectomy is another approach of treatment. However, Gingivectomies can only be performed when reduction of gin- gival tissues is minimal. The tissue is removed with gingivec- tomy knives, # 15 blades, dental laser or by radiosurgery. The advantages of this technique include; reduced pain, no sutures, and fast healing. 10–12 However, when extensive reduction of the tissue is required then crown lengthening procedures are the treatment of choice. 10,12 In this technique, contouring of the gingival tissues around each individual tooth with the accompanying bone is done followed by repositioning of the gingival tissues to the new position using sutures. The sutures are then removed after 7–10 days. 10–12 Although gingivectomy and crown lengthening procedures are not as invasive as the other surgical procedures, however, the move to a less invasive treatment options in esthetic Den- tistry was required. This led to the use of Botox in dental Esthetics. 13 Botox was used primarily for smoothing wrinkles of the forehead, the glabellar region and around the corners of the eyes. 13 Seven to eight percent of North American dentists provide Botox treatment to their patients as a part of cosmetic treat- ment. 14 The significant adjunctive therapy that Botox adds to the esthetics dental treatment is a fact lacked by many den- tists. Botox is a muscle relaxer and when used in the upper lip it can significantly decrease the strength of the muscle contrac- tions that cause the high lip line. 13 The non-surgical approach of using Botox to treat gummy smile is one of the advantages of this approach. Botox weakens the Orbicularis Oris muscle so they cannot raise the lip as high as before. This procedure is technique sensitive, as the patients should maintain full lip competency allowing them to speak, smile, and eat normaly. 13,14 As dentists, it is very important to present all options of treatments for gummy smile to the patient. Advantages and disadvantages of all options should be explained carefully to the patients as well. The advantages of the surgical treatment options of orthognathic surgery, such as lip repositioning and crown lengthening, are permanent esthetic results. The dis- advantages are the frequency of the appointments, the high cost, possible complications of treatment including sensitivity, recession and possibility of endodontic therapy later on. 6–9 The advantages of treatment with Botox and dermal fillers are immediate results with no removal of tooth structure. The disadvantages include; re-treatment 2–3 times a year and the cost associated with that treatment. 15 In conclusion; patients with gummy smile can be safely, simply, and successfully trea- ted (when indicated) in the dental office. Although, different http://crossmark.crossref.org/dialog/?doi=10.1016/j.sjdr.2014.06.001&domain=pdf http://dx.doi.org/10.1016/j.sjdr.2014.06.001 http://dx.doi.org/10.1016/j.sjdr.2014.06.001 http://www.sciencedirect.com/science/journal/23520035 http://dx.doi.org/10.1016/j.sjdr.2014.06.001 72 Editorial options of treatments are available and it makes no difference what type of treatment the patient chooses, however, the den- tist exposure to the different available treatment approaches significantly expands the treatment choices we provide to the patients. References 1. Robbins JW. Differential diagnosis and treatment of excess gingival display. Pract Periodontics Aesthet Dent 1999;11(2):265–72, quiz 73. 2. Kois JC. Altering gingival levels: the restorative connection part 1: biologic variables. J Esthet Dent 1994;6:3–7. 3. Kois JC. The restorative-periodontal interface: biological param- eters. Periodontol 2000 1996;11:29–38. 4. Silberberg N, Goldstein M, Smidt A. Excessive gingival display – etiology, diagnosis, and treatment modalities. Quintessence Int 2009;40:809–18. 5. Kim SPS. Incidence of complications and problems related to orthognathic surgery. J Oral Maxillofac Surg 2007;65:2438–44. 6. Simon ZRA, Dorfman W. Eliminating a gummy smile with surgical lip repositioning. J Cosmetic Dent 2007;23:100–8. 7. Litton CFP. Simple surgical correction of the gummy smile. Plast Reconstr Surg 1979;63:372–3. 8. Miskinyar SA. A new method for correcting a gummy smile. Plast Reconstr Surg 1983;72:397–400. 9. Ishida LHIL, Ishida J, Grynglas J, Alonso N, Ferreira M. Myotomy of the levator labii superioris muscle and lip reposi- tioning: a combined approach for the correction of gummy smile. Plast Reconstr Surg 2010;126:014–1019. 10. Kao RDS, Frangadakis K, Salehieh J. Esthetic crown lengthening: appropriate diagnosis for achieving gingival balance. J Calif Dent Assoc 2008;36:87–191. 11. Chu SKS, Mistry S. Short tooth syndrome: diagnosis, etiology, and treatment management. J Calif Dent Assoc 2004;32:143–52. 12. Lee EA. Crown lengthening: classification, biologic rationale and treatment planning considerations. Pract Proced Aesthetic Dent 2004;16:769–78. 13. Khanna B. Facial aesthetics-starting out. Aesthet Dent Today 2007;1(1):55–8. 14. Khanna B. Lip stabilisation with botulinum toxin. Aesthet Dent Today 2007;1(3):54–9. 15. Polo M. Botulinum toxin type A (botox) for the neuromuscular correction of excessive gingival display on smiling (gummy smile). Am J Orthod Dentofacial Orthop 2008;133:195–203. Editor in Chief Nahid Y. 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