Gummy Smile

How do we fix a gummy smile?

A gummy smile starts to become unattractive to others once about 3mm of gum shows, although some say as little as 1mm is unattractive. These definitions give somewhere between 10-30% of us a gummy smile. There are many treatment options available including lip repositioning surgery.

Before and after photos of a gummy smile surgery

Above is a before and after smile photo of a gummy smile surgery. This was a straight forward case that was done via laser gingivetomy. You can see in the photos a half done photo and how Sara left that day on the bottom right. As you can see, there is minimal to no bleeding with this technique.

Causes (Etiology) of a gummy smile

Excessive gingival display or excessive dentoalveolar display are the fancy formal ways dentists say gummy smile.

Dentoalveolar causes of a gummy smile include short crowns or the upper part of a tooth, altered passive eruption (APE), gingival overgrowth, and/or dentoalveolar extrusion. Nondentoalveolar causes include skeletal and/or facial soft tissue problems, including hypermobility of the upper lip, short upper lip, and/or vertical maxillary excess (VME). An orthodontist will confirm VME via cephalometric analysis, usually identifying a steep mandibular plane and an increased SNGoGn angle.

APE and mild VME are the most common cases we see. However, multiple causes are common, therefore multiple treatment steps are frequently indicated.

Treatment options for a gummy smile

There are several options that we utilize to treat a gummy smile. There is no right answer and what is bet for you will not only depend on you but what those treating you have the most experience doing.

Gummy smile treatment options in a tree.

Orthodontics aka braces:

We use braces to treat a gummy smile by intruding over erupted teeth. This levels them to the correct position thus eliminating the excessive gingival display. This is usually only an option for those that have a gummy smile due to severe grinding.

Periodontal surgery and gingivectomy:

Periodontal surgery would be crown lengthening in this case, which is the removal of bone and tissue. This may be ideal for people that simply have too much gum tissue that for some reason covers more of their tooth. This surgery moves gum levels up. This is almost always only an option for teeth that are visibly shorter. Gingivectomy is a very minor version of this where we only remove gum tissue instead of gum and bone. Coslet has a classification that helps identify which is likely to work best but we find simply knowing the bone needs to be 2.5mm away from the gingival margin is all that we need to know.

Gingivectomy of a gummy smile can really improve your look!

Gingivectomy which we often will use to expose more tooth that is hiding under the gums

A before and after photo of laser gingivectomy treatment for gummy smile.

Before and immediate after photo of a laser gingivectomy treatment

Orthognathic surgery:

Surgery that moves the entire jaw up. This is a very extreme measure but may be some peoples only option.

Botox:

When we inject Botox into the muscles of the upper lip we can temporarily make it so the gums do not show as much. This is because the lip can not raise as much. However, the improvement is temporary and we must repeat the Botox treatment every three to six months. This is often best for those with a hyper mobile upper lip which we say anyone with more than the normal 6-8mm of movement has.

Lip repositioning surgery for a gummy smile:

Lip repositioning surgery removes the tissue and a modified lip repositioning surgery severs the muscles that elevate the lip so it can no longer rise as far in a smile. We can do a trial version by stitching the labial mucosa to the mucogingival junction, which allows patients a chance to visualize the potential end results. There is some debate about how permanent lip repositioning surgery really is. The modified version with muscle dissection appears to have less relapse. Some say the lip returns in 12 months to some extent, but that is referring more to the traditional lip repositioning method. The Ishida 2010 study shows the results holding up well at 6 months.

Trying out lip repositioning before doing the surgery is possible.

Suturing method so patients can see the results we expect before actually doing the repositioning surgery.

Surgical steps of lip repositioning surgery

Can not do if less than 3mm of attached gingiva. Mark the surgical margins with a surgical marker, preserving the labial frenum. There are some variations on page 524 of Alamaar 2018 JERD. The inferior border is the mucogingival junction and extend the border laterally based on the horizontal extent of the dynamic smile, or mesial line angle of first molar. Look to do a 2:1 for removal; remove twice as much as want to reduce showing during full dynamic smile. So if looking to bring down 7mm then remove 14mm of tissue.
Split thickness flap for traditional but full thickness with muscle dissection for modified, which is arguably better. Cauterize any bleeding with electrosurge. Split thickness tissue removal and suture at midline first to line things up, then multiple interrupted sutures. For modified need to use resorbable suture like Vicryl for the muscles first.
Lip positioning surgery.
There are two suture modifications that work well to aid in long term results. The first is 3-4 periosteal vertical simple interrupted sutures that we place before closing. This suture goes into thick connective tissue or frenal attachments, starting 2 mm coronal to the base of attachment and then sliding the needle apically, passing the connective tissue attachment up to 6 mm before tying the knot. This suture moves and stabilizes the thick connective tissue attachments in a more coronal position. We use a 4-0 Vicryl absorbable suture. IJPRD 2021 Jasser An interesting alternative to this is to start in the attached gingiva and then do the same thing.
Another suture modification is seen by Mateo. Mateo 2021 IJPRD uses vicryl internal horizontal mattress. Both modifications pull the tissue down.
Lip reposition stabilization with horizontal internal mattress sutures

Post op instructions for lip repositioning surgery

  • Ibuprofen 600–800 mg every 6–8 hours as needed for pain
  • Chlorhexidine gluconate 0.12% twice daily for 2 weeks
  • Ice pack for 24 hours 15 on 15 off several times
  • Short dosage antibiotics possibly
  • Avoid moving lifting lip for 10-14 days. Limit talking
  • Soft diet for 2 weeks
  • Brush teeth at 48 hours but very minimal first 2 weeks in area.
  • 2-week post-op visit remove stitches
  • Most patients report feeling tightness of the upper lip
  • Avoid maximum smiling for 3 weeks

Complications of lip repositioning surgery

  • Bleeding and loss of sutures
  • Bruising may occur (black eyes)
  • Swelling for the first week
  • Scar forms at incision lines
  • Very Rare – formation of mucocele
  • Very Rare – paresthesia only unilateral ever reported but is more likely in modified
  • Rare – Unilateral or bilateral relapse in first 6 to 8 weeks after surgery is less likely in modified lip repositioning surgery
  • Rare and usually from narrow width removal in the midline is the appearance of a double lip

Really cool all on 4 case with a gummy smile. This allows for less bone reduction while maintaining a result that does not show the transition.

Excessive dentoalveolar display – more technical info on when to rely on what treatment

We can treat most dentoalveolar causes of gummy smile effectively by using restorative care, periodontal surgical approaches, and orthodontics. Nondentoalveolar cause rely on orthognathic surgery and lip repositioning. Botox works well for a hypermobile lip and mild VME patients.

When altered passive eruption (APE) is present alone or with other dentoalveolar factors, crown lengthening works well. Short or worn teeth usually require crowns or veneers. Orthodontics can work on intrusion cases.

For VME, we may need to utilize orthognathic surgery. To mask mild to moderate cases of VME, and/or hypermobile upper lip, treatments such as lip repositioning work. When APE coexists with hyper upper lip and/or VME, combining this procedure with crown lengthening produces optimal results.

Interesting gummy smile cases found in the literature

Cool case 

Surgical options for gingival display Nov 12

Several other very nice references from the literature. Gummy smile lip repositioning by Bhola, Mahn lip repositioning and lip repositioning case report by Ziv Simon.

 

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