Clinical Advances in Periodontics; Copyright 2017 DOI: 10.1902/cap.2017.

160074

Treatment of Gummy Smile of Multifactorial Etiology: A Case Report

Monica P. Gibson†* and Dimitris N. Tatakis†
†
Division of Periodontology College of Dentistry The Ohio State University.
* Present address: University of Alberta School of Dentistry, Faculty of Medicine & Dentistry.
Introduction: This case report describes the management of a patient diagnosed with excessive gingival
display caused by altered passive eruption and hyperactive lip. The treatment for this patient was staged and
included esthetic crown lengthening and subsequent lip repositioning procedure.
Case Presentation: A 17-year-old female was referred for assessment of “gummy smile”. Patient gave
history of mouth breathing and sports injury with non-vital #9, temporarily restored. Following periodontal
evaluation, patient was diagnosed with plaque-induced gingivitis and excessive gingival display due to hyperactive
lip and altered passive eruption. After initial therapy, esthetic crown lengthening procedure was performed on
maxillary anterior sextant, resulting in ideal maxillary anterior crown contours. Six-weeks after esthetic crown
lengthening, the patient was treated for hyperactive lip by a modified lip repositioning surgery. Subsequently the
patient received a permanent restoration on tooth #9. During the 1.5-year follow-up time the patient repeatedly
expressed her satisfaction with the improvement of her smile. Persistent mouth breathing and associated recurrent
gingival inflammation remained a challenge.
Conclusion: The presented case illustrates the results of sequentially applied techniques for management of
a gummy smile of multifactorial etiology and the limitations imposed by unresolved factors. Excessive gingival
display can be a significant esthetic concern for patients. Understanding the etiology can be challenging due to the
multiple factors that may be concomitantly involved. Accurate diagnosis and treatment planning are critical for
proper management. When multifactorial etiology is present, multiple treatment modalities, including various
surgical approaches, are necessary to obtain positive outcomes in such patients.

Key Words (Mesh Terms):

Alveolar Bone; Dental Esthetics; Gingiva; Lip; Mouth Breathing; Surgery.

Background:
Excessive gingival display (EGD), whether developmental or acquired in origin, can represent a
strong esthetic concern for patients. EGD etiology varies, including gingival enlargement, altered
or delayed passive eruption, vertical maxillary excess, anterior dentoalveolar extrusion, short
upper lip, hyperactive upper lip, and combinations thereof.1, 2
EGD resulting from skeletal deformities, such as increased maxillary arch vertical height,
typically requires orthognathic surgery.2-4 Altered passive eruption, often a EGD cause, can be
corrected by crown lengthening surgery (CLS), achieved through gingivectomy or apically
positioned flap with/without ostectomy depending on gingival width and alveolar bone crest
location relative to cemento-enamel junction (CEJ).2, 5 When hyperactive upper lip is the
underlying EGD etiology,2 either non-surgical (botulinum toxin injections)6 or surgical
approaches can be used for treatment. Among surgical approaches, lip repositioning surgery
(LRS) can reduce lip mobility during smile and minimize gingival exposure.7 Although LRS was
first described in 1973,7 only few cases have been documented in the literature.8 Silva et al.
recently reported the clinical and patient-centered outcomes for hyperactive lip associated-EGD
treated by a modified LRS.8 Because of the multiple possible etiologies, patients presenting with
EGD should be carefully diagnosed and treatment planned accordingly. The clinician must

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evaluate the relationships between dentition, alveolar bone, gingiva, facial skeleton and lip to
determine the underlying EGD etiology.
This case report describes the treatment of a patient diagnosed with EGD caused by altered
passive eruption and hyperactive upper lip. Patient treatment was staged and included esthetic
CLS and LRS.

Clinical Presentation:
A 17-year-old Caucasian female was referred (May 2014) to the Graduate Periodontics Clinic of
The Ohio State University College of Dentistry for assessment of “gummy smile” (Fig. 1). Chief
complaint was “make my smile better for my senior year pictures”. She was systemically healthy
and reported mouth breathing. She gave a recent sports injury history with endodontically treated
and temporarily restored #9. Injury-related localized swelling of the lower lip, corresponding to
the #9 area, was noted. Tooth #10 was supra-erupted, unrelated to the injury. Clinical periodontal
examination revealed gingival inflammation and pseudopockets (probing depth range: 3-6 mm).
Radiographic examination revealed interdental bone present at or coronal to the maxillary
anterior teeth CEJ (Fig. 2). Smile assessment revealed EGD, attributed to altered passive
eruption (Coslet classification 1A)2 and hyperactive upper lip. Gingival margin position and
sulcus depth relative to CEJ informed the eruption anomaly diagnosis.9 Excess translation of the
patient’s lip from repose to high smile led to hyperactive lip diagnosis. Patient was diagnosed
with plaque-induced gingivitis, gingival enlargement, and EGD.

Case Management:
Treatment plan included prophylaxis, oral hygiene instruction, CLS, and LRS. Patient declined
orthodontic treatment. Oral prophylaxis was performed and customized oral hygiene instructions
were provided to control gingival inflammation. Moisturizing oral mouthwash‡ was
recommended at bedtime to counter mouth breathing sequelae. Patient presented 5 weeks later
with markedly reduced inflammation (Fig. 3). Esthetic CLS was performed on teeth #6-11 (Fig.
4). Following local anesthesia, bone sounding was performed to confirm osseous crest position.
CLS included scalloping incisions on the buccal gingiva and osseous resection to bring the bony
crest 2-3 mm apical to CEJ (Fig. 4a-c), resulting in exposure of ideal maxillary anterior crown
contours (Fig. 4e-f). Six-weeks after CLS, EGD was still present and patient was treated for
hyperactive lip (Fig. 5). The LRS, performed as previously detailed,7 entailed partial thickness
horizontal incision, 1 mm coronally to the mucogingival junction on either side of the midline
frenum until the first molar, a parallel incision positioned 8 mm (based on amount of gingival
display) apical to the first incision, and connecting incisions to allow removal of bilateral
mucosal islands. New mucosal margin was then sutured (interrupted absorbable sutures) to the
gingiva (Fig. 6). Patient was prescribed analgesics (ibuprofen 600 mg TID) for 4 days and 0.12%
chlorhexidine rinse twice daily for 2 weeks. Postoperative instructions included ice pack
application, soft food consumption, avoidance of mechanical trauma to treated area, and minimal
possible lip movement. Sutures were removed at 2 weeks (Fig. 7). Patient was kept on strict oral
hygiene follow-up postoperatively.

Clinical Outcomes:
Postoperative healing was uneventful. Three months after LRS (4.5 months after CLS),10 patient
received permanent crown on #9, which further reduced inflammation between #9 and 10. She

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reported having her senior year photo taken. During subsequent follow-up a revision soft tissue
procedure was performed between teeth #9 and #10, to reduce the enlarged papilla. This was
accomplished by reflecting, thinning, and replacing the papilla (Fig. 8). The patient showed
marked improvement in maxillary anterior tooth contours and reduction in gingival display for
the duration of the periodic follow-up (Fig. 9), which lasted 18 months. At 18 months, recurrence
of slight gingival enlargement was noted (Fig. 9). The patient repeatedly expressed her
satisfaction with her smile improvement and her maxillary anterior tooth shape.

Discussion:
This case report illustrates how EGD of multifactorial etiology can be successfully managed by
application of indicated surgical techniques. The outcomes of these procedures appear stable 1.5
years postoperatively. The patient’s mouth breathing presented a limitation in this case, because
it contributed to recurrent gingival inflammation on the maxillary anterior teeth, despite her oral
hygiene efforts. Furthermore, the patient’s refusal of orthodontic treatment compromised the
final esthetic outcome.
There are several options to treat EGD.1, 2 Choices depend upon the etiology and should be
decided on a case-by-case basis, taking into consideration patient preferences. This case report
highlights two significant EGD etiologies; altered passive eruption and hyperactive upper lip.
Esthetic CLS, to correct dentogingival discrepancies arising from altered passive eruption, and
LRS, to address upper lip hyperactivity, were performed sequentially. The sequencing of these
procedures is important, because it is possible to reduce or completely resolve EGD by CLS
alone;5 therefore, in cases of altered passive eruption, potentially remaining need for LRS should
be reassessed after CLS. Although possible in select cases, performing both procedures
simultaneously could result in technical difficulties (lack of fixed gingival tissue for anchorage
of LRS flap). Other options to treat the hyperactive lip would include treatments with botulinum
toxin and myotomy.6, 11-13
Overall, the presented case highlights the possibility to successfully treat a gummy smile of
multiple etiology.

Summary:
Why is this case new information?
Treatment of excessive gingival display of multifactorial etiology accomplished by
sequential performance of crown lengthening and lip repositioning surgery.
What are the keys to successful management of this case?
• Case selection
• Proper identification of etiologic factors
• Appropriate application of indicated surgical techniques
What are the primary limitations to success in this case?
Unresolved factors (persistent mouth breathing) contributing to recurrent gingival
inflammation and refusal of orthodontic treatment leading to less than ideal final esthetic
outcomes.

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Acknowledgment:
The authors report no conflicts of interest related to this case report.

References:
1. Garber DA, Salama MA. The aesthetic smile: diagnosis and treatment. Periodontol 2000 1996;11:18-28.
2. Silberberg N, Goldstein M, Smidt A. Excessive gingival display--etiology, diagnosis, and treatment modalities.
Quintessence Int 2009;40:809-818.
3. Ezquerra F, Berrazueta MJ, Ruiz-Capillas A, Arregui JS. New approach to the gummy smile. Plast Reconstr
Surg 1999;104:1143-1150; discussion 1151-1152.
4. Zahrani AA. Correction of vertical maxillary excess by superior repositioning of the maxilla. Saudi Med J
2010;31:695-702.
5. Silva CO, Soumaille JM, Marson FC, Progiante PS, Tatakis DN. Aesthetic crown lengthening: periodontal and
patient-centred outcomes. J Clin Periodontol 2015;42:1126-1134.
6. 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.
7. Rubinstein AM, Kostianovsky AS. Aesthetic surgery of the malformation of the smile (in Spanish). Prensa
Medica Argentina 1973;60:952.
8. Silva CO, Ribeiro-Junior NV, Campos TV, Rodrigues JG, Tatakis DN. Excessive gingival display: treatment by
a modified lip repositioning technique. J Clin Periodontol 2013;40:260-265.
9. Alpiste-Illueca F. Morphology and dimensions of the dentogingival unit in the altered passive eruption. Med
Oral Patol Oral Cir Bucal. 2012;17:e814-20.
10. Pilalas I, Tsalikis L, Tatakis DN. Prerestorative crown lengthening surgery outcomes: a systematic review. J
Clin Periodontol 2016; 43:1094-1108.
11. Sucupira E, and Abramovitz A. A simplified method for smile enhancement: botulinum toxin injection for
gummy smile. Plast Reconstr Surg 2012; 130:726-728.
12. Mazzuco R, Hexsel D. Gummy smile and botulinum toxin: a new approach based on the gingival exposure
area. J Am Acad Dermatol 2010;63:1042-1051.
13. Ishida LH, Ishida LC, Ishida J, Grynglas J, Alonso N, Ferreira MC. Myotomy of the levator labii
superioris muscle and lip repositioning: a combined approach for the correction of gummy smile. Plast
Reconstr Surg 2010;126:1014-1019.

Corresponding author: Dr. Dimitris N. Tatakis 4121 Postle Hall 305 W. 12th Avenue Columbus,
OH 43210 Email: Tatakis.1@osu.edu Phone:614-292-0371.
Submitted October 24, 2016; accepted for publication February 20, 2017.

Fig 1.
Initial presentation, frontal clinical view: Gingival inflammation, gingival enlargement and excessive gingival
display are evident. Note provisional restoration on #9 and lesion on lower lip.

Fig 2.
Initial presentation, radiographic view: Note alveolar bone crest proximity to CEJ for teeth #6-11.

Fig 3.
Five weeks after initial therapy, clinical view: marked improvement in tissue appearance, with reduction in gingival
inflammation and enlargement.

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Fig 4.
Esthetic crown lengthening surgery, teeth #6-11, clinical view: a) Scalloping incision on buccal aspect; b) Full
thickness flap reflected, note alveolar crest level; c) Osseous reduction performed; d) Flap sutured; e) 2-week
postoperative follow up (suture removal); f) 4-week postoperative follow up, note progression of healing and
persistence of excessive gingival display.

Fig 5.
Six weeks following crown lengthening surgery, a) frontal and b) profile clinical views.

Fig 6.
Lip repositioning surgery, a) outline of mucosal tissue to be excised; b) mucosal islands removed; c) suturing
completed.

Fig 7.
Two weeks following lip repositioning surgery, a) retracted view; b) frontal and c) profile clinical views.

Fig 8.
Three months after lip repositioning surgery, a) retracted view; note light scarring at incision line, permanent
restoration on #9, improved gingival tissue contours and lack of gingival inflammation. Bottom panel: b) frontal
and c) profile clinical views (compare to preoperative views, Fig. 5)

Fig 9.
Eighteen months after lip repositioning surgery. Top panel: a) retracted view. Bottom panel: b) frontal and c)
profile clinical views. Compare to early healing (Fig 8), preoperative presentation (Fig 5), and initial presentation
(Fig 1).
‡
BioteneTM (GlaxoSmithKline) Brentford, UK

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