1.GUMMY SMILE:GUMMY SMILE: Differential diagnosisDifferential diagnosis and Management .and Management . Dr. ABHILASHA GOYAL PG STUDENT

2. LEARNING OBJECTIVES 3. Introduction The smile has an important role in the determination of the first impression of a person. The evaluation of smile has become an important part of our clinical assessment with a greater emphasis on dynamic evaluation. Frontal examination is gaining its due importance. 4. 3 primary factors affecting a smile 5. COMPONENTS OF BALANCED SMILE 6. DEFINITION Matthews TG. The anatomy of a smile. J Prosthet Dent 39: 128- 134, 1978Matthews TG. The anatomy of a smile. J Prosthet Dent 39: 128- 134, 1978 7. At smiling Over exposure seen in repose of lips 8. PREVALANCE 7% of young adult males 14% of young adult females Peck et al , 1992 : 26% of a sample of orthodontic patients displayed 2 mm or more of maxillary gingiva when smiling . Diamond O . Facial esthetics and orthodontics , J Esthet Dent,1996 9. DIAGNOSIS Excessive gingival display / Gummy smile is a descriptive term rather than a diagnosis, which would mandate the initiation of a specific therapy. Numerous factors Interplay of several etiologies 10. FACIAL EXAMINATION 1.Facial symmetry and proportions in both frontal and lateral views: 11. 2. Upper lip length at rest 12. 3. Display of maxillary central incisors at rest 13. 4. Amount of gingival exposure During a full smile , the upper lip should move to the tooth- gingiva interface on the maxillary central incisors and canines. Normal 1-2mm Most orthodontists and dentists prefer that the elevation of the lip for the posed smile stop at the gingival margins of the maxillary incisors. 14. Smile line It is the position of the upper lip relative to the maxillary incisors and gingiva during a natural full smile. Tjan AH et al 15. 5. Gingival margin outline The gingival margins of the maxillary central incisors and the canines should be symmetric and in a more apical position than those of the lateral incisors. Chiche and Pinault considered symmetry of the gingival margins at the midline (central incisors) to be essential, while more laterally a certain amount of asymmetry is permissible. 16. The effect of maturation and aging on the soft tissue of face : Lengthening of the resting philtrum and commissural height. Decrease in the turgor (tissue fleshiness) Decrease in incisor display at rest Decrease in incisor display during smiling Decrease in gingival display during smiling Dynamic smile visualization and quantication : Smile analysis and treatment strategies . David M. Sarver, DMD, MS, and Marc B. Ackerman, AJODO 2003; Dynamic smile visualization and quantication : Smile analysis and treatment strategies . David M. Sarver, DMD, MS, and Marc B. Ackerman, AJODO 2003; 17. INTRAORAL EXAMINATION 18. 1. Occlusal plane The occlusal plane should closely coincide with the imaginary line connecting the commissures of the lips and two-thirds the height of the retromolar pad. In this way, during a smile, there is mild exposure of the tips of the mandibular canines and premolars. 19. 2. Anatomy, proportions, and color of the teeth. ANATOMY Peg laterals A comparison between the anatomic crown height will help determine whether short clinical crowns are a result of incisal wear or of a coronal position of the gingival margin over the teeth 20. Proportions The Teeth should fit the rule of Golden Proportion The Perceived Width of the maxillary anterior teeth as viewed from the direct anterior should have a ratio of 1 : 0.618 with the tooth adjacent to it . 21. 3. Periodontal examination. The width and thickness of the keratinized attached gingiva must be measured, as well as probing depth, clinical attachment level, and crestal bone level with respect to the CEJ. There are 3 periodontal biotypes: Thin and scalloped Normal Thick and flat This information has a crucial influence on thetreatment strategies and decisions. 22. DIFFERENTIAL DIAGNOSIS AND MANAGEMENT 23. Periodontal Delayed passive eruption Gingival hyperplasia Soft tissue Morphologically short upper lip Hypermobile upper lip Dental Short clinical crown Anterior dentoalveolar extrusion Loss of torque on the anteriors Skeletal Vertical maxillary excess Rotations of maxilla Diagnosis and treatment planning of excessive gingival display - Review JIOS 2006Diagnosis and treatment planning of excessive gingival display - Review JIOS 2006 24. ALTERED / DELAYED PASSIVE ERUPTION 25. Normal anatomy 26. Classification ( coslet et al) Coslet JG, Vanarsdall R, Weisgold A. Diagnosis and classification of delayed passive eruption of the dentogingival junction in the adult. Alpha Omegan 1977;70:2428. 27. Clinical diagnosis of altered passive eruption 28. MANAGEMENT 29. GINGIVECTOMY 30. APICALLY POSITIONED FLAP WITH OSTEOTOMY 31. MORPHOLOGICALLY SHORT UPPER LIP Common cause . The average lip length is measured from subnasale to most inferior portion of the upper lip in midline. Normal upper lip length is about 23mm in males and 20mm in females. Lip length should be roughly equal to commissure height. Diagnosis and treatment planning of excessive gingival display - Review JIOS 2006Diagnosis and treatment planning of excessive gingival display - Review JIOS 2006 32. Management Diagnosis and treatment planning of excessive gingival display - Review JIOS 2006Diagnosis and treatment planning of excessive gingival display - Review JIOS 2006 33. HYPERACTIVE UPPER LIP At repose : 3-4mm of maxillary central incisors are displayed At full smile : entire clinical crown (10-11mm) is exposed Upper lip translates 6-8mm from repose to full smile In a patient with hyperactive upper lip ,the lip may translate 1.5 to 2 times more than the normal distance 34. MANAGEMENT 35. Commonly used : Objective : To decrease the amount of lip elevation on smiling Lowering the height of gingivolabial sulcus 36. Lip repositioning technique 37. The procedure restricts the muscle pull of the elevator lip muscles by shortening the vestibule, thus reducing the gingival display while smiling Eliminating a Gummy Smile with Surgical Lip Repositioning. Simon, Rosenblatt, Dorfman, The Journal of Cosmetic Dentistry Spring 2007 Eliminating a Gummy Smile with Surgical Lip Repositioning. Simon, Rosenblatt, Dorfman, The Journal of Cosmetic Dentistry Spring 2007 38. Injection of Botox to reduce excessive gingival display on smiling 39. When injected intramuscularly at therapeutic doses BTX-A produces partial chemical denervation of muscles, resulting in localized reduction in muscle activity. Botulinum toxin type A in the treatment of excessive gingival display. Mario Polo, AJODO 2005)Botulinum toxin type A in the treatment of excessive gingival display. Mario Polo, AJODO 2005) 40. BTX-A injections (2.5 units in both right and left LLSAN and LLS, and Zm muscles) are given for the neuromuscular correction of excessive gingival display (gummy smile) caused by hyperfunctional upper lip elevator muscles . It is effective and statistically superior to baseline smiles , although the effect is transitory. 41. PLAQUE-/DRUG-INDUCED GINGIVAL ENLARGEMENT A condition in which the enlarged gingival tissues are covering the clinical crowns, creating an unesthetic appearance . It is most often related to dental plaque and inflammation but can be associated with medication such as phenytoin, cyclosporine, and calcium channel blockers. Excessive gingival display Etiology, diagnosis, and treatment modalities Nir Silberberg, Moshe Goldstein,Smidt, QUINTESSENCE INTERNATIONAL 4; 10; 2009 42. MANAGEMENT Excessive gingival display Etiology, diagnosis, and treatment modalities Nir Silberberg, Moshe Goldstein,Smidt, QUINTESSENCE INTERNATIONAL 4; 10; 2009 43. SHORT CLINICAL CROWN 44. MANAGEMENT 45. ANTERIOR DENTOALVEOLAR EXTRUSION Overeruption of the maxillary incisors with their dentogingival complex leads to a more coronal position of the gingival margins and excessive gingival display. This condition may be associated with tooth wear at the anterior region (compensatory incisor over eruption) or with anterior deep bite. In cases with deep bite, there is usually a discrepancy in the occlusal plane between the anterior and posterior segments 46. MANAGEMENT 47. Orthodontic intrusion Burstones one piece intrusion arch Anterior dentoalveolar extrusion Should be used in association with High Pull Headgear or TPA 48. Use of mini implants Orthodontic treatment of gummy smile by using mini-implants : Treatment of vertical growth of upper anterior dentoalveolar complex. Tae-Woo Kim, Benedito Viana Freitas.Dental Press J. Orthod. 2010. Orthodontic treatment of gummy smile by using mini-implants : Treatment of vertical growth of upper anterior dentoalveolar complex. Tae-Woo Kim, Benedito Viana Freitas.Dental Press J. Orthod. 2010. 49. LOSS OF TORQUE OR PALATALLY TIPPED MAXILLARY INCISORS MANAGEMENT : If iatrogenic incorporation of torque in the wire 50. VERTICAL MAXILLARY EXCESS 51. Facial evaluation 52. Intraoral examination Constricted maxillary arch may result in crossbite Frequently anterior openbite Flat or accentuated curve of spee Crowding 53. CEPHALOMETRIC CHARACTERISTICS Increased lower anterior face height. Steep mandibular plane angle Decreases palatal to occlusal plane angle Increased anterior dentoalveolar height Increase in ANS-Pr value Maxillary incisor display >3mm at rest Mostly skeletal Class II ; occasionally Class I 54. MANAGEMENT 55. MANAGEMENT 56. Superior and distal displacement of maxilla Clockwise rotation of palatal plane Reduction in SNA angle Relative intrusion of maxillary molars. High pull headgear with or without maxillary splint 57. Mandibular bite blocks with vertical pull chin cup Vertical pull chin cup in association with cervical headgear , produces significant favorable skeletal and dental alterations by inhibiting maxillary molar eruption and descent of maxilla and redirecting mandibular growth in a more horizontal direction. It provides: 1. Decreased gonial angle 2. Redirection of condylar growth 3. Increased posterior height. 58. Case of gummy smile due to VME treated with orthognathic surgery 59. 60. ROTATION OF MAXILLA 61. DIFFERENTIAL DIAGNOSIS IN A NUTSHELL When planning a treatment for gummy smile the key is to diagnose the reason for excessive gingival margin to lip distance when the patient smiles. 62. Step 1: Assessment of the upper lip to the incisal edgeof the maxillary incisors At Rest: Normal display : 3-4mm 63. Normal incisal display at rest, but there is a Gummy smile?? Gummy smile is either due to : 64. If incisor display at rest is more than 3-4mm ?? Possible causes are : 65. Short upper lip vs Vertical maxillary excess & Over eruption of anterior maxillary dentoalveolar segment Evaluation of lip length Evaluation of lower anterior facial height cephalometrically: If normal : the problem is related to short upper lip If increased : the problem is due to VME 66. SUMMARY Excessive gingival display Etiology, diagnosis, and treatment modalities Nir Silberberg, Moshe Goldstein,Smidt, QUINTESSENCE INTERNATIONAL 4; 10; 2009 Excessive gingival display Etiology, diagnosis, and treatment modalities Nir Silberberg, Moshe Goldstein,Smidt, QUINTESSENCE INTERNATIONAL 4; 10; 2009 67. TAKE HOME MESSAGE .. With increasing awareness, esthetics has become the major concern of people. Orthodontist play a major role in diagnosing gummy smile. An interdisciplinary approach is needed for management of gummy smiles to achieve stable results. 68. REFERENCES Peck S, Peck L, Kataja M. The gingival smile line. Angle Orthod 1992;62:91100 'Diagnosis and treatment planning of EXCESSIVE GINGIVAL display- A REVIEW.JIOS 2006 J Williams Robbins. Differential diagnosis and treatment of excessive gingival display;Pract Periodont Aesthet Dent 1999;11(2). Dynamic smile visualization and quantication : Smile analysis and treatment strategies . David M. Sarver, DMD, MS, and Marc B. Ackerman, AJODO 2003. Excessive gingival display Etiology, diagnosis, and treatment modalities Nir Silberberg, Moshe Goldstein,Smidt, QUINTESSENCE INTERNATIONAL 4; 10; 2009 Arthur Dolt, J William Robbins.Altered Passive eruption:an etiology of short clinical crowns. QUINTESSENCE INTERNATIONAL 1997 69. See what you know know what you see THANK YOU