Treating a Gummy Smile

A gummy smile can influence great distress and a lack of confidence in many people. Treatment options traditionally come from the worlds of both dentistry and maxillofacial surgery but aesthetic procedures now offer a non-surgical approach.1 It is important, however, to know how to diagnose the source of the problem and to recognise when a multi, or interdisciplinary approach is required for best outcomes. I work with closely with my clinic’s co-owner, aesthetic practitioner Mr Benji Dhillon, so we can offer a comprehensive assessment and treatment plan for all our patients. What is a gummy smile? It is generally accepted by dentists that gum display in a full spontaneous smile of less than or equal to 2mm is aesthetically pleasing.1 For patients who have more than this, it can be distressing and responsible for an actual or perceived lack of confidence, as a display of more than 2mm of gum dispels aesthetic ideals. They will often adopt a more reserved or ‘practised’ smile to attempt to hide it. I have found that it can be a source of ridicule or bullying from a very young age. In my experience, sufferers can often appear less ‘happy’ or less ‘fun’ than others due to the development of a subconscious routine of preventing their most spontaneous smile to occur. Psychological impact While it is often generally believed that smiling can make us feel better, the theory has never been proven in the academic literature. However, a recent study was published in the Psychological Bulletin,

where American psychologists analysed nearly 50 years of data, from more than 100 studies, each of which tried to determine whether facial expressions can affect people’s moods.2 The studies, which included more than 11,000 people worldwide, concluded that smiling does make people feel happier, while scowling makes them feel angrier, and frowning makes them feel sadder.2 This raises the most important question: Q. When do we treat a gummy smile? A. When it bothers the patient Diagnosis Treating a Gummy Smile A gummy smile is a highly subjective diagnosis that shows tremendous variability over medical, dental and Dr Mark Hughes details the causes and diagnosis of a non-dental populations. When patients identify gingival (gum) display as an gummy smile and explores suitable treatment options area of concern, a treating practitioner has to be able to determine the aetiology prior to investigating treatment options. However, some patients do not express concern about their gum display or a desire to treat it, despite it being pointed out. The gum level is the gingiva to lip relationship. A study conducted by Dr Vincent Kokich Jr, asked a group of 300 people that included lay people (those who are not medically qualified) orthodontists and dentists what they thought, when presented with varying examples and severity of gum display. It was reported that lay people were unable to detect asymmetry until it was at 3mm, or a lateral incisor narrowing until 4mm.3 Orthodontists rated their threshold at 2mm, the strictest requirement in the study group. Surprisingly, open gum embrasure became detectable by dentists at 3mm whereas gum to lip distance was 4mm, the most lenient of the study group.3 This study demonstrates that almost everyone agreed that 2mm or less of gum tissue showing was the level where most thought the smile looked normal. Most started noticing the gum tissue at 3-4mm and thought that too much gum tissue was showing anything more than 4mm.3 Some research suggests that around 14% of women and 7% of men have excessive gingival exposure (more than 2mm) when smiling.4 However, it is most likely higher than we think, primarily due to the ability of the patient to learn how to ‘hide’ the situation. As a cosmetic dentist, it also worth explaining to my non-dental colleagues reading this article, that a gummy smile, is not necessarily unattractive, especially if the patient’s smile and teeth are aesthetically pleasing. In other words, a gummy smile is generally a far greater source of distress to patients, if their teeth are discoloured, crowed and out of proportion, shown in Figure 1. So, in my experience, often by simply correcting the smile first, the Before After gummy smile becomes far less important. Causes In my experience, gummy smiles occur for a variety of reasons but most commonly it is due to a short upper lip, excessive gum tissue or small teeth, all of which are genetic. 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.

Model treated with JUVÉDERM®. Results may vary. * Juvéderm® VOLUX contains lidocaine.1 The addition of lidocaine does not alter the physical properties of JUVÉDERM® products.5 † No available controlled clinical data on the effectiveness and tolerance of Juvéderm® VOLUX injection into anatomic regions other than the chin and jawline.1 ‡ Based on comparative preclinical testing and results from repeat treatment data, added to Juvéderm® VOLUX clinical study showing duration beyond 18 months after initial treatment or initial + top-up treatment in the chin and jaw, and based on clinical results for Juvéderm® VOLUMA with lidocaine showing 24 month duration in the mid-face establishes Juvéderm® VOLUX as having an in situ duration of 18–24 months.4 1. Juvéderm® VOLUX DFU. 72778JR10. Revision 2018-07-26. 2. Allergan. Data on File. INT/0663/2018. Juvéderm® VOLUX final clinical evaluation report. Oct 2018. 3. Allergan. Data on File.

INT/0654/2018. Juvéderm® VOLUX final clinical study report & clinical evaluation report – efficacy and duration data. Oct 2018. 4. Allergan. Data on File. INT/0074/2019. Juvéderm® VOLUX final clinical evaluation report, July 2018. Jan 2019. 5. Raspaldo H et al. J Cosmet Dermatol. 2010;9:11–15. ©2019 Allergan. All rights reserved. Material developed and produced by Allergan.

UK/0203/2019 Date of preparation: April 2019

Presented concern Concern explained

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 The lip moves too much

Vertical maxillary excess Short lower jaw and an overgrowth of the upper jaw

Overgrowth of the upper teeth Anterior over eruption, an excess overbite Possible treatment methods

• Fillers • Lip repositioning surgery

Botulinum toxin treatments

Orthognathic surgery

• Orthodontics • Cosmetic dentistry • Periodontal surgery • Combinations of the above

Tooth wear and subsequent overgrowth of the teeth downwards Compensatory eruption

Altered active eruption The teeth don’t make it out of bone

Altered passive eruption The gingiva doesn’t recede in a normal fashion, as the person matures

Treatment options So, how else can a gummy smile be treated? The ideal target is to get somewhere under 3mm for patients who desire to change their smiles. As mentioned in Table 1, there are some indications where only dental treatment or surgery will be suitable however, for the purpose of this article, I will be focusing on non-surgical techniques involving botulinum toxin and dermal fillers. These are often popular choices because they have little to no downtime associated with them. The price is also more appealing than surgery as generally botulinum toxin costs around £350 for this procedure in the UK, whereas a gum lift procedure and dental veneers can cost up to £15,000. Studies suggest that botulinum toxin, when injected into the elevator muscles of the upper lip can be an effective method.5 A botulinum toxin treatment works by injecting the product into the upper lip elevator muscles as it paralyses them and inhibits contraction of the upper lip when smiling to prevent the gummy smile, shown in Figure 2. 5 In my experience, placement in the alar fossa is most common – it usually determines the surface anatomy of levator labii superioris alaeque nasi muscle (LLSAN). I would recommend that two to three units of botulinum toxin is used per injection site. Thin lips, which would fall under the short upper lip category in our table can also contribute to the problem. They can be treated by using dermal filler to increase the volume and thus the position of the lower border of the upper lip, which helps to hide the excess gum display. However, botulinum toxins and fillers only work if the problem is in the lips, not the bone. As such, care has to be taken in diagnosis and one has to be careful not to over inject the muscles, or they

could create an unnatural look, or worse, and from experience, prevent the patient from being able to actually smile. It’s also important to note that the improvement with injectables is temporary and must be repeated every three to six months. It is important to make the patient aware that the procedure is not ‘permanent’ and requires maintenance injections over time. • • Orthodontics Cosmetic dentistry Conclusion • Periodontal surgery Often patients present with a combination • Combinations of the above of aetiological factors and a multi• • • Orthodontics Cosmetic dentistry Periodontal surgery disciplinary approach will provide the very best results. • Combinations of the above It is important to be able to know when Periodontal surgery to refer for advice from an experienced cosmetic dentist and vice versa. I work Table 1: Concerns and treatment methods available for gummy smile indications based on my experience very closely with an aesthetic practitioner in my clinic, which I believe allows us to offer our patients the most comprehensive assessment and the most effective treatment combinations. Treatment planning for a gummy smile is one such area where we can combine our expertise. Correct diagnosis in these cases is essential and this will determine what treatment is most suitable, however generally for patients with only upper lip hypermobility, injectable treatments can be a suitable option. Dr Mark Hughes is an accredited member of the British Academy of Cosmetic Dentistry and 15-year full member of the American Academy of Cosmetic Dentistry. He is the co-founder and dental director of Define Clinic in Beaconsfield, which offers cosmetic and restorative dentistry, as well as aesthetic treatments.

1. Izraelewicz-Djebali K, Gummy Smile: orthodontic or surgical treatment?, Journal of Dentofacial Anomalies and Orthodontics, 2015 <https://www.jdao-journal.org/articles/odfen/pdf/2015/01/ odfen2015181p102.pdf> 2. Coles NA, Larsen JT, Lench HC, A meta-analysis of the facial feedback literature: Effects of facial feedback on emotional experience are small and variable, Psychological Bulletin, 2019 1. Kokich VO Jr, Kiyak HA, Shapiro PA, Comparing the perception of dentists and laypeople to altered dental esthetics, J Esthet Dent, 1999 2. Livada R, Shiloah J, Correcting Excess Gingival Display, Decisions in Dentistry, 2016 <https:// decisionsindentistry.com/article/correcting-excess-gingival-display/> 3. Suber J et al., OnabotulinumtoxinA for the treatment of a gummy smile, ResearchGate, 2014 <https:// www.researchgate.net/publication/261187831_OnabotulinumtoxinA_for_the_Treatment_of_a_ Gummy_Smile>

• Levine RA, McGuire M, The diagnosis and treatment of the gummy smile, Compendium Contin Educ Dent, 1997 • Fowler P, Orthodontics and orthognathic surgery in the combined treatment of an excessively “gummy smile”, N. Z. Dent, 1999 • Lee EA, Aesthetic crown lengthening: classification, biologic rationale, and treatment planning considerations. Pract Proced Aesthet Dent, 2004 • Robbins JW, Differential diagnosis and treatment of excess gingival display, Practical periodontics and aesthetic dentistry, 1999 • Chu SJ, Karabin S, Mistry S. Short tooth syndrome: diagnosis, etiology, and treatment management. Journal of the California Dental Association, 2004 Before After • Ezquerra F, Berrazueta MJ, Ruiz-Capillas A, Arregui JS. New approach to the gummy smile, Plastic and Reconstructive Surgery 1999 • Bolas-Colvee B, Tarazona B, Paredes-Gallardo V, Arias-De Luxan S, Relationship between perception of smile esthetics and orthodontic treatment in Spanish patients, PLOS ONE, 2018