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## Gummy Smiles: The Challenge of Gingival Excess , The Digital Smile Design Concept

##### INTRODUCTION

Gummy smile is defined as exposure of a large amount of gingival tissues it is also known as a high lip-line. Numerous factors attribute to the gummy smile condition, such as; hyperactivity of the Orbicularis Oris muscle, altered passive eruption and reason connected to the dentogingival complex. 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.

As the facial aesthetics can be severely affected by the gummy smile, consideration of the available options of treatment is a must to adjust the condition BUT only upon the patient request.

One of the earliest ways to correct this problem was to undergo Orthognathic surgery to reposition the front segment of the upper jaw when the patient has a basal bone deformity. However, because of the surgical difficulty, the pain, the hospitalization, and the intrinsic complications, patients are NOT enthusiastic to go through this treatment.

Accordingly other treatment alternatives were established, which are less painful and less expensive. Lip repositioning procedure is one of these procedures ; it is a possible and inexpensive 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.  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.

Gingivectomy is another approach of treatment. However, Gingivectomies can only be performed when reduction of gingival tissues is minimal. The tissue is removed with gingivectomy knives,  No.15 blades, dental laser or by radiosurgery. The advantages of this technique include; reduced pain, no sutures, and fast healing.

In this case theres an extensive reduction of the tissue is required, so crown lengthening procedures are the treatment of choice.  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.

Gummy smile cases are always esthetically demanding cases. This article presents a case treated with an interdisciplinary treatment approach and Digital Smile Approach (DSA) using Keynote (DSA), to predictably achieve an esthetic outcome for a patient with gummy smile. 

Keynote software, able to help in the virtual dental plan. This technique consists of inserting lines and drawings on digital facial photos and intra patient’s mouth. This procedure helps in the analysis, documentation and communication between professional and patient, encouraging understanding and visualization of the proposed treatment. Thus, after identifying the problem and correct virtual diagnosis to implement appropriate for case resolution technique. Therefore, this work aims to present a Case Report in which the virtual planning was used as an aid in periodontal surgical planning in order to correct the gummy smile.




Other treatment options :

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 Dentistry was required. This led to the use of Botox in dental Esthetics. Botox was used primarily for smoothing wrinkles of the forehead, the glabellar region and around the corners of the eyes.

Botox treatment to their patients as a part of cosmetic treatment. The significant adjunctive therapy that Botox adds to the esthetics dental treatment is a fact lacked by many dentists. Botox is a muscle relaxer and when used in the upper lip it can significantly decrease the strength of the muscle contractions that cause the high lip line.

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.

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 disadvantages are the frequency of the appointments, the high cost, possible complications of treatment including sensitivity, recession and possibility of endodontic therapy later on.

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.

Conclusion

Patients with gummy smile can be safely, simply, and successfully treated (when indicated) in the dental office. Although, different options of treatments are available and it makes no difference what type of treatment the patient chooses, however, the dentist exposure to the different available treatment approaches significantly expands the treatment choices we provide to the patients.

The DSD, commonly used in cases of prosthetic rehabilitation, proved to be versatile in this work and it allowed using it in virtual periodontal surgical planning. This article report a case of periodontal surgery previously planned and developed with the assistance of the DSD. This method, performed on digital images, transfer important information that can be used in the study model, where a diagnostic wax-up accordance with the planning provided . This mechanism is intended as an aid in the treatment plan, providing a better understanding and motivation of the patient who can have a comprehensive view of before and after treatment.  This  Digital Design Smile treatment concept proved to be versatile, and can also be used in periodontal surgery planning.
##### Dr Kamsiah G Haider Prosthodontist, DSD Master & Instructor, BDS, MDSc

Dr. Kamsiah is also known as Dr. Kam is cosmetic dentist with over 30 years experience . Areas of interest are prosthodontics , dental implants and orthodontics as part of smile make over. . . . Dr. Kamsiah was a full time lecturer at the University of Malaya and an Associate Professor at the International Islamic University . She still lectures , mentors and conduct courses on the Digital Smile Design .

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