JIACD
The Journal of Implant & Advanced Clinical Dentistry
What is the best way to handle a gummy smile? What is the latest and greatest surgical and restorative technique to handle this issue?
Tue, 05/25/2010 - 01:58 — pierre le roux
With the advent of extreme makeovers and everyone wanting a model smile. I see more and more people who want to treat their excessive gummy display.
What are the best techniques to do this? GV or Crownlenghtening?
What do you do with a patient with a high smile that removing gum isnt enough?
Please describe the lip pulldown technique,and pitfalls to look out for?
Thank You
JIACD
© 2008 Journal of Implant and Advanced Clinical Dentistry. Privacy Policy | Terms & Conditions
Comments
Gummy Smile approaches and techniques
Here is several approaches to handling this issue:
GV or Crown lenghtening
Lip repositioning
Botox or lip fillers.
Sometimes you need a combination of all 3 to get the best esthetic results.
Gummy smile treatment: Reverse Frenectomy
Where can I find the protocol or papers of reverse frenectomy of the upper lip to treat a gummy smile case?
Does it work? I been an OMFS for 15 years and I never seen this work.
First things first.........
First you need to determine the incisal edge position. If the anterior teeth are too long then you can shorten them incisally and lengthen the teeth gingivally to maintain the W-L ratio. If the incisal edge is correctly placed then you need to determine if increasing the length will make the teeth appear to long and narrow when a gingivectomy is performed. One option is some of these patients is to use Botox on the upper lip to limit how high they can lift the lip when smiling. Before doing this I would suggest using some Septocaine in place of the Botox this will allow the pt over the next few hours to decide if thet like the look of that. If they dont then the anesthetic will disapate. if they do then use of a little Botox will assist in limiting the lip lifting and exposure of the gummy smile. In drastic cases it may require Orthognathic surgery to remove a segment of the premaxilla apical to the teeth so that the lop then lies more incisally but this should be the last option. As Dean indicated sometimes its a combination of several treatments to get the result desired by the pt.
Dr. Kurtzman what is the proper incisal length position?
Dear Dr. Kurtzman,
What is the proper incisal lenght position? How much should show at rest and smile?
What do you feel is proper golden proportion.
I saw you lecture recently and enjoyed it very much.
Dr. Pratt
Hi Dr. Pratt
Which lecture was it and where? grin
I think we need to base the incisal edge position on where it falls in relation to the lower lip at rest. In theory it should either be slight short of the lip or barely touching it. Thos pts that it is just touching and are comfortable with that then use that as the starting point. But I would not set the incisal edge to touch it in restoring the teeth as usually the pt complains its touching. The incisal edges should also mimick the curve of the lower lip.
With regard to setting "golden proportions" I like the Chu instruments from Hufriedy. These quickly allow you by matching the color bands on the width to get a length that fits the proper proportions (or visa versa) without having to do any math.
One thing that IMHO makes or breaks the smile is the gingival levels. When they are all even it doesnt look natural and as we were taught the laterals should be slightly shorter (not as high apically) as the centrals and cuspids. But I think we frequently focus on the teeth (the picture) and ignore the gingiva and lips (the frame)
Gummy smile...avoid the rookie mistake
The biggest problem I see with people treating "gummy smiles" is that they do a gingivectomy when osseous crown lengthening is what is really needed. If the bone is at the CEJ's, simply wacking off a little gingiva is going to be a short term fix. The gums are going to grow back and your patient will not be happy. I see this all of the time.
Patients say to me, "My dentist zapped my gums with a laser and my teeth looked great! BUT, ONE YEAR LATER, THE GUMS GREW BACK AND I HAVE SHORT TEETH AGAIN! WHAT HAPPENED? WAS IT SOMETHING THAT I DID?"
No, it was nothing you did...the bone needed adjustment along with the gums. Remember, the bone sets the tone.
Incisal Length at Rest
Dr. Prat, The incisal length at repose (length of tooth showing at rest) varies from .5 mm to 2mm.
I have done over 250 lip
I have done over 250 lip repositioning surgeries ove rthe last 5 years some with pre-surgery use of BOTOX and written numerous articles and a chapter in the new book "The Art of Treatment Planning" edited by Rafi Romano (Quintessence 2009), and my deduction is that all cases must be treated with an open approach and all carefully assessed as to their essential aeitiology and thus their treatment plan from a number of modalities. |The most difficult cases involve hyper active LLS and LLSAN muscle groups and here we stabalise the most active cases with botox prior to surgery , if using only Botox you generally need 40 units to have an effect and it only lasts 2-3 months in most active cases.
Most cases aree a combination of treatment modalities and now the use of mini implants in ortho have also helped with intrusion.
With surgery as we know in all soft tissue procedures relapse is the issue and this varies from case to case but generally over 90% of patients are delighted with the results.
Regards
Peter
Peter, Botox question
Do you know if there are different BOTOX rules for dentists in different states?
Unfortunately I am based in
Unfortunately I am based in the UK , I am sure the State authority will fill you in but I have been using botox for about 7 years and in the lip area for about 3 .
Although straight forward and safe the quantities generally used are high ( 40 u) some specialist training is advocated.
Peter
Botox rules in the USA
yes each state has different rules for DDS to admin Botox. Check with your state board to see if you are permitted to use it and what training requirments are needed.
Peter: Surgical Techniques for the Gummy smile?
Peter what surgical techniques do you offer the patient to treat the gummy smile?
Can you go through your technique?
How do you incoporate the botox?
Do you offer any training courses?
Brooke
Botox for upper lip and gummy smile
One thing you need to remember about botox and fillers to hide a gummy smile is they dont last forever.
You have to prepare the patient that they have to return for retreatments.
Guy
Dr. Fairbairn question on gummy smiles
Dr. Fairbairn,
Can you shed some light on your surgical technique for lip reposition? How to you also add botox into the fold post surgery? What are the risks and complications you have seen?
Thanks,
Shaz
Dr. Fairbairn question on gummy smiles, I use botox
What is the surgical technique you do on lip reposition?
I myself do crown lenghtening, lip fillers and botox to hid the gummy smile.
Thanks
Ted
Hi all ,as said I have a
Hi all ,as said I have a chapter in the new Book "The art of treatment planning" published by Quintessence (2009) but if needed I can send a PDF on-line of another article on technique . A multi-disciplinary approach is often best in extreme cases.
I will talking on the procedure in London in September (4 th) at the International academy of advanced facial aestheitcs forum .
As with all soft tissue cases relapse can be an issue and thus you have to build it in ,when dealing with the most extreme cases.
Botox when used prior to treament is placed 2 weeks before surgery to stabalise the over active LLS muscles.
Regards
Peter
Gummy Smile: Dr. Fairbairn email
I would like a copy of that PDF. What is your email?
It is
It is peterdent66@aol.com
Regards
Peter
Gummy Smile: Crown lengthening and Botox
I have treated several gummy smiles with crown lengthening and botox. You lenghten the teeth and decrease the smile height. Works like a charm.