Excessive gingival display Etiology, diagnosis and treatment modalities.

Smidt A, Silberberg N, Goldstein M. Quintessence International. 2009, 40:809-818.

This article addresses the aesthetic problem of the "gummy smile". The article nicely
describes the clinical presentation of the condition, the factors involved in its etiology, and
then the successful diagnosis of the condition, to determine how it was caused in a
particular patient - and hence guide the clinician to appropriate treatment based on the
etiological cause.
This is an article well worth the read. It covers principles of aesthetics as well as treating the
actual condition.

This summary was provided by Dr Michael Mandikos

Q U I N T E S S E N C E I N T E R N AT I O N A L

Excessive gingival display

Etiology, diagnosis, and treatment modalities
Nir Silberberg, DMD1/Moshe Goldstein, DMD2/
Ami Smidt, DMD, MSc, BMedSc2
Extensive exposure of the gingiva during a smile, called excessive gingival display, may be
a point of concern for both patients and clinicians. Patients often present to the dental
clinic seeking a solution to their gummy appearance. A clinician must fully understand
the various factors involved in this situation, to provide patients with an appropriate
answer. Thorough examination followed by the right diagnosis is imperative for achieving
an esthetic and predictable result in the treatment of such situations. The aim of this
article is to discuss the various aspects of excessive gingival display and its etiology and to
present the current solutions that exist in the literature. (Quintessence Int 2009;40:809818)

Key words: altered passive eruption, diagnosis, etiology, excessive gingival display,
gummy smile, vertical maxillary excess (VME)

Facial expressions and the smile are key

components for nonverbal communication.
The smile has an important role in the determination of the first impression of a person.1
An esthetic or pleasing smile is composed of 3 primary components2: the teeth,
lip framework, and the gingival scaffold. An
ideal esthetic and pleasing smile presents
the following characteristics (Fig 1)3,4: (1) minimal gingival exposure, (2) symmetric display
and harmony between the maxillary gingival
line and upper lip, (3) healthy gingival tissue

Graduate Student, The Center for Graduate Studies in

Prosthodontics, Department of Prosthodontics, Faculty of
Dental Medicine, The Hebrew UniversityHadassah, Jerusalem,
Israel.

Director, Graduate Studies in Periodontics, Department of

Periodontics, Faculty of Dental Medicine, The Hebrew
UniversityHadassah, Jerusalem, Israel.

Head, The Center for Graduate Studies in Prosthodontics,

Department of Prosthodontics, Faculty of Dental Medicine, The
Hebrew UniversityHadassah, Jerusalem, Israel.

Correspondence: Dr Nir Silbeberg, The Center for Graduate

Studies in Prosthodontics, Department of Prosthodontics,
Faculty of Dental Medicine, The Hebrew UniversityHadassah,
PO Box 12272, Jerusalem 91120, Israel. Fax: 972-2-6429683.
Email: sil76@012.net.il

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filling the entire interproximal spaces, (4) harmony between the anterior and posterior
segments (gradation principle5), (5) teeth in
correct anatomy and proportion (form and
position), (6) proper color and shade of the
teeth, and (7) lower lip parallel to the incisal
edges of the maxillary anterior teeth and to
the imaginary line going through the contact
points of these teeth.
The description excessive gingival display,
commonly called gummy smile, is used
when there is an overexposure of the maxillary gingiva during a smile6 (Fig 2). In severe
cases, the overexposure is also seen in
repose of the mouth and lips (Fig 3). In most
cases, the more the gingival tissues are displayed during the smile, the more unesthetic
the smile appears.7 The prevalence of excessive gingival display is 10% of the population
between the age of 20 and 30 years, and it is
seen more in women than in men.1,8 The incidence of this condition gradually decreases
with age as a consequence of dropping of
the upper and lower lips, which in turn leads
to a decrease in exposure of the maxillary
incisors and an increase in exposure of the
mandibular incisors.9,10

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Fig 1

A young woman presenting an ideal pleasing smile.

Fig 2

Excessive gingival display of a young female patient during a normal smile.

Fig 3

A severe case of excessive gingival display presenting an overexposure of anterior gingiva in repose.

Hair
1/2

1/3

1/3
Brows
Width equal to
brow-to-chin

1/3

Fig 4 (above) A woman presenting pleasing

gingival exposure during smiling.
Fig 5 (right)
nation.

1/2
Stomion Lips

1/3

1/3
2/3

Reference lines for facial exami-

Glabella
Eyes
1/3
Nose Subnasale
1/3

Soft tissue menton

When analyzing a smile, one must bear in

mind that a certain amount of gingival exposure during a smile is considered esthetically
pleasing, which gives the expression of a
youthful look4,11 (Fig 4).

DIAGNOSIS
For a correct diagnosis, a thorough examination must be performed.

Facial examination
Facial symmetry and proportions in both
frontal and lateral views. Assessment of
facial symmetry is made with respect to the
interpupillary line. This horizontal line divides
the face into equal halves.

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Accessory horizontal lines are the ophriac

line (a line going through the eyebrows) and
the commissural line. These lines should be
parallel to the interpupillary line, thus creating
an overall harmony of the face. These lines
can be used as a reference for orienting the
incisal plane, the occlusal plane, and the gingival contour. A line perpendicular to the
interpupillary line should divide the face into
2 symmetrical parts.
Face height is usually analyzed by dividing the face into thirds. The middle and lower
thirds are more involved in the esthetic consideration of the patient. When measured in
repose, these two thirds should be equal.
The lower third can br further divided by the
stomion into upper one-third and lower twothirds1215 (Fig 5).

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Subnasale

Lower border
of the upper lip

Fig 6 Upper lip length is measured between the

2 lines.

Fig 7

Upper lip length at rest (Fig 6). Upper

lip length is measured from the subnasale to
the lower border of the upper lip. The average lip length is 20 to 24 mm13 in young
adults and tends to increase with age.
Display of maxillary central incisors at
rest. Maxillary central incisor display at rest,
on average, is 3 to 4 mm in young women
and 2 mm in young men and tends to
decrease with age.9
Amount of gingival exposure during
rest, speech, smile, and laughter. During
an extensive smile, the upper lip should rest
at the level of the midfacial gingival margins
of the maxillary anterior teeth.13
Smile line. This term expresses the position of the upper lip relative to the maxillary
incisors and gingiva during a natural full
smile.1,8 A high smile line reveals the entire
crown of the tooth and an abundant amount
of gingiva (excessive gingival display). In the
average smile line, 75% to 100% of the
crowns is revealed with the interproximal gingiva. A low smile line is when less than 75%
of the crowns is revealed (Fig 7). A low smile
line is predominantly a male characteristic,
whereas a high smile line is predominantly a
female trait.11
Gingival margin outline. In patients with
excessive gingival display, any irregularities
and disharmony in the alignment of the gingival margin may have a significant effect on
smile esthetics. Harmony should exist
between the gingival line in the anterior and
posterior segments.12,15 The outline of the gingival margins should be parallel to both the

incisal edges and the curvature of the lower

lip. 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
Pinault12 considered symmetry of the gingival

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A low smile line in a man.

margins at the midline (central incisors) to be

essential, while more laterally a certain
amount of asymmetry is permissible.

Intraoral examination
Occlusal plane. The occlusal plane should
be evaluated by comparing it to the anatomic landmarks in the same way determined
during fabrication of complete dentures. 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.10 In this way, during a
smile, there is mild exposure of the tips of the
mandibular canines and premolars.
Harmony of the dental arches. The
anterior (incisal part) and posterior segments
should be in harmony with one another and
have no major discrepancies.
Anatomy, proportions, and color of the
teeth. Lombardi5 pointed out the importance of the proportions between width and
length in the dimensions of individual teeth.
A comparison between the anatomic crown
height (incisal edge to cementoenamel junction [CEJ]) and the clinical crown height
(incisal edge to free gingival margin) 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.

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Fig 8 A boy with pronounced gingival enlargement due to cyclosporine treatment.

Fig 9 A girl with altered passive eruption of multiple teeth. Teeth appear short and square.

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. The position of
the free gingival margins relative to the CEJ is
another important issue. The periodontal biotype may influence the reaction of the gingival
tissues to periodontal therapy and surgery.
There are 3 periodontal biotypes: thin and
scalloped, normal, and thick and flat.15,16 This

Altered/delayed passive eruption

information has a crucial influence on the

treatment strategies and decisions.
A correct diagnosis of excessive gingival
display performed according to all the abovementioned issues allows the clinician to
select the proper treatment modality and
achieve a clinical result that satisfies both
patient and operator.

ETIOLOGY OF EXCESSIVE
GINGIVAL DISPLAY AND
TREATMENT MODALITIES
Plaque-/drug-induced gingival
enlargement
This is a condition in which the enlarged gingival tissues are covering the clinical crowns,
creating an unesthetic appearance (Fig 8). It
is most often related to dental plaque and
inflammation but can be associated with
medication such as phenytoin, cyclosporine,
and calcium channel blockers. Treatment of
this condition should focus on meticulous
oral hygiene. Sometimes, periodontal surgery will be needed to eliminate the excessive amount of soft tissues.13,17

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Passive eruption is a normal condition in

which the gingival margins recede apically to
the level of the CEJ after the tooth has erupted completely. In cases in which the gingival
margins fail to recede to the level of the CEJ,
the condition is named altered passive eruption. Because the gingival tissues are positioned coronal to the CEJ, the teeth appear
short and square (Fig 9).
This condition may involve multiple teeth
or an isolated tooth. The incidence of altered
passive eruption in the general population is
about 12%. The physiologic condition of passive eruption may continue even in the third
decade of life; therefore, the diagnosis of
altered passive eruption must be made with
respect to age.
The alveolar crest may be at the level of
the CEJ or 1 to 2 mm apical to it, as exists in
a healthy condition. Parallel radiography will
help determine the level of the alveolar crest
interproximally, and probing to bone (sounding) will determine its level facially and orally.13,18,19
A classification for altered passive eruption was suggested by Coslet et al20:
Type 1Aexcessive amount of keratinized
gingiva with normal alveolar cresttoCEJ
relationship
Type 1Bexcessive amount of keratinized
gingiva with osseous crest at the CEJ level
Type 2Anormal amount of keratinized
gingiva with normal alveolar cresttoCEJ
relationship
Type 2Bnormal amount of keratinized
gingiva with osseous crest at the CEJ level

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Fig 10 Excessive gingival display due to overeruption of the maxillary incisors. Note the discrepancy in the occlusal plane between the
anterior and posterior segments.

Fig 11 A typical case of vertical maxillary

excess. Note the amount of gingival tissues
exposed and the lower lip covering the maxillary canines and premolars.

Fig 12 Cephalometric analysis. The anterior maxillary height is measured between the palatal plane
and the incisal edge of the maxillary incisors.

Palatal plane
3
Incisal edge

Altered passive eruption may be resolved

with periodontal surgery. The selected surgical procedure depends solely on the type of
altered passive eruption.

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 overeruption) 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 (Fig 10).
Treatment of this condition may include
orthodontic intrusion of the involved teeth
moving the gingival margin apically, surgical
periodontal correction with or without
adjunctive restorative therapy, or an interdisciplinary comprehensive treatment plan.2,12,15

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Vertical maxillary excess (VME)

This condition involves an overgrowth of the
maxilla in the vertical dimension. Many times,
it appears with a long-face syndrome.12,21 An
increase in facial height appears mainly in the
lower half of the face, and in contrast to overeruption of the maxillary incisors, harmony of
the occlusal plane between the anterior and
the posterior segments is found. Because the
occlusal plane is relatively lower than normal,
individuals with VME will have excessive gingival display with the lower lip covering the
incisal edges of the maxillary canines and premolars (Fig 11). These clinical findings may
lead the clinician toward diagnosing VME,
which must be confirmed with a cephalometric radiograph reading. It was found in a
gummy smile group8 that the distance
between the palatal plane and the incisal edge
of the maxillary incisors (anterior maxillary
height) was approximately 2 mm higher than
in individuals without gummy smiles (Fig 12).

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Ta b l e 1
Degree

Classification of vertical maxillary excess*

Gingival and mucosal
display (mm)

24

II

48

III

Treatment modalities

Orthodontic intrusion
Orthodontics and periodontics
Periodontal and restorative therapy
Periodontal and restorative therapy
Orthognathic surgery (Le Fort I osteotomy)
Orthognathic surgery with or without adjunctive periodontal and
restorative therapy

*Taken from Garber and Salama2

Fig 13

In cases of VME, most often, the length of

the upper lip is normal, although clinically, it
appears relatively short.
A classification of VME was introduced by
Garber and Salama in 19962 offering 3
degrees of gingival exposure and corresponding treatment modalities (Table 1).

Short upper lip

In this instance, the upper lip is shorter than
15 mm, measured from the subnasale to the
lower border of the upper lip22 (Fig 13).
Interestingly, a number of studies showed
that in most cases of excessive gingival display, the upper lip length is normal even
though the lip appears clinically short.8 The
treatment modality recommended for this
condition will be discussed ahead.

Hyperactive upper lip

This condition represents increased activity
of the elevator muscles of the upper lip during smile. According to the study of Peck et
al,8 individuals with excessive gingival display
present significantly more efficient lip-elevation musculature compared to those with
average smile lines. In this study, people with

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A girl with short upper lip.

a high lip line raise the upper lip an average

of 1 extra millimeter, or nearly 20% more,
than the reference group during a smile.
The treatment modalities recommended
for short upper lip and hyperactive upper lip
are similar. Plastic reconstructive surgery
was the solution offered in several reports
published in the 1970s and 1980s for treatment of such conditions. The first technique
reported was the lip adhesion technique
described by Rubinstein and Kostianovsky.23
In this technique, the internal connection of
the upper lip is severed, and an elliptical
piece of tissue is removed from the dissected
area. Then, a lower connection is established
between the upper lip and gingival soft tissues, about 4 mm above the free gingival
margin. This procedure of reconnection
restricts upper lip elevation during the smile,
limiting the amount of gingival tissue exposure. Litton and Fournier in 197924 discussed
and supported this treatment modality in
their work and recommended that it be used
more widely. Their modification was to
detach the lip muscles from the bony structures in cases of short upper lip to increase
the lip length.

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Excessive gingival and teeth display

Increased incisor
exposure during rest
Normal lip
length

Short
upper lip

Difference between anterior

and posterior occlusal planes

Harmonious
occlusal plane

Incisor
overeruption

VME

Incisor
overeruption
(compensatory)

Fig 14

Normal incisor
exposure during rest
Short clinical
crown
Incisal
attrition

Normal clinical
crown length

No
attrition

Hyperactive mobile
upper lip

Differential diagnosis

Altered passive
eruption
(1 or more teeth)

Gingival
hyperplasia

A flow chart to determine the correct etiology of excessive gingival display.

In 1983, Miskinyar,25 being disappointed

with the previous technique, described the
levator myectomy and partial removal technique. Ellenbogen and Swara26 described
the implant spacer technique in 1984. These
2 techniques were based on the same concept of transecting the levator labii superioris
muscle (or part of it), one of the essential
muscles participating in smile formation.
According to the authors, this procedure
results in a decreased elevation of the upper
lip during smile. Ellenbogen and Swara
offered insertion of a space maintainer (silicone, cartilage, polyamide, or turbinate
bone) to prevent the muscle from reconnecting. Another important factor in the presence
of such an implant spacer is its ability to limit
the activity25,26 of the elevator muscles. The
latter reports presented good results with a
limited number of complications but had no
follow-ups. A literature search conducted by
the authors of this review in search of
updates in this field revealed a small and
nonsignificant number of current reports on
these methods with no actual innovations. In
a recent publication, the original lip adhesion
technique23 was used with a follow-up of 8
months reporting good results.27

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Polo in 200528 offered the use of botulinum toxin injections as a new nonsurgical
method for treating excessive gingival display. The toxin is injected into the area of the
upper lip to decrease the elevating muscle
activity, aimed in particular at the levator labii
superioris muscle. The major disadvantage
of this technique is the short effect of the
toxin, which lasts only 3 to 6 months.
In contrast to the above-mentioned treatment options, some cases of excessive gingival display due to short or hyperactive upper
lip may be treated by periodontal surgery
with or without an adjunct restorative therapy.

Asymmetric upper lip

In 2001, Benson and Laskin29 evaluated the
smile in a group of 195 subjects and found
9% with asymmetric smile, due to canting of
the upper lip. This asymmetry can lead to
excessive and asymmetric gingival exposure.
When this asymmetry appears only during a
smile, (in most cases) it is uncorrectable. It is
imperative to draw the patients attention to
such an asymmetry before the onset of any
comprehensive dental treatment.
A flow chart that can help determine the
correct etiology of a specific excessive gingival display case is shown in Fig 14.

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In general, cases of excessive gingival display may have more than one etiology and
should therefore be diagnosed carefully, and
an interdisciplinary treatment should be considered. It is of high importance to involve the
patient throughout the process of diagnosing
and treatment planning. An informed patient
is a key factor to treatment success and personal satisfaction.

TREATMENT
CONSIDERATIONS
As stressed before, proper examination and
correct diagnosis must be performed before
deciding whether to include periodontal surgery in the treatment. A decision has to be
made on the type of surgery, with or without
bone resection6,2931:
Gingivectomy is indicated when there is
excess keratinized soft tissue and the
bone level is appropriate. Careful evaluation must take place before surgery so that
adequate keratinized gingival tissues will
remain after surgery. This procedure
applies to cases of gingival overgrowth
and altered passive eruption type 1A.
Apically positioned flap without osseous
resection is recommended for cases in
which the bone level is appropriate but
gingivectomy will leave less than 3 mm of
keratinized gingival tissues. This is performed in cases of altered passive eruption type 2A.
Apically positioned flap with osseous
resection is recommended for all other
cases where osseous resection is required.
The osseous resection should bring the
bone crest 2.5 to 3.0 mm away apically
from the CEJ or from the definite location
of the finishing line of the final restoration to
achieve a physiologic biologic width.
It is imperative to evaluate the root length of
the teeth before surgery. Any procedure that
needs a considerable amount of bone resection will result in a relative reduction in the
bony support and has a negative influence
on the crown-to-root ratio,32 teeth mobility,

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and bony support. After periodontal surgery,

it becomes more difficult to achieve an
esthetic result with the restorative treatment.
Because the remaining roots have a smaller
diameter, it becomes complicated to deal with
the emergence profile and the big interproximal distances that lead to the black holes
appearance.
Restorative therapy should be planned in
cases of excessive gingival display in the following situations: (1) short clinical crowns
due to loss of tooth structure (ie, tooth wear);
(2) existing faulty restoration or following an
esthetic complaint by the patient; and (3)
exposed roots as a consequence of periodontal therapy causing teeth hypersensitivity and impaired esthetics.
When planning restorative treatment after
periodontal surgery, one of the important
issues to be considered is soft tissue maturation. During this period, changes may
occur in the coronoapical position of the free
gingival margins, and thus careful observation and evaluation of tissue healing is needed before the case can be finalized. The
preparation finishing line must be placed
supragingivally during the healing period,
avoiding any disturbance to the maturation
process.33 In esthetic regions, a healing period of at least 6 months should be allowed following the periodontal surgical procedure for
the final maturation and location of the free
gingival margins.13,34,35 After proper healing
and maturation of the tissues, final preparation of the teeth will be performed, where the
finishing line is set no deeper than 0.5 mm
subgingivally.13
The extent of the periodontal corrective
procedure for excessive gingival display
depends on the patients display during smile
and repose. Because most people (about
80%) expose the maxillary teeth from second
premolar to second premolar while smiling,1
the surgical procedure should be performed
between the first molars to achieve a harmonious smile and correct gingival contours.18
Prediction of the final outcome of periodontal and restorative therapy is important
in treating cases of excessive gingival display. Therefore, it is recommended to use a
surgical stent during surgery.33 The first step
is to prepare a total waxup of the teeth and

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Fig 15a and 15b

Use of a surgical stent during periodontal surgery in a case with excessive gingival display.

Fig 16 Use of a surgical stent to determine the flap

position at the end of surgery.

Figs 18a and 18b

gingival display.

Before and after comprehensive periodontic and restorative treatment of excessive

create a correct gingival contour on a study

model. A surgical acrylic stent is made
according to the waxup, which provides several advantages (Figs 15a and 15b): preoperative imaging of the final result in the mouth,
allowing in cases of excess keratinized gingival tissues a definite incision line of the gingivectomy, guiding the osteotomy for correct
osseous architecture and proper soft tissue
healing, determining the flap position at the
end of surgery (Fig 16), and monitoring the
tissue position and maturation during followups (Fig 17).

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Fig 17 Three-week follow-up. Use of surgical stent

in monitoring the tissue position and maturation.

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CONCLUSION
Excessive gingival display is an esthetic concern both to the patient and the clinician,
especially when restoration of the anterior
teeth is indicated. Understanding the etiology and treatment options is crucial in the
process of treatment of a patient with a
gummy smile. The principles and concepts
discussed in this review will lead the clinician
toward achieving an esthetic result and
patient satisfaction with the performed treatment (Figs 18a and 18b).

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REFERENCES

20. Coslet JG, Vanarsdall R, Weisgold A. Diagnosis and

classification of delayed passive eruption of the

1. Tjan AH, Miller GD, The JG. Some esthetic factors in

a smile. J Prosthet Dent 1984;51:2428.
2. Garber DA, Salama MA. The aesthetic smile:
Diagnosis and treatment. Periodontol 2000 1996;
11:1828.
3. de Castro MV, Santos NC, Ricardo LH. Assessment of
the golden proportion in agreeable smiles.

dentogingival junction in the adult. Alpha Omegan

1977;70:2428.
21. Kawamoto HK Jr. Treatment of the elongated lower
face and the gummy smile. Clin Plast Surg 1982;9:
479489.
22. Ahmad I. Anterior dental aesthetics: Dentofacial
perspective. Br Dent J 2005;199:8188.
23. Rubinstein A, Kostianovsky A. Cosmetic surgery for

Quintessence Int 2006;37:597604.

4. Landsberg CJ, Sarne O. Management of excessive
gingival display following adult orthodontic treatment: A case report. Pract Proced Aesthet Dent

the malformation of the laugh: Original technique.

Prensa Med Argent 1973;60:952954.
24. Litton C, Fournier P. Simple surgical correction of the
gummy smile. Plast Reconstr Surg 1979;63:372373.

2006;18:8994.
5. Lombardi RE. The principles of visual perception
and their clinical application to denture esthetics.

25. Miskinyar SA. A new method for correcting a

gummy smile. Plast Reconstr Surg 1983;72:397400.
26. Ellenbogen R, Swara N. The improvement of the

J Prosthet Dent 1973;29:358382.

6. Allen EP. Use of mucogingival surgical procedures
to enhance esthetics. Dent Clin North Am 1988;32:

gummy smile using the implant spacer technique.

Ann Plast Surg 1984;12:1624.
27. Rosenblatt A, Simon Z. Lip repositioning for reduc-

307330.
7. Isiksal E, Hazar S, Akyalcin S. Smile esthetics:
Perception and comparison of treated and untreated smiles. Am J Orthod Dentofacial Orthop 2006;

tion of excessive gingival display: A clinical report.

Int J Periodontics Restorative Dent 2006;26:
433437.
28. Polo M. Botulinum toxin type A in the treatment of

129:816.
8. Peck S, Peck L, Kataja M. The gingival smile line.

excessive gingival display. Am J Orthod Dentofacial

Orthop 2005;127:214218.

Angle Orthod 1992;62:91100.

9. Vig RG, Brundo GC. The kinetics of anterior tooth

29. Benson KJ, Laskin DM. Upper lip asymmetry in

adults during smiling. J Oral Maxillofac Surg 2001;

display. J Prosthet Dent 1978;39:502504.

10. Zarb GA, Bolender CL, Hickey JC, Carlsson GE.
Bouchers Prosthodontic Treatment for Edentulous

59:396398.
30. Foley TF, Sandhu HS, Athanasopoulos C. Esthetic
periodontal considerations in orthodontic treat-

Patients, ed 10. St Louis: Mosby, 1990.

11. Peck S, Peck L. Selected aspects of the art and science
of facial esthetics. Semin Orthod 1995;1:105126.
12. Chiche GJ, Pinault A. Esthetics of Anterior Fixed
Prosthodontics. Chicago: Quintessence, 1994.

mentThe management of excessive gingival display. J Can Dent Assoc 2003;69:368372.

31. Wennstrom JL, Prato GPP. Mucogingival therapy
Periodontal plastic surgery. In: Lindhe J, Karring T,
Lang NP (eds). Clinical Periodontology and Implant

13. Jorgensen MG, Nowzari H. Aesthetic crown lengthening. Periodontol 2000 2001;27:4558.

Dentistry, ed 4. Oxford: Blackwell Munksgaard, 2006.

32. Grossmann Y, Sadan A. The prosthodontic concept

14. Ahmad I. Anterior dental aesthetics: Facial perspective. Br Dent J 2005;199:1521.

of crown-to-root ratio: A review of the literature.

J Prosthet Dent 2005;93:559562.

15. Fradeani M. Esthetic Rehabilitation in Fixed

Prosthodontics. Chicago: Quintessence, 2004.

33. Landi L, Manicone PF, Piccinelli S, Raia R, Marinotti R,

Scutella F. Determining osseous resection during

16. Ahmad I. Anterior dental aesthetics: Gingival perspective. Br Dent J 2005;199:195202.

surgical crown lengthening in the esthetic zone

with the use of a radiographic and surgical tem-

17. Claffey N. Plaque-induced gingival disease. In: Lindhe

plate. Quintessence Dent Technol 2004;27:101113.

J, Karring T, Lang NP (eds). Clinical Periodontology

34. Pontoriero R, Carnevale G. Surgical crown lengthen-

and Implant Dentistry, ed 4. Oxford: Blackwell

ing: A 12-month clinical wound healing study.

Munksgaard, 2006.

J Periodontol 2001;72:841848.

18. Levine RA, McGuire M. The diagnosis and treatment

35. Bragger U, Lauchenauer D, Lang NP. Surgical length-

of the gummy smile. Compend Contin Educ Dent

ening of the clinical crown. J Clin Periodontol

1997;18:757762, 764.

1992;19:5863.

19. Evian CI, Cutler SA, Rosenberg ES, Shah RK. Altered
passive eruption: The undiagnosed entity. J Am
Dent Assoc 1993;124:107110.

818

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