How important is the diagnostic process of gummy smile?
In my opinion, diagnostic process is everything or the only thing that can ensure success of the treatment. Patient must not have any systemic health problem that is contraindicated to the surgical procedure. Noted that many medication contributes to uncontrolled gingival overgrowth (Nifedipine, Beta-blocker, Dilantine, Cyclosporine, etc…)
First of all, we must determine the gummy smile is due to the teeth hypoerupt or because of the excessive vertical growth of the maxilla. The first case can be correct with esthetic crown lengthening, the second must be correct with either orthodontics and/or oral maxillofacial surgery of which the entire maxillary process must be repositioned. Oral habits must be ruled out because they contribute to the developmental or growth problems (for example, narrow arch, mouth breather, thumb sucking, etc…) of the dentofacial structures, especially in children. Identify these pathological causes will allow us to early intervene and prevent the problem worsen or recur in the future.
The next step is determine the severity of the gummy smile appearance. The height to width ratio of central incisors is 11/8.5. We must look at how much the gingival tissue needed to be removed or repositioned apically. We also must look at the probing depth of the anterior teeth to locate the position of CEJ ( the border demarcated the root portion and the anatomical crown portion of the teeth) to determine whether alveolar bone removal is anticipated during the procedure. In many case, alveolar bone removal is the must to prevent relapse. The approximate preferred distance from alveolar bone crest to the CEJ is 2.5-3.0mm. When this distance is violated, we either will have regrowth of the gingival tissue in the future or inflammation (could be subclinical) of the pocket gingiva. In certain case, orthodontic therapy is used to intrude the teeth so that the entire attachment apparatus (the gingiva and CEJ) will reposition more apically and thus reduce the “gummy smile” appearance.
One area that is often overlooked is the methodology of which we reduce the gummy smile. The dentist/surgeon must look at the amount of attached gingiva on the buccal surfaces of the teeth. Literature have shown that the amount of attached gingiva contributes to the protection of bacterial invasion and prevent the inflammation to the gingiva. The dentist/surgeon must NOT remove the attached gingiva for the sake of reducing gummy smile. This happen many times when laser was used and flap was NOT raised or reflected due to the fact that laser was market as a tool to do quick surgical removal procedure without the need of anesthesia. However, due to the extensive involvement with the procedure, we always anesthetize patient and use our laser as to reduce hemostatis and provide the initial esthetic contouring of the gingiva. In many case, we combine the effects of limited tissue removal (to preserve the attach gingiva) with apically reposition flap (to reposition the gingival tissue more apically) to achieve our result.
Next, we must NOT forget the health of the periodontal apparatus, i.e., the periodontal ligament, the cemental attachment, and the alveolar bone. Healthy periodontal apparatus ALWAYS ensure beautiful appearance of the teeth. Inflamed gingiva never give the tooth the good appearance. There must be no bleeding upon probing, no vertical bone loss, or any sign or symptom of the PROGRESSION of gum disease. Neglecting the health of the periodontium may lead to excessive gingival recession, complication during healing, uneven gingival crest, and ultimately the ugly smile that is worse than the before picture!
Finally, we must paint the picture of the final smile to the patient. The success of this whole procedure base on how accurate we can reproduce this picture in real life. Before I start, my patient and I must know what the end looks like. I believe that there is NO such thing as “the smile look close enough to being good”.