What are the treatment options for correcting a gummy smile?

Gummy Smile Correction

For gummy smile correction, treatment selection depends on the underlying etiology: periodontal surgical approaches (gingivectomy with or without osteoplasty) for altered passive eruption, orthodontic treatment with skeletal anchorage for dentoalveolar extrusion, orthognathic surgery for vertical maxillary excess, and lip repositioning surgery or botulinum toxin injections for hypermobile upper lip. 1, 2

Diagnostic Assessment

The first step requires identifying the specific cause of excessive gingival display, as this directly determines the appropriate treatment modality 1, 2:

• Measure gingival display during full smile (normal is ≤3mm; gummy smile typically shows 5-7mm) 3
• Assess clinical crown length and position of gingival margins relative to the cemento-enamel junction 1
• Evaluate bone crest position radiographically to distinguish between gingival overgrowth versus altered passive eruption 1
• Measure upper lip mobility and length during smiling to identify hypermobile lip as the cause 4, 5
• Assess vertical maxillary excess through cephalometric analysis if skeletal discrepancy is suspected 2

Treatment Algorithm by Etiology

Altered Passive Eruption (Gingival Margins Too Coronal)

Periodontal surgical correction is the definitive treatment when gingival margins are positioned more coronally than normal 1:

• Gingivectomy alone when adequate keratinized tissue exists and bone crest is properly positioned 1, 3
• Gingivectomy plus osteoplasty when bone crest is within 3mm of gingival margin, requiring bone recontouring to establish proper biologic width 1, 3
• This approach provides permanent correction without relapse when properly executed 3
• Clinical examination and radiographic evaluation must determine the position of gingival margin, bone crest, and cemento-enamel junction before surgery 1

Hypermobile Upper Lip

Botulinum toxin injection provides a minimally invasive first-line option for hypermobile lip with 6-8 month duration 4, 5, 2:

• Inject into the levator labii superioris alaeque nasi muscle to reduce lip elevation during smiling 4, 5
• Provides immediate improvement with mean duration of 213 days (range 186-240 days) 4
• Safer and less invasive than surgical alternatives, making it appropriate for patients reluctant to undergo surgery 2
• Can be combined with resective gingival surgery when both etiologies coexist 5

Lip repositioning surgery offers permanent correction but carries higher relapse risk 3, 2:

• Modified technique: remove partial-thickness ribbon of keratinized attached gingiva and suture labial alveolar mucosa to attached gingiva at more coronal position 3
• One-year follow-up shows reduction of excessive gingival display by 2mm without relapse when properly executed 3
• Traditional technique removing vestibular mucosa has documented high relapse rates 3

Hyaluronic acid injection represents an emerging alternative 4:

• Infiltrate paranasal area at most cranial portion of nasojugal fold, 3mm lateral to alar cartilage wing 4
• Provides compression of lateral fibers of levator labii superioris alaeque nasi 4
• Duration ranges 186-240 days with immediate improvement 4

Dentoalveolar Extrusion

Orthodontic treatment with skeletal anchorage devices effectively corrects less severe cases 2:

• Particularly effective for dentoalveolar extrusion without significant skeletal component 2
• Provides stable long-term results when properly planned 2

Vertical Maxillary Excess

Orthognathic surgery (maxillary impaction) is the definitive treatment for skeletal vertical maxillary excess 2:

• Offers lasting outcomes for patients with true skeletal discrepancy 2
• Reserved for cases where skeletal component is the primary etiology 2

Combined Approach Strategy

When multiple etiologies coexist, combine treatments sequentially 5, 3:

• Perform periodontal surgery first if altered eruption is present 1, 5
• Add botulinum toxin or lip repositioning if residual gingival display persists from hypermobile lip 5, 3
• This staged approach addresses each component systematically 3

Critical Pitfalls to Avoid

• Do not perform gingivectomy without assessing bone crest position, as inadequate biologic width will cause gingival recession and poor esthetic outcome 1
• Do not use traditional lip repositioning technique removing vestibular mucosa, as high relapse rates are documented; use modified technique removing keratinized gingiva instead 3
• Do not apply single treatment modality without identifying specific etiology, as treatment must match the underlying cause 1, 2
• Do not overlook the need for osteoplasty when bone crest is too close to gingival margin, as gingivectomy alone will fail 1, 3

Expected Outcomes

• Periodontal surgical approaches provide permanent correction when properly indicated 1, 3
• Botulinum toxin requires repeat treatments every 6-8 months but avoids surgical risks 4, 5
• Modified lip repositioning shows 2mm reduction in gingival display at one year without relapse 3
• Orthognathic surgery offers lasting correction for skeletal cases 2