Esthetic Disharmony Research Articles

GUMMY SMILE, PANORAMIC REVIEW, DESCRIPTION, ETIOLOGY, EPIDEMIOLOGY, TREATMENT AND PROGNOSIS

Introduction: gummy smile is defined as a non-pathological condition that causes aesthetic disharmony in which more than 3 mm of gingival tissue is present when smiling. The smile is an essential aesthetic component of the face and significantly determines the perception of beauty and personality of each person. Objective: to detail the current information related to the gingival smile, description, etiology, epidemiology, evaluation, treatment and prognosis. Methodology: a total of 42 articles were analyzed in this review, including review and original articles, as well as clinical cases, of which 34 bibliographies were used because the other articles were not relevant to this study. The sources of information were PubMed, Google Scholar and Cochrane; the terms used to search for information in Spanish, Portuguese and English were: gingival smile, gingival hyperplasia, maxillary excess, orthognathic surgery. Results: Gummy smile presents a prevalence between 10.5% and 29% of young adults, being more frequent in women, and this prevalence is reduced with age due to the drooping of the upper and lower lips, which reduces the exposure of the gingiva and upper incisors. The perception of excessive gingival display is subject to cultural and ethnic preferences, showing that the amount of gingiva presented that is found to be unaesthetic or excessive is relative and changes between men and women. Conclusions: the smile is a common human expression that represents multiple feelings, as well as an essential esthetic component of the face and significantly determines the perception of beauty and personality of each person. The gummy smile is a non-pathological condition that causes aesthetic disharmony in which more than 3 mm of gingival tissue is present when smiling. A gummy smile can usually have repercussions in the perception and psychosocial behavior of the affected individual. The etiology of the gummy smile presents several factors, which usually manifest themselves at the same time. Treatment should be targeted according to the origin of the condition. Among the less invasive treatment alternatives are botulinum toxin injection and hyaluronic acid injection. The surgical repertoire includes gingivectomy, modified lip repositioning and orthognathic surgery. KEY WORDS: gummy smile, gingival hyperplasia, maxilla, orthognathic surgery.

Aesthetic Rehabilitation of Anterior Maxillary Diastema with Ceramic Veneers: A Case Report

The use of ceramic veneers is becoming increasingly common in Ästhetik dentistry. This method is considered to be minimally invasive with high aesthetic results due to the major advances in ceramic and bonding techniques. The success of a restorative treatment in anterior teeth depends on the esthetic integration between soft tissues and hard tissues. Aesthetic management of diastema using veneers is nowadays a well-established method. The purpose of this clinical report is to describe a conservative treatment approach to recover an esthetic disharmony caused by multiple maxillary diastemas. A 27 years old female patient was seeking to improve her smile. Ceramic veneers were planned and build-up with the help of diagnostic models, wax-up and mock-up.

Alternative management of patients with gummy smile due to maxillary growth: Clinical case

The patient's smile plays an important role in his psychology, managing to express joy, confidence, kindness, among other emotions. Gummy smile or subsequently, short tooth syndrome has been defined as a nonpathological condition causing esthetic disharmony in which more than 3 mm of gingival tissue is exposed when smiling. Having various etiologies such as excessive maxillary growth, short upper lip, or abnormal eruption of maxillary anterior teeth, it indicates that the approach to the problem can also be varied. Despite orthognathic surgery being the ideal treatment for some cases, it is important to recognize that there are contraindications and disadvantages of this type of surgery. The lip stabilization technique or LipStaT® is a minimally invasive and novel procedure that seeks to improve the appearance of the smile by repositioning the upper lip and decreasing the amount of gum showed during dynamic smile. In this clinical case, it was detected that the main problem of the patient lies in the excessive maxillary growth, for which the ideal treatment of the patient lies in orthognathic surgery, however, he does not agree to this, for which the approach will focus on something minimally invasive compared to orthognathic surgery, such as crown lengthening elaboration and lip repositioning.

Rehabilitation of peg shaped lateral incisors with ceramic veneer: A case report

The most common discrepancy concerning tooth size is the presence of peg shaped lateral incisors, which can cause teeth with reduced size, anterior diastema and consequently an unpleasant smile. The development of adhesive dentistry and ceramic veneers allowed all ceramic bonded restorations to become an esthetic, durable and functional approach to reestablish the smile harmony. The purpose of this clinical report is to describe a conservative treatment approach using ceramic veneer to restore an esthetic disharmony caused by bilateral peg shaped lateral incisors.

English

An unpleasant smile can have a psychosocial effect leading to lack of self-esteem and a challenge in social relations. A perfect smile is a balance among 3 parameters: the white (teeth), the pink (gum) and the lips. A predictable smile correction warrants a multidisciplinary approach and good treatment planning. We planned for a minimally invasive interdisciplinary treatment approach for the restoration of a gummy smile with dental fluorosis in a young female patient. An interdisciplinary management of smile correction is crucial for successful results. Lasers for soft tissue management and minimal tooth preparation for direct composite veneer restorations being minimally invasive periodontal and restorative approaches were the key to success with exceptional patient satisfaction. Minimally invasive procedures in interdisciplinary dentistry should be embraced in the management of procedures requiring correction of both hard and soft tissues, for successful outcomes. Pre-treatment mock-up can build patients' confidence in dentistry and are useful tools for planning treatments with a predictable outcome. A beautiful smile is the fruit of a coordinated and balanced interplay between teeth, gingiva and lips. A compromise in any of these cornerstones can impair the beauty of a smile. Thorough knowledge and understanding about the various elements involved and their harmonious synchronisation makes smile makeovers a challenging task. One such challenge is the treatment of gummy smile. A gummy smile is a clinical condition that has gained tremendous focus and attention recently. Gummy smile is the excessive gingival display when a person smiles. It has been defined as a nonpathological condition causing aesthetic disharmony in which more than 3 mm of gingival tissue is exposed while smiling.1 Aetiology of a gummy smile can be multifactorial and the main factors being altered passive eruption (APE), vertical maxillary excess and upper lip hypermobility. The diagnosis must be accurate to deliver the appropriate line of treatment. Based on the complexity of the underlying aetiological factors involved, the treatment modalities also change from conservative approaches like aesthetic restorations and orthodontic tooth movements to periodontal and maxillofacial surgical procedures.2 Altered passive eruption (APE) also knows as “impaired passive eruption” is a clinical condition characterised by the coronally positioned marginal gingiva in relation to the cementoenamel junction (CEJ). Passive eruption is a physiological phase involved in the process of tooth eruption. As the teeth meet the occlusal plane, the soft tissue covering the teeth migrates apically till the CEJ is reached. Retardation in this process causes failure of the gingiva to migrate apically, resulting in short clinical crowns and excessive soft tissue exposure while smiling. This is visualised as a gummy smile.

Gummy Smile: Mercado-Rosso Classification System and Dynamic Restructuring with Hyaluronic Acid

BackgroundGummy smile (GS) is a nonpathological condition causing esthetic disharmony in which an excessive amount of gingival tissue is exposed when smiling. Nowadays, there is not unanimous agreement regarding both classification and management of GS. This study aimed to present an organized and comprehensive clinical classification of the GS, as well as to discuss a therapeutic approach, with hyaluronic acid dermal fillers.MethodsThis study is presenting the clinical experience of the authors regarding GS.ResultsThe Mercado-Rosso GS classification has into account aesthetic aspects, etiopathogenetic criteria, and functional aspects of the smile. According to Mercado-Rosso GS-classification-system, GS is divided into 3-types: Type 1, characterized by a lack of support and/or a lack of projection of the upper maxilla; Type 2, due to an imbalance between the strength (excess) and the resistance (defect) of the levator muscles; and Type 3, defined by an excessive strength of the zygomatic muscles, which causes a wide smile and an excessive visualization of the molar teeth.ConclusionsThe Mercado-Rosso GS classification system is a tool that facilitates the diagnostic and therapeutic approach to the gummy smile. RD Dynamic Restructuring® constitutes a comprehensive therapeutic approach that makes reference to both the effect of the HA filler on the muscle movement and the balance between the muscle strength and the resistance of the soft tissue to be folded in different facial structures). Level of evidence: Level V.

Miomodulação com ácido hialurônico para o tratamento do sorriso gengival

The "gummy smile" occurs when more than 3-4 mm of gingiva appears during the act of smiling. It is considered unattractive and causes aesthetic disharmony. It has a multifactorial etiology, with several techniques described for its correction. Myomodulation with hyaluronic acid is a non-surgical alternative with immediate and lasting results. In this article, we present a case of myomodulation with hyaluronic acid to correct "gummy smile" in a 31-year-old patient.

Orthodontic Traction of Impacted Teeth with Modified Nance Appliance : Case Reports

Proper treatment of an impacted tooth is required as it causes functional and esthetic disharmony, as well as it can cause root absorption of adjacent teeth. Treatment options for impacted teeth include periodic observation, surgical exposure, orthodontic traction followed by surgical exposure, tooth transplantation, and extraction. Modified Nance appliance, used for orthodontic traction, is clinically useful because it does not require patient cooperation. Through orthodontic traction combined with surgical exposure of impacted maxillary incisors, canines, and molars using modified Nance appliance, adequate results can be obtained.

Mentalis muscle resuspension. The foundation for chin surgery

Background: The Mentalis Muscle is one of the main supporting anatomical entities of the soft tissues of the lower lip and chin. A Mentalis muscle dysfunction can result in lower lip ptosis, eversion of the lower lip, lip incompetence, and esthetic disharmony with unnatural exposure of the lower incisors. The most common etiological factor we have seen is previous genioplasty procedures where there was a failure to resuspend the mentalis muscle at the time of the initial surgery. Traditional muscle suspension techniques will fail to obtain acceptable outcomes in these cases.

Digitally-processed custom plate versus conventional plate fixation in Genioplasty

Purpose: The fundamental position of the chin contributes to the aesthetic perception of the face and the subsequent esthetic disharmony when deficient or retruded. In this study, we aimed to verify differences in plate design used in fixation of chin after Genioplasty with relation to postoperative tissue relapse.Patients and methods: Sixteen patients suffering from a retruded chin affecting the facial esthetics which needed advancement Genioplasty were included in this study. They were selected from the outpatient clinic of the departments of oral and maxillofacial surgery and Orthodontics, faculty of Dentistry, Cairo University, with a mean age of 28 years. Facial analysis was performed through clinical intra and extra-oral photographs. Preoperative data from CT scans were documented. Digital planning was done to fabricate a cutting template and a positioning chin template. The patients were then divided into two groups; eight patients each. In Group A patients, custom digital plates designed on the computer software and processed from CAD data from titanium were used to fix the chin after Genioplasty. In group B patients, conventional titanium T-shaped plate was adapted and used in fixation of the chin. Postoperative patient satisfaction and any postoperative complications were recorded. Clinical evaluation including fragment mobility and/or parasthesia was documented on one week, one month, 3 months and 6 months postoperatively. CT scan was performed immediately postoperative and on 6 months to assess fixation and/or tissue relapse through measuring the linear Antero-posterior measurements and the transverse measurements.Results: All the patients were clinically satisfied and content about the new chin position and facial contour. All the surgeries went uneventful with no hardware exposure. Numbness of the lower lip was reported in all patients, which faded with time and reported full recovery later on. Radiographic CT scan measurements revealed the accurate postoperative measurements compared to the preoperative plan. The mean linear Pog-orbit-mental measurements showed net overall significant increase, however, with a statistical significant decrease from one period to another in each groups. In both groups, there were no statistical significant changes in mean Pog- Right mental plane and Pog- left mental plane transverse measurements. Statistical correlation between results of both groups showed no significant differences over the study period.Conclusion: This study recommended the use of digital planning of Genioplasty and template fabrication due to the documented exact pre-to-postoperative chin alignment. The specific custom plate design and processing proved to be an insignificant hassle which can be spared by using the conventional plate for fixation after Genioplasty.

Multidisciplinary Dentistry - Ceramic Laminate Veneers for Orthodontic Finalization - Clinical Case Report

Abstract Currently, patients seeking dental treatment are increasingly concerned with the esthetics. Accordingly, the professional must be able to indicate treatment approaches that often include more than one specialty. This concept of integrated dentistry allows achieving excellence in results, which may not be reached one single Dentistry specialty. In addition, the multidisciplinary dentistry enables the solution of cases more conservatively, especially cases where aesthetics is a relevant factor. This study aimed to report a clinical case showing esthetic disharmony of the anterior teeth even after the ending of the orthodontic treatment, causing dissatisfaction for both the patient and the dentist. From a functional point of view, the occlusion was adequate. However, the esthetics prevented a satisfactory outcome. To solve this issue, the case was treated through minimally-invasive ceramic laminates, then reaching the expected result.

Dealing with gingival recession associated with non-carious cervical lesion

Gingival recession is a very common problem and can affect 100% of the individuals older than 50 years. Almost 50% of these cases, gingival recession is associated with a noncarious cervical lesion and together, they form a combined lesion that requires multidisciplinary approach to properly deal with this condition. When the combined lesion is treated by only a restorative procedure, the position of the gingival zenith is kept more apically due to the persistence of the gingival recession, which would lead to a longer tooth and consequently to a possible esthetic disharmony in case of recession greater than 2 mm. On the other hand, if the surgical procedure for root coverage is individually performed, the coronal portion of the non-carious cervical lesion may not be covered with the periodontal flap after the healing period. It happens because, in most cases, the non-carious cervical lesions affect the enamel above of the cemento-enamel junction, and this zone of the tooth crown cannot be covered, which gives the impression that the procedure was unsuccessful. In order to overcome these limitations, some randomized clinical trials evaluated the clinical outcome of different multidisciplinary approaches that combined restorative materials, such as resin-modified glass ionomer and composite resin, with periodontal surgical techniques for root coverage. These approaches restored the entire length of the cervical lesion and placed the flap/graft on top of it. After a healing period, good clinical outcome was achieved; the root zone of the restorative material was coverage by a healthy soft tissue, and good esthetic outcome could be observed. However, questions began to arise: What if the restoration fail? Do we need to reopen the flap and do it all over again? Despite some studies showed good clinical outcome after some years, other therapeutic options need to be tested. Some case reports suggested that partial restorations of the cervical lesion (just the coronal zone) may be a valid option. However, clinical trials are needed to test this option. In addition, no guideline that takes in account the anatomy of the cervical lesions is available. Ergo, we are still evolving our knowledge regarding the best way to deal with this combined lesion and clinicians should be aware of what will come next. Mauro Pedrine Santamaria

Planning and clinical strategy in direct composite restorations

Patients are seeking increasingly the expertise of dental surgeons for esthetic dental improvement. The dental surgeons should know the restorative materials and techniques in order to optimize the clinical practice and to obtain satisfactory results. Also the dentist should know the average heights and widths of the anterior teeth to detect the esthetic disharmony and to eliminate it for reproducing the correct dental anatomy. Thus, this study aimed to describe a clinical case report of direct restoration using the palatal barrier technique.

Mucosal dehiscence coverage for dental implant using sprit pouch technique: a two-stage approach

PurposeSoft tissue recessions frequently cause esthetic disharmony and dissatisfaction. Compared with soft tissue coverage around a tooth, the coverage of an implant site is obviously unpredictable. Particularly in the cases of thin mucosa, a significant greater amount of recession takes place compared to thick mucosa. To overcome this problem, this case report demonstrates a two-step mucosal dehiscence coverage technique for an endosseous implant.MethodsA 33-year-old female visited us with the chief complaint of dissatisfaction with the esthetics of an exposed implant in the maxillary left cental incisor region. A partial-thickness pouch was constructed around the dehiscence. A subepithelial connective tissue graft was positioned in the apical site of the implant and covered by a mucosal flap with normal tension. At 12 months after surgery, the recipient site was partially covered by keratinized mucosa. However, the buccal interdental papilla between implant on maxillary left central incisor region and adjacent lateral incisor was concave in shape. To resolve the mucosal recession after the first graft, a second graft was performed with the same technique.ResultsAn esthetically satisfactory result was achieved and the marginal soft tissue level was stable 9 months after the second graft.ConclusionsThe second graft was able to resolve the mucosal recession after first graft. This two-step approach has the potential to improve the certainty of esthetic results.

A digital video photographic technique for esthetic evaluation of anterior mandibular teeth

Improvement of dental and facial esthetics is an important indication for dental treatment. Photographic records aid in identifying esthetic disharmony, planning for esthetic correction, and establishing mutually compatible expectations of the dentist and patient. The conventional photograph of a smile is used ubiquitously for this purpose and effectively shows primarily the maxillary anterior teeth with surrounding facial structures. However, in the older patient, and especially in men, 1 Vig R.G. Brundo G.C. The kinetics of anterior tooth display. J Prosthet Dent. 1978; 39: 502-504 Abstract Full Text PDF PubMed Scopus (221) Google Scholar , 2 Tjan A.H. Miller G.D. Some esthetic factors in a smile. J Prosthet Dent. 1984; 51: 24-28 Abstract Full Text PDF PubMed Scopus (417) Google Scholar the mandibular anterior teeth receive greater exposure than those of the maxilla and are a zone of primary esthetic significance for these patients. Exposure of mandibular anterior teeth is generally evaluated with the lips in rest position 1 Vig R.G. Brundo G.C. The kinetics of anterior tooth display. J Prosthet Dent. 1978; 39: 502-504 Abstract Full Text PDF PubMed Scopus (221) Google Scholar ; however, their primary esthetic significance is more obvious during speech. Neither rest nor speech positions are shown by the standard smile photograph, which is therefore unsuitable for esthetic analysis of mandibular incisors. This article shows how the video function of a digital camera with readily available software can be used for effective esthetic analysis of the mandibular anterior teeth. The procedure is described for a specific digital camera but can be applied to other models with appropriate modifications.

Pertimbangan Estetik dalam Perawatan Restorasi Implan (Kajian Klinik)

The demand of implant restorations is increasing due to its superiority in function, safety and comfort, However, aesthetic disharmony commonly occurs, due to metal color, implant’s profile, position and engulations. To overcome this limitation, it is important to balance the aesthetic with the biomechanical requirements. This requires implant selection (material, shape and angulations), modifying superstructure (retainer, pontic, attachment) to improve improper implants position and angulations and preprosthetic bone augmentation to facilitate implant placement to fulfil aesthetic and biomechanical requirements.