Background: Excessive gingival display, or “gummy smile,” occurs in up to 14% of adults and is associated with lip hyperactivity, dentoalveolar extrusion, or vertical maxillary excess. Botulinum toxin A (BTA) has emerged as a minimally invasive therapeutic option, but protocols vary widely and long-term data are limited. Objectives: To critically evaluate the current literature on BTA in gummy smile management, focusing on classification systems, injection techniques, efficacy, safety, and comparative outcomes against conventional surgical and orthodontic treatments. Methods: A narrative review was performed using PubMed, MEDLINE, and Scopus (2000-2023) with the terms “gummy smile,” “excessive gingival display,” and “botulinum toxin.” Clinical studies, case series, and reviews addressing BTA use were included. Data were synthesized into thematic categories. Results: BTA consistently reduced gingival exposure by 3 to 5 mm, with effects lasting 4 to 6 months. Three main injection strategies were identified: single-point (Yonsei), multi-point, and orbicularis oris (“lip flip”). Reported complications were rare and transient (mild asymmetry, lip weakness). Standardized protocols were lacking, with heterogeneity in dosing (2-5 units per site) and injection depth. Comparative studies suggested BTA is less durable than surgical approaches but offers superior patient acceptability and safety for mild to moderate cases. Conclusion: BTA provides reproducible, temporary improvement in gummy smiles with high safety and satisfaction rates. However, absence of consensus on optimal technique and limited long-term evidence highlight the need for standardized protocols and prospective multicenter studies.

AI-based segmentation of gingival display for gummy smile assessment: Model development and clinical validation.

Excessive gingival display (EGD) is most commonly attributed to vertical upper lip elevation, short lip length, or dentoalveolar disproportion. However, some patients exhibit gingival or mucosal visibility during smiling despite minimal vertical upper lip displacement, suggesting the presence of alternative dynamic patterns. This exploratory case series examined an inversion-dominant smile presentation and its documented modulation in association with conservative intraoral chemodenervation directed toward the marginal region of the orbicularis oris. Ninety-four patients with dynamic inversion during smiling were assessed using a qualitative rating aid (Armenti Inversion Scale, AIS) and a quantitative composite proportional measure of vermilion loss (ΔLv%). All patients received low-dose intraoral Onabotulinum toxin A (4-6 U) as part of routine aesthetic care. At Day 15 follow-up, a shift toward lower inversion grades was observed across the cohort, with a large proportion of patients showing minimal residual inversion. Quantitative ΔLv% values showed proportional changes that were directionally consistent with shifts in AIS grade. The functional alterations were mild, transient, and self-resolving. Preliminary inter-rater agreement for AIS and measurement repeatability for ΔLv% suggested acceptable internal consistency for exploratory reporting tools. These findings suggest that inward vermilion inversion may represent a potentially distinct dynamic contributor to gingival or mucosal exposure in selected individuals, and that conservative marginal chemodenervation was associated with transient modulation of this pattern with generally preserved oral competence. AIS and ΔLv% are preliminary documentation tools. Further studies incorporating objective neuromuscular assessment, three-dimensional imaging, and comparative designs are required to refine phenotypic characterization.

Individuals’ perceptions of self-confidence, trustworthiness, attractiveness, intelligence, and friendliness are negatively influenced by Excessive Gingival Display (EGD). Perio-aesthetics focuses on the factors that contribute to a beautiful smile by improving the balance between the pink (gingival) and white (teeth) components of the dentition. Lip repositioning is a surgical technique used to correct excessive gingival display. The present case series includes three young female patients with excessive gingival display (5-6 mm) to assess the outcomes of the lip repositioning technique. Lip Repositioning Surgery (LRS) was performed after Phase I therapy. Aesthetic crown lengthening and gingival depigmentation were also performed wherever required to correct short clinical crown lengths and gingival pigmentation. Patients were recalled at 6 months. Gingival Display (GD) was assessed presurgically, postsurgically, and at six months. There was a significant improvement in GD at maximum smile at six months, with high patient satisfaction regarding smile enhancement.

Lip repositioning for gummy smile: A case series evaluating postoperative lip length and patient satisfaction with 6-month follow-up

Comparison of lip repositioning and lip repositioning with botulinum toxin application in gummy smile treatment.

Introduction : In the modern era, dental esthetics has become an important consideration, particularly in cases of gummy smile, which may significantly reduce a patient’s self-confidence. A gummy smile is defined as excessive gingival display of more than 3 mm in the vertical dimension of the maxillary anterior region during smiling. The etiology of gummy smile is multifactorial and may include hyperactivity of the upper lip elevator muscles, vertical maxillary excess, and delayed passive eruption. Case Report: A 32-year-old woman presented with the chief complaint of excessive gingival display during smiling and dissatisfaction with poorly fabricated veneers, which negatively affected her confidence. She also reported halitosis following veneer placement performed at a non-clinical setting. Intraoral examination of the maxillary and mandibular anterior regions revealed poor-quality veneers, hyperemic and edematous gingival margins, and abnormal gingival texture. Discussion: A pleasant smile requires harmony among tooth shape, color, size, gingival health, and an appropriate amount of gingival display during smiling. This case report describes a surgical approach combining periodontal soft tissue reconstruction with smile elevator tissue containment for the correction of gummy smile. The technique aims to reduce excessive gingival display by limiting the excessive retraction of the smile elevator muscles. Conclusion: Periodontal soft tissue reconstruction in combination with smile elevator tissue containment represents an innovative surgical technique for the correction of gummy smile.

This study evaluated the clinical outcomes, surgical accuracy, and patient satisfaction in treating excessive gingival display caused by altered passive eruption (APE) using a comprehensive digital workflow and double surgical guide. A prospective case series study was conducted enrolling 30 patients diagnosed with APE Type 1B. Cone-beam computed tomography (CBCT), intraoral scanning, and digital smile design were used to design and fabricate a 3D-printed double surgical guide for both gingivectomy and osteotomy. The primary outcome was surgical accuracy, assessed by the gingival margin relapse at 6 months. Secondary outcomes included gingival display (GD), clinical crown length (CCL), periodontal and papillary parameters, and patient satisfaction. Statistical analyses were performed with significance set at p < 0.05. Thirty participants were treated successfully. The digital workflow demonstrated high accuracy with a median gingival margin relapse of 0.69 [0.58-0.87] mm at 6 months. Regarding clinical efficacy, a statistically significant reduction in GD was observed (from 3.13 [2.90-3.85] to 1.06 [0.56-1.99] mm; p < 0.001) alongside a statistically significant increase in CCL (from 7.64 [7.25-8.16] to 10.00 [9.56-10.46] mm; p < 0.001). Patient-reported outcomes indicated 100.0% satisfaction with the esthetic result. Within the limitations of this case series, the described comprehensive digital workflow using a double surgical guide is a predictable and effective method for treating excessive gingival display. The technique achieves significant esthetic improvements and results in a high level of patient satisfaction. This study presents a comprehensive digital workflow for the treatment of gummy smile caused by altered passive eruption. By integrating digital planning with a double surgical guide, clinicians can achieve precise soft and hard tissue management, leading to predictable esthetic outcomes and high patient satisfaction.

Gummy smile (GS), defined as excessive gingival display, compromises facial harmony and self-confidence. Traditional treatments, including orthognathic surgery, botulinum toxin (BTX-A), and lip repositioning, carry limitations in invasiveness, durability, or adaptability. Micro-Autologous Fat Transplantation (MAFT) presents a minimally invasive alternative by volumizing the upper lip and modulating perioral biomechanics. A retrospective study was conducted on 52 patients (mean age: 43.4 years; 92.3% female) who underwent MAFT for GS correction between 2014 and 2023. Fat was harvested, purified, and micro-injected using the MAFT-GUN® into the nasolabial groove, ergotrid, and upper lip. Gingival exposure was measured at four maxillary incisor regions pre- and postoperatively. Patient satisfaction was assessed via a 5-point Likert scale; mean follow-up was 56.4 months. Mean preoperative gingival exposure (3.31 mm) significantly decreased to -0.82 mm postoperatively (p < 0.00001), with a mean reduction of 4.13 mm. The right central incisor showed the greatest improvement. Satisfaction scores increased from 1.40 to 4.90. Mean injected fat volume was 16.1 mL (SD: 3.4 mL), with a calculated graft weight of 14.8 g. No significant correlation was found between volume and outcome (p > 0.40), suggesting anatomical responsiveness. Only two patients (4%) required minor touch-ups; no major complications occurred. MAFT is a safe, effective, and durable treatment for GS. By harmonizing perioral musculature and preserving dynamic lip movement, it bridges the gap between temporary neuromodulators and invasive surgeries, offering a reproducible, minimally invasive solution with long-term aesthetic and functional benefits.

This study aimed to evaluate the quality, reliability, and readability of online patient-centered information related to the management of gummy smile. A systematic search was conducted using Google, Yahoo, and Bing to identify websites providing patient-oriented information on gummy smile treatments. A total of 257 websites met the inclusion criteria and were analyzed. Content quality was assessed using the DISCERN instrument, Journal of the American Medical Association (JAMA) benchmarks, and the Health on the Net (HON) code certification. Readability was evaluated using the Flesch Reading Ease Score (FRES), Flesch -Kincaid Grade Level (FKGL), Simplified Measure of Gobbledygook (SMOG) index, and Coleman -Liau index. The overall quality of online information was low to moderate, with a mean DISCERN score of 40 ± 9.9. Only 11 websites were certified by the HON code, indicating limited adherence to established standards for trustworthy health information. According to JAMA benchmarks, only two websites fulfilled all four criteria. Readability analysis demonstrated that the content was relatively complex, with a mean FRES of 60.1 ± 9.2 and a mean FKGL of 8.9 ± 1.8, exceeding the recommended reading level for the general public. Online patient-centered information regarding gummy smile is generally of suboptimal quality and readability. The limited number of reliable and easily understandable resources underscores the need for improved quality control, standardization, and patient-focused content development. Enhancing the accessibility and reliability of online information may support better patient understanding and informed decision-making in dental aesthetics.

Background: Crown lengthening procedures are often required to restore proper tooth proportions and re-establish biological width prior to restorative treatment. This article presents a case of conventional crown lengthening with bone reduction (osseous resection) performed on the anterior maxilla. The surgical procedure involved a full-thickness flap, osseous recontouring, and apical repositioning of the gingival margin. The postoperative evaluation of the treatment shows good healing, proper biological width and apical reposition of the gingival margin. Purpose: The purpose of writing this article is to describe crown lengthening process accompanied by bone reduction to correct excessive gingival display in a patient that requires esthetic improvement of the maxillary anterior teeth. Case: A 21-year-old female who was from the Department of Conservative Dentistry to the Department of Periodontics, Faculty of Dental Medicine, Airlangga University with a complaint of wanting to fix the front teeth for esthetic improvement. The patient currently undergoes a treatment in the conservative department and was referred for gingival reduction of the front teeth to become more esthetic. Patient had no systemic illness or allergy history and had last scaling done one year ago. Case Management: After periodontal evaluation and bone sounding, crown lengthening with bone reduction was performed. A full thickness flap, osseous recontouring and apical repositioning of the gingival margin were carried out to re-establish the biological width and enhance the esthetics.

A 28-year-old woman with facial asymmetry after aligner treatment visited our hospital. She complained of an asymmetric gummy smile and a deviated mental area developed after clear aligner treatment. On CT examination, occlusal cant was found, leading to facial asymmetry. We made a clinical diagnosis of jaw deformity with an asymmetric face, and recommended her orthognathic surgery using wire orthodontics. She accepted jaw surgery; however, she refused wire orthodontic treatment. Therefore, we selected bimaxillary osteotomy with a surgical-first approach using her clear aligner to correct the inclined occlusal plane and improve the deviated jaw. The functional occlusion could be established, and improvement of facial form could be gained with a proper occlusal plane. This case report is a rare case, in which retreatment of the surgical approach for bimaxillary osteotomy for marked facial asymmetry developed after aligner treatment. We must be aware of the necessity of thorough and careful examination to avoid misdiagnosis.

Many popular botulinum neurotoxin treatments are off-label, yet no review has comprehensively captured their effects. This study provides a systematic review of neurotoxin's off-label aesthetic applications, focusing on muscle targets, aesthetic goals, outcomes, and patient satisfaction. A systematic review of PubMed, MEDLINE, and Web of Science was conducted per Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Eligible studies were published between 2014 and 2024, describing nonwrinkle aesthetic uses of botulinum toxin type A in adults. Data extracted included patient demographics, muscle targets, aesthetic goals, procedural approaches, outcome measures, and patient satisfaction. Proportion meta-analyses were performed using Stata software. Of 531 search-identified studies, 38 met inclusion criteria, totaling 1903 patients aged 17 to 93 years. Patients were primarily female (94.3%, P < 0.0001), with a mean age of 43.7 years. Most interventions targeted the lower face (70.3%, P < 0.0001). Facial aesthetic goals included eyebrow lift, forehead fat graft retention, nasal flare reduction, nasal tip sculpting, facial slimming, and correction of gummy smile, downturned mouth, chin retrusion, mentalis strain, and lower-face descent. Nonfacial aesthetic goals included neck, arm, and calf contouring and scrotal relaxation. Interventions focused on reducing volume/bulk (n = 21, 61.8%) or reshaping (eg, lifts and smile correction) (n = 16, 47.1%). Overall satisfaction was high (94%; 95% confidence interval, 88%-98%). Studies with quantitative measurements during the first follow-up (n = 23) reported sustained results (75.0%, P < 0.0001), with minimal reported complications. Beyond rhytid reduction, botulinum toxin type A demonstrates versatile aesthetic utility in facial and body contouring, with high patient satisfaction and minimal adverse effects. Standardized protocols and refined evaluation methods are needed to inform decision-making, expand clinical guidance, and optimize outcomes.

This study aimed to investigate buccal bone thickness (BT) patterns in the maxillary anterior region, examine correlations with clinical and radiographic parameters, and assess the predictive value of these parameters in patients with gummy smiles. Eighty-four gummy smile patients were included. Six anterior maxillary teeth (canine to canine) per patient were evaluated using clinical examination, digital photography, cone-beam computed tomography, and intraoral scanning. Pearson correlation and multiple regression analyses were performed. Thick BT (>1 mm) was observed in 75.4% and 69.1% of teeth at 1 mm (BT1) and 3 mm (BT3) below the bone crest (BC), respectively. Thicker BT was more prevalent in males, canines, thick-flat gingival architecture, and sagittal root position class III. Positive correlations were found between BT at both levels and keratinized tissue width, smile line, crown width-to-length ratio, gingival thickness (GT) at the cementoenamel junction (CEJ), and sagittal root angulation. Negative correlations were identified between the CEJ-to-BC and gingival margin-to-BC distances and GT at 1 and 3 mm. Multiple regression analysis identified GT as the strongest predictor of BT. Gummy smile patients predominantly exhibit a thick bone morphotype. GT below the BC was the strongest negative predictor of BT. These distinct bone characteristics may affect treatment planning for esthetic procedures such as surgical crown lengthening.

Background: Altered passive eruption (APE) is one of the etiological factors associated with excessive gingival display and is commonly treated with esthetic crown lengthening (ECL). However, existing classification systems provide limited guidance for selecting appropriate treatment approaches. Objectives: The aim of this study was to evaluate (1) the expected outcome of ECL in eliminating unattractive excessive gingival display (4 mm) based on digital smile assessment and (2) the distribution of teeth and patients according to the modified APE classification. Methods: Forty-two Thai patients with APE underwent clinical examination, digital smile assessment, intraoral scanning, and CBCT. Predicted gingival display (PGD) was calculated to assess the expected outcomes of ECL. The modified APE classification, incorporating CEJ–BC distance and buccal bone thickness, was analyzed at both the tooth and patient levels. Results: A total of 252 maxillary anterior teeth were assessed. Most patients (78.57%) presented with APE and hyperactive upper lip. The mean gingival display (GD) was 6.04 ± 1.76 mm, with GD ≥ 4 mm observed in 92.86% of patients. The mean PGD was 3.56 ± 1.71 mm, and ECL was predicted to reduce GD to < 4 mm in 66.67% of patients. Teeth were classified as Class I (28.97%), II (15.48%), III (41.27%), and IV (14.28%); only Types II (11.9%) and III (88.1%) occurred at the patient level. Conclusions: ECL performed at the CEJ level is predicted to eliminate excessive gingival display in approximately two-thirds of APE patients. The modified APE classification offers guidance for selecting surgical approaches, highlighting the necessity of open-flap procedures and the limited applicability of flapless approaches.

Gingival excess, also referred to as excessive gingival display (EGD), represents a multifactorial esthetic concern influenced by skeletal, dental, and soft tissue factors. Conventional orthodontic or orthognathic interventions, while effective, may present increased morbidity. This prospective case series evaluates a minimally invasive, interdisciplinary approach integrating periodontal and cosmetic techniques for managing multifactorial gingival excess. Twelve systemically healthy adult patients (mean gingival display: 5.3 mm) diagnosed with both altered passive eruption and hyperactive upper lip were treated in a private practice using a combined single-session protocol. The "combo technique" involved esthetic crown lengthening, botulinum toxin-A (Botox) injections, and hyaluronic acid-based lip augmentation. Diagnosis and treatment planning were based on comprehensive clinical and radiographic assessments. Outcome measures included gingival display reduction, patient satisfaction, and postoperative discomfort, evaluated at 6 and 18 months. The integrated "combo technique" offers a minimally invasive and highly effective alternative for correcting EGD. It enables individualized treatment planning, reduces the amount of Botox needed, and results in stable esthetic outcomes with high patient satisfaction and minimal postoperative discomfort. This interdisciplinary approach provides a predictable and long-lasting solution for complex GS cases in patients unwilling or unsuitable for orthognathic surgery.

Introduction:Modern aesthetic dentistry increasingly integrates techniques from aesthetic medicine to improve the appearance and function of the oral cavity. Growing patient expectations concerning not only health but also the aesthetics of teeth and perioral tissues have led to the development of interdisciplinary treatment methods. Materials and Methods:This article reviews current techniques used in aesthetic medicine, such as botulinum toxin, tissue fillers, and mesotherapy, and their adaptation in dental practice. The use of platelet-rich plasma (PRP) for aesthetic treatment of the face and perioral structures is also discussed. Results and Discussion:Aesthetic dentistry now includes procedures that enhance both teeth and facial soft tissue aesthetics. Botulinum toxin is used to treat gummy smile, bruxism, and muscular asymmetry. Dermal fillers help in contouring facial structures and enhancing lip volume. Mesotherapy and PRP support tissue regeneration and skin quality, also aiding healing after dental procedures.

This study is aimed at evaluating the prevalence of etiologies of excessive gingival display (EGD) in Egyptian females including gingival enlargement (GE), altered passive eruption (APE), incisor over-eruption (IO), protrusion (P), vertical maxillary excess (VME), short upper lip (SUL), and hyperactive upper lip (HUL) and to identify clinical diagnostic patterns. A total of 160 participants showing EGD > 2 mm were recruited. Clinical photos, videos, and measurements of facial proportions, upper lip length, upper lip mobility, incisor display upon rest, clinical crown dimensions, occlusal plane discrepancies, probing depth, transgingival probing, and keratinized gingiva were recorded and analyzed. Mean age was (27.62 ± 6.21) years. Overall prevalence of EGD 13.3% among them 55.8% EGD caused by single etiology, 44.3% EGD caused by multiple etiologies. 29.4% APE, 16.3% SUL + APE, 10% VME + APE, 8.8% VME, 6.3% HUL, 5% Incisor over-eruption, 3.8% GE, 3.8% SUL + GE, 3.1% VME + HUL, 2.5% SUL, 2.5% APE + HUL, 1.3% VME + GE, and 1.3% …. APE both alone and combined with another etiology is the most prevalent cause of EGD and the most common diagnostic pattern is APE + SUL among Egyptian females. Single-factor and multifactorial EGD showed no significant difference in prevalence (p = 0.115), suggesting a similar likelihood of occurrence. This study aimed to provide the clinician with a step-by-step guide for EGD comprehensive diagnosis, highlight the differences in prevalent etiologies between different populations and identify diagnostic patterns.

Managing excessive gingival display (EGD) is challenging and requires precise diagnosis and etiology-driven treatment for long-term stability. This report describes a digitally guided, staged approach combining esthetic crown lengthening (ECL) and lip repositioning (LR) for multifactorial EGD. A 28-year-old female presented with 7 mm of gingival display on dynamic smile, upper lip length of 19 mm, and lip mobility of 6 mm. The etiologic diagnosis was vertical maxillary excess (VME) Class II, hyperactive upper lip (HUL), and altered passive eruption (APE) (Coslet Type 1 B). Digital planning was performed using 3Shape intraoral scanning integrated with digital smile design (DSD) to establish target gingival zeniths and smile line. A dual-purpose three-dimensional (3D)-printed surgical guide (Form 3, Formlabs) was designed to (1) control the apical extent of crown lengthening and (2) visualize the anticipated dynamic lip line, targeting a residual gingival display of 2-3 mm. Phase 1 involved ECL with gingivectomy and osseous recontouring to reestablish biologic width and create ideal crown proportions. After 6 weeks of healing, LR was performed following Bhola's technique with a partial-thickness mucosal excision, selective myectomy, and deep horizontal mattress sutures for stabilization. Gingival display reduced from 7 mm at baseline to 0 mm at 3 months, and measured ~2-3 mm after 5 years of follow-up, maintaining a pleasing smile arc and high patient satisfaction. A digitally guided staged approach integrating ECL and LR effectively managed combined EGD etiology. The 3D-printed guide enhanced surgical precision and predictability, with sustained esthetic improvement at 5 years and minor recurrence (2-3 mm).

Prevalence of Gummy Smile and Its Etiological Factors: A Cross-Sectional Study among a Sample of Egyptian Dental Patients