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.

An esthetic smile plays a pivotal role in enhancing patient confidence and social well‐being. Smile esthetics are influenced by multiple factors, including maxillary anterior tooth morphology, lip length and mobility, periodontal health, and the degree of gingival display. Short clinical crowns associated with excessive gingival display are generally perceived as unesthetic and frequently require esthetic crown lengthening. Altered active eruption (AAE) and altered passive eruption (APE) represent common etiologic factors in such presentations. Management typically involves gingivectomy with or without osseous resection while ensuring adequate space for the supracrestal tissue attachment. Violation of the supracrestal tissue attachment may lead to gingival inflammation, recession, and alveolar bone loss; therefore, a postoperative healing period of 3–6 months is recommended to allow soft tissue maturation and assessment of marginal gingival stability. Conventionally, restorative rehabilitation following esthetic crown lengthening has relied on invasive approaches, including porcelain‐fused‐to‐metal crowns, all‐ceramic crowns, and porcelain veneers. However, evidence supporting minimally invasive or noninvasive restorative modalities—particularly direct composite restorations—remains limited. This case series is aimed at describing a minimally invasive restorative protocol utilizing direct nanocomposite veneering following esthetic crown lengthening and soft tissue maturation to achieve favorable pink esthetic score (PES) and white esthetic score (WES) outcomes. Two patients presenting with a gummy smile, microdontia, and spacing in the maxillary anterior region were diagnosed with APE Type I associated with AAE and exhibited low baseline PES and WES values. Diagnosis was established through clinical transgingival probing, cone‐beam computed tomography (CBCT), diagnostic casts, and digital smile design. Treatment involved esthetic crown lengthening via gingivectomy and ostectomy, followed by a 3‐month healing period for soft tissue maturation. Subsequently, minimally invasive direct veneering was performed using a bioactive nano‐hybrid composite. This approach resulted in improved pink and white esthetic outcomes while preserving tooth structure and maintaining periodontal health. At approximately 24 months of follow‐up, minor restoration chipping was observed, along with mild gingival inflammation associated with plaque accumulation, whereas gingival levels remained relatively stable, ranging from −1.5 to +0.5. The primary limitation of this case series is the absence of long‐term data regarding color stability, periodontal response and restorative complications.

A gummy smile can result from several factors, often leading to a disharmonious appearance and causing physical and psychological discomfort for the patient. This study aimed to evaluate changes in self-esteem and quality of life for patients, as well as the recidivism rate, following aesthetic crown lengthening (ACL) surgery. Twenty-two periodontally healthy patients who expressed interest in undergoing ACL and met the procedural indications were selected. Before surgery, at 30 days, and 2 years postoperatively, the Oral Health Impact Profile - 14 items (OHIP-14) and the Rosenberg Self-Esteem Scale were used to assess patients' perceptions of quality of life and self-esteem. Crow dimensions, gingival phenotype, and the recidivism rate were assessed. ACL significantly improved the psychosocial parameters of patients (p < 0.05). Both self-esteem and quality of life showed improvement 30 days post-surgery (p = 0.02 and 0.00024, respectively). After 2 years, further improvements were observed in the self-esteem index compared to the 30-day results (from 11 [interquartile range {IQR}: 8.0-14.0] to 14 [IQR:12-15, p < 0.05]) and in the OHIP score (from 19 [IQR:14-27] to 6 [IQR: 0.0-8.0]). The clinical crown length established 30 days after surgery remained stable after 2 years (0.82 ± 0.11). ACL can enhance patients' quality of life and self-esteem, serving as a valuable procedure in aesthetic periodontics. A "gummy smile," where too much gum tissue shows when a person smiles, can affect both appearance and confidence. This study looked at whether aesthetic crown lengthening surgery (a procedure that reshapes the gums and exposes more of the teeth) could improve how people feel about themselves and their daily lives. We followed 22 patients who underwent this surgery and measured their self-esteem and quality of life before the procedure, 1 month later, and again 2 years after the procedure. Results showed that patients felt noticeably better about their smiles and overall quality of life just 1 month after surgery. Even more encouraging, these benefits continued to grow over the course of 2 years, with patients reporting higher self-esteem and fewer problems related to their oral health. Importantly, the changes achieved by the surgery-such as the new tooth and gum proportions-remained stable, with no return of the gummy smile. These findings suggest that crown lengthening is not only an effective and lasting solution for improving the appearance of a gummy smile but also has meaningful, long-term benefits for patients' confidence and well-being.

Treatment for excessive gingival display, commonly known as gummy smile, remains challenging. This cross-sectional study investigates the clinical use of soft tissue CBCT (ST-CBCT) to measure the hard and soft tissues in the dento-gingival unit to diagnose and plan treatment for excessive gingival display. The dento-gingival complex of maxillary anterior teeth was investigated, including gingival thickness, alveolar bone thickness, and supracrestal tissue attachment. A detailed clinical treatment sequence of the therapeutic journey of a patient with altered passive eruption is presented to illustrate the clinical application of CBCT, from diagnosis to the final outcome, using Digital Smile Design. Thirty patients with altered passive eruption were evaluated. The mean distance from the gingival margin to the bone crest was 4.2 ± 1.1 mm. The mean gingival thickness was 1.1 ± 0.3 mm, and crestal labial bone thickness was 1.0 ± 0.4 mm. The majority presented thick gingiva (≥ 1 mm, 63.4%), and nearly half of all teeth (48%) showed thick crestal bone (≥ 1 mm). Male participants demonstrated a higher prevalence of thin crestal bone than female participants (66.7% vs 49.2%; P = 0.007). Contralateral teeth exhibited statistically significant differences in the distance from the cementoenamel junction to the bone crest, soft tissue thickness, and bone thickness. The dento-gingival unit presented inter- and intra-individual variability. Tomographic diagnosis, classification, and treatment planning of altered passive eruption should be conducted on a tooth-by-tooth basis for higher surgical precision and predictability, ultimately improving patient care. Soft tissue CBCT offers a comprehensive 3D overview of the soft and hard tissues in the dento-gingival unit.

Background: Orthodontic intrusion of maxillary incisors is commonly used to treat gummy smiles in deep bite patients. The effectiveness of using one versus two miniscrews for this purpose remains debated. This systematic review and meta-analysis aimed to compare the dental effects of one versus two miniscrews for maxillary incisor intrusion. Materials and Methods: A literature search was conducted across multiple databases for studies published up to December 31, 2024. Five studies (four randomized controlled trials and one non-randomized study) met the inclusion criteria. Risk of bias was assessed using the RoB 2 and ROBINS-I tools. Results: Intrusion was greater in the two-miniscrew group, while incisor proclination was higher in the one-miniscrew group. No significant difference was found between the groups in overbite correction. Root resorption was observed in both groups, with central incisor resorption more in the one-miniscrew group and lateral incisor resorption slightly more in the two-miniscrew group. Conclusion: Two miniscrews placed distal to lateral incisors offer greater incisor intrusion and less proclination than a single miniscrew between central incisors. Overbite reduction was comparable, and root resorption varied by location

Crown lengthening serves as a key procedure for addressing aesthetic concerns such as gummy smile, short clinical crowns, and uneven gingival contours. Advances in digital technology, particularly computer-aided design and computer-aided manufacturing (CAD/CAM), now allow precise translation of preoperative plans into surgical execution, enabling accurate control over gingival margin and alveolar ridge positioning. To standardize the clinical application of this technology, the Chinese Society of Digital Dental Industry (CSDDI) convened a panel of experts to develop this guideline document. It aims to define steps for digital data acquisition, integration, and design in guided crown lengthening within the aesthetic zone; standardize the digital workflow for designing surgical guides for aesthetic crown lengthening; assist clinicians in formulating appropriate digital surgical plans through thorough digital analysis and diagnosis; and offer practical guidance on performing crown lengthening surgery using digital guides in aesthetic areas. Ultimately, this guideline seeks to standardize the surgical protocol for digital guide assisted crown lengthening, thereby improving procedural accuracy and predictability of treatment outcomes.

Background: Excessive gingival display is frequently associated with upper lip hypermobility and represents a common aesthetic concern. Several therapeutic approaches have been proposed, including botulinum toxin type A injections, lip repositioning surgery (LRS), and combined techniques; however, no clear consensus exists regarding the most effective and stable treatment option. Methods: A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PRISMA) guidelines. A comprehensive search of multiple electronic databases was performed, leading to the inclusion of 17 human studies that met predefined PICOS criteria. The review protocol was registered in PROSPERO (CRD420261281920). Results: Most included studies reported favorable outcomes in terms of reduction in gingival display, improvement in smile aesthetics, and patient satisfaction. No major adverse effects were reported, suggesting acceptable safety profiles for all therapeutic modalities. Outcomes varied depending on the type of intervention, surgical technique, botulinum toxin dosage and injection protocol, and the initial severity of upper lip hypermobility. Conclusions: Both botulinum toxin injections and LRS demonstrated effectiveness in reducing excessive gingival display. Botulinum toxin provided a rapid but temporary improvement, whereas modified LRS showed greater stability over time. Combined approaches appeared to offer the most consistent long-term results by limiting postoperative relapse. Further standardized protocols and long-term clinical studies are needed to confirm these findings and support evidence-based clinical decision-making.

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.

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

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

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.

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.

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.

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.

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.

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.