| Abstract|| |
Some tools can be used as an aid to the surgical planning for gummy smile correction, such as digital smile design (DSD), which allows to determine patterns of harmony and eventual asymmetries between teeth and gums. This work aims to report a gummy smile correction using DSD as reverse planning. The clinical examination revealed the presence of gummy smile and extensive bone exostosis in the premolar region. DSD was performed in the upper arch, determining the amount of gingiva to be removed, thus providing more safety and precision to the procedure. The surgery was performed by performing using an internal bevel incisions, detachment of a full thickness flap, and osteotomy and osteoplasty. After 6 months of preservation, there was an increase in the clinical crown of the teeth, with smile harmony, less exposure of the gingiva in the smile and a high level of patient aesthetic satisfaction.
Keywords: Gingiva, periodontics, smiling, specialties, surgical, tooth eruption
|How to cite this article:|
Levi YL, Cota LV, Maia LP. Digital smile design for gummy smile correction. Indian J Dent Res 2019;30:803-6
| Introduction|| |
The gummy smile is usually the result of an inadequate relationship between the upper lip and the position of the anterosuperior teeth.,, One possible factor that contributes to the presence of a gummy smile is the altered passive eruption (APE). It is called APE when the gingiva does not migrate to the expected position with excessive gum overlapping over the tooth enamel, resulting in the appearance of a short clinical crown. The gummy smile that has as causal factor the APE requires surgical periodontal treatment to give back the biological distances and facial harmony related to the clinical crown height/width ratio.
The full-thickness apically positioned flap (FTAPR) surgical technique allows exposing the remaining anatomical crown and reducing exaggerated gingival exposure. Basically, this technique consists of removal of a gingival band by means of an inverted bevel incision and elevation of a full-thickness flap that is repositioned at a more apical location in relation to its initial position. If osteotomy is necessary, it must be made according to the curvilinear architecture of the bone contour and removing the bone tissue until the distance between the CEJ and the ABC is of 2–3 mm, always preserving the interproximal bone to avoid the appearance of black spaces.
Recently, the digital smile design (DSD) was introduced as a tool that can help in the accomplishment of this surgical technique, since it amplifies the diagnostic vision. DSD is based on the use of high-quality digital tools with a possible static and dynamic practice, promoting a more effective and personalized treatment plan. Drawing lines and reference forms on high-quality images on the computer screen, following a predetermined guide, will help the team to consider limitations and risk factors, such as asymmetries, disharmonies, and violations of aesthetic principles. Once the problem is identified and the solution is viewed, the selection of the appropriate technique is simplified.
To plan a periodontal surgery, especially when it involves an area with great aesthetic requirements, it is necessary to perform an excellent planning in order to obtain excellence in the surgical result. In this context, DSD can be considered a valuable tool in the execution of reverse planning in periodontal plastic surgery, since it provides the possibility of creating a personalized treatment plan, besides allowing the preview of the result.
This study aims to report the correction of a gummy smile using DSD as reverse planning.
| Case Report|| |
Anamnesis and clinical examination
A 20-year-old female patient with leucoderma attended the university dental clinic reporting dissatisfaction with the appearance of her smile, which exhibited great exposure of the gingiva during the smile and short teeth [Figure 1].
In the anamnesis, it was verified that the patient had no systemic alteration and was also not a smoker. No abnormality was detected in the extraoral exam. In the intraoral clinical examination, the presence of gummy smile associated with an extensive gum band was observed, with the presence of keratinized mucosa covering the anatomical crown [Figure 2], and extensive bone exostosis in the premolars. There was also no bleeding on probing, probing depth ranging from 2 to 3 mm and height of keratinized mucosa ranging from 5 to 10 mm throughout the upper anterior sextant. Radiographically, it was observed that the CEJ was very close to the ABC [Figure 3]. All these characteristics led to the diagnosis of APE. Facing the diagnosis, the surgical technique of choice was the FTAPR, with osteotomy and osteoplasty to increase the clinical crown and removal of bone exostosis.
|Figure 2: Intraoral view of upper anterior teeth. The image shows the appearance of the gummy smile, with the presence of bony exostoses and short clinical crowns|
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|Figure 3: Initial periapical radiographs for the analysis of the relationship between the cementum–enamel junction and the alveolar bone crest|
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The patient was submitted to basic periodontal therapy and digital planning was performed in the upper arch from the right second premolar to the left second premolar, determining the amount of gingiva to be removed in order to offer more precision and safety to the surgical procedure [Figure 4].
|Figure 4: Reference lines for face (a) and for each dental element (b) resulting from digital smile design, allowing to determine the amount of gingiva to be removed during the surgical procedure (c), and predictability of the final result (d)|
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The surgical procedure started with extraoral buccal antisepsis with 2.0% chlorhexidine in the lower and middle thirds of the face and intraoral antisepsis with 0.12% chlorhexidine. Subsequently, anesthesia was performed by bilateral infraorbital nerve block with 2% mepivacaine with epinephrine 1:100,000 (Nova DFL - Rio de Janeiro/RJ - Brazil).
The surgical technique was initiated by performing gingival demarcations with the Willian periodontal probe, outlining the gingival margin and following the measurements defined in the DSD [Figure 5]a. Internal Beveled incision More Detailss were performed with a 15C scalpel blade [Figure 5]b, following the demarcations. Due to the large extent of the flap, it was chosen to not perform oblique releasing incisions. The incised gingival band was then removed with the help of Goldman-Fox curettes and a full-thickness flap was done with the molt detachment, exposing the bone tissue and, thus, it could be confirmed that the ABC was positioned about 1 mm from CEJ [Figure 5]c.
|Figure 5: Demarcations performed with the Willian periodontal probe (a) following the measures defined in the digital smile design. Internal bevel incisions (b) following the demarcations; and detachment of the full-thickness flap, evidencing the presence of bone exostoses (c)|
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Osteotomy and osteoplasty were performed with the aid of a long-stem spherical diamond tip and chisels of Ochsenbein and Microchsenbein. During the osteotomy, to remove bone exostosis and to restore the biological space, the concern was to respect the curvilinear architecture of the bone contour and remove the bone tissue until the distance between the CEJ and the ABC reached 2–3 mm. In addition, the interproximal bone tissue was preserved to avoid the appearance of black spaces. After restoration of the biological distances and removal of bone exostosis, the flap was positioned apically and sutured in a vertical mattress with absorbable core 6.0 [Figure 6].
|Figure 6: Immediate aspect of the relation of the gingival tissue with the clinical crown after the apical positioning of the flap and suture of the gingival tissue|
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After 6 months of proservation, the gingiva presented a pale pink color, “orange peel” appearance and interdental niches completely filled by the papillae, characteristics compatible with the healthy periodontium [Figure 7]. There was also an increase in the clinical crown of the teeth, restoring the harmony among teeth, lips and gingiva, with less exposure of the gingiva during the smile and a high level of aesthetic satisfaction of the patient.
|Figure 7: Frontal images after 6 months of control. The images show the resolution of the gummy smile (a), the pale pink color and the “orange peel” appearance of the gingiva, and the interdental niches completely filled by the papillae (b)|
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| Discussion|| |
The extent of gingival exposure when smiling is a determining factor to promote dentogingival harmony., Generally, an ideal smile is one that exposes the minimum of gingiva. The literature shows that a smile can be classified as gingival when the cervicoincisal height of the teeth is completely seen or when the amount of visible gingival tissue reaches values greater than 3 mm., The gingival contour is also an aspect of great importance with regard to an ideal smile; for this, it must follow the conformation of the cervical portion of the teeth and the underlying bone tissue, filling the cervical area and zenith of the gingival margin. This set, in its turn, needs to be symmetrical to the upper lip. Considering the teeth, they must have a length proportional to their width.
Excessive gingival display is a clinical finding with many etiologies and may include extra or intraoral components. It is important to identify the type of gummy smile to establish the correct treatment. The identification of the correct surgical procedure guarantees the adequate positioning of the interpapillary tissue, avoiding root exposures, gingival retractions, and the formation of black spaces. To determine the best course of action to be taken, clinical examination with probing depth of dental elements is essential to determine the need for bone remodeling. In addition, factors, such as lip positioning, gingival architecture, quantity of keratinized mucosa, and gingival zenith should also be taken into account.
In the present clinical case, depth of shallow probing was observed, which discards the hypothesis of gingival growth. Radiographically, it was verified that the ABC was in the level of the CEJ, confirming the diagnosis of gingival smile caused by APE in the anterosuperior region. Therefore, in order to define the treatment plan, the clinical examination with the depth of probing of each element associated to the radiographic examination was essential to verify the distance from the gingival margin to the ABC, through which it was possible to define the need for bone remodeling through osteotomy.
The use of DSD made the diagnosis more effective and the treatment plan more complete, since it allows the visualization of the case in an enlarged form through photographs, and the analysis of the dental proportion and the relationship between teeth, gingiva, lips, and face., From the planning performed with DSD it was possible to determine the ideal amount of gingiva to be removed in each dental element, facilitating the surgical procedure by making it faster and more precise. In addition, the DSD allowed the comparison of the anterior and posterior images, determining if they were in accordance with the original planning or if some other complementary procedure would be necessary to improve the final result.,,
For the treatment of the reported case the technique used was the FTAPR associated with the osteotomy, with the aim of removing a narrow band of keratinized tissue. As the distance between the ABC and CEJ was insufficient to allow the creation of a space to ensure conjunctive insertion accommodation, osteotomy was necessary to ensure the formation of adequate biological space and a greater increase of the clinical crown after the removal of the gum.
The periodontal surgery to increase the clinical crown, with aesthetic purpose, reduces the discrepancy of the gummy smile, with greater exposure of the dental tissues, promoting a more harmonic, comfortable, and aesthetic smile, which consequently generates an increase in the patients self-esteem., In the present case, a high level of aesthetic satisfaction was observed after the surgical procedure, showing that DSD is a useful tool to guarantee a satisfactory result.
| Conclusion|| |
The DSD allows an accurate planning of the amount of gingival tissue that should be removed during the surgical procedure of gummy smile correction and guarantees a better perspective of the treatment by the patient, being a tool of great value for dentists.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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Prof. Luciana P Maia
Coordenação da Odontologia, Universidade do Oeste Paulista – UNOESTE, Rua José Bongiovani, 700 - Bloco B, Cidade Universitária, Presidente Prudente, SP
Source of Support: None, Conflict of Interest: None
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