Periodo11tology2000,Vol.

11,1996, 18-28 Copyright 0 Munksgaard 1996

Printed in Denmark. All rights reserved
PERIODONTOLOGY 2000
ISSN 0906-6713

The aesthetic smile:

diagnosis and treatment
A. GARBER
DAVID A. SALAMA
& MAURICE

Until recently, dentists’ and the public’s concept of the teeth

dental aesthetics was necessarily limited to alter- lip framework
ations of the teeth themselves. Dentists concerned the gingival scaffold.
themselves with changing the position, the shape
and the color of the teeth - basically restoring
missing units or enhancing those already present. The teeth
For the most part the dentist was forced to accept
the pre-existing relationship between the three The dentist is concerned with the color, the posi-
components of the smile; the teeth, the gingival tion, and the shape or silhouette form of teeth. The
scaffold and the lips. advent of adhesive dentistry has allowed literally
Interestingly, the restorative dentist’s concept of an instantaneous change in the color, the shape
aesthetics varied considerably from that practiced and the position of teeth via bonding techniques
by removable prosthodontists where, in the full such as porcelain laminate veneers and direct
denture set-up, they could not only select the most composite bonding.
desirable shape and color of denture tooth
concomitant with the patient’s facial features but
could position them in the optimal relationship The gingival scaffold
with regards to the upper lip, the lower lip and the
commissures of the mouth - thereby creating the The primary objective of periodontal therapy is to
desired ideal smile. restore and maintain the health and integrity of the
The three basic tenets germaine to optimal attachment apparatus. From an aesthetic perspec-
aesthetics in removable prosthetics were not really tive this is often not enough. An irregular gingival
a part of the restorative dentist’s rules, as any arrangement, despite being healthy, may strike a
changes in the pre-existing lip-tooth-gingival discordant note, and it may become desirable to
relationships were thought to necessitate long- establish a certain harmony and continuity of form
term orthodontic therapy, often in combination to the free gingival margin. In its broadest sense,
with orthognathic surgery or aggressive this would require that the gingival architecture for
periodontal procedures. Today much of this has the two central incisors mimic one another. For the
changed; with the advent of soft tissue periodontal lateral incisors, one would like to see these gingival
plastic procedures designed to enhance margins somewhat more incisally placed and, for
dentofacial harmony following the same basic the most part, bilaterally symmetrical. The cus-
tenets as those of the removable prosthodontist.
The domain of periodontics has changed from _ _ _ _ _ _ ~
being strictly a health service to one where smile Table 1. Methods of developing gingival
enhancement has been brought to the forefront of harmony
~~ - -
treatment planning. Surgery Orthodontics
The essentials of a smile involve the Additive gingival techniques Extrusion
relationships between the three primary Resective gingival techniques Intrusion
components:

18
 ~~
Principles of aesthetic diagnosis

pids, in turn, would have the free gingival margin To develop this symmetry, both surgical and
at the same level of the central incisors and match- orthodontic procedures might be used (Table 1).
ing one another. Extending distally, the tissues on
the premolars would be somewhat coronally posi-
tioned (1,9). Surgical techniques
Periodontic plastic procedures, such as the basic
gingivectomy, soft tissue grafting or the apically Additive techniques for augmenting gingiva have
positioned flap, may be used to change the evolved from the early free gingival grafts through
silhouette form of teeth and their relative the many different forms of contiguous grafting.
proportion. This would include pedicle grafts, connective tis-

Fig. 2. Postoperative view following semilunar graft dis-

playing optimally developed gingival symmetry
Fig. 3. Postorthodontic case showing excessive display of
gingival tissue below the inferior border of the upper lip.
This is a case of altered passive eruption, which should be
differentiated from vertical maxillary excess. The short,
rather squat teeth and hyperplastic tissue usually indicate
an altered passive eruption case. Compare this with the
postoperative result in Fig. 5 where the gingiva line falls
just below the inferior border of the upper lip.
Fig. 4. Periodontal probing showing the amount of tissue
readily removed without compromising the biological
width. A basic gingivectomylgingivoplastyis therefore the
procedure of choice.
Fig. 1. Preoperative view showing gingival recession of the Fig. 5. The case following a gingivectomy showing nor-
maxillary left central incisor. This is the only apically no- mally proportioned teeth with a decrease in the amount of
tated gingival margin showing an overall lack of harmony. gingival display just below the border of the upper lip.

19
Garber & Snlama

sue grafting, semilunar techniques, coronally posi- The medium lipline in western culture is
tioned grafts and guided tissue regeneration (Fig. 1, deemed to be the most attractive. When the patient
2) (2,3,5 , 7 , 8 , 10, 11, 13, 14). smiles, a nominal exposure of 1 to 3 m m of gingiva
Resective techniques involve both the basic from the most apical extent of the free gingival
gingivectomy with or without gingivoplasty, as well margin to the inferior border of the upper lip is
as the full flap procedure incorporating osseous exposed. Thus the teeth in their entirety are on
removal for crown lengthening of one or more display as well as the interdental gingival tissue
teeth (Fig. 3-5). and the border of free gingiva around the cervical
area of the tooth.
Orthodontic techniques
The great advantage in moving teeth orthodonti- The geometry of harmony
cally is that the entire attachment apparatus, in-
corporating the osseous structure, periodontal lig- Within the confines of the lipline, the remaining
aments and the soft tissue components, moves to- two components of the smile need to be arranged
gether with the tooth. This means that, in health, in such a way as to develop a certain continuity of
during an extrusive movement, the free gingival form, harmony and balance (Fig. 11). Classically,
margin will move coronally at the same distance as the prosthodontist would like to set up a denture
the incisal edge moves (Fig. 6). Concomitantly, the so that the level of the gingival margins of the max-
osseous level will move an identical distance in the illary teeth parallel the form of the upper lip. The
same direction. incisal edges of these maxillary teeth tend to follow
From an aesthetic perspective, this means that the form of the lower lip. In a transverse dimen-
any intrusive or extrusive tooth movement can be sion, the teeth should extend progressively posteri-
used to develop symmetry of the gingival margin in orly and laterally to fill the vestibule extending to
a nonsurgical mode (Fig. 7-9). This is particularly the corners of the smile. In the composition of a
useful when any form of restoration is necessary, as beautiful smile, the form, balance, symmetry and
a surgical procedure invariably exposes root relationship of the elements make it attractive or
structure, where the mesiodistal dimension of the unattractive. An expanse of soft tissue should not
tooth is now considerably narrower (Fig. 10). In be considered to be unaesthetic per se, but the way
attempting to restore this, it becomes necessary to this soft tissue is arranged relative to the teeth and
prepare the tooth and the tissue in such a way that lips is of aesthetic concern. Continuity of linear
an emergence profile can be developed from deep horizontal form between the gingival expanse, the
within the sulcus to avoid lateral horizontal teeth and the upper lip is critical. Any asymmetry
extensions from the preparation line on the in this parallelism disturbs the sense of balance in
narrower root surface to the desired wider form of the composition, disturbing the flow and results in
the restoration. If there is a dramatic diminution of an unaesthetic smile (Fig. 12).
the mesiodistal width of the root at the original By this definition, a high lipline in itself may not
gingival level versus the desired level, then be unaesthetic if these basic rules are followed.
orthodontics may be the treatment of choice. However, in today's mass media-influenced
culture, many people consider eventhe slightest
excessive display of gingival tissue - the "gummy
The lips smile" - unattractive.
The gummy smile or high lipline case with an
The lips form the frame of a smile and as such, de- expanse of soft tissue can result from two basic
fine the aesthetic zone. Liplines have classically problems:
been defined as being high, medium or low (6).
altered passive eruption
In the typical low lipline, only a portion of the
vertical maxillary excess.
teeth are exposed below the inferior border of the
upper lip. The definitive diagnosis of the problem determines
The high lipline shows a large expanse of gingiva the treatment.
extending from the inferior border of the upper lip One of the clinical criteria in determining which
to the free-gingival margin. of these two factors is responsible for a "gummy

20
 Primiples of .aesthetic
~-
diagnosis

Fig. 6. Orthodontic clinical eruption sequence showing

how movement of the left central incisor in an incisal di-
rection results in a concomitant change in the level of the
free gingival margin as well as the osseous crest
Fig. 7. Preoperative smile showing compensatory overe-
ruption of the maxillary central incisors as a result of a
long-term anterior bruxing pattern. Note the unaesthetic
change in gingival line as compared with the drape of the
upper lip
Fig. 8. Orthodontic appliance is in position showing the use
of an intrusive archwire. The stainless steel archwire in a
passive position lays in the maxillary anterior vestibule.
When ligated to the central incisor brackets, it exerts an in-
trusive force.
Fig. 9. Postorthodontic result showing alignment of the
gingiva on the two central incisors without harming the
adjacent teeth. No surgery was performed in this situation.
Compare with Fig. 7.
Fig 10. Computer simulation showing restorative differen-
tial in preparation of cases where the gingival harmony is
restored with orthodontic intrusion versus surgical crown
lengthening

21
Garber & Salama

Fig. 11. Computer simulation showing a smile with the var- a large dimension between the free gingival margin and the
ious components in harmony. The incisal edge line follows cementoenamel junction, as well as space between cemen-
the form of the lower lip - while the line joining the tops of toenamel junction and the osseous crest for insertion of the
the free gingival margins form the upper lip. The teeth bi- biological width. The green line on the teeth is indicative of
laterally extend to fill the vestibules to the commissures of the preoperative level of the free gingival margin.
the lips. Fig. 14. A gingivectomy was performed to elevate the level
Fig. 12. A preoperative maxillary anterior reconstruction in of the free gingival margin - developing a more proportion-
place showing the lack of harmony between the various ate form for the teeth, as well as removing an excessive dis-
components of the smile, the teeth, the lips, and the gin- play of gingiva below the inferior border of the upper lip.
giva. The gingival line is diametrically opposed before the Fig. 15. Postoperative healing of the gingivectomy as well
maxillary arch. Note the harmony developed in the postop- as orthodontic repositioning of the right central incisor
erative case between the lips, the teeth, and the gingival without closing the diastema provides for bonding in equal
scaffold. amounts between the two central incisor without closing
Fig. 13. Preoperative view showing rather short, squat teeth the diastema.
in which the height is inadequate relative to the width. Peri- Fig. 16. Preoperative view of smile showing short nonpro-
odontal bone-sounding via the sdcus indicates that there is portionate teeth as well as an excessive display of gingiva.

22
 Principles of aesthetic diagnosis

smile" relates to the basic shape of the teeth. If the cementoenamel junction of the tooth. In
teeth appear to be somewhat short and squat - subcategory A, the dimension between the level of
meaning that the vertical dimension appears to be the cementoenamel junction and the osseous crest
too short as compared with the horizontal is greater than 1 mm, which is sufficient for the
dimension, the gummy smile is probably due to insertion of the connective tissue fibrous
altered passive eruption. attachment component of the biological width. In
If, however, the silhouette form of the tooth subcategory B, detected by the process of bone
appears to be normal and an expanse of tissue is sounding via the sulcus, the osseous crest occurs in
exposed below the inferior border of the upper lip, close proximity to the cementoenamel junction,
this is probably due to an overgrowth of the maxilla thereby diminishing the space for the insertion of
in a vertical dimension or a vertical maxillary the connective tissue of the biological width.
excess. The biological width, which comprises the
In many situations, the gummy smile may be a junction epithelium, the connective tissue fibrous
combination of these two factors. attachment and the sulcus, is considered to be an
inviolate parameter. This implies that the
biological width should not be impinged upon by
The gummy smile - altered passive restorative endeavors. Based on early necropsy
eruption studies, the average dimensions of the biological
width were considered to be approximately 2.7 mm
Altered passive eruption is an aberration in normal - about 1 mm for the junctional epithelium, 1 mm
development where a large portion of the ana- for the connective tissue attachment and 1 mm for
tomic crown remains covered by the gingiva. This the sulcus. In clinical practice, we have found this
complicates developing dentofacial harmony for to be a more varied dimension often exceeding the
two dominant reasons: 3 mm average.
The tissue being positioned coronally on the
teeth results in a silhouette form that is unattrac- Treatment of type I - altered passive eruption
tive. There is only a nominal degree of scallop to
The typical case of altered passive eruption type I-
the free gingival margin, resulting in a tooth
A exhibits short, square-looking teeth and an ex-
shape that is somewhat square instead of a more
panse of gingiva below the inferior border of the
attractive elliptical or ovoid form.
upper lip. A needle probing of the osseous crest
The excess soft tissue tends to be displayed
through the gingival sulcus detects a distance be-
below the inferior border of the upper lip, com-
tween the cementoenamel junction and the 0s-
plicating the desired relationship in that it makes
seous crest that is sufficient to maintain the biolog-
a potentially medium lipline into a high lipline.
ical width (Fig. 13). A gingivectomy using scalpel,
Altered passive eruption has been classified into electrosurgery or carbon dioxide laser will readily
two distinct types (4). remove this tissue. The tissue should be removed
In type I, there is typically an excessive amount cervically in order not to compromise the inter-
of gingiva, as measured from the free gingival dental papillae. This procedure will result in a re-
margin to the mucogingivaljunction. vised silhouette form for the tooth (Fig. 14) that is
In type 11, there is a normal dimension of gingiva more elliptical and attractive and will resolve the
when measured from the free gingival margin to unwarranted excessive display of gingiva apparent
the mucogingival junction. Although these might during smiling (Fig. 15).
appear to be clinically similar in that there is tissue
extended over the coronal portion of the tooth,
Altered passive eruption - type I-B
therapeutically the diagnosis between the two
types is essential to determine the appropriate Diagnosis is confusing in this subcategory, as the
treatment modality. clinical appearance is similar, with an excessive
Type I can be further subdivided on an amount of gingiva from the free gingival margin to
anatomical histological basis into sub-categories A the mucogingival junction readily shown during
and B. This subclassification depends on the smiling (Fig. 16). On bone sounding via the sulcus,
relationship of the osseous crest to the it would appear that the osseous crest is at the

23
Garber & Salama

Fig. 17. The bone-sounding process viewed by making a ence of interdental papillae and realigning the gingival
submarginal incision, leaving the free gingival margin in margin optimally, not with the cementoenamel junction,
place while elevating mucoperiosteal full-thickness flaps. but with the drape of the upper lip.
With a probe in place, the dimension from the free gingival Fig. 21. Postoperative early healing of the case following
margin to the cementoenamel junction and level of the os- the second stage of electrosurgery. Compare with Fig. 16
seous crest is evident. and note the more proportionate teeth as well as the di-
Fig. 18.The osseous has been redeveloped apicallywith the minished amount of gingival display.
form following and paralleling the rise and fall of the ce- Fig. 22. Lateral oblique view of a patient with vertical max-
mentoenamel junctions typical of this genetic phenotype. illary excess in combination with altered passive eruption.
Fig. 19. The flaps coapted and sutured in position just in- The green line on the gingiva indicates the extent of the re-
cisal to the cementoenamel junction quired gingivectomy to develop gingival harmony as well
Fig. 20. Following initial healing of the flap procedure, a as optimal tooth proportion. The black lines on the incisal
gingivectomylgingivoplasty is performed as part of the edges denote the tooth structure to be removed in cosmetic
two-stage procedure using electrosurgery to fine-tune the contouring to develop ideal embrasure form and incisal
harmony of the free gingival margin, ensuring the pres- edge line.

24
 -
Principles_of_aesthetic diagnosis
_ _ _ _ _ ~ ~ ~

The sounding with a probe tends to identify the

Table 2. Vertical maxillary excess classification
more incisally positioned outer cortical plate. The
Gingival and proximity of the osseous crest to the cementoe-
Degree mucosal display Treatment modalities name1 junction requires surgical relocation of the
I 2-4 mm Orthodontic intrusion only soft tissue apically via reduction of the osseous
Orthodontics and periodontics
Periodonticsand restorative crest (Fig. 18, 19) (1, 5) to allow for insertion of
therapy _ these fibers in a more coronal position followed by
I1 4-8 mm Periodontics and restorative a concomitant apical positioning of the junctional
therapy epithelium and the sulcus. This ultimately results
Orthognathic surgery
in the free gingival margin being positioned right at
The choice depends on the
remaining amount of root the cementoenamel junction. The surgical proce-
encased in bone and crown-to- dure, however, may require modification depend-
root ratio ing on the relative position of the upper lip to the
I11 28mm Orthognathicsurgery with or cementoenamel junction (Fig. 20,21).
without adjunctive periodon-
tal and restorative therapy
complete dentofacial harmony
_ _ Altered passive eruption - type I1
In altered passive eruption type 11, the pathogno-
monic short teeth are clinically evident, but the
same level as the cementoenamel junction. This zone of masticatory mucosa is not excessive as in
would seem to be contrary to the concept of the bi- type I. This then requires reduction apically of the
ological width, as the connective tissue fibrous at- entire dentogingival complex, with or without os-
tachment cannot insert into the enamel and yet seous reduction, to aesthetically solve the aesthetic
must be present (Fig. 17).Clinical and histological problem.
necropsy observations suggest that, in altered pas-
sive eruption type I-B, there is an added dimension
buccolingually to the osseous form. This extra The gummy smile - vertical
thickness to the osseous structure allows for an maxillary excess
apical angulation of the bone crest from the gingi-
val aspect of the periodontal ligament side. Al- The gummy smile frequently results from a skeletal
though periodontal connective tissue fibers nor- dysplasia (Fig. 22), such as a hyperplastic growth of
mally run horizontally across the osseous crest ex- the maxillary skeletal base. This results in the teeth
tending from the cementum to the gingiva, in this being positioned farther away from the skeletal
form of altered passive eruption, the fibers run api- maxillary base and a display of gingiva below the
cally, parallel to this angular crest, allowing for in- inferior border of the upper lip. Diagnosis in the
sertion of the connective tissue fibers just apical to high lipline case involving a vertical maxillary ex-
the cementoenamel junction in the cementum. cess requires ruling out the cases due to a superim-

Table 3. Treatment of the gummy smile: altered passive eruption or vertical maxillary excess
Condition 'Ikeatment options -
_~ __ __ -.
Altered passive eruption
-
type 1-A Gingivectomy
_ __
Altered passive eruption_type 1-B Flap with osseous resection
- __________-
___
Vertical maxillary excess - degree 1 Orthodontics
Orthodontics and periodontics
Periodonties
- ____
Periodontics
_ _
and restorative dentistry
Vertical maxillary excess - degree 2 Periodontics and restorative dentistry
Orthognathic
__ -
surgery _ _____
_ _ _ _
Vertical maxillary excess - degree 3 Orthognathicsurgery plus periodontics and
restorative dentistry where necessary

25
Garber & Salama
_.__

26
 Principles of aesthetic diagnosis

Fig. 23. The gingivectomy is performed with the CO, laser

on the upper right side, but contrasted to the left side. This Table 4. Desirable traits of an attractive smile
is done prior to any orthognathic surgery to give the sur- Three teeth
geon a more precise guideline as to the degree of impaction components gingiva
required during his procedures. lips
Fig. 24. The patient following the orthognathic procedures. Teeth color
This depicts the patient with lips at rest showing a nominal position
amount of incisal edge as well as a full smile. The degree of silhouetteshape
vertical translation of the lip between the rest and full Gingiva health
smile is the required dimension of a tooth to eliminate any harmony and continuityof form
show of gingiva. This, however, may result in an excessively symmetry central incisors
long tooth. The lip at rest is the limitation to vertical im- balance to laterals, cuspids and premolars as
paction for the orthognathic surgeon, as any further im-
determinedby lip drape
paction will result in no show of incisal edge at rest and a
more aged appearance for the patient. Here, following or- Lips define the aestheticzone
thognathic procedures, there is still a show of gingiva be- three forms of liplines: high, medium, and low
low the inferior border of the lip in full smile view. the geometry of harmony
gingival line follows upper lip contour
Fig. 25. To eliminate this postorthognathic surgery show of incisal edge line follows lower lip form
tissue, the patient elected to have further periodontal sur-
gery to lengthen the teeth - eliminating the gingiva. The
green dot on the teeth is indicative of the cementoenamel
junction to which the original gingivectomy was done.
Now the osseous structures redeveloped in a more apical
level and the flap repositioned further apically to display The classification of vertical maxillary excess
more tooth structure. (Tables 2, 3) was developed to help determine the
Fig. 26. Postoperative early healing showing the relocated most appropriate treatment modality. The
gingiva line following bleaching of these teeth and cos- diagnosis relative to the degree of severity is
metic contouring of the incisal edges above the mandibu- predicated upon first treating the altered gingival
lar teeth.
display (removing the altered passive eruption
Fig. 27. A preoperative view of the completion of the orth-
odontic phase prior to orthognathic surgery.
component) and to develop a normal tooth form
(crown form). Degrees of severity I, I1 and I11 are
Fig. 28. The postoperative view following gingivectomy, or-
thognathic procedure, surgical crown lengthening, bleach- then determined by the amount of remaining
ing, and cosmetic contouring 5 years following completion gingiva displayed. The treatment modalities range
of the case. from orthodontic intrusion alone through complex
Fig. 29. The implant site optimally developed showing a treatments involving orthognathic surgery,
continuity of form of the free gingival margin, as well as the orthodontics, restorative components and
three-dimensional reconstruction of the papillae and root periodontal plastic procedures.
eminence.
In vertical maxillary excess cases degrees I1 and
Fig. 30. Postoperative view of the lateral incisor and resto-
I11 involving orthognathic surgery, the treatment
ration in place. Note harmony with the rest of the natural
teeth, but supported by the soft tissue reconstruction to planning relates to developing the relationship
make it indistinguishable from the adjacent dentition. between the incisal edge and the lip at rest. In
some combination cases, the vertical translation of
the lip from rest to its position at maximal smile
may, in fact, exceed the normal length of a tooth
position of altered passive eruption in combina- crown. As such, patients must decide whether to
tion with maxillary hyperplasia. These combined accept a nominal display of gingiva below the
cases should first be treated for any altered rela- upper lip and normal crown dimensions or to
tionship between gingiva and cementoenamel prefer an increased length of the crowns and no
junction (Fig. 21). This results in the development display of gingiva.
of a more aesthetic tooth silhouette form and al- It is critical in these cases to treat to the position
lows for more accurate diagnosis. Orthognatic pro- of the lip at rest, as otherwise the surgeon may
cedures can take place to reposition the maxilla. overimpact the maxilla, burying the incisal edge
The combined cases require for optimal treatment beyond the vermilion border of the lip - resulting
a multidisciplinary approach to treatment plan- in a dramatically aged appearance.
ning involving an orthodontist, a periodontist, an In combination cases, the diagnostic procedural
orthognathic surgeon and a restorative dentist. treatment is as follows:

27
Garber & Salama - -- -

First create an attractive silhouette form for the Summary

teeth developing normal anatomical form. This
will remove any altered passive eruption compo- As the public becomes increasingly concerned
nent from the case, leaving only the vertical max- with looking younger and healthy, aesthetic con-
illary excess or skeletal dysplasia evident. It also siderations will become increasingly more relevant
gives the surgeon a definitive guideline as to the in dental treatment planning. As such, dentists
potential lip-to-tooth relationships and the must define the basic tenets of an aesthetic smile -
amount of impaction necessary (Fig. 23). extending that vision beyond simply "pretty teeth"
The orthognathic procedure is limited by the to a concept whereby total dentofacial harmony is
incisal edge to lip at rest position. A minimum of developed. Aesthetics is not simply a matter for re-
2.0 mm of the incisal edge of the teeth should be storative dentists - it uses restorative dentistry as
shown at rest; that is, the maxilla is not to be one of the disciplines, but it is about beauty. The
impacted beyond this level (Fig. 24). same rules that apply for a denture are therefore
Following orthognathic impaction, any remain- pertinent for crown and bridge and/or implants
ing gingival display may be removed as deter- and must be applied in all aesthetic endeavors.
mined by the patient's subjective needs by using
a periodontal flap with osseous resection accom-
plished in a two-stage approach. The flap should
first be replaced and sutured at its original posi-
References
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