Q U I N T E S S E N C E I N T E R N AT I O N A L

Excessive gingival display—

Etiology, diagnosis, and treatment modalities
Nir Silberberg, DMD1/Moshe Goldstein, DMD2/
Ami Smidt, DMD, MSc, BMedSc2

Extensive exposure of the gingiva during a smile, called excessive gingival display, may be
a point of concern for both patients and clinicians. Patients often present to the dental
clinic seeking a solution to their “gummy” appearance. A clinician must fully understand
the various factors involved in this situation, to provide patients with an appropriate
answer. Thorough examination followed by the right diagnosis is imperative for achieving
an esthetic and predictable result in the treatment of such situations. The aim of this
article is to discuss the various aspects of excessive gingival display and its etiology and to
present the current solutions that exist in the literature. (Quintessence Int 2009;40:809–818)

Key words: altered passive eruption, diagnosis, etiology, excessive gingival display,
gummy smile, vertical maxillary excess (VME)

Facial expressions and the smile are key
components for nonverbal communication.
The smile has an important role in the deter-
mination of the first impression of a person.1
An esthetic or pleasing smile is com-
posed of 3 primary components2: the teeth,
lip framework, and the gingival scaffold. An
ideal esthetic and pleasing smile presents
the following characteristics (Fig 1)3,4: (1) min-
imal gingival exposure, (2) symmetric display
and harmony between the maxillary gingival
line and upper lip, (3) healthy gingival tissue
1
Graduate Student, The Center for Graduate Studies in
Prosthodontics, Department of Prosthodontics, Faculty of
Dental Medicine, The Hebrew University–Hadassah, Jerusalem,
Israel.
2
Director, Graduate Studies in Periodontics, Department of
Periodontics, Faculty of Dental Medicine, The Hebrew
University–Hadassah, Jerusalem, Israel.
filling the entire interproximal spaces, (4) har-
mony between the anterior and posterior
segments (gradation principle5), (5) teeth in
correct anatomy and proportion (form and
position), (6) proper color and shade of the
teeth, and (7) lower lip parallel to the incisal
edges of the maxillary anterior teeth and to
the imaginary line going through the contact
points of these teeth.
The description excessive gingival display,
commonly called gummy smile, is used
when there is an overexposure of the maxil-
lary gingiva during a smile6 (Fig 2). In severe
cases, the overexposure is also seen in
repose of the mouth and lips (Fig 3). In most
cases, the more the gingival tissues are dis-
played during the smile, the more unesthetic
the smile appears.7 The prevalence of exces-
sive gingival display is 10% of the population
between the age of 20 and 30 years, and it is

3
seen more in women than in men.1,8 The inci-
Head, The Center for Graduate Studies in Prosthodontics,
Department of Prosthodontics, Faculty of Dental Medicine, The dence of this condition gradually decreases
Hebrew University–Hadassah, Jerusalem, Israel. with age as a consequence of dropping of
Correspondence: Dr Nir Silbeberg, The Center for Graduate the upper and lower lips, which in turn leads
Studies in Prosthodontics, Department of Prosthodontics,
to a decrease in exposure of the maxillary
Faculty of Dental Medicine, The Hebrew University–Hadassah,
PO Box 12272, Jerusalem 91120, Israel. Fax: 972-2-6429683.
incisors and an increase in exposure of the
Email: sil76@012.net.il mandibular incisors.9,10

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Fig 1 A young woman presenting an ideal pleasing smile.

Fig 2 Excessive gingival display of a young female patient during a normal smile.
Fig 3 A severe case of excessive gingival display presenting an overexposure of anterior gingiva in repose.

Hair
1/2
1/3 1/3
Brows
Glabella
Width equal to Eyes
1/3
brow-to-chin 1/3

Fig 4 (above) A woman presenting pleasing 1/2 Nose Subnasale

1/3
gingival exposure during smiling. Stomion Lips
1/3 1/3
Fig 5 (right) Reference lines for facial exami- 2/3
nation.
Soft tissue menton

When analyzing a smile, one must bear in
mind that a certain amount of gingival expo-
sure during a smile is considered esthetically
pleasing, which gives the expression of a
youthful look4,11 (Fig 4).
DIAGNOSIS
For a correct diagnosis, a thorough examina-
tion must be performed.
Facial examination
Facial symmetry and proportions in both
frontal and lateral views. Assessment of
facial symmetry is made with respect to the
interpupillary line. This horizontal line divides
the face into equal halves.
Accessory horizontal lines are the ophriac
line (a line going through the eyebrows) and
the commissural line. These lines should be
parallel to the interpupillary line, thus creating
an overall harmony of the face. These lines
can be used as a reference for orienting the
incisal plane, the occlusal plane, and the gin-
gival contour. A line perpendicular to the
interpupillary line should divide the face into
2 symmetrical parts.
Face height is usually analyzed by divid-
ing the face into thirds. The middle and lower
thirds are more involved in the esthetic con-
sideration of the patient. When measured in
repose, these two thirds should be equal.
The lower third can br further divided by the
stomion into upper one-third and lower two-
thirds12–15 (Fig 5).

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Subnasale
Lower border
of the upper lip
Fig 6 Upper lip length is measured between the
2 lines.
Upper lip length at rest (Fig 6). Upper
lip length is measured from the subnasale to
the lower border of the upper lip. The aver-
age lip length is 20 to 24 mm13 in young
adults and tends to increase with age.
Display of maxillary central incisors at
rest. Maxillary central incisor display at rest,
on average, is 3 to 4 mm in young women
and 2 mm in young men and tends to
decrease with age.9
Amount of gingival exposure during
rest, speech, smile, and laughter. During
an extensive smile, the upper lip should rest
at the level of the midfacial gingival margins
of the maxillary anterior teeth.13
Smile line. This term expresses the posi-
tion of the upper lip relative to the maxillary
incisors and gingiva during a natural full
smile.1,8 A high smile line reveals the entire
crown of the tooth and an abundant amount
of gingiva (excessive gingival display). In the
average smile line, 75% to 100% of the
crowns is revealed with the interproximal gin-
giva. A low smile line is when less than 75%
of the crowns is revealed (Fig 7). A low smile
line is predominantly a male characteristic,
whereas a high smile line is predominantly a
female trait.11
Gingival margin outline. In patients with
excessive gingival display, any irregularities
and disharmony in the alignment of the gin-
gival margin may have a significant effect on
smile esthetics. Harmony should exist
between the gingival line in the anterior and
posterior segments.12,15 The outline of the gin-
gival margins should be parallel to both the
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Fig 7 A low smile line in a man.
incisal edges and the curvature of the lower
lip. The gingival margins of the maxillary cen-
tral incisors and the canines should be sym-
metric and in a more apical position than
those of the lateral incisors. Chiche and
Pinault12 considered symmetry of the gingival
margins at the midline (central incisors) to be
essential, while more laterally a certain
amount of asymmetry is permissible.
Intraoral examination
Occlusal plane. The occlusal plane should
be evaluated by comparing it to the anatom-
ic landmarks in the same way determined
during fabrication of complete dentures. The
occlusal plane should closely coincide with
the imaginary line connecting the commis-
sures of the lips and two-thirds the height of
the retromolar pad.10 In this way, during a
smile, there is mild exposure of the tips of the
mandibular canines and premolars.
Harmony of the dental arches. The
anterior (incisal part) and posterior segments
should be in harmony with one another and
have no major discrepancies.
Anatomy, proportions, and color of the
teeth. Lombardi5 pointed out the impor-
tance of the proportions between width and
length in the dimensions of individual teeth.
A comparison between the anatomic crown
height (incisal edge to cementoenamel junc-
tion [CEJ]) and the clinical crown height
(incisal edge to free gingival margin) will help
determine whether short clinical crowns are
a result of incisal wear or of a coronal posi-
tion of the gingival margin over the teeth.
811
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Fig 8 A boy with pronounced gingival enlarge-
ment due to cyclosporine treatment.
Periodontal examination. The width and
thickness of the keratinized attached gingiva
must be measured, as well as probing depth,
clinical attachment level, and crestal bone
level with respect to the CEJ. The position of
the free gingival margins relative to the CEJ is
another important issue. The periodontal bio-
type may influence the reaction of the gingival
tissues to periodontal therapy and surgery.
There are 3 periodontal biotypes: thin and
scalloped, normal, and thick and flat.15,16 This
information has a crucial influence on the
treatment strategies and decisions.
A correct diagnosis of excessive gingival
display performed according to all the above-
mentioned issues allows the clinician to
select the proper treatment modality and
achieve a clinical result that satisfies both
patient and operator.
ETIOLOGY OF EXCESSIVE
GINGIVAL DISPLAY AND
TREATMENT MODALITIES
Plaque-/drug-induced gingival
enlargement
This is a condition in which the enlarged gin-
gival tissues are covering the clinical crowns,
creating an unesthetic appearance (Fig 8). It
is most often related to dental plaque and
inflammation but can be associated with
medication such as phenytoin, cyclosporine,
and calcium channel blockers. Treatment of
this condition should focus on meticulous
oral hygiene. Sometimes, periodontal sur-
gery will be needed to eliminate the exces-
sive amount of soft tissues.13,17
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Fig 9 A girl with altered passive eruption of multi-
ple teeth. Teeth appear short and square.
Altered/delayed passive eruption
Passive eruption is a normal condition in
which the gingival margins recede apically to
the level of the CEJ after the tooth has erupt-
ed completely. In cases in which the gingival
margins fail to recede to the level of the CEJ,
the condition is named altered passive erup-
tion. Because the gingival tissues are posi-
tioned coronal to the CEJ, the teeth appear
short and square (Fig 9).
This condition may involve multiple teeth
or an isolated tooth. The incidence of altered
passive eruption in the general population is
about 12%. The physiologic condition of pas-
sive eruption may continue even in the third
decade of life; therefore, the diagnosis of
altered passive eruption must be made with
respect to age.
The alveolar crest may be at the level of
the CEJ or 1 to 2 mm apical to it, as exists in
a healthy condition. Parallel radiography will
help determine the level of the alveolar crest
interproximally, and probing to bone (sound-
ing) will determine its level facially and oral-
ly.13,18,19
A classification for altered passive erup-
tion was suggested by Coslet et al20:
• Type 1A—excessive amount of keratinized
gingiva with normal alveolar crest–to–CEJ
relationship
• Type 1B—excessive amount of keratinized
gingiva with osseous crest at the CEJ level
• Type 2A—normal amount of keratinized
gingiva with normal alveolar crest–to–CEJ
relationship
• Type 2B—normal amount of keratinized
gingiva with osseous crest at the CEJ level
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Fig 10 Excessive gingival display due to over- Fig 11 A typical case of vertical maxillary
eruption of the maxillary incisors. Note the dis- excess. Note the amount of gingival tissues
crepancy in the occlusal plane between the exposed and the lower lip covering the maxil-
anterior and posterior segments. lary canines and premolars.

Fig 12 Cephalometric analysis. The anterior maxil-

lary height is measured between the palatal plane
and the incisal edge of the maxillary incisors.

Palatal plane
3

Incisal edge

Altered passive eruption may be resolved Vertical maxillary excess (VME)

with periodontal surgery. The selected surgi-
cal procedure depends solely on the type of
altered passive eruption.
Anterior dentoalveolar extrusion
Overeruption of the maxillary incisors with
their dentogingival complex leads to a more
coronal position of the gingival margins and
excessive gingival display. This condition
may be associated with tooth wear at the
anterior region (compensatory incisor over-
eruption) or with anterior deep bite. In cases
with deep bite, there is usually a discrepancy
in the occlusal plane between the anterior
and posterior segments (Fig 10).
Treatment of this condition may include
orthodontic intrusion of the involved teeth
moving the gingival margin apically, surgical
periodontal correction with or without
adjunctive restorative therapy, or an interdis-
ciplinary comprehensive treatment plan.2,12,15
This condition involves an overgrowth of the
maxilla in the vertical dimension. Many times,
it appears with a long-face syndrome.12,21 An
increase in facial height appears mainly in the
lower half of the face, and in contrast to over-
eruption of the maxillary incisors, harmony of
the occlusal plane between the anterior and
the posterior segments is found. Because the
occlusal plane is relatively lower than normal,
individuals with VME will have excessive gingi-
val display with the lower lip covering the
incisal edges of the maxillary canines and pre-
molars (Fig 11). These clinical findings may
lead the clinician toward diagnosing VME,
which must be confirmed with a cephalomet-
ric radiograph reading. It was found in a
gummy smile group8 that the distance
between the palatal plane and the incisal edge
of the maxillary incisors (anterior maxillary
height) was approximately 2 mm higher than
in individuals without gummy smiles (Fig 12).

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Ta b l e 1 Classification of vertical maxillary excess*

Gingival and mucosal

Degree display (mm) Treatment modalities

I 2–4 Orthodontic intrusion

Orthodontics and periodontics
Periodontal and restorative therapy
II 4–8 Periodontal and restorative therapy
Orthognathic surgery (Le Fort I osteotomy)
III ≥8 Orthognathic surgery with or without adjunctive periodontal and
restorative therapy
*Taken from Garber and Salama2

Fig 13 A girl with short upper lip.

In cases of VME, most often, the length of
the upper lip is normal, although clinically, it
appears relatively short.
A classification of VME was introduced by
Garber and Salama in 19962 offering 3
degrees of gingival exposure and correspon-
ding treatment modalities (Table 1).
Short upper lip
In this instance, the upper lip is shorter than
15 mm, measured from the subnasale to the
lower border of the upper lip22 (Fig 13).
Interestingly, a number of studies showed
that in most cases of excessive gingival dis-
play, the upper lip length is normal even
though the lip appears clinically short.8 The
treatment modality recommended for this
condition will be discussed ahead.
Hyperactive upper lip
This condition represents increased activity
of the elevator muscles of the upper lip dur-
ing smile. According to the study of Peck et
al,8 individuals with excessive gingival display
present significantly more efficient lip-eleva-
tion musculature compared to those with
average smile lines. In this study, people with
a high lip line raise the upper lip an average
of 1 extra millimeter, or nearly 20% more,
than the reference group during a smile.
The treatment modalities recommended
for short upper lip and hyperactive upper lip
are similar. Plastic reconstructive surgery
was the solution offered in several reports
published in the 1970s and 1980s for treat-
ment of such conditions. The first technique
reported was the lip adhesion technique
described by Rubinstein and Kostianovsky.23
In this technique, the internal connection of
the upper lip is severed, and an elliptical
piece of tissue is removed from the dissected
area. Then, a lower connection is established
between the upper lip and gingival soft tis-
sues, about 4 mm above the free gingival
margin. This procedure of reconnection
restricts upper lip elevation during the smile,
limiting the amount of gingival tissue expo-
sure. Litton and Fournier in 197924 discussed
and supported this treatment modality in
their work and recommended that it be used
more widely. Their modification was to
detach the lip muscles from the bony struc-
tures in cases of short upper lip to increase
the lip length.

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Excessive gingival and teeth display

Increased incisor Normal incisor

exposure during rest exposure during rest

Normal lip Short Short clinical Normal clinical

length upper lip crown crown length

Difference between anterior Harmonious Incisal No Hyperactive mobile

and posterior occlusal planes occlusal plane attrition attrition upper lip

Incisor VME Differential diagnosis

overeruption

Incisor Altered passive Gingival

overeruption eruption hyperplasia
(compensatory) (1 or more teeth)

Fig 14 A flow chart to determine the correct etiology of excessive gingival display.

In 1983, Miskinyar,25 being disappointed
with the previous technique, described the
levator myectomy and partial removal tech-
nique. Ellenbogen and Swara26 described
the implant spacer technique in 1984. These
2 techniques were based on the same con-
cept of transecting the levator labii superioris
muscle (or part of it), one of the essential
muscles participating in smile formation.
According to the authors, this procedure
results in a decreased elevation of the upper
lip during smile. Ellenbogen and Swara
offered insertion of a space maintainer (sili-
cone, cartilage, polyamide, or turbinate
bone) to prevent the muscle from reconnect-
ing. Another important factor in the presence
of such an implant spacer is its ability to limit
the activity25,26 of the elevator muscles. The
latter reports presented good results with a
limited number of complications but had no
follow-ups. A literature search conducted by
the authors of this review in search of
updates in this field revealed a small and
nonsignificant number of current reports on
these methods with no actual innovations. In
a recent publication, the original lip adhesion
technique23 was used with a follow-up of 8
months reporting good results.27
Polo in 200528 offered the use of botu-
linum toxin injections as a new nonsurgical
method for treating excessive gingival dis-
play. The toxin is injected into the area of the
upper lip to decrease the elevating muscle
activity, aimed in particular at the levator labii
superioris muscle. The major disadvantage
of this technique is the short effect of the
toxin, which lasts only 3 to 6 months.
In contrast to the above-mentioned treat-
ment options, some cases of excessive gingi-
val display due to short or hyperactive upper
lip may be treated by periodontal surgery
with or without an adjunct restorative therapy.
Asymmetric upper lip
In 2001, Benson and Laskin29 evaluated the
smile in a group of 195 subjects and found
9% with asymmetric smile, due to canting of
the upper lip. This asymmetry can lead to
excessive and asymmetric gingival exposure.
When this asymmetry appears only during a
smile, (in most cases) it is uncorrectable. It is
imperative to draw the patient’s attention to
such an asymmetry before the onset of any
comprehensive dental treatment.
A flow chart that can help determine the
correct etiology of a specific excessive gingi-
val display case is shown in Fig 14.

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In general, cases of excessive gingival dis-
play may have more than one etiology and
should therefore be diagnosed carefully, and
an interdisciplinary treatment should be con-
sidered. It is of high importance to involve the
patient throughout the process of diagnosing
and treatment planning. An informed patient
is a key factor to treatment success and per-
sonal satisfaction.
TREATMENT
CONSIDERATIONS
As stressed before, proper examination and
correct diagnosis must be performed before
deciding whether to include periodontal sur-
gery in the treatment. A decision has to be
made on the type of surgery, with or without
bone resection6,29–31:
• Gingivectomy is indicated when there is
excess keratinized soft tissue and the
bone level is appropriate. Careful evalua-
tion must take place before surgery so that
adequate keratinized gingival tissues will
remain after surgery. This procedure
applies to cases of gingival overgrowth
and altered passive eruption type 1A.
• Apically positioned flap without osseous
resection is recommended for cases in
which the bone level is appropriate but
gingivectomy will leave less than 3 mm of
keratinized gingival tissues. This is per-
formed in cases of altered passive erup-
tion type 2A.
• Apically positioned flap with osseous
resection is recommended for all other
cases where osseous resection is required.
The osseous resection should bring the
bone crest 2.5 to 3.0 mm away apically
from the CEJ or from the definite location
of the finishing line of the final restoration to
achieve a physiologic biologic width.
It is imperative to evaluate the root length of
the teeth before surgery. Any procedure that
needs a considerable amount of bone resec-
tion will result in a relative reduction in the
bony support and has a negative influence
on the crown-to-root ratio,32 teeth mobility,
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and bony support. After periodontal surgery,
it becomes more difficult to achieve an
esthetic result with the restorative treatment.
Because the remaining roots have a smaller
diameter, it becomes complicated to deal with
the emergence profile and the big interproxi-
mal distances that lead to the “black holes”
appearance.
Restorative therapy should be planned in
cases of excessive gingival display in the fol-
lowing situations: (1) short clinical crowns
due to loss of tooth structure (ie, tooth wear);
(2) existing faulty restoration or following an
esthetic complaint by the patient; and (3)
exposed roots as a consequence of peri-
odontal therapy causing teeth hypersensitivi-
ty and impaired esthetics.
When planning restorative treatment after
periodontal surgery, one of the important
issues to be considered is soft tissue matu-
ration. During this period, changes may
occur in the coronoapical position of the free
gingival margins, and thus careful observa-
tion and evaluation of tissue healing is need-
ed before the case can be finalized. The
preparation finishing line must be placed
supragingivally during the healing period,
avoiding any disturbance to the maturation
process.33 In esthetic regions, a healing peri-
od of at least 6 months should be allowed fol-
lowing the periodontal surgical procedure for
the final maturation and location of the free
gingival margins.13,34,35 After proper healing
and maturation of the tissues, final prepara-
tion of the teeth will be performed, where the
finishing line is set no deeper than 0.5 mm
subgingivally.13
The extent of the periodontal corrective
procedure for excessive gingival display
depends on the patient’s display during smile
and repose. Because most people (about
80%) expose the maxillary teeth from second
premolar to second premolar while smiling,1
the surgical procedure should be performed
between the first molars to achieve a harmo-
nious smile and correct gingival contours.18
Prediction of the final outcome of peri-
odontal and restorative therapy is important
in treating cases of excessive gingival dis-
play. Therefore, it is recommended to use a
surgical stent during surgery.33 The first step
is to prepare a total waxup of the teeth and
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Fig 15a and 15b Use of a surgical stent during periodontal surgery in a case with excessive gingival display.

Fig 16 Use of a surgical stent to determine the flap Fig 17 Three-week follow-up. Use of surgical stent
position at the end of surgery. in monitoring the tissue position and maturation.

Figs 18a and 18b Before and after comprehensive periodontic and restorative treatment of excessive
gingival display.

create a correct gingival contour on a study CONCLUSION

model. A surgical acrylic stent is made
according to the waxup, which provides sev-
eral advantages (Figs 15a and 15b): preoper-
ative imaging of the final result in the mouth,
allowing in cases of excess keratinized gingi-
val tissues a definite incision line of the gin-
givectomy, guiding the osteotomy for correct
osseous architecture and proper soft tissue
healing, determining the flap position at the
end of surgery (Fig 16), and monitoring the
tissue position and maturation during follow-
ups (Fig 17).
Excessive gingival display is an esthetic con-
cern both to the patient and the clinician,
especially when restoration of the anterior
teeth is indicated. Understanding the etiolo-
gy and treatment options is crucial in the
process of treatment of a patient with a
gummy smile. The principles and concepts
discussed in this review will lead the clinician
toward achieving an esthetic result and
patient satisfaction with the performed treat-
ment (Figs 18a and 18b).

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REFERENCES 20. Coslet JG, Vanarsdall R, Weisgold A. Diagnosis and

classification of delayed passive eruption of the
dentogingival junction in the adult. Alpha Omegan
1. Tjan AH, Miller GD, The JG. Some esthetic factors in
1977;70:24–28.
a smile. J Prosthet Dent 1984;51:24–28.
21. Kawamoto HK Jr. Treatment of the elongated lower
2. Garber DA, Salama MA. The aesthetic smile:
face and the gummy smile. Clin Plast Surg 1982;9:
Diagnosis and treatment. Periodontol 2000 1996;
479–489.
11:18–28.
22. Ahmad I. Anterior dental aesthetics: Dentofacial
3. de Castro MV, Santos NC, Ricardo LH. Assessment of
perspective. Br Dent J 2005;199:81–88.
the “golden proportion” in agreeable smiles.
23. Rubinstein A, Kostianovsky A. Cosmetic surgery for
Quintessence Int 2006;37:597–604.
the malformation of the laugh: Original technique.
4. Landsberg CJ, Sarne O. Management of excessive
Prensa Med Argent 1973;60:952–954.
gingival display following adult orthodontic treat-
24. Litton C, Fournier P. Simple surgical correction of the
ment: A case report. Pract Proced Aesthet Dent
gummy smile. Plast Reconstr Surg 1979;63:372–373.
2006;18:89–94.
25. Miskinyar SA. A new method for correcting a
5. Lombardi RE. The principles of visual perception
gummy smile. Plast Reconstr Surg 1983;72:397–400.
and their clinical application to denture esthetics.
J Prosthet Dent 1973;29:358–382. 26. Ellenbogen R, Swara N. The improvement of the
gummy smile using the implant spacer technique.
6. Allen EP. Use of mucogingival surgical procedures
Ann Plast Surg 1984;12:16–24.
to enhance esthetics. Dent Clin North Am 1988;32:
307–330. 27. Rosenblatt A, Simon Z. Lip repositioning for reduc-
tion of excessive gingival display: A clinical report.
7. Isiksal E, Hazar S, Akyalcin S. Smile esthetics:
Int J Periodontics Restorative Dent 2006;26:
Perception and comparison of treated and untreat-
433–437.
ed smiles. Am J Orthod Dentofacial Orthop 2006;
129:8–16. 28. Polo M. Botulinum toxin type A in the treatment of
excessive gingival display. Am J Orthod Dentofacial
8. Peck S, Peck L, Kataja M. The gingival smile line.
Orthop 2005;127:214–218.
Angle Orthod 1992;62:91–100.
29. Benson KJ, Laskin DM. Upper lip asymmetry in
9. Vig RG, Brundo GC. The kinetics of anterior tooth
adults during smiling. J Oral Maxillofac Surg 2001;
display. J Prosthet Dent 1978;39:502–504.
59:396–398.
10. Zarb GA, Bolender CL, Hickey JC, Carlsson GE.
30. Foley TF, Sandhu HS, Athanasopoulos C. Esthetic
Boucher’s Prosthodontic Treatment for Edentulous
periodontal considerations in orthodontic treat-
Patients, ed 10. St Louis: Mosby, 1990.
ment—The management of excessive gingival dis-
11. Peck S, Peck L. Selected aspects of the art and science
play. J Can Dent Assoc 2003;69:368–372.
of facial esthetics. Semin Orthod 1995;1:105–126.
31. Wennstrom JL, Prato GPP. Mucogingival therapy—
12. Chiche GJ, Pinault A. Esthetics of Anterior Fixed
Periodontal plastic surgery. In: Lindhe J, Karring T,
Prosthodontics. Chicago: Quintessence, 1994.
Lang NP (eds). Clinical Periodontology and Implant
13. Jorgensen MG, Nowzari H. Aesthetic crown length- Dentistry, ed 4. Oxford: Blackwell Munksgaard, 2006.
ening. Periodontol 2000 2001;27:45–58.
32. Grossmann Y, Sadan A. The prosthodontic concept
14. Ahmad I. Anterior dental aesthetics: Facial perspec- of crown-to-root ratio: A review of the literature.
tive. Br Dent J 2005;199:15–21. J Prosthet Dent 2005;93:559–562.
15. Fradeani M. Esthetic Rehabilitation in Fixed 33. Landi L, Manicone PF, Piccinelli S, Raia R, Marinotti R,
Prosthodontics. Chicago: Quintessence, 2004. Scutella F. Determining osseous resection during
16. Ahmad I. Anterior dental aesthetics: Gingival per- surgical crown lengthening in the esthetic zone
spective. Br Dent J 2005;199:195–202. with the use of a radiographic and surgical tem-
17. Claffey N. Plaque-induced gingival disease. In: Lindhe plate. Quintessence Dent Technol 2004;27:101–113.
J, Karring T, Lang NP (eds). Clinical Periodontology 34. Pontoriero R, Carnevale G. Surgical crown lengthen-
and Implant Dentistry, ed 4. Oxford: Blackwell ing: A 12-month clinical wound healing study.
Munksgaard, 2006. J Periodontol 2001;72:841–848.
18. Levine RA, McGuire M. The diagnosis and treatment 35. Bragger U, Lauchenauer D, Lang NP. Surgical length-
of the gummy smile. Compend Contin Educ Dent ening of the clinical crown. J Clin Periodontol
1997;18:757–762, 764. 1992;19:58–63.
19. Evian CI, Cutler SA, Rosenberg ES, Shah RK. Altered
passive eruption: The undiagnosed entity. J Am
Dent Assoc 1993;124:107–110.

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