Innovative and Precise Solutions in Gummy Smile Management: The Impact of Digital Technology on Smile Regeneration

Abstract

A gummy smile is a condition, in which the gingival tissue is excessively displayed when smiling. Orthodontic treatment is often combined with other treatments such as crown lengthening and composite restorations to treat the gummy smile. Crown lengthening may be executed utilizing a three-dimensional (3D) printed surgical guide, which provides precise digital measurement of the patient’s optimal gingival height and facilitates enhanced predictability in esthetic treatment results. This case reported postorthodontic treatment combined with a 3D-printed crown lengthening guide design to enhance the smile line and follow up with a composite restoration on lateral incisors. Patient exhibits a Class II skeletal malocclusion with gummy smile. The ultimate results of orthodontic treatment, as well as crown lengthening and composite restoration, are assessed through the use of a digital wax-up intraoral mock-up in 3D printing. Crown lengthening with a surgical guide offered precise results on a reference basis. The treatment was subsequently concluded with the placement of composite restorations on the lateral incisors. An examination of the complete smile showed 6.24 mm preoperative gingival display and 0.24 mm postoperative. Following 14 days, 1 month, and 3 months, the gingival appearance was steady. The patient expressed satisfaction with the final results of the interdisciplinary orthodontic treatment, which addressed their concerns while achieving the desired aesthetic outcomes. The utilization of 3D-printed technology helps to forecast treatment outcomes, which improves patient care in modern dentistry.

Introduction

The primary objectives of orthodontics are to resolve patients’ complaints, achieve optimal functional outcomes, and encourage favorable esthetic outcomes.[1,2,3] The main reason for approaching an orthodontist is esthetic concern, which is affected by malocclusion. Malocclusion, whether skeletal or dental in origin, is prevalent in every community, but with varying prevalence.[4] The global prevalence of Class II was 19.56%. The lowest incidence was observed in Africans at 6.76%, while the highest was noted in Caucasians at 22.9%; the prevalence for Mongoloids was intermediate at 14.14%.[5] Treatment for Class II malocclusion in growing patients includes growth modification, whereas adults typically get camouflage treatment for mild-to-moderate skeletal discrepancies. The complexity of treatment escalates with the severity of the sagittal discrepancy, particularly when accompanied by maxillary vertical excess.[6] In contemporary dentistry, it is essential for both patients and dental practitioners to recognize the significant impact of gingival health on the overall attractiveness of a person’s smile.[7] Excessive gingival exposure results in what is typically referred to as a “high gingival” or “gummy smile.” A gummy smile is characterized by the visibility of more than 2 mm of gingiva during maximal smiling.[8] The occurrence of a gummy smile might be attributed to excessive vertical development of the maxilla. The phenomenon results in an increased lower facial height, leading the maxilla to adopt a somewhat inferior position, which may lead to a tilted occlusal plane.[9]

Accurate diagnosis and treatment planning are necessary to achieve long-term esthetic results with a gummy smile.[10] A surgical crown lengthening is necessary to enhance tooth exposure and restore the biological width, involving gingivoplasty and osteotomy. Crown lengthening is recommended to address restorative requirements, increase the height of the clinical crown, establish a ferrule for restorations, or relocate the margins of restorations. Crown lengthening is frequently recommended to be conducted postorthodontic treatment, when feasible, to prevent the necessity of subsequent corrective surgery.[11] Postorthodontic crown lengthening is typically performed to address esthetic problems that persist despite appropriate tooth alignment. Preserving the biologic width is crucial during crown lengthening. The average measurement is 2.04 mm. The mean sulcus depth, epithelial attachment, and connective tissue attachment measured 0.69 mm, 0.97 mm, and 1.07 mm, respectively. All healthy dentitions possess these measures, but they vary from tooth to tooth.[12,13]

In recent years, the digitalization of dentistry has resulted in the emergence of a plethora of novel concepts, which have paved the way for new methods of diagnosing, planning, communicating, and conducting dental treatments. The guidance of dental procedures is facilitated by the introduction of digital tools and the establishment of a digital workflow.[14,15] Three-dimensional (3D) technology has been used to print surgical guides, reducing operating time and complication rates, resulting in higher patient acceptance and satisfaction.[16] At present, crown lengthening can be accomplished manually using conventional methods or with the help of 3D printing technology, which enables precise gingival height measurements tailored to the patient’s condition. During the observation period, both methods demonstrate comparable results in terms of gingival margin stability, healing process, and pain control. Nevertheless, the digital 3D printing method provides benefits in terms of measurement accuracy and procedural time efficiency. In addition, technological methods contribute to the mitigation of subjective errors. Consequently, the outcome is rendered more esthetically appealing and precise. This efficacy transforms the digital method a potential alternative for crown lengthening procedures, particularly in cases that necessitate high precision.[17] The aim of this case report is to showcase the efficacy of digital-assisted crown lengthening as a novel and precise solution for the management of gummy smiles.

Case Report

The dental clinic received a compliment from a 23-year-old female concerning dental crowding in both her upper and lower jaws. Initial examination on a complete smile showed 6.24 mm of gingival display below the maxillary lip’s bottom border [Figure 1a]. Teeth 36 and 46 were extracted, resulting in mesial tilting of teeth 37 and 47. Tooth 22 showed hyperpigmentation and an asymmetry in the length of the gingival border in relation to the clinical crown, with canine Class II relationship detected [Figure 2].

Figure 1.

(a) Initial patient smile. (b) Postoperative smile results

Figure 2.

Preorthodontic treatment intra oral photographs; occlusal, frontal and lateral view, respectively

The upper first premolars were extracted to initiate orthodontic treatment. Passive self-ligating brackets (Protect, China) were installed [Figure 3]. For 8 months, copper nickel–titanium wires in sizes 0.014”, 0.018”, 0.014” × 0.025, and 0.018” × 0.025 were utilized for alignment with bite risers on teeth 37 and 47. The extraction area was closed over 3 months by retracting the upper canines with power chains after alignment. To prevent tilting and upright the molars in the lower jaw, 0.016” × 0.022” stainless steel rectangular wires with uprighting coils on the mesial of teeth 37 and 47 were utilized for 2 months. The treatment improved interdigitation, closed lower arch gaps, and addressed overjet and overbite [Figure 4]. The patient’s facial profile improved; however, the upper front teeth had irregular gingival height.

Figure 3.

Orthodontic treatment intra oral photographs; occlusal, frontal and lateral view, respectively

Figure 4.

Post-orthodontic treatment intra oral photographs; occlusal, frontal and lateral view, respectively

The crown-to-gingiva ratio was examined before treatment, and calculus was removed with a curette (Younger-Good, Hu FriedyTM, USA). A digital guidance was used to plan a crown lengthening surgery. The model was scanned with a 3D Zaiku-Indonesia intraoral scanner and assessed for gingival margin height with ExoCad [Figure 5a]. The 3D-printed gingival trimming guide (Asiga-Australia) was customized for the patient [Figure 5b]. A guide was inserted over teeth 14–24 and the gingiva clipped under local anesthesia (xylocaine with 1:100,000 epinephrine). A sulcular incision was made to complete the procedure after removing the guide [Figure 6a]. After achieving the desired result, composite resin restorations were applied to the mesial surface of tooth 12 and the cervical region of tooth 22 [Figure 6b]. Finally, the interdental papilla was sutured, and the labial gingiva was packed with periodontal material. The patient was observed 7 days postsurgery without complications. The postoperative gingival display was 0.24 mm at the conclusion of the treatment. High satisfaction is expressed by patients as the crown lengthening surgery improves the cosmetic appearance of their smile by enhancing the height and contour of their gingiva [Figures 7 and 1b]. Patient satisfaction was assessed using a patient satisfaction questionnaire ranging from 0 (very dissatisfied) to 10 (very satisfied). The patient rated their satisfaction as 9/10 at the 3-month follow-up, indicating a high level of perceived esthetic and functional improvement. The gingival display was relatively stable during follow-up assessments at 14 days, 1 month, and 3 months, indicating satisfactory healing and stable gingival margin position within the early-to-intermediate healing phase.

Figure 5.

(a) Mock-up cutting guide design. (b) Adapted cutting guide design

Figure 6.

(a) The process of gingival cutting adjusted with the cutting guide. (b) Suturing in the interdental area at the interdental papilla

Figure 7.

(a) Initial intraoral smile. (b) Final result of orthodontic, crown lengthening, and restorative procedure

Discussion

A person’s confidence and attractiveness, as well as other social parameters, are significantly influenced by their smile esthetics. The esthetic appearance of the patient may be adversely affected by certain issues, such as an excessive gingival display or a gummy smile, which patients may complain about. This is the result of gingival enlargement, hyperactivity of the elevator muscle of the upper lip, vertical downward development of the maxilla, and/or altered passive eruption. Depending on the underlying cause, the management of gummy smile may necessitate one or more treatment approaches.[9,10,17] Owing to the surge in demand for gummy smile correction, authors have proposed the implementation of surgical esthetic crown lengthening.[18]

The primary factors that contribute to the success of esthetic crown lengthening procedures are the attainment and preservation of optimal gingival margin levels and architecture, which are influenced by biologic requirements. The digitally obtained double guide ensures the proper management of soft and hard tissues, thereby reducing the probability of under or overcontouring these tissues. This facilitates predictability, reproducibility, and long-term pleasurable outcomes.[19] The integration of digital technology in dentistry, particularly in the management of gummy smiles, has revolutionized treatment planning and execution. The case report highlights the use of a 3D-printed crown lengthening model to achieve precise esthetic outcomes in a patient with a Class II skeletal malocclusion with gummy smiles. This approach, combined with postorthodontic treatment and composite restoration, underscores the transformative impact of digital tools in modern dental practice. The use of digital wax-up and intraoral mock-up in 3D printing facilitated accurate assessment and execution of the treatment plan, leading to high patient satisfaction. This case exemplifies the broader trend in dentistry toward digital solutions for enhanced predictability and patient care. The study by Alazmi demonstrated that 3D-printed surgical guides in esthetic crown lengthening resulted in precise outcomes and straightforward procedures, with complete healing and high patient satisfaction observed during the 12-month follow-up period.[20]

While digital technology offers significant advantages in gummy smile management, it is essential to consider potential challenges such as the risk of excessive bone reduction and the need for patient-specific customization.[21] The integration of digital tools in dentistry requires careful planning and execution to maximize benefits and minimize risks. As digital technology continues to evolve, it holds the promise of further enhancing the precision, efficiency, and outcomes of dental treatments, ultimately improving patient satisfaction and care.[22,23] Digitally aided esthetic crown lengthening shortens operating time and eliminates the likelihood of human error during measurement. This will assist practitioners attain greater results. Reduced operational durations and diminished margins for error will contribute to cost reduction, as chairside time is curtailed and the probability of requiring a subsequent surgical intervention is lowered. This will also enhance patient satisfaction significantly.

Given that this example showed some good results, there are certain limitations that need to be pointed out. The results are derived from a single patient exhibiting a particular clinical condition – Class II skeletal malocclusion accompanied by a gummy smile – thereby constraining the applicability of the findings to more extensive patient demographics. Furthermore, while the application of digital technology and 3D-printed surgical guides demonstrated significant accuracy and patient satisfaction, the limited duration of follow-up hindered a comprehensive evaluation of long-term stability and periodontal results. In order to confirm the reliability and reproducibility of this methodology, further investigation necessitates extended observation periods and larger sample sizes. Future study may potentially look into combining artificial intelligence-assisted planning with real-time intraoperative navigation to improve precision and predictability. If validated by extensive clinical research, this digital technique could serve as an invaluable framework for standardizing esthetic crown lengthening operations in routine practice.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.