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StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-.

StatPearls [Internet].

Show detailsTreasure Island (FL): StatPearls Publishing; 2025 Jan-.Search term Excessive Gingival Display

Melina Brizuela; Dallel Ines.

Author Information and Affiliations

Authors

Melina Brizuela1; Dallel Ines2.

Affiliations

1 International University Of Catalunya (UIC)2 Dental Faculty, Monastir Tunisia

Last Update: March 19, 2023.

Introduction

Exposing the gingiva when smiling up to some extent provides a youthful look and is cosmetically appealing.[1] A gingival display of 1 to 2 mm when smiling is considered normal.[2] Excessive gingival display, also known as "gummy smile," is the overexposure of the maxillary gingiva while smiling (see Images. Excessive Gingival Display, Gummy Smile, Excessive Gingival Display, Overexposure of the Maxillary Gingiva). In some severe cases, the overexposure of the gingival tissue is evident even in the resting position of the lips.[1]

The critical element in managing a gummy smile is identifying its etiology, which determines the treatment plan and outcomes. A gummy smile may result from various disorders, including a short or hypermobile upper lip, altered passive eruption, vertical maxillary excess (VME), dentoalveolar extrusion, and gingival hyperplasia, but VME is 1 of its most common causes.[3] The investigations needed to diagnose a gummy smile, and its etiology include frontal and lateral facial analysis, static and dynamic lip analysis, lip line, interlabial distance, and display of incisors at rest, and complete periodontal examination. Oral radiographs and cephalometric analysis may also be needed; the latter is indicated for diagnosing VME.[1]

Etiology

A gummy smile is multifactorial in etiology, and more than 1 factor can present simultaneously (see Image. Excessive Gingival Display, Multifactorial in Etiology). Professionals must accurately identify the cause of the condition since the treatment differs according to the etiology.[3][4]

1. Short upper lip length
2. Hypermobile upper lip 
3. Altered passive eruption
4. Gingival hyperplasia
5. Vertical maxillary excess (VME)
6. Dentoalveolar extrusion

Vertical Maxillary Excess (VME)

Vertical maxillary excess is the overgrowth of the maxillary bone in the vertical plane that gives an elongated appearance to the lower half of the face.[1] It is 1 of the most common causes of excessive gingival display, and a cephalometric analysis is usually needed to confirm its diagnosis.[1][3] Excessive gingival display results from an occlusal plane that is lower than expected. The lower lip covering the incisal edges of the upper canines and premolars is almost a pathognomonic feature of the disorder. In VME, the anterior occlusal plane continues without interruption with the posterior occlusal plane, which differs from the overeruption of incisors.[1] Even though the upper lip appears clinically short, its length is usually normal.[1]

Altered Passive Eruption

Teeth erupt in an active phase, where the tooth reaches its occlusal position, and a passive phase, where the gingival tissues migrate apically, exposing the crown.[5] Passive eruption develops in 4 stages:

1. Junctional epithelium on the enamel
2. Junctional epithelium in part on enamel and cementum apical to the cementoenamel junction (CEJ)
3. Junctional epithelium is entirely on the cementum and the sulcus' base at the CEJ
4. Stage 3 and a part of the root is clinically exposed.[3]

Altered passive eruption is the gingival tissue's incapacity to migrate apically past stage 2.[5] Teeth appear short and square because the gingival tissues are coronal to the CEJ.[1] Vital elements to diagnosing altered passive eruption include ruling out a hypermobile lip and checking the CEJ and alveolar crest location. The lips should be examined while resting and smiling. In a hyperactive lip, a translational movement from rest can be up to 10 mm, while in a normal lip activity, it is between 6 and 8 mm.[5] In altered passive eruption, the CEJ can be found at up to 10 mm apical to the free gingival margin.[5] The alveolar crest level is the same as in a healthy condition: at the level of 1 to 2 mm apical to the CEJ.[5] Probing to the bone and a parallel x-ray determine the alveolar crest level.[6][7][8]

Anterior Dentoalveolar Extrusion

Anterior dentoalveolar extrusion is the overeruption of the maxillary incisors, resulting in excessive gingival display due to a more coronal position of the gingival margins.[1] Tooth wear and an anterior deep bite may be the causes of the anterior extrusion. A compensatory incisor overeruption is seen in cases of anterior tooth wear.[1] A discrepancy between the anterior and posterior occlusal planes is usually found in deep bite cases.[1]

Epidemiology

Around 10% of the population between 20 to 30 years of age presents excessive gingival display, which is more prevalent in women.[9][10]The prevalence of the condition decreases with age due to the dropping of the upper and lower lips, which reduces the exposure of the gingiva and maxillary incisors.[11]

History and Physical

Pleasing smiles are found to show: at least the second premolars, little upper gingiva, no gingival recession with healthy interdental papillae filling all interdental areas;[12] a lower lip line that is parallel to the incisal line of the upper teeth and to a virtual line that connects the contact points of these teeth, the symmetry between anterior and posterior teeth, and teeth with correct form, position, color, and shade.[12][1] See Image. Lip Lines.

Some authors define a gummy smile as more than 3 to 4 mm of exposed gingival tissue in a smile, whereas others consider more than 2 mm of gingival exposure as excessive.[13] In general, a gum-to-lip distance of 4 mm or more during a smile is deemed "unattractive" by dentists.[14] Once we identify that a patient has excessive gingival exposure, the next step is to determine its etiology (Table 1).

Table

Table 1. Etiology of excessive gingival display is organized according to the affected tissue.

Evaluation

Medical History

The patient’s age indicates the dentition’s eruptive stage, which helps to identify an altered passive eruption. Gingival hyperplasia may be seen in patients taking anticonvulsants, calcium channel blockers, or immunosuppressive drugs after an organ transplant.

Facial Analysis

The face must be evaluated in the frontal and lateral planes to identify any anomalies or vertical maxillary excess.[3] Most patients with VME have a skeletal class 2 relationship.[3]

Lip Analysis (static and dynamic)

When the cause of the gummy smile is in the lips, it can come from a short lip, a hypermobile lip, or both.[5] The upper lip length corresponds to the distance between the subnasale to the upper lip stomion (lower border of the upper lip). The average length is 20 to 24 mm in young adults and rises with age.[6] A measure less than 20 mm is considered a short lip, and gummy smile and lip incompetence may also be seen in such patients.[5] See Image. Upper Lip Length Measurement.

A hypermobile lip (also known as a hyperactive lip) results from increased activity of the upper lip elevator muscles when smiling.[1] More specifically, the hyperactivity of the levator labii superioris muscles increases the exposure of the teeth and gingival tissues when smiling due to a higher lip position, resulting in a gummy smile.[3]

Display of the Upper Central Incisors at Rest

It must be 3 to 4 mm for young women and 2 mm for young men; however, it decreases with age.[11]

Interlabial Distance at Rest

The normal interlabial distance at rest ranges from 0 to 4 mm.[3] An increased interlabial gap can be caused by short lips, dentoalveolar extrusion, or VME, and clinicians should investigate and identify which is the cause of the discrepancy.[3][5]

Smile Line 

The smile line is defined as the upper lip position concerning the upper incisors and gingiva during a natural full smile.[9] A standard smile line shows 75% to 100% of the crowns with the interproximal gingiva.[1] A low smile line shows less than 75% of the crown, usually a male feature.[15] A high smile line (gummy smile) shows the whole crown and an excessive amount of gingiva, usually a female characteristic.[1][15]

Periodontal Examination

The periodontal examination includes measuring the width and thickness of the attached gingiva, the clinical and attachment level, the crestal bone level concerning the CEJ, and probing depths.[1] A clinical short tooth can be due to gingivitis, gingival hyperplasia, altered passive eruption, or tooth wear, and examining the periodontal tissues helps identify the etiology.[5]

Treatment / Management

Treatment options for excessive gingival display include:

1. Hyaluronic acid
2. Botulin toxin
3. Modified lip repositioning
4. Gingivectomy
5. Orthodontic treatment
6. Orthognathic surgery

The treatment modalities vary according to the etiology of the gummy smile - the key is accurately recognizing the cause of the pathology. In some cases, the gummy smile results from more than 1 factor, eg, vertical maxillary excess and hypermobile lip, and a combination of techniques can be implemented. Less invasive treatment options include botulin toxin injection and a newer alternative: hyaluronic acid injection; the surgical management ranges from gingivectomy, modified lip repositioning, and orthognathic surgery, which is reserved for severe VME as it carries high rates of morbidity and requires hospitalization.[16] Finally, orthodontic treatment by itself may be sufficient to resolve some cases of a gummy smile.

Gingivectomy

Crown lengthening with or without bony resection, called gingivectomy, removes the excessive gingival tissue and reinserts the attachment apparatus.[16] The decision of performing only a gingivectomy or a gingivectomy with osseous resection depends on the amount of biological width. A gingivectomy is sufficient to resolve a gummy smile when there are adequate osseous levels and attached gingiva, and the gingival tissue from bone to the gingival crest is more than 3 mm.[16] But, a full-thickness periodontal flap in combination with osteotomy is indicated when the osseous level is near the cementoenamel junction - a gingivectomy alone disrupts the biologic width.[17]

Lip Repositioning Surgery

Lip repositioning surgery aims at narrowing the vestibule and reducing the gingival display by restricting the muscle pull.[18] It involves eliminating a long piece of mucosa from the labial vestibule and making a partial-thickness flap between the mucogingival junction and the upper lip muscles.[17] After this, the lip mucosa is sutured to the mucogingival line.[18] Lip repositioning surgery is indicated in mild VME and an upper hypermobile lip.[5] A short upper lip of non-skeletal origin may also be addressed by repositioning.[4] It must be avoided in patients with severe VME and those with insufficient attached gingiva width.[4] The technique can be performed by electrocautery, laser, or using a scalpel.[5]

Hyaluronic Acid Infiltration

In 2018, Diaspro et al proposed what they called "a novel corrective technique" to address the concern of excessive gingival display.[4] The procedure involves injecting a small bolus of hyaluronic acid into the paranasal region to compress the lateral fibers of the levator labii superioris alaeque nasi (LLSAN), which inhibits the motility of its deep portion.[4] This lessen the elevation of the upper lip when smiling, significantly improving a gummy smile.[4] The infiltration point corresponds to the most cranial part of the nasolabial fold, at around 3 mm lateral to the wing of the alar cartilage (the same anatomical site where it is commonly recommended to inject botulinum toxin).[4] Hyaluronic acid infiltration is a valid technique that can be an alternative to botulinum toxin injection, although it is not appropriate for all cases of excessive gingival display.[4] It requires an experienced injector with a vast knowledge of anatomy since the substance is infiltrated in a vascularly rich zone.[4]

Botulin Toxin A Injection

Botulinum toxin induces muscle paralysis by inhibiting the presynaptic release of acetylcholine at the neuromuscular junction.[5] It is a good alternative to address a gummy smile caused by a hyperactive lip.[5] The toxin infiltrates into the levator labii superioris alaque nasi (LLSAN) muscles and levator labii superioris on both sides of the face.[19] Around 4 to 6 units of botulin toxin are injected into the following points bilaterally: 2 mm lateral to the alar facial groove, 2 mm lateral to the first injection point in the same horizontal plane, and 2 mm inferior and between the first 2 sites.[19]

Orthognathic Surgery

Dentoalveolar or orthognathic surgery becomes the only alternative in some severe cases of vertical maxillary excess: LeFort osteotomy, or maxillo-mandibular reposition, combining LeFort and Obwegeser mandibular osteotomy and surgical orthodontic treatment.[4]

Differential Diagnosis

The excessive gingival display does not have a differential diagnosis; however, it is essential to differentiate between the conditions that cause the gingival overexposure.

Prognosis

Most cases of gummy smiles can significantly improve with the available treatment alternatives, but the amount of reduction of the gingival excess depend on its cause. Some cases can be easily resolved with less invasive procedures, such as botulin toxin or hyaluronic acid, but these results only last for some months. Others require surgery, achieving permanent results.

Complications

An excessive gingival display is an aesthetic concern that interferes with patients’ self-esteem and psychological status.[17] Gummy smiles can be a cause of embarrassment, leading to patients hiding or controlling their smiles.[17] 

Deterrence and Patient Education

• Excessive gingival display is considered an aesthetic problem.
• The cause of the excessive display determines the treatment.
• It is important to manage patients' expectations regarding treatment results.
• Patients must be aware of possible complications of treatment and consent to it.

Enhancing Healthcare Team Outcomes

An attractive smile results from a harmonious relationship between the teeth, the extent of the gingival display, and the lip framing while smiling.[20] Dental professionals must not underestimate the crucial role of gingival display in configuring an appealing smile. While the general dentist is almost always involved in the care of patients with excessive gingival display, it is essential to consult with an interprofessional team of specialists, including periodontists, oral surgeons, orthodontists, and oral and maxillofacial surgeons, for the most challenging cases. The treatment outcomes of a gummy smile depend on the cause. However, to improve results, prompt consultation with an interprofessional group of specialists is recommended.

Review Questions

• Access free multiple choice questions on this topic.
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Figure

Excessive Gingival Display, Gummy Smile. Contributed by C Fantasia, BDS

Figure

Excessive Gingival Display, Multifactorial in Etiology. Contributed by C Fantasia, BDS

Figure

Excessive Gingival Display, Overexposure of the Maxillary Gingiva. Contributed by C Fantasia, BDS

Figure

Lip Lines. The illustrated image shows examples of low, medium, and high lip lines. Contributed by R Kabir, MD

Figure

Upper Lip Length Measurement. Contributed by R Kabir, MD

References

1.Silberberg N, Goldstein M, Smidt A. Excessive gingival display--etiology, diagnosis, and treatment modalities. Quintessence Int. 2009 Nov-Dec;40(10):809-18. [PubMed: 19898712]2.Rao AG, Koganti VP, Prabhakar AK, Soni S. Modified lip repositioning: A surgical approach to treat the gummy smile. J Indian Soc Periodontol. 2015 May-Jun;19(3):356-9. [PMC free article: PMC4520129] [PubMed: 26229285]3.Pavone AF, Ghassemian M, Verardi S. Gummy Smile and Short Tooth Syndrome--Part 1: Etiopathogenesis, Classification, and Diagnostic Guidelines. Compend Contin Educ Dent. 2016 Feb;37(2):102-7; quiz 108-10. [PubMed: 26905089]4.Diaspro A, Cavallini M, Piersini P, Sito G. Gummy Smile Treatment: Proposal for a Novel Corrective Technique and a Review of the Literature. Aesthet Surg J. 2018 Nov 12;38(12):1330-1338. [PubMed: 30010767]5.Dym H, Pierre R. Diagnosis and Treatment Approaches to a "Gummy Smile". Dent Clin North Am. 2020 Apr;64(2):341-349. [PubMed: 32111273]6.Jorgensen MG, Nowzari H. Aesthetic crown lengthening. Periodontol 2000. 2001;27:45-58. [PubMed: 11551299]7.Levine RA, McGuire M. The diagnosis and treatment of the gummy smile. Compend Contin Educ Dent. 1997 Aug;18(8):757-62, 764; quiz 766. [PubMed: 9533335]8.Evian CI, Cutler SA, Rosenberg ES, Shah RK. Altered passive eruption: the undiagnosed entity. J Am Dent Assoc. 1993 Oct;124(10):107-10. [PubMed: 8409000]9.Tjan AH, Miller GD, The JG. Some esthetic factors in a smile. J Prosthet Dent. 1984 Jan;51(1):24-8. [PubMed: 6583388]10.Peck S, Peck L, Kataja M. The gingival smile line. Angle Orthod. 1992 Summer;62(2):91-100; discussion 101-2. [PubMed: 1626754]11.Vig RG, Brundo GC. The kinetics of anterior tooth display. J Prosthet Dent. 1978 May;39(5):502-4. [PubMed: 349139]12.de Castro MV, Santos NC, Ricardo LH. Assessment of the "golden proportion" in agreeable smiles. Quintessence Int. 2006 Sep;37(8):597-604. [PubMed: 16922018]13.Peck S, Peck L, Kataja M. Some vertical lineaments of lip position. Am J Orthod Dentofacial Orthop. 1992 Jun;101(6):519-24. [PubMed: 1598892]14.Kokich VO, Kiyak HA, Shapiro PA. Comparing the perception of dentists and lay people to altered dental esthetics. J Esthet Dent. 1999;11(6):311-24. [PubMed: 10825866]15.Peck S, Peck L. Selected aspects of the art and science of facial esthetics. Semin Orthod. 1995 Jun;1(2):105-26. [PubMed: 8935049]16.Ezquerra F, Berrazueta MJ, Ruiz-Capillas A, Arregui JS. New approach to the gummy smile. Plast Reconstr Surg. 1999 Sep;104(4):1143-50; discussion 1151-2. [PubMed: 10654758]17.Mostafa D. A successful management of sever gummy smile using gingivectomy and botulinum toxin injection: A case report. Int J Surg Case Rep. 2018;42:169-174. [PMC free article: PMC5985251] [PubMed: 29248835]18.Rosenblatt A, Simon Z. Lip repositioning for reduction of excessive gingival display: a clinical report. Int J Periodontics Restorative Dent. 2006 Oct;26(5):433-7. [PubMed: 17073353]19.Suber JS, Dinh TP, Prince MD, Smith PD. OnabotulinumtoxinA for the treatment of a "gummy smile". Aesthet Surg J. 2014 Mar;34(3):432-7. [PubMed: 24676413]20.Pham TAV, Nguyen PA. Morphological features of smile attractiveness and related factors influence perception and gingival aesthetic parameters. Int Dent J. 2022 Feb;72(1):67-75. [PMC free article: PMC9275111] [PubMed: 33707026]

Disclosure: Melina Brizuela declares no relevant financial relationships with ineligible companies.

Disclosure: Dallel Ines declares no relevant financial relationships with ineligible companies.

Copyright © 2025, StatPearls Publishing LLC.

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

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• Cite this PageBrizuela M, Ines D. Excessive Gingival Display. [Updated 2023 Mar 19]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-.

In this Page

• Introduction
• Etiology
• Epidemiology
• History and Physical
• Evaluation
• Treatment / Management
• Differential Diagnosis
• Prognosis
• Complications
• Deterrence and Patient Education
• Enhancing Healthcare Team Outcomes
• Review Questions
• References

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