Excessive gingival display (EGD), commonly referred to as a gummy smile, is a multifactorial esthetic condition in which an excessive amount of maxillary gingiva is visible during smiling.
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Current management emphasizes etiologic diagnosis rather than a single universal treatment. Altered passive eruption, dentoalveolar extrusion, vertical maxillary excess, gingival enlargement, short or hypermobile upper lip, and combinations of these factors may coexist.
Therefore, treatment selection should be based on a comprehensive periodontal, dental, orthodontic, and facial assessment.
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A predictable treatment plan begins with identifying the principal source of gingival exposure. Clinical evaluation should include:
▪️ Gingival display during posed and maximum smile.
▪️ Upper lip length and mobility.
▪️ Maxillary incisor display at rest and during smiling.
▪️ Clinical crown dimensions and tooth proportions.
▪️ Periodontal probing and assessment of the cementoenamel junction.
▪️ Incisor inclination and vertical position.
▪️ Occlusal relationships and overbite.
▪️ Facial proportions and lower anterior facial height.
▪️ Cephalometric assessment when vertical maxillary excess is suspected.
This diagnostic process is particularly important because treating only one component of a multifactorial gummy smile may produce an incomplete or unstable esthetic result.
✅ Updated Treatment Options for Gummy Smile
| Etiologic Factor | Preferred Treatment Approach | Main Clinical Objective |
|---|---|---|
| Altered passive eruption | Esthetic crown lengthening ± osseous recontouring | Increase clinical crown exposure |
| Dentoalveolar extrusion | Orthodontic intrusion, frequently with TAD-supported anchorage | Reposition the incisors apically |
| Hypermobile upper lip | Lip repositioning or botulinum toxin type A | Reduce excessive upper-lip elevation |
| Vertical maxillary excess | Orthognathic surgery | Correct the underlying skeletal discrepancy |
| Gingival enlargement | Periodontal therapy, gingivectomy, or appropriate surgical correction | Reduce excessive gingival tissue |
| Multifactorial EGD | Multidisciplinary treatment | Address dental, periodontal, skeletal, and muscular components |
Esthetic crown lengthening is particularly appropriate when excessive gingival display results from altered passive eruption or excessive gingival coverage of otherwise adequately proportioned teeth.
The procedure may involve gingivectomy alone or, when necessary, apical repositioning with osseous recontouring to establish an appropriate supracrestal tissue relationship. The American Academy of Periodontology recognizes crown lengthening as an approach for exposing additional tooth structure when excessive gingival tissue makes the teeth appear short.
Importantly, crown lengthening should not be used to compensate for a skeletal or muscular etiology.
2. Orthodontic Intrusion
When EGD is associated with maxillary incisor or anterior dentoalveolar extrusion, orthodontic intrusion can reduce gingival exposure while preserving the periodontal architecture.
Temporary anchorage devices (TADs) have expanded the clinician's ability to achieve controlled anterior intrusion while minimizing unwanted posterior movement. Recent evidence suggests that TAD-supported mechanics can provide favorable intrusion outcomes, although the certainty of evidence remains limited and treatment protocols vary.
This approach is especially relevant when EGD is accompanied by deep overbite, excessive incisor display, or an unfavorable vertical incisor position.
3. Lip Repositioning
Lip repositioning surgery reduces the upward movement of the upper lip by limiting vestibular muscle excursion. It is most appropriate when upper-lip hypermobility is a major contributor and there is no major skeletal discrepancy requiring orthognathic correction.
A systematic review and meta-analysis reported an overall reduction in gingival display of approximately 3 mm at 6 months, with reductions remaining measurable at 12 and 36 months. Some modified techniques, particularly those incorporating periosteal suturing, demonstrated greater reductions.
However, patient selection remains important because recurrence or partial relapse can occur, particularly during the early postoperative period.
4. Botulinum Toxin Type A
Botulinum toxin type A (BTX-A) is a minimally invasive option for patients whose EGD is predominantly associated with hyperactivity of the upper-lip elevator muscles.
Systematic reviews and meta-analyses demonstrate a clinically relevant short-term reduction in gingival exposure. One meta-analysis reported an average reduction of approximately 3.4 mm at two weeks, with the effect progressively diminishing and tending to approach baseline by approximately 24 weeks.
Consequently, BTX-A should be regarded as a temporary treatment, rather than a definitive correction of skeletal or dental abnormalities. It can be particularly useful when the patient prefers a minimally invasive approach or when muscle hyperactivity is the dominant etiologic factor.
5. Orthognathic Surgery
When vertical maxillary excess is the principal cause of excessive gingival display, Le Fort I maxillary impaction or another appropriately planned orthognathic procedure may provide the most comprehensive correction.
Unlike treatments directed primarily at gingival tissue or lip dynamics, orthognathic surgery addresses the underlying skeletal discrepancy. Current evidence supports its role particularly in patients with significant vertical maxillary excess, although treatment involves substantially greater morbidity and requires multidisciplinary planning.
6. Multidisciplinary and Combined Treatment
Many patients do not have a single etiologic factor. For example, altered passive eruption may coexist with incisor extrusion and upper-lip hypermobility.
In such cases, combined treatment may provide a more predictable result than attempting to correct all gingival exposure through one procedure. Periodontal surgery, orthodontic intrusion, lip repositioning, BTX-A, or orthognathic surgery should therefore be considered according to the dominant etiologic components rather than simply the amount of gingiva displayed.
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A practical treatment sequence is:
Diagnosis → Etiologic classification → Severity assessment → Identify dominant factor → Select the least invasive effective treatment → Evaluate residual EGD → Consider combined therapy when indicated.
The objective should not simply be to eliminate every millimeter of visible gingiva. Facial harmony, tooth–lip relationships, periodontal health, and patient expectations should determine the final treatment target.
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The contemporary management of gummy smile has shifted from procedure-driven correction toward etiology-driven treatment planning. The available evidence supports several effective interventions, but their indications differ substantially.
Crown lengthening is highly appropriate for altered passive eruption, whereas orthodontic intrusion addresses an unfavorable dentoalveolar position. Lip repositioning and BTX-A primarily target excessive lip elevation, while orthognathic surgery is indicated when the underlying problem is skeletal.
The evidence is strongest for the principle that accurate diagnosis is fundamental, while comparative evidence between many treatment modalities remains limited. Recent systematic reviews also emphasize heterogeneity in patient selection, treatment protocols, outcome measurements, and follow-up periods.
Therefore, treatment should be individualized rather than based exclusively on a numerical gingival-display threshold.
🎯 Clinical Recommendations
1. Determine the etiology before selecting the procedure.
2. Use esthetic crown lengthening when altered passive eruption is the primary cause.
3. Consider TAD-assisted orthodontic intrusion when excessive incisor vertical position contributes to EGD.
4. Reserve lip repositioning primarily for patients with clinically significant upper-lip hypermobility.
5. Consider BTX-A when muscle hyperactivity predominates and a temporary, minimally invasive correction is acceptable.
6. Evaluate orthognathic surgery when vertical maxillary excess is clinically significant.
7. In multifactorial cases, consider sequential or combined interdisciplinary treatment rather than overcorrecting a single component.
✍️ Conclusion
Updated gummy smile treatment is increasingly based on individualized etiologic diagnosis rather than a single corrective technique. Crown lengthening, orthodontic intrusion, lip repositioning, botulinum toxin, and orthognathic surgery each have specific indications and limitations.
The most predictable results are achieved when clinicians identify the relative contribution of the periodontal, dental, skeletal, and muscular components before treatment. For complex cases, interdisciplinary planning remains essential to achieve stable and proportionate smile esthetics.
📚 References
✔ Ahmad Amro, L., et al. (2026). Prevalence of different etiologies of excessive gingival display: Identifying diagnostic patterns. The Scientific World Journal.
✔ AlMaghlouth, B., AlMubarak, A., Almaghlouth, I., AlKhalifah, R., Alsadah, A., & Hassan, A. (2021). Orthodontic intrusion using temporary anchorage devices compared to other orthodontic intrusion methods: A systematic review. Clinical, Cosmetic and Investigational Dentistry, 13, 11–19. https://doi.org/10.2147/CCIDE.S283102
✔ Dym, H., & Pierre, R. (2020). Diagnosis and treatment approaches to a “gummy smile.” Dental Clinics of North America, 64(2), 341–349. https://doi.org/10.1016/j.cden.2019.12.003
✔ Mendoza-Geng, A., Gonzales-Medina, K., Meza-Mauricio, J., Muniz, F. W. M. G., & Vergara-Buenaventura, A. (2022). Clinical efficacy of lip repositioning technique and its modifications for the treatment of gummy smile: Systematic review and meta-analysis. Clinical Oral Investigations, 26(6), 4243–4261. https://doi.org/10.1007/s00784-022-04467-0
✔ Pavone, A. F., Ghassemian, M., & Verardi, S. (2016). Gummy smile and short tooth syndrome—Part 1: Etiopathogenesis, classification, and diagnostic guidelines. Compendium of Continuing Education in Dentistry, 37(2), 102–107.
Silberberg, N., Goldstein, M., & Smidt, A. (2009). Excessive gingival display—Etiology, diagnosis, and treatment modalities. Quintessence International, 40(10), 809–818.
✔ Tomaz, A. F. G., et al. (2020). Impact of orthognathic surgery on the treatment of gummy smile: An integrative review. Oral and Maxillofacial Surgery.
✔ Vilarinho, D. F., et al. (2023). Contemporary treatment techniques for excessive gingival display caused by altered passive eruption or lip hypermobility. Journal of Esthetic and Restorative Dentistry.
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