Treatment of Gummy Smile of Multifactorial Etiology: A Case Report.

Introduction: This case report describes the management of a patient diagnosed with excessive gingival display caused by altered passive eruption and hyperactive lip. Treatment for this patient was staged and included esthetic crown lengthening and a subsequent lip repositioning procedure.

Case Presentation: A 17-year-old female was referred for assessment of a "gummy smile." The patient reported a history of mouth breathing and a sports injury causing a non-vital tooth #9, which had been temporarily restored. After periodontal evaluation, the patient was diagnosed with plaque-induced gingivitis and excessive gingival display due to hyperactive lip and altered passive eruption. After initial therapy, an esthetic crown lengthening procedure was performed on the maxillary anterior sextant, resulting in ideal maxillary anterior crown contours. Six weeks after esthetic crown lengthening, the patient was treated for hyperactive lip by a modified lip repositioning surgery. Subsequently, the patient received a permanent restoration on tooth #9. During the 1.5-year follow-up time the patient repeatedly expressed her satisfaction with the improvement of her smile. Persistent mouth breathing and associated recurrent gingival inflammation remained a challenge.

Conclusions: The presented case illustrates results of sequentially applied techniques for management of a gummy smile of multifactorial etiology and limitations imposed by unresolved factors. Excessive gingival display can be a significant esthetic concern for patients. Understanding the etiology can be challenging due to multiple factors that may be concomitantly involved. Accurate diagnosis and treatment planning are critical for proper management. When multifactorial etiology is present, multiple treatment modalities, including various surgical approaches, are necessary to obtain positive outcomes in such patients.