Gummy smile: when to think beyond toxin

"When I smile, too much gum shows." It is a concern that mixes aesthetics and self-esteem. The patient learns to smile with a half-open mouth, covers the smile with a hand, avoids photos. In the office they hear that "toxin fixes it", and often it really does. Other times it does not, because a gummy smile has more than one cause.

This page shows how to tell the causes apart, in which cases toxin is the best answer and when the path goes through dentistry or surgery. Team reasoning is part of good practice.

What gum display is

A smile is considered gummy when the gum shows in a way that bothers the patient. In general, showing a small band of gum is considered normal by many authors, and the limit is subjective. What matters in practice is the patient's perception and the objective measurement of display in millimeters. See the measurement and concept in incisor display.

The relationship between the upper lip and the maxilla, at rest and in motion, also matters. A short or overactive upper lip, an elongated maxilla or small teeth change the equation. That is why, before thinking about treatment, you need to understand why the gum shows.

The three main causes

There is also the lip cause: an upper lip that is short at rest exposes teeth and gum with no movement at all. The causes almost always combine, and the most common case is a mix of muscular and dental. See long upper lip, thin lip and visible gum and smile that shows little tooth, which covers the opposite case.

How to assess

Whenever a bony or dental cause is suspected, a joint assessment with the orthodontist or dentist is essential. The decision to treat only the muscular part must be made consciously, with the patient informed that the other causes remain.

When toxin is the answer

Botulinum toxin can reduce upper lip elevation when the cause is predominantly muscular. The logic is to partially relax the elevator muscles, especially the levator labii superioris alaeque nasi, so the lip rises less. Injection points and doses are at the discretion of the qualified professional. See botulinum toxin for a gummy smile, botox for a gummy smile and toxin and the nasal ala.

Possible effects to explain: temporary result, individual variation, asymmetric smile, a "heavy" upper lip or difficulty pronouncing some words, and asymmetry. Over-relaxing can leave the smile flat. See stiff smile after toxin and asymmetric smile after toxin.

When to think beyond toxin

There are three situations in which insisting on toxin is a mistake.

Dental cause. When the gum covers part of the crown, the approach is dental. Gum surgery and other dental approaches may be considered by the dentist. See veneers and smile planning in HOF.

Bony cause. Vertical excess of the maxilla usually requires orthodontics and orthognathic surgery. No injection solves a skeletal problem, and promising otherwise is an improper promise. See open bite and appearance.

Mixed cause. Many patients have a little of each factor. The best approach may be to treat the muscular part with toxin for a modest gain and, if the patient wants more, discuss dentistry. See concerns that HOF does not solve.

In some cases, upper lip filler is considered. Volume can reposition the lip edge and reduce display, but it changes the design of the smile and the lip. See lip filler and lips: assessing the thin lip.

Timeline of an approach

Risks

Toxin in the perinasal area and upper lip can cause smile asymmetry, a heavy lip, difficulty speaking and a "stiff smile" feeling. Upper lip filler carries risks of swelling, bruising, nodules and, more rarely, a serious vascular complication. Hyaluronidase must be available whenever hyaluronic acid is used. See complications with botulinum toxin and safety and complications: overview.

How Harmy fits in

Harmy simulates volume, and a gummy smile is a concern of movement and muscle. For that reason, the app does not show the effect of toxin on a gummy smile or the reduction in gum display. At most, it can be used to plan the Lips point if the approach includes lip volume.

Record keeping

Record the measurements, the video (with consent and safe storage), the classification, the shared opinion and the guidance about limits. Doses and techniques are at the discretion of the qualified professional, after assessment and in line with the rules of their professional council in Brazil.