Photographing the gummy smile for clinical documentation

The gummy smile is a concern that can be seen and measured in an instant: the patient smiles, shows gum, and the question is how much. Photographing it seems obvious, and that is exactly why it is easy to do wrong. A more forced smile, a head tilted slightly back or a camera below the lips all exaggerate the exposure. A shy smile hides it. If the before and after photos are taken with different smiles, the comparison loses all value.

This page covers how to document gum exposure with photos, at rest and in smile, in a comparable way. The clinical side, assessment and management, is in botulinum toxin for gummy smile, which is not the subject here.

What is documented in a gummy smile?

Three different situations appear under the same name, and the photo needs to record each one:

• Rest: how much of the upper incisor shows with the lips relaxed (incisor exposure).
• Natural smile: the spontaneous smile, the one the patient shows in daily life.
• Maximum smile: the forced smile, which shows how far the upper lip can rise.

The smile line and the smile arc appear in the last two. Whoever takes only the maximum smile records the worst possible situation, and whoever takes only the natural one may miss the cause. The two together, labeled, tell the whole story. The relationship between the resting and smiling photos is discussed in the entry resting and smiling photo and in smile photo in facial assessment.

How to get a natural smile?

A posed smile is the enemy of this photo. If the patient understands they are being evaluated, they smile in a rehearsed way, usually higher and wider. Some strategies to get the smile they actually use:

• chat about something light and take the photo in the middle of the conversation;
• ask them to think of a happy memory and smile "with their eyes";
• avoid "say cheese" or "smile," which produce a more forced smile;
• take a sequence of three or four photos and choose the most faithful;
• if video is authorized, extract the frame of the spontaneous smile (speech video to assess the lips).

For the maximum smile, the command is the opposite: "smile as wide as you can and hold." See photo with a forced smile that misleads to understand why the two photos cannot be mixed.

What lighting and framing to use?

The light needs to reach the mouth from the front. Light from above creates a shadow under the upper lip and hides the gum; side light creates a shadow between the teeth. Diffuse frontal light, as in lighting for clinical facial photos, is the best base. Avoid the phone flash, which shines off the teeth and moist gum and erases the gum boundaries.

For framing, the whole face is the standard, but an additional close-up of the smile area helps show the gum. In that close-up, keep the camera at mouth height and roughly parallel to the frontal plane of the face. A camera below the lips makes the teeth look longer and the gum smaller; above, it does the opposite, as in camera height in the patient photo.

How to measure without being fooled?

Measuring the exposed gum is a clinical task, done with a millimeter ruler during the smile. The photo is for recording. If you want to measure on the image, place a scale reference beside the face, at the same distance as the plane of the face, and use the same camera, the same lens and the same distance at each visit. A wide-angle lens distorts proportions, as in wide-angle lenses distort the face.

One important note: the image alone does not define the cause of the gummy smile (it can be muscular, skeletal, dental or mixed). That depends on the clinical exam and, sometimes, additional tests, at the discretion of the qualified professional.

What about the teeth?

The smile shows teeth, and teeth show history. Cracked teeth, restorations and wear appear in close-up photos and can distract from the assessment or be part of it. The page cracked teeth in the lip photo covers the subject. Ask the patient to remove any removable appliance, and never retouch tooth color in the photo.

How to talk with the patient?

The smile is a sensitive area. Many patients are bothered by their gums and avoid smiling in photos. Explain that the photos are for recording and comparing, show the image together with them and use neutral terms.

If you will plan a procedure on the lip, see lip photos in documentation and the lips page.

What mistakes to avoid?

• Photographing only the maximum smile and treating it as the patient's smile.
• Tilting the head back or changing camera height between visits.
• Using flash, which erases the gum boundary.
• Not labeling rest, natural and maximum.
• Asking the patient to remove an appliance without warning and without giving them time.

What makes a gummy smile photo useful is the same thing that makes any clinical photo useful: being repeatable. Note the distance, height, lighting and command, and the record will speak for itself months from now.