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Digital Smile Design concept delineates the final potential result of crown
lengthening and porcelain veneers to correct a gummy smile

Article  in  The International Journal of Esthetic Dentistry · July 2016

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 CASE REPORT

Digital Smile Design concept

delineates the final potential result
of crown lengthening and porcelain
veneers to correct a gummy smile
Richard Trushkowsky, DDS
Cariology and Comprehensive Care – International Aesthetics,
New York University Division College of Dentistry, NYU College of Dentistry

David Montalvo Arias, DDS

Cariology and Comprehensive Care – International Aesthetics,
New York University Division College of Dentistry, NYU College of Dentistry

Steven David, DDS

Cariology and Comprehensive Care – International Aesthetics,
New York University Division College of Dentistry, NYU College of Dentistry

Correspondence to: Dr Richard Trushkowsky

483 Jefferson Blvd, Staten Island, New York, 10312-2332 US; Tel.: 18-948-5808; E-mail: rt587@nyu.edu

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Abstract extraoral photographs, mounted diag-

nostic casts, physical examination, and
Prior to initiating any treatment, it is radiographs were the diagnostic modal-
necessary to visualize the desired out- ities. The gathered information served
comes. It then becomes possible to for- as a starting point for a wax-up and in-
mulate the steps required to achieve this traoral mock-up. This case report dem-
result. Digital Smile Design (DSD) utiliz- onstrates how the DSD served as a tem-
es patient input and information gath- plate for crown lengthening procedures
ered through diagnostic procedures to and design of the final porcelain veneer
create an esthetic treatment scheme. In restorations.
the case presented here, the NYUCD
Esthetic Evaluation Form, intraoral and (Int J Esthet Dent 2016;11:338–354)

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 CASE REPORT

Introduction The upper third may fluctuate due to the

variability of the hairline. The middle and
Esthetic dental concerns have become lower thirds are more involved in esthetic
more widespread among people with rel- perception. The midface is measured
atively affluent lifestyles in at least some from the glabella to the subnasale (the
segments of the population in almost all most protruding area on the forehead
countries. Patients’ esthetic awareness between the eyebrows and the point di-
and expectations have increased, so rectly under the nose). The lower face is
that close to what are perceived to be measured from the subnasale to the soft
ideal outcomes are required. Long-term tissue menton. Often, VME can be treat-
stability necessitates dental restorations ed by orthognathic surgery. A short up-
that are congruent with the periodon- per lip (determined by measuring from
tium and occlusion.1 An esthetic smile the subnasale to the inferior border of
consists of three main constituents: the the upper lip) can also cause a gummy
teeth, the lip framework, and the gingi- smile. HUL is the result of hyperfunction
val scaffold.2 An ideal smile has the fol- of the lip elevator muscles and is usu-
lowing properties: minimal gingival dis- ally the cause of a gummy smile if the
play, symmetry and harmony between lip length is within normal limits and the
the maxillary gingiva and the upper lip, lower third of the face is in proportion
healthy gingival tissue filling the entire to the remaining two thirds. Yet another
interproximal spaces, harmony between cause of a gummy smile is altered pas-
the anterior and posterior segments, sive eruption (APE), which is due to a
teeth with correct form and position, deviation in normal development result-
proper tooth color and shade, and the ing in a large amount of the anatomic
lower lip parallel to the incisal edges of crown being covered by the gingiva,
the maxillary anterior teeth and to an im- and minimal scalloping. APE has been
aginary line going through the contact classified into two types: Type 1 is a
points of these teeth.3,4 When a smile result of a disproportionate amount of
displays a disproportionate amount of gingiva measured from the free gingival
gingiva, this phenomenon is referred to margin to the mucogingival junction. In
as a gummy smile.5 Type 2, there is a normal dimension of
At rest, young women usually display gingiva when measured from the free
3 to 4 mm of the maxillary central inci- gingival margin to the mucogingival
sors, and young men display an aver- junction, but the gingiva extends over
age of 2 mm or less. Extraoral causes the coronal portion of the tooth. Based
of a gummy smile are vertical maxillary on an anatomic histological foundation,
excess (VME), hypermobile upper lip Type 1 can be categorized into 1A – an
(HUL) or a short upper lip. Face height excessive amount of keratinized gingiva
is usually measured by dividing the face with normal alveolar crest-to-cementoe-
into thirds. A visual diagnosis of VME namel junction (CEJ) relationship; and
can be made when, on cephalometric 1B – an excessive amount of keratinized
analysis, the lower third of the face is gingiva with the osseous crest at the CEJ
longer than the middle and upper thirds. level. The association of the osseous

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 TRUSHKOWSKY ET AL

Fig 1 Full-face view. Fig 2 Smile full-face view.

crest to the CEJ of the tooth is the critical Case report

aspect. Type 2 can be categorized into
2A – normal amounts of keratinized gin- The patient, an Afro-American social
giva with normal alveolar crest-to-CEJ worker in her late 30s, presented with the
relationship; and 2B – normal amounts chief complaint of broken veneers. She
of keratinized gingiva with the osseous reported that she had never liked the ap-
crest at the CEJ level.6 Anterior dentoal- pearance of the old veneers, which she
veolar extrusion is the overeruption of had lived with for 18 years (Figs 1 to 3).
the maxillary anterior teeth in conjunc- A medical history was taken and a com-
tion with the dentogingival complex, re- prehensive extraoral and intraoral exam-
sulting in a more coronal position of the ination conducted. The patient’s previ-
gingival margin and disproportionate ous dental history included veneers on
gingival display. This is usually a result of the maxillary and mandibular arches and
tooth wear of the maxillary incisors and two amalgam restorations that appeared
compensatory overeruption or an anter- to be in good condition. An esthetic
ior deep bite. evaluation was also performed, which

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 CASE REPORT

The first thing one does with every gum-

my smile patient is determine the origin
of the problem, which may be skeletal,
muscular, dentogingival, or a combina-
tion of these factors. Knowing the origin
of the problem helps to guide treatment
decisions.
Evaluation of the facial thirds is the
first step in the process. The finding of
an incremented lower third will lead to a
suspicion of maxillary excess. A cepha-
lometric study can be performed to con-
firm the diagnosis. In this case, the origin
was not skeletal, as the lower third of our
patient’s face was equal to the middle
and upper thirds.
The second step is to evaluate the
lip length. A short lip can be diagnosed
whenever the distance from the anterior
nasal spine (ANS) to the lower border
of the vermilion is less than 15 mm. This
was not the case with our patient, as her
lip length was found to be average (with-
Fig 3 Smile profile close-up view.
in the range of 20 to 24 mm). Another
muscular origin of gummy smile could
be lip hypermobility, which is the default
diagnosis in the absence of evidence of
any other origin.
The third step is to evaluate the incisal
included mounted models, radiographs, edge position of the incisors. In patients
photographs, and an esthetic evaluation with incisal edge wear, a gummy smile
form incorporating the changes desired can be due to the overeruption of these
by the patient (Figs 4 to 6). teeth. The dentoalveolar complex will
The following problem list was cre- compensate for the wear of the incisal
ated from the gathered data: edge by moving teeth, bone and gin-
„Excessive maxillary gingival giva coronally, as if it were a slow forced
display; eruption.
„Broken veneers on teeth 11, 12, and If there is no wear, the next step is to as-
21; sess individual tooth proportions. If these
„Margins of veneers broken or stained are correct, the problem is related to an
on teeth 5 to 10, and 22 to 28; altered active eruption (AAE). Our patient
„Unattractive proportions of the presented with incorrect proportions, for
anterior teeth. which there were two possible scenarios:

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Fig 4 Rest position close-up view. Fig 5 Smile close-up view.

Fig 6 Retracted close-up view. Fig 7 Disproportional anterior teeth.

The first could be a gingival overgrowth nostic wax-up, in conjunction with an

due to medicine or systemic conditions; intraoral mock-up, would also allow the
the second could be related to an APE. patient to visualize the outcome of the
After investigating the origin of the pa- proposed treatment.
tient’s gummy smile, it was determined The digitally designed images al-
to be dentogingival rather than skeletal, lowed the patient to visualize the final re-
which meant that the problem could be sult and comprehend the issues raised
addressed restoratively and periodon- by her current oral condition. The num-
tally (Fig 7). Having determined the ber of teeth requiring restoration and the
cause, we could move on to the first step need for periodontal surgery became
in treatment planning, which is visualiza- apparent. The patient’s approval to pro-
tion of the final outcome. In this case, ceed with the treatment was based on
we used Digital Smile Design (DSD) to her viewing the potential outcome via
preview the final esthetic result. A diag- the DSD images (Figs 8 to 11).

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 CASE REPORT

Fig 8 DSD facial reference lines. Fig 9 Appropriate tooth measurements.

Fig 10 Full-face smile project. Fig 11 Intraoral calipered teeth project.

Precisely replicating every detail of The first wax-up was created based
our DSD, and strictly adhering to the on the DSD measurements (Fig 10). The
information derived from the DSD, ena- restorations proposed in the wax-up
bled us to achieve the predicted esthet- were transferred to the patient’s mouth
ic outcome. A digital caliper was used (the mock-up) through the use of a sili-
to measure some reference points on cone putty matrix (Lab Putty, Coltène
the casts. With the aid of a calibrated Whaledent) and bis-acryl (Luxatemp
virtual digital ruler, the reference points Ultra, DMG). The incisal edge position
were transferred to the computer photo- and parallelism to the horizontal refer-
graphs of the patient. Incisal edge pos- ence line were verified. A few minor in-
ition, as always, dictated the design of traoral modifications were carried out,
the restorations, and the initial position and an impression of the mock-up was
of the edge was considered correct. made. The final wax-up was created

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Fig 12 Wax-up based on DSD measurements. Fig 13 Mock-up.

Fig 14 Impression of the mock-up after a few cor- Fig 15 Final preparation indexes.
rections.

on the newly poured models. Indexes new provisional restorations were fab-
fabricated from this new wax-up were ricated from the putty silicon index. As
used as the surgical and preparation the provisional restorations will remain in
guides (Figs 12 to 15). With the aid of the place until the end of the soft tissue heal-
guides, the esthetic crown lengthening ing process, they were highly polished
surgery and gingival margin correction and bonded for retention. Osseous re-
were accomplished.7 contouring to establish an acceptable
The thickness and adaptation of the biologic width was then accomplished.
mock-up makes it a precise surgical A full thickness flap was raised to allow
stent and increases the predictability of visualization during the osteoplasty and
the procedure. A gingivectomy was ac- to permit accurate positioning of the
complished and the mock-up removed. gingival margin with interrupted sutures
Once the soft tissue collar was removed, (Figs 16 to 27).

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 CASE REPORT

Fig 16 Old veneer removal. Fig 17 Mock-up used as a surgical stent.

Fig 18 Gingivectomy, mock-up removal, and tis- Fig 19 Acid etching the old porcelain.
sue collar removal.

Fig 20 Acid etching the enamel. Fig 21 Silane application.

Preparation modification was ac- (Aquasil, Dentsply Caulk) were used.

complished, and final impressions were Maximum intercuspation (centric oc-
made 6 months post-surgery. Retrac- clusion) bites were recorded (Blu-Bite
tion cord (Ultrapak, Ultradent) and a HP, Henry Schein). Impressions, bites,
polyvinyl siloxane impression material clinical photographs, and shades were

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Fig 22 Bonding application. Fig 23 Provisional restorations.

Fig 24 Once the provisional restorations are in Fig 25 Osteoplasty conducted.

place, a full thickness flap is raised to expose the
bone.

Fig 26 Interrupted vertical mattress sutures. Fig 27 After 3 months of healing.

sent to the laboratory. The models In consultation with the laboratory, it

were mounted in centric relation on a was decided to fabricate feldspathic
semi-adjustable articulator with a face- porcelain veneers on teeth 4 to 13 in
bow transfer (Artex Articulator System, the maxilla, and on teeth 21 to 28 in the
Amann Girrbach). mandible. The material was chosen for

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 CASE REPORT

Fig 28 Final preparations.

its esthetic qualities and due to the ab- transparent shade try-in gel (Variolink II,
sence of contraindicating occlusal is- Ivoclar Vivadent). The patient was given
sues. Although not as strong as pressed the opportunity to see the restorations
veneers, feldspathic veneers provide in her mouth and consented to their ce-
better color control. Moreover, less re- mentation. A water rinse was used to
duction is required. When the veneers remove all traces of the try-in gel from
were returned from the laboratory, they the restorations. The internal surfaces of
were inspected for conformity to the final the restorations were scrubbed for 15 s
wax-up. They were then tried in using a with a 35% phosphoric acid solution
(Ultra-Etch, Ultradent) and ultrasonically
cleaned in alcohol for 1 min. Silane prim-
er (Ultradent) was placed on the internal
surface of the veneers and allowed to air
dry. Bonding agent (Prime & Bond NT,
Dentsply) was applied, allowing 30 s for
the solvent to evaporate. The veneered
teeth were isolated with rubber dam,
etched with Ultra-Etch for 15 s, then
rinsed with water for 30 s. Prime & Bond
NT bonding agent was applied to the
internal surface of the veneers. The res-
torations were then loaded with the base
shade (Variolink II cement transparent)
Fig 29 Feldspathic veneers. and seated on the teeth. A small brush

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as well as floss was used to remove the

excess cement before light curing for
40 s. A final check of the occlusion was
made with articulating paper (AccuFilm,
Parkell) and minor adjustments were
performed (Figs 28 to 31).
Due to its dentogingival origin, we
were able to completely correct the
patient’s gummy smile. The final result
achieved in this case demonstrates
what may be accomplished by using a
systematic interdisciplinary approach, Fig 30 Complete isolation cementation.

assisted by DSD (Figs 32 to 36).

Discussion
Excessive gingival display or gummy
smile represents an emotionally charged
esthetic concern for many patients and
a technique-sensitive challenge for clin-
icians. The clinician must understand
the various causes, determine the cor-
rect diagnosis, and formulate a clinically
predictable esthetic treatment plan. The
diagnosis of gummy smile is not rare; the
incidence of excessive gingival display
is 10% of the population between 20 and
30 years of age, and is more commonly Fig 31 Incisal characterization of the veneers.

diagnosed in women.8,9 In their study,

Peck et al found a significant gender
dimorphism in the vertical lip–tooth–jaw
relationship: the upper lip of the females
in the study was positioned on average
1.5 mm more superiorly at maximum
smile than that of the males (P < 0.01).10
The gingival smile line is the smile at its
fullest and exposes the gingiva super-
ior to the maxillary anterior teeth.10 Ac-
cording to orthodontists, clinicians and
laypeople, the most attractive female
smile is when the upper lip rests on the
gingival margin of the maxillary incisor Fig 32 Final profile close-up view.

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a b c

Fig 33 Final full-face smile view.

and the whole incisor crown is displayed at rest; amount of gingival exposure at
(P < 0.05). In the case of the male smile, rest, during speech, smile, and laughter;
laypeople consider it most attractive smile line; and gingival margin line.
when the upper lip rests on the gingival As previously stated, the treatment re-
margin of the maxillary incisor clinical quired to address a gummy smile is de-
crown. Orthodontists and clinicians dif- pendent on the diagnosis of the cause
fer slightly – they consider it esthetically of the problem. Gummy smile cases
most pleasing when the upper lip is on diagnosed as being the result of VME
the gingival margin of the maxillary inci- can often be treated by orthognathic
sor crown, and when there is 2 mm of surgery. A LeFort I procedure involves
upper lip incisor coverage (P < 0.05).11 the down fracture of the maxilla with the
Oshagh et al found that in short-face pat- repositioning of the dentoalveolar com-
terns, lower smile lines are more accept- plex.13 However, a multidisciplinary ap-
able by both dentists and laypeople, and proach is required in some instances, in
in long-face patterns, higher smile lines addition to or instead of surgery. Ortho-
are more acceptable.12 All these find- dontic treatment, periodontal treatment
ings should be considered when setting or restorative dentistry is often indicat-
orthodontic treatment goals. ed.14,15 The development of temporary
A correct diagnosis can be made from anchorage devices (TADs) has resulted
an appropriate examination consisting in a variety of techniques used to treat a
of: facial symmetry and proportions in gummy smile with orthodontics.16 Botu-
both frontal and lateral views; upper lip linum toxin type A, with effects lasting
length at rest; display of maxillary teeth 3 to 6 months, has been reported.17,18

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a b c

Fig 34 Final smile close-up view.

a b c

Fig 35 Final retracted view.

Fig 36 DSD vs final result.

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Reestablishing the depth of the vesti- In these cases, the body will spontane-
bule to treat a short upper lip has also ously attempt to reestablish the correct
been reported. Similarly, a surgical pro- biologic width. Recession will occur in
cedure to limit the movement of the el- thin biotypes due to crestal resorption,
evator muscles has also been recom- and protracted inflammation will occur
mended.19 in thick biotypes. Either scenario would
In this case, the origin of the gummy be detrimental to any restoration placed
smile was determined to be dentogin- in this environment. Osseous recontour-
gival. Once that assessment had been ing is required to rectify the violation of
made, DSD was used to visualize the fi- the biologic width. As in this case, this
nal esthetic result. The key to successful can be accomplished by placing pro-
treatment was then to select the appro- visionals at the preferred crown length
priate techniques to correct the anatom- and then waiting for soft tissue healing.
ic problems, maintain the biologic width, A flap is later raised while the papilla is
and achieve the visualized final esthetic maintained, and osseous recontouring is
result. Based on the work of Gargiulo et accomplished, with the provisional res-
al, the biological width is defined as the toration providing a surgical template.
dimension of the soft tissue that is at- The flap is then replaced in its previous
tached to the portion of the tooth coro- position. Type III crown lengthening is
nal to the crest of the alveolar bone.20 needed when repositioning of the gingi-
After evaluating 171 cadaver tooth sur- val margin would result in disclosure of
faces, Vacek et al reported the follow- the osseous crest. To encourage rees-
ing mean dimensions: a sulcus depth tablishment of a healthy biologic width,
of 0.69 mm; an epithelial attachment of a surgical template is required to assist
0.97 mm and a connective tissue attach- in appropriate bone reshaping under the
ment of 1.07 mm; observed mean meas- elevated flap. The gingival margin is re-
urements of 1.34 mm for sulcus depth; positioned coronally to conserve soft tis-
1.14 mm for epithelial attachment; and sue. Type IV esthetic crown lengthening
0.77 mm for connective tissue attach- is required when inadequate attached
ment.21 Esthetic crown lengthening is gingiva is present. An apically pos-
categorized as being either Type I, II, itioned flap is required with a definitive
III, or IV. In Type I cases, there is suf- margin, and provisional construction ac-
ficient attached gingiva coronal to the complished at a later date.
osseous crest, and the need for osse- For this patient, a Type III one-stage
ous recontouring is therefore obviated. surgical crown lengthening procedure
A simple gingivectomy that simultane- was selected as being the most benefi-
ously sculpts, contours and maintains cial. According to Sonick et al,23 a sin-
appropriate zeniths may be all that is gle-stage crown lengthening procedure
required.22 Type II crown lengthening often results in a 1 to 3 mm rebound of
is categorized by gingival proportions the free gingival margin 6 months to 1
that permit an apical positioning of the year post-surgery. This would especially
gingival margin, do not reveal the osse- apply to patients with a thick biotype.
ous crest, but violate the biologic width. The procedure allowed for the gingivec-

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tomy and placement of the provisional Conclusion

veneers at the same visit. Sonick et al
recommend a two-phase crown length- Precise treatment planning is essential to
ening procedure, in which an ostectomy achieve a long-lasting esthetic outcome
is initially accomplished and, several for patients presenting with a desire to
weeks later, a gingivectomy is performed correct a gummy smile. DSD is a pow-
subsequent to initial attachment and erful tool that can be used to expedite
bone healing. In Lee’s opinion,22 since the analysis of the patient’s facial and
the reaction of the soft tissue to violation dental features and assist in determin-
of the biologic width is not immediate, ing how the finished case will look. The
restorations can be placed immediately proper diagnosis of a gummy smile is a
after a gingivectomy, and osseous re- prerequisite to any restorative treatment
contouring surgery can be done later. that may be required.
This allows precise placement of the os-
seous crest relative to the margins of the
provisional restoration so as to reestab- Acknowledgment
lish the biologic width.
The authors wish to thank Jason J. Kim, CDT (Jason
J. Kim Oral Design Center) for the excellent labora-
tory work.

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