Download Management of patients with excessive gingival display for maxillary

Management of patients with excessive
gingival display for maxillary complete
arch fixed implant-supported prostheses
Avinash S. Bidra, BDS, MS,a John R. Agar, DDS, MA,b and
Stephen M. Parel, DDSc
University of Connecticut Health Center, Farmington, Conn
Maxillary complete arch fixed implant-supported prostheses are a popular treatment option for edentulous patients.
Excessive gingival display or gummy smile in edentulous patients is relatively uncommon. However, many partially
edentulous patients or completely dentate patients with compromised dentition and excessive gingival display may
seek a fixed implant-supported prosthesis. Some of these patients may be candidates for immediate implant placement and insertion of the prosthesis, while others may carry over their preexisting excessive gingival display to the
edentulous state for a variable period of time. Both types of patients require meticulous treatment planning and often
require additional preprosthetic interventions before the placement of dental implants. This report provides an overview of the etiology, diagnosis, treatment planning, and options for management of patients with excessive gingival
display who seek a maxillary complete arch fixed implant-supported prosthesis. (J Prosthet Dent 2012;108:324-331)
Improved surgical and prosthodontic treatment protocols and
improved prosthetic designs and
materials have resulted in the increased popularity of the maxillary
fixed implant-supported prosthesis.1
It is known that the number of people in the United States receiving a
complete denture prosthesis will increase despite an anticipated decline
in the age-specific rates of edentulism.2 Douglass et al2 estimated that
about 38 million adults will need 1
or 2 complete denture prostheses by
the year 2020 because of the significant increase in the population older
than 55 years. These projections were
based on factors such as age-specific
population, age-specific percentage of edentulism, declining trends
in edentulism, and percentage use
of dentures. The actual number of
adults in need of complete dentures
and subsequent implant-based rehabilitation may be even higher than
projected in this study. This is because
the study did not consider those completely dentate and partially eden-
tulous adults with compromised or
terminal dentition who may be indicated for edentulism when they seek
comprehensive dental rehabilitation.
Therefore, in the contemporary
setting, patients seeking a maxillary
fixed implant-supported prosthesis
exist across all age groups and encompass clinical characteristics that
a clinician would not expect to see in
a typical elderly edentulous patient.
Such clinical characteristics may include excessive gingival display (commonly called gummy smile), discordant occlusal plane and associated
alveolar bone levels, unfavorable jaw
relationships, and bony characteristics that may not be congruent with
the patient’s age. These patients may
be unwilling to accept a removable
prosthesis (complete dentures or implant retained overdentures) for psychological or social reasons and desire
their prosthesis to be fixed and not
worn.1 Some of these patients may be
willing to make large financial investments for treatment and may also be
willing to manage the challenges in-
volved in oral hygiene and the prosthetic complications associated with
the fixed implant-supported prosthesis.1 All of these factors require the
clinician to diagnose the condition
and meticulously plan a treatment
that will provide these patients with
the optimal fixed implant-supported
prosthesis.
Patients seeking a maxillary fixed
implant-supported prosthesis have
been categorized into 4 groups for
the purpose of treatment planning
and choosing the appropriate design
of a fixed prosthesis (Fig. 1).3 Class I
patients are those requiring a gingival
prosthesis for esthetic tooth proportions, prosthesis contour, and adequate lip support. Class II patients
are those requiring a gingival prosthesis only to obtain esthetic tooth proportions and for prosthesis contour.
Lip support is not a consideration in
this group, because the difference in
lip projection with and without any
prosthesis is not significant. Class
III patients are those who do not require any gingival prosthesis. While
Presented at the 93rd Annual Meeting of the Academy of Prosthodontics, Hilton Head, SC, May 5, 2011.
Assistant Professor and Assistant Program Director, Post-Graduate Prosthodontics.
Professor and Program Director, Post-Graduate Prosthodontics.
c
Private practice, Dallas, Texas.
a
b
The Journal of Prosthetic Dentistry
Bidra et al
325
November 2012
gies of gingival display in dentate patients include (1) skeletal (conditions
such as vertical maxillary excess)6,11;
(2) dental (anterior dentoalveolar extrusion related to Angle Class II division 2 malocclusion)6-9,11; (3) gingival
(altered passive eruption)12; (4) labial
(thin, short and/or hypermobile maxillary lip)11-13; and (5) a combination of
the above.6,7,11 Depending upon the
etiology, patients present with a varying
amount of gingival display; consequently, the management methods differ.
1 Representation of classification of patients for maxillary complete arch
fixed implant-supported prosthesis showing 4 different groups. Red line
depicts excessive gingival display and vertical arrow shows need for bone reduction for conversion of Class IV to another class. (Figure reproduced with
publisher’s permission from Bidra AS, Agar JR. A classification system of
patients for esthetic fixed implant-supported prostheses in the edentulous
maxilla. Compend Contin Educ Dent 2010;31:366-79.)
Class I, II, and III patients can either
have a low smile or medium smile,
Class IV patients are distinct as they
are the only group of patients who
have a high smile or excessive gingival display. Therefore, they require
preprosthetic intervention and conversion to another class for optimal
treatment. As such, they may require
a gingival prosthesis based on the
outcome of the preprosthetic intervention. The purpose of this article
is to provide an overview of the options for the management of patients
with excessive ginigival display (Class
IV) seeking a maxillary complete arch
fixed implant-supported prosthesis.
Types of smiles
In 1984, Tjan et al4 classified human smiles from a dental perspective
into low, average, and high smiles. The
authors defined a display of less than
75% of the anterior tooth length as a
low smile; a display of 75% to 100%
of the anterior tooth length and interproximal gingiva as an average smile;
and a display of 100% of the anterior
tooth length and contiguous band of
gingiva as a high smile.4 This classification has been accepted by prosthodontists and orthodontists.1,5 Other
Bidra et al
authors have classified the excessive
gingival display as a fourth type of
smile.6-8 This type of smile is distinct
from the high smile and has been defined as exposure of the total length
of the maxillary anterior teeth along
with an exposure of about 4 mm of
gingival tissues.8,9 This type of smile
may have a multifactorial etiology.
Etiology of excessive gingival display
Excessive gingival display in the
edentulous patient has not been frequently reported.1,3,10 This may be
partly attributable to edentulism being typically associated with elderly
patients, who rarely have a high or excessive gingival display.5 The reasoning could be a decrease in the ability
of muscles involved in the creation of
a smile to display gingiva.5 However,
it is important for a clinician performing fixed implant-supported rehabilitation to understand the etiologies of
excessive gingival display in dentate
patients. This is because many partially edentulous patients or completely
dentate patients with terminal dentition who seek fixed implant rehabilitation may carry over their preexisting excessive gingival display to their
edentulous state.1 Accepted etiolo-
Diagnosis and treatment planning
Patients with excessive gingival display who seek complete arch fixed implant-supported prostheses can present to the clinician in various ways.
They can either be completely dentate
with generalized compromised teeth,
partially edentulous with a few uncompromised teeth, completely and
recently edentulous, or completely
edentulous for a long period of time
(Fig. 2). Some completely dentate and
partially edentulous patients may be
candidates for extractions, immediate
implant placement, and immediate
insertion of a fixed prosthesis. Typically, the patient with a vertical maxillary excess (VME) has an anterior and
posterior excessive gingival display
due to the downward position of the
entire maxilla, while the patient with
Class II division 2 malocclusion has
an anterior excessive gingival display
due to the dentoalveolar extrusion of
the anterior teeth. Patients with short
clinical crowns can have a varying degree of excessive gingival display, and
hypermobility of the maxillary lip can
be found in combination with any of
the previously described situations.
By using complete denture principles, the optimal maxillary incisal
edge and cervical edge positions of
the prosthetic teeth should be determined at the diagnostic stage.1 This
allows the clinician to determine the
position of the prosthesis-tissue junction (PTJ) with respect to the existing bone level and the most apical
(superior) position of the maxillary
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2 Patients with excessive gingival display seeking maxillary fixed implant-supported prosthesis can present in various ways: A, Dentate patient with compromised teeth. B, Partially edentulous patient with compromised teeth. C,
Recently edentulous patient. D, Long-term edentulous patient.
A
B
3 A, Excessive gingival display in this patient had been managed without addressing preprosthetic interventions or
following appropriate prosthetic contours. B, Intraoral image reveals unfavorable contours (complete ridge-lap) of
intaglio surface of prosthesis to compensate for excessive gingival display, which led to significant oral hygiene problems, halitosis, and failure of multiple implants.
lip during maximum smile.3 If the clinician determines the need for a gingival
prosthesis, then it is acceptable to display prosthetic gingiva, but it is imperative that the PTJ should not be visible
in the final prosthesis during maximum
smile.3 This is because it is difficult to
satisfactorily match the shade of the
prosthetic gingiva with the natural tissues and avoid esthetic failures.1,3 It is
important to understand that the incisal and cervical edge positions of the
prosthetic diagnostic teeth can affect
the amount of display of the gingival
The Journal of Prosthetic Dentistry
prosthesis. Diagnostic teeth that are
shorter than ideal or positioned too
incisally may exaggerate the display of
prosthetic gingiva during a patient’s
maximum smile.7
Bidra et al
327
November 2012
Management options
From a maxillary fixed prosthetic
standpoint, patients with excessive
gingival display require the most complex treatment.3 This is because they
require additional preprosthetic interventions, which adds to the complexity of the treatment. Regardless of the
choice of preprosthetic intervention,
it is imperative that the bony platform
is superior to the cervical edge positions of the teeth. This allows sufficient
space for a smooth anterior-inferior
transition of the prosthesis from the
implant platform to the labial surface
of the teeth. This will also permit the
intaglio surface of the final prosthesis
to have a convex contour and avoids
ridge-lap contours.3 Failure to create
the bony platform superior to the PTJ
can result in 1 of 2 complications.
First, if the bony platform is inferior to the cervical edge positions of the
teeth, then the prosthesis will require
a ridge lap tissue surface to conceal
the visibility of the PTJ due to the patient’s gingival display. Such unfavorable contours may temporarily solve
esthetic issues but can compromise
the patient’s oral hygiene and lead
to associated complications (Fig. 3).
It is impossible to adequately correct
this situation without removing the
implants and raising the bony platform to a position superior to the lip
during maximum smile. Second, if the
bony platform were at the same level
as the cervical edges of the teeth, then
the tissue surface would have a horizontal ledge that makes it difficult to
maintain good hygiene. The correction of this situation may necessitate
more superior or inferior positioning
of the anterior teeth, which may compromise esthetics, occlusion, and oral
hygiene performance. The various options for managing patients with ex-
cessive gingival display who seek fixed
implant-supported prostheses are
further described.
Ostectomy procedures
Ostectomy (formerly called aveolectomy) is defined as the excision of
bone or a portion of a bone, usually
by means of a saw or chisel, for the removal of a sequestrum, the correction
of a deformity, or any other purpose.14
This procedure is generally indicated in
patients with mild to moderate gingival display attributable to dental (Angle Class II division 2 malocclusion),
gingival (altered passive eruption),
or labial (thin, short, and/or hypermobile maxillary lip) causes. An ostectomy should be undertaken before
implant placement, such that the bony
platform is superior to the most apical
position of the maxillary lip in maximum smile15 (Fig. 4). The new bony
A
B
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4 A, Partially edentulous patient with excessive gingival display desiring fixed prosthesis. B, After extractions, ostectomy was
performed with reciprocating saw to raise level of bony platform superior to predetermined maximum lip position. C, Appearance of new bony platform before placement of implants and confirmed to be superior to level of lip during maximum smile.
D, Posttreatment result shows prosthesis-tissue junction adequately concealed underneath lip during maximum smile.
Bidra et al
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5 A, Esthetic failure in this patient with excessive gingival display occurred because implants had been placed without addressing preprosthetic interventions. Use of gingival prosthesis and posterior metal margins further compromised esthetics because of visibility of prosthesis-tissue junction. B, Situation was managed by eliminating posterior
metal margins and gingival prosthesis and conversion to Class III. Long proximal contacts continued to compromise
esthetic result.
platform should ensure that there is
adequate width and sufficient height
for implant placement, without encroaching on the nasal floor or the
maxillary sinus.15 If this is not possible, alternative sites for implant placement, which may change the design of
the planned fixed prosthesis, should
be carefully considered. A combination of advanced radiographic imaging and a bone reduction guide made
from a diagnostic denture can help
the clinician achieve the appropriate
amount of reduction.15 Depending
upon the excessive gingival display
and the planned prosthetic design,
the ostectomy procedure may be required only in the anterior region,
where a gingival prosthesis may be
needed; the posterior region can then
be restored with a fixed dental prosthesis without gingival prosthesis. The
patient could, therefore, be classified
as a Class II in the anterior region and
Class III in the posterior region.3
Lefort I osteotomy
Lefort I osteotomy is commonly
recommended in the orthodontic and
orthognathic surgery literature for situations such as vertical impaction of the
maxilla in the VME condition, to advance the maxilla, and to decrease facial
height.6,7,16 In patients with a dolichofacial appearance and a retruded chin,
this procedure can also involve autorotation of the mandible, which can improve the overall facial appearance.6,7
Several articles in the implant literature
have also described the use of Lefort
I osteotomy to advance the atrophic
edentulous maxilla and in combination
with interpositional grafts to provide
bone augmentation for fixed implantsupported prostheses.17-21
The use of Lefort I osteotomy to
correct excessive gingival display in an
edentulous patient with VME has been
reported previously in the prosthodontic literature.10 This procedure involved
the vertical impaction of the maxilla,
followed by the autorotation of the
mandible and the subsequent fabrication of new complete dentures. Although no similar reports are presently
found in the literature for patients seeking complete arch fixed implant-supported prosthesis, the same approach
is indicated. The goal is to ensure that
the Lefort I osteotomy can position the
bony platform superior to the most apical position of the maxillary lip to avoid
display of the PTJ. Excessive ostectomy
is not a substitute for Lefort I osteotomy in VME patients because of the
risk of encroaching on the nasal floor
or maxillary sinus and also the risk of
divesting any available bone for placement of implants.3
The Journal of Prosthetic Dentistry
Preprosthetic orthodontic intrusion
Preprosthetic orthodontic intrusion of the anterior teeth may be indicated in patients with an anterior
excessive gingival display, attributable
to Class II division 2 malocclusion.6,11
It may also be indicated in patients
with a hypermobile maxillary lip and
an insufficient height of bone in the
anterior maxilla. In such situations if
the planned fixed prosthetic design
necessitates the placement of implants
in the maxillary anterior region, ostectomy procedures should be avoided.
This is because it can deprive the clinician of any available bone for placing implants in this region and risk
encroaching on the nasal floor. Appropriate preprosthetic orthodontic
intrusion by itself, or in combination
with minor bone contouring, can ensure that when the teeth are extracted,
the bony platform for implants is not
only adequate but lies superior to the
lip during maximum smile.3 This can
prevent the visibility of the PTJ under
maximum smile. Potential root resorption related to any rapid orthodontic
intrusion movements are less of a concern in this situation because the teeth
would eventually be extracted.
Bidra et al
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November 2012
Plastic surgery procedures
When a patient’s excessive gingival
display is due to a hypermobile maxillary lip not found in combination
with other etiologies, and the patient
refuses ostectomy, Lefort I, or preprosthetic orthodontic procedures,
then plastic surgery procedures may
be an option. These procedures can
range from surgical techniques such
as lip repositioning procedures11 or
lip lengthening procedures such as V-Y
cheiloplasty,13,22 or use of nonsurgical
techniques such as botulinum toxin
injections.9,23,24 The inherent approach
with both modalities is to limit the apical movement of the upper lip during
maximum smile. Depending on each
patient, the outcome may be different
and may require repetitive treatment.
Patients choosing these options should
be cautioned about the lack of longterm validity of such interventions.
In lip lengthening procedures such
as V-Y cheiloplasty, a V-Y shaped incision
is made in the vestibule of the anterior
maxilla with a vertical incision behind
the philtrum of the maxillary lip. The incisions are then closed by mattress sutures, resulting in a vertical scar closure
and eventual reorientation of the associated muscles.13,22 The lip repositioning
procedure was initially described by Rubinstein and Kostianovsky25 by limiting
the retraction of the elevator muscles
involved in a smile. It has been reported
by plastic surgeons and periodontists
with minor modifications.26-29 This
technique involves making 2 partial
thickness incisions in the gingiva and
mucolabial fold and dissecting an elliptical piece of tissue between them.
Then, the upper lip is inferiorly positioned, and the inner labial mucosa
is sutured to the gingiva about 4 mm
above the free gingival margin.28,29
This procedure reduces the vestibular
depth and restricts upper lip elevation
during the smile, thereby reducing the
amount of gingival tissue exposure.
All of these procedures may allow the
PTJ to be concealed underneath the
upper lip during maximum smile.
Bidra et al
No intervention and conversion to a
Class III patient
This option can be selected as
long as the patient does not present with skeletal or dental etiologies
of excessive gingival display, which
can preclude prosthetic teeth from
being positioned for optimal esthetics. Additionally, this option may be
chosen for those patients who refuse
any preprosthetic interventions, such
as ostectomy or plastic surgery procedures, to conceal the PTJ underneath
the lip. Therefore, a gingival prosthesis
should not be used in these patients,
and they should be converted to a
Class III situation (patients who do not
require a gingival prosthesis).3 This is
because when the PTJ is visible during
maximum smile, the use of any gingival prosthesis (porcelain/composite
resin/acrylic resin) can lead to esthetic
failures as it is difficult to match the
shade of the prosthetic gingiva and the
natural tissues satisfactorily3 (Fig. 5).
A slight gingival display, especially
in younger women, has been reported
to be esthetically acceptable.30 However, management of such situations
in complete arch fixed implant-supported prosthetic rehabilitation is
challenging.3 This is because achieving
an esthetic interproximal papilla-like
tissue between 2 implants or between
an implant and pontic is often difficult.31,32 To overcome this situation,
long proximal contacts are required
between all prosthetic teeth, which can
compromise the esthetic result. Furthermore, achieving optimal contours
of other elements related to dentogingival esthetics, such as gingival levels,
gingival symmetry, and gingival zenith,
is challenging, but could otherwise be
achieved relatively easily by using prosthetic gingiva.33,34 In completely dentate and partially edentulous patients,
immediate placement and immediate
loading may be helpful to obtain better soft tissue outcomes.35,36 The patient should be cautioned about the
esthetic compromises involved with
this option before proceeding with
treatment.
No intervention/reconsider
removable prosthetic options
Patients with excessive gingival
display who refuse preprosthetic interventions or refuse to accept the
esthetic compromises involved with
the option of conversion to Class III
should be counseled to reconsider removable prosthetic options.37,38 This
could involve a conventional complete
denture, implant-supported overdenture (complete palatal coverage or a
horseshoe design), or a fixed-detachable overdenture that includes a locking feature to provide a more secure
retentive feeling similar to the Marius
Bridge.39 However, it is important to
caution these patients that once the
implants are placed for a removable
prosthesis, any future desire to obtain a fixed prosthesis may necessitate
the removal of these implants during preprosthetic intervention. This
is followed by ostectomy procedures
to establish the new bony platform
superior to the most apical position
of the maxillary lip and placement of
new implants (Fig. 6). All of these can
result in additional treatment procedures, time, and expense. Patients
refusing this option should be encouraged to obtain treatment with a
conventional complete denture or no
treatment until they are certain about
their treatment choice.
SUMMARY
This article provided a review of
the etiology, diagnosis, treatment
planning, and management options
for patients with excessive gingival display who seeking a maxillary complete
arch fixed implant-supported prosthesis. Patients with excessive gingival
display can present in various ways,
such as completely dentate with generalized compromised teeth, partially
edentulous with a few good teeth,
completely and recently edentulous, or
completely edentulous for a long period of time. The management options
range from preprosthetic hard or soft
tissue interventions to providing no
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6 A, Patient with excessive gingival display was unsatisfied with bar-supported overdenture and
requested fixed prosthesis. B, Overdenture bar was so inferior (due to excess bone) that bar itself was
revealed when lips were in repose. C, As patient desired fixed prosthesis, removal of previous
implants and ostectomy to raise bony platform and placement of new implants was needed. D, Fixed
implant-supported prosthesis was immediately inserted on new implants. E, Posttreatment result
shows prosthesis-tissue junction adequately concealed underneath lip during maximum smile.
treatment and reconsidering the removable prosthetic option. Successful
communication with the patient at the
treatment planning stage is imperative
before proceeding with this expensive
and potentially invasive treatment.
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Corresponding author:
Dr Avinash S. Bidra
University of Connecticut Health Center
263 Farmington Avenue, L6078
Farmington, CT 06030
Fax: 860-679-1370
E-mail: [email protected]
Acknowledgments
The authors thank Dr. Bridget Willet-Wenning
DDS for sharing her clinical image (Figure 5).
Copyright © 2012 by the Editorial Council for
The Journal of Prosthetic Dentistry.
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Bidra et al