The gingival smile line By Sheldon Peck, DDS, MScD; Leena Peck, DMD, MSI and Matti Kataja, PhD hena person senses happiness pleasure, WW nnssor or erecting. 2 smile develops For some people the smile at its fullest exposes the gingiva superior to the maxillary anterior teeth. Ths anatomical feature defines & gingival smile line (CSL), ‘The gingival smile line traditionally provokes more interest and concern among orthodontists than alow smile line, one that conceals the gine iva and part of the maxillary anterior teth, Orthodontists and surgeons are conditioned to seca gingivalsmileas "undesirable" The varied nomencatue for this anatomical smile variation includes"gummy smile high ip line short upper lip and fll denture smile" Tan, Miller and The performed a sem-quanti- tative study of smiletine variations; thir data suggest evidence of sexual dimorphism of smile lines in the vertical dimension, Full face photo- graphs ofsmilingmenand women wereanalyzed with the intention of identifying features of lip position for help in designing esthetic dental restorations. One part of the study divided the smiles into three categories: a "low smile" dis- playing less than 75% of the clinical crown height of the maxillary anterior teeth, an "average smile” revealing 75% to 100% of the maxillary anterior crown height, and a “high smile” exposing a band. of contiguous maxillary gingiva. Among these three categories, there was a sex difference in smile-line frequency: low smile lines were pre~ dominantly a male characteristic, 25 to 1, and high smile lines were predominantly a female characteristic, 2 to 1. Feature Article Abstract ‘A comparative study was performed to examine the nature of the gingival smile line (GSL}, a spectic dentolabial configuration characterized by the exposure of maxillary anterior gingiva during a ful smile, Five soft-tissue, three dental and three skeletal variables were selected, measured and reported for a GSL sample (n=27) and a reference sample (n=88), both consisting of North American white orthodontic patients with a median age of 14.4 years. The results indicated that the capacity to project a gingival smile was related to: anterior vertical maxillary excess and the muscular ability to raise the upper lp significantly higher than average when smiling. Other variables significantly associated with GSL were greater overjet, greater interlabial gap at rest, and greater overbite. Factors that did not appear associated with the GSL phenomenon were upper-lip length, incisor clinical Crown height, mandibular plane angle, and palatal plane angle. Clinical aspects of GSL were discussed, This manuscript was submitted August 1991. It was revised and accepted October 1991. It was presented in part before the Edward H. Angle Society of Orthodontists, Easter Component, Washington, D.C., March 1990. Key Words Lip e Maxilla e Facial anatomy e Anthropometry ¢ Cephalometry. The Angle Orthodontist Vol. 62 No. 2 1992 1Peck; Peck, Kataja Figure 1C Figure 10 Figure 1 Representative sub- jects from the gingival | Distribution of subjects accor smile line sample, two males andtwofemales. Table | _ Angle Classification ‘Sample Group Class! Class Il Class Ill GSL, male 6 5 0 GSL, female az 9 0 Reference, a 19 2 male Reference, 30 15 1 female 92 The Angle Orthodontist Vol. 62 No.) 1992 Recent work by Peck, Peck and Kataja’ confirms these findings and identifies quantitatively the smile line dimorphism between male and female reference samples. At maximum smile, the up- per-lip line, relative to the gingival margin of the ‘maxillary central incisors, is positioned 1.5mm ‘more superiorly in females than in males,a statis tically significant difference (p<0.01). The gingival smile line is often an associated feature of maxillary alveolar overdevelopment or vertical maxillary excess (VME). This GSL-VME association was first published in 1974 by Karin Willmar in her description of the idiopathic long face. Since then, other researchersin orthognathic surgery have studied lip position in relation to skeletal discrepancies and surgical treatments.*** ‘The present study of the gingival smile line was undertaken to begin establishing a detailed un- derstanding of this specific dentolabial configu- ration. Soft tissue, dental and skeletal variables ‘seemingly related to the gingival smile line were measured and are reported. Materials and methods, Two samples were collected, consisting of pa- tients from private orthodontic practices, who ‘were either in treatment or on posttreatment ob- servation. The 115 subjects studied were North American whites with a mean age of 15.5 years and a median age of 14.4 years. One sample was composed of 27 subjects (1! malesand 16 females) with very prominent gingival smiles, defined as2 ‘mm or more of maxillary gingiva exposed above the left central incisor at maximum smile (Figure 1), Areference sample of 88 subjects (42 malesand -46females) was constructed from unselected orth- cxontic patients who had appointments on ran- domly chosen days. The reference sample, 26% of whom demonstrated GSL as defined above (8 males, 15 females), is fully described and ana- lyzed elsewhere’ Noone in this study had under- ‘gone any maxillofacial surgery. Distribution of the subjects, pretreatment, ac- cording to the Angle classification of malocclu- sion is given in Table 1. Of the 115 subjects, 64 ‘were Class , 48 were ClassIll and 3 were Class I It was difficult to accumulate the gingival smile sample, particularly male subjects, apparently due to the rarity of high smile lines among males. Therefore, for statistical testing purposes, each sample was formed by combining the male and female subjects. However, for comparative pur- poses, the means and standard deviations for the male and female components were separately computed and reported as wel. For each subject, data were compiled for 11 variables which describe lip position and otherFigure 2 dental and skeletal factors seemingly relevant to the gingival smile line. Five frontal soft tissue relationships, measured directly on the face, three direct dental measurements, and three sagittal x- ray cephalographicmeasurements were recorded: 1. Frontal soft tissue measurements, in milli- meters ‘upper lip smile line upper lip length, in rest position upper lip to upper incisor edge, in rest position . upper lip to upper incisor edge, smiling e. interlabial gap, in rest position 2. Dental measurements, in millimeters a. overbite b. overjet «clinical crown height of the upper incisor 3. Sagittal cephalographic measurements a. SN-Mandibular plane, in degrees b. SN-Palatal plane, in degrees Palatal plane to upper incisor edge, in millimeters Linear measurements were recorded tothenear- est millimeter and angular measurements to the nearest degree. In rest position, the upper and lower teeth were apart slightly and at maximum. smile, the teeth usually were lightly closed. To reach the maximum smile position, each subject was coached and was required to achieve the same lip configuration at least twice successively before any soft tissue measurements were taken. In this fashion, most subjects easily attained a reproducible maximum smile, ‘The first measurement, upper lip line at maxi- mum smile or the upper lip smile line, was made on an imagined vertical axis along the facial mid- line (Figure 2). A perpendicular tangent to the gingival margin of the upper central incisors es- tablished the horizontal zero point. When the Figure 3 Gingival smile line Figure 2 Measuring the upper lip smile line. A verti- cal axis graduated in millimeters is visual- ized along the soft-tis- sue facial midline. A perpendicular, tangent to the cervical margin of the upper central in- cisors, defines the horizontal axis (zero). Figure 3 Measuring the relation- ship between the infe- rior border of the up- per lip and the incisal edge of the maxillary Figure 4 border of the upper lip on smiling was superior to this zero point, the amount of gingival display in millimeters was signed positively. When the up- per lip border on smiling was inferior to the zero point, the measurement was signed negatively. Upper lip length was measured directly on the subject's face. The subject's mandible was led into ‘occlusal rest position. The alar base of the nose ‘wasrecorded atthe soft tissue septum Subnasale), and a vertical measurement was taken from this point to the inferior border of the upper lip. The next two measurements recorded the dis- tance between the inferior border of the upper lip and the incisal edge of the upper left central incisor with the subject first in rest position and. then in a maximum smile (Figure 3). ‘The interlabial gap is the vertical midline open- ing between the relaxed upper and lower lips ‘with the mandible in rest position. Lip seal at rest was recorded as zero. Overbite,overjet and clinical crown height were The Angle Orthodontist leftcentralincisor. Two ‘measurements are re- corded, at maximum ‘smile (as represented) and in rest position. jsurements. corded, derived trom sagittal x-ray cephalo- ‘metric films: (1) SN-MP angle, (2) SN-palatal plane angle, (2) palatal plane to incisal edge distance inmillimeters. Vol. 62 No. 2 1992 93Peck; Peck, Kataja 94 The Angle Orthodontist Table Il. Error analysis with 30 double determinations DIFFERENCE = MEAN ‘STANDARD MEASUREMENT UNIT 0 1 2 DIFFERENCE = ERROR Upper lp tine mm 82 007 018 ‘at maximum smile Upper tip length mm at 8 ot 033 os, atrest SNMP angle degrees 13 14 3 os7 06s measured on the subjects. Overbite (vertical over- lap) and overjet (horizontal overlap) were mea- sured to the nearest half-millimeter, from the mesio-incisal corner of the maxillary left central incisor to its opposing mandibular tooth. Clinical crown height was recorded as a millimetric verti- cal projection on the maxillary left central incisor from the incisal edge to the most superior point at the gingival margin. ‘Three skeletal factors were measured from a pretreatmentsagittal cephalometricfilmwitheach subject in centric occlusion (Figure 4). A Margolis cephalostat was employed. The sella-nasion to ‘mandibular plane relationship (SN-MP) isan an- ‘gular measurement often used to describe facial vertical dimension ard specifically mandibular vertical development. The sella-nasion to palatal plane(ANS-PNS) relationship isan angular mea- ‘surement (SN-Pal) expressing the inclination of the maxilla relative to a cranial reference line. The third skeletal factor is a linear measurement of anterior maxillary height: a perpendicular was constructed from the palatal plane to the incisal edge of the maxillary central incisor. Correlation matrices were computed from the data on both samples. Estimates of measurement error were caleu- lated using the double-determination method. Two linear measurements and one angular mea- surement were retaken on 30 subjects by the same investigator. The error analysis (Table I), dis- playing a tabulation of the differences between two determinations, the mean difference and the Vol. 62 No.2 1992 standard error for a single determination, is con- sistent with expectations. More than two-thirds ofthe second measurements were identical to the first measurements, Results Means, standard deviations and ranges for all the variables measured are reported in Tables III, IV and V. Also, values for the male and female subgroups of both samples are displayed for ref- erence purposes. The Student's t-test was employed to evaluate differences between the means of the gingival smileline (GSL) sampleand the reference sample. Many variables showed statistically significant differences. ‘The three variables relating the position of the ‘upper lip to the upper incisor crown all demon- strated highly significant differences (p<0.001) on statistical comparisons between samples (Table HD. The upper lip was positioned 2.1mm to 34 ‘mm more superiorly on average for the GSL. ‘group compared to the reference group in three ‘measurements: upper lip smile line, upper lip to incisal edge at rest position, and upper lip to incisal edge at maximum smile. ‘TheselectionDias for theGSL sample waslargely accountable for the substantial differences noted between samples in these three variables which describe upper lip-incisor-jaw relativity. ‘A useful data transformation was performed using two of the above variables and effectively neutralizing the GSL sample selection bias. TheGingival smile line Table Ill. Linear vertical dentolablal measurements, gingival smile-line sample and reference sample (in millimeters) FEMALES MALES TOTAL SAMPLE MEASUREMENT SAMPLE N MEAN SD| N MEAN SD N MEAN SD RANGE t-TEST Upperipsmiletne | Gingvatsmio | 16 a6 13] 1 92 19 | a a4 19 208 1a, Reference 46 °°07~«24 42 08 24 & 00 23 705 755 Upper. length, Gingvaismto | 16 219 1¢| 1 229 14 | a7 223 21 t91007 ‘rest position Reterence 46 212 24 42 234 25 @8 223 27 141030 909.NS Upperipioincsat | Ginghatsmte | 16 74 19| 11 06 29'| a 71 18 4010 - ‘edge, rest position Reference 4653 (18 42 47° 20 e860 «19 «tto11 508 Upperiptoincis | Gingvalsmte | 16 197 15] 11 127 12 | oy 199 14 tt edge, maximum smile | Reference 4 105 21| @ ‘99 22 | g 102 22 ‘stole Intertabal gap, Gighalemte | 16 67 29] 1 6s 27 | a oc 28 ow .., rest position Reference 46 33 29] 42 26 32 | a8 30 31 oto 4% <0.001 fot tatetcalysignitcant Table IV. Upper-lip elevation, superiorly, from rest position to maximum smiling position (in millimeters) FEMALES MALES TOTAL SAMPLE SAMPLE N MEAN SD | N MEAN SD N MEAN SD RANGE t-TEST Gingialsmio | 16 63 17] 1 61 19 | a 02 198 a0010 f eae Rotrence w 53 18] @ 51 18 | « 52 16 209 s+ =pcoot absolute value of the difference between the two “upper lip to incisal edge” measurements repre- sents the vertical linear change in upper lip posi- tion in the formation of smile. The millimetric change in upper lip position from rest position to maximum smile— the amount of lip elevation on. smiling — was derived for each subject and is reported in Table IV. The GSL sample demon- strated a greater mean increment of lip elevation onsmiling, 6.2mm, than did the reference sample, 5.2mm. In other words, the upper lip of the GSL. subjects showed a 1.0mm greater elevation supe- riorly from rest to maximum smile than did the reference group, a statistically significant differ- ence (p<0.01), The interlabial gap measurement at rest posi- tion averaged 6.2mm for the GSL sample and 3.0mm for the reference sample, a highly signifi- cant difference statistically (p<0.001). More im- portantly, a remarkable difference between the ‘The Angle Orthodontist Vol. 62 No. 2 1992Peck; Peck, Kataja Table V. Skeletal and dental measurements, gingival smile-line sample and reference sample FEMALES MALES TOTAL SAMPLE. MEASUREMENT | SAMPLE. N MEAN SD | N MEAN SD | _N MEAN SD RANGE t-TEST SNMP, degrees Gingival si 16 966 79] 11 344 61 | 27 357 72 221052 oforenco 48 a7 58 | 42 351 55 | 62 349 56 21toas O62NS SN Palatal plane, Gingivalsmio | 16 70 47| 11 65 40 | a7 68 44 ot018 degrees Relerence 4 75 34| 42 71 39 | @8 73 36 21016 O6%NS Palatal plane to Gingvatsmio | 16 317 91 | 11 225 28 | 27 320 30 251097 scesee ‘upper Inciser, mm Reterence 48 27 26 | «2 209 28 | o 27 29 2t0s7 355" Overt, mm Gingvatsmie | 16 46 19 | 11 51 19 | 27 48 17 15107 soeeee Reference 4 32 17] 42 34 19 | 6 33 18 119 99 (Overbite, mm Ginghalsmie | te 32 20| 11 47 24 | 27 38 27 209 3 Reference 4 28 16] 4 29 17 | o& 28 16 2007 24 Ginical crown height, | Ginghalsmie | 16 100 15] 11 98 12 | 27 98 14 71012 mm Reterence 4 98 12 | 42 106 11 | a 102 12 Btoi2 '8NS p<0.0o1 INS = not statistically signiioant 96 The Angle Orthodontist samples existed in the number of subjects exhib- iting lip separation in rest position (interlabial ‘gap>0): gingival smile (n=27): lip separation, 25 subjects (93%); reference (n=88): lip separation, 55 subjects (63%). ‘The difference in lip separation frequency be- tween the two samples was statistically signifi- cant chi-square=7 47, p<001).Thelikelihood ratio calculated from this datais55. Inother words, the GSL subjects were 5.5 times more likely to exhibit an interlabial gap at rest than the reference popu- lation. In addition, the upper lip smile line was moderately correlated with the interlabial gap (r=0.46, n=88, p<0,001). Further data on the interlabial gap for GSL sub- jects was derived by analyzing the composition of the reference group. Of the 88 subjects, 36 dis played gingival smile lines of one millimeter or ‘more. And of these 36 GSLs in the reference sample, 31 (86%) exhibited lip separation in rest position and 5 (14%) attained lip seal (gap=0). In Vol. 62 No.2 1992 contrast, of the 55 reference subjects with lip separation in rest position, these 31 who also displayed gingival smile lines comprised 56%. Upper lip length in rest position showed no difference between the selected GSI. sample and. the reference group. Both samples had an identi- cal mean value of 22.3mm for the upper lip length at rest. Moreover, with the data segregated into ‘male and female groupings, the mean upper lip lengths of the GSL. groups were actually slightly longer than those of the reference samples. Table V shows sample comparisons for three skeletofaciat dimensions and three dental mea- surements. The sella-nasion to mandibular plane angle (SN-MP) and the sella-nasion to palatal plane angle (SN-Pal) both showed non-signifi- ‘cant, slight differences between the GSL sample and the reference group. In contrast, the linear, cephalometric measurement of anterior maxil- lary height (palatal plane to upper incisor edge) revealed mean values of 320mm for the GSLGingival smile line Figure 5 - Stage 0 Stage 1 sample and 2.7mm for the reference sample, a highly significant difference of 23mm (p<0.001). In the reference sample, anterior maxillary height correlated strongly with upper lip length (r=0.60, n=88, p<0,001), while in the GSL sample, the correlation was weak and non-significant (r=0.29, n=27, NS). Measurements of overbite and overjet yielded significant differences between the GSL sample and the reference sample. The difference between the mean overjets was 15mm (p<0.001) and the differencebetween themean overbites was LOmm. (p<0.05), with the GSL sample having the larger value in both dimensions. All correlation coeffi- cients derived for both variables against the up- per lip smile line variable were very weakly positive, the strongest being reference-sample overjet and upper lip smile line (r=0.24, n=88, p<0.05). The upper incisor clinical crown height was slightly shorter for the GSL sample than for the reference sample, but this difference was not sta- tistically significant, Discussion ‘The gingival smilelineisa distinctivedentolabial configuration, often mentioned clinically, but never earlier the central question of a scientific publication. Although the dental literature on this subject is almost nonexistent, research found. in a related discipline, plastic surgery, bears sig- nificance. Work by Rubin, Mishriki and Lee!” has elucidated the anatomic mechanism produc- Stage 2 ing the open smile. These researchers were par ticularly interested in the muscular basis of the smile in surgically reanimating patients with fa- ial paralysis. As a result of extensive cadaver dissections, Rubin and his colleagues have iden tified the nasolabial fold as the keystone of the smiling mechanism, ‘Thesmileis formed in two stages (Figure). The first stage raises the upper lip to the nasolabial fold by contraction of the levator muscles origi nating in the fold and inserting at the upper lip. ‘The medial muscle bundles raise the lip at the anterior teeth and the lateral muscle groups raise the lip at the posterior teeth. The lip then meets. resistance at the nasolabial fold because of cheek fat. The second stage involved further raising superiorly of the lip and the fold by three muscle groups: (1) the levator labii superior muscles of the upper lip, originating at the infraorbital re- gion, 2) the zygomaticus major muscles and (3) superior fibers of the buecinator. Often, the appearance of squinting accompanies the final stage of smiling. It represents the con- traction of the periocular musculature to support ‘maximum upper-lip elevation through the fold. Building upon Rubin's anatomical work on the smiling mechanism, a theory can be proposed linking the elevator muscles atthe nasolabial fold with the ability of some individuals to project a ‘gingival smile Data from the present study indi- cated that persons with gingival smile lines have significantly more efficient lip-elevation muscu- lature than those with average lip lines (see Table The Angle Orthodontist Vol. 62 No. 2 1992 Figure 5 Stages in the genesis, of a full smile. Stage 0 — rest posi- tion; Stage 1 — upper lip elevation to the nasolabial fol Stage 2 — maximum upper lip and fold elevation by the lev tor labii superioris (LLS), zygomaticus ‘major (2M), and supe- rior fibers of the buceinator (B). 7Peck; Peck, Kataja Figure 6A Figure 6 Frontal facial views of 32-year-old female be- fore (A) and after (8) Le Fort | osteotomy with orthodontic treat- ment to resolve verti- cal maxillary excess and gingival smile line. 98 The Angle Orthodontist Figure 68 IV), The facial muscular capacity to raise the upper lip on smiling an average of one extra ‘millimeter, or nearly 20% more than the reference ‘group, may be a key anatomical determinant in the genesis of the gingival smile line. ‘The finding of no significant difference between the mean upper lip lengths of the GSL and refer- cence samples may appear counter-intuitive, butit is not surprising. Surgical patients with vertical maxillary excess also are reported to have normal lip lengths? The clinical notion that the upper lip would likely measure shorter in a high smile line pattern is simply false. In a study of 70 GSL. females, Singer! actually detects a significantly longer upper lip for the gingival display group ‘when compared with a non-display sample. The present study also indicated slightly longer mean. lip lengths in the GSL group, after dividing the samples according to sex. The mean upper lip length of 22.3mm derived for both samples in this, study compares favorably with other normative data." Ina descriptive essay, Matthews” proposes that an individual exhibiting an interlabial gap in rest position will also have a gingival smile line. This isa specious assumption, according to the results of the present study. The data showed GSL sub- jects exhibiting an interlabial gap in 86% t0 93% of the instances, a remarkably high relative fre- quency. The converse, however, was not true: only 56% of those with interlabial gaps had gingi- val smile lines, much less than a predictive level. ‘Therefore, an interlabial gap or lip separation in rest position is logically an associated facial fea- ture of the gingival smile line, but, contrary to Matthews’ view, it cannot be considered predic- tive of the GSL phenomenon, Among theskeletal measurements recorded (see Vol. 62. No.2 1992 Table V), two cephalometric variables —SN-MP and SN-Pal — showing statistically non-signifi- cant results have been cited in a study by Singer! as having characteristic values associated with gingival display. In the present study, both vari- ables demonstrated remarkably consistent mean, values and variabilities in all sample compari- sons, so there is no reason to believe that man- dibular vertical development or palatal plane inclination play significant roles in the gingival smile line equation. Singer's work compares a GSL-sampleagainsta non-GSL group (rather than an unselected reference sample), a difference in methodology that is likely responsible for the exaggerated results, ‘One of the most important factors uncovered in this investigation was the highly significant dif- ference (p<0.001) in anterior maxillary height (palatal plane to upper-incisor edge) between the GSL sample and the reference sample, The GSL sample, compared with the reference sample, showedamean vertical maxillary excess of 2.3mm. ‘The resultant upper lip-incisor-jaw discrepancy is similar to that reported in long-face syndrome: an excess display of the anterior maxillary teeth and jaw coupled witha normal upper-lip length Furthermore, the GSL sample's mean anterior maxillary height of 32.0mm (s.d.=3.0) is remark- ably close to that reported by Isaacson and oth- ers® for a combined sex sample of untreated high mandibular plane subjects. The substantial difference in the correlation co- cfficients for anterior maxillary height to upper lip length between the reference sample (r=0.60) and the GSL sample (r=0.29) may help explain a causal, proportional relationship between verti- cal maxillary height and gingival display on smil ing. Less than one-quarter of the variability accounted for in the reference sample coefficient is explained in the GSL sample coefficient. Lip length is relatively stable for both samples, so the ‘major disturbance in variability must be concen- trated in the weaker field — the GSL sample — with the weaker variable— anterior vertical ma illary height. The findings of statistically significant differ- ‘ences between the GSL and reference groups in ‘overjet (p<0.001) and overbite (p<0.05) may have immediate clinical relevance for orthodontists. In both variables, theGSL sample exhibited thelarger values. Vig and Brundo® observed that individu- als with moderate to severe Class II maloceli- sions show exceptional resistance to the usual pattern of increased lip coverage of the maxillary incisors with age. If this clinical observation is scientifically valid,# perhaps orthodontic reduc-tion of overt and, to a lesser extent, overbite can effectively moderate a gingival smile line in a Class Il condition. In another article” we suggested that differ- ences in incisor clinical crown height may be a factor in the formation of various smile-line pat- terns. The present study showed clinical crown height differences were not statistically signifi- cantand, therefore, a causal association is unwar- ranted. Previous studies*” uncovered a considerable gender difference associated with the gingival simile line: females possess this characteristic in a 2to I ratioover males. A complete explanation for the significant sex difference in frequency of the gingival smile ine remains indeterminable. ‘Although the subjects inthis study had a mean age of 155 years, similar results would be ex- pected with’a somewhat older sample. Vig and Cohen’ investigated the vertical growth of the lips using serial x-ray cephalometry. Among the variables in their study were lip height (length), and lip separation (interlabial gap). The reported ‘changes in both soft-tissue variables from age 15 020 years are very smalland within thestandard Nevertheless, there is reasonable evidence that ‘gingival smile lines will diminish with age. Vig and Brundo” describe a gradual drooping of lip position as an aging phenomenon. They collected five adult samples in different age categories to ‘beyond 60 years. With the lips gently parted in repose, the older adult samples in their study displayed progressively less maxillary incisor and more mandibular incisor than younger ‘groups. In support of an age-related reduction in SL frequency, the adult samples (between 20 and 30 years) of Tjan, Miller and The showed less than one-third the frequency of GSL. occurring than that reported by Peck, Peck and Kata’ for orthodontic-aged samples (meanage=15.0 year). The sagging of the perioral soft tissue with age is in part due to the natural flattening, stretching and decreased elasticity of skin, according to Peck and Peck2* Clinical remarks ‘The gingival smile line is not as objectionable to others as many clinicians might imagine. It is prevalent in all populations, and gingival display is generally compatible with pleasing facial es- thetics in the eyes of the public, A sampling of fashion and beauty magazines will show a re- markable number of models of both sexes with ‘gingival smiles. In the 1989 Miss America pag- cant, five of the 51 contestants had conspicuous gingival smile lines and one of them, Miss Iino, was among the five finalists. ‘A specialist may validly ask why one person’s gingival smile ine is seen asan unobtrusive facial feature while another person’sis viewed as unsat- isfactory. Perhaps other visual factors are opera- tive suchas the shape orsize ofthe smile aperture and the extent to which the maxillary posterior gingiva is exposed at maximum smile. Neverthe- less, differences may be more a function of ob- server bias than of actual form. Inlightof the new understanding offered inthis articleanditscompanion study,’cliniciansshould perceive the gingival smile line as an acceptable anatomical variation and should refrain from conditioning patients to regard itas anomalous or undesirable. In fact, a moderate gingival smile line swell within the usual range of lip-tooth jaw variation, especially for women? However, should a patient deliver an uncoached complaint about gingival smile line, several remedial path- ways exist at present. Orthodontic treatment directed at the intrusion ‘of maxillary anterior tecth with significant reduc tions of overjet and overbite may succeed in mod- erating a gingival smile linein somecases. Yet, the ‘most effective treatment includes a reduction of the associated vertical maxillary excess with max- illary superior repositioning surgery (LeFort | osteotomy) in conjunction with orthodontic therapy (Figure 6). This method does have limita- tions along with the vertical maxillary reduction, the upper lip shortens by up to50% ofthe surgical skeletal intrusion. Other approaches to reduce the gingival smile line are less definitive than orthodontic treatment combined with orthognathic surgery. In special cases of altered passive eruption, the gingival isplay is partly due to excessive marginal gin- giva and atypically short clinical crowns, Peri- odontal crown lengthening procedureshavebeen designed to surgically remove the collar of excess gingiva, exposing more of the anatomical crown and reducing the gingival display.™ A speculativeplasticsurgery technique has been proposed recently as a simple alternative to orthognathic surgery.” A sel-curing silicone im- plants injected at anterior nasal spine in patients ‘with gingival smile lines. The resulting, hidden subspinal mass acts to restrict mechanically up- per lip elevation on smiling, thus reducing gingi- val display. Conclusions From the results of this comparative study, the biologicmechanism underlying the gingival smile The Angle Orthodontist Gingival smile line Vol. 62 No. 2 1992 99Peck; Peck, Kataja 100 The Angle Orthodontist line appears to include the combined effects of several variables: 1 anterior vertical maxillary excess (2 to 3 mm_ additional) 2. greater muscular capacity to raise the upper lip fon smiling (Imm additional) 3. supplemental associated factors, including ex- cessive overt, excessive interlabial gap at rest and excessive overbite. The following variables do not seem associated with the ability to project a gingival smile line: ‘upper lip length 2. incisor clinical crown height 3. mandibular plane angle 4. palatal plane angle. Acknowledgment Appreciation is extended to Dr. Liisa Santavuori at“Paavontupa”, Anttoora, Finland forherrolein the preparation of the manuscript. ‘Author Address Dr. Sheldon Peck 1615 Beacon Street Newton, MA 02168 SS. Peck is with the Department of Orthodontics, Haroard School of Dental Medicine, Boston, Mass. L. Peck is with the Department of Orthodontics, Harvard School of Dental Medicine, Boston, Mass. 1M. Kataja is with the National Public Health Insti- tute, Helsinki, Finland. References Ricketts R Esthetic, environmentandthelaw ofp relation. Am J Ortho 1968/54:272288 2. Janzen EA balanced smile — a most important treatment objective. Am] Orthod 197772350372. 3, Armstrong MM, Contoling the magnitude, direc tin, and duration of exraral force. Am J Orthod w7is6217-263 4. Singer RE. A study ofthe morphologk reatment and estheticaspects of gingival dip. MS thesis. Ann Arbor, University of Michigan 1972, 47p, Ab stracted in Am Orthod 197455:35-136 5. Kawamoto HK. Treatment ofthe elongated lower face and gummy sve. Chin Plast Sarg 198292479. 489 6. TanAHL,MillerGD, The|GP.Someesthetcfators ina smile) Pros Dent 1988:51.2428 7. Pecks, Peck. Kats M, Some vertical lineaments flip postion” Am} Orthod Dentofacial Orthopin nai 8 Willmar K. On LeFert I osteotomy. Scand J Plast Reconstr Surg 1974Suppl 121-68 9, Schendel SA, Eisenfeld J, Bell WH, Epker BN, Mishalevich Dy. The long face syndrome: vertical nnaxllry exces. Arm J Orthod 197670996408 10, Fields HW, ProftWR, Nixon WI. PhilipsC Stanek Facial pattern diferenes in fog fae children and adults Am J Orthod 1984, 85217-223 1, Philips; Profit WK Pll aces tissue response to-srgial maxillary intrusion, Int] Adult Orthod Onthognathic Surg 1986:29-304 12, Rosen IM. Lipnasal esthetics following Le For csteotomy. Plast Reconstr Surg 198881171178 13, Wolford (M. Discussion, lp-nasal aesthetic fl lowing Le Fort L osteotomy, Plat Reconstr Surg 1988: 180-182 14 Profit WR, Philips C. Adaptations in lip posture and pressure followingorthognathicsurgery. Am} Oritod Dentofacial Orthop 196695294902 Vol. 62 No.2 1992 15, Sarver DM, Weissman SM. Long-term soft tissue response to LeFort I maxillary superior reposition- ing. Axcur Ogmo0 1991 61267276. 16. Rubin LR, Mishriki Y, Lee C. Anatomy of the ‘nasolabial fold: the keystone of the smiling mecha- nism. Plast Reconst Surg 1989;83:1-8, 17, Rubin LR. Theanatomy ofa smile:itsimportancein thetreatmentof facial paralysis. Plast Reconstr Surg 1974;53384-387. 18. Burstone C}. Lip posture and its significance in treatment planning, Am J Orthod 1967:53:262 284, 19. Matthews TG. The anatomy of a smile, J Prosthet Dent 1978;39:128-134 20. Isaacson JR, Isaacson RY, Speldel TM, Worms FW. Extreme variation in vertical facial growth and associated variation inskeletaland dentalrelation. ‘AxcLE Oxnton 1971;41:219-229, 21. Vig RG, Brundo GC. The kinetics of anterior tooth display. | Prosthet Dent 1978;39:502-504. 22, Jacobs ID. Vertical lip changes from maxillary inci- sor retraction. Am Orthod 1978,74:396-404, 23, Vig PS, Cohen AM. Vertical growth of the lips: a serial cophalometricstudy. Am] Orthod 1979,75:405- a5. 24, Peck, Peck H. The aesthetically pleasing face: an orthodontic myth. Trans Europ Orthod Soc 1971,47.175-185. 25. Rosenberg ES, Torosian]. Periodontal problemsolv- ing: interrelationship of periodontal therapy and estheticdentistry. DentClinNorth Am1989;33221- 261, 201-208. 26. Garber DA. Problems of the high lip line - the gummy smile, In: Bell WH ed. Modern Practice in Orthognathic and Reconstructive Surgery. Phila- delphia, WB Saunders, vol 1, 1992, pp 252-261, 27. Austin HW. Correction of the guramy smile — a plastic surgeon's view. Dent Today 1990,93)25.