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