Join me as I summarise Mona Ghoussoub’s lecture looking at the excessive gingival display (EGD).

Mona looked at the diagnosis and treatment of EGD, with a focus on aetiology leading to treatment method, effect of age, and input of multidisciplinary care for appropriate cases.

Definition Kokich 1999, Machado 2014

· Negative effects = 4mm + gingival display

Treatment approach

Early treatment

o Medical  ENT allergology

o Excessive gingival show age 7-8 years

o Nasal obstruction causes decrease in lip closing force Sabashi 2011

o Detect and refer ENT if suspect nasal obstruction

§ Dark eyes

§ Flat cheeks

§ Increase LAFH

o Orthodontic – prevention

o Utility arch

§ Intrusion upper anterior teeth

§  4 brackets and molar bands

§ Retain with 2 layers of Essix + brass wire – for rigidity

Late treatment

o Orthodontic

o Alignment

§ 2 occlusal planes in maxilla in 2 div 2, posterior higher, anterior lower

· Straight wire – reciprocal effects

o Intrusion of anterior teeth

o Extrusion of posterior teeth

o Expansion

§ RME

· Posterior expansion = gingival position moves upwards

o When constricted, greater posterior gingival show

o Intrusion

§ Ricketts / Burstone 3 piece intrusion arch

§ Headgear – J hook intrude upper anterior teeth

§ TAD placement for anterior intrusion

·  UR1-UL1 labial

· Powerchain archwire to TAD

§ TAD for posterior intrusion

· U5-U6 region buccal

· Direct retraction U3- TAD

o Below centre of rotation = posterior intrusion

o MDT

o Periodontics

§ Gingivectomy – passive over-eruption of dentition

· Ideal where tooth width:height ratio increased

§ Guided Tissue Regeneration for VME

· Stable after 1 year

· 40-60% improvement in excessive gingival growth, with crown lengthening

· Bony cavity at anterior superior aspect of maxilla

o Results in the lip raising higher

o Bone augmented at the level of the Le-fort 1

o Can be clinically simulated with cotton wool rolls in upper labial sulcus and taking photos

o Orthognathic surgery

§ Decompensate

· Maxillary impaction

o Plastic surgery Pierre 2020

§ Short lip / mild VME = lip repositioning surgery Rubinstein 1973

· Limit the smile muscle pull by reducing the depth of the upper vestibule– zygomaticus minor, levator Angulo, orbicularis oris, levator labil superior Tawfik 2018

· Conservative when compared to OGN

· Technique

o Split thickness flap – expose connective tissue

o Advance mucosa and suture at mucogingival junction

· Limited studies

· Overcorrect as some relapse expected

· Systematic review improve EGD 3-4mm Tawfik 2018

§ Hypermobile lip – Botox Cengiz 2020

· Reduce muscle activity – levator labil superios LLSAN, zygomaticus minor / major, risorius muscle

· NOT classified as an alternate treatment for EGD

o Use = indication for patient outcomes possible for lip reposition

· Temporary effects – relapse at 6 months

· Problems

o Dose related results

o Excessive upper lip ptorsis

o Too little – not achieve desired result

o Smile effected if erroneous

§ = require expert to use