Include the gingiva as part of the smile exam

Dec. 1, 2000
A comprehensive treatment plan includes techniques for the preservation or correction of gingival architecture

A comprehensive treatment plan includes techniques for the preservation or correction of gingival architecture

Kristine A. Hodsdon, RDH, BS

The discussion of esthetic dentistry in journals dwells on such factors as the shape of teeth, color, and position, as well as other characteristics of the teeth. What is often overlooked is the gingiva and its effect on the beauty of a smile. At least four areas involving gingival esthetics can be easily evaluated during the dental hygiene pre-diagnosis session.

Consideration should be given to the:

* Standard for excellence of the gingival health and surrounding structures

* Levels of the gingival crests (crown lengthening)

* Excessive gingival display (gummy smile)

* Gingival embrasures (black triangle)

The esthetic result is dependent upon proper soft tissue management. The fundamental principles of esthetic hygiene rely on a disease-free oral cavity resulting from a strong emphasis on prevention. We must pay strong attention to the client`s total health while facilitating the client`s esthetic desires. A dental hygienist cannot simply pay lip service to a standard of excellence for the periodontal tissue and surrounding structures.

The tissue must be ideal. Ideal gingival health is 0-3 mm pockets and no bleeding index - in other words, an oral stage that has zilch in terms of disease. There must be full assessment, periodontal charting and/or graphing, care planning, treatment, and evaluation completed on every client under a "no excuse clause." This no-nonsense approach means that every hygienist, with the support of the esthetic practice, must commit the time and energy needed to accomplish a disease-free environment. It is our responsibility to inform the restorative dentist and client about our pre-diagnosis periodontal summary and treatment plan. The hygiene services must not stop - whether they are provided in your practice or referred to an oral health partner - nor must any esthetic modalities begin until ideal tissue results are achieved.

In addition, paying attention to the gingival margin lines can make a world of difference to the outcome of esthetic treatments. The gingival levels should radiate symmetry and balance. Symmetry should be established at the gingival margins of each contralateral tooth from the central to the second molars. The gingival crest of the lateral incisors should be approximately 1 mm below the crest of the central incisors. The crest of the canines should be equal to that of the central incisors. The remaining posterior teeth should follow a natural graduation in appearance from canine to second molar.

One scenario that relates to the height of the gingival crests is when, for example, a male client states, "Some of my teeth are shorter than the others." After your examination, you discover that teeth #8, #7, and #6 have a reduced crown length due to excessive gingival coverage. Your client is dissatisfied with his visual perception of the difference in lengths of his clinical crowns. It is generally better to correct this discrepancy prior to beginning restorative therapy. In some cases, however, after minor gingival recontouring has been done (with no violation of the biological width - something I will discuss under "gingival embrasure"), the client may decide that he is happy with the outcome and that is all that he desires.

When continuing to assess a client for esthetic modalities, the face, lips, and smile must all be considered. The teeth should be in the center of the mouth with no distractions. The upper lip should fall near the maxillary gingival line; the lower lip should cradle the maxillary incisal plane.

If the teeth are not in the middle of the smile, which is often termed a "gummy smile." Generally, that is defined as any client who shows more than 2 mm of gingiva during a full smile. The etiologies of such a condition are beyond the scope of this column, but may include short or hyperactive lip, altered passive eruption, dentoalveolar extrusion, and/or vertical maxillary excess. Excessive gingival display also should be alleviated before any definitive therapy. The anatomic crown hidden prior to the surgery, and then exposed afterwards, will affect the visual presence and the restorative/gingival margin interface.

Additionally, the appearance of the interdental papilla must also be considered when attempting to achieve optimal effects. The papilla must fill in the interproximal spaces. Open gingival embrasures, or "black triangles," may occur for a variety of reasons, such as the shape of the crown, (contour and contact point), root angulations (the roots are not parallel or straight), and interproximal bone loss due to periodontal disease and/or recession/iatrogenic insult.

These conditions make the papilla unable to fill the entire embrasure space and cause disharmony of the smile. Corrective treatments of open gingival embrasures may involve one or any combination of orthodontic therapy, periodontal therapy, and a refabrication of the restoration.

"Biological width" is a term used to describe the approximate 3 mm distance from the gingival crest to the crest of the alveolar bone. It is measured by "sounding the bone."

After profound anesthesia has been administered, a periodontal probe is placed midfacially on a central incisor and pushed through the attachment apparatus until the alveolar crest is found. A "high crest" is when less than 3 mm distance is determined from the gingival margin to the alveolar crest; a "low crest" is when the distance from gingival crest to the alveolar crest is more than 3 mm.

Therefore, before beginning any restorative treatment, each client must be evaluated to establish his or her own attachment height. This is determined by subtracting the true sulcus (measured sulcus depth minus 0.5 mm for penetration of the probe) from the sounding depth (measurement from the free gingival margin to the osseous crest).

In restorative options, the location of the margin relative to the bone and height of the attachment is crucial. If this is not considered, and the restoration violates the biological width, it is then a hygienist`s nightmare. Biological-width invasion results in poor gingival health, which breaches the standard of excellence for gingival tissues. It also remains unresolved until the defective restoration is replaced.

Esthetic balance and symmetry cannot be accomplished in a mouth if the teeth or tissue are in the wrong place. A comprehensive treatment plan includes techniques for the preservation or correction of gingival architecture, as well as interdisciplinary care. The hygienist`s analysis of the client`s smile incorporates all aspects of the dentition. The soft tissue must be assessed for health, contour, and measure of display to facilitate a pleasing smile for our clients.

References available upon request.

Kristine A. Hodsdon, RDH, BS, presents seminars nationally about esthetic hygiene. Her company, Dental Essence, is based in Chester, N.H. She can be e-mailed at