esthetic crown lengthening in the treatment of gummy smiledetermine smile esthetics, which has been...

370 | The International Journal of Esthetic Dentistry | Volume 14 | Number 4 | Winter 2019

CASE REPORT

Esthetic crown lengthening

in the treatment of gummy smile

Mauricio Andrés Tinajero Aroni, MSc

Diagnosis and Surgery, UNESP, São Paulo State University, Brazil

Suzane Cristina Pigossi, PhD

Clinics and Surgery, Federal University of Alfenas, Brazil

Elton Carlos Pichotano, PhD


Guilherme José Pimentel Lopes de Oliveira, PhD

Periodontia e Implantodontia, Universidade Federal de Uberlândia, Brazil

Rosemary Adriana Chierici Marcantonio, PhD


Correspondence to: Prof Suzane Pigossi

Clinics and Surgery, Federal University of Alfenas, Gabriel Monteiro da Silva St, 700 Alfenas Minas Gerais 37130-001, Brazil;

Tel: +55 35 3701-9000; Email: [email protected]

ARONI ET AL

371The International Journal of Esthetic Dentistry | Volume 14 | Number 4 | Winter 2019 | 371The International Journal of Esthetic Dentistry | Volume 14 | Number 4 | Winter 2019 |

Abstract

The aim of this article was to evaluate 1 year after sur-

gery a surgical protocol that included gingivectomy

and an apically positioned flap plus osseous resective

surgery to correct excessive gingival display (EGD) in

patients with altered passive eruption (APE) of the

maxillary anterior teeth. Six female patients aged 18 to

22 years were diagnosed with APE type 1B. Surgical

crown lengthening with flap surgery and bone recon-

touring was performed to achieve the biologic width.

Photographic images were analyzed to evaluate the

stable improvement of crown length before the pro-

cedure (baseline), immediately after surgery (immedi-

ate postoperative), and at 3 and 12 months postsur-

gery. Moreover, a lip repositioning procedure was also

performed in one case to complement the periodon-

tal therapy. Compared with baseline, an increase of

1.6 mm in the mean tooth crown height was ob-

served in the photographic analysis at 12 months. A

minimal difference was observed between the mean

tooth crown height immediate postoperative and at

12 months, which indicates stability of the gingival

margin. In conclusion, the surgical protocol outlined

in this article describing esthetic crown lengthening

for the treatment of APE/gummy smile resulted in pre-

dictable outcomes and stability of the gingival margin

1 year after surgery.

(Int J Esthet Dent 2019;14:370–382)

371The International Journal of Esthetic Dentistry | Volume 14 | Number 4 | Winter 2019 |

CASE REPORT


Introduction

A harmonious smile is considered a symbol

of beauty in modern society.1 A multifacet-

ed scenario, including tooth form and posi-

tion, gingival tissue levels, and lip position

determine smile esthetics, which has been a

focus of dental treatment.1,2 There has been

particular interest in the treatment of exces-

sive gingival display (EGD), commonly

termed gummy smile, and periodontal plas-

tic surgery techniques have been used to

improve smile esthetics.1 EGD is character-

ized by an overexposure of the maxillary

gingiva during smiling or speaking.3 This

condition occurs in 10.57% of the popula-

tion,4 affecting people (predominantly

females) of 20 to 30 years of age.5

Possible etiologic factors for EGD in-

clude plaque or drug-induced gingival en-

largement or overgrowth, altered passive

eruption (APE), short clinical crowns, verti-

cal maxillary excess, hyperactive or short

upper lip presence or a combination of

these clinical conditions.6,7 From the clinical

perspective, APE is associated with in-

creased gingival band width and gingival ex-

posure during smiling.8 In a normal eruption

phase, the gum tissue migrates apically,

with gradual exposure of the tooth crown

stabilizing at the cervical level.9 Thus, mostly

due to developmental or genetic factors,

Fig 1 Changes in tooth dimensions and gingival display of cases 1 to 6 from baseline (a), immediate postoperative (b), 3 months (c),

and 12 months (d) after the crown lengthening surgery.

Case 1 Case 2 Case 3

a

b

c

d

a

b

c

d

a

b

c

d

ARONI ET AL


the alteration in APE may lead to the per-

sistence of an excessive amount of soft tis-

sue over the enamel surface, resulting in an

excessive quantity of gingival tissue at the

maxillary anterior teeth during smiling.1

In addition, APE has been subclassified

into two types:10 type 1 is characterized by

an excessive amount of attached gingiva

with shorter crowns, while type 2 is a gum-

my smile associated with a normal gingival

dimension. In addition, two possible sub-

classes (A and B) have been suggested, de-

pending on the relationship of the bone

crest (BC) to the cementoenamel junction

(CEJ) of the tooth (BC–CEJ). In subcategory

A, the BC–CEJ is > 1.5 mm, allowing ade-

quate space for the insertion of a connec-

tive tissue attachment to the root surface. In

subcategory B, this space is minimal and

does not allow for a correct biologic

width.1,11 Depending on the classification,

different possible treatments are indicated.

The treatment plan for APE type 1B should

include the management of the periodontal

tissue and incorporate gingivectomy and

apically positioned flap plus osseous resec-

tive surgery (esthetic crown lengthening

surgery).12 However, APE type 2 showing ex-

cessive growth of the maxillary process

generally requires a multidisciplinary treat-

ment plan, including orthognathic surgery

and orthodontic treatment.13 It is empha-


a

b

c

d

a

b

c

d

a

b

c

d

CASE REPORT


sized that APE type 1 treatment is a chal-

lenge and is risky because excessive bone

resection on the maxillary anterior teeth

may lead to residual gingival recession.1,12

On the other hand, a limited resection may

result in coronal regrowth of the gingival

margin, reducing the length of the postsur-

gical clinical crowns.1 Therefore, an ade-

quately planned surgical procedure its es-

sential to guarantee proper treatment of

APE and satisfy patients’ expectations.

In some cases, where the EGD is caused

by the combined etiology of a hyperactive

upper lip and APE, other techniques are as-

sociated with crown lengthening surgery to

resolve the EGD. In these cases, procedures

such as botulinum toxin injection14 or lip re-

positioning15 have been proposed. The lip

repositioning technique is accomplished by

a single partial-thickness elliptical incision in

the depth of the anterior maxillary vestibule.

Then, the lip mucosa is sutured to the mu-

cogingival line.15 This technique was de-

signed to be shorter in duration and less ag-

gressive than orthognathic surgery, and also

causes fewer postoperative complications.16

The aim of this case series was to evalu-

ate the efficiency of a surgical protocol con-

sisting of gingivectomy and an apically re-

positioned flap combined with osseous

resective surgery to correct EGD in patients

with APE at the maxillary anterior teeth. The

gingival margin stability obtained with the

crown lengthening procedure was evaluat-

ed at 3- and 12-months postsurgery.

Case description

Inclusion criteria

Six periodontally and systemically healthy

female patients aged 18 to 22 years who

were non-smokers sought treatment. They

were dissatisfied with their smile esthetics

due to the overexposure of the maxillary

gingiva during smiling or speaking. During

the clinical intraoral examinations, the pa-

tients’ oral cavities were examined under

natural light using sterile instruments to re-

cord the plaque index (PI) and the gingival

index (GI) using the criteria proposed by Sil-

ness and Loe.17 Only patients with a PI and

GI of < 20% were included in the study.1

Moreover, all patients presented inadequate

tooth width and height proportions in the

superior anterior maxilla. These parameters

were detected using a specific probe (Chu’s

Aesthetic Gauges; Hu-Friedy). Transgingival

probing (TP) using a conventional periodon-

tal probe (Hu-Friedy) detected a BC–CEJ

distance of < 1.5 mm in the superior anter-

ior teeth. Based on this, the patients were

diagnosed with APE type 1B, and surgical

crown lengthening with flap surgery and

bone recontouring was the indicated treat-

ment (Figs 1a and 2a).

Esthetic crown lengthening and frenectomy surgery

Local anesthesia was induced using a 4% ar-

ticaine solution with epinephrine 1:100,000

(Nova DFL). The surgical procedure was ini-

tiated with gingival demarcation on the mid-

buccal aspect of the teeth using a specific

probe (Chu’s Aesthetic Gauges) (Fig 2b and c).

After the gingival demarcation, the CEJ pos-

itions were checked with a conventional

periodontal probe (Hu-Friedy). An internal

bevel incision was made following the CEJ

anatomy using a No. 15 C blade at each

tooth (teeth 13 to 23), preserving the inter-

dental papillae (Fig 2d). The removal of the

marginal gingival strip was made with a

perio dontal curette (Hu-Friedy) (Fig 2e). The

gingival contour was delineated using a

Goldman Fox microscale (Quinelato) to-

gether with delicate Goldman Fox pliers to

reduce the gingival volume (Fig 2f).

An intrasulcular incision was made, and a

conservative full-thickness flap to the level

of the mucogingival junction (MGJ) was

ARONI ET AL


Fig 2 Representative case illustrating the esthetic crown lengthening surgical procedure (case 6). (a) Pretreatment view of the maxillary

anterior teeth. (b) Gingival margin measurement using a specific tip. (c) Gingival demarcation on midbuccal aspect. (d) External bevel incision

following the CEJ anatomy. (e) Gingival margin removal with a periodontal curette. (f) Gingival contour finalization using a Goldman Fox

microscale and pliers. (g) Full-thickness flap elevation. (h) Ostectomy and osteoplasty using carbide steel burs. (i) Ostectomy and osteoplasty,

final aspect. (j) Single interrupted sutures. (k) Labial frenectomy. (l) Immediate postoperative, final aspect.

raised on the buccal aspect, including teeth

13 to 23 (Fig 2g). Teeth 14 and 24 were also

affected by the APE and included in the flap.

The BC–CEJ distance was measured on the

midbuccal aspect, then carbide steel burs

and hand chisels were used for ostectomy

and osteoplasty, aiming to attain a 2-mm

BC–CEJ distance (Fig 2h and i). No inter-

proximal crestal bone was removed.

The flap was repositioned, and single in-

terrupted sutures (Cytoplast PTFE sutures,

PERIO USP, 4/0) were used to stabilize the

flap (Fig 2j). In all cases, the labial frenum was

closely attached to the gingival margin in the

superior incisive region. Then, a frenectomy

was made (Fig 2k) to complete the removal

of the frenum using the conventional tech-

nique described by Devishree et al.18 The fre-

num was engaged with a hemostat tweezer

inserted into the depth of the vestibule, and

incisions were placed on the upper and un-

derneath surfaces of the tweezer using a

No. 15 C blade. The triangular resected por-

tion of the frenum was removed, and a blunt

dissection was performed on the bone to

relieve the frenum attachment. The edges of

the wound were sutured with single inter-

rupted sutures (Cytoplast PTFE sutures,

PERIO USP, 4/0) (Fig 2l).

The patients were prescribed 0.12%

chlorhexidine gluconate (Periogard; Col-

gate) and instructed to rinse gently twice

daily for 15 days. Tooth brushing was to be

discontinued in the surgical area during this

time. An antibiotic (Azithromycin, 500 mg,

once daily) was prescribed for 3 days to pre-

vent possible postoperative infection. A

nonsteroidal anti-inflammatory (Nimesulide,

100 mg, 12/12 h) and an analgesic (Dipy-

rone, 500 mg, 6/6 h) were also prescribed.

a b c

d e f

g h i

j k l

CASE REPORT


Postsurgical follow-up

The 7-day postoperative healing was un-

eventful and the sutures were removed. For

case 1, a restorative phase was carried out

3 months after the surgical crown length-

ening procedure to close the diastema be-

tween teeth 11 and 21 using composite res-

in (Fig 1d). Patient photographs were taken

before the surgery (baseline), immediately

after the surgery (immediate postoperative),

after 3 months, and after 12 months (Fig 1a

to d). The photographs were analyzed to

evaluate the stability of the results of the

crown lengthening procedure. Distortions

between the photographs were adjusted

using mathematic calculations following

the modified sequence proposed by Teren-

zi et al19. The reference structures (dental

crown width) were measured with the digi-

tal ruler of the digital smile design (DSD)

program, using millimeters as the unit of

measurement (Fig 3). First, the digital ruler

was cali brated to a real measurement using

an initial photograph of the teeth with a

millimeter probe in each case. The dental

crown width of two teeth (superior central

incisors) in the initial photograph (baseline

– preoperative) was obtained. In the same

way, the widths of the same teeth were

measured in the immediate postoperative

and 3- and 12-month follow-up photo-

graphs. An average of the two measure-

Fig 3 Scheme of image measurement standardization. (a) Digital ruler calibration using an initial photograph of the teeth with a millimeter

probe. (b) Dental crown width measurement in the initial photograph (baseline to preoperative) using a digital ruler. (c) Dental crown height

measurement in the initial photograph (baseline to preoperative) using a digital ruler.

a b c

Table 2 Dental crown height mean length (millimeters) obtained in each case at

immediate postoperative and 12 months

Immediate postoperative 12 months

Case 1 9.3 8.7

Case 2 9.0 9.2

Case 3 7.2 7.2

Case 4 9.3 8.9

Case 5 6.3 5.7

Case 6 10.0 9.6

Final mean

9.1 8.8

The distortion ratio was calculated by dividing the average width obtained in the

photograph at 12 months by the width obtained in the photograph at 3 months.

Table 1 Dental crown height mean length (millimeters) obtained in each case at

baseline, immediate postoperative, 3 months, and 12 months

BaselineImmediate postoperative

3 months 12 months

Case 1 8.6 10.1 9.6 9.6

Case 2 5.8 7.0 6.9 8.2

Case 3 7.0 7.0 7.1 7.1

Case 4 7.3 9.2 9.3 8.9

Case 5 6.0 6.8 6.3 6.2

Case 6 6.5 9.0 8.2 8.6

Final mean

6.8 8.0 7.7 8.4

The distortion ratio was calculated by dividing the average width obtained in the final

photograph (immediately postoperative, 3 months or 12 months) by the width obtained in

the initial photograph (baseline).

ARONI ET AL


ments was obtained for each photograph.

A distortion ratio was calculated by dividing

the mean width obtained in the final pho-

tograph (immediate postoperative, 3 or

12 months) by the width obtained in the ini-

tial photograph (baseline). This distortion

ratio was used to normalize the measure-

ments of crown length utilized to compare

the crown length after immediate postop-

erative, 3 and 12 months, with the crown

length obtained from the baseline photo-

graph ( Table 1). Moreover, a distortion ratio

was also calculated by dividing the mean

width obtained in the 12-month photo-

graph by the width obtained in the immedi-

Fig 4 Changes in smile appearance in cases 1 to 6 from baseline (a) to 12 months (b) after the crown lengthening procedure.


a

b

a

b

a

b


a

b

a

b

a

b

ate postoperative photograph. This distor-

tion ratio was used to compare the crown

length obtained in the immediate postoper-

ative photograph with that obtained in the

12-month one (Table 2).

The smile photographs 1 year after the

crown lengthening procedure (Fig 4) show

a reduction in the gingival smile and a cor-

rection of the gingival zenith. Table 1 shows

a 1.2 mm increase in the average crown

length after the surgical procedure (differ-

ence between immediate postoperative

and baseline). After 12 months, the average

crown length remained 1.6 mm higher than

at baseline (difference between 12 months

CASE REPORT


Fig 5 Lip reposition-

ing procedure

(case 6). (a to c)

Measurement of

keratinized gingiva.

(d and e) Elliptical

incision demarcation

using a marking

pencil. (f to i) Single

partial-thickness

elliptical incision.

(j) Simple interrupted

suture in the

medium, canine, and

molar regions.

(k) Immediate

postoperative, final

aspect.

a b c

d e

f g

h i

j k

ARONI ET AL


postoperative and baseline). Moreover,

Table 2 shows a minimal difference (0.3 mm)

between the average crown length in the

immediate postoperative measurement and

12 months after the procedure; in other

words, the gingiva rebound 12 months after

the surgical procedure was only 0.3 mm,

indicating gingival margin stability after

12 months of follow-up.

Lip repositioning technique

One patient (case 6) was dissatisfied with the

degree of gingival exposure during smile

even after the crown lengthening proce-

dure. In this case, the EGD occurred due to

the combination of APE with a hyperactive

upper lip. Therefore, lip repositioning was

performed according to the technique pro-

posed by Rosenblatt and Simon20 to com-

plement the gummy smile treatment. The

preoperative protocol described above was

followed. The location of the mucogingival

junction and the keratinized gingiva size

were determined using a periodontal probe

(Fig 5a to c). A marking pencil was used to

outline the borders of the elliptical incision

(Fig 5d and e). The lower incision coincided

with the mucogingival line in order to avoid

any loss of attached gingiva, and was ex-

tended from the mesial aspect of the first

premolars bilaterally. The distance between

the superior and inferior borders was

1.5 mm, which was the length of the repos-

itioning desired in the patient’s smile as de-

termined by the preoperative measurement.

A single partial- thickness elliptical incision

was created with a No. 15 C blade, removing

the epithelium but keeping the underlying

connective tissue intact (Fig 5f and i). Care

was taken to avoid damage to the minor sal-

ivary glands in the submucosa. The area of

frenectomy was approximated with a simple

interrupted suture (polyglycolic resorbable

5/0 suture, Vicryl; Ethicon/Johnson & John-

son) to ensure symmetry and proper midline

placement. Other key sutures were made

bilaterally in the canine and molar regions

(Fig 5j). Then, multiple interrupted sutures

were made bet ween the initial key suture

placement areas to complete the wound

closure (Fig 5k). The same postoperative

protocol described above was followed,

and the patient was instructed to minimize

lip movements when smiling or talking for

2 weeks after the surgery. The sutures were

removed at the 2-week follow-up appoint-

ment. Postoperative healing was uneventful.

A minor scar formed on the suture lines but

remained invisible during smiling. The

3-month follow- up showed a reduction of

gingival display, and the patient was satisfied

with the final treatment result (Fig 6).

Discussion

A careful diagnosis and treatment plan are

essential to indicate the most predictable

APE treatment protocol.15 The most com-

mon diag nostic method is TP, which is used

to detect the CEJ subgingivally and to cal-

culate the real clinical crown dimension.21

a b c

Fig 6 Changes in smile appearance in case 6 from baseline (a), to 12 months after the crown lengthening surgery (b), and 3 months after

the lip repositioning surgery (c).

CASE REPORT


The soft tissue height is measured with a

periodontal probe down to the BC, and this

dimension can also be used to guide the

amount of osseous resection to be ful-

filled.22 Studies comparing TP with direct

bone-level measurements immediately af-

ter flap reflection suggest that TP is an accu-

rate method of determining BC levels.23,24

However, although transgingival bone prob-

ing measurements seem to be very close to

the histometric bone level,25 the use of cone

beam computed tomography (CBCT) has

also been proposed, which allows for the

three-dimensional (3D) visualization of the

alveolar bone/soft tissue as well as accurate

and precise measurements.26 A retrospec-

tive study by Batista et al27 showed that

CBCT enabled a precise diagnostic of the

reduced distance between the CEJ and the

BC as well as the precise determination of

the anatomical crown length, a key refer-

ence for APE surgical treatment.27 However,

TP alone was used to diagnose and select

all APE type 1B cases treated in this case se-

ries due to the unavailability of the patients

to undergo CBCT scanning during the sur-

gical planning period.

In this case series, Chu’s Aesthetic Gaug-

es were successfully used to guide the ex-

cess gingival tissue removal and correct the

tooth size proportion. These measurement

tips include Chu’s Proportion Gauge, which

represents an objective mathematic ap-

praisal of tooth size ranges.28 Additionally, a

full-thickness flap was performed to access

the BC and restore the biologic width, as-

suring the stability of the long-term clinical

results. Ribeiro et al29 suggested another

method to treat APE, ie, a minimally invasive

flapless esthetic crown lengthening proced-

ure using micro chisels, via incision without

flap elevation. However, in their randomized

controlled trial, the esthetic crown length-

ening, with or without flap elevation,

showed similar and stable clinical results for

up to 12 months.

Clinical studies evaluating the esthetic

crown lengthening procedure have shown

that less soft tissue rebound occurs when

the postoperative gingival margin is posi-

tioned 3 mm coronal to the surgically re-

duced BC, compared with flaps reposi-

tioned at or below it.6,18 In these case reports,

the BC was placed 2 mm apical to the CEJ,

and the flap 1 mm coronally, to allow for a

proper biologic width and to ensure the sta-

bility of crown height gained over time. In

these case reports, a clinically insignificant

gingival rebound of 0.01 mm was observed

between 3 and 12 months. On the other

hand, according to a review by Marzadori et

al,30 a buccal ostectomy should be per-

formed after choosing the guiding tooth,

following the esthetic proportion para-

meters. Thus, for these authors, the bone

reduction could be considered complete

when the flap was precisely adapted over

the underlying bone.30 The tissue biotype

might also significantly influence the gingi-

val tissue rebound, as previous studies have

shown that the mean tissue regrowth in pa-

tients with a thick biotype was significantly

greater than those with a thin one.31,32 There-

fore, the identification of tissue biotype is

necessary before crown lengthening sur-

gery, since the presence of a thick biotype

will require greater bone reduction to avoid

tissue rebound.31

The photographic analysis performed in

the present case series suggests that the

crown lengthening procedure described in

this article was successful in increasing the

clinical crown length and maintaining it for

12 months (average crown length 1.6 mm

higher than at baseline). The average crown

length values observed in these case reports

was 6.8 mm (baseline), 8.0 mm (immediate

postoperative), 7.7 mm (3-month follow-up),

and 8.4 mm (12-month follow-up) (Table 1).

Using the same surgical protocol, Silva et

al33 observed values of 8.5 mm (baseline),

10.3 mm (immediate postoperative) and

ARONI ET AL


9.9 mm (6-month follow-up). Cairo et al1

also observed average crown length values

of 8.5 mm (baseline), 10.2 mm (immediate

postoperative), and 10.1 mm (6-month fol-

low-up). Moreover, certain clinical studies

have shown some gingival rebound ranging

from 0.1 to 0.2 mm over the time period.1,29

However, in these case reports, a clinically

insignificant gingival rebound of 0.3 mm

was observed between the immediate post-

operative measurement and the one taken

at 12 months (Table 2).

The case 6 patient was dissatisfied with

the degree of gingival exposure during smile

even after the crown lengthening proce-

dure. In this case, the EGD occurred due to

the combination of the APE with a hyperac-

tive upper lip. The less-invasive options for

hyperactive upper lip treatment are botuli-

num toxin injection14 or lip repositioning.16

Injecting overactive muscles with measured

quantities of botulinum toxin results in a re-

duction of muscle activity, a relaxing of the

lip muscles, and a decrease of the upward

pull on the lip.34,35 Although the botulinum

toxin injection is the least-invasive treat-

ment, the results are temporary and only

last for a period of 3 to 6 months before

slowly fading.35 Due to this, lip repositioning

was successfully indicated for the hyperac-

tive upper lip treatment in this case. A recent

systematic review published by Tawfik et al35

showed that lip reposi tioning successfully

reduced the EGD by 3.4 mm. Faus-Matoses

et al15 showed in three case reports that lip

repositioning can produce stable results

1 year after the proce dure. Thus, lip repos-

itioning is indicated for patients with minor

discrepancies as well as for those who de-

sire a treatment that is less invasive than or-

thognathic surgery but which has a more

immediate (and long-term) result compared

with orthodontics or botulinum toxin injec-

tion treatment.35 However, this technique is

contraindicated in the presence of a mini-

mal zone of attached gingiva as well as in

cases of several vertical maxillary excesses,

where an interdisciplinary approach is re-

commended.36

In a modified lip repositioning technique,

the maxillary labial frenulum is maintained,

and two mucosal strips (one at each side of

the frenulum) are removed.16 In this modifi-

cation, the frenulum helps to maintain the

position of the labial midline and prevents

changes in lip symmetry. However, the fren-

ulum maintenance can limit the correction

of the EGD in the region of the maxillary

central incisors during lip repositioning.15 A

recent clinical study showed that the modi-

fied lip repositioning technique shows less

relapse after surgery as well as excellent

cosmesis. Moreover, compared with the

conventional technique, it shows greater

sustainability after 6 months.37 In case 6 in

the present case series, the frenulum was

removed during the crown lengthening

procedure due to its insertion near to the

gingival margin. For this reason, in this case

the conventional lip repositioning technique

was utilized.

The methodological limitations of the

present case series include a relatively low

number of participants and the absence of

any clinical analysis of the periodontal

parameters to confirm the photographic

analysis described in this article. Therefore,

additional controlled clinical studies are

necessary to evaluate the long-term out-

comes of the procedure here described

with a larger sample size.

In conclusion, the surgical protocol in-

cluding gingivectomy and apically posi-

tioned flap plus osseous resective surgery

could be considered a predictable protocol

for the reduction of EGD associated with

APE.

Disclaimer

The authors declare that there are no con-

flicts of interest.

CASE REPORT


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esthetic crown lengthening in the treatment of gummy smiledetermine smile esthetics, which has been...

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