|Year : 2014 | Volume
| Issue : 4 | Page : 488-492
Visibility of gingiva - An important determinant for an esthetic smile
Shipra Sepolia, Gaurav Sepolia, Rupinder Kaur, Devendar Kumar Gautam, Vikas Jindal, Subhash Chander Gupta
Department of Periodontics, Himachal Dental College and Hospital, Sundernagar, Himachal Pradesh, India
|Date of Submission||27-Jan-2012|
|Date of Acceptance||21-Jan-2014|
|Date of Web Publication||14-Aug-2014|
Department of Periodontics, Himachal Dental College and Hospital, Sundernagar, Himachal Pradesh
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Need for having better esthetics is the new emerging trend seen in patients' demands and expectations. Various periodontal procedures including the mucogingival procedures have been designed to enhance the esthetics. The amount of gingival display of the patient is also an important parameter while considering the esthetics of the patient. Till date, very few studies have been done in which the amount of gingival visibility have been determined. So, the aim of this study was to evaluate the amount of visibility of gingiva during natural smile and forced smile in the patients visiting Himachal Dental College and Hospital. Materials and Methods: A total of 400 patients (242 females and 158 males), aged between 18 to 49 years, attending the outpatient department of Himachal Dental College, were included in this study. Patients were divided into two groups according to age and gender. Clinical photographs of the patients were taken and analyzed according to the following classification: (1) Very high smile line that is more than 2 mm of marginal gingiva visible or more than 2 mm apical to the cementoenamel junction visible for the reduced but healthy periodontium, (2) high smile line that is between 0 and 2 mm of marginal gingiva visible or between 0 and 2 mm apical to the cementoenamel junction visible for the reduced but healthy periodontium, (3) average smile line in which only gingival embrasures are visible, (4) low smile line in which gingival embrasures and cementoenamel junction not visible. Examination of the gingiva was done for both natural smile and forced smile. Results: During smile analysis, the following results were revealed for Natural smile and forced smile. Natural smile analysis revealed following: C1: 1%, C2: 6%, C3: 43.50% and C4 was 49.50%. Forced smile analysis revealed the following: C1: 1%, C2: 15.50%, C3: 59% and C4: 24.50%. Conclusions: Excessive gingival display is an esthetic concern both to the patient and clinician. Therefore, understanding the etiology and treatment options is crucial for the treatment of such patients. So, it becomes utmost duty of the dentist to see that visual attractiveness of the smile is associated strongly with the health of the periodontium.
Keywords: Age, gender, periodontium, smile line
|How to cite this article:|
Sepolia S, Sepolia G, Kaur R, Gautam DK, Jindal V, Gupta SC. Visibility of gingiva - An important determinant for an esthetic smile. J Indian Soc Periodontol 2014;18:488-92
|How to cite this URL:|
Sepolia S, Sepolia G, Kaur R, Gautam DK, Jindal V, Gupta SC. Visibility of gingiva - An important determinant for an esthetic smile. J Indian Soc Periodontol [serial online] 2014 [cited 2019 Oct 17];18:488-92. Available from: http://www.jisponline.com/text.asp?2014/18/4/488/138703
| Introduction|| |
A smile develops whenever a person senses happiness, pleasure, or humor. An attractive or pleasing smile clearly enhances the initial impression in interpersonal relationships which subsequently enhances the acceptance of an individual in the society. It is more than a method of communication. It influences personality which in turn affects the performance of an individual in his or her job. 
If eyes are mirror to the heart of a person, then a smile can be considered as an important determinant of the facial attractiveness of an individual. Facial attractiveness and an aesthetic smile are important components of an individual's personality and psychologic well-being.  There are 2 types of smile. The one is a natural smile and the other one is forced smile.  The forced smile is voluntary in nature. It is also called as social smile which is used as a greeting. It occurs when lips part due to moderate muscular contraction of the lip elevator muscles.  The natural smile is involuntary in nature and represents the emotion person experiences at that moment. It results from maximal contraction of the upper and lower lip, elevator, and depressor muscles, respectively. This causes full expansion of the lips, with maximum anterior tooth display and gingival visibility.
The harmony and symmetry of an esthetic smile is determined by various components. The various etiological factors which have been described for an aesthetic smile is not only determined by tooth position, size, shape, and color but also by the amount of gingival tissue revealed and the framing of lips.  All of these components together will result in an esthetically pleasing smile.
Resective surgical procedures are being done to achieve an esthetic application.  These surgical procedures that date back to many years can be utilized to achieve ideal gingival symmetry and tooth length. These procedures include internal bevel gingivectomy alone or in combination with osseous surgery. Dentogingival analysis is done in which the balance between the amount of gingival margin placement, tooth length, and lip dynamics should be maintained. The amount of gingival exposure depends on the position of the smile line which is a curve that passes through the incisal margins of the maxillary incisors and canines making an arch. 
Till now, very few studies have been done in which the association between gingival visibility during the natural and forced smile have been mentioned. So, the purpose of the present study is to determine the amount of gingival visibility during natural smile and forced smile in the patients visiting the Himachal Dental College and Hospital.
| Materials and methods|| |
A total of 400 patients were included in the study. All the participants were informed of the purpose of the study and consulted to participate. A written informed consent was taken from the participants. Participants were selected based on the following criteria: (1) Older than 18 years of age. (2) At least 8 continuous anterior teeth equally distributed between right and left side, i.e. 14 to 24. (3) A healthy periodontium or a reduced but healthy one.
Patients having fixed, removable prosthesis were excluded from the study because that might have an effect on esthetics and periodontal health. Gender and age were recorded for each participant. Participants were classified into 2 groups according to age groups: (a) 18-34 years and (b) 35-49 years.
For evaluation of smile line, patients were photographed. The headrest was aligned to allow proper positioning of the head in Frankfurt horizontal plane to assure optimal angulation [Figure 1]. Two different pictures were taken of each participant: One during natural smile and another during forced smile. Two examiners evaluated the position of the smile line during natural and forced smile from the pictures and evaluation was done at the same time. Training and caliberation was done for the evaluation of smile lines both during natural and forced smile. Interexaminer reliability was assessed using kappa statistics. And values came out to be 0.86.
|Figure 1: Standardisation of the photograph done in frankfurt horizontal plane|
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The smile line was analyzed according to the following classification: 
Class 1:-Very High Smile Line: More than 2 mm of marginal gingiva visible or more than 2 mm apical to the cementoenamel junction visible for the reduced but healthy periodontium.
Class 2:- High Smile Line: Between 0 and 2 mm of marginal gingiva visible or between 0 and 2 mm apical to the cementoenamel junction visible for the reduced but healthy periodontium.
Class 3:- Average Smile Line: Gingival embrasures only visible.
Class 4:- Low Smile Line: Gingival embrasures and cementoenamel junctions not visible.
Chi - square test analysis was used to assess the statistical significance of difference between groups. A probability of P < 0.05 was accepted to reject the null hypothesis. Chi Square Test 14.4861 degree of freedom 1 As the computed value exceeds the critical value in the table for 0.05 probability level, we can reject the null hypothesis.
| Results|| |
The sample of the present study was composed of 242 women and 158 men aged 18 to 49 years. [Table 1] represents the sample distribution of the male and female population in the younger (18-34 yrs) and older age group (35-49 yrs). [Figure 2] represents pie diagram of gender distribution. Class 4 was the most frequent for natural smile (49.5%) and Class 3 was the most frequent for forced smile (59.0%). During natural and forced smile, 1% of the total study population had a very high smile line. Whereas 49.5% had very low smile line during natural smile and 24.5% had a very low smile line during forced smile. The gingiva was more visible in the forced smile (Class 1 + Class 2 + Class 3 = 75.5 %) [Table 2] than in the natural smile (Class 1 + Class 2 + Class 3 = 50.5%) [Table 3]. Women revealed their gingiva (51.84%) more than men (39.24%) during natural smile. During forced smile, women again revealed more of their gingiva (76.96%) in comparison to men (73.42%). [Figure 3] and [Figure 4] represents the frequency distribution of males and females both during natural and forced smile. When younger and older age groups were compared during forced smile, older age group revealed more gingiva (Class 1 + Class 2 + Class 3 = 81.38%) then younger age group (73.89%). [Table 4] During natural smile, older age group (53.25%) revealed more gingiva then younger age group (50%) [Table 5]. No statistically significant differences have been found between younger and older age groups both during natural and forced smiles. [Figure 5] and [Figure 6] represents the frequency distribution for age group 18-34 yrs and 35-49 yrs both during natural and forced smile.
|Figure 3: Frequency distribution of males during natural smile and forced smile|
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|Figure 4: Frequency distribution of females during natural smile and forced smile|
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|Figure 5: Frequency distribution for age group 18-34 years during natural smile and forced smile|
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|Figure 6: Frequency distribution for age group 35-49 years during natural smile and forced smile|
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|Table 1: Sample distribution of the male and female population in the younger and older age group |
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|Table 2: The frequency distribution of the study population according to age and gender during forced smiles |
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|Table 3: The frequency distribution of the study population according to age and gender during natural smile |
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|Table 4: Frequency distribution of the study population aged between 18 - 34 years and 35 - 49 years during forced smile |
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|Table 5: Frequency distribution of the study population aged between 18 - 34 years and 35 - 49 years during natural smile |
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| Discussion|| |
In the present study, data showed that low smile line was the most frequent smile for natural smile, whereas average smile line was the most frequent smile for forced smile. These results vary from the work done by Liebart et al.  who reported that average smile line was the most common group both during natural and forced smile. This can be explained on the basis that there can be numerous kinds of natural smile because patient can smile in different ways based on how they are feeling. Another important factor which can explain this variation in result is that study done by Liebart et al. was in France. However, present study has been done in Indian population which to our present knowledge has not been done in Indian population so far.
Gingival architecture and tooth length are important contributors to an esthetically pleasing smile.  The individual variables like upper and lower lip muscle mobility and strength, lip vertical length, clinical crown length, and skeletal relationship, especially vertical maxillary length can lead to variation in the amount of dental and gingival exposure during speech and smile in different persons.  Various conditions like malpositioning of teeth, altered passive eruption, recession, loss of interproximal papilla leads to an unesthetic appearance. 
Very few studies have been done in which the visibility of gingival margin has been determined. Crispin and Watson  reported that upper lateral incisor was the most common visible tooth during his evaluation of 425 dental school students. Gingival margin was visible in 66% of the students during normal smile. However, during forced smile, 84% of the subjects displayed the gingival margin. But one of the drawbacks of this study was that it did not include the presence of interproximal papilla and neither the influence of age, gender on the subjects examined. However, present study included presence of interproximal papilla in Class 3, i.e., average smile line group (Class 3) allowed only the detection of interproximal papilla, not involving the gingival margin.
Age and gender can also influence smile attractiveness which is an important determinant of personality traits and satisfaction of oral appearance.  In our study, women revealed more gingiva than men both during natural and forced smile. Statistically significant differences were found in C1, C2, and C3 groups when they were compared during forced and natural smile.
Also, present study showed that low smile line group exhibited wide variation during natural and forced smile both in male and female groups. The presence of this result can be attributed to our Indian culture in which people feel more shy to smile normally unless and until they are told to do so.
Jensen et al.  reported that women had higher smile line in comparison to males. Tijan et al.  who did a study on 20- to 30-year-old students also reported that high and very high smile line was found more in women (14% and 75%) than in men (7% and 63%). These studies were carried out in caucasian population which were of different ethnic background in comparison to our study which was done on Himachali population.
As far as influence of age is concerned, our study showed no significant differences in younger and older age groups both during natural and forced smile. Similar results have been reported by Wichmann M  in which he said that there were no significant differences in visibility of gingival margins between younger (Average age 25 years) and older subjects (Average age 55 years).
| Conclusion|| |
The present study was done to determine the amount of gingival visibility during natural smile and forced smile. A pleasant, beautiful smile enhances a person's esthetic appearance which emphasizes on the importance of smile analysis. The desire to have an attractive personality forces an individual to have an attractive smile for which they seek dental treatment. With the expansion in horizon of dentistry, various new esthetic surgical procedures have evolved which offers a wonderful opportunity to enhance the patients smile. Excessive gingival display is an esthetic concern both to the patient and clinician. The esthetic influence of gingival architecture on "smile line" can be altered through periodontal surgical techniques. Therefore, understanding the etiology and treatment options is crucial for the treatment of such patients. So, it becomes utmost duty of the dentist to see that visual attractiveness of the smile is associated strongly with the health of the periodontium.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]