Harmonizing the smile post-orthodontics: beyond dental alignment

Dental alignment is not always sufficient to produce an aesthetic smile. This case report presents the clinical situation of a 33-year-old patient, dissatisfied after a successful aligner treatment for the closure of a median inter-incisal diastema. Despite satisfactory occlusion and alignment, the examination revealed a major residual disharmony: excessive gingival exposure, short clinical crowns, and asymmetrical margins.

The objective of this study is to illustrate how a rigorous etiological analysis allows for the treatment of post-orthodontic aesthetic failures. Using Digital Smile Design (DSD), the authors identified that the problem was not due to a skeletal vertical maxillary excess, but rather to an anomaly of the dento-gingival complex coupled with marked lip dynamics, featuring a 7 mm translation of the upper lip during a forced smile.

The study tests the hypothesis that a sequenced multidisciplinary protocol — combining aesthetic crown lengthening with osteotomy/osteoplasty and surgical lip repositioning — can stabilize smile harmony over the long term. This case highlights that soft tissue management and crown proportions are the essential complement to orthodontic movement to achieve a predictable result where biomechanics alone have reached their limits.

Methodology of the multidisciplinary approach

This case report describes the management of a 33-year-old female patient presenting with persistent aesthetic disharmony following orthodontic treatment with clear aligners. The protocol was based on digital analysis and a two-stage surgical sequence.

• Analysis and planning: The evaluation included an extra-oral facial analysis and a dynamic smile study (highlighting a lip mobility of 7 mm). Aesthetic planning was performed via 3Shape software for Digital Smile Design (DSD), allowing for the definition of ideal dental proportions and gingival contours.
• Surgical phase 1 (Crown lengthening): Performed under local anesthesia using a printed surgical guide. After transgingival bone sounding, internal bevel incisions were made, followed by the elevation of a full-thickness flap. Osteotomy and osteoplasty were performed to position the bone crest 3 mm apically relative to the planned gingival margin.
• Postoperative care: Prescription of 0.12% chlorhexidine (twice daily for 2 weeks). Sutures were removed at 7 days and a tissue stability reassessment was performed at 1 month.
• Surgical phase 2 (Lip repositioning): This procedure was selected as a second-line treatment to correct residual gingival display related to upper lip dynamics.
• Follow-up and evaluation: Clinical and aesthetic stability was documented over a 2-year period (24 months), including regular photographic evaluations and monitoring of periodontal health.

Facial analysis and surgical precision: the figures for success

The initial evaluation revealed that upper lip mobility reached 7 mm during maximum smile. Although this value is physiological, it was identified as a key factor in residual gingival exposure following aligner treatment. Digital Smile Design (DSD) then allowed for the quantification of the disharmony, highlighting insufficient crown proportions and asymmetrical gingival architecture.

Aesthetic crown lengthening, guided by a digital surgical template, ensured precise osteotomy and osteoplasty at 3 mm from the planned gingival margin. This step immediately corrected the clinical length of the anterior teeth and harmonized the gingival zeniths. At one month, soft tissue stability allowed for the second phase of treatment to begin.

The lip repositioning procedure completed the protocol by limiting the superior displacement of the lip. Clinical results show a significant reduction in gingival exposure without altering labial function or natural facial expression. The multidisciplinary approach transformed an orthodontically correct but aesthetically unsatisfactory smile into a balanced dento-facial result.

The two-year follow-up confirms the robustness of the protocol. The team observed no recurrence of excessive gingival exposure ("gingival rebound") or deterioration of smile aesthetics. The clinical crown dimensions established during surgery remained stable, and the periodontal tissues maintained optimal health without loss of attachment or visible scar formation.

Beyond alignment: deciphering aesthetic failure

Why does a perfectly executed aligner treatment sometimes leave a sense of incompleteness? The case of this 33-year-old patient illustrates a blunt clinical reality: dental symmetry does not guarantee smile harmony. Dynamic analysis here revealed a lip mobility of 7 mm, a key factor that orthodontics alone could not neutralize. The use of Digital Smile Design (3Shape) allowed for the quantification of the deficit: the problem was not the alignment, but a disharmonious gingival architecture and a hypermobile upper lip.

The two-stage surgical strategy was decisive. First, a digitally guided crown lengthening with a precise osteotomy 3 mm apical to the future margin to stabilize the biological space. Then, the lip repositioning acted as a mechanical brake, limiting the apical displacement (upwards) of the lip during a forced smile. This multidisciplinary approach transforms a "correct" orthodontic result into a lasting aesthetic success.

Admittedly, this is a single case report (n=1), which limits the generalization of the results to all patients suffering from gummy smile. While the 2-year stability is encouraging, the literature often points to a risk of partial relapse of lip repositioning in the very long term. Nevertheless, the absence of gingival rebound or visible scarring after 24 months confirms the precision of the surgical protocol and the importance of periosteum preservation during dissection.

Summary of results

This clinical case reports the success of a combined approach in a 33-year-old female patient whose dissatisfaction persisted after clear aligner orthodontics. The combination of a DSD-guided aesthetic crown lengthening (with 3 mm osteotomy) and lip repositioning allowed for the correction of a complex gummy smile, with aesthetic and functional stability confirmed at the 2-year follow-up.

In concrete terms, for the practitioner:

• Beyond orthodontics: perfect alignment does not guarantee an aesthetic smile if crown proportions or lip dynamics (7 mm of mobility in this case) are ignored during the initial diagnosis.
• Reliability in osteotomy: use surgical guides derived from Digital Smile Design (DSD) to secure the repositioning of the bone crest at 3 mm from the future gingival margin and guarantee the symmetry of the zeniths.
• Adopt a sequential strategy: if crown lengthening is not sufficient to mask the gingival excess during a forced smile, lip repositioning constitutes an effective minimally invasive complement to limit the hyper-mobility of the upper lip.

Technical lexicon of the study

Digital Smile Design (DSD): Virtual planning protocol (using the 3Shape platform here) allowing for the analysis of dental proportions, gingival contours, and dento-labial relationships in order to simulate and guide corrective oral surgery.

Aesthetic crown lengthening: A periodontal plastic surgery procedure aimed at increasing the clinical crown dimension. In this study, it includes gingival and bone resection to harmonize margins and reduce gingival exposure.

Transgingival bone sounding: Clinical measurement performed under local anesthesia to evaluate the distance between the gingival margin and the alveolar crest, allowing for the confirmation of supracrestal tissue dimensions before osteotomy.

Osteotomy and osteoplasty: Procedures for the removal and remodeling of the alveolar bone. The study specifies that the bone crest was repositioned approximately 3 mm apically to the planned gingival margin to ensure the biological stability of the tissues.

Lip repositioning surgery: A minimally invasive surgical technique consisting of excising a strip of epithelium in the maxillary vestibule. It aims to restrict the upward muscular pull of the upper lip, thereby reducing dynamic gingival display.

Gingival zenith: The most apical point of the marginal gingiva contour. Its position was precisely controlled in this clinical case using a digital surgical guide to ensure the symmetry of the dental arch.

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