ORIGINAL ARTICLE

Upper lip changes and gingival exposure on

smiling: Vertical dimension analysis
Hagai Miron,a Shlomo Calderon,b and Dror Allona
Petach Tikva, Israel

Introduction: Our objectives were to evaluate and quantify upper lip soft-tissue changes in the vertical
dimensions both at rest and at maximum smile, and to examine the correlation between upper labial
vestibular attachment height and maxillary gingival exposure on smiling. Methods: Seventy-two volunteers
(36 men, 36 women) aged 20 to 40 (mean, 30.49 years) were recruited for this study. For each subject, 9 mea-
surements of upper lip position and maxillary incisor crown height at rest and in maximum smile were recorded.
Results: A statistically significant sexual dimorphism was apparent in most of the measured variables. Relaxed
external upper lip length was 3.1 mm shorter in the women than in the men. The mean maxillary central incisor
display at rest was 1.78 mm greater in the women than in the men. A high smile line was 2.5 times more prevalent
in the women. The upper lip was shortened by 30% in subjects with a high smile line compared with 23% in
subjects with a low smile line. Conclusions: The following findings were observed in subjects with a high smile
pattern: (1) short upper lip length, (2) low smiling/resting upper lip length ratio, (3) inferior attachment of the upper
labial vestibule, and (4) prominent upper lip vermilion. (Am J Orthod Dentofacial Orthop 2012;141:87-93)

T
he smile is a voluntary facial expression indicating
happiness, pleasure, and greeting. According to
Garber and Salama,1 the essentials of the esthetic
smile involve the relationship between 3 primary compo-
nents: teeth, lip framework, and gingival scaffold.
Maxillary gingival exposure during smiling causes interest
and concern among many dental practitioners and plastic
surgeons. An excessive gingival display on smiling,
referred to as “gummy smile,” “high lip line,” or “high smile
line,” is often esthetically displeasing and considered unde-
sirable.1-7 Several etiologic factors have been suggested in
the literature, including skeletal, gingival, and muscular
factors that can contribute alone or in combination to
this feature.1,7-10 Several treatment modalities have
been proposed in the literature to diminish the gingival
display on smiling. In patients with clinically short
anterior tooth crowns, surgical crown lengthening or
gingivectomy is recommended.1,7 In other patients,
From the Department of Oral and Maxillofacial Surgery, Rabin Medical Center,
Beilinson Campus, Petach Tikva, Israel.
a
Senior surgeon.
b
Head.
The authors report no commercial, proprietary, or financial interest in the
products or companies described in this article.
Reprint requests to: Hagai Miron, 6 Atlit St., Petach Tikva, Israel; e-mail,
hagaimi@gmail.com.
Submitted, December 2010; revised and accepted, July 2011.
0889-5406/$36.00
Copyright Ó 2012 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2011.07.017
whose teeth crowns are proportionally balanced, but
muscular hyperactivity is suspected, injection of
botulinum toxin-A to the lip elevator muscles10-12 or
a lip repositioning procedure13-16 is advocated. In
patients whose gingival display is excessive as a result
of maxillary vertical excess, orthognathic surgery has
been suggested.1,14 Some soft-tissue surgical
procedures, especially lip repositioning, lack wide scien-
tific evidence and long-term follow-ups as do some other
surgical procedures; they can lead to relapse and unde-
sirable side effects such as scar contraction.
The purposes of this study were to evaluate and quan-
tify upper lip soft-tissue changes in the vertical dimensions
at both rest and maximum smile, and to examine the
correlation between upper labial vestibular attachment
height and maxillary gingival exposure on smiling.
MATERIAL AND METHODS
Seventy-two volunteers (36 men, 36 women) aged 20
to 40 years were recruited for this study. No participants
had undergone any maxillofacial surgery or anterior
maxillary tooth prosthodontic rehabilitation. All partici-
pants signed an informed consent, in accordance with
the requirements of the ethics committee at Rabin
Medical Center, Beilinson Campus, Petach Tikva, Israel.
For each subject, 9 measurements of upper lip
position and maxillary incisor crown height at rest and
in maximum social smiling were recorded. To reach the
87
88 Miron, Calderon, and Allon

maximum social smile position, each subject was “low smile” displaying less than 75% of the clinical
requested to present his or her full smile a few times, crown height of the maxillary anterior teeth, “average
and measurements were taken when the subject success- smile” revealing 75% to 100% of the maxillary anterior
fully repeated the full smile pattern. In addition, the age crown height, and “high smile” exposing the whole
and sex of each subject were recorded. anterior maxillary crown height and a band of contigu-
The measurements and the methods used to obtain ous maxillary gingiva.
these variables are as follows. Total lip elevation length was defined (smiling
maxillary central incisor display 1 gum exposure in smile –
1. Performed both at rest and maximum smiling (Fig 1):
resting maxillary central incisor display) to quantify the
(a) external upper lip length, the vertical measure-
vertical exposure capacity of the lip. This variable is com-
ment from the alar base of the nose (subnasale) to
plementary to the smiling/resting external upper lip
the inferior border of the upper lip (stomion superio-
length ratio variable in representing the upper lip’s
ris); (b) vermilion height, the vertical measurement
vertical contraction during smiling. When no resting
from the superior border of the vermilion at the
maxillary central incisor display was noticed, the total
Cupid’s bow to the inferior border of the upper lip;
lip elevation was not calculated, since negative resting
and (c) maxillary central incisor display, the vertical
maxillary central incisor display was not measured.
measurement from the inferior border of the upper
Independent Student t tests were performed to assess
lip to the incisal edge of the left central incisor.
differences between the sexes, and between subjects
2. Performed once in maximum smiling when applica-
with and without gingival exposure in maximum smiles.
ble: gingival display in maximum smiling, recorded
One-way ANOVA was used to assess the differences be-
in patients whose gingival display was noticed in the
tween smile pattern groups. Pearson correlation analysis
maximum smile.
was used to find the relationship between the 2
3. Performed once at rest position: (a) internal upper
variables. The level of significance was set at P #0.05.
lip length, the vertical measurement, with an appro-
priate ruler (Esthetic Lip Ruler, GDIT, Tulsa, Okla) RESULTS
that was slightly modified, from the labial vestibule
Means and standard deviations, derived for all
apical to the central incisors to the inferior border of
measured variables of the subjects, are reported with
the upper lip (Fig 2). During ruler placement, the
some statistical information in Table I.
upper lip was slightly elevated temporarily, and
The mean age of the whole study population was
the ruler was gently pressed into the center of the
30.49 years. The youngest subject was 20 years old,
upper vestibule under direct vision until the anterior
and the oldest was 39 years old. The women’s mean
nasal spine was felt. Next, the upper lip was released
age was 1 year younger than the mean, and the men’s
and gently moved to verify that it was not under ex-
mean age was 1 year older than the mean.
aggerated tension. Two consecutive trials were
A statistically significant sexual dimorphism was
made in each subject before recording the measure-
apparent in most of the measured variables. Relaxed
ment to verify the validity of the position. Measure-
external upper lip length was 3.1 mm shorter in the
ment of hard-tissue landmarks by estimation over
women than in the men (P \0.01). The mean maxillary
soft-tissue landmarks is a common and acceptable
central incisor display at rest was 1.78 mm greater in the
concept used in various measurements in medicine
women than in the men (P \0.01). The upper vermilion
(eg, the identification of nasion and porion with
comprised 31% to 33% of the external upper lip length.
a facebow). (b) Maxillary central incisor height, the
Although it was not statistically significant, the women
vertical measurement of the clinical crown height
tended to have a higher percentage of vermilion display
of the maxillary left central incisor. The measure-
relative to the men. Surprisingly, the same ratio of
ment was made under direct vision at the center
vermilion display was preserved when smiling. The
of the tooth.
resting internal upper lip length/external upper lip
All measurements were recorded by the first author length ratio represented the vertical relationship
(H.M.) to the nearest millimeter directly on the face using between the internal lip length, measured from the
a simple, small metal ruler. Internal upper lip length was upper labial vestibule attachment, and between the
measured by using the modified Esthetic Lip Ruler upper lip external length, an external and easily identifi-
mentioned above. able anatomic landmark. This parameter was calculated
Smile pattern was classified according to the 3 cate- to check whether internal lip insertion is a contributing
gories defined by Tjan et al,5 relating to the anterior factor in upper lip mobility. The level of insertion of
maxillary tooth crown exposure at maximum smile: the upper lip at the upper labial vestibule was lower in

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Miron, Calderon, and Allon
Fig 1. Vertical measurements: A, at rest; B, at smiling (EUL, External upper lip; UID, upper incisor
display).
Fig 2. Modified lip ruler.
the women. The internal upper lip length/external upper
lip length ratios were 71% in the women and 78% in the
men (P \0.01). Central incisor clinical crown height was
0.5 mm shorter in the women compared with the men
(P 5 0.04). External upper lip length became shorter
by about 27% at maximum smiling in both sexes.
High smiles, with exposure of the entire maxillary
incisors and a band of gingiva, were noticed in 38.9%
of the study population and were 2.5 times more prev-
alent in women (55.6%) than in men (22.2%). Low
smiles, noticed in only 22.2% of the subjects, were 4
times more common in men (36.1%) than in women
(8.3%). Table II summarizes the smile patterns by sex
in the whole study population.
A positive, statistically significant correlation was
found between smile patterns and the following
American Journal of Orthodontics and Dentofacial Orthopedics
89
parameters: resting external upper lip length, resting
maxillary central incisor display, total lip elevation, and
smiling/resting external upper lip length ratio. Table III
summarizes some parameters in correlation to the differ-
ent smile patterns. The mean external upper lip length in
subjects with a low smile pattern was 2.46 mm greater
than in subjects with a high smile (P \0.01). The
mean maxillary central incisor display at rest in subjects
with a low smile pattern was 1.31 mm, whereas, in those
with a high smile pattern, the mean maxillary central
incisor display was 2.55 mm (P \0.01). Total lip eleva-
tions were 4.2 mm in the subjects with a low smile,
6.3 mm in those with an average smile, and 7.75 mm
in those with a high smile (P \0.01). The same positive
correlation was noticed between mean smiling/resting
external upper lip length ratio and smile patterns. In
the low smile group, external upper lip length in maxi-
mum smiling was only 23% shorter than resting external
upper lip length; in the average smile group, the external
upper lip was shortened by 27%, and in the high smile
group by 30% (P \0.01). Refining the results and com-
paring each pair of smile pattern groups, as presented in
Table III, shows that most of the statistically significant
differences between smile groups relied on the differ-
ence between the high and the low smile groups.
Although there were differences between the high and
the average smile groups, no statistical significance
was found in most of the factors that were measured.
These findings support the assumption that patients
with a gummy smile have hyperfunction of the upper lip.
Vermilion display was significantly greater in the high
smile group (34.2%) compared with the other groups
(30.2%) (P 5 0.028). The mean maxillary central incisor
height was 0.75 mm shorter in the high smile group in
relation to the others (P \0.01).
Almost statistically significant, the resting internal up-
per lip length/external upper lip length ratio demon-
strated a positive correlation between labial vestibule
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90 Miron, Calderon, and Allon

Table I. Sex differences of study parameters

Female (n 5 36) Male (n 5 36)
Student
Factor Mean SD Mean SD t test
Age (y) 29.44 0.68 31.52 0.73 2.09*
Resting external upper lip length (mm) 20.97 0.37 24.00 0.35 5.94y
Resting maxillary central incisor length (mm) 3.86 0.25 2.08 0.28 4.74y
Resting vermilion/external upper lip length ratio 0.33 0.01 0.31 0.01 1.26 NS
Resting internal upper lip length (mm) 14.78 0.23 18.64 0.31 9.98y
Resting internal upper lip/external upper lip length ratio 0.71 0.02 0.78 0.01 3.25y
Maxillary incisor height (mm) 9.67 0.21 10.17 0.10 2.14*
Smiling external upper lip length (mm) 15.14 0.30 17.57 0.37 5.08y
Smiling maxillary central incisor display (mm) 8.89 0.26 8.31 0.40 1.23 NS
Smiling/resting external upper lip length ratio 0.72 0.01 0.73 0.01 0.47 NS
*P \0.05; yP \0.01; NS, not statistically significant.

regarding the relationship between external lip length

Table II. Smile pattern by sex
Smile type Female (%) Male (%) Total (%)
Low smile 3 (8.3%) 13 (36.1%) 16 (22.2%)
Average smile 13 (36.1%) 15 (41.7%) 28 (38.9%)
High smile 20 (55.6%) 8 (22.2%) 28 (38.9%)
Total 36 (100%) 36 (100%) 72
location and smile pattern. In the low smile group, the in-
ternal upper lip length was 79% of resting external upper
lip length; in the average and high smile groups, the inter-
nal upper lip lengths were 75% and 72% of the resting
external upper lip lengths, respectively (P 5 0.06).
Statistical analysis
With the Pearson correlation test, no statistically sig-
nificant association was found between the subjects’
ages and between resting external upper lip length, rest-
ing maxillary central incisor display, and smiling/resting
external upper lip length ratio, respectively. A positive
significant association (correlation coefficient, 0.363;
P \0.01) was found between upper lip shortening (smil-
ing external upper lip length – resting external upper lip
length) and the gap of internal and external lip length
(resting external upper lip length – resting internal upper
lip length). The shallower the upper labial vestibule rel-
ative to subnasale, the more upper lip shortening during
smile is expected. Also, a positive association was found
between the amount of gingival exposure in maximum
smiling and total lip shortening (correlation coefficient,
0.464; P \0.01). When checking whether there was
a correlation between resting upper lip length (external
upper lip length) and lip shortage (smiling external upper
lip length – resting external upper lip length), a positive,
significant correlation was noticed (correlation coeffi-
cient, 0.511; P \0.01). The longer the upper lip, the
more it shrinks. Yet, when examining the true indicators
and lip shortening capacity (resting external upper lip
length and smiling/resting external upper lip length ra-
tio), no correlation was noticed.
DISCUSSION
Gingival and tooth exposure during smiling are chal-
lenging issues to many physicians, especially those who
deal with smile esthetics. Overexposure of teeth and gin-
gival tissues is considered by many to be unattractive
and usually requires intervention.1-4,6,7,13,14,17,18
Data from this study, similar to other studies, clearly
indicate sexual dimorphism in lip and tooth measure-
ments. These differences are reflections of simple bio-
logic scaling: male subjects are uniformly larger than
equivalent female subjects. The upper lip at rest was
3 mm shorter in the women than in the men (P \0.01),
and maxillary incisor exposures at rest were 3.86 mm in
the women and 2.08 mm in the men (P \0.01). Peck
et al,19 who recorded vertical measurements in young or-
thodontic patients (mean age, 15 years), observed that
the difference in upper lip length between the sexes
was only 2.2 mm, and that tooth exposures at rest were
5.3 mm in the girls and 4.7 mm in the boys. Although
our study population was significantly older (mean age,
30.5 years), age-related lip changes reported in the liter-
ature do not explain the differences in lengths between
the 2 studies.20
The clinical central incisor crown was 0.5 mm shorter
in the women than in the men, slightly less than the dif-
ference observed by Peck et al.19 The upper lip intraoral
attachment at the labial vestibule was less in the women
relative to the men. The internal upper lip length com-
prised 71% of the external upper lip in women and
78% in men. No difference was observed in lip elevation
capacity between the sexes. Upper lip vermilion height,

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Miron, Calderon, and Allon 91

Table III. Lip measurements by smile pattern

Low smile Average High smile
(n 5 16) smile (n 5 28) (n 5 28)
High-low High-average
Factor Mean SD Mean SD Mean SD 1-way ANOVA Student t test Student t test
Resting external upper 24.00 2.45 22.58 2.43 21.54 2.59 P \0.01 P \0.01 P 5 0.13
lip length (mm)
Resting maxillary central 1.31 1.14 3.04 1.60 3.86 1.72 P \0.01 P \0.01 P 5 0.07
incisor display length (mm)
Total lip elevation (mm) 4.20 1.32 6.30 1.54 7.75 1.80 P \0.01 P \0.01 P \0.01
Smiling/resting external 0.77 0.05 0.73 0.07 0.70 0.08 P \0.01 P \0.01 P 5 0.11
upper lip length ratio
Resting internal upper lip length/ 0.79 0.07 0.75 0.08 0.72 0.10 P 5 0.06 P 5 0.01 P 5 0.22
external upper lip length ratio

Table IV. Comparison of smile patterns with other studies

Female Male

Study High Low Sample High Low Sample

Tjan et al5 34 (14%) 31 (12%) 247 14 (7%) 62 (30%) 207
Rigsbee et al22 32 (70%) — 46 21 (38%) — 55
Peck et al19 25 (54%) 7 (15%) 46 11 (26%) 14 (33%) 42
Current study 20 (56%) 3 (8%) 36 8 (22%) 13 (36%) 36

defined elsewhere as upper lip thickness, comprised 33%
of the whole upper lip length in women and 31% in
men.20 This observation was somewhat smaller than
the 40% ratio mentioned in other studies.20,21 The
upper lip length was 27% shorter in maximum smiling
relative to the resting position in both sexes.
Our findings suggest that a high smile pattern can be
considered a female norm, since more than half of the
women in this study exposed their gums while smiling,
and a low smile pattern can be considered a male
norm. Similar results and female/male ratios were ob-
served by others in slightly younger population
groups.5,12,19 Table IV compares smile patterns by sex
between this study and previous studies. Although other
authors have found a 2:1 ratio of gingival exposure be-
tween female and male subjects, we found a slightly
higher ratio of 2.5 women to 1 man in exposure of gin-
givae when smiling.5,12,19 In our opinion, this might be
attributed to the difference between the study groups
because of mean age or ethnic-related features, but it re-
quires further investigation.
Short upper lip and hyperactivity of the lip elevator
muscles are 2 distinctive features observed in subjects
with high smile patterns in this study. Contrary to the
observation by Peck et al8 of no significant difference
between the mean upper lip lengths of a gingival smile
pattern and a reference group, we found that subjects
with a high smile line have an upper lip on average
2.42 mm shorter than do subjects with a low smile pat-
tern. The reduction in upper lip length was gradual
among the smile pattern groups (high, average, and
low); in other words, the higher the smile pattern, the
shorter the upper lip length. In keeping with the reduc-
tion of upper lip length, maxillary incisor display at rest
was higher among subjects with higher smile patterns.
Vertical maxillary excess, a bony hyperplasia of the max-
illa in the vertical axis causing high maxillary central in-
cisor display at rest and exposure of gingiva in smiling,
was not suspected among the subjects with a high smile
line in this study because of the matching differences
between upper lip length and maxillary central incisor
display at rest among the low and high smile line
groups. The 2.42 mm of upper lip length deficiency
that was noticed in the high smile line group compared
with the low smile line group was compensated with
2.55 mm of maxillary central incisor display in the
high smile line group, therefore not supporting the di-
agnosis of vertical maxillary excess in subjects with
a high smile line.
Data from our study support findings of other studies
on the subject of smile pattern and efficiency of upper lip
elevation.8,19 In our study, the upper lip contracted by
30% of its original height at rest in subjects with
a high smile pattern, by 27% in the average smile
pattern group, and by 23% in the low smile pattern
group. According to Peck et al,8 subjects with a gummy

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92
smile pattern (more than 2 mm of gingival exposure in
maximum smiling) had 20% more muscular capacity
to raise the upper lip than did subjects without a gummy
smile. When dividing the high smile group into gummy
smile and nongummy smile subgroups according to
the earlier definition, it appears that subjects with
a gummy smile have 25% more muscular capacity to
raise the upper lip than do subjects with nongummy
smiles.
Upper labial vestibule attachment was lower in sub-
jects with a high smile pattern. Although this finding
was not statistically proven, a direct positive correlation
was observed between the internal upper lip length/ex-
ternal upper lip length ratio and the smile pattern.
Some surgeons are attempting to restrict upper lip
mobility by inferiorly relocating the upper labial vesti-
bule.13,14 No evidence-based or long-term follow-up
studies have been published about this approach. The re-
sults from our study are opposite to the above approach;
in other words, subjects with an inferiorly based vesti-
bule had higher smile patterns and no restricted lip
mobility, as one might expect.
Upper lip vermilion height was significantly greater in
subjects with gummy smiles. Whereas the vermilion of
subjects without a gummy smile was 30.5% of the whole
upper lip length, the vermilion in subjects with a gummy
smile was more prominent, consisting of 35% of the en-
tire upper lip length (P 5 0.025). Since a prominent,
thick upper lip vermilion might be considered a female
trait, and since most subjects in the gummy smile group
were female (81%), an explanation for the higher vermil-
ion/lip ratio in the gummy smile group could be sug-
gested.
In contrast to a previous report, upper lip changes
with aging were not observed in our study popula-
tion.20 The young and narrow age distribution in this
study is 1 reason that no age-related changes were
observed.
Some pitfalls of this study were related to the selec-
tion criteria of the patient sample. To eliminate any ac-
quired changes in dental and hard-tissue relationships to
the soft tissues of the lip, one should ideally exclude all
patients who had previous orthodontic treatment that
affects the vertical position of the central and lateral in-
cisors, by either intrusive or extrusive mechanics. In our
opinion, this point should be considered as a determining
factor in future, more comprehensive studies. Determin-
ing factors such as prosthetic or conservative dental res-
toration, unilateral or bilateral extraction of teeth, and
previous orthodontic treatment should be recorded
and analyzed as a cause of anterior tooth display on
smiling and resting. Standard age and sex groups should
be determined to eliminate any age-related soft-tissue
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Miron, Calderon, and Allon
changes, and previous plastic or esthetic interventions
should also exclude patients from the study.
CONCLUSIONS
Data from this study clearly indicate sexual dimor-
phisms in upper lip length, maxillary incisor display,
and upper labial vestibule insertion. Higher smile pat-
terns are more common among female patients, and
lower smile patterns are more common among male pa-
tients. The following findings were observed in subjects
with a high smile pattern compared with those with
a low smile pattern.
1. Short upper lip length.
2. Low smiling/resting upper lip length ratio (indicates
greater upper lip shortening and might suggest hy-
peractivity of the lip elevator muscles).
3. Low (inferior) attachment of the upper labial vesti-
bule.
4. Prominent upper lip vermilion.
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