The Combo Strategy: Triple Approach for Gummy Smile—18-Month Case Series

Objective: Gingival excess, also referred to as excessive gingival display (EGD), represents a multifactorial esthetic concern influenced by skeletal, dental, and soft tissue factors. Conventional orthodontic or orthognathic interventions, while effective, may present increased morbidity. This prospective case series evaluates a minimally invasive, interdisciplinary approach integrating periodontal and cosmetic techniques for managing multifactorial gingival excess. Clinical Considerations: Twelve systemically healthy adult patients (mean gingival display: 5.3 mm) diagnosed with both altered passive eruption and hyperactive upper lip were treated in a private practice using a combined single-session protocol. The “combo technique” involved esthetic crown lengthening, botulinum toxin-A (Botox) injections, and hyaluronic acid-based lip augmentation. Diagnosis and treatment planning were based on comprehensive clinical and radiographic assessments. Outcome measures included gingival display reduction, patient satisfaction, and postoperative discomfort, evaluated at 6 and 18 months. Conclusions: The integrated “combo technique” offers a minimally invasive and highly effective alternative for correcting EGD. It enables individualized treatment planning, reduces the amount of Botox needed, and results in stable esthetic outcomes with high patient satisfaction and minimal postoperative discomfort. This interdisciplinary approach provides a predictable and long-lasting solution for complex GS cases in patients unwilling or unsuitable for orthognathic surgery.