An innovative cosmetic technique called lip repositioning.

A clinical report describing the successful use of the lip repositioning technique for the reduction of excessive gingival display. A female patient aged 34 years reported with a chief complaint of gummy smile and was treated with this technique performed under local anesthesia with the main objective to reduce gummy smile by limiting the retraction of elevator muscles (e.g., zygomaticus minor, levator anguli, orbicularis oris, and levator labii superioris). The technique is fulfilled by removing a strip of mucosa from maxillary buccal vestibule and creating a partial thickness flap between mucogingival junction and upperlip musculature, and suturing the lip mucosa with mucogingival junction, resulting in a narrow vestibule and restricted muscle pull, thereby reducing gingival display.

INTRODUCTION

Several people have an illusion that they possess gummy smile or that when they smile most of the gums are visible since they have short teeth or gums have grown over their teeth. This makes them feel conscious and they are unable to give a complete smile. However, they should be aware that something can be done dentally to give them a beautiful smile. Gummy smile due to excessive gingival display always makes a normal person conscious while smiling, especially when the problem is related with female patients who are more esthetically conscious than male. Gummy smile is seen due to improper relation between gingival tissue and the tooth, with gingival tissue in excess and tooth portion in a small amount.

Gummy smile is governed by various etiological factors, for example jaw deformities, which cause excessive gingival display and require a orthognathic surgery.[1] This occurs due to excessive increased vertical height of maxillary arch. The orthognathic surgery is a complicated procedure and requires team work with hospitalization and general anesthesia, while lip repositioning is innovative and effective, less time consuming and is performed under local anesthesia.

Apart from it, delayed eruption as a cause of excessive gingival display and its treatment by esthetic crown lengthening are well documented.[23] The clinician must consider the dynamic relationship between the patient's dentition, gingival, and lips while smiling.[4]

CASE REPORT

A female patient aged 34 years reported to the department of Periodontology and Implantology, Sardar Patel Post Gradute Institute of Dental and Medical Sciences, Lucknow (India), with the chief complaint of excessive display of gums while smiling. There was no significant medical or family history and patient was medically sound and fit for the surgical procedure. On clinical examination, extraorally face was found to be bilaterally symmetrical with incompetent lips. Intraorally, a moderate gingival display was seen during smiling, which extended from maxillary right first molar to maxillary left first molar [Figure 1].

Figure 1

Preoperative

Technique

Aim of the technique

Lip repositioning is a surgical way to correct gummy smile by limiting the retraction of the elevator smile muscles (e.g., zygomaticus minor, levator anguli, orbicularis oris, and levator labii superioris).

Surgical technique

Complete extra oral and intraoral mouth disinfection was done with 2% betadine, followed by infiltration with local anesthesia, (2% lignocaine hydrochoride with 1:80,000 epinephrine). Thereafter, the surgical area to be operated was demarcated with the help of an indelible pencil also shown in schematic diagram [Figures 2 and 3]. The surgical area started at the mucogingival junction, which extended 10-12 mm superiorly in the vestibule [Figure 4]. Incisions were made in the above-mentioned surgical area and both superior and inferior partial thickness flap was raised from maxillary right first molar to maxillary left first molar. The incisions were then connected with each other in an elliptical outline. The epithelium was then removed [Figure 5] within the outline of the incision leaving the underlying connective tissue exposed [Figures 6 and 7]. The parallel incision lines were approximated with interrupted stabilization sutures at the midline [Figures 8 and 9] and other location along the borders of the incision to ensure proper alignment of the lip midline with the midline of the teeth and then a continuous interlocking suture was used to approximate both flaps. Sutures were resorbable in nature [Figures 10 and 11]. Patient was discharged with all post surgical instructions and medications for five days which included analgesic (ibuprofen 600 mg QID daily for 2 days), antibiotic (amoxicillin 500 mg TDS for five days), along with cold packs extra orally to decrease post surgical swelling.

Figure 2

Area demarcated with indelible pencil

Figure 3

Demarcated area

Figure 4

The surgical area started at the mucogingival junction, which extended 10-12 mm superiorly in the vestibule

Figure 5

Removing epithelium

Figure 6

Exposed connective tissue

Figure 7

Raw wound area

Figure 8

Midline suture

Figure 9

Midline suture (schematic diagram of midline suture)

Figure 10

Continuous interlocking sutures

Figure 11

Continuous suture

Patient was recalled after one week for a follow-up [Figure 12]. The patient after a week complained of mild pain and tension on the upper lip. It was seen later that the suture area healed in the form of a scar [Figure 13 after 3 months], which was not apparent when the patient smiled because it was concealed in the upper lip [Figure 14 after 6 months].

Figure 12

After one week

Figure 13

After 3months

Figure 14

Postoperative after 6 months

Precautions while surgery

Care must be taken to avoid damage to minor salivary glands in submucosa. Some cases with rare complication reported in the literature are paresthesia[5] and transient paralysis.[6]

Clinicians must look for adequate width of attached gingiva.

Do not perform the procedure with patients having vertical maxillary excess, in such cases orthognathic surgeries is the solution

DISCUSSION

In most patients, the lower edge of the upperlip assumes a ‘gumwing’ profile, which limits the amount of gingiva that is exposed when a person smiles. Patient who have a high lip line exposes a broad zone of gingival tissue and may often express concern about their ‘gummy smile’. The form of the lips and the position of the lips during speech and smiling cannot be easily changed, but the dentist may, if necessary, modify/control the form of the teeth and interdental papillae as well as the position of the gingival margins and the incisal edges of the teeth along with repositioning of the lip. In other words, it is possible by a combination of periodontal and prosthetic treatment measures to improve dentofacial esthetics. The above case presents the successful clinical outcome of lip repositioning technique. In the present case the crown length was appropriate and did not require any crown lengthening. Some authors advocated performing myoectomies to detach the smile muscle attachment.[7] Variation in the technique was also reported. Lip repositioning was most commonly used as a plastic surgical procedure and is rarely used as a dental procedure. Another method to prevent reattachment of the of the smile muscles is to use an alloplastic or autogenous separator.[8] This spacer is placed with nasal approach between the elevator muscles of the lip and the anterior nasal spine, and thus prevents the superior displacement of the repositioned lip. Lip repositioning has also been performed in conjugation with rhinoplasty.[9] The nasal approach allows both surgical procedures to be combined; the surgical site is extended only minimally. This should be done only if rhinoplasty is to be performed and if the patient desires a remedy for excessive gingival display.

CONCLUSION

Lip repositioning is an innovative and effective way to improve the gummy smile of a patient. This technique is an easy and less time consuming cost-effective way to give satisfactory results to the patient.