Lip repositioning: An alternative cosmetic treatment for gummy smile.

Excessive gingival display, commonly referred to as 'gummy smile' is a major hurdle in overall personality of an individual. Gummy smile, secondary to altered passive eruption and tooth mal-positioning, can be predictably treated with Surgery and orthodontic therapy. In patients with jaw deformities, orthognathic surgery can be performed. However, this requires hospitalization and entails significant discomfort. Lip repositioning is a simple surgical procedure to treat 'gummy smile'. The procedure restricts the muscle pull of the elevator lip muscles thereby reducing the gingival display while smiling. This procedure is safe and predictable with minimal risk or side effects. This case report describes the successful treatment of excessive gingival display using surgical lip repositioning procedure which can be used as an alternative treatment modality for treatment of excessive gingival display.

INTRODUCTION

The harmony of the smile is determined not only by the shape, the position, and the colour of teeth but also by the gingival tissues. Excessive gingival display (EGD), which is commonly described as ‘gummy smile’ adversely affects smile aesthetics and therefore undesirable. It is one of the several developmental or acquired deformities and conditions that manifest in the periodontium.[1] It is an aesthetic concern that can affect a large portion of the population, with a reported prevalence between 10.5% and 29%.[23] In the recent years, EGD has received an increased emphasis in dental literature and various treatment options are now available for correction of gummy smile.

The various causes of gummy smile include vertical maxillary excess, anterior dentoalveolar extrusion, altered passive eruption, short or hyperactive upper lip, or combinations thereof.[45]

Treatment of EGD by esthetic crown lengthening with or without osseous resection is well documented.[67] Dentoalveolar extrusion can be treated successfully by orthodontic therapy.[8] EGD, due to vertical maxillary excess, can be successfully treated by orthognathic surgery.[9] However, this surgery is associated with significant morbidity and requires hospitalization. Therefore, lip repositioning is recommended as an alternative treatment for EGD.

The objective of lip repositioning is to limit the retraction of elevator smile muscles. Lip repositioning results in shallow vestibule restricting the muscle pull thereby limiting the gingival display during smiling.

CASE REPORT

A 22-year-old female patient undergoing orthodontic treatment, presented with the complaint of gummy smile following retraction of maxillary anterior teeth [Figure 1].

Figure 1

Preoperative smile

The patient's medical history was noncontributory with no contraindication for surgery. Clinical examination revealed moderate amount of maxillary gingival display. With full smile, patient's teeth were visible from maxillary right first molar to maxillary left first molar with 5-6 mm of gingival display. Maxillary anterior teeth had normal crown height and width/length ratio. A diagnosis of moderate vertical maxillary excess was made. Orthognathic surgery as a treatment option was discussed with the patient. However, patient preferred less invasive lip repositioning procedure over orthognathic surgery. Informed consent was obtained prior to the procedure.

Surgical procedure

Adequate local anesthetic (lignocaine 2% with epinephrine 1:100,000) was administered in vestibular mucosa and lip from maxillary right first molar to maxillary left first molar. The surgical site was marked with an indelible pencil. A partial thickness flap was raised from mesial line angle of left maxillary first molar to the mesial line angle of right maxillary first molar at the mucogingival junction [Figure 2]. A second incision 10–12 mm above the first incision was made in the labial mucosa. The two incisions were joined on either side and a strip of partial thickness flap was removed, exposing the underlying connective tissue [Figure 3]. The two incisions were then approximated using continuous interlocking sutures [Figure 4].

Figure 2

Removal of split thickness flap

Figure 3

Exposed underlying connective tissue

Figure 4

Margins approximated by sutures

Patient was prescribed nonsteroidal anti-inflammatory drugs (diclofenac sodium 50 mg three times daily for 3 days) and oral antibiotics (amoxicillin 500 mg three times daily for 5 days). Patient was instructed to apply ice pack post operatively and minimize lip movement for 1 week. Sutures were removed 2 weeks post operatively. Patient reported mild pain and tension while smiling during the first week after surgery.

Sutures were removed 2 weeks postoperatively. Suture line healed in the form of a scar which was covered by labial mucosa and therefore not visible on smiling [Figure 5].

Figure 5

Scar tissue as seen 6 month postoperatively

RESULT

Gingival display at baseline was 5-6 mm which changed drastically at 3 and 6 months postoperatively [Figure 6]. At 3 month and at 6 months gingival display was 3 mm. There was no difference in gingival display between 3 and 6 months. However, the lip reverted back to its original position with almost complete relapse after 12 months [Figure 7].

Figure 6

Postoperative smile after 6 months

Figure 7

Postoperative smile after 1 year

DISCUSSION

This report aimed to document lip repositioning technique to decrease the amount of gingival display in patients with gummy smile. The results showed esthetic satisfaction up to 6 months postoperatively after which lip slowly reverted back towards its original position with almost complete relapse at the end of 1 year.

Studies have shown that minimal gingival display during smile is considered esthetically acceptable.[101112] However, aesthetic perception varies depending on social environment, personal experience and culture.[1314] Dental professionals are usually more critical than laypersons regarding gingival display.[1516] The amount of gingival display that is considered attractive varies from 1-3 mm.[1718]

The results showed that the employed surgical procedure successfully reduced the gingival display with low morbidity. The procedure is safe and has minimum side effects.[19] Reports in the literature have shown minimal post operative bruising, discomfort and swelling. Mucocele formation has been the most severe reported complication.[2021]

Lip repositioning procedure began as a plastic surgical treatment and ever since variations have been reported.[20] The original technique did not include severing the muscle attachment after flap reflection.[1922] However, some authors suggested performing myectomies to detach smile muscle attachment to prevent relapse.[232425] Another method to prevent reattachment of smile elevator muscles is the placement of spacer between elevator muscles of lip and anterior nasal spine thereby preventing superior displacement of repositioned lip.[26]

Contraindications for lip repositioning surgery include inadequate width of attached gingiva in maxillary anterior sextent. Insufficient amount of tissue poses difficulty in flap reflection, stabilization and suturing. Patients with severe vertical maxillary excess cases are also not the ideal candidates for lip repositioning and should be treated with orthognathic surgery.[20]

Silva et al. in 2012 reported successful management of excessive gingival display in a study wherein thirteen patients with excessive gingival display were treated with a modified lip repositioning technique. Treatment consisted of the removal of two strips of mucosa, bilaterally to the maxillary labial frenum and coronal repositioning of the new mucosal margin. The baseline gingival display of 5.8 ± 2.1 mm significantly decreased to 1.4 ± 1.0 mm at 3 months and was maintained until 6 months (1.3 ± 1.6 mm). Subjects were satisfied with their smile after surgery and would likely choose to undergo the procedure again (92%).[27]

Similar results were obtained in other case reports by Rosenbaltt,[20] Simon,[21] and Humayun et al.[28] who achieved approximately 4 mm of reduction in gummy smile.

Jacobs et al. in 2013 reported a case series where seven patients were successfully managed with trial, and then definitive, lip repositioning wherein a mean reduction in gingival display of 6.4 ± 1.5 mm was achieved.[29]

Vital et al. in 2013 presented case report of two patients treated with modified lip repositioning technique and obtained significant improvement in the amount of gingival exposure and esthetic satisfaction after a 6 month follow up.[30]

The literature shows only clinical case reports for gummy smile treatment.[30] Several authors have presented case reports of single patients successfully treated with lip repositioning surgery with a follow up period of 6 months.[29]

This case report shows that although the results of lip repositioning surgery appear stable for up to 6 months postoperatively, its utility as a long term treatment option remains questionable. More studies with larger sample size and long term follow-up are necessary to establish the level of scientific evidence of this procedure.

CONCLUSION

Lip repositioning procedure is an effective way of reducing the EGD. However, long-term stability of the results needs to be seen. None the less, this procedure appears to be a promising alternative treatment option for excessive gingival display.