Modified lip repositioning: A surgical approach to treat the gummy smile.

Gummy smile has been an esthetic concern for many patients. This clinical report describes a successful surgical coverage obtained by modified lip repositioning, thus surgically treating the gummy smile. The technique was performed to limit the retraction of elevator muscles (e.g., zygomaticus minor, orbicularis oris, leviator anguli oris and levator labi oris.) The technique is fulfilled by removing two strips of mucosa from maxillary buccal vestibule on both the sides leaving the frenum untouched and creating a partial thickness flap between mucogingival junction and upper lip musculature, and suturing the lip mucosa with mucogingival junction, resulting in a narrow vestibule and restricted muscle pull, thereby reducing gingival display. This technique is different from the conventional surgical lip repositioning as labial frenum is left untouched over here as it helps in maintain Litton the midline for lip repositioning and reduces the morbidity associated with it.

INTRODUCTION

An esthetically pleasing smile requires gingival health, a proportional amount of gingival display during forced smiling and harmony among the size, shape, position, and color of the teeth.[1] Excessive gingival display during smiling has been a case of esthetic embarrassment for many patients. Gummy smile is seen due to improper relation between the gingival tissue and the tooth, with gingival tissue in excess and tooth portion in a small amount. At least 50% of the patients exhibits some form of gingival display in a normal smile.[2] However, exaggerated or forced smile patterns display gingiva in up to 76% of all patients.[3] In absolute numbers, a normal gingival display between the inferior border of the upper lip and the gingival margin of the maxillary central incisors during a normal smile is 1–2 mm. In contrast, an excessive gingiva-to-lip distance of 4 mm or more is classified as “unattractive” by lay people and general dentists.[4] A subset of this patient population exhibits an upper lip that lies far enough above the maxillary gingival zenith that it is described as unattractive.[4] Gummy smile may not present with any pathologic difficulties, but definitely affects the patient's psychosocial behavior.[5] It is the gingiva which dominates the visual feature in gummy smile when compared with teeth and lips giving an unaesthetic appearance. Patients having excessive gingival display because of delayed eruption of teeth can be treated by crown lengthening and gingivectomy, but some patients might require further treatment. A careful diagnosis and a proper treatment plan thus are very essential correcting the deformity. Diagnoses such as hypermobile upper lip, short upper lip, and/or vertical maxillary excess require surgical corrections. Moderate gingival display that is not skeletal in origin and vertical maxillary excess that ranges between 4 and 8 mm can effectively be treated by surgical repositioning of upper lip limiting the retraction muscles such as zygomaticus minor, orbicularis oris, levator anguli oris and levator labi oris. Conventional lip repositioning has been described in many case reports recently for the designing the gummy smile; however, only few have described the modified lip repositioning procedure. This case report describes the surgical technique and outcome of modified lip repositioning in the treatment of excessive gingival display.

CASE REPORT

A 23-year-old male patient reported to the Department of Periodontology and Implantology, Vyas Dental College and Hospital, Jodhpur (India), with the chief complaint of excessive display of gums while smiling. There were no significant medical or family history and the patient presented with no medical conditions that could contradict the surgical procedure. On extra oral examination, the facial symmetry was seen to be well maintained. However, the high lip line was noted during smiling, which presented with a moderate gingival display. Intraorally, a moderate gingival display was seen during smiling, which extended from maxillary right first molar to maxillary left first molar. Also, there was slight higher pull of the upper lip on the right side near first molar when compared to the left side which gave an unesthetic appearance [Figure 1]. Measurements such as gingival display, while forced smiling [Figure 2] and the upper vermillion lip length were recorded with UNC calibrated probe. There was a 6 mm of gingival display on forced smiling and 7 mm of upper vermillion lip length.

Figure 1

The preoperative figure showing the gummy smile

Figure 2

7 mm of gingival display as measured by UNC-15 probe

Informed consent was obtained after discussion of the benefits, possible complications, and alternatives to lip repositioning.

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 oris, orbicularis oris, and levator labi superioris) and yet preserve the labial frenum.

Modified lip repositioning surgery

Local anesthesia (xylocaine 2% with epinephrine 1:80,000) was administered at the vestibular mucosa and lip from the maxillary right to left first molar. With the help of a sharp probe, bleeding points were induced at the mucogingival junction, which guided the first incision to be carried out. A partial thickness incision was made at the mucogingival junction from the mesial line angle of the right central incisor to the mesial line angle of the right first molar [Figure 3]. A second partial thickness incision that ran parallel to the first incision and 10–12 mm apical of the mucogingival junction was made in the labial mucosa. The incisions were connected at the central incisor region without involving the maxillary labial frenum and at the right first molar region creating a quadrilateral outline [Figure 4]. The epithelium was then carefully dissected within this outline [Figure 5], leaving the underlying connective tissue exposed [Figure 6]. The same procedure was carried out on the left side at the mucogingival junction by making an incision from mesial outline of left central incisor to the mesial outline of left first molar. The next partial thickness incision was the one parallel to the first incision and 10–12 mm apical to the mucogingival junction. The incisions were then joined without touching the maxillary labial frenum in the center. The second strip of epithelium was then removed by careful dissection [Figure 7]. Care was taken to avoid damage to any minor salivary glands in the submucosa.

Figure 3

The first partial thickness incision on mucogingival junction from mesial line angle of right central incisor to mesial line angle of right first molar

Figure 4

The second partial thickness about 8–10 mm above the first incision and two vertical incisions to join at both the ends

Figure 5

The strip of the epithelium which was removed

Figure 6

The partial thickness dissection which was carried out

Figure 7

The same procedure was done on the left side leaving the intact frenum

The parallel incision lines were approximated with interrupted stabilization sutures (silk 4/0) [Figure 8]. Coe-Pack was then placed to close the wound. Patient was discharged with all postsurgical instructions and medications for 5 days which included analgesic (ketorolac trimethamine 10 mg twice daily for 3 days), antibiotic (amoxicillin 500 mg TDS for 5 days), along with cold packs extra orally to decrease postsurgical swelling.

Figure 8

The 4-0 mersilk sutures were placed

Patient was recalled after 1-week for a follow-up. The patient reported with mild pain and tension at the surgical site during the 1st week after surgery. It was seen later that the suture area healed in the form of a scar, which was not apparent when the patient smiled because it was concealed in the upper lip. Patient satisfaction was recorded after 1-week of the procedure on a scale of 10 with score 1 for extremely unsatisfactory to 10 for a highly satisfactory score. Patient was highly satisfied with the treatment carried out and rated a score of 9 on a scale of 10. The gingival display measured after 1-week was <1 mm with only interdental papilla being seen after forced smiling giving an esthetically pleasing appearance. Furthermore, the upper lip vermillion length was increased to 12 mm.

Revaluation was further carried out after 1-month to see the stability of the results obtained. There were no changes in the scores obtained even after 1-month period. The gingival display noted after 1-month was 1 mm while smiling [Figure 9]. Patient was very comfortable and presented with no complications. After a period of 1-month he did not find any tension or pain while smiling [Figure 10].

Figure 9

1 mm of gingival display on smiling postoperatively after 1-month

Figure 10

The postoperative picture after 1-month

DISCUSSION

This case report describes an innovative surgical procedure to treat the excessive gingival display during smiling. The procedure is different from the conventional lip repositioning surgery which was first reported in the medical literature in 1973 by Rubinstein and Kostianovsky.[6] Lip repositioning surgery has undergone many modifications since then. In 1979, Litton and Fournier described gummy smile correction with lip repositioning surgery, including elevator muscle detachment in cases with a short upper lip. Miskinyar, in 1983, found no relapses for the 27 patients treated with myectomy and partial resection of either one or both of the levator labii superioris muscles bilaterally in lip repositioning surgery.[7] In 2010, Ishida et al.[8] reported a significant reduction in gingival exposure in 14 patients treated with levator labii superioris myotomy, subperiosteal dissection, and frenectomy. Modified lip repositioning, however, does not include the maxillary labial frenum. The main objective for preserving the maxillary labial frenum is that it prevents the midline being shifted thus guiding for an esthetically pleasing smile and also avoids the morbidity associated with the removal of maxillary labial frenum.

The surgical procedure yielded great results by achieving a greater degree of gingival coverage to hide the gummy smile. Also, there were no potential complications reported after 1-month period. The chief complaint of a gummy smile was completely resolved by modified lip repositioning surgical procedure. The quality of life was improved as the procedure met the esthetic demands of the patient.

The demerits of the surgical procedure would include: (a) Chance of recurrence of a gummy smile (b) decrease in the vestibular depth following surgery. Thus considering all the perspectives, Modified lip repositioning definitely is a promising surgical approach to treat gummy smile.