Lip repositioning surgery for correction of excessive gingival display.

Esthetic demands have considerably increased over the years in routine clinical practice. A pleasant smile can give supreme confidence to an individuals personality. However, a perfect smile is dictated by a perfect balance of the white (teeth) and pink (gingival) display. This balance can be managed different treatment modalities, which is based on proper diagnosis. This case report demonstrates a successful management of gummy smile with a lip-repositioning procedure in a patient with an incompetent upper lip. This was accomplished by removing a partial thickness strip of mucosa from the maxillary buccal vestibule and suturing the lip mucosa to the mucogingival line. This resulted in a narrower vestibule and restricted muscle pull, thereby resulting incompetent lips and reduced gingival display during smiling.

Gingival health and display are important aspects of a pleasing smile. One of the common causes for a compromised smile is excessive gingival display. The cause of excessive gingival display can be due to a vertical maxillary excess,[1] incompetent upper lip and delayed eruption.[2] Excessive gingival display caused due to vertical maxillary excess can be treated by orthognathic surgery,[3] and excessive gingival display resulting due to delayed eruption can be treated by esthetic crown lengthening. An alternative approach that should be considered is the lip re-positioning surgery, which is very effective, with fewer postoperative complications. Based on the relationship between the patients lips, gingival, and tooth display while smiling an appropriate technique should be chosen.[4] In the case of this report, we used a minimally invasive surgical procedure for the management of excessive gingival display.

Case Report

A healthy 32-year-old female patient reported to a private clinic in Chennai (India), with the chief complaint of the excessive display of gums while smiling. There was no significant medical or family history, and the patient was fit for the surgical procedure. On clinical examination, the extraorally face was bilaterally symmetrical with incompetent lips. Intraorally, a moderate gingival display was seen during smiling, which extended from maxillary right second premolar to maxillary left first molar, with 5–6 mm of excessive gingival tissue display [Figure 1] and the maxillary anterior teeth had normal anatomic proportions.

Figure 1

Excessive gingival tissue display

Technique

The aim of the technique lip repositioning is a surgical way to correct gummy smile by limiting the retraction of the elevator smile muscles (orbicularis oris, levator anguli oris, levator labii superioris, zygomaticus minor).

A local anesthetic (xylocaine with 1:100,000) was administered. Thereafter, the surgical area to be operated was demarcated with a marking pen. The surgical area started at the mucogingival junction, which extended 10–12 mm superiorly in the vestibule [Figure 2]. Incisions were made in the surgical area, and both superior and inferior partial thickness flap was raised from maxillary right second premolar to maxillary left second premolar. The incisions were then connected with each other in an elliptical outline. The epithelium was then removed [Figures 3 and 4] within the outline of the incision leaving the underlying connective exposed [Figure 5]. The parallel incision lines were approximated with interrupted stabilization sutures at the midline [Figure 6] 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 [Figure 7] was used to approximate both flaps with 5-0 vicryl sutures. Periodontal dressing with coe pack was given. Patient was discharged with all postoperative instructions and medications for 5 days which included amoxycillin 500 mg T.D.S and ibuprofen 400 mg B.D was prescribed. Postoperative healing occurred, and the patient reported minimal postoperative complications 1 week after surgery [Figure 8]. Sutures were removed 2 weeks later. Reduction in gingival display at the 1-year follow-up visit was stable along with competent lips [Figure 9].

Figure 2

Surgical area

Figure 3

Removal of epithelium

Figure 4

Removed epithelial tissue

Figure 5

Exposed connective tissue

Figure 6

Stabilization sutures at the midline

Figure 7

Continuous interlocking suture

Figure 8

One week after surgery

Figure 9

One year follow-up visit with stable competent lips

Discussion

One of the most common causes of the excessive gingival display is a short upper lip with high lip line. The form of the upper lip and the position of the upper lip during smile and speech can be altered by a combination of periodontal and restorative treatment modalities to improve the esthetics. This report presents the use of lip repositioning surgery for the management of gummy smile. In the present case, as there was an adequate width of attached gingiva and adequate crown length, crown lengthening was not appropriate. Moreover, gingival display was <6 mm, which indicated that vertical maxillary excess was not severe requiring orthognathic surgery; hence, the lip repositioning surgery was planned in the present case.

Some authors have advocated myoectomies to detach the smile muscle attachment.[5] Lip repositioning is com monly used as a plastic surgical procedure and is rarely used as a dental procedure. Alloplastic or autogenous separators can also be used to prevent the reattachment of the smile muscles.[6] This spacer is placed with a nasal approach between the elevator muscles of the lip and anterior nasal spine which helps in prevention of the superior displacement of the repositioned lip.

Lip repositioning can also be performed along with rhinoplasty.[7] The nasal approach helps in combining both the procedures with the minimal surgical extension. This can be considered in patients requiring rhinoplasty along with the excessive gingival display. However, Lip repositioning surgery should be avoided in patients with an inadequate width of attached gingiva and in patients with severe vertical maxillary excess.[8]

Conclusion

It can be said that lip repositioning is a viable treatment option to improve the gummy smile of a patient provided a systematic evaluation of the case is done to choose the appropriate treatment option. It is less traumatic with fewer postoperative complications and has a faster recovery time compared to orthognathic surgery. However, longitudinal studies with more sample size are needed to evaluate the stability of this treatment modality.