Treating short upper lip with "Unified lip repositioning" technique: Two case reports.

Excessive gingival display can be an esthetic concern for the patient. Conventional lip repositioning provides a conservative surgical option with less patient morbidity. The unified technique is a modification of conventional lip repositioning technique using the orthodontic brackets as anchorage to provide better soft-tissue closure with the lesser chances of relapse. This technique has been modified to be less invasive with better results. In this case report, patients undergoing orthodontic treatment with short upper lip were recommended for the surgical lip repositioning to reduce excess gingival display. Cases were treated with conventional lip repositioning technique and with unified lip repositioning technique, and after evaluation, comparison was done postoperatively. The unified lip repositioning technique showed better results with a significant decrease of gingival appearance and more patient compliance. Thus, in patients with short upper lip, unified lip repositioning technique can be a viable conservative treatment option. Copyright:

INTRODUCTION

Smiling and facial appearance are the methods of socializing, communication, and attraction among people and so achieving a “perfect smile” has become a major goal. This includes an interaction between the hard and soft tissue of the face, i.e., the teeth, lips, and gingival framework.[1] In an ideal smile, the gingival margins should be healthy and harmonious with well-aligned teeth. Hyperactive lip is considered to be mobile if it has more than 8 mm of movement and is without dentoalveolar deformity, whereas neuromuscular type of gummy smile is due to the short upper lip.[2] Various muscles responsible for the upper lip movement comprise the orbicularis oris, levator labii superioris alaeque nasi, levator labii superioris, zygomaticus major, levator anguli oris, depressor septi nasi, zygomaticus minor, and risorius. Hyaluronic acid injection, botulinum toxin injection, lip repositioning, myotomy/myectomy, or combinations of them are the only options available which mainly restrict the movement of the muscles.[3]

From the mentioned treatments, lip repositioning and myectomy are the only options which provide a permanent effect. Lip repositioning aims at reducing the excess display of gingiva by restricting the retraction of elevator muscles while smiling. Various modifications have been made in the conventional method to prevent relapse which involved myotomy, maxillary labial frenal sparing, and laser surgery.[456] It is very well-known that when jaw malformations exist, orthodontic treatment with orthognathic surgery is the main treatment option to re-establish the accurate inter-arch relationship and decrease the display of gingiva when smiling which is an invasive process and often ends up with substantial morbidity. Among the cases without jaw malformations, surgical lip-repositioning could be a better treatment option in reducing the gingival display.[7]

The visual assessment is extremely personal, though most patients state an enhancement in the smile. Therefore, lip-repositioning procedure proves to be a better substitutive treatment option for patients complaining of gummy smile, high visual prospects, and normal tooth proportions.

CASE REPORT

Two patients, a healthy 20-year-old female (case-1), [Figure 1a and b] and a healthy 21 year old male patient (case 2), [Figure 3a and b] were referred to the department of periodontology from the department of orthodontics in the final stage of orthodontic therapy with a chief complaint of gummy smile and incompetent lips. Figure 5a depicts the short upperlip. Complete history and oral examination of the patients was taken into consideration followed by thorough orthodontic workup. Upon examination, both the patients exhibited excessive gingival display with incompetent lip closure. Figure 5b depicting retraction for oral examination. The patients had vertical maxillary excess with short upper lip. Treatment options were discussed, and both the patients consented for surgical lip repositioning.

Figure 1

Case 1-Conventional lip repositioning. (a) Lateral profile (preoperative); (b) Frontal profile (preoperative); (c) marked area to be removed; (d) After excision of mucosal strip; (e) Sutures placed

Figure 3

Case 2-Unified lip repositioning. (a) Lateral profile (preoperative); (b) Frontal profile (preoperative); (c) Marked area to be removed; (d) After excision of mucosal strip; (e) Sutures placed

Figure 5

(a) Frontal profile with gummy smile; (b) Retraction of upper lip; (c) Area to be removed marked with indelible pencil; (d) Holding suture after excision of mucosal strip; (e) Interrupted sutures placed using anchorage from respective orthodontic brackets

Before the procedure, extraoral sepsis was carried out (using 5% povidone-iodine solution), and intraoral disinfection was performed (using 10 ml of 0.2% chlorhexidine gluconate rinse). The preoperative evaluation and the surgical procedure were carried out by the same clinician. At the time of the procedure, the area to be removed was marked using indelible pencil at the vestibular region of alveolar mucosa in an elliptical form [Figures 1c, 3c and 5c] extending from mucogingival junction to 12 mm apically acc. to the guidelines of “twice gingival display.” This was expanding to the distal of first premolar region bilaterally until the last tooth, and it showed the full dynamic smile. This was an important step to be performed before local anesthesia (Lidocaine HCL 2% with 1:100,000 epinephrine), because these points provide a correct re-alignment of the area to be excised. Under local anesthesia, incisions were placed in the previously marked areas, with the intention of raising a partial thickness flap thus exposing the underlying connective tissue [Figures 1d and 3d].

For Case 1, simple uninterrupted suturing [Figure 1e] with 4-0 black braided silk suture was given. The apical mucosa was approximated at midline first to reduce the vestibular depth and then sutured at the mucogingival junction for both anchoring and stabilization to maintain proper facial proportion. Finally, the gaps were closed using uninterrupted stabilizing sutures to help keep the lip in the new position coronally and later periodontal pack was placed. Postoperative instructions were given, which included soft diet, limited facial movements for 4 weeks, and placing ice packs over the upper lip. The patient was advised to take NSAIDs and antibiotics for the first 5 days along with oral hygiene instructions and antimicrobial rinses. Follow-up was done at an interval of 14 days, 1 and 3 months. After 10 days, it was noticed that there was a transformation in the gum line of the patient while performing facial movements such as smiling and laughing. The patient also experienced mild swelling around the lips along with minimal restriction of lip movement. All sutures were removed after 14 days postoperatively as the swelling had subsided by that time. The site showed good healing and better lip movement than earlier follow-up visits. The patient's satisfactory level was recorded at the 14th day follow-up on a scale of 10, (score 1 to score 10 from extremely unsatisfactory to highly satisfactory score). The patient remained satisfied with the outcome of the surgical procedure and scored it as 7 and was satisfied even at 3 months interval [Figure 2a and b].

Figure 2

Case 1-Post treatment (a) Lateral profile (3 months); (b) Frontal profile (3 months); (c) Lateral profile (18 months); (d) Frontal profile (18 months)

For Case 2, the apical mucosa was approximated at midline [Figure 5d] to reduce the vestibular depth and then was sutured at the mucogingival junction using 4-0 braided silk sutures. Suturing was performed initially by penetrating through the mucogingival junction, and then, the anchorage was acquired from the respective brackets to ensure constant pull and preventing relapse during healing [Figures 3e and 5e]. The sutures were placed in all the area of incision line. Postoperative instructions were given as in Case 1. Follow-up was done at an interval of 14 days, 1,3 and 18 months. At an interval of 10 days, moderate bilateral swelling around the lip of the patient was noticed. A small ulceration of approximately 3 mm in size was also noticed on the upper lip, which healed uneventfully. All sutures were removed at 14 days’ follow-up after swelling and bruising had resolved completely. The site showed good healing than earlier follow-up visits. The patient remained satisfied with outcome of the surgical procedure and scored it as 8.5 and was satisfied even at 3 months interval [Figure 4a and b].

Figure 4

Case 2-Post treatment (a) Lateral profile (3 months); (b) Frontal profile (3 months); (c) Lateral profile (18 months); (d) Frontal profile (18 months)

The patients were satisfied with the results of postoperative healing. No complications were noted in during and after the surgery. The second follow-up was taken at 18 months after the procedure, and the results were found excellent in Case 2 [Figure 4c and d], whereas in Case 1 [Figure 2c and d], it was found satisfactory.

DISCUSSION

Accurate assessment of etiology of excessive gingival display is imperative for making treatment recommendations. The commonly known causes of excessive gingival display are variable and may comprise of intraoral/extraoral components. Intraoral components include altered passive eruption, short clinical crowns, gingival hypertrophy/hyperplasia and dentoalveolar extrusion, whereas extraoral component comprises of short/incompetent upper lip, hyperactive upper lip, and vertical maxillary excess. While most intraoral causes of excessive gingival display can be improved by periodontal and restorative approaches, extraoral discrepancies necessitate different approaches. The camouflage therapy using the conventional lip repositioning procedure is a simple surgical technique which was intended to be quicker, shorter, least destructive, and with less postoperative complications that were associated with orthognathic surgery.[8]

Lip repositioning technique was first introduced as surgical lip repositioning in 1973 by Rubinstein and Kostianovsky.[8] The procedure subjected to many modifications and was being performed using various methods including the scalpel, the laser or the electro cautery with a similar goal of removing a strip of mucosa, shortening of the vestibular depth, and thereby restricting the muscle pull of elevator muscles while smiling.[456] In 1979, Litton and Fournier performed the lip repositioning procedure by detaching the muscles from the underlying bone to position the lip more coronally.[9] Miskinyar in 1983 reported lower success rate with the conventional method and modified this procedure in 19 patients whom he treated with myectomy and partial resection of Levator labii superioris muscle bilaterally.[10] Ellenbogen proposed that resection of Levator labii superioris muscles was short lived, and the gummy smile returned within 6 months. He suggested the placement of either nasal cartilage or prosthetic material as a spacer to prevent reunion of the muscle fibres and reoccurrence of gummy smile.[11] Various authors also mentioned that modified lip repositioning technique performed by myotomy or myectomy was more aggressive as the patients experienced numbness of upper lip, long postoperative trauma period, and irreversible morbidity postoperatively.[51213] The most common complications of conventional and modified technique as reported includes relapse and formation of mucocele because of severing of minor salivary glands in the upper lip.[581014] Hence, to overcome these limitations, Unified technique has been introduced. The name Unified describes a new modified technique, a unification of conventional lip repositioning technique with orthodontic appliances, i.e., brackets for anchorage.

In this case report, the procedure was performed by the placement of sutures with the use of respective brackets as anchorage to ensure minimal relapse during healing. Furthermore, sutures were maintained for a period of 14 days to ensure enhancement of tissue maturity and were removed after 14 days postoperatively. To avoid the chances of infection, irrigation of the surgical site was performed until 2 weeks till the sutures were removed and the surgical site was closely monitored to avoid wound dehiscence.[15] For evaluation of pain and swelling, the Visual Analog Scale (VAS) was implemented due to its ease of use and with least difficulty to patient in expressing the feeling of pain and swelling. VAS was used for the measurement of pain indicated score 0 for no pain to score 5 for extremely severe pain. VAS for swelling indicated score 0 for no swelling to score 5 for extremely severe swelling. The score of Case 1 for pain and swelling on day 10 was 1 and 1, whereas on day 14 was 0 and 1, respectively; the score of Case 2 for pain and swelling on day 10 was 2 and 3, whereas on day 14 was 0 and 1, respectively.

Being less invasive and aggressive, the authors feel that this technique should result in faster healing time and lesser complications. More researches with a larger sample size are warranted in this direction.

The advantages and disadvantages of this procedure are as follows:

Advantages

Procedure is less aggressive than the modified technique which includes myotomy and myectomy

Procedure is more patient conducive

Satisfactory healing of the surgical site is noted

It may have a lesser chance of relapse due to the continuous pull being exerted by the fixed brackets during the healing process.

Disadvantages

The patient may experience slight discomfort due to the constant pull

The maintenance of oral hygiene is a challenge as the patient already has orthodontic brackets which can be overcome by judicious use of interdental brushes and mouthwashes.

The technique's limitations are that it can only be performed in patients having orthodontic brackets. The authors quote an opinion that the limitation of the technique can be overcome by the placement of temporary brackets in nonorthodontic patients. The other limitation comprises the treatment of gummy smile which can be done using crown lengthening procedures, but the presence of short upper lip with an adequate clinical crown length invoked a lip repositioning procedure in the present case instead of performing crown lengthening. Despite the recently reported excellent results, lip repositioning is considered to be associated with the high recurrence rate. As per the author's knowledge, this was the first attempt to stabilize the upper lip of the patient using Unified lip repositioning technique in a conservative way to prevent relapse over the long term. Further, studies with large population are needed to confirm the results.

The current technique appears to be a viable option in effectively treating gummy smile. It is relatively easy to perform and appears to have good patient acceptance. Further research is required with more patients in this direction to evaluate the effectiveness of the Unified technique.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.