|Year : 2019 | Volume
| Issue : 3 | Page : 290-294
Esthetic lip repositioning: A cosmetic approach for correction of gummy smile – A case series
Asha Ramesh, Radha Vellayappan, Sheethalan Ravi, Kaarthikeyan Gurumoorthy
Department of Periodontics, Saveetha Dental College and Hospital, Chennai, Tamil Nadu, India
|Date of Submission||24-Aug-2018|
|Date of Acceptance||09-Nov-2018|
|Date of Web Publication||2-May-2019|
Dr. Asha Ramesh
Department of Periodontics, Saveetha Dental College and Hospital, No. 162, Poonamallee High Road, Vellappanchavadi, Chennai - 600 077, Tamil Nadu
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Gummy smile has been a prevalent esthetic disorder commonly affecting younger individuals due to various causes such as skeletal, dento-alveolar, or soft-tissue origin. It can be due to jaw deformities, altered passive eruption, or tooth malpositioning. Usually, the corrective measures incorporate orthognathic surgery and orthodontic treatment. Orthognathic surgery results in significant morbidity and hospitalization. Lip repositioning can be employed as an alternative cosmetic treatment modality for the correction of an excessive gingival display with minimal risk or side effects. Although there are many articles existing in the literature on this topic, a series of three cases is unique in demonstrating the esthetic smile enhancement in an orthodontic patient and also a combination of lip–repositioning technique and laser-assisted crown lengthening in vertical maxillary excess cases. This case series also showed the predictability of lip-repositioning technique with a follow-up of 2 years.
Keywords: Crown lengthening, esthetics, gummy smile, lip repositioning, periodontal surgery
|How to cite this article:|
Ramesh A, Vellayappan R, Ravi S, Gurumoorthy K. Esthetic lip repositioning: A cosmetic approach for correction of gummy smile – A case series. J Indian Soc Periodontol 2019;23:290-4
|How to cite this URL:|
Ramesh A, Vellayappan R, Ravi S, Gurumoorthy K. Esthetic lip repositioning: A cosmetic approach for correction of gummy smile – A case series. J Indian Soc Periodontol [serial online] 2019 [cited 2019 Dec 7];23:290-4. Available from: http://www.jisponline.com/text.asp?2019/23/3/290/251774
| Introduction|| |
A beautiful smile is due to the harmonious relationship between the components of the oral cavity such as (i) lips (ii) teeth, and (iii) gingiva. “Gummy smile” (GS) has been described as the visibility of excessive amount of gingiva during smiling. In a study done by Tjan et al. on 450 individuals, with an age range of 20–30 years, the authors observed that 7% of men and 14% of women were found to have GS. The major etiological factors for excessive gingival display or GS include short upper lip, hyperactive upper lip (HUL), altered passive eruption where the excess gingiva covers the teeth, or skeletal conditions such as vertical maxillary excess (VME).,
In VME cases, the diagnosis can be made when the upper third of the face is longer than the other thirds. Treatment option includes orthognathic surgery where Le Fort I osteotomy can be performed. In some VME patients, an interdisciplinary approach of orthodontic, orthognathic, periodontal, and restorative treatment has to be employed. With this procedure, patients are required to undergo hospital stay for recovery and they encounter significant morbidity such as pain, swelling, edema, bruising, and discomfort. Conservative approaches may be warranted for the correction of excessive gingival display for esthetic reasons.
The average length of the upper lip is about 20–22 mm in young females and 22–24 mm in young males, and GS has been associated with a short upper lip. HUL also results in GS that is due to the hyperactivity of the elevator muscles of the lip. The diagnosis of HUL is usually made when there is normal upper-lip length and equal facial thirds. Some case reports have suggested that injection of botulinum toxin can be effective in the treatment of hypermobility of the upper lips., Another minimally invasive minor surgical technique for the correction of GS is lip repositioning. It can limit the retraction of the elevator muscles of the lip and results in a shallow vestibule, hampering the muscle pull, thereby obscuring the excessive gingival display during smiling. This case series aims to demonstrate lip-repositioning technique with 2-year follow-up, which was used for the correction of excessive gingival display.
| Case Reports|| |
A 23-year-old female patient reported with a complaint of excessive gingival display on smiling and dark pigmentation of the gingiva [Figure 1]. She had esthetic concern and required the correction of GS. The GS was attributed to the VME, and the patient was advised to undergo orthognathic surgery. However, the patient refused to undergo orthognathic surgery due to its invasive nature and preferred lip-repositioning surgery. In the first stage, depigmentation was performed using soft-tissue diode laser along with crown-lengthening surgery to achieve sufficient crown height. Following this, the second stage of surgery that involved lip repositioning was carried out.
|Figure 1: Preoperative image showing excessive gingival display and gingival hyperpigmentation of case 1|
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Adequate local anesthesia was obtained with the infiltration of 2% lignocaine with 1:100,000 epinephrine from the maxillary right to left premolar region. The first stage of surgery which utilized a soft-tissue diode laser (Zolar Technology) with a power setting of 0.5 W and energy of 120 mJ was used to perform gingival depigmentation and crown-lengthening surgery to achieve esthetic gingival zenith [Figure 2]. The second stage of surgery was performed after adequate local anesthesia where a partial-thickness flap was raised from the right to left maxillary premolar region [Figure 3] using a scalpel and blade no 15. The second incision was placed 10 mm from the first incision on the labial mucosa, and both the incisions were connected [Figure 4]. The strip of connective tissue was removed, and the flap margins were sutured using resorbable sutures. A periodontal pack was placed at the surgical site.
|Figure 2: Crown lengthening and gingival depigmentation using soft-tissue diode laser|
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|Figure 4: Strip of connective tissue removed adjoining the two incisions in lip-repositioning surgery|
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Postoperative instructions included prescription of antibiotics (amoxicillin 500 mg tid for 5 days) and analgesics (paracetamol 650 mg tid for 4 days). Furthermore, the patient was asked to refrain from active lip movements by limited talking and smiling. In the 1st-week follow-up, the surgical area was irrigated with saline, and there were no biological complications. The patient reported mild discomfort only in the 1st week and then recovered. The 2-year follow-up showed no relapse, and the patient was satisfied with her esthetically enhanced smile [Figure 5].
|Figure 5: Postoperative image at 2-year follow-up showing the esthetically enhanced smile|
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A 30-year-old female patient with noncontributory medical history reported to the department of periodontics with the complaint of GS, and she was not satisfied with her smile [Figure 6]. This was the patient's first consultation regarding her concern, and clinical examination revealed that she had a healthy periodontium. The examination also showed that the patient had incompetent lips and that her gingival display was excessive on smiling. It could also be noted that the maxillary central incisors had a lower gingival zenith when compared to the lateral incisors, and it was not esthetically appealing to the patient [Figure 7].
|Figure 6: Preoperative image showing gummy smile and altered gingival zenith in case 2|
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|Figure 7: Preoperative intraoral view showing the excessive gingival display|
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Local anesthesia was obtained in the maxillary right premolar to left premolar region by injecting 2% lignocaine with 1:100,000 epinephrine. The recontouring of the gingival zenith of the maxillary central incisors was carried out using a soft-tissue diode laser (Zolar Technology) with a power setting of 0.5 W and an energy setting of 120 mJ. The laser-assisted surgery resulted in esthetic reshaping of the gingival margin of the maxillary central incisors [Figure 8]. Following this, a partial-thickness flap was elevated between right and left maxillary premolar regions, and the incision for lip repositioning was placed about 10 mm from the first incision in the labial mucosa. Both the incisions were connected, and the resultant strip of connective tissue from the partial-thickness flap was removed [Figure 9]. The flap margins were sutured with resorbable sutures in a simple interrupted manner [Figure 10]. A periodontal pack was applied to the surgical site.
|Figure 8: Crown-lengthening surgery to alter the gingival zenith in the maxillary incisor region|
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|Figure 10: Resorbable sutures placed following lip-repositioning surgery|
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The patient was prescribed with antibiotics (amoxicillin 500 mg tid for 5 days) and nonsteroidal anti-inflammatory drugs (paracetamol 650 mg tid for 4 days) to aid in postoperative healing. The patient was instructed to refrain from active lip movements such as talking, smiling, and opening the mouth wide. The patient was also advised to adhere to postoperative instructions such as application of ice pack, avoiding hot and spicy food, and having a soft diet. The patient was recalled after 1 week for the reapplication of the periodontal pack. The surgical area was irrigated with saline, and it showed satisfactory healing for the 1st week. The periodontal pack was reapplied. The 2-year follow-up revealed esthetically enhanced smile, and the patient was satisfied [Figure 11].
A 19-year-old female patient undergoing orthodontic treatment reported to the department of periodontics with excessive gingival display following retraction of the maxillary anterior teeth [Figure 12]. The patient's systemic and periodontal health status was good. Clinical examination revealed moderate gingival display on smiling and, on full smile, the bilateral maxillary premolars were visible. Lip-repositioning technique was indicated for the patient, and crown lengthening was not advised as there was no alteration in the gingival zenith of the maxillary anterior teeth. An informed consent was obtained for this minimally invasive treatment modality.
Adequate local anesthesia (2% lignocaine with 1:100,000 epinephrine) was administered in the vestibular mucosa extending from the right maxillary premolar to the left maxillary premolar. A partial-thickness flap was raised in the aforementioned region at the mucogingival junction using a scalpel and blade no 15. A second incision was placed about 10 mm above the first incision in the labial mucosa, and the two incisions were connected [Figure 13]. The strip of connective tissue from the partial-thickness flap was removed, and the approximating ends were sutured with interrupted sutures. A periodontal pack was placed on the surgical site.
|Figure 13: Strip of connective tissue removed during lip-repositioning surgery|
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The patient was prescribed nonsteroidal anti-inflammatory drugs (paracetamol 650 mg tid for 3 days) and antibiotics (amoxicillin 500 mg tid for 5 days). Furthermore, the patient was given postoperative instructions to avoid hot and spicy food, to apply ice pack, to avoid mechanical trauma, to eat only soft food, and to restrict lip movements for 2 weeks by limited smiling and talking until suture removal. On complete healing of the surgical site following 2 weeks of postoperative period, suture removal was done, the patient reported slight tension on smiling, and no postoperative complications were observed in the area. The 1-year follow-up of the patient showing the esthetically enhanced smile has been depicted in [Figure 14].
|Figure 14: Postoperative image with 2-year follow-up showing esthetically enhanced smile|
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| Discussion|| |
This case series documents the lip-repositioning surgery that has been advised for the correction of GS, and there is also a modified technique with the use of laser-assisted crown lengthening that has been combined with lip-repositioning surgery. About 2–3 mm of the exposed gingiva while smiling is cosmetically acceptable; however, more than this is considered as “GS.” GS has been associated with various conditions, and the literature is replete with numerous treatment modalities for the correction of it. Invasive procedures such as myotomy, myectomy, and orthognathic surgery have been indicated for the correction of GS, whereas there are also conservative techniques such as lip repositioning, crown lengthening, or the use of botulinum, which have promising results.,,
Lip repositioning has gained a lot of impetus over the recent years after its inception in 1983 by Miskinyar who treated patients with myectomy and partial resection of one or both of the levator labii superioris muscles. This has become a chosen treatment modality because of the shorter, less aggressive approach, and it is shown to have lesser postoperative complications when compared to orthognathic surgery. A systematic review by Tawfiq et al. on the use of lip repositioning for the treatment of excessive gingival display collated evidence from 22 articles which were mostly case reports, and it observed that there was a mean improvement of 3.4 mm with the use of lip-repositioning technique.
In this case series, three female patients in the age group of 18–25 years observed that their smile was not esthetically pleasing and desired to undergo cosmetic correction for the same. Various treatment modalities were discussed, and they preferred surgical lip repositioning because of its less invasive nature. The cases had varying degrees of gingival display ranging from mild to moderate, and one case also had uneven gingival contour. The conventional lip-repositioning surgery was performed in one patient, and a combination with laser-assisted crown lengthening was performed in two cases.
Jacobs and Jacobs in 2013 observed the results in seven patients who underwent lip repositioning and found that there was a mean reduction of gingival display of 6.4 ± 1.5 mm in those patients. Similarly, Ribeiro-Júnior et al. in 2013 also reported a significant improvement in the gingival exposure in two patients following modified lip-repositioning surgery and a satisfactory esthetic outcome in the 6-month follow-up. Farista et al. observed that a combination of laser-assisted crown lengthening with lip-repositioning surgery where gingival contouring was done to correct the gingival asymmetry showed satisfactory esthetic outcome only at 6-month follow-up, but there was a mild recurrence at the 1-year follow-up.
There are numerous case reports in the literature that have supported lip-repositioning surgery in GS patients and shown achievement of esthetically pleasing smiles. These reports have shown stable results in 6-month follow-up, but very few have shown results of long term. A systematic review also quoted that further studies are required to properly evaluate the surgical approach and the stability of the procedure. In our case series, the mean follow-up is about 2 years which is longer than that observed in various case reports, and the surgical outcome has been favorable without any recurrence in these cases. Future clinical trials can be conducted to compare the esthetic results obtained from various techniques for the correction of GS, and also a long-term follow-up to assess the stability of the treatment modality should be definitive.
| Conclusion|| |
Lip repositioning has been under the radar because of its unique approach to correct GS. It favors clinicians and patients due to its less invasive approach and minimal postoperative complications. This case series shows the esthetically enhanced smiles in three patients who underwent lip-repositioning surgery. With due consideration of these results, lip repositioning is a promising and patient-friendly approach to the correction of GS.
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
Conflicts of interest
There are no conflicts of interest.
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