|Year : 2014 | Volume
| Issue : 5 | Page : 656-660
Treatment of gummy smile: Gingival recontouring with the containment of the elevator muscle of the upper lip and wing of nose. A surgery innovation technique
Carmen Lucia Mueller Storrer1, Fabiane Kristine Bochenek Valverde2, Felipe Rychuv Santos3, Tatiana Miranda Deliberador1
1 Professor of Periodontics, Professional Masters Program in Clinical Dentistry, Positivo University, Curitiba, PR, Brazil
2 Postgraduate Student, Positivo University, Curitiba, PR, Brazil
3 Department of Periodontology, Positivo University, Curitiba, PR, Brazil
|Date of Web Publication||10-Oct-2014|
Carmen Lucia Mueller Storrer
Positivo University, Rua: Professor Pedro Viriato Parigot de Souza, 5300, Campo Comprido - Curitiba - PR - CEP: 81280-330
Source of Support: None, Conflict of Interest: None
| Abstract|| |
The containment of the elevator muscle of the upper lip and wing of nose was used for the treatment of patients with gummy smile. This technique had corrected esthetic alterations of smile, reducing the upper lip elevation, which results in a smaller gingival display. An upper lip lengthening as well as a reduction in the upper lip shortening when the patient smiled could be observed. The high smile line was corrected without compromising the labial harmony. This study presents an innovative and effective therapeutic option to obtain a natural and harmonious smile. The patient expressed a high degree of satisfaction.
Keywords: Esthetics, gingival recontouring, gummy smile, smile esthetics
|How to cite this article:|
Storrer CL, Valverde FK, Santos FR, Deliberador TM. Treatment of gummy smile: Gingival recontouring with the containment of the elevator muscle of the upper lip and wing of nose. A surgery innovation technique. J Indian Soc Periodontol 2014;18:656-60
|How to cite this URL:|
Storrer CL, Valverde FK, Santos FR, Deliberador TM. Treatment of gummy smile: Gingival recontouring with the containment of the elevator muscle of the upper lip and wing of nose. A surgery innovation technique. J Indian Soc Periodontol [serial online] 2014 [cited 2021 Jun 16];18:656-60. Available from: https://www.jisponline.com/text.asp?2014/18/5/656/142468
| Introduction|| |
There has been a growing demand by patients for esthetic solutions to their smile. Therefore, the current dentistry, which must be based on scientific evidences, has been searching for alternatives and new techniques on a regular and evolutionary basis.
Periodontics is a branch of dentistry that searches for solutions in the construction of the facial esthetics, in which the harmony between lips, teeth and gums is extremely important. Lips define the esthetic zone of what is considered a smile frame.  According to the literature, some aspects should be observed in order to rate each patient's type of smile. The excessive gingival display when a patient smiles (from 4 mm or more), known as gummy smile, along with a short clinical crown of the maxillary anterior teeth characterize esthetic problems.  There are different etiologies of gummy smile, such as: Excessive vertical bone growth, dentoalveolar extrusion, short upper lip, upper lip hyperactivity, altered passive eruption and the combination of some of these factors. , There is an adequate treatment for each kind of etiology, and two or more techniques can be associated.
When gummy smile is caused by excessive gingival tissue partially covering the anatomical crown of the teeth (which is also caused by altered passive eruption), a resective gingival surgery (gingivoplasty) is recommended.  Thus, a surgical technique to position the gingival margin more apically should be planned, without exposing the root surface, observing the amount of keratinized gingiva and the relationship between the cement - enamel junction, the gingival margin and the alveolar bone crest. , However, some cases are not solved only through gingival recontouring (GR) because the amount of gingival display on smile is still significant.
In search of a more satisfactory result and a more harmonious smile, this study proposes to demonstrate a new surgical technique with the combination of GR + the traction and containment surgery of the elevator muscle of upper lip and wing of nose (EMULWN).
Such a technique requires the knowledge of anatomy, location and insertions of the EMULWN. In the literature, this muscle is described as being long and slender, extending from the frontal process of the maxilla at the level of the eye's angle up to the upper lip. Before it is inserted in the lip, the muscle sends fibers to the wing of the nose skin. Then, it is divided into medial and lateral cords; the lateral cord raises and everts the upper lip and raises, deepens and increases the curvature of the upper part of the nasolabial groove. The medial cord pulls the lateral branch superiorly, displaces the circumalar groove laterally and changes its curvature: It is a dilator of the nostrils.  In the technique described, only the lateral bundle of the muscle was pulled and then contained. This surgical technique was first demonstrated in a corpse from the Miami Anatomical Research Center (MARC) [Figure 1], [Figure 2], [Figure 3] and [Figure 4]. This technique is considered a surgical innovation and has not been reported in the scientific literature yet.
|Figure 1: Photo illustrating the vestibule of the upper arch in a human corpse (MARC). Anatomical details of the anterior third of the arch (keratinized gingiva and alveolar mucosa). Vertical incision on the labial frenum and horizontal incisions on a superficial layer of the mucogingival line up to the height of the canines|
Click here to view
|Figure 2: Image after the divulsion and separation of the external epithelium from the mucosa with the use of Goldman-Fox scissors, exposing and pulling the lateral bundle of the elevator muscle of the upper lip and wing of nose bilaterally|
Click here to view
|Figure 3: Containment of the muscle bundles with an absorbable suture thread in the highest portion of the inserted gingiva on both sides|
Click here to view
|Figure 4: Sutures made with a 4-0 silk thread in the horizontal incisions and in the vertical incision on the labial frenum|
Click here to view
| Case report|| |
Patient CM, a 30-year-old female, came to the Clinic of Specialty in Periodontics at Positivo University relating her dissatisfaction with her smile after the removal of a fixed orthodontic appliance, which she had worn for 2 years. On clinical examination, it was found that her periodontal condition was satisfactory, but she wanted to improve the esthetics of her smile because it "showed too much of her gum" [Figure 5]. It was observed that, after the analysis of her facial thirds, which looked increased, the patient had too much gingival display while smiling, an extreme case of gummy smile measuring 7 mm from the gingival margin to the lower border of the upper lip [Figure 6].
|Figure 6: Measurement of the gummy smile, with the help of a periodontal probe, with 7 mm of gingival display|
Click here to view
A probing clinical depth with an average of 3 mm from the anterior teeth up to the second right and left maxillary premolars was detected through the use of a periodontal probe. The GR technique was an option given to the patient in order to eliminate these 3 mm. To soften the image of the remaining 4 mm-gum display when the patient smiled, a releasing technique to contain bilaterally the elevator muscle of upper lip and wing of the nose was chosen.
Firstly, the technique of GR was used under the effect of an infiltrative infraorbital anesthesia on both sides of the upper arch. The gingival groove was fully measured and marked in its maximum depths through the use of a periodontal probe in order to identify the homogeneity of the probing values. Afterwards, a superficial delimitation joining the markings previously made was made with a scalpel blade 15. These markings were deepened with the same blade in an internally beveled incision. In addition, intrasulcular incisions were made in order to remove the gingival tissue that partially covered the anatomical crown of the teeth. A slight elevation of the flap was made with a Molt Periosteal Elevator and the flap was kept in the keratinized gingiva in order to loosen the fibers and avoid the recurrence of the gingival margin on the crown of the teeth. The upper part of the inserted gingiva was fully preserved in order to support the sutures, which will contain the elevator muscle of upper lip and wing of nose. Some suspensory sutures were made after the repositioning of the flap [Figure 7], [Figure 8], [Figure 9] and [Figure 10].
|Figure 7: Markings of the depth of gingival sulcus with a periodontal probe or a Crane Kaplan probe. Union of these markings with an internal bevel incision|
Click here to view
|Figure 8: The excess of gingival tissue is removed with the use of an Orban knife. Note the significant increase of the dental crowns|
Click here to view
|Figure 9: Traction of the elevator muscle of the upper lip and wing of nose with an absorbable suture thread. Sutures in a deep layer between the muscle and the upper portion of the keratinized gingiva|
Click here to view
|Figure 10: Continuous suture made with a 4-0 silk thread on the labial frenum and in between the mucosa and the keratinized gingiva|
Click here to view
Subsequently, a vertical incision was made on the labial frenum and two more horizontal incisions were made on the mucogingival line, starting from the frenum incision up to the height of the canines. The flap was carefully divulsed with Goldman Fox scissors and also a curved hemostat, separating the external epithelium from the muscle bundle mucosa, on both sides, at the height of the lateral incisors and canines. With an absorbable suture thread, the elevator muscle of upper lip and wing of nose was pulled downwards, repositioning its bundle nearer the highest portion of the keratinized gingiva. Simple sutures were made, as many as necessary, in order to contain the pulled muscle in this position. The procedure ended up with a continuous suture in the labial frenum and in the horizontal incisions with the use of a 4-0 silk suture thread. The external stitches should be removed in 10-15 days' time [Figure 11].
The esthetics of the smile showed an improvement at just 13 days post-surgery. This esthetic result remained for a 12-month follow-up [Figure 12].
|Figure 11: After 12 months of post-operative control. The patient's lip was repositioned closer to the teeth. It was brought down to show less gingiva|
Click here to view
|Figure 12: View profile after 12 months of post-operative control. The patient's lip was still closer to the teeth. She can smile with confidence|
Click here to view
| Discussion|| |
The present study demonstrated a new surgical technique with the combination of GR + the traction and containment surgery of the EMULWN. The objective was to reduce the shortening of the upper lip and, therefore, the lowering of the smile line toward a more esthetic height. Through a simple ambulatory procedure, under local anesthesia, excellent results were achieved.
As a result of the socio-economic development, the expectations of patients searching for esthetic treatments have undoubtedly become a challenging goal, especially because such expectations are often created from famous people's esthetic standards. Esthetic principles do not only follow dental parameters but also gingival parameters, and the ideal result is the integration of these factors with the person's face and smile. 
It is important to assess the patients' expectation and understanding of the possible therapeutic solutions as the result of such a treatment plan may not meet their expectation.
In cases of a high or gummy smile, some cosmetic procedures are available and began to be studied in patients with facial paralysis since 1973. The technique described confronts existing techniques such as silicon implants on the bottom of the vestibule at the base of the anterior nasal spine, the infiltration of the botulinum toxin A and the resective procedures in the muscles that are responsible for the upper lip mobility; these techniques also have favorable esthetic results. ,
More recently, a lip repositioning surgery technique aimed to treat the excessive gingival display, removing a strip of outlined mucosa by a superficial split thickness dissection, leaving the connective tissue exposed. This procedure obtained 80% average reduction in gingival display considering only 6 months of follow-up.  In the present study, the esthetic result remained for a 12-month follow-up. Also, the elevator muscle of the upper lip and wing of nose is pulled downwards, repositioning its bundle nearer the highest portion of the keratinized gingiva, avoiding shortening of the vermillion length and mucocele formation.
As the nasolabial musculature greatly influences the harmony and the smile esthetics, some authors, who have been researching it, reported the connection between the nasal septum muscle and the excessive upper lip lifting, operating on this muscle through a plastic surgery technique of containment, resulting in a visible reduction in the gummy smile.  The technique reported in this article demonstrates that the containment of a muscle bilaterally is more efficient than the simple containment of the septum nasal depressor muscle, which is located in the center of the upper lip, resulting in better upper lip lowering. Furthermore, the containment of the muscle can be carried out on just one side, correcting the cases of asymmetrical upper lip, when a patient lifts one side of the upper lip more than the other side while smiling.
The authors also agree with Ishida et al.  that once the myotomy allows the muscle to reunite, the repositioning of the upper lip in a lower situation turns this muscle into a longer one. One of the objectives of this approach is to maintain the muscular action, as opposed to the injection of botulinum toxin type A. When the botulinum toxin is used, the septum nasal depressor muscle is paralyzed; however, this technique has its drawbacks such as limited time of action and an undesired muscular blocking that can possibly cause unaesthetic effects.  The surgical technique presented here may have a more traumatic post-operative period, but the result of it is undoubtedly more durable and esthetic. This specific case clearly showed satisfactory esthetic results, which, besides lowering the upper lip, provided the containment of it, preventing its eversion and keeping its original width when the patient smiled.
The present study proposed to demonstrate a new surgical technique with the combination of GR + the traction and containment surgery of the EMULWN.
It appears that the treatment modality (myotomy) proposed by Ishida et al.  provides similar benefits in terms of gingival display reduction. However, the surgery of rhinoplasties is a much more aggressive approach with irreversible outcomes and greater potential post-operative morbidity, such as paresthesia. , Also, dentists can easily perform the technique presented here with an intraoral access.
The present study aimed to reduce the shortening of the upper lip and, therefore, the lowering of the smile line toward a more esthetic height. Through a simple ambulatory procedure, under local anesthesia, excellent results were achieved.
Regardless of the fact that gummy smile has many causes, this technique represents another therapeutic option in order for patients to obtain a more harmonious and natural smile. However, the patient needs follow-up for some years so that any risk of recurrence can be assessed, especially in cases of upper lip hyperactivity. Thus, the containment surgery of the EMULWN may prove to be a successful esthetic alternative.
The esthetics is part of the current dentistry; therefore, it is crucial to work in full knowledge of the biological principles that guide it in order to harmonize face and smile as well as maintaining periodontal health through the control of biofilm and the attention to a supportive periodontal therapy.
The containment surgery of the muscle of upper lip and wing of nose should be considered as a possible treatment for gummy smile, and when this treatment is used in association with GR and other restorative treatments, the outcome is excellence in smile esthetics. It is necessary, however, to carry out a long-term follow-up of these cases in order to establish the effectiveness of this treatment in maintaining the height of the smile line for a long time.
| References|| |
|1.||Garber DA, Salama MA. The aesthetic smile: Diagnosis and treatment. Periodontol 2000 1996;11:18-28.1. |
|2.||Kokich VO Jr., Kiyak HA, Shapiro PA. Comparing the perception of dentists and laypeople to altered dental esthetics. J Esthet Dent 1999;11:311-24. |
|3.||Levine RA, McGuire M. The diagnosis and treatment of the gummy smile. Compend Contin Educ Dent 1997;18:757-62. |
|4.||Wennström JL, Zucchelli G, Pini Prato GP. Mucogingival Therapy - Periodontal Plastic Surgery. In: Clinical Periodontology and Implant Dentistry, 5 th ed. Oxford: Blackwell Munksgaard; 2008. p. 955-1028. |
|5.||Dong JK, Jin TH, Cho HW, Oh SC. The esthetics of the smile: A review of some recent studies. Int J Prosthodont 1999;12:9-19. |
|6.||Seixas MR, Costa-Pinto RA, de araújo TM. Checklist of esthetic features to consider in diagnosing and treating excessive gingival display (gummy smile). Dental Press J Orthod 2011;16:131-57. |
|7.||Rubin LR, Mishriki Y, Lee G. Anatomy of the nasolabial fold: The keystone of the smiling mechanism. Plast Reconstr Surg 1989;83:1-10. |
|8.||Reddy MS. Achieving gingival esthetics. J Am Dent Assoc 2003;134:295-304. |
|9.||Rubinstein AM, Kostianovsky AS. Cirugia estetica de la malformacion de la sonrisa. Prensa Med Argent 1973;60:952-4. |
|10.||Polo M. Botulinum toxin type A (Botox) for the neuromuscular correction of excessive gingival display on smiling (gummy smile). Am J Orthod Dentofacial Orthop 2008;133:195-203. |
|11.||Silva CO, Ribeiro-Junior NV, Campos TV, Rodrigues JG, Tatakis DN. Excessive gingival display: Treatment by a modified lip repositioning technique. J Clin Periodontol 2013;40:260-5. |
|12.||Pessoa TJ, Freitas RS, Lida AC, Beck PT. Liberação do músculo depressor do septo nasal para tratamento do sorriso gengival. Implant News 2010;7:777-83. |
|13.||Ishida LH, Ishida LC, Ishida J, Grynglas J, Alonso N, Ferreira MC. Myotomy of the levator labii superioris muscle and lip repositioning: A combined approach for the correction of gummy smile. Plast Reconstr Surg 2010;126:1014-9. |
|14.||Miskinyar SA. A new method for correcting a gummy smile. Plast Reconstr Surg 1983;72:397-400. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12]