|Year : 2015 | Volume
| Issue : 2 | Page : 151-154
Management of excessive gingival display: Lip repositioning technique
Upasana Sthapak, Sneha Kataria, Kabbur Thippanna Chandrashekar, Rohit Mishra, Vandana Dubey Tripathi
Department of Periodontology and Implantology, Hitkarini Dental College and Hospital, Jabalpur, Madhya Pradesh, India
|Date of Web Publication||3-Sep-2015|
Dr. Kabbur Thippanna Chandrashekar
Dean, Professor and Head, Department of Periodontology and Implantology, Hitkarini Dental College and Hospital, Jabalpur - 482 005, Madya Pradesh
Source of Support: None, Conflict of Interest: None
| Abstract|| |
The lips form the frame of a smile and define the esthetic zone. Excessive gingival display during smile is often referred to as "gummy smile". A successful management of excessive gingival display with lip repositioning procedure has shown excellent results. The procedure involves removing a strip of partial thickness mucosa from maxillary vestibule, then suturing it back to the lip mucosa at the level of mucogingival junction. This technique results in restricted muscle pull and a narrow vestibule, thereby reducing the gingival display. In this case gummy smile was treated by modification of Rubinstein and Kostianovsky's surgical lip repositioning technique which resulted in a harmonious smile.
Keywords: Elevator muscles, esthetic, gummy smile, upper lip
|How to cite this article:|
Sthapak U, Kataria S, Chandrashekar KT, Mishra R, Tripathi VD. Management of excessive gingival display: Lip repositioning technique. J Int Clin Dent Res Organ 2015;7:151-4
|How to cite this URL:|
Sthapak U, Kataria S, Chandrashekar KT, Mishra R, Tripathi VD. Management of excessive gingival display: Lip repositioning technique. J Int Clin Dent Res Organ [serial online] 2015 [cited 2019 Sep 21];7:151-4. Available from: http://www.jicdro.org/text.asp?2015/7/2/151/164397
| Introduction|| |
An individual's smile contributes immensely to the first impression and expresses a feeling of joy, sensuality, affection, courtesy or self confidence. A peaceful smile is more than a method of communication, socialization and attraction. The harmony of smile is determined not only by the shape, the position and color of the teeth but also by the gingival tissues. Excessive gingival exposure during smile is referred to as "gummy smile" and is an esthetic concern for most of the patients. It is diagnosed in cases, where gingival appearance is excessive that is, ≥3 mm from gingival margin up to the upper lip line. Excessive gingival appearance might be caused by labial hyperactivity, gingival overgrowth, delayed passive eruption, vertical maxillary excess or a combination of them.
Labial hyperactivity is characterized by marked contraction of the upper lip elevator muscles that is zygomaticus minor, levator anguli, orbicularis oris and levator labii superioris. A classification for altered passive eruption was suggested by Coslet et al., 1977 [Table 1]. 
Vertical maxillary excess is a condition that involves an overgrowth of the maxilla in the vertical dimension and many times it appears as a long face syndrome [Table 2]. 
An ideal esthetic smile presents the following characteristics: Minimal gingival exposure, symmetric display and harmony between the maxillary gingival line and upper lip, healthy gingival tissue filling the entire interproximal spaces, harmony between the anterior and posterior segments, teeth in correct anatomy and proportions, proper color and shade of teeth, lower lip parallel to the incisal edges of the maxillary anterior teeth and to the imaginary line going through the contact points of these teeth. 
The objective of lip repositioning technique described in this case report is to minimize the gingival appearance by limiting the retraction of elevator muscles. In addition, it also preserves the vital labial frenum. The procedure can be performed in esthetically aware patients with lips in coronal position during smiling. However, adequate width of attached gingiva is a pre-requisite to accomplish the satisfactory outcome.
| Review of Literature|| |
Rubinstein & Kostianovsky in 1973, described a procedure where by an elliptical portion of gingiva and buccal mucosa was excised and borders were approximated and sutured together.  Litton & Fournier in 1979, referred to muscle detachment from the bony structures above to bring the lip down.  Miskinyar, in 1983 performed myectomy and partial resection of levator labii superioirs muscles; one or both of the bellies of the muscles were amputated 1.0-2.0 cm at their junction with the orbicularis oris.  Ellenbogen, in 1984 reported that resection of levator labii superioris is short lived, with gummy smile returning within 6 months. He advocated placing a spacer, either nasal cartilage or prosthetic material, between the stumps to prevent the muscles from being reunited and again hyper elevating the lip. 
Polo et al., in 2005 used botulinum toxin in patients with hyperfunctional upper elevator musculature to correct gummy smile. 
| Case Report|| |
A 25-years-old, male patient reported with the chief complaint of gummy smile. On extra-oral examination, face was found to be bilaterally symmetrical with incompetent lips. Intra-orally, gingival display was 7 mm, during smiling, which extended from premolar to premolar [Figure 1]. The treatment planned was to minimize gingival display in his smile surgically as the patient was unwilling for orthodontic treatment.
| Surgical Procedure|| |
The surgical procedure was explained and a written informed consent was taken from the patients.
Forty minutes prior to the operation, 650 mg Ibuprofen was given to the patient to reduce post-surgery pain. Complete extra oral and intraoral mouth disinfection was done with Betadine (5% w/v; RANBAXY, Povidine Iodine solution) followed by infiltration with local anesthesia. A sterile pencil was used to mark the border line of incisions on the mucosa. The incision began horizontally on one side of maxilla from the labial frenum and extended to the premolar. The surgical procedure was initiated, with a partial thickness horizontal incision 1 mm coronal to the mucogingival line from the midline until the premolar region. Two vertical incisions at the extremities of the first incision, extending 10-12 mm apically, were made [Figure 2]. In addition, horizontal incision, parallel to the first, connecting the vertical incisions was made. The partial thickness flap of 4 mm width strip was removed, leaving the connective tissue exposed between mucogingival junction and upper lip musculature. The lip mucosa is then sutured to the mucogingival line resulting in a narrow vestibule and a restricted muscle pull, thereby reducing the gingival display during smiling [Figure 3]. All incisions and mucosal removal were performed using #15 c blades. Continuous interlocking sutures (silk 4-0) were used to stabilize the mucosa to the gingival. The procedure was repeated on the contralateral side, leaving the midline frenum intact [Figure 4].
Postoperative instructions included application of ice pack, a soft food diet during the first week, avoidance of any mechanical trauma to the surgical site, and restriction of lip movement during smiling or talking in the first 2 weeks. Patient was prescribed acetaminophen 650 mg four times per day for 5 days and was recalled after one week for suture removal and was followed up for a period of one month to assess the healing status. The gingival display was reduced to 3 mm post operatively after a follow up period of 3 months. Post operative healing, analyzed 1 week after suture removal was satisfactory [Figure 5] and [Figure 6]. A minor scar line was formed on suture line which remained invisible during smiling.
| Discussion|| |
A common observation in gummy smile cases is the presence of excessive gingival display on anterior teeth, and hyperactive muscles which tensions and displaces the lip to a more coronal position during smiling thus increasing gingival exposure. 
There are two basic types of smiles - the social smile and the enjoyment smile. Each type involves a different anatomic presentation of the elements of the display zone. The social smile, or the smile typically used as a greeting, is a voluntary, unstrained, static facial expression. The lips part due to moderate muscular contraction of the lip elevator muscles, thus along with the teeth, sometimes the gingival scaffold are displayed. The enjoyment smile, elicited by laughter or great pleasure, is involuntary. It results from maximal contraction of the upper and lower lip elevator and depressor muscles, respectively. This causes full expansion of the lips, with maximum anterior tooth display and gingival show.
Smile style is another soft-tissue determinant of the dynamic display zone. There are three styles: The cuspid smile, the complex smile and the Mona Lisa smile. The cuspid or commissure smile is characterized by the action of all the elevators of the upper lip, raising it like a window shade to expose the teeth and gingival scaffold. The complex or full-denture smile is characterized by the action of the elevators of the upper lip and the depressors of the lower lip acting simultaneously, raising the upper lip like a window shade and lowering the lower lip like a window. The Mona Lisa smile is characterized by the action of the zygomaticus major muscles, drawing the outer commissures outward and upward, followed by a gradual elevation of the upper lip. 
However, gummy smile are treated only when the patient is dissatisfied with his/her own appearance. Several techniques for excessive gingival display had been used in cases of hyperactive upper lip, although, with a wide variation in the outcome of the treatment. Detachment of the lip muscles, myectomy and partial muscle removal, lengthening of the lip associated with rhinoplasty, and recently use of botulinum toxin, are the few modalities of treatment frequently considered for the treatment in such cases. 
A decision is to be made on the type of surgery, with or without bone resection.  The treatment modalities recommended for short upper lip and hyperactive upper lip are similar. Plastic reconstructive surgery was the solution in 1970 and 1980 treatment of excessive gingival display.  This lip repositioning procedure is a modification of the original technique of Rubinstein and Kostianovsky, initially used in medical plastic surgery and adapted for use in dentistry.  The modification employed here, the maxillary labial frenum was maintained and two mucosal strips, one at each side of the frenum, were removed. This modification was introduced to maintain the labial midline and reduce postoperative morbidity.
Contraindications of this surgery, is the presence of an inadequate zone of attached gingiva, which can create difficulties in flap design, stabilization and suturing. Others being severe vertical maxillary excess and a thin gingival biotype. Presence of a severe vertical maxillary excess establishes the need for orthodontic treatment or an orthognathic surgery whereas chances of relapse are more with a thin gingival biotype.
Drawbacks of this procedure are the initial discomfort and pain to the patient while biting, smiling and speaking. This can be overcome by gentle handling of the tissues and prescribing analgesics. Asymmetry upon smiling could have been encountered as another important drawback. This was avoided by keeping labial frenum intact at midline during the surgical procedure. Recurrence rate for this procedure is influenced by the presence of the gingival biotype, although in this patient it was thick biotype which reduces the possibility of relapse. The patient is still in follow-up.
| Conclusion|| |
This modified lip repositioning technique to decrease the amount of gingival display has shown to be more conservative method, and provides good esthetic outcomes in 6 months follow up. Furthermore, the results suggest that the technique presented is a useful resource for esthetic improvements in gummy smile patients.
| References|| |
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Rubinstein AM, Kostianovsky AS. Cosmetic Surgery malformation of Smiles. Pren Med Argent 1973;60:952.
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Miskinyar SA. A new method for correcting gummy smile. Plast Reconstr Surg 1983;72:397-400.
Ellenbogen R, Swara N. The improvement of the gummy smile using the implant spacer technique. Ann Plast Surg 1984;12:16-24.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
[Table 1], [Table 2]