JICDRO is a UGC approved journal (Journal no. 63927)

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Year : 2019  |  Volume : 11  |  Issue : 1  |  Page : 43-48

An Integrated modified lip repositioning using bioresorbable collagen membrane: A long-lasting auxiliary treatment approach for gummy smile

Department of Periodontics and Oral Implantology, Ahmedabad Dental College and Hospital, Ahmadabad, Gujarat, India

Date of Web Publication24-Jun-2019

Correspondence Address:
Dr. Dhar Devang Thaker
H/3, Sugam Apartment, Near Vasna Bus-Stop, Vasna, Ahmadabad - 380 007, Gujarat
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jicdro.jicdro_15_18

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Excessive gingival display is one of the major causes of patient embarrassment. An imbalance in the gingiva–tooth ratio results in the dominance of gingival appearance often referred to as “gummy smile.” A normal gingival display between the inferior border of the upper lip and the gingival margin of the central incisors during a normal smile is 1–2 mm. In contrast, an excessive gingivae-to-lip distance of 4 mm or more is classified as an unattractive. The objective of lip repositioning surgery is surgical correction of unesthetic gummy smile by limiting the retraction of the elevator smile muscles resulting in a narrow vestibule and restricted muscle pull, thereby reducing gingival display during smiling. This article presents a case of a gummy smile in which esthetic correction was achieved through periodontal plastic surgical procedure wherein 10–12 mm of partial-thickness flap was dissected apical to mucogingival junction sparing the midline maxillary labial frenum and placement of bioresorbable collagen membrane on excised area followed by approximation of flaps. This case with score 3 smile line was treated by lip repositioning technique with successful clinical outcome and enormous patient satisfaction. This technique holds importance as perioesthetics has become an integral part of periodontal treatment plan with the periodontist playing akey role to combat the patient's embarrassment.

Keywords: Bioresorbable collagen membrane, esthetics, gummy smile, lip-repositioning

How to cite this article:
Thaker DD, Shah S, Shah RS, Kikani A. An Integrated modified lip repositioning using bioresorbable collagen membrane: A long-lasting auxiliary treatment approach for gummy smile. J Int Clin Dent Res Organ 2019;11:43-8

How to cite this URL:
Thaker DD, Shah S, Shah RS, Kikani A. An Integrated modified lip repositioning using bioresorbable collagen membrane: A long-lasting auxiliary treatment approach for gummy smile. J Int Clin Dent Res Organ [serial online] 2019 [cited 2020 Feb 23];11:43-8. Available from: http://www.jicdro.org/text.asp?2019/11/1/43/260946

   Introduction Top

Currently, a growing concern for beauty and physical appearance has motivated the clinician to evaluate the essentials of patient's smile and consider the dynamic relationship between the dentition, gingivae, and lips while smiling, with greater demands regarding esthetic dentistry.[1] Management of gingival and skeletal deformities is most challenging and of esthetic concern to the patient in day-to-day life. With the advent of modern cosmetic dentistry, new materials, and techniques, it is possible to achieve the desired esthetic outcome. A beautiful smile comprises three components, i.e., lip, teeth, and gingiva all of which should be in harmony with each other.[2]

A pleasant smile usually depends on the extent of gingival exposure, the upper and lower lip line, gingival health, correct anatomy, and teeth proportion. The normal gingival display is between inferior border of upper lip and gingival margin of anterior central incisors during smile, which accounts for the entire crown of maxillary central incisors and 1 mm of pink attached gingiva.[3]

An exposed gingiva of 2–3 mm is cosmetically acceptable; however, more than this is considered to be unattractive and commonly known as “gummy smile.”[4]

The lip line, assessed when the patient is in full smile, can be classified as the “smile line” upper lip-interdental and marginal gingiva [Table 1].
Table 1: Classification of smile line

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Various surgical modalities have been documented to eliminate the excessive gingival display including gingivectomy, flap surgery with osseous contouring, apically displaced flaps, myectomies, and orthodontic therapy.[5]

Excessive gingival display has four possible etiologies.

The cause may be related to one or more factors relating to gums themselves, the teeth, or even the lip or jaw. Each of these areas will require different approach to solve the problem.

First, it may be a result of delayed eruption in which the gingiva fails to complete the apical migration over the maxillary teeth to a portion that is 1 mm coronal to the cementoenamel junction.[6] In such cases, restoring the normal dentogingival relationships can be achieved with an esthetic crown lengthening.[7] This procedure involves moving the gingival margins apically through soft and possibly hard tissue resection.

Second possible cause is compensatory eruption of maxillary teeth due to natural variations in the tooth eruption process that can result in shorter than normal teeth and gumminess of the smile. This happens in case of attrition of the teeth. To compensate for the wear and maintain a functional bite, the teeth actually begin to move (or erupt) very slowly outward from the gum. This makes the smile appear gummier. In such cases, orthodontic treatment can be used to move the affected teeth back up into correct position.[8] The length of the teeth can be corrected by (crowning) them or covering them with thin porcelain veneers.

The third possibility related to jaws is vertical maxillary excess in which there is an enlarged vertical dimension of the mid-face and “incompetent” lips. Treatment involves orthognathic surgery to restore normal interjaw relationships and to reduce the gingival display;[9] this procedure involves hospitalization, but it can achieve dramatic results.

Finally, the cause may be related to lips, may be short or hyperactive upper lip where, when the patient smiles, the upper lip moves in an apical direction and exposes the dentition and excessive gingiva. On average, the upper lip moves 6–8 mm from its normal resting position to a full smile.

Gummy smile due to hyperactive upper lip can be corrected using various techniques, with highly variable outcome:

  • Botulinum toxin (Polo 2005, Mazzuco and Hexsel 2010)
  • Lip elongation associated with rhinoplasty (Ezquerra et al. 1999)
  • Detachment of lip muscles (Litton and Fournier 1979)
  • Myotomy and partial removal (Miskinyar1983, Ishida et al. 2010)
  • Lip repositioning (Rubinstein and Kostianovsky 1973,[10] Rosenblatt and Simon 2006, Simon et al. 2007).

The objective of lip repositioning is to minimize the gingival display by limiting the retraction of the elevator smile muscles (e.g., zygomaticus minor, levator anguli oris, orbicularis oris, and levator labii superioris) which is achieved by removing a strip of mucosa from the maxillary buccal vestibule and creating a partial thickness flap between the mucogingival junction and the upper lip musculature. The lip mucosa is then sutured to the mucogingival line, resulting in a narrower vestibule and restricted muscle pull, thereby reducing gingival display during smiling.

This technique was originally described as cosmetic surgery by Rubinstein and Kostianovsky[10] for the correction of a gummy smile caused by a hypermobile lip. The literature includes only isolated case reports of lip repositioning surgery (Rosenblatt and Simon 2006, Simon et al. 2007, and Humayun et al. 2010). This surgical procedure was designed to be shorter, less aggressive, and to have fewer postoperative complications compared to orthognathic surgery. Lip repositioning is the reverse of vestibular extension procedure.

The modification of the original Rubinstein and Kostianovsky (1973) technique, wherein the midline maxillary labial frenum was not excised, was introduced to facilitate maintaining the position of the labial midline and to reduce the morbidity associated with the procedure.

Simultaneously, before the closure, the placement of bioresorbable Type I collagen membrane Periocol® on surgical site was carried out to reduce the relapse duration. Collagen is biocompatible and has an hemostatic function (aggregates platelets) facilitating early clot formation and wound stabilization. It also has a chemotactic function for fibroblasts, which may aid in cellular migration to promote primary wound closure. It provides a collagenous scaffold for tissue repair as well as augmenting the gingival tissue thickness. Being semipermeable, it permits gaseous exchange and nutrient passage to ensure better flap healing. Type I collagen membrane Periocol® is easy to manipulate and was well tolerated by the patients with no negative response as regard to its postoperative healing as well as signs and symptoms of any other allergic manifestation. These findings are also supported by Wang et al. (1994).

Collagen membrane Periocol® mechanically prevents the epithelial cell migration[3] during the initial stages of healing, which may allow the repopulation of the treated surface by connective tissue cells, leading to reattachment of excised muscle fibers. The cross-linked structure slows the degradation rate, so that the membrane stays for a sufficient period of time underneath the flap and prevents the apical migration of epithelial cells in later stages of healing, thus discouraging the formation of epithelial attachment and favoring development of connective tissue attachment.

The article presented here with a similar case of gummy smile, and hyperactive upper lip in which the “modified lip repositioning” to reduce gingival display.

   Methods Top

A 37-year-old woman reported to the Department of Periodontics and Oral Implantology, Ahmedabad Dental College and Hospital, with the chief complaint of excessive gum display during smile. The patient's medical history was not significant with any contraindication for surgery. Clinical examination revealed a good amount of attached gingiva and the patient was diagnosed with a case of “gummy smile.” However, when the patient was asked to smile, her teeth were visible from the maxillary right first premolar to maxillary left first premolar with 10-mm gingival display and “score 3” smile line because of hyperactive upper lip while smiling [Figure 1]. Maxillary anterior teeth had normal crown height and width/length ratio. Lip repositioning as a treatment option was discussed with the patient, and written informed consent was obtained before the procedure.
Figure 1: preoperative 10-mm gummy smile

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Adequate local infiltration (lignocaine 2% with epinephrine 1:80,000) was administered in the buccal vestibule between the first maxillary premolars. The incision outline was marked with an indelible marker on the dried tissue using mucogingival junction and base of the vestibule as reference lines connected at mesial line angles of the right and left maxillary premolars to create two elliptical outline on either side of the midline maxillary frenal attachment by preserving it as shown in [Figure 2]. A partial thickness incision was made between these two lines, and epithelial band approximately 10–12 mm wide was excised leaving underlying connective tissue exposed [Figure 3], [Figure 4], [Figure 5]. Care was taken to avoid damage to any minor salivary glands in the submucosa. Placement of Periocol® on excised surgical site was done [Figure 6].
Figure 2: incision marking

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Figure 3: two elliptical incisions on either side of the frenum

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Figure 4: excised tissues

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Figure 5: preserved frenal attachment

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Figure 6: placement of bioresorbable Type-I collagen membrane Periocol®

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The mucosal flap was then advanced and sutured with interrupted stabilization sutures along the borders of the incision mucogingival junction in such a way that Periocol® membrane is enveloped within the raised flap using 5-0 Vicryl sutures [Figure 7]. No periodontal dressing was placed. Postoperative instructions included soft diet, limited facial movements, no brushing around the surgical site for 7 days, and placing ice packs over the upper lip. The patient was instructed to rinse gently with 0.2% chlorhexidine gluconate twice daily for 2 weeks. Postoperative amoxicillin 500 mg three times a day (TDS) and ibuprofen 400 mg twice a day (BD) for 5 days were prescribed.
Figure 7: suturing done with Vicryl 5-0

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   Results Top

Uneventful postoperative healing occurred and the patient reported minimal postoperative bruising, or extraoral swelling, and slight tension when smiling 1 week after surgery. It was seen later that the suture area healed in the form of a scar, which was not apparent when the patient smiled because it was concealed in the upper lip. Patient satisfaction was recorded after 1 week of the procedure on a scale of 10 with score 1 for extremely unsatisfactory to 10 for a highly satisfactory score. The patient was highly satisfied with the treatment carried out and rated a score of 9 on a scale of 10. The gingival display measured after 1 week was <1 mm with only interdental papilla being seen after forced smiling, giving an esthetically pleasing appearance [Figure 8].
Figure 8: gingival display < 1mm

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Sutures were removed after 2 weeks [Figure 9], and a significant reduction in the amount of gingival display at the 6-month follow-up visit was seen, which was stable along with competent lips [Figure 10].
Figure 9: suture removed after 15 days

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Figure 10: six months follow-up

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   Discussion Top

Lip repositioning was first described in the literature of plastic surgery in 1973 by Rubinstein and Kostianovsky,[10] which was advocated again by Litton and Fournier for the correction of excessive gingival display in the presence of short upper lip.

Excessive gingival display, referred to as a “gummy smile,” can be a source of embarrassment for some patients. Delayed eruption and tooth malpositioning can be predictably treated with respective surgery and orthodontics; orthognathic surgery can also be performed. The case presented here entails surgical technique to reduce gingival display.

In most patients, the lower edge of the upper lip assumes a “gum-wing” profile, which limits the amount of gingiva that is exposed when a person smiles. Patients who have a high lip line expose a broad zone of gingival tissue and may often express concern about their “gummy smile.”

Therefore, the earlier-mentioned procedure is safe with minimal side effects as the patient did not complain of any postoperative complication.

By contrast, the use of botulinum toxin represents a simple, fast, and effective method for the esthetic correction of a gummy smile; however, the results obtained by this nonsurgical approach remain questionable.

Silva et al. in 2012 reported successful management of excessive gingival display using a modified lip repositioning technique. Treatment comprised the removal of two strips of mucosa, bilaterally to the maxillary labial frenum, and coronal repositioning of the new mucosal margin. Most of the subjects showed satisfied results in their smile after the surgery. In this case, additional placement of bioresorbable collagen membrane over underlying connective tissue was carried out to prevent reattachment of fibers in the same surgical site and thereby preventing the relapse ratio.

Ideally, the smile should expose minimal gingiva, the gingival contour should be symmetrical, and in harmony with the upper lip, the anterior segment should be in harmony with the posterior segment, and the teeth should have a normal anatomy.[2] The limitations of this surgical technique include patients with inadequate attached gingiva and patients with severe skeletal deformities and severe vertical maxillary excess that has to be treated with orthognathic surgeries.

   Conclusion Top

To conclude, surgical lip repositioning is an effective procedure to reduce gingival display by positioning the upper lip in a more coronal direction. This technique holds promise as an alternative treatment modality in esthetic rehabilitation.

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Conflicts of interest

There are no conflicts of interest.

   References Top

Jacobson A. Psychological aspects of dentofacial esthetics and orthognathic surgery. Angle Orthodontist 1983;54:18-35.  Back to cited text no. 1
Simson Z, Rosenblatt A, Dorfman W. Eliminating a gummy smile with surgical lip repositioning. J Cosmet Dent 2007;23:100-8.  Back to cited text no. 2
Mantovani MB, Souza EC, Marson FC, Corrêa GO, Progiante PS, Silva CO, et al. Use of modified lip repositioning technique associated with esthetic crown lengthening for treatment of excessive gingival display: A case report of multiple etiologies. J Indian Soc Periodontol 2016;20:82-7.  Back to cited text no. 3
[PUBMED]  [Full text]  
Silberberg N, Goldstein M, Smidt A. Excessive gingival display – Etiology, diagnosis, and treatment modalities. Quintessence Int 2009;40:809-18.  Back to cited text no. 4
Gupta KK, Srivastava A, Singhal R, Srivastava S. An innovative cosmetic technique called lip repositioning. J Indian Soc Periodontol 2010;14:266-9.  Back to cited text no. 5
[PUBMED]  [Full text]  
Maynard JG Jr., Wilson RD. Physiologic dimensions of the periodontium significant to the restorative dentist. J Periodontol 1979;50:170-4.  Back to cited text no. 6
Lee EA. Aesthetic crown lengthening: Classification, biologic rationale, and treatment planning considerations. Pract Proced Aesthet Dent 2004;16:769-78.  Back to cited text no. 7
Kokich VG. Esthetics: The orthodontic-periodontic restorative connection. Semin Orthod 1996;2:21-30.  Back to cited text no. 8
Ezquerra F, Berrazueta MJ, Ruiz-Capillas A, Arregui JS. New approach to the gummy smile. Plast Reconstr Surg 1999;104:1143-50.  Back to cited text no. 9
Rubinstein AM, Kostianovsky AS. Cosmetic surgery for the malformation of the laugh: Original technique in Spanish. Pren Med Argent 1973;60:952.  Back to cited text no. 10


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]

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