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 Table of Contents  
Year : 2019  |  Volume : 4  |  Issue : 1  |  Page : 21-24

LIP repositioning surgery and its sequelae in the treatment of a gummy smile: A case report

Department of Periodontics and Community Dental Sciences, College of Dentistry, King Khalid University

Date of Web Publication13-Aug-2020

Correspondence Address:
Saad M Alqahtani
Department of Periodontics and Community Dental Sciences, College of Dentistry, King Khalid University, Abha-61471

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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1658-743X.292031

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Excessive gingival display, also known as “gummy smile” has several etiologies. A gummy smile is a drawback for the esthetics and social behavior of various patients. Lip repositioning surgery confers predictable results. However, lip repositioning surgery is indicated in patients with a hyperactive upper lip, while gummy smile owing to altered passive tooth eruption and vertical maxillary excess need to be addressed with crown lengthening and orthognathic surgeries, respectively. Lip repositioning surgery is an uncomplicated procedure, which reduces the muscular pull on the upper lip to achieve minimal display of dento-gingival unit while smiling. Nonetheless, few authors question the relapse of the lip position. This report describes a case showing satisfactory results with lip repositioning surgery and after 1 year follow-up shows a nonsignificant relapse in the position of the upper lip. Hence, lip repositioning surgery is a safe and predictable approach for gummy smiles with negligible relapse.

Keywords: Gummy smile, Excessive gingival display, Lip repositioning.

How to cite this article:
Alqahtani SM. LIP repositioning surgery and its sequelae in the treatment of a gummy smile: A case report. King Khalid Univ J Health Scii 2019;4:21-4

How to cite this URL:
Alqahtani SM. LIP repositioning surgery and its sequelae in the treatment of a gummy smile: A case report. King Khalid Univ J Health Scii [serial online] 2019 [cited 2021 Jan 25];4:21-4. Available from: https://www.kkujhs.org/text.asp?2019/4/1/21/292031

  Introduction Top

Harmony among gum, teeth and lips is necessary in order to attain an esthetic smile.[1] Excessive gingival display (EGD), also called “gummy smile,” is a disproportionate display of gingiva (≥ 4 mm) when the patient smiles, is an undesirable, unesthetic, and awkward component in smile esthetics.[2] The gingiva- to -tooth ratio is an indispensable factor in smile esthetics, and a defect in the same can cause a gummy Smile.[3],[4]

Several etiologies have been proposed for EGD: first, failure of the apical migration of gingiva due to delayed eruption of teeth; second, coronal migration of the gingiva due to compensatory eruption of teeth; third, incompetent lips due to vertical maxillary excess; and last, retraction of the muscle elevating the upper lip and movement of upper lip when the patient smiles (lip hypermobility).[5]

Lip position can be assessed with the “lip line”. Lip line is the distance between the upper lip border and the inter-dental or marginal gingiva and is classified as low, average, high, and very high smile linebased on the proportion of visibility of the inter-dental and marginal gingivae.[3]Orthognathic or lip repositioning surgeries can effectively treat a gummy smile. Although orthognathic surgery is indicated in patients with skeletal deformities, hospitalization and patient morbidity are some disadvantages.[5],[6]

Rubinstein AM and Kostianovsky AS (1973) first described the lip repositioning surgery in the literature of plastic surgeries.[7] Subsequently, the procedure was widely used for patients with lip hypermobility after the publication of several case reports.[8],[9] Currently, after modifications, the lip reposition surgery involves surgical correction of muscles of the lip which restricts the muscular pull and corrects the EGD.[8] However, severing the musculature was not proposed in the initial lip repositioning surgery by Rubinstein AD. Lip repositioning surgery is contraindicated in attached gingiva of inadequate width at the anterior region of the maxilla and in excessive skeletal discrepancy. As stated above, a gummy smile due to vertical maxillary excess can be effectively treated with orthognathic surgery.[8] This case report presents the results of lip repositioning periodontal plastic surgery.

  Case Report Top

A 26-year-old woman with no systemic diseases reported to the Department of Periodontics, King Khalid University, Abha, Kingdom of Saudi Arabia with the chief complaint of gummy smile. On examination, the dentogingival unit was found to be 68 mm, extending from the maxillary right to left 2nd premolars (tooth numbers 15 and 25, respectively) [Figure 1]a and [Figure 1]b. No relevant medical history was reported. After a thorough examination and elimination of other etiologies, the reason for the gummy smile was identified as the severe contraction of the elevator muscles of the upper lip.

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Lip reposition surgery was proposed as the treatment of choice. The patient was explained the advantages and complications associated with the surgery. Informed consent was obtained from patient, and ethical clearance (SRC/ETH/2018-19/034) was obtained from the Scientific Research Committee, College of Dentistry, King Khalid University. A 10% povidone-iodine solution was used for skin surface preparation, and 2% lignocaine with 1:80000 adrenaline was administered for anesthesia of the vestibular mucosa from the upper right to left 2nd premolar.

A pre-surgical outline was made using a sterile pencil, and Bard-Parker® (no. 15) blade was used to make incisions along the outline [Figure 2]. Two parallel incisions (partial thickness), 10-12 mm apart, were made. The first incision was along the mucogingival junction, extending between the 2nd premolars on both sides, and the second incision was apical and parallel to the first incision [Figure 3]. The two parallel incisions were connected at each end [Figure 4]. A partial thickness flap was elevated, and the mucosal band was excised, leaving the underlying connective tissue. [Figure 5] shows the excised tissue.
Figure 2: First incisoin in the vestibular mucosa

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Figure 3: Second incision, 12 mm apical to the first incision

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Figure 4: Tissue after excision

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Figure 5: Excised tissue flap

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A pressure pack was applied for attaining hemostasis, after which the incised margins were approximated and stabilized with Vicryl 4-0 sutures. The suturing was started from the midline and extended on both the sides. The interrupted suturing technique was followed, with 1 mm of inter-suture distance. Thorough postoperative instructions were given to the patient. The patient was advised to limit upper lip movements while talking, eating, and smiling and to apply an ice pack on the upper lip intermittently for a few hours. Nonsteroidal anti-inflammatory medications as analgesics (oral ibuprofen 400 mg, 3 times a day for 3 days) and antibiotics (oral amoxicillin 500 mg, 3 times a day for 7 days) were prescribed. The patient was followed-up every week up to 1 month and after 1 year. [Figure 6] and [Figure 7] show the follow-up results.
Figure 6: One month follow-up

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Figure 7: One year follow-up

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No major postoperative complications occurred. Mild postoperative pain was reported, without swelling, postoperative bleeding, or scar formation along the incision line. The patient was recalled every 3 months for a year to check for relapse. The visibility of the dentogingival unit had reduced from 8 mm to 4 mm

  Discussion Top

Correcting EGD to achieve smile esthetics has become an integral part of periodontal plastic surgeries. Smile esthetics plays a significant role in social wellbeing. Improvement of the esthetics of teeth and gingiva has been well-researched, and the correction of circumoral anatomical structures is considered to achieve an esthetic smile. The lower edge of the upper lip limits the appearance of the dentogingival apparatus. A greater apical mobility of the upper lip upon smiling may lead to a gummy smile.

This case report showed the results of lip repositioning surgery in a patient with hypermobile upper lip and a gummy smile. We followed-up the patient for a year to check for relapse, and almost no relapse in the lip position was observed. 9. Ribeiro-Júnior NV (2013)[9] and Jacobs et al. (2013)[10] followed-up the patients for 6 months, and did not notice any significant relapse either. Neither immediate nor delayed complications occurred. Minimal postoperative complications associated with lip repositioning surgery were evident.[11] However, the development of mucocele and scars was observed in some cases.[8] Although minimal gingival display is proposed to be elegant and esthetic,[12],[13] esthetic perceptions are subjective and vary with the social environment, culture, and personal experiences.[14] The gingival display of 1-3 mm is considered attractive.[1516] In this case report, gingival display while smiling was reduced from 8 mm to approximately 4.5 mm after 1 year follow-up. Similarly, a reduction of 4 mm in gingival display was observed in previous case reports[717] and series.[18] Furthermore, Jacobs et al. (2013) presented a case series with more than 6-mm mean reduction of gingival display.[10]

  Conclusions Top

Lip repositioning surgery seems to be promising in the treatment of EGD due to hypermobility of the upper lip. However, relapse after a certain period is expected. Furthermore, identifying the etiology of EGD and patient selection for the procedure are crucial for the success of lip repositioning surgery.

Conflicts of Interest: None

Acknowledgements: None

  References Top

Garber DA, Salama MA. The aesthetic smile: diagnosis and treatment. Periodontol 2000. 1996;11:18–28.  Back to cited text no. 1
Kokich VO, Kiyak HA, Shapiro PA. Comparing the perception of dentists and lay people to altered dental esthetics. J Esthet Dent. 1999;11:311–24.  Back to cited text no. 2
Sheth T, Shah S, Shah M, Shah E. Lip reposition surgery: A new call in periodontics. ContempClin Dent. 2013;4:378–81.  Back to cited text no. 3
Dayakar MM, Gupta S, Shivananda H. Lip repositioning: An alternative cosmetic treatment for gummy smile. J Indian SocPeriodontol. 2014;18:520–3.  Back to cited text no. 4
Storrer CLM, Valverde FKB, 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 SocPeriodontol. 2014;18:656–60.  Back to cited text no. 5
Khechoyan DY. Orthognathic Surgery: General Considerations. SeminPlast Surg. 2013;27:133-6.  Back to cited text no. 6
Rubinstein AM, Kostianovsky AS. Cosmetic surgery for the malformation of the laugh: Original technique in Spanish. Prensa Med Argent. 1973;60:952.  Back to cited text no. 7
Rosenblatt A, Simon Z. Lip repositioning for reduction of excessive gingival display: a clinical report. Int J Periodontics Restorative Dent. 2006;26:433–7.  Back to cited text no. 8
Ribeiro-Junior NV, Campos TV de S, Rodrigues JG, Martins TMA, Silva CO. Treatment of excessive gingival display using a modified lip repositioning technique. Int J Periodontics Restorative Dent. 2013;33:309–14.  Back to cited text no. 9
Jacobs PJ, Jacobs BP. Lip repositioning with reversible trial for the management of excessive gingival display: a case series. Int J Periodontics Restorative Dent. 2013;33:169-75.  Back to cited text no. 10
Kamer FM. “How I do it”—plastic surgery. Practical suggestions on facial plastic surgery. Smile surgery. Laryngoscope. 1979;89:1528–32.  Back to cited text no. 11
Arnett GW, Bergman RT. Facial keys to orthodontic diagnosis and treatment planning. Part I. Am J OrthodDentofacialOrthop. 1993;103:299-312.  Back to cited text no. 12
Fowler P. Orthodontics and orthognathic surgery in the combined treatment of an excessively “gummy smile.” N Z Dent J. 1999;95:53-04.  Back to cited text no. 13
Oumeish OY. The cultural and philosophical concepts of cosmetics in beauty and art through the medical history of mankind. ClinDermatol. 2001;19:375-86.  Back to cited text no. 14
Geron S, Atalia W. Influence of sex on the perception of oral and smile esthetics with different gingival display and incisal plane inclination. Angle Orthod. 2005;75:778-84.  Back to cited text no. 15
Kokich VO, Kokich VG, Kiyak HA. Perceptions of dental professionals and laypersons to altered dental esthetics: asymmetric and symmetric situations. Am J OrthodDentofacialOrthop. 2006;130:141-51.  Back to cited text no. 16
Humayun N, Kolhatkar S, Souiyas J, Bhola M. Mucosal coronally positioned flap for the management of excessive gingival display in the presence of hypermobility of the upper lip and vertical maxillary excess: a case report. J Periodontol. 2010;81:1858-63.  Back to cited text no. 17
Silva MAB da, Vitti RP, Consani S, Sinhoreti MAC, Mesquita MF, Consani RLX. Linear dimensional change, compressive strength and detail reproduction in type IV dental stone dried at room temperature and in a microwave oven. J Appl Oral Sci. 2012;20:588-93.  Back to cited text no. 18


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]


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