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Lip Repositioning to Eliminate the Gummy Smile
Too much gingival display is considered unattractive
Douglas H. Mahn, DDS
Excessive gingival display is a detriment to an esthetic smile. Gingival display of more than 3 mm of gingiva is considered unattractive by many patients.1 Tjian and colleagues found in a study of 450 adults aged 20 to 30 years that 7% of men and 14% of women have a gummy smile.2 Gingival hyperplasia, altered passive eruption, vertical maxillary excess, and upper-lip hypermobility can all result in excessive gingival display when a patient smiles.3,4 Considering the irreversible nature of many dental procedures, choosing the correct treatment is critical in achieving desired outcomes.
Gingivectomies, clinical crown lengthening, and orthognathic surgery have all been used to correct excessive gingival display.5-7 Each treatment modality has its own indications and limitations. In recent years, lip repositioning has become a popular method for decreasing excessive gingival display when the patient smiles.4 Lip repositioning does not change the clinical crown size of the teeth. It can be performed in a dental office setting and does not have the morbidity associated with orthognathic surgery.4,8
This article describes a case in which lip repositioning is used to eliminate excessive gingival display and develop a beautiful smile. The purpose of this article is to discuss lip-repositioning surgery and contrast it with other methods for eliminating excessive gingival display.
A 42-year-old woman presented with a chief complaint of a “gummy smile” (Figure 1). She reported a history of orthodontics. Her maxillary teeth were attractive and within proper proportions. Her periodontium was healthy with a broad zone of attached keratinized gingiva (Figure 2). Approximately 6 mm to 7 mm of gingiva showed between the inferior border of her upper lip and the gingival margins of her maxillary central incisors when she smiled. She was determined to have a hypermobile lip.
Profound local anesthesia was obtained using 2% lidocaine with 1:100,000 epinephrine. Using a #15 Bard-Parker scalpel blade, an epithelial layer of mucosa was removed. The inferior incision line was made in attached keratinized gingiva about 2 mm from the mucogingival junction. The band of mucosal tissue removed was approximately 12 mm to 15 mm wide and extended from tooth Nos. 3 to 14 (Figure 3). The wound margins were sutured together with interrupted 4.0 VICRYL® sutures (Ethicon, Inc.; Patterson Dental Supply, Inc.; www.pattersondental.com). A continuous sling 4.0 VICRYL suture was then placed, engaging the vestibular mucosal tissues, to minimize tension on the wound margins (Figure 4). Immediately after surgery, there was no gingival display when she smiled (Figure 5). The patient was prescribed ibuprofen 600 mg for discomfort and amoxicillin 875 mg twice daily for 10 days and instructed to rinse twice daily with 0.12% chlorhexidine gluconate (Peridex™, Proctor & Gamble; us.pg.com.) for 2 weeks. Gentle toothbrushing was permitted.
At the 2-week postoperative appointment, the remaining sutures were removed. Her smile no longer showed excessive gingival display (Figure 6). Mild swelling of the superior lip was present. The patient reported “mild tightness” in her upper lip when she smiled, but she had no discomfort. The patient was advised to resume normal oral hygiene measures.
At the 6-month reevaluation, the surgical site was found to have healed very well (Figure 7). The patient reported that her lip felt comfortable and “normal.” When smiling, the new upper lip position exposed minimal gingiva. The upper lip also appeared to be less inverted, more full, and more attractive than prior to treatment (Figure 8). The patient reported being very happy with the results of her treatment.
While nonsurgical treatment modalities exist for the correction of a gummy smile, they are not without their own limitations. Botulinum toxin type A (Botox®) has been used in the correction of excessive gingival display. Botox induces weakness of striated muscles by inhibiting transmission of alpha motor neurons at the neuromuscular junction. In one study, patients had Botox injected into their upper lip elevator muscles.9 All patients were pleased with the results, and no adverse effects were reported. The results were transitory, however, with the effect lasting from 3 to 6 months. Long-term results using Botox would require repeated treatments.
Orthodontic treatment can be used as a long-lasting and nonsurgical method to correct excessive gingival display. Orthodontic treatment may require years for completion, however. Rui et al reported on a case in which a patient with a Class II Division 1 malocclusion had her gummy smile corrected with orthodontic treatment using temporary anchorage devices.10 No hypermobile lip or vertical maxillary excess was present. The gummy smile was eliminated, but the case took 38 months to complete.
When the etiology of the gummy smile is excessive gingiva covering the anatomic crown, a gingivectomy is the treatment of choice.5 A gingivectomy involves the removal of the gingiva only. No bone recontouring is performed. Gingivectomies typically involve minimal discomfort and are routinely done in one office visit. Removal of the excess gingiva decreases the gingival display by moving the gingival margin apically. The amount of reduction of gingival display is limited by the height of the anatomic crown.
As described by Kois, some patients have a thick biotype with high crestal bone levels.11 In these situations, clinical crown lengthening is required to expose the entire anatomical crown. Crestal bone levels are recontoured to achieve stable gingival margins and accommodate traditional expectations regarding biologic width.12 At times, the periodontium is so thick and bulbous that the alveolar ridge may need to be reduced to achieve the desired results.6 Like a gingivectomy, clinical crown lengthening typically involves minimal discomfort, is an in-office procedure, and decreases gingival display by moving the gingival margin apically. Unlike a gingivectomy, the amount of reduction is not determined by the anatomic crown. It is determined by the restorative dentist who chooses the new position of the gingival margin based on esthetic restorative needs.13 In some cases, root structure will be surgically exposed and later covered by a restoration with proper crown proportions.
Vertical maxillary excess (VME), a maxillo-mandibular discrepancy, is another cause of excessive gingival display. LeFort I maxillary osteotomies with impaction can be used to correct VME. This procedure can be used in combination with other orthognathic surgical procedures.7 This type of surgery must be done in a hospital, however, and is performed under general anesthesia. Orthognathic surgery is associated with significant morbidity.8 It is typically coordinated with orthodontic treatment.
Lip repositioning can be used to correct excessive gingival display when the etiology is vertical maxillary excess or a hypermobile lip.4,14 It is an in-office procedure that can be done using local anesthesia. Lip repositioning was first reported as a correction of a gummy smile in 1973 by Rubinstein and Kostianovsky.15 In 2006 and 2007, the use of an elliptical-shaped surgical design was described.4,14 Lip repositioning results in a narrowed vestibule that limits muscle pulls, which, in turn, restricts gingival display during smiling. Patients with minimal zones of attached gingiva may not be ideal candidates for this procedure due to potential difficulties in flap approximation and suturing.14 In a case report from 2010, it was recommended that the width of the epithelial band be twice the amount of gingival display.16
Lip repositioning surgery can be used in conjunction with or following a gingivectomy or clinical crown lengthening.17,18 Once the proper tooth proportions have been established, the amount of lip repositioning required can be determined. Lip repositioning is a safe procedure with less complications than orthognathic surgery.13,19 High satisfaction with treatment was reported up to 2.5 years after treatment.18 Additional studies are needed, however, to determine the predictability and long-term stability of the results obtained with lip-repositioning techniques.20
Lip repositioning can be an effective method of eliminating excessive gingival display and improving the appearance of the smile.
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About the Author
Douglas H. Mahn, DDS