ABSTRACT

'Gummy Smile' (GS) has been described as the visibility of excessive gingiva, characterized by the exposure of over 3 mm of maxillary gingiva during smiling. Various factors contribute to a gummy smile, including vertical maxillary excess, a short and hyperactive upper lip, altered passive eruption, anterior dentoalveolar extrusion, or a combination of these underlying causes. Lip repositioning is a conservative treatment modality to limit upper lip hypermobility. The current case report presents the successful management of a gummy smile with lip repositioning.

INTRODUCTION

Excessive gingival display (EGD), commonly termed gummy smile, is characterized by overexposure of the maxillary gingiva while smiling, which is generally considered unesthetic. To manage a gummy smile, several treatments are employed to reestablish the dentogingival connection. The procedures used are crown lengthening, orthodontic alignment to level the gingival margins of maxillary teeth, intrusion of maxillary teeth, lip repositioning, orthognathic surgery, and nonsurgical interventions like the application of botulinum toxin. Orthodontic intrusion addresses anterior dentoalveolar extrusion, while vertical maxillary excess is conventionally managed through orthognathic surgery.¹

In the case of mild vertical maxillary excess up to 4 mm of the gingival display, the ideal treatment option is management by periodontal and restorative treatments, orthodontic intervention, or combined intervention. If the vertical maxillary excess is moderate to severe, the ideal treatment modality will include periodontal and restorative management and orthognathic surgery. In case of altered passive eruption, gingivectomy can be performed.

In the case of upper lip hypermobility, a lip repositioning procedure or lip repositioning along with myotomy or botulinum toxin injections are carried out.

Lip repositioning is a minimally invasive surgical procedure to reduce excessive gingival display (EGD) or a 'gummy smile.' It involves repositioning the upper lip to minimize gingival exposure, resulting in a more aesthetically pleasing smile. The simple procedure requires basic surgical instruments and leads to fast healing and positive outcomes. The surgery aims to limit smile muscle pull (zygomaticus minor, levator anguli, orbicularis oris, and levator labii superioris) by reducing the depth of the upper vestibule.²

CASE REPORT

A 20-year-old female patient reported to the Department of Periodontics and Implantology with the chief complaint of excessive gingival display while smiling (Fig.1). The patient had undergone fixed orthodontic therapy for two years. On periodontal examination, the patient had 4.5 mm of gingival visibility while smiling, reduced scalloping, and irregular gingival contour with respect to teeth #16,15,13,23,25,26. Intra-oral examination showed missing teeth #14,24,34 and 44.

#16 to 26 were visible, and a reduced width/length ratio was observed with respect to #11 and 21 while smiling. The patient was diagnosed to have vertical maxillary excess and was advised to undergo an orthognathic surgery. However, the patient was not willing to undergo an extensive procedure. Hence, an alternative option for the lip repositioning procedure was suggested. Written informed consent was obtained following a discussion of the risks and benefits of the procedure.

SURGICAL PROCEDURE

Local anesthetic was administered. Gingivectomy was done in relation to #13, 15, 16 to eliminate pseudo pockets (Fig. 2a) and #11 and 21 to correct the width/length ratio (Fig. 2b). Coronoplasty was done in relation to #12 and 22 so that their length remains 1 mm apical to #11 and 21 (Fig. 3).

The amount of gingival display was 4.5mm while smiling. Parallel lines were marked along the mucogingival junction from premolar to premolar with almost twice the length of  gingival display, i.e., 9 mm apart coronally (Fig. 4). The lines were joined, and incisions were placed based on the markings (Fig. 5). Removal of a flat strip of mucosa of partial thickness between the Muco-Gingival Junction (MGJ) and upper lip musculature was done (Fig. 6). Sutures were placed from the midline, which proceeded bilaterally (Fig. 7, 8).

POST OPERATIVE INSTRUCTIONS

The patient was instructed to restrict excessive movement of the lips and was advised to use ice packs repeatedly during the first 24 hours. It was recommended that regular oral hygiene methods be stopped for two days. The patient was prescribed Chlorhexidine mouthwash 0.12% 15 ml for two weeks along with antibiotics and analgesics if required.

DISCUSSION

This clinical report describes a lip repositioning procedure to reduce excessive gingival display. This technique was designed to be less aggressive and have fewer postoperative complications than orthognathic surgery.

Proper diagnosis of the etiological factors is the first step to selecting the appropriate treatment protocol since excessive gingival display has several etiologies. Also, lip repositioning procedures are contraindicated in patients with limited attached gingiva and severe vertical maxillary excess, i.e., beyond 8 mm of gingival visibility.³

In the current case, the patient presented with 4.5 mm of gingival display while smiling. Though an interdisciplinary approach involving periodontal and restorative intervention and orthognathic surgical intervention was the ideal treatment of choice, the patient was unwilling to undergo an extensive procedure for the correction. Hence, the   patient was advised to undergo a lip repositioning procedure.

In a case report by Gupta et al., based on the treatment of gummy smile by surgical lip repositioning technique, they concluded that this procedure is a simple technique with reduced surgical time and economical to provide acceptable results.¹ 

In a case series by Ramesh et al., regarding the treatment of gummy smile using the lip repositioning technique, all the patients had satisfactory results and did not have any post operative complications as per their report.⁴

In the current case report, intra-operatively and post-operatively, the patient did not experience any complications and achieved satisfactory results.

Rosenblatt and Simon reported on one patient following a lip repositioning procedure with a mucocele that resolved without treatment.⁵

The patient’s one month follow-up showed that the results were consistent and did not result in any relapse of the condition.

Though several studies have shown a certain degree of relapse, only one case report has shown a complete relapse of the condition. According to Dayakar et al., there was a complete relapse of the condition after a one year follow-up after the procedure.⁶

However, in a systematic review by Tawfiq et al., due to the smaller number of patients and the short duration of follow-up (6-18 months), could not conclude the stability of the outcome of the procedure.²

CONCLUSION

The lip repositioning procedure proves effective in the reduction of excessive gingival display. However, the stability of outcomes in the long term has to be followed-up. Nonetheless, this procedure is a promising alternative treatment option for excessive gingival display.