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| CASE REPORT |
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| Year : 2022 | Volume
: 17
| Issue : 1 | Page : 122-125 |
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Modified lip repositioning technique to improve the smile harmony: A 3-year follow-up
Anitha Vijayarangan, Adline Vadhana, Shanmugam Muthukali, Ashwath Balachandran
Department of Periodontology, Chettinad Dental College and Research Institute, Chengalpattu, Tamil Nadu, India
| Date of Submission | 15-Nov-2021 |
| Date of Decision | 26-Feb-2022 |
| Date of Acceptance | 18-Mar-2022 |
| Date of Web Publication | 25-Jul-2022 |
Correspondence Address:
Dr. Adline Vadhana
Department of Periodontology, Chettinad Dental College and Research Institute, Rajiv Gandhi Salai, Kelambakkam, Chengalpattu, Tamil Nadu
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jdmimsu.jdmimsu_423_21
Excessive gingival display (EGD) is a highly prevalent condition and poses esthetic concerns. Lip repositioning is a simple technique for the treatment of EGD due to vertical maxillary excess (VME) and hypermobility of the upper lip. Various modifications have been proposed to the original technique to improve the predictability and stability of the results over the long term. This article presents the long-term results of the modified lip repositioning technique.
Keywords: Esthetics, excessive gingival display, lip repositioning, vertical maxillary excess
How to cite this article:
Vijayarangan A, Vadhana A, Muthukali S, Balachandran A. Modified lip repositioning technique to improve the smile harmony: A 3-year follow-up. J Datta Meghe Inst Med Sci Univ 2022;17:122-5 |
How to cite this URL:
Vijayarangan A, Vadhana A, Muthukali S, Balachandran A. Modified lip repositioning technique to improve the smile harmony: A 3-year follow-up. J Datta Meghe Inst Med Sci Univ [serial online] 2022 [cited 2022 Aug 18];17:122-5. Available from: http://www.journaldmims.com/text.asp?2022/17/1/122/352239 |
| Introduction | |  |
A pleasant smile is the key feature of the overall esthetic appearance of a person and it is dependent on the relationship between three primary components – the teeth, lip framework, and the gingival scaffold.[1] Excessive gingival display (EGD), commonly referred to as a “gummy smile,” is characterized by overexposure of maxillary gingiva while smiling and is a cause for major esthetic concern. Kokich et al. found that the gingiva-to-lip distance of 2 mm and 4 mm during a dynamic smile was considered unattractive by orthodontists and laypersons, respectively.[2]
EGD can be caused due to dental, soft tissue, or skeletal discrepancies. Bhola et al. classified the etiological factors of EGD into five categories: (a) altered passive eruption, (b) bony maxillary excess, (c) conditions causing gingival enlargements such as dental plaque, medications, hormonal changes, and hereditary gingival fibromatosis, (d) deficient lip length, and (e) excessive mobility of the maxillary lip.[3]
Treatment varies according to the etiology of EGD. EGD caused by the altered passive eruption is treated by gingivectomy and apically positioned flap with or without osseous reduction. EGD due to bone maxillary excess is treated by esthetic crown lengthening, orthodontic intrusion, botulinum type A toxin, lip repositioning, or orthognathic surgery, depending on the degree of the gingival display. Hypermobility of the upper lip causes EGD which is treated by lip repositioning technique or botulinum type A toxin.[3]
The lip repositioning technique was first introduced in the field of plastic surgery by Rubenstein and Kostianovsky in 1973[4] and was later modified and introduced into dentistry by Rosenblatt and Simon in 2006.[5] The authors described it as an alternative procedure for invasive orthognathic surgery for the treatment of EGD due to vertical maxillary excess (VME). The main objective of this surgical procedure is to limit the retraction of the elevator smile muscles (zygomaticus minor, levator anguli oris, orbicularis oris, and levator labii superioris) by removing a strip of tissue in the buccal vestibule between the mucogingival junction and upper lip musculature which leads to a reduction in the vestibular depth and causes muscle restriction and reduction in the gingival display.[5] Complications occur infrequently, which include mucocele in the upper lip, paresthesia, and transient paralysis.[5],[6],[7]
Various modifications were described to increase the predictability and for long-term stable results. Myectomies were advocated to detach the elevator smile muscles and to prevent relapse.[6] Two elliptical-shaped incisions to remove the band of tissue, twice the width of the gingival display was described by Humayun for long-term stable results.[8] Silva et al. proposed the removal of two strips of mucosa, bilaterally to the maxillary labial frenum and coronal repositioning of the new mucosal margin.[9]
The main aim of this article is to describe the long-term results of the modified lip repositioning technique for the treatment of EGD due to VME and hypermobile upper lip (HUL).
| Case Report | | |
In August 2018, an 18-year-old female patient was referred from the department of orthodontics, Chettinad Dental College and Research Institute after the completion of orthodontic treatment, for the management of a gummy smile. The patient was systematically healthy. Extraoral and intraoral examinations were done.
The smile line was first established, as described by Peck et al.[10] A high smile line with EGD of 5 mm was noted [Figure 1]. The lip length at rest was measured from the subnasale to the inferior border of the upper lip. The upper lip length was 24 mm which was within the normal limits [Figure 2].[10],[11] The facial height was examined by measuring the upper, middle, and lower thirds of the face, and the lower third of the face was longer.
Intraoral examination and periodontal charting were done. The patient was periodontally healthy and displayed good oral hygiene. The width of keratinized gingiva was adequate [Figure 3]. The length and width of the anatomical crowns were within the normal range and proportion [Figure 4]. Finally, the amount of translation of lip from rest to dynamic smile was measured. The mobility of the upper lip was calculated as 11 mm.
The diagnosis was given as EGD subclass 2 (5 mm of the gingival display) due to VME and HUL.[3] The treatment options were explained to the patient. The patient preferred the conservative lip repositioning technique. Hence, a modified lip repositioning technique with the removal of 10 mm of mucosa (twice the amount of EGD) was planned. Written informed consent was obtained from the patient.
Surgical procedure
As a preprocedural mouth rinse, 0.12% chlorhexidine mouthwash was given. Following the administration of local anesthesia (lignocaine with 1:200,000 adrenaline), the elliptical-shaped incisions were marked with a surgical marker. The inferior border of the elliptical incision was given at the mucogingival junction, bilaterally to the maxillary labial frenum and it was extended up to the second premolar on either side. The superior border of the incision was made 10 mm apical to a mucogingival junction in the vestibule (twice the amount of gingival display), leaving the frenal attachment intact. The horizontal incisions were connected by vertical incisions on either side. The outlined mucosa was removed by partial thickness dissection and connective tissue was exposed [Figure 5]. Care was taken to avoid damage to the minor salivary glands and muscles. The incisions were approximated with 5-0 prolene suture by simple interrupted technique leaving the frenum intact [Figure 6]. | Figure 5: Mucosal strip removed leaving the maxillary labial frenum intact
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 | Figure 6: About 5-0 prolene suture was placed by simple interrupted technique
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Postsurgical care
The patient was put under systemic analgesics (ibuprofen, three times daily for 3 days) and antibiotics (amoxicillin 500 mg, three times daily for 5 days). The patient was advised to intermittently place an ice pack over the upper lip and to limit smiling and talking for 1 day. Furthermore, the patient was instructed to avoid brushing near the surgical site and to use a 0.12% chlorhexidine gluconate mouth rinse twice daily for 2 weeks.
| Results | | |
At the 1-week postoperative visit, the patient reported swelling with minimal pain and discomfort and a reduction in gingival exposure during lip movements. The sutures were removed at the second visit, 2 weeks postoperatively and good healing of the surgical site was evident. At the 1-month postoperative visit, there was a greater reduction in the EGD during talking and smiling. Healing was uneventful with scar formation which was not visible during the lip movements. The patient was satisfied with the esthetic outcome and she was put under regular follow-up. At the 3-year postoperative visit, the reduction in the EGD was maintained [Figure 7].
| Discussion | | |
In this modern era, increased scrutiny is placed on improving the smile and esthetic appearance. Gingival exposure >1 mm during dynamic smile can be categorized as EGD and it causes esthetic breakdown and there is a drastic increase in the number of people who seek treatment to reduce the gingival display.[3] There are various treatment modalities to treat EGD and the selection of one treatment procedure over the other depends on the etiology. Lip repositioning is a less invasive surgical procedure to treat EGD.
This case report discusses the modified lip repositioning technique for the treatment of EGD. The indications of the lip repositioning technique are EGD caused due to degree 1 and degree 2 bone maxillary excess and excessive mobility of the upper lip.[3] In patients with degree 3, bone maxillary excess lip repositioning is not indicated. For this patient, the measurements revealed degree 2 VME with excessive mobility of the upper lip and adequate width of keratinized gingiva. Hence, this patient was an ideal case for lip repositioning surgery.
Lip repositioning surgical procedure was first described in the field of plastic surgery by Rubenstein for the correction of a gummy smile due to hypermobility of the upper lip.[4] This surgical procedure was less aggressive and had fewer complications when compared with orthognathic surgery.
Several variations in the technique have been reported to increase the stability of the results. Miskinyar proposed the myectomy and partial resection of the levator labii superioris muscle to prevent relapse.[6] He attempted to eliminate the cause of the deformity. Adequate resection of these muscles thoroughly eliminated the regeneration of muscle to achieve a permanent correction. Ishida et al. proposed myotomy of the levator labii superioris muscles, subperiosteal dissection associated with a subcutaneous dissection upper lip frenectomy and reported stable results for 6 months.[12] The disadvantage of the myotomy is that it is more aggressive and there is a greater chance of incidence of paresthesia.[6]
Ellenbogen and Swara introduced the spacer technique to prevent relapse. The spacer was placed through a nasal approach between the elevator muscles of the lip to prevent superior displacement of the repositioned lip.[13] Humayun et al. proposed to remove the band of tissue, twice the width of the gingival display for optimal results and reported a reduction in the amount of gingival display which was maintained for 1 year.[8] Ribeiro-Júnior et al. described the surgical procedure without involving the maxillary labial frenum.[14] The advantages of leaving the frenum intact are, that it helps to maintain the position of the labial midline, prevents changes in lip symmetry, and decreases the morbidity associated with the procedure. Two patients were treated with the proposed technique and they presented significant improvement in the amount of gingival exposure and esthetic satisfaction. Silva et al. treated 13 patients with a modified lip repositioning technique and reported about 4.4 mm reduction in the gingival display which was maintained for 6 months and the reduction in EGD was similar to those obtained with myotomy.[9]
In this case, the lip repositioning technique was performed according to the modifications given by Humayun et al.[8] and Ribeiro-Júnior et al.[14] About 10 mm of mucosa was removed leaving the frenum intact. The surgical procedure was less invasive without any complications. There was a reduction in the EGD which was maintained for 3 years. These results were in accordance with Sánchez et al. who reported predictable results in a reduction of EGD with less morbidity when the maxillary labial frenum was left intact.[15] In a systematic review by Tawfik et al., he found that a mean improvement of 3.4 mm can be achieved using the lip repositioning technique.[16]
Only a few case reports are available in the literature that demonstrates the clinical efficacy and stability of the modified lip repositioning technique. This case report presents the long-term stability of the technique. Clinical trials with a larger sample size are definitive to assess the predictability of this technique.
| Conclusion | | |
The modified lip repositioning technique is a simple and noninvasive technique that offers long-term stable results. In this case report, there was a reduction in the EGD and the patient was satisfied with the esthetic outcome.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Garber DA, Salama MA. The aesthetic smile: Diagnosis and treatment. Periodontol 2000 1996;11:18-28.  |
| 2. | Kokich VO Jr., Kiyak HA, Shapiro PA. Comparing the perception of dentists and lay people to altered dental esthetics. J Esthet Dent 1999;11:311-24. |
| 3. | Bhola M, Fairbairn PJ, Kolhatkar S, Chu SJ, Morris T, de Campos M. LipStaT: The lip stabilization technique- indications and guidelines for case selection and classification of excessive gingival display. Int J Periodontics Restorative Dent 2015;35:549-59. |
| 4. | Rubenstein AM, Kostianovsky AS. Cirugia estetica de la malformacion de la sonrisa. Pren Med Argent 1973;60:952. |
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| 6. | Miskinyar SA. A new method for correcting a gummy smile. Plast Reconstr Surg 1983;72:397-400. |
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| 8. | 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. |
| 9. | Silva CO, Ribeiro-Júnior NV, Campos TV, Rodrigues JG, Tatakis DN. Excessive gingival display: Treatment by a modified lip repositioning technique. J Clin Periodontol 2013;40:260-5. |
| 10. | Peck S, Peck L, Kataja M. Some vertical lineaments of lip position. Am J Orthod Dentofacial Orthop 1992;101:519-24. |
| 11. | Prabu NM, Kohila K, Sivaraj S, Prabu PS. Appraisal of the cephalometric norms for the upper and lower lips of the South Indian ethnic population. J Pharm Bioallied Sci 2012;4:S136-8. |
| 12. | Ishida LH, Ishida LC, Ishida J, Grynglas J, Alonso N, Ferreira MC. Myotomy of the levator labii superioris muscle and lip repositioning: A combined approach for the correction of gummy smile. Plast Reconstr Surg 2010;126:1014-9. |
| 13. | Ellenbogen R, Swara N. The improvement of the gummy smile using the implant spacer technique. Ann Plast Surg 1984;12:16-24. |
| 14. | Ribeiro-Júnior NV, Campos TV, Rodrigues JG, Martins TM, Silva CO. Treatment of excessive gingival display using a modified lip repositioning technique. Int J Periodontics Restorative Dent 2013;33:309-14. |
| 15. | Sánchez IM, Gaud-Quintana S, Stern JK. Modified lip repositioning with esthetic crown lengthening: A combined approach to treating excessive gingival display. Int J Periodontics Restorative Dent 2017;37:e130-4. |
| 16. | Tawfik OK, El-Nahass HE, Shipman P, Looney SW, Cutler CW, Brunner M. Lip repositioning for the treatment of excess gingival display: A systematic review. J Esthet Restor Dent 2018;30:101-12. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
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