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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 17  |  Issue : 1  |  Page : 47-50

Evaluation of effectiveness of management of excessive gingival display (Gummy Smile) with lip reposition procedure: A case series


1 Department of Periodontics, Swargiya Dadasaheb Kalmegh Smruti Dental College and Hospital, Nagpur, Maharashtra, India
2 Department of Periodontics, Sharad Pawar Dental College, Wardha, Maharashtra, India

Date of Submission18-Jan-2021
Date of Decision22-Oct-2021
Date of Acceptance08-Jan-2022
Date of Web Publication25-Jul-2022

Correspondence Address:
Dr. Sneha S Puri
Department of Periodontics, Swargiya Dadasaheb Kalmegh Smruti Dental College and Hospital, Hingna, Nagpur - 441 110, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdmimsu.jdmimsu_17_21

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  Abstract 


Background and Aim: Excessive gingival display can be managed by a variety of treatment modalities, depending on the specific diagnosis. Lip repositioning surgery is a largely unknown and underutilized treatment modality for excessive gingival display. The aim of the present study was to minimize gingival display with a lip reposition procedure. Materials and Methods: A total of three patients with a gummy smile were selected for the study. This case report demonstrates the successful management of excessive gingival display with a lip-repositioning procedure. This is accomplished by removing a strip of mucosa from the maxillary buccal vestibule, then suturing the lip mucosa to the mucogingival line. Results: The procedure resulted in a narrower vestibule and restricted muscle pull, thereby reducing gingival display during smiling. Conclusion: The lip repositioning technique to decrease the amount of gingival display proved to be more conservative and provided a good esthetic outcome.

Keywords: Gummy smile, hypermobile lip, lip repositioning procedure


How to cite this article:
Puri SS, Jaiswal PG, Shewale A. Evaluation of effectiveness of management of excessive gingival display (Gummy Smile) with lip reposition procedure: A case series. J Datta Meghe Inst Med Sci Univ 2022;17:47-50

How to cite this URL:
Puri SS, Jaiswal PG, Shewale A. Evaluation of effectiveness of management of excessive gingival display (Gummy Smile) with lip reposition procedure: A case series. J Datta Meghe Inst Med Sci Univ [serial online] 2022 [cited 2022 Aug 18];17:47-50. Available from: http://www.journaldmims.com/text.asp?2022/17/1/47/352213




  Introduction Top


An esthetic smile is an important aspect of a person's beauty. With the growing demand for esthetics, the problem of the excessive gingival display has garnered much importance in the field of dentistry. There has also been a steady rise in the importance of the potential of plastic periodontal surgical procedures to enhance the smile line. A smile may be considered as pleasant when the upper teeth are completely exposed, and approximately 1 mm of buccal gingival tissue is visible, whereas an excessive exposure (>3 mm) is generally considered not attractive by many patients.[1] The excessive gingival display is a condition characterized by excessive exposure of the maxillary gingiva during smiling, commonly called a “gummy smile.” It is a condition caused primarily by a skeletal deformity in which there is vertical excess of the maxillary tissue, a soft-tissue deformity in which there is a short upper lip, or a combination of the two.[2] The other causes of the excessive gingival display are insufficient clinical crown length due to coronal destruction resulting from traumatic injury, caries, or incisal attrition, as well as coronally situated gingival complex resulting from tissue hypertrophy due to a phenomenon known as altered passive eruption. The identification of the correct etiology is essential for the establishment of an adequate treatment plan. Altered passive eruption requires periodontal surgery that includes gingivectomy or an apically repositioned flap associated with or without osseous resection,[3] whereas dentoalveolar extrusion is usually treated with orthodontic intrusion and vertical maxillary excess with orthognathic surgery.[4],[5] For treatment of gummy smile due to hyperactive upper lip, variable outcomes have been reported with the use of different techniques, such as botulinum toxin injection,[6] lip elongation associated with rhinoplasty, detachment of lip muscles, myectomy and partial removal, and lip repositioning. Therefore, the aim of the present study was to minimize gingival display with a lip reposition procedure.


  Materials and Methods Top


Three patients with a mean age range of 20.5 years, ranging from 17 to 25 years with the presence of excessive gingival display (Gummy smile) were selected randomly for the study. However, patients showing teeth with malposition and/or alteration in crown morphology and having a history of periodontal surgery in the selected area were excluded from the study.

Before initiating of this study, the purpose and diagnostic procedure of this clinical trial were explained to the patients, and provided verbal informed consent to participate in the study.

Information concerning dietary status, mouth cleaning habits, systemic background, and gingival and periodontal status along with other routine clinical details was recorded in a specially designed chart. Patients were examined under good illumination with the help of a mouth mirror and William's graduated periodontal probe.

The patient's oral hygiene was evaluated using the Plaque Index (Turkesy-Gilmore-Glickman Modification of Quigley-Hein, 1970)[7] as an expression of the level of localized mouth supragingival plaque accumulation. Gingival inflammation was assessed by papillary bleeding index [Figure 1] and [Figure 2].[8]
Figure 1: Pre-operative measurements

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Figure 2: Incisions placed

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Surgical procedure

Local anesthesia (2% lidocaine, epinephrine 1:100,000) was administered in the vestibular mucosa and lip from maxillary right to left first molar. A partial-thickness incision was made at the mucogingival junction from the mesial line angle of the right first molar to the mesial line angle of the left first molar. A second partial-thickness incision, parallel to the first, was made in the labial mucosa, 10–12 mm apical to the mucogingival junction. The incisions were connected at each first molar, creating an elliptical outline [Figure 3]. The epithelium was removed within the outline of the incisions, leaving the underlying connective tissue exposed [Figure 4] and [Figure 5]. Care was taken to avoid damage to any minor salivary glands in the submucosa. The parallel incision lines were approximated with interrupted stabilization sutures at the midline and other locations along the borders of the incision to ensure proper alignment of the lip midline with the midline of the teeth. Then, a continuous interlocking suture was used to approximate both flap ends [Figure 6].
Figure 3: Dissection of Mucosa

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Figure 4: Excised Mucosa

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Figure 5: Sutures placed

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Figure 6: Post-operative measurements

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Postoperative care

After surgery, nonsteroidal anti-inflammatory, IBUGESIC – ibuprofen + paracetamol, and antibiotic coverage consisting of amoxicillin 500 mg three times a day was prescribed for 5 days. Patients were instructed not to brush their teeth in the treated area. All patients were placed on 0.12% chlorhexidine gluconate (Hexidine – ICPA) twice daily, for 1 min, for 1 week. They were instructed not to disturb the pack and to avoid undue trauma to the treated site.

One week following surgery, the periodontal pack and sutures were removed. At this time, the healing was observed and a second periodontal pack was placed, if necessary. After irrigation with saline, polishing was done with the help of polishing paste and a rubber-cup, taking care that it did not traumatize the treated site. Patients were instructed to clean the treated site with a cotton pellet saturated with 0.12% chlorhexidine gluconate for additional 4–5 weeks in an apico-coronal direction. No mechanical oral hygiene procedures or chewing was allowed for 6 weeks in the treated area. After this period, patients were reinstructed to resume mechanical oral hygiene measures, including careful brushing with a soft toothbrush, interdental cleaning with an interdental brush, and discontinuing chlorhexidine.


  Results Top


Three female patients with the age range of 17–25 years (mean 26.8 ± 6.41 years) associated with excessive gingival display of 11.05 ± 2.89 mm were treated using lip reposition surgery. During the course of the study, wound healing was uneventful. There was no postoperative complication in any patients and all the patients were satisfied with the result. At 3 months follow-up, a reduction in the mean gingival display was 8.18 ± 1.72 mm [Table 1].
Table 1: Comparison between gingival display at baseline and at 3 months postsurgically

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  Discussion Top


The aim of the present study was to minimize gingival display with a lip reposition procedure. In the present case series study, three patients showing a mean gingival display of 11.05 ± 2.89 mm were treated with lip reposition surgery. The results of the clinical cases show esthetic satisfaction after 3 months of follow-up with a mean reduction in the gingival display of 8.18 ± 1.72 mm. In the first two cases, 3 mm of lip movement reduction was achieved, and in the third case, it was 2.6 mm. Similar outcomes were reported by Rosenblatt and Simon[9] and Humayun et al.,[10] who achieved approximately 4 mm of gummy smile reduction.

An asymmetric effect on reduction of lip movement is a possibility but did not occur in this study. This symmetric outcome was ensured by maintaining the lip frenum, which facilitates repositioning of the labial midline; removal of the same amount of tissue on both sides of the frenum; and removal of both strips of mucosa before suturing, which allows comparison of the two sides.

Several other techniques for excessive gingival display have been used in cases of the hyperactive upper lip, with a wide variation in outcomes. Detachment of the lip muscles,[11] myectomy and partial muscle removal,[12] lengthening of the lip associated with rhinoplasty,[13] and, recently, use of botulinum toxin[14],[15] are the examples of treatment modalities described in the literature. For patients who desire a more conservative technique, surgical lip repositioning is a viable alternative. In technique selection, the procedure shown in this case report could be the first choice because it is less invasive and presents good stability during the 3-month follow-up.


  Conclusion Top


This case report described the successful management of a gummy smile. The treatment resulted in reduced gingival display and an esthetically pleasing smile. Lip repositioning surgery is a promising technique to improve esthetics in the maxillary anterior sextant through a minimally invasive, fast, and easy procedure.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Allen EP. Use of mucogingival surgical procedures to enhance esthetics. Dent Clin North Am 1988;32:307-30.  Back to cited text no. 1
    
2.
Garber DA, Salama MA. The aesthetic smile: Diagnosi s and treat ment. Periodontol 2000 1996;11:18-28.  Back to cited text no. 2
    
3.
Dolt AH 3rd, Robbins JW. Altered passive eruption: An etiology of short clinical crowns. Quintessence Int 1997;28:363-72.  Back to cited text no. 3
    
4.
Allen EP. Surgical crown lengthening for function and esthetics. Dent Clin North Am 1993;37:163-79.  Back to cited text no. 4
    
5.
Kim TW, Kim H, Lee SJ. Correction of deep overbite and gummy smile by using a mini-implant with a segmented wire in a growing Class II Division 2 patient. Am J Orthod Dentofacial Orthop 2006;130:676-85.  Back to cited text no. 5
    
6.
Mazzuco R, Hexsel D. Gummy smi le and botulinum toxin: A new approac h based on the gingival exposure area. J Am Acad Dermatol 2010;63:1042-51.  Back to cited text no. 6
    
7.
Turesky S, Gilmore ND, Glickman I. Reduced plaque formation by the chloromethyl analogue of vitamin C. J Periodontal 1970;41:41-3.  Back to cited text no. 7
    
8.
Muhlemann HR. Psychological and chemical mediators of gingival health. J Prev Dent 1977;4:6.  Back to cited text no. 8
    
9.
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. 9
    
10.
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. 10
    
11.
Litton C, Fournier P. Simple surgical correction of the gummy smile. Plast Reconstr Surg 1979;63:372-3.  Back to cited text no. 11
    
12.
Miskinyar SA. A new method for correcting a gummy smile. Plast Reconstr Surg 1983;72:397-400.  Back to cited text no. 12
    
13.
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. 13
    
14.
Polo M. Botulinum toxin type A in the treatment of excessive gingival display. Am J Orthod Dentofacial Orthop 2005;127:214-8.  Back to cited text no. 14
    
15.
Mazzuco R, Hexsel D. Gummy smile and botulinum toxin: A new approach based on the gingival exposure area. J Am Acad Dermatol 2010;63:1042-51.  Back to cited text no. 15
    


    Figures

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

  [Table 1]



 

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