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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 17  |  Issue : 3  |  Page : 744-746

Management of gummy smile with an interdisciplinary approach


Department of Periodontology, School of Dental Sciences, Krishna Institute of Medical Sciences Deemed University, Karad, Maharashtra, India

Date of Submission07-Jan-2020
Date of Decision08-Dec-2020
Date of Acceptance18-Jul-2021
Date of Web Publication2-Nov-2022

Correspondence Address:
Dr. Sameer A Zope
Department of Periodontology, School of Dental Sciences, Krishna Institute of Medical Sciences Deemed University, Karad - 415 110, Satara, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdmimsu.jdmimsu_3_20

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  Abstract 


In this extremely competitive society, esthetic appearance plays an important role in the acceptance and self-esteem of individuals. Facial expressions and smile are the primary constituents of fast and effective nonverbal communication. Gummy smile is a frequent finding that can occur because of various intraoral or extraoral etiologies. Gummy smile is considered unattractive and a major cause of embarrassment. Lip repositioning was first described in 1973 by Rubinstein and Kostianovsky as a conservative surgical method for correcting a gummy smile. This procedure minimizes the gingival display by limiting the retraction of the elevator smile muscles. This case report describes the management of gummy smile using an interdisciplinary approach. Despite other possible alternatives, the present case was treated with minimally invasive perioplastic surgery (crown lengthening and lip repositioning) and cosmetic restorations of maxillary anterior teeth. Surgical lip repositioning is a safe, predictable procedure with minimal risks or side effects.

Keywords: Cosmetic restoration, gummy smile, high smile line, lip repositioning, minimally invasive


How to cite this article:
Disale PR, Zope SA, Suragimath G, Varma S. Management of gummy smile with an interdisciplinary approach. J Datta Meghe Inst Med Sci Univ 2022;17:744-6

How to cite this URL:
Disale PR, Zope SA, Suragimath G, Varma S. Management of gummy smile with an interdisciplinary approach. J Datta Meghe Inst Med Sci Univ [serial online] 2022 [cited 2023 Feb 4];17:744-6. Available from: http://www.journaldmims.com/text.asp?2022/17/3/744/360205




  Introduction Top


A pleasant smile is regarded as a symbol of an individual's beauty and well-being. The harmony of three main components is essential for a beautiful smile, i.e., teeth, lips, and gingiva. The gingival display of 4 mm or more between the inferior border of the upper lip and the crest of gingival margin of the central incisors during a normal smile is referred as a gummy smile.[1] Various potential etiologies associated with gummy smile comprise vertical maxillary excess (VME), altered passive eruption (APE), gingival enlargement, and a hypermobile or short upper lip.[2] The present case report highlights the use of surgical procedure (i.e., crown lengthening and lip repositioning) and cosmetic restoration as a treatment modality in the correction of gummy smile.


  Case Report Top


A 23-year-old female patient with the chief complaint of excessive gum display presented to the Department of Periodontology, School of Dental Sciences, Karad. Medical and family histories were noncontributory. The face was bilaterally symmetrical, with a short upper lip and potentially incompetent lips. Intraoral examination revealed VME with a very high smile line and a slight rotation with the maxillary lateral incisors' spacing present with both maxillary and mandibular anterior teeth. On periodontal examination, she had an altered position of the gingival zenith and the presence of APE Type 1B along with short clinical crowns [Figure 1]. A diagnosis of Degree II VME with potentially incompetent lips, APE, very high smile line, and short upper lip was confirmed. Several treatment options like Botulinum toxin Type A, orthodontic treatment, orthognathic surgery, and periodontal treatments were all discussed with the patient. The patient chose a less invasive procedure, lip repositioning, along with aesthetic crown lengthening and anterior teeth restoration. Prior to the surgical procedure, written informed consent was obtained.
Figure 1: Pretreatment extraoral and intraoral photographs. (a) Photograph showing a very high smile line which extended from the premolar to premolar. (b) Frontal view showing short clinical crowns, spacing with the maxillary and mandibular anterior teeth, and slight rotation with the maxillary lateral incisors

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Case management

Surgical procedure for esthetic crown lengthening

After adequate local anesthesia, biological width was measured with transgingival probing in the maxillary anterior teeth region. Esthetic crown-lengthening procedure was performed with the maxillary right canine to the left canine region as shown in [Figure 2]. The patient was discharged with all necessary post-operative instructions and medications.
Figure 2: Surgical procedure for esthetic crown lengthening. (a) The initial internal bevel incision away from the gingival margin extending from the distal aspect of 13 to the distal aspect of 23 both on the buccal and palatal aspects, followed by crevicular incision. (b) A full-thickness mucoperiosteal flap reflection, followed by osteotomy. (c) The flap sutured with simple interrupted silk. (d) 21-day postsurgical photograph showing satisfactory healing and increased clinical crown height

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Cosmetic restoration with maxillary anterior teeth

A vacuum-formed retainer for the maxillary anterior teeth was prepared using a Bioplast® Duran sheet. This retainer was then used as a guide for direct composite veneering from the maxillary canine to canine [Figure 3].
Figure 3: Postcosmetic restoration photograph

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Surgical procedure for lip repositioning

The surgical area was demarcated with a pencil according to the technique described by Rosenblatt and Simon after achieving adequate anesthesia [Figure 4].[3] An elliptical outline was formed by placing partial thickness incisions and connecting them. The epithelium was removed, and a frenotomy was performed. Sutures were placed to stabilize the mucosa with the gingiva. All the required postoperative instructions and medications were given to the patient before discharge. Two days after the surgery, the patient reported mild swelling in the upper lip which resolved on its own. The patient was recalled after 15 days for suture removal. After one month, a two-millimeter gingival display was observed while smiling [Figure 5]. The patient was pleased with her smile and presented with no complications.
Figure 4: Surgical procedure for lip repositioning. (a) Demarkation of the surgical area. (b) The partial-thickness lower incision at the mucogingival junction extending from the right first molar to the left first molar. A parallel upper incision in the labial mucosa at approximately 10–12 mm distance from the lower incision. (c) Epithelial excision along the incision outline, leaving the underlying connective tissue exposed. (d) Bilateral symmetry was ensured by placing the first interrupted suture at the midline, followed by continuous interlocking suture from the midline to the distal aspects of the premolars

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Figure 5: Posttreatment intraoral and extraoral photographs. (a) 1-month postsurgical photograph showing satisfactory healing and an intraoral scar formation at the suture line. (b) Reduced gingival display while smiling

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  Discussion Top


The first critical step in the treatment of gummy smile is a thorough understanding of the etiology, diagnosis, and treatment options. The etiology of gummy smile in this case report can be attributed to the VME, short lip, and APE. Surgical crown lengthening alone was not sufficient in this case, and orthognathic surgery was required to manage maxillary excess. An interdisciplinary approach is vital in such cases when the patient is unwilling for such a complex procedure.

Crown-lengthening surgery was performed for the treatment of APE, which eliminates excess gingiva and restores the clinical crown height through dentogingival complex remodelling.[4] The treatment of choice depends on the amount of biological width, keratinized gingiva available, and crown–root ratio of the tooth.[5] The present case did not report any complications such as recession and gingival rebound post-treatment.

An excellent and less invasive alternative to treat gummy smile is lip repositioning. Rubinstein and Kostianovsky first described lip repositioning surgery in the medical literature in 1973.[6] In this technique a partial thickness strip of the mucosa is removed from the maxillary buccal vestibule and the lip mucosa is sutured to the mucogingival line. The pull of the elevator smile muscles (orbicularis oris, levator anguli oris, zygomaticus minor, and levator labii superioris) is reduced, resulting in a narrow vestibule with the reduced gingival display while smiling.[3] This procedure is indicated for cases with hyperactive upper lip and short lip. The presence of severe VME and a minimal zone of the attached gingiva contraindicates this surgery.[7] The advantages of this technique include minimal instrumentation, less time spent, cost-effectiveness, quick recovery, and patient satisfaction. Postoperative pain, bruising, discomfort, swelling of the upper lip, and suture loosening are the minimal side effects of this surgery.[3]

In the present case, successful clinical outcomes were achieved using esthetic crown lengthening along with lip-repositioning technique and cosmetic restorative treatment. Few previous studies have reported a significant reduction in the gingival display with no complication and stable results at 1-year follow-up.[8],[9],[10] A recent systematic review concluded that lip repositioning can successfully improve excessive gingival display by 3.4 mm.[11] There are some demerits of this technique. The classical technique has shown increased chances of relapse due to reattachment of the muscles to the original position. To overcome this, Miskinyar suggested severing the smile muscle attachment to prevent the muscle from reverting to its original position. The muscle severance may result in mucocele formation and transient paresthesia.[12] A randomized clinical trial by Tawfik et al. reported that muscle severance produces a more stable result after 12 months when compared to the classical technique.[9] A contradictory result was observed in a case report by Ambrosio F in identical twins with severe VME, where he obtained acceptable cosmetic results with the classical technique that were stable at 12 and 24 months.[2]


  Conclusion Top


This case report highlights a multidisciplinary strategy to manage gummy smile. The classical lip-repositioning technique is an effective and less invasive approach for the treatment of gummy smile. However, knowledge of various etiological factors and an indication of the surgical technique is essential to define the treatment protocol.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
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.  Back to cited text no. 1
    
2.
Ambrosio F, Gadalla H, Kapoor N, Anthony L, Neely LA, Kinaia MB. Surgical lip repositioning procedure to correct excessive gingival display: A case report of identical twins. Clin Adv Periodontics 2018;8:48-53.  Back to cited text no. 2
    
3.
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. 3
    
4.
Ser Yun JB, Luo M, Yin Y, Zhi Hui VL, Fang B, Han XL. Etiology-based treatment strategy for excessive gingival display: Literature review. World J Surg Surg Res 2019;2:1103.  Back to cited text no. 4
    
5.
Johnson RH. Lengthening clinical crowns. J Am Dent Assoc 1990;121:473-6.  Back to cited text no. 5
    
6.
Rubinstein A, Kostianovsky A. Cosmetic surgery for the malformation of the laugh: Original technique. Prensa Med Argent 1973;60:952-4.  Back to cited text no. 6
    
7.
Sthapak U, Kataria S, Chandrashekar KT, Mishra R, Tripathi VD. Management of excessive gingival display: Lip repositioning technique. J Int Clin Dent Res Organ 2015;7:151-4.  Back to cited text no. 7
  [Full text]  
8.
Bhimani RA, Sofia ND. Lip Repositioning, Aesthetic Crown Lengthening, and Gingival Depigmentation: A Combined Approach for a Gummy Smile Makeover. J Cutan Aesthet Surg. 2019;12(4):240-43.  Back to cited text no. 8
    
9.
Tawfik OK, Naiem SN, Tawfik LK, Yussif N, Meghil MM, Cutler CW, et al. Lip repositioning with or without myotomy: A randomized clinical trial. J Periodontol 2018;89:815-23.  Back to cited text no. 9
    
10.
Gadalla H. Surgical lip repositioning procedure to improve facial profile in a patient with excessive gingival display: A case report. EC Dent Sci 2019;18:377-82.  Back to cited text no. 10
    
11.
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 Esthetic Rest Dent 2018;30:101-12.  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
    


    Figures

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



 

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