SL Dentistry, Oral Disorders And Therapy
Special Issue Article “Periodontal Disease” Case Report
Lip Repositioning Surgery Without Myotomy to Achieve an Aesthetic Smile
Cemre Vergili Yılmaz* and Ozge Gokturk
Department of Periodontology, BoluAbantIzzetBaysal University Faculty of Dentistry, Periodontology, Turkey
ARTICLE INFO ABSTRACT
The concept of dentofacial aesthetics in modern society is changing and developing
Received Date: February 03, 2020
Accepted Date: March 01, 2020 day by day. Patients who are inspired by perfect smiles want to stand out in the
Published Date: March 04, 2020 community by having a similar smile aesthetic. The harmony of the three components
KEYWORDS can provide this perfect smile aesthetic that patients wish to us to achieve. These three
components that make up the smile frame are teeth, gums, and lips. Any exposure of
Excessive gingival display
the maxillary gingiva during a smile beyond 2 mm is known as a gummy smile.
Gummy smile
Lip repositioning Nonsurgical or surgical methods can treat the gummy smile condition. In this case
Hyperactive upper lip report, we used lip repositioning without myotomy, a minimally invasive surgical
procedure for the management of excessive gingival display. Also, no supportive
Copyright: © 2020 Cemre Vergili treatment was applied. The technique is based on partial removal of the tissue
Yılmaz et al., SL Dentistry, Oral
Disorders And Therapy. This is an open between a coronal incision following a mucogingival line and a parallel apical incision
access article distributed under the and moving the lip to a new position by joining the two lines. This method aims to limit
Creative Commons Attribution License, the contraction of the muscles that lift the lip during a smile. With this procedure, a
which permits unrestricted use,
narrower vestibule, limited muscle activity, and less gum appearance during a smile
distribution, and reproduction in any
medium, provided the original work is are obtained. The patient was clinically evaluated and photographed in the 3rd and
properly cited. 12th months after the surgical procedure. In control performed in the 3rd month, the
patient observed to be satisfied with the aesthetic smile, and the appearance of the
Citation for this article: Cemre Vergili
Yılmaz and Ozge Gokturk. Lip gums was within normal limits. In the 12th month, the patient's complaint recurred, and
Repositioning Surgery Without the appearance of a scar on the smile line added to the negative picture. Lip
Myotomy to Achieve an Aesthetic repositioning is successful in the short term but, additional treatments required for
Smile. SL Dentistry, Oral Disorders And
Therapy. 2020; 3(1):114 long-term or permanent results. Considering the possible complications by myotomy,
botulinum toxin-a recommended for long-term success.
INTRODUCTION
The concept of dentofacial aesthetics in modern society is changing and developing
day by day. Patients who are inspired by perfect smiles want to stand out in the
community by having a similar smile aesthetic. The harmony of the three components
can provide this perfect smile aesthetic that patients wish to us to achieve. These three
components that make up the smile frame are teeth, gums, and lips [1-4]. The shape,
color, and location of these components play a decisive role in the aesthetic
Corresponding author: appearance. The pink component analysis should include the following: the amount of
Cemre Vergili Yılmaz, gingiva display during a smile, the periodontal health of the gingiva, the gingival
Department of Periodontology,
contours, the aesthetic gingival line, and the presence of papillae [5].
BoluAbantIzzetBaysal University,
Faculty of Dentistry, Turkey, During a un usual smile, the healthy gingival view is 1-2 mm. The measurement is
Email: [email protected] made between the gingival edge of the central incisors and the lower border of the
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Lip Repositioning Surgery Without Myotomy to Achieve an Aesthetic Smile. SL Dentistry, Oral Disorders And Therapy. 2020;
3(1):114.
SL Dentistry, Oral Disorders And Therapy
upper lip [6-8]. Any exposure of the maxillary gingiva during report, we used lip repositioning, a minimally invasive surgical
a smile beyond 2 mm is known as a gummy smile. This situation procedure for the management of excessive gingival display.
described as the Excess Gingival Display (EGD) and gingival As an alternative to invasive surgeries, it provides low
smile [9]. This condition is often seen a sun attractive [10]. morbidity, low incidence of complications, and rapid recovery.
Excessive gingival presentation is more common in women than The primary disadvantage of the procedure is relapse. This
in men. Its prevalence is 10% of the population between the technique aims to limit the contraction of the muscles that lift the
ages of 20-30 [11,12]. lip during a smile to reduce the amount of gum that occurs
EGD during a smile may be due to Vertical Maxillary Excess during a smile [29]. With this procedure, a narrower vestibule,
(VME), anterior dentoalveolar extrusion, altered or delayed limited muscle activity and less gum appearance during a smile
passive eruption, plaque or drug-induced gingival are obtained [24].
enlargement, short or hyperactive or asymmetrical upper lip CASE PRESENTATION
(HUL), or a combination there of [7,13]. The basis of the A 22-year-old healthy girl applied to our clinic for an
treatment is the detection of the cause of a gummy smile. unsatisfactory smile (Figure 1). In clinical examination, the
Due to the short crown length, a gummy smile can be treated patient had a maxillary gingival appearance of more than 5
with periodontal approaches include gingivectomy or an mm when she smiled (Figure 2). The patient has skeletal class II
apically repositioned flap [14-17]. Vertical maxillary excess, div 1 malocclusion (vertical maxillary excess degree II).
dentoalveolar extrusion, short and/or hyperactive upper lip Orthognathic surgery or/and orthodontic treatment are
may be treated both surgically and nonsurgical [9,18-21]. needed, but the patient demanded short-term and less
EGD treatments include procedures such as orthognathic morbidity treatment. The aim was to minimize the Gingival
surgery, orthodontic treatment, detachment of lip muscles by Display (GD) in the shortest time and with a minimally invasive
myectomy and myotomy [22,23], lip elongation associated with surgical procedure.
rhinoplasty [13], lip repositioning [24], and botulinum toxin-A
injections [25].
Table 1: Vertical maxillary excess classification.
Gingival and
Degree Treatment modalities
mucosal display
Orthodontic intrusion only
I 2-4 mm Orthodontics and periodontics
Periodontics and restorative therapy
Periodontics and restorative therapy
Orthognathic surgery
II 4-8 mm The choice depends on the remaining
amount of root encased in bone and
crown to root ratio
Orthognathic surgery with or without
III ≥ 8 mm adjunctive periodontal and restorative Figure 1: Pre‑operative view smiling.
therapy complete dentofacial harmony
*Taken from Garber and Salama20
VME classification made by Garber et al. and facilitated the Intraoral and extraoral examinations of the patient were
selection of the treatment method suitable for this classification performed. Face symmetry and proportions were ordinary in
(Table 1) [20]. In the definitive diagnosis of Excessive Lip both frontal and lateral views (Figure 3,4). Her upper lip was
Motility (ELM), the appearance of teeth at rest and the measured as 15 mm (from the lower border of the upper lip to
relationship between teeth and lower lip while smiling should the sub-nasal). It was below the standard value. Maxillary
be evaluated and considered clinically regular [26]. To date, central incisor displays at rest, on average, is 6 mm. A
many treatments have been proposed for EGD due to upper periodontal examination performed. The patient's probing
lip hyper mobility and VME. However, there is no definite and depths ranged from 1 to 3. Her gingival phenotype was
accepted minimally invasive approach [12,27,28]. In this case medium. The clinical crown length was in usual anatomic
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proportions. At the same time, she had an adequate width of The patient was informed about the procedure and
the attached gingiva. The keratinized attached gingiva width post-surgical complications. Written consent was obtained from
ranged from 8 to 12 mm, and the thickness was 1-2 mm. The the patient for the surgical procedure, and the use of patient
distance between the mucogingival composition and the data and photographs. The vestibule depth, lip thickness, and
maxillary labial vestibule depth in the anterior region varies ideal gum appearance of the patient were evaluated, and the
between 4 mm and 8 mm. Smile gingival appearance was limits of the tissue to be removed were determined with a
5.5millimeters. Teeth lengths at rest and the relationship marker pen (Figure 5). Local anesthetic (%4 ArticaineHcl with
between teeth and lower lip while smiling were considered 1:200,000 epinephrine) was administered. A scalpel # 15 was
clinically expected. Thus, the hyperactive lip presence was used for the incision. The coronal incision was a partial-thickness
diagnosed. incision and located on the mucogingival junction line. It was
among the mesial of the right and left premolars. An apical
incision was made in a single line parallel to the coronal incision
and keeping the mucosa stretched. The incision line also
included labial and buccal frenulum. While the epithelial tissue
was removed, the small salivary glands in the sub mucosa were
preserved, and the underlying connective tissue was left intact
(Figure 6,7). The mucosal flap was sutured with simple
interrupted sutures using a 4-0 silk suture starting from the first
midline (Figure 8). Immediately after the operation, the
appearance of the gum when smiling varied between 3-4 mm,
Figure 2: Exposure of the maxillary gingiva during a smile and the lip length and thickness increased (Figure 9).
beyond 5 mm.
Figure 3: Gummy smile view from patient's profile.
Figure 5: Incision outline is made with a marking pencil.
Postoperative care and possible complications were explained
to the patient. The patient was instructed to avoid trauma, soft
nutrition, and ice application until the next day. It was also
suggested to limit facial movements such as laughing and
Figure 4: Orthopantomography x-ray of the patient. talking. The patient was asked not to brush teeth for ten days
and instead to shake gently with 2% chlorhexidine gluconate
[30]. Postoperative 1000 mg Augment in BID (875 mg
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Lip Repositioning Surgery Without Myotomy to Achieve an Aesthetic Smile. SL Dentistry, Oral Disorders And Therapy. 2020;
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amoxicillin hydrate and 125 mg clavulanic acid) and 25 mg
Arveles (25 mg dexketoprofen) twice a day for five days,
were prescribed. Besides, it was recommended not to use milk
and dairy products for the use of silk suture. The patient was
called for control one week later, and no complications other
than edema and pain were observed; the region was washed
with serum. Sutures were removed from the area 2 weeks later.
The patient's edema did not go away completely in the 2nd
week, and she could not smile at ease yet. At the 3rd month
check, there was a thin scar on the suture line, but it did not
Figure 8: Sutures placed.
appear when the patient smiled (Figure 10). Six months after
the procedure, the GD increased by 1 mm compared to the
third month of post-op. Her last visit was 12 months after the
operation, and the patient's lip position had almost returned to
the place before the operation, and the patient's aesthetic
complaint was renewed. However, the scar tissue formed in the
incision line was located within the framework of the smile
(Figure 11). A comparative GD is shown during the treatment
process (Figure 12).
Figure 9: The amount of gum appearance immediately
after the operation.
Figure 6: Operation View.
Figure 10: Clinical view 3 months after the operation:
increased nasolabial angle and lip thickness.
DISCUSSION
In this case report, it was aimed to decrease the quantity of
GD with lip repositioning technique in gummy smile patient with
VMEdegree-2 and HUL. The results show that the method is
successful and satisfactory in the short term (3-6 months), but in
Figure 7: The strip of the epithelium which was removed.
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the long term (12 months and later) the lip slowly returns to its extrusion, VME, short clinical crowns, and HUL. GD treatments
original position. are as follows gingivectomy, an apically repositioned flap,
orthodontic intrusion, botulinum toxin-A injections, and lip
repositioning with or without myectomy or myotomy [29].
A hyper plastic growth of the maxillary skeletal base results in
the teeth being positioned farther away from the skeletal
maxillary base and a display of gingiva below the inferior
border of the upper lip. Which defined as VME [20]. HUL is
caused by hyper function of the lip lift muscles, while the
maxillary lip length is normal at rest [38]. In simple VME
degree, I or II and in cases of HUL, lip repositioning procedure
is indicated [39,40]. Contraindications of the lip repositioning
procedure are inadequate attached gingiva and severe
vertical maxillary excess (VME III) [34]. Our case has adequate
attached gingiva and the vertical maxillary protrusion is not
advanced.
The technique was initially defined as cosmetic surgery to
correct the gummy smile caused by the HUL [24]. It was later
used for the management of a case with a short upper lip [22].
Figure 11: Clinical view 12 months after the operation: Later; the original method was modified to include myectomy
recurrence ofexcessive gingival display and scar and partial resection of the levator labii superioris [23]. The
formation in the smile line.
purpose of the modification was to reduce the risk of
recurrence with muscle resection, but postoperative
paraesthesia complications were reported. The procedure was
used much later, with an elliptical-shaped incision of 10-12 mm
breadth in partial-thickness and without any process on the
muscles, and good results were reported for a maximum
follow-up period of 8 months [34,41]. In one of the studies in
which the method was used in VME and HUL patients, it was
suggested to remove the mucosa so that it was twice the width
of the visible gum, and they achieved excellent results over a
year [39]. In the other study, an etiology-therapy protocol was
presented for clinicians [40]. The main disadvantage of the
process is relapse. When recurrence occurs, surgery can be
Figure 12: Comparative gingival appearance in the
repeated to include more mucosa, or botulinum toxin-A may be
treatment process.
administered as recommended in other studies
Although smile aesthetics vary according to the societies, the [34,39,40,42,43]. Botulinum toxin-A injections for treatment of
appearance of GD more than 3 mm is considered as a non- excessive gingival display is indicated when the patient
aesthetic condition in the common denominator [29,31,32]. In presents with GD upon smiling that exceeds 2 mm and at least
the literature, there are many etiologies of excessive gingival one of the following: the primary cause of GS is muscle
manifestation and various treatments [9,14,16,20,22-24,33- hyperactivity, the patient opts for the least invasive treatment,
37]. Etiologies include altered passive eruption, dentoalveolar the patient requests a temporary treatment while awaiting
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definitive surgery, or treatment is a complement to surgical believed that only an optimal result will be obtained in this
treatment [27]. way.
Common postoperative complications are swelling, bruising, CONFLICT OF INTEREST
some restrictions of lip movement and paraesthesia. Mucocele The authors declare that they are no conflict of interest in this
is a rare complication [22-24,39,40]. It has been demonstrated study.
by various authors that the procedure with good prognosis and REFERENCES
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