Scholars Journal of Dental Sciences (SJDS) ISSN 2394-496X (Online)

Sch. J. Dent. Sci., 2015; 2(6):383-387 ISSN 2394-4951 (Print)

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Case Report
Treatment of gingival display using a Lip Repositioning Technique: A literature
review with case report
Jalaleddin H Hamissi
Associate Professor in periodontics and Implant Dentistry, College of Dentistry, Qazvin University Medical Sciences,
Qazvin, Iran.

*Corresponding author
Dr. Jalaleddin, H. Hamissi
Email: jhamissi@gmail.com

Abstract: The objective of this prospective study was to investigate outcomes of a lip repositioning technique for the
treatment of excessive gingival display by limiting the retraction of the elevator smile muscles. One of the most
important goals of clinicians is to meet the esthetic expectations of the patients. Excessive gingival display during
smiling is defined as gummy smile; and lip repositioning procedure may be an alternative in the treatment of some
gummy smile cases. This article reports ahealthy32-year old female with complaint of excessive gingival display upon
smiling. The lip repositioning technique was performed under local anesthesia with the main objective of reducing
gummy smile. The technique is fulfilled by removing a strip of mucosa from the maxillary buccal vestibule, creating a
partial-thickness flap between mucogingival junction and upper lip musculature junction. This case report demonstrates
the successful management of a lip-repositioning procedure in a patient with incompetent short upper lip. This was
accomplished by resulting in a narrow vestibule, thereby reducing gingival display and suturing the lip mucosa to the
mucogingival line. This clinical report describes the successful use of lip repositioning technique. At the 1-year follow-
up, it was observed that the results were maintained and patient was satisfied with her clinical appearance. Lip
repositioning procedure performed in the accurate indication may be an alternative in the treatment of gummy smile.
Keywords: Gummy smile; Excessive gingival display; Lip repositioning; Periodontal plastic surgery.

INTRODUCTION another of the main causes, muscular hyper-activity,

Smile is considered as an important aesthetic which can result in an unsatisfactory outcome even after
reference; therefore, the study and technique of this orthognathic surgery. Another factor is over-eruption
changes lead to its disharmony have played a rather which can with difficulty be treated with orthodontic
more relevant role within dentistry. Gingiva excessive intrusion and finally merely a short upper lip which is
exposure during smile is referred to as “gummy smile”, rare[8- 11].The lip repositioning technique was first
being diagnosed in cases where, during smile, gingival described1973 by Rubenstein and Kostianovsky as part
display measures more than 3 mm from its margin up to of medical plastic surgery [9]. Later on, it was
the upper lip line [1, 2, 3]. Good appearance is not introduced in dentistry, after being modified in year
considered a pride sign, but precisely is a needed, and 2006by Rosenblatt and Simon[10].
the dentistry has a fundamental role to obtain it, since
the face is the exposed area and the mouth a prominent The Benefits of Lip Repositioning
line of the body [4, 5]. A smile expresses a feeling of  Lip repositioning exposes a consistent,
joy, success, sensuality, liking and good manners, and proportional amount of teeth and gums.
reveals self-assurance and sympathy [6]. Gummy smile  Recovery is very fast. Only local anesthesia is
in severe cases, the overexposure is present in used and because the repositioning takes place
repositioning of the mouth and lips. The hyperactivity inside the mouth, there is no external scarring.
of the elevator muscle of the upper lip is one of the After lip repositioning, we often see our
main causes of a gummy smile, and several techniques patients smile confidently for the first time.
have been proposed for its treatment [7]. Our patients claim to have improvements in
confidence not only in their appearance, but
The etiology of the extreme high lip line is also in their relationships and communication.
often multi-factorial, a combination of the four main
causes. Skeletal deformity often leads to the most
difficult cases and they are often associated with
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Pre-procedural assessment SUPA.Co. Theran, Iran) sutures (2 in the frontal part,1

Prior to developing a suitable treatment plan, it is above the canine area, and 1 between the second
essential to establish a complete and accurate premolar and the first molar bilaterally) were placed.
assessments of the conditions with which the patient Suture design involved a vertical tissue bite taken at the
presents. Reasons for seeking treatment: superior border in the movable mucosa, a horizontal
a. Assessment of systemic health and habits; tissue bite at the mucogingival junction, and inverting
b. Height and symmetry of face; and tucking behind the tissue proposed for excision.
c. Thickness, length, and profile of lips; The treatment plan consisted of reversible lip
d. Smile line; repositioning and definitive surgical repositioning.
e. Condition and dimensions of teeth;
f. Width of keratinized gingiva; Patient was discharged with all post-surgical
g. Gingival biotype; and instructions and medications for five days which
h. Facial and lingual bone levels, thickness of included analgesic (Tedaphen® 400 mg Tehran Darou
alveolar. Co, Iran)QID daily for five days, antibiotic
(Amoxicillin 500 mg TDS for five days), along with
CASE REPORT cold packs extra orally to decrease post-surgical
Patients profile, pre-surgical evaluation, and consent swelling. Extra oral and intraoral antisepsis was
This clinical report presents a case of a young performed with 2.0% chlorhexidine solution (Share
female patient with an EGD larger than 10 mm during Drau, Tehran, Iran) rinse for 1 minute.Initial anesthesia
smiling caused by a combined etiology of a hyperactive consisted of bilateral infraorbita lblocks (2% Lidocaine
upper lip and altered passive eruption of the frontal with 1:200,000 Epinephrines). No periodontal dressing
maxillary teeth. The treatment plan consisted of a was placed.
modified lip repositioning technique with a reversible
clinical trial. Post-operative management
The patient was visited for follow-up the day
A systematically healthy 32-year-old woman after surgery. Post‑operative instructions included soft
came to private clinic in Qazvin, Iran. Her chief diet, limited facial movements, no brushing around the
complaint was excessive gingival display during surgical site for 14 days and placing ice packs over the
smiling. There was no significant medical or family upper lip. The patient was instructed to rinse gently
history and the patient was medically sound fit; no with 0.2% Chlorhexidine Gluconate twice daily for 2
tobacco habit and not take any medication reported for weeks. Post‑operative Amoxicillin 500 mg T.D.S and
the surgical procedure. Prior to surgery, the patient was Tedaphen® 400 mg (Tehran Darou Co, Iran) B.D for 5
submitted to basic periodontal therapy, and the sites days were prescribed. She complained of tension while
operated did not present, bleeding on probing, or talking or smiling, it was lasted for a week. Sutures
probing depth higher than 3 mm, her chief complaints were removed at 14 days.
were reported displeasure with the amount of gingiva
exposed while smiling and her treatment goal was to Post-operative healing was uneventful and she
minimize the gingival display during smiling. revealed minimal discomfort for few days. A minor scar
On clinical examination extra orally, the face was formation appeared along the suture lines. The 1-year
bilaterally symmetrical with incompetent lips. follow-up displayed a reduction of gingival display with
Intraorally, a severe gingival display was seen during minor scar formation. The patient was satisfied with her
smiling which extended from the maxillary right first clinical appearance.
premolar to the maxillary left first premolar. Treatment
options mentioned above were then explained to the
patient. In accordance with the patient choice of
therapy, a lip repositioning surgery was scheduled.
Before surgery, the patient signed the informed consent.
A written informed consent was taken and the patient
was educated about post‑surgical complications such as
possible scar formation, mucocele formation,
post‑operative bruising and extra oral swelling.

Surgical Procedure
Two hours before surgery Dexamethasone amp
were injected; Local anesthetic (Xylocaine with
1:200,000 adrenalines: Daro-Pakhsh, Tehran, Iran) was Fig-1:Pre-treatment clinical view with excessive
administered. A marking pen was used to outline the gingival display upon smiling.
apical, coronal and lateral boundaries of the elliptical
incision which was 1.5 the length of the repositioning
desired in the patient„s smile. Eight4.0 nylon (Supaniy®
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Fig-2: Exposed submucosa after removal of the Fig- 6:Clinical appearance upon smiling at 1 year
mucosal strips later.

DISCUSSION
This report documents the use of Lip
Repositioning Surgery(LRS) for the management of
Excessive Gingival Display (EGD) seen with a SUL.
The original technique for the procedure was described
as cosmetic surgery[14]. The lip repositioning technique
is an excellent alternative to more costly procedures
with higher morbidity rates[19, 20]. The lip reposition
surgery was originally described in the medical
literature in 1973 [8]. This surgical procedure reported
no complications but there were reports of relapse.

Fig-3:Intra-oral appearance following suturing Previous studies reported that a relapse can
using nylon with interrupted sutures for occur after lip repositioning surgery [12-14]. One of the
stabilization of the new mucosal margin to the most important predisposing factors for relapse is the
gingiva. presence thin biotype [15, 16]. In our case, no relapse
occurred through 1 year of follow-up. Thick biotype in
our patient probably played the key role in this
outcome. Although having not occurred in our case,
asymmetry upon smiling could have been encountered
as another important complication. This complication
was avoided by keeping labial frenulum intact at
midline during the surgical procedure. Same amounts of
vertical incisions i.e., 12 mm on both sides of maxilla
allowed removal of equal amounts of mucosa on right
and left operation regions[5].Various techniques have
been used in the treatment of gummy smile such as
myectomy, botulinum toxin injection, lip elongation
(associated with rhinoplasty), detachment of lip muscles
Fig-4:Post- operative two week following removal of [17, 18]. Dental clinicians would select the least
sutures. invasive and more simple and predictable treatment
choice in such cases. Lip repositioning performed in our
patient serves as a good sample.

This case presentation aimed to present the

one-year outcome for a gummy smile treated with lip
repositioning surgery which demonstrated hyperactive
upper lip. In this case, 12 mm of mucosa was removed
as the other investigators [21, 22] suggested without any
prediction on the amount of reduction in gingival
display. Accurate diagnosis and a pertinent case
selection are critical for the success of any LR
procedure. Contraindications to LR surgery include the
presence of a minimal zone of attached gingiva, which
Fig-5:Clinical appearance after 6 months can create difficulties in flap design, stabilization, and

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suturing, and severe VME (>8 mm of gingival display) 2. Garber DA, Salama MA; The aesthetic smile:
[14, 15]. Diagnosis and treatment. Periodontol, 1996; 2000;
11:18–28.
There are some contraindications for lip 3. Silberberg N, Goldstein M, Smidt A; Excessive
repositioning surgery including inadequate width of gingival display–Etiology,diagnosis, and treatment
attached gingiva in maxillary anterior sextant. modalities. Quintessence Int., 2009; 40:809‑18.
Insufficient amount of tissue poses difficulty in flap 4. Simon J; Using the golden proportion in aesthetic
reflection, stabilization and suturing. Patients with treatment: A case report. Dent Today, 2004; 23: 82,
severe vertical maxillary excess cases are also not the 84.
ideal candidates for lip repositioning and would be 5. Arayan S, Narayan TV, Jacob PC; Correction of
treated with orthognathic surgery [9]. gummy smile: A report of two cases. J Indian Soc
Periodontol, 2011; 15:421-4.
In a study by Jacobs and co-worker reported in 6. Humayun N, Kolhatkar S, Souiyas J, Bhola M;
a case series study of seven patients which were Mucosal coronally positioned flap for the
successfully managed with trial, and then definitive, lip management of excessive gingival display in the
repositioning wherein a mean reduction in gingival presence of hypermobility of the upper lip and
display of 6.4 ± 1.5 mm were achieved [22]. Riberio- vertical maxillary excess: A case report. J
Junior and collogues have already reported that no Periodontol, 2010; 81:1858–63.
correlation existed between the amount of tissue 7. Ribeiro-Júnior NV, Campos TV, Rodrigues JG,
removed and reduction of gingival display [7]. Martins TM, Silva CO; Treatment of excessive
gingival display using a modified lip repositioning
Precautions while surgery technique. Int J Periodontics Restorative Dent.,
a) Care must be taken to avoid damage to minor 2013; 33(3):309-14.
salivary glands in sub mucosa. 8. Rubenstein A, Kostianovsky A; Cosmetic surgery
b) Some cases with rare complication reported in for the malformation of the laugh: Original
the literature are paresthesia [23] and transient technique. Prensa Med Argent;1973; 60: 952
paralysis [24]. 9. Rosenblatt A, Simon Z; Lip re-positioning for the
c) Clinicians must look for adequate width of reduction of excessive gingival display; a clinical
attached gingiva. report. Int J Periodontics Restorative Dent, 2006;
d) Do not perform the procedure with patients 26: 433-37.
having vertical maxillary excess, in such cases 10. Fairbairn P; Lip Repositioning surgery. Esthetic
orthognathic surgeries is the solution. and Implant dentistry, 2006; 9: 33-37
11. Fairbairn P; Lip repositioning surgery– a
CONCLUSION photographic guide. Aesthetic Dentistry Today,
Lip repositioning procedure is an effective way 2007; 1: 66-73.
of reducing the excessive gingival display (EGD) and 12. Deodhar AK, Rana RE; Surgical physiology of
itsappears to be a promising alternative treatment option wound healing: a review. J Postgrad Med., 1997;
for excessive gingival display. However, long-term 43: 52-56.
stability of the results needs to be seen. Both the patient 13. Naini FB, Gill DS; Facial aesthetics: 1.Concepts
and the clinicians were satisfied with the final outcome. and clinical assessment. 2. Clinical assessment.
Treatment of excessive gingival display by means of a Dent Update. 2008; 35:102-170.
modified lip repositioning technique results in high 14. Rosenblatt A, Simon Z; Lip repositioning for
level of patient satisfaction and predictable outcomes reduction of excessive gingival display: A clinical
that are stable in the short term [20]. report. Int J Periodontics Restorative Dent, 2006;
26: 433-7.
Acknowledgement 15. Simon Z, Rosenblatt A, Dortman W; Eliminating a
The author would like to thank Dr. Zahra gummy smile with surgical lip repositioning. J
Alizadeh Tabari for all her kind support required for the Cosmetic Dent, 2007; 23: 100-8.
case report and preparation of the manuscript. 16. Ezquerra F, Berrazueta MJ, Ruiz-Capillas A,
Arregui JS; New approach to the gummy smile. J
REFERENCES Plast Reconstruct Surg, 1999; 104: 1143-50.
1. Salimon Ribeiro F, Castro Garção FC, Tadeu 17. Litton C, Fournier P; Simple surgical correction of
Martins A, Sakakura E, Egbert Corrêa de Toledo the gummy smile. Plast Reconstr Surg, 1979; 63:
B, Farias Pontes A E ; A modified technique that 372-3.
decreases the height of the upper lip in the 18. Silberberg N, Goldstein M, Smidt A; Excessive
treatment of gummy smile patients: A case series gingival display-etiology, diagnosis, and treatment
study. Jof Dent and Oral Hygiene, 2012; 4(3):21- modalities. Quintessence Int., 2009; 40:809-18.
28. 19. Ishida LH, Ishida LC, Ishida J, Grynglas J, Alonso
N, Ferreira MC; Myotomy of the levator labii
superioris muscle and lip repositioning: A

386
Jalaleddin H Hamissi., Sch. J. Dent. Sci., Vol-2, Iss-6 (Oct, 2015), pp-383-387

combined approach for the correction of gummy

smile. Plast Reconstr Surg, 2010; 126(3): 1014
20. Simon Z, Rosenblatt A, Dortman W; Eliminating a
gummy smile with surgical lip repositioning.
Cosmet Dent, 2007; 23: 102-108.
21. Silva CO, Riberio-Junior NV, Campos TVS,
Rodriguez J, Tatakis D; Excessive gingival display:
Treatment by a modified lip repositioning
technique. J Clin Periodontol, 2013;40: 260-265.
22. Jacobs P J, Jacobs BP; Lip repositioning with
reversible trial for the management of excessive
gingival display: A case series. Int J Periodontics
Restorative Dent, 2013; 33:169-75
23. Miskinyar SA; A new, method for correcting a
gummy smile. Plast Reconstr Surg. 1983; 72:397–
400.
24. Kamer F; “How do I do it”: Plastic surgery.
Practical suggestions on facial plastic surgery,
smile surgery. Laryngoscope. 1979; 89:1528–32.

387