Lip Repositioning Technique With Smile Elevator Muscle Containment – A Novel Cosmetic Approach for Gummy Smile: Case Report

Gustavo Javier Salazar Littuma, DDS, MSc; Humberto Cherem Mendez de Souza, DDS; Gabriella Mercedes Peñarrieta, DDS, MSc; Ricardo de Souza Magini, DDS, MSc, PhD; and Eduardo Saba-Chujfi, DDS, MSc, PhD

An attractive smile depends on the proper proportion and arrangement of three components: teeth, gingivae, and lips.^1,2 The upper lip should symmetrically expose up to 3mm of gingiva, and the gum line must follow the contour of the upper lip.² Excessive gingival display (EGD), commonly called gummy smile, is the term used when there is an overexposure of maxillary gingivae during a smile.³ EGD has received increased emphasis in recent years, as it affects a significant proportion of the population with a reported prevalence between 10.5% and 29% of people between the ages of 20 and 30 years.⁴

In addition to patients’ esthetic concerns, the incidence of this condition is frequently associated with different etiologies such as altered passive eruption, anterior dentoalveolar extrusion, vertical maxillary excess, and short and hyperactive upper lip.^2,5 To establish an appropriate treatment plan, knowledge of the etiology of the EGD and an accurate diagnosis are needed.^2,5 In such cases, various surgical techniques have been reported in medical literature with variable outcomes; these include botulinum toxin injection,^6,7 lip elongation associated with rhinoplasty,⁸ detachment of the lip muscles,⁹ myectomy,¹⁰ and lip repositioning.^11,12

The treatment of EGD by esthetic crown lengthening with or without osseous resection is well described in literature.^13,14 Dentoalveolar extrusion can be treated with orthodontic therapy, and vertical maxillary excess in which there is a enlarged dimension of the midface with incompetent lips can be treated with orthognathic surgery, however this surgery is associated with significant morbidity and hospitalization.^12,15

This article presents a case report that demonstrates a surgical procedure for EGD that combines a lip repositioning technique and suture traction with containment of the smile elevator muscles, which is performed after removing a strip of mucosa from the maxillary buccal vestibule, minimizing the risk of postoperatory lip relapse toward its original position, as described in the literature.^15,16 By combining these two surgical procedures, retraction of the smile elevator muscles will be limited, helping to achieve a stable and esthetically pleasant result.

Case Report

A 25-year-old female patient was referred to the Department of Implant Dentistry at the Federal University of Santa Catarina, Brazil with the chief complaint of being dissatisfied with an excessive amount of gingiva exposed while smiling. The patient’s medical history revealed systemic health, with no contraindication for surgery. Through extraoral clinical examination, symmetric facial thirds as well as a normal upper lip length of 20 mm were found. It was verified with a fully dynamic smile that the patient’s teeth were visible from the maxillary right first molar to the maxillary left first molar, with 4 mm to 5 mm of gingival display. At intraoral examination, healthy periodontal tissue with an adequate width of attached gingivae was found along with average tooth proportion (Figure 1).

The etiology of the EGD could be attributed to hyperactive upper lip. After discussion of treatment alternatives and the possible complications of lip repositioning, patient informed consent was received. Oral hygiene instructions were given. The surgical planning began with the use of methylene blue to outline the proposed incisions on dried tissues at a distance of two times the amount of gingival display (Figure 2). The surgical procedure was initiated after adequate local anesthesia (2% lidocaine with 1:100,000 epinephrine) in the vestibular mucosa and lip from the maxillary right first molar to the maxillary left first molar. A partial-thickness “v”-shaped horizontal incision was made with a No. 15 C blade 1 mm coronally to the mucogingival line, from the midline frenum to the first molar region, followed by a second partial-thickness incision parallel to the first incision 8 mm to 10 mm apical to the mucogingival junction. Finally, the two incisions were joined on both sides and a strip of outline mucosa was removed, leaving the underlying connective tissue exposed (Figure 3). Minor salivary glands were removed when necessary.

Once the lip muscle bundle fibers were identified on both sides of the maxilla, the suture containment of the smile elevator muscles, including the orbicularis oris (OO), levator labii superioris (LLS), levator labii superioris alaeque nasi (LLSAN), and zygomaticus minor (Zm), was initiated using an absorbable suture (VICRYL 4.0, Ethicon, ethicon.com). The suture was started by grasping the bundle of muscle fibers from the OO on either side of the middle line with an interrupted suture (Figure 4). Subsequently, at the height of the lateral incisors and canines, the suture needle entrance followed the same direction starting from distal to mesial on both sides of the surgical area. First, the left muscle bundle fibers of the LLS and LLSAN were grasped and pulled downward using a sling suture, which allows the fibers to be maintained close to their medial and lateral bands before continuing the same procedure on the right side (Figure 5).

Then, at the height of the angle corner of the mouth, the Zm muscle fibers from the left and right sides were properly grasped following the same steps described above, holding the same amount of tissue with an adequate tension (Figure 6). Consequently, after grasping the LLS, LLSAN, and Zm muscle bundle fibers, the suture needle was returned to the anchor starting point by grasping the OO again, engaging all the suture threads together with a surgeon’s knot. This helps to maintain the lip in a coronal position and avoid dislocation, keeping it completely immobilized (Figure 7). A second sling suture is then used on both sides of the surgical area, following the same steps described above, ensuring containment of the smile elevator muscles with equilibrated tension (Figure 8).

The procedure was concluded by approximating the midline tissues first, using VICRYL 5.0 (Ethicon) with single interrupted suture to ensure symmetry and proper lip midline placement with the midline of the teeth (Figure 9). The remaining wound margins were approximated with interrupted sutures (Figure 10).

Postoperative prescriptions included amoxicilin 500 mg, 3 times a day for 5 days; meloxicam 15 mg, 2 times a day for 3 days; paracetamol 500 mg, 4 times a day for 3 days; and a gentle bathing with 0.12% chlorhexidine gluconate 2 times a day for 2 weeks. The patient was instructed to apply ice pack, avoid any mechanical trauma in the surgical site, and minimize lip movement when smiling and talking for 2 weeks. 

Sutures were removed 2 weeks postoperatively. The patient reported mild pain and tension while smiling or talking for 1 week. A minor scar was formed on the suture line but remained invisible during smiling (Figure 11). A follow-up examination 12 months later showed a reduction in the patient’s EGD (Figure 12).

Discussion

An EGD is an esthetic concern that affects a large portion of the population.⁴ Knowledge of the etiologic factor is mandatory in order to produce a correct treatment plan.¹⁷ Several surgical techniques have been proposed to reduce EGD. The original technique initially used in plastic surgery was first described in 1973 by Rubinstein and Kostianovsky.¹⁸

In 1978, Litton and Fournier⁹ advocated for performing detachment of muscles from the bony structures in cases of short upper lip. A more aggressive approach reported by Miskinyar¹⁰ in 1983 included myectomy and partial resection of the LLS. Ellenbogen and Swara¹⁹ have proposed another method limiting lip elevation on smiling by placing a silicon spacer between elevator muscles of the lip and the anterior nasal spine. 

Ronsenblatt and Simon¹¹ used an elliptical-shaped incision at the mucogingival junction and the alveolar mucosa, reflecting a partial-thickness flap and removing a strip of the mucosa. Humayun²⁰ described the same surgical procedure, which consisted of removal of an elliptical band of epithelium followed by a coronal advancement of the flap. Silva²¹ introduced a modification of the technique by removing two strips of the mucosa, bilaterally to the maxillary labial frenum, repositioning the new mucosal margin coronally. Storrer²² reported a novel surgical technique with gingival recontouring and containment of the elevator muscles of the upper lip and wing nose for the treatment of gummy smile. 

Multiple authors have presented case reports of patients successfully treated by lip repositioning technique, with approximately 4 mm of reduction in gummy smile being achieved,^11,12,19 and most cases appearing stable with a follow-up period of 6 months.^15,16,23

In 2013, Silva et al reported successful management of EGD with a high satisfaction rate after 2.5 years.²¹ In a survey, 70% of the patients said that the postoperative amount of gingival display was “about right,” and more than 90% reported that they would undergo the procedure again.²¹ Nevertheless, despite the short-term results reported in the dental literature, additional studies with long-term outcomes are needed.¹⁷

Regardless, hypermobility of the maxillary lip can be managed by a lip stabilization technique.^11,12,17,20 An examination of the amount of translation of the maxillary lip from the rest position to that seen during a dynamic smile is relevant to identify whether an excessive mobility of the lip is present.¹⁷

In the present case report, the patient was found to have EGD due to hypermobility of the maxillary lip with a gingival display of 4 mm to 5 mm in a dynamic smile. Through an ambulatory procedure, the combination of a lip stabilization technique with the traction and containment of the smile elevator muscles (OO, LLS, LLSAN, Zm) described by Saba-Chujfi²⁴ allowed a pleasant and stable result to be achieved within a 1-year follow-up without lip relapse to its original position or further postoperatory complication such as the formation of mucocele, paresthesia, or transient paralysis as reported in the literature.^11,12

To execute a proper technique requires an accurate diagnosis and an appropriate clinical evaluation and case selection, as these are essential for a surgical treatment.²³ Having a good understanding of the anatomy, location, and insertion of the lip elevator muscles is necessary, as this will enhance execution of an appropriate bilateral containment suture.²²

Contraindication for lip repositioning surgery includes inadequate width of attached gingiva because of the difficulties of performing a flap reflection, stabilization, and suturing.^11,12 Also, patients with severe vertical maxillary excess (>8 mm) are not candidates for a lip repositioning technique, but instead require an interdisciplinary approach that includes orthognathic, orthodontic, and periodontal therapy_.^17,20

With regard to a suture technique, the sling suture allows the stabilization of the muscle bundle on both sides of the surgical area. The direction of the sutures induces an immobilization of the lip with a symmetric balance, avoiding lip movement upward during smile.

Conclusion

The present case report described a predictable procedure for excessive gingival display. The association of a lip repositioning technique with the traction and containment of the lip elevator muscles using a sling suture demonstrated a good esthetic outcome with reliable stability at the 1-year follow-up. Additional clinical trials and long-term studies that involve a larger patient sample are necessary to evaluate the effectiveness and stability of this technique as a treatment modality for gummy smile.

About the Authors

Gustavo Javier Salazar Littuma, DDS, MSc
Master student in Implantology
Federal University of Santa Catarina
Florianópolis, Brazil

Humberto Cherem Mendez de Souza, DDS
PhD student in Implantology
Federal University of Santa Catarina
Florianópolis, Brazil

Gabriella Mercedes Peñarrieta, DDS, MSc
PhD student in Implantology
Federal University of Santa Catarina
Florianópolis, Brazil

Ricardo de Souza Magini, DDS, MSc, PhD
Associate Professor
School of Dentistry
Federal University of Santa Catarina
Florianópolis, Brazil

Eduardo Saba-Chujfi, DDS, MSc, PhD
Associate Professor
School of Dentistry
São Leopoldo Mandic
Campinas, Brazil

References

1. Gill DS, Naini FB, Tredwin CJ. Smile aesthetics. Dent Update. 2007;34(3):152-157.

2. Garber DA, Salama MA. The aesthetic smile: diagnosis and treatment. Periodontol 2000. 1996;11:18-28.

3. Allen EP. Use of mucogingival surgical procedures to enhance esthetics. Dent Clin North Am. 1988;32(2):307-330.

4. Dong JK, Jin TH, Cho HW, Oh SC. The esthetics of the smile: a review of some recent studies. Int J Prosthodont. 1999;12(1):9-19.

5. Silberberg N, Goldstein M, Smidt A. Excessive gingival display–etiology, diagnosis, and treatment modalities. Quintessence Int. 2009;40(10):809-818.

6. Polo M. A simplified method for smile enhancement: botulinum toxin injection for gummy smile. Plast Reconstr Surg. 2013;131(6):934e-935e.

7. Mazzuco R, Hexsel D. Gummy smile and botulinum toxin: a new approach based on the gingival exposure area. J Am Acad Dermatol. 2010;63(6):1042-1051.

8. Ezquerra F, Berrazueta MJ, Ruiz-Capillas A, Arregui JS. New approach to the gummy smile. Plast Reconstr Surg. 1999;104(4):1143-1150.

9. Litton C, Fournier P. Simple surgical correction of the gummy smile. Plast Reconstr Surg. 1979;63(3):372-373.

10. Miskinyar SA. A new method for correcting a gummy smile. Plast Reconstr Surg. 1983;72(3):397-400. 

11. Rosenblatt A, Simon Z. Lip repositioning for reduction of excessive gingival display: a clinical report. Int J Periodontics Restorative Dent. 2006;26(5):433-437.

12. Simon Z, Rosenblatt A, Dorfman W. Eliminating a gummy smile with surgical lip repositioning. J Cosmet Dent. 2007;23(1):100-108.

13. Lee EA. Aesthetic crown lengthening: classification, biologic rationale, and treatment planning considerations. Pract Proced Aesthet Dent. 2004;16(10):769-758.

14. Mahn DH. Elimination of a “gummy smile” with crown lengthening and lip repositioning. Compend Contin Educ Dent. 2016;37(1):52-55.

15. Dayakar MM, Gupta S, Shivananda H. Lip repositioning: an alternative cosmetic treatment for gummy smile. J Indian Soc Periodontol. 2014;18(4):520-523.

16. Jacobs PJ, Jacobs BP. Lip repositioning with reversible trial for the management of excessive gingival display: a case series. Int J Periodontics Restorative Dent. 2013;33(2):169-175.

17. Bhola M, Fairbairn PJ, Kolhatkar S, et al. LipStaT: The lip stabilization technique – indications and guidelines for case selection and classification of excessive gingival display. Int J Periodontics Restorative Dent. 2015;35(4):549-559.

18. Rubinstein A, Kostianovsky A. Cirugia estetica de la malformacion de la sonrisa. Pren Med Argent. 1973;60:952.

19. Ellenbogen R, Swara N. The improvement of the gummy smile using the implant spacer technique. Ann Plast Surg. 1984;12(1):16-24.

20. 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(12):1858-1863.

21. Silva CO, Ribeiro-Júnior NV, Campos TV, et al. Excessive gingival display: treatment by a modified lip repositioning technique. J Clin Periodontol. 2013;40(3):260-265.

22. Storrer CL, Valverde FK, Santos FR, Deliberador TM. Treatment of gummy smile: Gingival recontouring with the containment of the elevator muscle of the upper lip and wing of nose. A surgery innovation technique. J Indian Soc Periodontol. 2014;18(5):656-660.

23. Ribeiro-Júnior NV, Campos TV, Rodrigues JG, et al. Treatment of excessive gingival display using a modified lip repositioning technique. Int J Periodontics Restorative Dent. 2013;33(3):309-314.

24. Saba-Chujfi E. Cirugía para corrección y reducción de la sonrisa gingival de Saba-Chujfi de 2007. In: Cirugías Plásticas Periodontales y Periimplantarias - Atlas Simplificado de las Propuestas Técnicas. 1a Edición. São Paulo, Brazil: Editora Santos - GEN; 2009:214-217.