Journal of Indian Society of Periodontology
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   Table of Contents    
CASE REPORT
Year : 2021  |  Volume : 25  |  Issue : 4  |  Page : 355-359  

Modified laser-assisted lip repositioning surgery to treat gummy smile


1 Laser Dentistry-Multispeciality Dental Laser Lounge, G1 Sea Pebble, Perry Cross Road, Bandra(W), Mumbai, Maharashtra, India
2 Department of Periodontology, Kalinga Institute of Dental Sciences, KIIT Deemed to be University, Bhubaneswar, Odisha, India
3 Diagnopein Diagnostic Centre, Tempo Chowk, Wadgaon Sheri, Pune, Maharashtra, India

Date of Submission01-Feb-2020
Date of Decision24-Sep-2020
Date of Acceptance11-Oct-2020
Date of Web Publication01-Jul-2021

Correspondence Address:
Aditi Chaudhary
Dentistry - Multispeciality Dental Laser Lounge, G1 Sea Pebble, Perry Cross Road, Bandra (W), Mumbai - 400 050, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jisp.jisp_65_20

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   Abstract 


Excessive gingival display (EGD), known as “gummy smile,” is a major esthetic hurdle in today's population. The condition occurs due to various etiologies such as skeletal, dentoalveolar, or soft-tissue origin. The treatment modalities range from orthognathic surgery to periodontal plastic procedures. Lip-repositioning surgery (LRS) is a better alternative for the conventional orthognathic surgery and laser-assisted LRS can be a reliable and a less invasive alternative to conventional (scalpel) LRS. The present case describes the successful treatment of a young female exhibiting an EGD caused by hypermobility of the upper lip and was treated with a modified laser-assisted LRS coupled with gingival recontouring. In a study published earlier, a mild recurrence was observed and hence, to overcome the recurrence, a modified technique, by excising a strip of mucosa with an additional 2 mm of tissue along with the muscular attachment rather than scraping, was attempted.

Keywords: Crown lengthening, diode laser, excessive gingival display, gummy smile, lip-repositioning surgery


How to cite this article:
Farista S, Chaudhary A, Manohar B, Farista S, Bhayani R. Modified laser-assisted lip repositioning surgery to treat gummy smile. J Indian Soc Periodontol 2021;25:355-9

How to cite this URL:
Farista S, Chaudhary A, Manohar B, Farista S, Bhayani R. Modified laser-assisted lip repositioning surgery to treat gummy smile. J Indian Soc Periodontol [serial online] 2021 [cited 2021 Sep 19];25:355-9. Available from: https://www.jisponline.com/text.asp?2021/25/4/355/319672




   Introduction Top


Esthetics today has become a major demand for the fast-growing population. An esthetic or pleasing smile is a result of the interaction between the teeth, the lip framework, and the gingival scaffold.[1] A medium smile line with a minimum gingival display is considered to be the most pleasing.

Ideally, clinical crown lengths of the maxillary central incisors and cuspids should be compatible with the laterals being comparatively shorter. This tooth length relationship should extend posteriorly to provide a smooth, front to back progression with the bicuspid teeth visible at the corners of the buccal vestibule. Approximately 1–2 mm of the gingiva should be exposed at the lateral incisors.[2] Each tooth exhibits a distinct incisogingival and mesiodistal width, which in harmony builds a maxillary unit, and is usually pleasing. An ideal ratio is usually 10:8.[3]

The lips form smile framework and also mark the esthetic zone. The lip line classification has been done as low, medium, and high. A low lip line is stated when only a portion of the teeth exposure is below the inferior border of the upper lip. A medium lip line is stated when there is gingival exposure of 1–3 mm from the apical extent of free gingival margin to the inferior border of the upper lip. A high lip line is stated when >3 mm gingival exposure extending from the inferior border of the upper lip to free gingival margin is seen, which is often termed as “gummy smile” or excessive gingival display (EGD).[4]

A healthy but irregular gingival arrangement may disturb the esthetic balance among teeth, lip, and gingival scaffold. Therefore, gingival esthetics is significantly dependent on the contour progression (gingival zenith) from incisor to canine and should follow in a parabolic manner.

EGD results from varied etiologies:[1],[5] altered/delayed passive eruption, compensatory eruption, vertical maxillary excess, hypermobile upper lip/or short upper lip, and dentoalveolar extrusion.

The treatment of EGD should include a proper diagnosis including factors that dictate the underlying cause of gummy smile. Hypermobile upper lip due to hyperfunction of the lip elevator muscles often shows EGD. It is considered a primary etiology in EGD when maxillary lip length is in normal range and the lower third of the face is proportionate to the remaining third. The modalities for correcting a gummy smile due to Hyperactive Upper Lip (HUL) include esthetic lip surgery (lip-repositioning surgery [LRS]),[6] botulinum toxin injection,[7] detachment of lip muscles, myotomy, and lip elongation associated with rhinoplasty.

The intention of LRS is to reduce gingival display by restricting the retraction of lip elevator muscle. The procedure is performed by excising a strip of mucosa from the maxillary buccal vestibule, creating a partial-thickness flap between mucogingival junction (MGJ) and upper lip musculature. Following this, the lip mucosa is sutured to the mucogingival line, resulting in a narrower vestibule and a limited muscle pull, thereby minimizing the gingival display upon smiling. The former technique done using a scalpel resulted in few postoperative complications with enhanced postoperative morbidity including severe discomfort, bruising, paresthesia, upper lip swelling, and mucocele formation.

Hence, in the present report, along with the use of laser, an incision (partial thickness) was made at the MGJ, and the whole epithelium with a layer of connective tissue was excised in the elliptical outline along with frenum and its muscular attachment, exposing the remaining underlying connective tissue.


   Case Report Top


A 26-year-old female reported to the private clinic with a chief complaint of excessive gum display on smiling. She had been recommended orthognathic surgical correction which she refused to undergo knowing the postoperative morbidity and the involvement of bone reduction in it and wanted an alternative treatment.

Her medical and family history were nonsignificant. A systematic extra and intraoral examination was performed. Upon extraoral examination, no facial asymmetry was noted. Her upper lip length measurements were recorded from sub-nasale up to the most inferior portion of the upper lip at the midline in the rest position [Figure 1] that measured 19 mm which is considered to be short. A HUL, with 10-mm lip rise was observed on smiling. Periodontal examination revealed probing depths within a range of 1–3 mm, and transgingival probing revealed alveolar crest at 2–3 mm distance apical to the cementoenamel junction. A moderate display of gingival tissue extending from the maxillary left first molar to the maxillary right first molar was observed on complete smile; there was an overall gingival excess of 5–6 mm (measured from the gingival margin) [Figure 2] and [Figure 3]. Intraoral examination also revealed short clinical crowns with respect to the maxillary right and left first premolars [Figure 4], which was corrected by a laser-assisted crown-lengthening procedure (CLP) before the LRS to maintain a harmonious gingival contour after the surgery.
Figure 1: Upper lip length measurement at rest position

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Figure 2: Preoperative view showing excessive gingival display

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Figure 3: Measurements taken at individual sites showing 5–6 mm gingival display

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Figure 4: Short clinical crown with respect to the maxillary first premolar

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As the patient opted for a minimally invasive procedure for smile correction, a modified laser-assisted LRS as an alternative was performed. An informed consent was taken after explaining about the surgical technique, safety aspects of the dental laser, possible complications, and possibility of a relapse.

Surgical procedure

Based on the diagnosis, a modified laser-assisted LRS with gingival recontouring was planned. Five percent povidone-iodine solution was used for extraoral disinfection. Intraoral disinfection was performed with a 10 mL of 0.2% chlorhexidine gluconate rinse. The surgical area was anesthetized using 2% lignocaine with 1:100,000 epinephrine. Laser safety protocols were strictly followed.

A diode laser (EZLASE, 940 nm, BIOLASE, Irvine, California, United States) was used for the procedure. First, CLP was done to correct the gingival asymmetry of the maxillary right and left first premolars. A 400-μm laser tip was used at a power setting of 0.4 W in continuous-wave mode, in order to produce an ideal scalloping pattern of the gingival tissue and increase the crown length with respective premolars on both sides [Figure 5]. The height of the gingival contour was evaluated when the patient smiled and remnants of ablated tissue were removed with a sterile gauze soaked in saline.
Figure 5: Postoperative view after crown lengthening with respect to the maxillary first premolar

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In the laser assisted lip repositioning procedure, the amount of mucosal strip to be excised should always be twice the amount of the gingival tissue display that needs to be reduced.[8] A 400-μm laser tip in a continuous-wave mode at 0.8 W was first used for demarcating the area to be excise [Figure 6]. The inferior border of the incision was outlined at MGJ and the superior border at about twice the gingival display, but slightly modifying the technique, the measurements at individual sites along with an additional 2 mm of the tissue were removed so as to avoid the relapse. Both the outlines were joined at the distal end of the first molars, forming an elliptical pattern.
Figure 6: Incision line demarcation done using laser

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Laser ablation was carried out at a power setting of 1 W in continuous-wave mode. After the entire mucosa demarcated between the outlined area was excised [Figure 7] and [Figure 8], tissue tags were removed with a sterile gauze soaked in saline and the area was irrigated with saline. The surgical area was evaluated, the wound margins were approximated using interrupted 3-0 silk sutures [Figure 9], and as laser stimulates healing by the production of basic fibroblast growth factor enhancing the proliferation and differentiation of fibroblasts, a laser bandage was performed.[9] The procedure took 30 min after administering the local anesthesia.
Figure 7: Excised strip of the mucosa

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Figure 8: Laser-assisted ablation of the strip of mucosa

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Figure 9: Multiple interrupted sutures given to approximate wound margins

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The patient was prescribed a mild analgesic twice daily postoperatively for 3 days. The patient was advised dietary instructions with intermittent ice pack application over the treated area. She was instructed to avoid activities such as talking and smiling that caused lip movement for the next 24 h. The patient was recalled after 3 days where she was evaluated and again given a laser bandage.[10] Suture removal was performed after 15 days [Figure 10]. Healing was uneventful. There was no discomfort with phonetics and speech. The patient was re-evaluated at the end of 1 month and 6 months [Figure 11]. The results showed a marked reduction in maxillary gingival display. The patient was quite satisfied and pleased with her smile. Furthermore, a follow-up visit after 1 year revealed slight recurrence (1 mm) of her gummy smile [Figure 12], which was definitely less than that observed in our first study. The recurrence was negligible for the patient to notice it.
Figure 10: Postoperative view after suture removal

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Figure 11: Gingival display after 6 months

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Figure 12: Gingival display at 1-year follow-up

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   Discussion Top


Numerous studies have been quoted in the literature regarding conventional LRS using a scalpel. A study by Rao et al.[11] used a technique of conventional surgical lip repositioning where the labial frenum was left untouched, leading to recurrence. Another study by Dayakar et al.,[12] where the conventional surgical LRS was performed including the labial frenum, showed a total relapse after 12 months.

In the study conducted earlier by Farista et al.,[6] the conventional technique was compared to laser-assisted LRS. The major advantages of lasers in soft-tissue surgery are relatively bloodless surgical field with coagulation and reduced bacteremia with minimum postoperative discomfort. Furthermore, a bloodless surgical field enhances relative ease of suturing, which is crucial for the surgical success.

A major benefit with laser in our case report was less discomfort postoperatively. When compared to the conventional scalpel technique, there is reduced intraoperative bleeding and reduced bacteremia, which can be attributed to sterile inflammatory condition. An extra advantage with the laser was high patient acceptance due to its ease and reduced morbidity and also no postoperative medications other than an analgesic SOS were prescribed. However, a major limitation related to the surgical procedure is the recurrence of the gummy smile and in our previous study,[6] there was a mild recurrence observed and hence to overcome this, a modified laser-assisted LRS was performed.

The advantage of modified laser-assisted LRS over laser-assisted LRS are as follows:

  • With the help of laser, a strip of partial-thickness flap can be removed rather than scrapping off of mucosa
  • In the laser-assisted LRS, the amount of excision of the mucosal strip was twice the amount of the gingival tissue display that needs to be reduced, whereas in modified laser-assisted LRS, an additional tissue of 2 mm was removed so as to avoid relapse
  • In the modified laser-assisted LRS, laser bandage was given to aid in healing and reduce the inflammation and postoperative discomfort.



   Conclusion Top


The present case report demonstrates that modified laser-assisted LRS shows promising results in the correction of gummy smile. The result revealed a marked reduction in the gingival display at a 6-month follow-up. Furthermore, slight recurrence was observed in the follow-up period after 1 year. Yet, keeping into consideration the simplicity of the technique, excellent patient acceptance, and providing highly satisfying treatment outcome, this can be considered as a novel, feasible, less invasive alternative in the esthetic correction of EGD (gummy smile).

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.
Garber DA, Salama MA. The aesthetic smile: Diagnosis and treatment. Periodontol 2000 1996;11:18-28.  Back to cited text no. 1
    
2.
Ackerman MB, Brensinger C, Landis JR. An evaluation of dynamic lip-tooth characteristics during speech and smile in adolescents. Angle Orthod 2004;74:43-50.  Back to cited text no. 2
    
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Gruel G. The Science and art of Porcelain Laminate Veneers. New Malden, Surrey, United Kingdom: Quintessence; 2003.  Back to cited text no. 3
    
4.
Allen EP. Use of mucogingival surgical procedures to enhance esthetics. Dent Clin North Am 1988;32:307-30.  Back to cited text no. 4
    
5.
Silberberg N, Goldstein M, Smidt A. Excessive gingival display--etiology, diagnosis, and treatment modalities. Quintessence Int 2009;40:809-18.  Back to cited text no. 5
    
6.
Farista S, Yeltiwar R, Kalakonda B, Thakare KS. Laser-assisted lip repositioning surgery: Novel approach to treat gummy smile. J Indian Soc Periodontol 2017;21:164-8.  Back to cited text no. 6
[PUBMED]  [Full text]  
7.
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. 7
    
8.
Simon Z, Rosenblatt A, Dorfman W. Eliminating a gummy smile with surgical lip repositioning. Cosmet Dent 2007;23:100-8.  Back to cited text no. 8
    
9.
Dawood MS, Salman SD. Low level diode laser accelerates wound healing. Lasers Med Sci 2013;28:941-5.  Back to cited text no. 9
    
10.
Kohale BR, Agrawal AA, Raut CP. Effect of low-level laser therapy on wound healing and patients' response after scalpel gingivectomy: A randomized clinical split-mouth study. J Indian Soc Periodontol 2018;22:419-26.  Back to cited text no. 10
[PUBMED]  [Full text]  
11.
Rao AG, Koganti VP, Prabhakar AK, Soni S. Modified lip repositioning: A surgical approach to treat the gummy smile. J Indian Soc Periodontol 2015;19:356-9.  Back to cited text no. 11
[PUBMED]  [Full text]  
12.
Dayakar MM, Gupta S, Shivananda H. Lip repositioning: An alternative cosmetic treatment for gummy smile. J Indian Soc Periodontol 2014;18:520-3.  Back to cited text no. 12
[PUBMED]  [Full text]  


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12]



 

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