DR.

PRASANT ET AL: LIP REPOSITIONING April 5, 2020

Case report on Lip Repositioning : A boon for gummy

smile patients
Dr. MC Prasant*, Dr. Abin Varghese**, Dr. Deepa Davis***, Dr. Anuj Vyas**,
Dr. Sandesh Singh Chouhan**, Dr. Akankasha Chaurasia**

*Professor & Head, **Post-graduate Student – Dept. of Oral & Maxillofacial

Surgery, ***Post-graduate Student – Dept. of Conservative Dentistry

RKDF Dental College & Research Centre, Bhopal, MP, India

Abstract

An excessive gingival display during smiling approaches of orthodontics and

will always produce a negative impact on
the society. An individual may even canget
depressed for this reason because of their
unpleasant smile. A great concern even
when smiling to others can produce
psychological stress and which may can
even affect the confidence and thereby the
performance of an individual. These can be
due to multiple reasons. Multidisciplinary
maxillofacial surgery can treat this and but
this treatment of surgical or orthodontic
correction or even the combination of both
has various disadvantages such increased
time duration of treatment, fear of surgery
which leads to creation of psychological
stress, increased hospitalization after the
surgery, complications of General
anaesthesia etc. The technique of surgical

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 DR. PRASANT ET AL: LIP REPOSITIONING April 5, 2020

repositioning of lip for the correction of
excessive gingival display can be a boon for
the patients who requires a very small
correction as it can be well accepted for the
patient because of the procedure itself is
carried out under local anesthesia and
thereby the reduced postoperative
discomfort, reduced hospitalization and the
immediate result which the patient can walk
Key words
off from the clinic within 45minutes and
moreover the fear of surgery under GA
thereby waves off. This case report
emphasizes the treatment of excessive
gingival display by conventional lip
repositioning technique. In the present case
Gummy smile of 5mm was treated with
conventional lip repositioning technique.

Gummy smile, Lip repositioning, Lip lengthening

Introduction

In the last decade the demand of the
minimally invasive cosmetic procedures are
increased throughout the globe. Cosmetic
surgical procedures, the use of botulinum
toxin type A (BTX-A) (Botox; Allergan,
Irvine, Calif) and dermal fillers, orthodontic
and orthognathic procedures, dental
bleaching, and other dental cosmetic
procedures are widely requested by adults.(1-
4)
An undeniable psychological benefit of
cosmetic procedures is the increase in self-
esteem.
An excessive gingival display during
smiling which is called as a gummy smile
which can be self-conscious, embarrassed,
or even psychologically affected, and thus
seek intervention.5
Etiological factors contributing in a gummy
smile can be hyperactivity of the muscles of
the upper lip, Vertical maxillary excess6 etc.
these factors contribute to the imbalance in
the gingiva- tooth ratio,inturn produces an
excessive gingival display. Gingival display
of 1 – 2mm is considered to be normal and
when its 4mm or more thenits classified as
unattractive. For patients who are unwilling
for the orthognathic surgery lip
repositioning is an alternative treatment.9
There two types of lip repositioning
techniques for the treatment of gummy smile
mentioned in the literature, they are the i)
conventional technique and ii) the modified
technique.10

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 DR. PRASANT ET AL: LIP REPOSITIONING April 5, 2020

Case report
A 21 year old female patient reported to
Department of Oral and Maxillofacial
Surgery, RKDF Dental College and
Research Centre, Bhopal (M.P) with the
chief complaint of excessive gingival
display during smiling. Past medical and
dental history was non contributory. The
patient was moderately build and nourished.
The patient was well oriented. On clinical
examination during smiling 5mm gingival
display was noted from 14(maxillary first
premolar of right side) to 24 (maxillary first
premolar of left side).(Figure 1) A diagnosis
of moderate vertical maxillary excess with
hypermobility of upper lip was made. Since
the patient preferred a minimally invasive
procedure , Conventional lip repositioning
technique of treatment modality was
explained to the patient and the informed
consent was obtained from the patient even
after discussing the other treatment
modalities, the benefits and the possible
complications.

Lip repositioning procedure

Standard painting and draping done
following strict and aseptic
protocol.Lignocaine with 2% Adrenaline
was injected to anesthetize the operating
site. (Figure 2) The 2 incision lines were
marked using sterile marker pen. Partial
thickness incision stared at mucogingival
junction from upper right first premolar
extending to the upper left first premolar
was given. A second incision, ie, the parallel
incision was given 12-14 mm above the first
incision was given following the marking.
The two incisions were attached together on
the right and left side which created an
elliptical design and the connective tissue
was exposed. Great care was taken to
prevent the damage of minor salivary glands
which are present in the submucosal layer.
The epithelium was excised leaving the
connective tissue exposed. (Figure 3) Local
anesthetic with 2% Adrenaline and
electrocautery was used to arrest the
bleeding. Dissection was carried out to
relive the muscular attachments to a smaller
extent. Tissue tags were removed and the
upper flap is advanced and checked for its
adaptation to the new site. Interrupted suture
placed using 4-0 silk, starting at the
midlineof the lip to ensure the proper
alignment of the lip with the midline of

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 DR. PRASANT ET AL: LIP REPOSITIONING April 5, 2020

teeth. Then further 4 more interrupted was adviced. Postoperatively regular

sutures on either side was placed for the
complete closure of the wound. (Figure 4)
Intraoral pressure pack was placed using
gauze piece over the surgical site and
extraorally pressure pack applied using
Dynaplast. (Figure 5)Post operative
instructions including the placement of ice
packs for several hours, avoiding of
brushing at the surgical site, vigorous
gargling and soft gargling with warm saline
antibiotics and analgesics were prescribed
and the patient was recalled after 10 days for
suture removal. Patient reported back on the
12th day postoperatively for the suture
removal, showed a reduction in the gingival
display during smiling. Healing of the
tissues were acceptable.(Figure 6)Gingival
display was checked during smiling again
and the result was satisfactory. (Figure 7)

Discussion
In patients with excessive gingival display, a
dentist offers multiple non invasive
treatment modalities such as the botox
injection7, crown lengthening , modify or
control the form of teeth, lip repositioning
technique etc . Satisfactory result was
obtained in this case. For an
excessive gingival display according to
VME classification degree II, III
orthognaticsurgey is preferred.8 But for
those patients which are unwilling to go for
the orthognathic surgery , lip repositioning
technique is the alternative treatment.9 Its an
effective procedure to reduce gingival
display by positioning the upper lip in a
more coronal location.9 This technique is an
easy, cost effective, less time consuming,
psychologically more acceptable with a
promising result in selected cases as case
selection plays a major role for the success
of this procedure. Contraindications for this
procedure includes patients with severe
VME, minimal zone of attached gingiva
which inturn creates difficulty in flap
design, stabilization and suturing.6

Conclusion
In cases with excessive gingival display technique is a surgical alternative in selected
during smiling and is unwilling for the patients. Sound diagnosis and careful case
orthognathic correction, lip repositioning selection is the key for the surgical outcome.

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 DR. PRASANT ET AL: LIP REPOSITIONING April 5, 2020

Figure : 1 Figure : 2

Figure 1: Preoperative image showing Figure 2 : Prepared surgical site

excessive gingival display of 5mm from
14 to 24

Figure : 3
Figure : 4

Figure 3 : Elliptical incision with exposed Figure 4: Suturing done using 4-0 silk
connective tissue

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 DR. PRASANT ET AL: LIP REPOSITIONING April 5, 2020

Figure : 5 Figure : 6

Figure 5 : Pressure pack given extraorally Figure 6 :Post operative healing after 12
with Dynaplast days

Figure : 7

Figure 7: Post operative image of the

patient showing reduced gingival display
during smiling

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 DR. PRASANT ET AL: LIP REPOSITIONING April 5, 2020
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